The Medical Record
Introduction to the Medical Record
Medical records are a crucial part of a medical practice. A medical record is a written record of the important information regarding a patient, including the care of that individual and the progress of his or her condition. A patient is defined as an individual receiving medical care.
The patient’s medical record serves many important functions. The physician uses the information in the medical record as a basis for decisions regarding the patient’s care and treatment. The medical record documents the results of treatment and the patient’s progress. The medical record provides an efficient and effective method by which information can be communicated to authorized personnel in the medical office.
The medical record also serves as a legal document. The law requires that a record be maintained to document the care and treatment being received by a patient. If something goes wrong, good documentation works to protect the physician and the medical staff legally. Incomplete records could be used as evidence in court to show that a patient did not receive the quality of care that meets generally accepted standards.
The medical assistant must always keep in mind that the information contained in a patient’s medical record is strictly confidential and must not be read by or discussed with anyone except the physician or medical staff involved with the care of the patient (see Highlight on the HIPAA Privacy Rule).
Components of the Medical Records
A medical record consists of numerous documents. Each document in the medical record has a specific function or purpose. Most of these documents are preprinted forms or computer templates that contain specific information entered by a physician or other health professionals. A large variety of forms or templates are available; the type of form or template used is based on the specific requirements of each medical office.
Medical record documents can be classified into categories. Each of these categories is outlined in the box on page 872 along with the specific documents included in each.
It is important that the medical assistant be familiar with each type of document in the medical record. A description of the function or purpose of each type of medical record document follows (by category), along with the specific information that each contains.
Medical Office Administrative Documents
Administrative documents contain information necessary for the efficient (record-keeping) management of the medical office. Medical office administrative documents include the patient registration record and patient-related correspondence.
Patient Registration Record
The patient registration record (Figure 36-1) consists of demographic and billing information. All new patients must complete a patient registration record form. After the patient completes the registration record, the medical assistant enters the information into a computer. This allows the demographic and billing information to be used for numerous computerized functions, such as scheduling appointments, posting patient transactions, and processing patient statements and insurance claims. With a paper-based patient record (PPR), the original patient registration record is then usually placed in the front of the patient’s medical record. With an electronic medical record (EMR), the original registration record is usually shredded.
NPP Acknowledgment Form
A Notice of Privacy Practices (NPP) is a written document that explains to patients how their protected health information will be used and protected by the medical office. The patient must sign a form acknowledging that he or she has received the NPP. The NPP form is then filed in the patient’s chart.
Correspondence
Correspondence is an important part of the medical record. Correspondence regarding a patient may be received from various individuals or facilities, such as the patient’s insurance company, the patient’s attorney, and the patient himself or herself. Insurance correspondence includes such documents as a precertification authorization for a hospital admission and a request for additional information from the insurance company. Correspondence also includes copies of letters concerning the patient that are sent out of the office; examples are a copy of a letter referring the patient to a specialist and a copy of a collection letter sent to the patient.
What Would You Do? What Would You Not Do?
Moira Celeste, an account executive for a large insurance company, comes to the office complaining of insomnia and depression. Three months ago, her husband of 27 years left, and now they are legally separated. Since then, Moira has had a lot of trouble sleeping at night. She also feels lethargic during the day and hasn’t been eating much. Moira says that she’s been having some problems with alcohol. She wants to know of any community agencies that could help her with her problem but that would be sure to keep the information confidential. She has a very responsible job with her firm and does not want anyone to know about her alcohol problem. She also does not want any information about her problem put in her chart, and she especially does not want the physician to know about it because he is friends with many of her colleagues at work. 
Putting It All into Practice
My name is Dawn Bennett, and I work for an orthopedic surgeon. I work in the front area of the office as an administrative supervisor in billing and collections.
Working in billing and collections is very challenging and sometimes stressful. It can even be embarrassing. We are a new practice, and when we opened, there was no collection system. When it came time to review our accounts, we realized that, like every other business, we needed a collection system. We immediately jumped in and took charge.
The primary physician at our office is from New York, and we were unfamiliar with his family members. One day he walked into our office with a very puzzled look. I asked him what was wrong. He replied, “You guys are doing a great job with our collection rate. I asked you to be stern, but thoughtful, when sending out patient collection letters, but did you have to send one to my mother-in-law?!” Needless to say, we fixed the error immediately. This incident prompted us to restructure our collection system, and we added a comment screen to our computer system on all of our patients’ accounts. Going into a medical office that already has a system in place may be easier, but you can learn a lot more by setting up an office system yourself. 
