Physician office records: Are they complete?

Attorneys often ask Med League to organize medical records for the purposes of doing a medical summary or to send to an expert. The question may arise: Are these records complete? There are wide differences in how records are kept and supplied to an attorney. Some physicians’ offices will yield everything in the file whereas others will decide what the attorney (or patient) should receive. Knowing what should be in the file enables Med League’s nurses to recognize what is missing.

Office records may span the lifetime of an individual although this is not common with today’s mobile society. Office medical records are typically not as voluminous as hospital or nursing home records. The method of organization of the following sections is variable from office to office. In addition, some physicians will keep laboratory, radiology, and correspondence next to the corresponding office visit note. The following list details components that may be found within office records.

Initial intake form: This is a document that is typically filled out by the patient and details complaints and other illnesses. The intake form summarizes current medications, allergies, past surgeries, previous hospitalizations, prior illnesses, vaccination record, social history, which includes employment, marital status, lifestyle habits such as smoking, alcohol intake, seat belt usage, exercise, the presence of advanced directives in place and power of attorney. Also noted is family history including the health status of parents and siblings or current illnesses of these family members and a check-off list of symptoms previously or currently experienced.

Initial history and physical: The physician performs a detailed history and physical the first time the patient is being seen.

Problem list: Once the initial history is obtained, the physician office will frequently make a separate and continually updated the list of medications, allergies, and vaccinations, as well as a list of all chronic illnesses or conditions. These are sometimes consolidated into one summary sheet and kept highly visible on the left-hand side of the patient file as it is opened.

Physician office notes of visits: Notes may be dictated and transcribed, handwritten, documented in the form of reports to a referring physician, or entered into an electronic medical record. Data should include weight, blood pressure, pulse, complaints, examination findings, diagnoses, and treatment and plan for care, including prescriptions and advice on when to return to the office. Physician assistants and nurse practitioners may alternate with the physician in seeing the patient and recording in the chart. Appointments missed by the patient may be noted as “NS” (no show), or “DNKA” (Did Not Keep Appointment.)

Laboratory, radiology, EKG and other medical procedure results: Test results should have some notation either on the test report itself or within the physician office notes that the results were reviewed by the physician, communicated to the patient, and that follow-up was given to the patient, if necessary, to further evaluate the results or monitor the findings at a specific time interval. This can be accomplished through a phone call, letter, or follow-up office visit. Some physicians simply initial the test results. Routine and normal results may be communicated to the patient by the office staff following a specified office procedure.

Correspondence: This section includes letters sent to and from the physician, consultation notes with other physicians, outpatient services such as physical therapy, and letters sent to or received from the patient. It should also include email messages to and from the patient.

Copies of hospital records: Included have discharged summaries, histories and physicals, operative reports, and consultations with other physicians. Copies of hospital records are not always included and may be incomplete if present.

Home health care records: The office records may include reports from the agency providing care under the direction of the office. Records typically include the plan of care and discharge summaries.

Phone call records: These are frequently noted before or after office visits to maintain an easily readable time sequence of events. Phone message slips may be taped or stapled to office records.

Billing records: These documents may or may not be kept within the body of the medical record and should be compared with the dates of the office visits to see if all visits are documented in the form of notes.

Prescriptions: On occasion, copies of prescriptions for medications or therapeutic treatments will be found within records.

Return to work or excuse from work/school notes, and disability records: Copies of these forms are kept in the records.

The article is modified from in Medical Legal Aspects of Medical Records, Second Edition, Tucson, Lawyers and Judges Publishing Company, 2010.

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