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Medical Record Documentation Guidelines

The medical record is a comprehensive document that tracks a patient's hospital experience, including medical history, care plans, and details from admission to discharge. It must be consistently written, legible, and follow institutional guidelines, with clear processes for correcting errors. Major components include admission notes, pre-operative notes, operative notes, progress notes, and discharge notes, each serving specific purposes in patient care documentation.

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Anntonette Sharmaine Cortes
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49 views2 pages

Medical Record Documentation Guidelines

The medical record is a comprehensive document that tracks a patient's hospital experience, including medical history, care plans, and details from admission to discharge. It must be consistently written, legible, and follow institutional guidelines, with clear processes for correcting errors. Major components include admission notes, pre-operative notes, operative notes, progress notes, and discharge notes, each serving specific purposes in patient care documentation.

Uploaded by

Anntonette Sharmaine Cortes
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

MEDICAL RECORD

• a chart that documents the patient’s experiences in the hospital from admission to his discharge;
• It contains details like:
1. patient’s medical history & current conditions
2. Plan/s for patient care from admission through discharge

Who writes in the medical record


Physicians
Nurses
Physician assistants
Social workers

Note: Those who encounter the patient must describe their activities and findings in the medical record

CHARACTERISTICS OF AN ACCEPTABLE MEDICAL RECORD


• It should be written consistently without shortcuts.
• All entries & signatures must be legible & follow the institution’s guidelines or format.
• All entries must indicate the date & time at which they were written
• Abbreviations used should be approved by the institutions
• It should be clear, concise & problem-oriented.
• Narratives & anecdotal comments should be avoided unless they are necessary

CORRECTION OF ERRORS IN THE MEDICAL RECORD


It is done by DRAWING A LINE THROUGH THE CORRECTION and RECORDING THE DATE AND TIME of the
change.
The INITIALS of the corrector is required followed by the STAMPED or PRINTED version of his name

MAJOR PARTS OF A MEDICAL RECORD


I. ADMISSION NOTES
- gives the reason for the admission of the patient in the hospital
Details considered:
1. HISTORY & PHYSICAL EXAMINATION - questioning and gross examination
2. Medical History = relates past medical conditions to present condition
3. Family & Psychosocial history - familial diseases & behavioral aspects of the patient
4. Review of Systems - an orderly & systematic progression through each system of the body that
permits the diagnostician to supplement the information supplied by the patient
5. Physical Examination - utilizes the physician’s senses & instruments to note the vital signs,
appearance of the patient for evaluation.
6. Radiographic Examination - allows the physician to make subjective interpretation of radiographic
images related to the condition of the patient
7. Impressions - describe conclusions & tentative diagnosis that have been reached based on the
information gathered; listed in descending order
8. Plan - lists subsequent tests for the patient & consultations required by the physician; indicates the
disposition of the patient

1
II. PRE-OPERATIVE NOTES
- contain pertinent information needed by the physician & health care team before surgery
• Pre-operative diagnosis
• Procedure to be performed
• Lab test results
• Vital signs
• ECG & chest x-ray films
• Blood bank info
• Medications / IV line orders
• Diet restrictions
• Permission & consent documentation

III. OPERATIVE NOTES AND POST-OPERATIVE ORDERS

Operative Notes
- are dictated and written immediately after surgery
- A summary & review of all activities that occurred during surgery
Details found in the Operative Notes
• Pre- and Post operative Diagnosis
• Summary of the Procedure
• List of all those in the OR
• Type & duration of anesthesia
• Condition of the patient upon leaving the OR

Post Operative Notes and Orders


• describe findings noted on examination of the patient 5-6 hours after the operation

• Describes the:
- vital signs of the patient
- level of consciousness & activity
- PE results
- General assessment
- Plan of action
- etc.

IV. PROGRESS NOTES


- Describe the results of the interaction of the medical team with the patient post-operatively and outline any course of action for
any subsequent treatments.

V. DISCHARGE NOTES
- summary of events during the patient’s hospitalization
- written 2 weeks after discharge.

Common questions

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Listing impressions in descending order in admission notes is important because it prioritizes the most critical diagnoses or conclusions first, which helps healthcare providers focus on the most pressing issues. This arrangement aids in clinical decision-making by allowing care providers to efficiently allocate resources and make timely decisions regarding diagnostic testing and treatment options, thereby optimizing patient outcomes .

Errors in a medical record are corrected by drawing a line through the error and recording the date and time of the change. The initials of the person making the correction must also be added, followed by the stamped or printed version of their name. This method is important as it maintains the transparency and traceability of corrections, ensuring that medical records remain accurate and reliable. This practice helps preserve the chronological integrity of the record, preventing potential legal issues and maintaining trust in the record's accuracy .

Admission notes in a medical record include the history and physical examination, medical history, family and psychosocial history, review of systems, physical examination, radiographic examination, impressions, and a plan for subsequent tests and consultations. These components are necessary as they provide a comprehensive baseline assessment that informs diagnosis and treatment plans, ensuring tailored patient care and facilitating informed decision-making across all stages of the patient's hospital stay .

Radiographic examinations in the admission notes play a crucial role by providing visual evidence that may confirm or suggest diagnoses, thus supplementing the subjective information provided by the patient. These examination results assist diagnosticians in verifying clinical findings from the history and physical examination, guiding them in developing accurate, comprehensive diagnoses, and subsequent treatment plans .

It is essential for multiple healthcare professionals to document in a patient's medical record to ensure a comprehensive and collaborative approach to patient care. Physicians, nurses, physician assistants, and social workers all provide unique perspectives that contribute to a complete picture of the patient's condition and treatment plan. This multi-disciplinary documentation allows for seamless continuity of care from admission through discharge by providing detailed, organized observations and decisions that are critical for effective patient management .

Pre-operative notes are crucial as they prepare the healthcare team by providing pertinent information necessary for surgical planning and risk assessment. They include the pre-operative diagnosis, the procedure to be performed, lab test results, vital signs, ECG, chest x-ray films, blood bank information, medication and IV line orders, diet restrictions, and consent documentation. This comprehensive preparation minimizes risks and ensures the safety and efficiency of the surgical procedure .

Progress notes describe the outcomes of the medical team's interaction with the patient post-operatively, outlining subsequent treatments and responses. They track the patient’s recovery trajectory, document any changes or complications, and detail interventions needed for continued recovery. These notes are instrumental in evaluating treatment efficacy, adjusting care plans, and ensuring that all healthcare providers are informed about the patient's progress and needs .

An operable medical record must be consistently written without shortcuts, with legible entries and signatures following the institution’s guidelines or format. Entries must include the date and time they were written, approved abbreviations, and should be clear, concise, and problem-oriented. Narratives and anecdotal comments are generally avoided unless necessary. Corrections must be made by drawing a line through errors and recording the date and time of change, along with the corrector's initials, followed by their stamped or printed name .

Post-operative notes and orders record findings from examinations conducted 5-6 hours following surgery, including the patient's vital signs, level of consciousness and activity, physical examination results, and general assessment. A plan of action and other relevant information are also included. These details are critical as they enable healthcare providers to monitor patient recovery, identify complications early, and adjust treatment plans as necessary to ensure effective post-operative care management .

Discharge notes summarize the events during a patient's hospitalization to provide a concise record of the patient's medical journey. This includes diagnoses, treatments, and responses observed during their stay. Such summaries are necessary as they inform post-discharge care by guiding follow-up appointments, ongoing treatment, and potential adjustments to medication regimes, thereby ensuring continuity of care after the patient leaves the hospital .

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