Medical OFFICE Clinical Documents
Medical office clinical documents include a variety of records and reports that assist the physician in the care and treatment of the patient. Common medical office clinical documents are listed and described next.
Health History Report
A health history report is a collection of subjective data about the patient. Most of this information is obtained by having the patient complete a preprinted form that is then reviewed for completeness by the medical assistant. Some of the information included in the health history is obtained by the physician or medical assistant by interviewing the patient.
Along with the physical examination and laboratory and diagnostic tests, the health history is used for the following reasons: to determine the patient’s general state of health, to arrive at a diagnosis and to prescribe treatment, and to document any change in a patient’s illness after treatment has been instituted. The term diagnosis refers to the scientific method of determining and identifying a patient’s condition.
A thorough history of personal health is obtained for each new patient, and subsequent office visits provide additional information regarding changes in the patient’s condition or treatment. A complete discussion of the health history report is presented later in this chapter.
Physical Examination Report
A physical examination is an assessment of each part of the patient’s body. The purpose of the physical examination is to provide objective data about the patient, which assists the physician in determining the patient’s state of health. (The physical examination is described in detail in Chapter 20.)
Progress Notes
Progress notes involve updating the medical record with new information each time the patient visits or telephones the medical office. Progress notes serve to document the patient’s health status from one visit to the next. It is important that the date and time be included with each progress note, along with the signature and credentials of the individual making the entry. A thorough discussion of charting progress notes is presented later in this chapter.
Medication Record
A medication record consists of detailed information related to a patient’s medications. The record may include one or more of the following categories: prescription medications, over-the-counter (OTC) medications, and medications administered at the medical office. Most medical offices use one form to record prescription and OTC medications and another form to record medications administered to the patient at the medical office.
Medication Administration Record Form
A form for recording medications administered to the patient at the medical office (Figure 36-2) includes the following:
Consultation Report
A consultation report is a narrative report of a clinical opinion about a patient’s condition by a practitioner other than the primary physician, known as a consultant (Figure 36-3). The consultant is usually a specialist in a certain field of medicine (e.g., cardiology, endocrinology, urology). The consultant’s opinion of the patient’s condition is based on a review of the patient’s record and an examination of the patient. The consultation report must include the following:
Home Health Care Report
Home health care is the provision of medical and nonmedical care in a patient’s home or place of residence. The purpose of home health care is to minimize the effect of disease or disability by promoting, maintaining, and restoring the patient’s health. There is a growing preference for home health care over equivalent health care options. Research shows that familiar surroundings contribute positively to a patient’s emotional and physical well-being.
Home health care must be ordered by the patient’s physician and is provided by skilled professionals. Home health care professionals include nurses, home health aides, dietitians, physical therapists, occupational therapists, speech therapists, and social workers. Examples of specialized services available through home health care include cardiac home care, intravenous (IV) therapy, respiratory therapy, pain management, diabetes management, rehabilitation, and maternal-child care. Home health care providers must periodically provide a summary report (Figure 36-4) to the patient’s physician that includes the following:
Laboratory Documents
A laboratory report is a report of the analysis or examination of body specimens. Its purpose is to relay the results of laboratory tests to the physician to assist in diagnosing and treating disease. The specific categories of laboratory tests include hematology, clinical chemistry, immunology, urinalysis, microbiology, parasitology, cytology, and histology. A thorough discussion of laboratory documents is presented in Chapter 29.
Diagnostic Procedure Documents
A diagnostic procedure report consists of a narrative description and interpretation of a diagnostic procedure. A diagnostic procedure is a type of procedure performed to assist in the diagnosis, management, or treatment of a patient’s condition. The procedure may be performed by a physician, the medical assistant, or a technician specially trained in the procedure. A physician is responsible for interpreting the results of the diagnostic procedure and completing the written report. Examples of diagnostic procedure reports follow.
Radiology Report
A radiology report is a narrative description of a diagnostic or therapeutic radiologic procedure (Figure 36-5). A radiologist examines the radiograph and provides a written report, which includes a detailed interpretation of the radiograph and his or her impressions. The patient’s physician receives a copy of the radiology report; the actual radiographic film or digital images are kept on file in the hospital’s radiology department but are available for review by the patient’s physician.
Diagnostic Imaging Report
A diagnostic imaging report is a narrative description of a diagnostic imaging procedure (Figure 36-6). The report includes a detailed interpretation of the diagnostic image, along with the practitioner’s impressions. Examples of common diagnostic imaging procedures include ultrasonography, computed tomography (CT) scan, and magnetic resonance imaging (MRI). The diagnostic computer image is kept on file at the hospital but is available for review by the patient’s physician.
