Medical Record Documentation Reminder

The primary focus of medical record documentation is to communicate a patient’s treatment plan and support continuity regarding their treatment. Accurate and complete documentation is an essential component of patient care that enhances quality.

Medical record documentation should provide a road map for every member of the treatment team about a patient’s current state of health, preventive care, treatment interventions and planning, care delivery, progress, and discharge planning.

Minimum documentation requirements to include on each page of a medical record include, but are not limited to the following:

• Patient’s full name
• Date of birth
• Unique medical record number or other identifier
• Physician’s name
• Date of occurrence
• Author’s identification (signature, unique electronic identifier or initials)

Medical record documentation should include, at minimum, the following components:

• Significant illnesses and medical conditions are indicated on the problem list
• Medication allergies and adverse reactions are prominently noted in the record. If the patient has no known allergies or history of adverse reactions, this information should be appropriately noted in the medical record.
• Past medical history (for patients seen three or more times) is easily identified and includes serious accidents, operations and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations and childhood illnesses.
• Working diagnoses are consistent with findings
• Treatment plans are consistent with diagnoses
• There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure.

Quality documentation enhances patient safety, justifies medical claims, fosters a patient-physician relationship, and provides physician protection. Complete and accurate documentation is critical. Additional items to address in medical record documentation can be found on the Blue Cross and Blue Shield of Texas provider website in the Provider Manual, Section J Quality Improvement.