The Essential Details of Medical Record-Keeping-

The Essential Details of Medical Record-Keeping

Jeannine LeCompte, Compliance Research Specialist

A medical record must contain the complete details of a patient or resident, and be continually updated throughout the treatment or care period. In a nursing home environment, this should not be limited to medicines issued and physician visits, but must include the entire scope of a resident’s interaction with the facility.

For example, each time that a resident issue is addressed, a progress note should be made in the medical record. Most often, this will consist of a series of short descriptive statements written throughout the shift to make the narrative of the interaction clear.

This narrative will be concluded at the end of a shift by a full handover statement.This handover must include all significant facts that other practitioners will need to assess the patient—something that is particularly important in preventing later inspectors of the record from suspecting fraud or the hiding of evidence. When finality on any particular issue is reached, the record will be concluded with all orders, treatments, etc., drawn from all providers who have written notes.

It is important to include any changes in the original care plan which may have been affected.This includes changes in treatment, and detailed explanations about why specific treatment was not administered, as well as any communication with the physician in charge.

Each step should be documented as it happens, but in the event that any late entries are made, care must be taken to ensure that the entry always contains the correct date and time and an indication of when the event occurred.

It is vital that all personal opinions or criticisms are withheld from the record.Staff should be taught that the medical record might one day be a court document, and anything recorded in it might have serious legal implications for the staff, facility, and residents.

All vague entries, such as “resident had a good day” should be avoided. It is better to be specific: “resident reported his discomfort was a 2/10 and that he felt better.”

In summary, the medical record must contain all of the following elements:

– Initial patient assessments;

– Plan of care;

– Nursing actions;

– Ongoing/frequent nursing assessments;

– Accountability information. This includes forms signed by the patient, location of valuables, resident education;

– Notification of other providers;

– Collaboration with other clinicians;

– Notations of care by other disciplines;

– Procedures & diagnostic tests;

– Evaluation of resident responses to medications, therapy, etc.;

– Statements made by the resident;