Therapeutic Service Documents
A therapeutic service report documents the assessments and treatments designed to restore a patient’s ability to function. Examples of therapeutic services that the physician may order follow.
Physical Therapy
Physical therapy involves the use of therapeutic exercise, thermal modalities, cold, hydrotherapy, electrical stimulation, massage, and other physical agents to restore function and promote healing after an illness or injury. A physical therapist might help a football player with a knee injury to regain normal functioning of the knee or assist a patient recovering from a stroke to use his or her legs to walk again. Figure 36-7 shows an example of a physical therapy report.
Occupational Therapy
Occupational therapy helps a patient learn new skills to adapt to a physically, developmentally, emotionally, or mentally disabling condition. This enables the patient to perform activities of daily living and to achieve as much independence as possible. An occupational therapist might help an individual with a physical disability learn how to get dressed and how to prepare meals.
Hospital Documents
Hospital documents are prepared by the physician responsible for the care of a patient while at the hospital; this physician is known as the attending physician. The attending physician may be the patient’s regular physician or a different physician. An example of the latter is a physician attending a patient at an urgent care center or in the emergency department of a hospital.
Hospital documents are dictated by the attending physician and transcribed at the hospital. The original document is filed in the patient’s hospital medical record, and a copy is sent to the patient’s regular physician. Hospital documents assist the patient’s physician in reviewing the patient’s hospital visit and in providing follow-up care.
History and Physical Report
The term inpatient refers to a patient who has been admitted to the hospital for at least one overnight stay. A health history must be obtained and a physical examination performed on all inpatients. There is one exception to this: If a patient history and physical examination are performed at the medical office within 1 week before admission, a copy of these documents may be used. In the event that a reliable health history cannot be obtained from the patient, it must be obtained from the person best able to relay the facts.
The history and physical report is a physician’s narrative report of the patient’s history and physical examination, along with the physician’s medical impressions (Figure 36-8). The purpose of the history is to document the patient’s current complaints and symptoms, whereas the purpose of the physical examination is to assess the patient’s current health status. Medical impressions, or simply impressions, are conclusions drawn from an interpretation of data. In this case, the physician interprets the data from the health history and physical examination and draws conclusions as to the patient’s state of health. Other terms for impressions include provisional diagnosis and tentative diagnosis.
Operative Report
An operative report (Figure 36-9) must be completed for all patients who have had a surgical procedure. This report describes the surgical procedure and must be completed and signed by the surgeon who performed the operation. The operative report must include the following:
• Patient identification information
• Date and location of the surgery
• Names of primary surgeon and assistants
• Name of the surgical procedure
• Full description of the findings at surgery (normal and abnormal)
• Description of the technique and procedures used during surgery
• Numbers of packs, drains, and sponges used
• Description of any specimens removed
• Condition of the patient at the completion of surgery
Discharge Summary Report
The discharge summary report is a brief (usually one-page) summary of the significant events of a patient’s hospitalization (Figure 36-10). The report must be completed and signed by the attending physician. The discharge summary report includes a concise account of the patient’s illness, course of treatment, and response to treatment, as well as the condition of the patient at the time of discharge from the hospital. The purpose of this report is to document information needed by the patient’s physician to provide for the continuity of future care. It also is used to respond to authorized requests for information regarding the patient’s hospitalization. The discharge summary report must include the following:
Pathology Report
A pathology report consists of a macroscopic (gross) and a microscopic description of tissue removed from a patient during surgery or a diagnostic procedure. The macroscopic description includes information about the size, shape, and appearance of the specimen as it appears to the naked eye. The report also includes a diagnosis of the patient’s condition (Figure 36-11). A pathologist is required to examine the tissue specimen, complete the report, and sign it.
Emergency Department Report
The emergency department report is a record of the significant information obtained during an emergency department visit (Figure 36-12). The report is prepared and signed by the emergency department physician, and a copy is sent to the patient’s family physician for the purpose of providing follow-up care. The emergency department report includes the following:
Consent Documents
Consent forms are legal documents required to perform certain procedures or to release information contained in the patient’s medical record.
Consent to Treatment Form
Completion of a consent to treatment form (Procedure 36-1) is required for all surgical operations and nonroutine therapeutic and diagnostic procedures (e.g., sigmoidoscopy) performed in the medical office. The form must be signed by the patient or his or her legally authorized representative and must provide written evidence that the patient agrees to the procedure or procedures listed on the form (Figure 36-13).
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