Medical Record Contents and How to Make Entries inside the Medical Record
There are several components listed in a medical record. These components are listed below:
• Consumer’s entire name, demographics, contact numbers, social security number, date of birth, and whether or not they are married (Fremgen, 2012).
• Consumer’s previous medical history (Fremgen, 2012).
• Days and hours of every appointment and treatment (Fremgen, 2012).
• History of the presenting illness (Fremgen, 2012).
• Review of symptoms, and why the patient came in to the office (Fremgen, 2012).
• Main Complaints (Fremgen, 2012).
• Results of the exam performed by the doctor (Fremgen, 2012).
• Doctor’s assessment, diagnosis, and what he/she recommends as far as treating the illness (Fremgen, 2012).
• Progression documentation of former appointments and therapeutics (Fremgen, 2012).
• Medical problems of kindred (Fremgen, 2012).
• Individual medical problems (Fremgen, 2012).
• History of medicines as well as notes regarding all orders to refill meds (Fremgen, 2012).
• Treatments (Fremgen, 2012).
• X-ray reports (Fremgen, 2012).
• Lab reports (Fremgen, 2012)
• Reference Statements (Fremgen, 2012).
• Identification of disease or illness (Fremgen, 2012).
• More communication regarding patients include: when it is needed, documents regarding compliance, patient’s permission to give out information, and a copy of a living will if the patient has one (Fremgen, 2012).
• Documents regarding all prescription medication and all authorizations to refill prescriptions (Fremgen, 2012).
• Documents regarding the copying of medical records, and documents regarding whom these documents were sent to (Fremgen, 2012).
• Documents regarding patients not showing up for appointments, and what actions were taken in regards to the missed appointment such as calling the patient on the phone and finding out the reason for the missed appointment, and an opportunity to reschedule (Fremgen, 2012).
• Directions regarding eating habits, home care, exercising, as well as follow-up visits (Fremgen, 2012).
• Hospital medical records are made up of:
- Documentations made by a person trained to care for the sick (Fremgen, 2012).
- Operational Reports (Fremgen, 2012).
- Childbirth Records (Fremgen, 2012).
- Narcosis Reports (Fremgen, 2012).
- Records of medicine and treatments (Fremgen, 2012).
- Documentations made by Social Services (Fremgen, 2012).
- Documentations made by Physical therapists (Fremgen, 2012).
- Documentations made by the Dietician (Fremgen, 2012).
- Documentations regarding how much the patient is taking in and is putting out (Fremgen, 2012).
- Documents regarding the patient’s discharge (Fremgen, 2012).
There are also several general rules for correctly putting some sort of documentation into a medical record. They are listed below:
1. Always look twice to ensure that you are making documentations in the right patient’s medical record (Fremgen, 2012).
2. Write in black ink, and write where it can be read. If your handwriting is hard to read, then print (Fremgen, 2012).
3. The name and I.D. number of the consumer must be on each page. Some sorts of stamping devices may be used to do this (Fremgen, 2012).
4. All entries must contain a date, and must have the signature of the individual that is working on the record at that point in time. If that individual chooses to use his/her initials, then they must make certain that the individual’s whole signature has to be present either in the medical record or in the office of the doctor (Fremgen, 2012).
5. Documentations must be concise, but must be stated in their entirety (Fremgen, 2012).
6. Only use abridgements that the entire staff understands (Fremgen, 2012).
7. All words related to medical terminology must be properly spelled (Fremgen, 2012).
8. Do not erase or try to use white out to take out data from a medical record (Fremgen, 2012).
9. Do not leave extra space for anyone to go back and add to your documentation (Fremgen, 2012).
10. Keep a record of all phone calls and communications that are related to the consumer (Fremgen, 2012).
11. Document all actions taken as a result of telephone conversations (Fremgen, 2012).
12. Document all missed appointments (Fremgen, 2012).
13. Document all incidents of noncompliance (Fremgen, 2012).
14. Document all patient education (Fremgen, 2012).
15. Do not record any personal opinions, speculations, or judgment (Fremgen, 2012).
16. All corrections on paper files should be made by drawing a single line through the error, writing the correction above the error, dating the change, and then initialing it (Fremgen, 2012).
References
Fremgen, B. F. (2012). Medical Law and Ethics. (4th Ed.). Upper Saddle River, NJ: Prentice Hall.
