FAQs About Documentation

• Do I need to document all normal and abnormal findings from an examination?
• What should be stated or written if the standard of previous care is questioned?
• What should I do if a patient requests that information be withheld from the medical record?
• Do I need patient consent for releasing medical records to a third party?
• What should I do with medical records from my practice when I retire?
• What are the risks surrounding electronic communication of medical records?
• What are the pros and cons of using an addendum in a medical record after an adverse event?
• What documentation practices can help reduce allegations of a failure to diagnose breast cancer?

• Do I need to document all normal and abnormal findings from an examination?

  No.

  However, you should always document "pertinent negatives." Because memory does not serve as well as the printed word, you should list all negative findings that are associated with any of the processes in your working differential diagnosis.

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• What should be stated or written if the standard of previous care is questioned?

  Medical records often reflect differences of opinion and inconsistencies among the patient's health care team. Outright oral or written criticism of previous health care contributes nothing to the patient's needs and could lead to a malpractice claim, even when no negligence occurred. Remarks or record entries critical of prior care are a frequent reason patients consider litigation. Since all pertinent facts about prior care are rarely available, caution is advised in making judgments and comments.

  Patients may take casual remarks critical of prior caregivers seriously, possibly destroying those relationships. Basing an opinion on a patient's report of prior circumstances may be unfair since symptoms and findings change over time and the patient's perceptions and recollections may be inaccurately reported. If, after you have considered the complete information, you judged prior care to have been flawed, summarize the clinical events with the patient and dispassionately answer his or her questions.

  One of the most valuable practice habits involves accurately and objectively documenting and stating the patient's condition at the time you assume care. This, combined with a thorough review of prior care treatment records, should "keep the record straight" without pointing fingers or blaming others should prior care actually be problematic.

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• What should I do if a patient requests that information be withheld from the medical record?

  Information necessary for providing proper care of the patient should always be documented in the record. For example, an HIV-positive status is clinically relevant data and should be documented for optimal care to be provided. Care may be compromised by incomplete medical information, such as known conditions or test results, to the extent that diagnoses may be missed and useful treatments delayed. In addition, hiding information from health or life insurance investigators could be deemed as abetting an act of fraud. On the other hand, omitting data that has no bearing on the patient's current care or condition, such as social history and history of distant past substance abuse, may be appropriate.

  When faced with a patient who asks you to not record important data, stressing the clinical importance of recording the sensitive information is the first and most effective solution. If the patient still objects, the conflict may pit the patient's interests against your own; termination of the care relationship may be necessary.

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• Do I need patient consent for releasing medical records to a third party?

  Yes, No, and Maybe.

  As outlined below, the requirement for the patient's permission to release information varies depending on what's being shared and with whom. Stricter regulations that may go into effect after this web posting are likely to further restrict unauthorized release, including some circumstances that currently do not require written permission.

  When Release DOES Require Specific Written Consent

  The following information cannot be released without the specific written consent of the patient, or upon a specific court order.

  Communications with:

  • Social workers
  • Psychotherapists or psychologists
  • Marriage/family rehabilitation/mental health counselors
  • Domestic violence victims
  • Sexual assault victims

  Information concerning:

  • Drug treatment
  • Alcohol treatment
  • Blood alcohol test results
  • Federally assisted drug/alcohol abuse treatment programs
  • Venereal disease records
  • AIDS/HIV records

  When Release DOES NOT Require Specific Written Consent

  Health Benefit Providers

  By enrolling in or accepting coverage by health benefit programs (Medicare, Medicaid, Blue Cross/Blue Shield, commercial insurers, HMOs, PPOs, etc.) patients grant those third parties access to the information necessary to process claims and to determine coverage and eligibility for benefits. Additional patient consent is not required for release of the necessary information.

  Mandatory Reporting Requirements

  Physicians are required to report certain patient conditions to specified state and local health officials. (See "What patient conditions must I report?".) The patient's consent is not needed:

  Other

  Under Massachusetts law, the medical records of hospital/clinic patients may be released without patient consent when:

  • Information is being provided to the Commissioner of Public Health
  • Upon proper judicial order
  • Upon being served with a subpoena when the patient is a named party in the case caption, and release is to a court or place of hearing

  In general, the statutory authorizations governing hospitals apply to physicians in medical group practices and individual providers.

