A medical record contains documentation of a patient’s medical history and care. These records include a patient’s entire history with personal and confidential information. Every medical record should have accurate and precise documentation to support diagnoses, justify treatment, and make sure that there is a connection for continuous care among healthcare providers.
In an effort to protect patient information, there are specific federal and state laws and regulations to maintain confidentiality. All entries in a patient’s medical record should be in compliant.
Rheumatology practices should make sure that patient medical documentation is timely, complete, and consistent to meet the necessity of quality of care. Below are a few tips to maintain compliance with patient medical records:
- Patient’s name and ID number should be on every page of the record;
- All documentation should be clear and legible;
- Physician signature or initials should be on every page of the record (but make sure that the last page has a full signature);
- Pencil or red ink should not be used for recording any documentation;
- Cutting and pasting in electronic medical records should be reviewed so as to not cause confusion with cloned notes;
- All entries should be dated, signed, and time entered; and
- Late entries, addendums, or corrections should be made as soon as information is received.
Medical record documentation is very important and should not be taken lightly. For questions or additional information on medical record standards, contact Cindy Gutierrez, the ACR insurance and practice management senior specialist, at [email protected] or at (404) 633-3777 ext. 310.
