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The Atlantic Provinces Medical Peer Review has printed a pamphlet, Adequate Medical Records, as an educational guide to medical record standards. Copies of this pamphlet, reprinted below, are available through our Moncton office.
For the Atlantic Provinces Medical Peer Review Program, the evaluation of patient records makes up a major portion of the assessment process. It is, therefore, essential for us to have some understanding of what our standards for patient records are - or should be - and for us to be able to communicate those standards to our assessors, the physicians being assessed, and others in our profession.
Many of us would agree that we "know a good medical record when we see it." If, however, we were asked to justify our positions, it would be difficult to articulate exactly what has shaped our opinions, and more difficult still to communicate the specifics to someone seeking guidance.
For an APMPR assessor to explain to a physician that he needs to be able to tell from a record: "why the patient came, what was found and what was done" is really only part of the story. We believe that an adequate patient record must also be an accurate reflection of the intellectual process which occurred during the office visit.
In an article from "Members' Dialogue", a publication of the Ontario College of Physicians & Surgeons, the four primary purposes served by a medical record are noted:
- It saves the physician time in recalling details of the patient's history, and allows the physician to monitor the progress of a patient's treatment.
- Colleagues and locums can use the record when called upon to treat the patient.
- It is useful for medical-legal reference, such as enabling the physician to provide a patient with a comprehensive report relating to an illness or injury. It can also help a physician called upon to present evidence in court.
- The record can be invaluable to the physician when responding to inquiries regarding the treatment of a patient from Medicare, a Provincial licensing authority , or in a legal action against the physician.
In "general", a patient record should stand on its own as a chronicle of patient history and care, providing the reader with an understanding of how and why certain decisions were made - the intellectual process noted above. The overall content of a quality record should provide a clear and accurate guide which will enable an incoming physician to assume the care of that patient without hesitation and without difficulty.
The "specific" contents of a quality record are harder to establish, although both regulatory bodies and Governments have determined certain basics which are either suggested, or - as in Ontario - form part of the regulations under the Health Disciplines Act.
Based on a compilation of data gathered by APMPR, the minimum information required would appear to be:
- the name, address, date of birth and sex of the patient
- the date of each visit in which the patient is seen
- an adequate patient history for each visit
- the particulars of each physical examination, including the positive and negative physical findings
- a diagnosis or provisional diagnosis
- investigation orders, and the results
- the treatment prescribed, any referrals made, and any plan of follow-up
Additionally, based on their experience with over 5000 assessments, the Ontario Peer Review Program recommends that:
- the identity of the patient be clearly evident on each component of the file hospital summaries, pathology
reports, operative notes, etc. should either be retained by the physician, or appropriate information
extracted and documented - a system ( such as initialling ) should be in place to ensure that all results of investigations, letters
from consultants and so on are seen by the physician before being filed
Our own APMPR assessors would also add the following:
- drug allergies should be clearly "flagged" on the file
- in the case of a pediatric patient, an updated pediatric growth chart is recommended
While it is not mandatory, APMPR supports and strongly recommends the use of Cumulative Patient Profiles (CPP's) and the Subjective Objective Assessment Plan ( SOAP ) format. It is our opinion that these represent the most appropriate way to document medical information in both general and specific terms.
And - none of the above will have any bearing at all if the record is not legible. Clearly handwritten, printed or typed notes are absolutely essential.