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• What should I do with medical records from my practice when I retire?

  You must make provisions for former patients and subsequent providers to have access to the information contained in your medical records. If you are in a practice situation where the medical records are the property of a corporate entity, responsibility for maintaining these records and providing subsequent access may be assumed by that entity. If you are a solo practitioner, or dissolving a partnership or small group practice, responsibility for some or all of the records may fall to you. This responsibility includes not only deciding what medical records to retain, but also coordinating arrangements for safety, storage, and access on a timely basis. Storing records is space consuming, and space saving methods such as microfilming or electronic capture are expensive. No matter what storage choice is made, consider future access to the data.

  How long medical records must be retained after closure of a practice depends on state law. Massachusetts requires a retiring physician to retain medical records for a minimum of seven years, or until a child patient reaches the age of nine. The physician must furnish the Board of Registration in Medicine (BRM) with a written statement agreeing to provide access to medical records for the required period. Keep in mind that the retention period is based on the date of the letter of retirement to the BRM, not the date of the last patient encounter (as required for active physicians).

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• What are the risks surrounding electronic communication of medical records?

  The same levels of physician and staff responsibility for patient confidentiality and protection apply to electronic records as apply to a paper record:

  • All patient information is sensitive
  • Every patient needs protection
  • Access patient information on a need-to-know basis only
  • Systematic tracking of every entry, look-up, and printing of patient information using unique and confidential signature computer keys (or passwords) is advocated as the best safeguard. Ideally, patients should be able to find out who accessed their record and why

  While e-mail has become an efficient way to impart patient information, clinicians must consider any patient-specific e-mail messages to be part of the medical record.

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• What are the pros and cons of using an addendum in a medical record after an adverse event?

  While information in the medical record should never be deleted, obliterated, or altered after the fact, the judicious use of an addendum in a medical record is reasonable, as long as the addendum is designated as such and dated. Accepted rationale for including an addendum would be for the correction of facts (i.e., persons involved, time of event, sequence of events) and for the addition of facts or clarifying information. Individuals who participated in the care, but were unable to access the record until a later date, may also provide added information. Addenda should not be used to state opinions, perceptions, or defenses.

  Arguments Supporting Addenda

  Accuracy: The witness to the event may not be the person who documents it. Inaccuracies, even those that appear minor, should be corrected by someone who did witness the event.

  Recall: Recording everything that is happening during an emergency situation is often impossible. Witnesses to an event may recall details at a later time, in which case, an addendum is appropriate.

  Clarification: Information previously thought irrelevant may become important as events unfold. Reevaluation of the case by a consultant may shed light on a potential precipitating factor in the possible cause of the event. Additional clarifying comments in the record may be important to future care.

  Arguments Against Addenda

  Perception: The major argument against writing addenda is the potential that they may be perceived as attempts to falsify or change the record of fact. Inappropriately phrased, an addendum may appear to be "self-serving" rather than providing information important in the course of a patient's recovery. For example, following an adverse event, individuals may attempt to explain their own particular role (or lack of one) in addenda. This appears defensive, does not contribute to the care of the patient, and should be avoided.

  Vulnerability: An addendum will be interpreted by plaintiff counsel as an attempt to alter the medical record and, if at all possible, used to support his or her client's claim. Seemingly insignificant record details are often magnified and used effectively to emphasize a plaintiff's point.

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• What documentation practices can help reduce allegations of a failure to diagnose breast cancer?

  • Document a thorough breast examination in the history and physical examination; enter, in quotes, the patient's breast complaints and what she says.
  • Use a diagram (or descriptive notes) to record the exact location of all lesions.
  • In the event that a patient's breast care is being managed by another clinician, document the date of the patient's last exam to ensure that subsequent exams are performed when appropriate.
  • During each visit, update the patient's risk factor assessment and your recommendations for screening based on their current risk for developing breast cancer.
  • Consider using a problem list to highlight patients with a positive family history of breast cancer.

  For more information view: CRICO/RMF's Breast Care Management Algorithm

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