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Medical Record Documentation

Responsibility

SME: Medical Director
Last Review Date: 6 /6/07

A complete, legible medical record on every patient admitted to UTHCPC must be under the oversight of an attending physician. See Legibility.

If a physician's resident records any medical report document, the attending physician must review and make corrections if necessary.

Requirements

The following are the documentation requirements:

Unacceptable abbreviations may not be used in the medical record

Written consent of a patient is required for release of information in his/her medical record.
Exception: Medical staff members such as Medical Staff Committee audit function or Service audit functions, Federal and State review agencies, the Joint Commissions on Accreditation of Hospitals can be authorized to review records.

The Medical Record is filed only when the attending physician completes required physician documentation, or if the Medical Records Committee orders it to be filed.

Multidisciplinary documentation must be completed within 14 days after the patient's discharge.

Removal

The medical records are the property of UTHCPC and may be removed from UTHCPC by court order, subpoena, or statute.

Unauthorized removal

Unauthorized removal of a medical record may result in disciplinary action, including termination of the employee.

Entries

The physician responsible for the patient must date and sign written physician entries in the medical chart at the time of entry. Physician must state in note they have seen the patient.

Documentation schedule

The following table describes the schedule for writing in the medical chart, and who is responsible for the documentation:

When due

Who

What

Within 24 hours of admission

Resident (if applicable) or attending physician

If the resident completes the IPE, the attending physician writes an admission note verifying the examination by the resident

IPE

Throughout stay

All staff as assigned

Progress notes

Attending physician or nurse for telephone orders

Physician's orders

Admission to end of 72 hours

Treatment team lead by attending physician

Master treatment plan (MTP)

Day of discharge

Resident (if applicable) or attending physician

Discharge summary

Attending physician

Attending discharge note

Day of discharge if stay <36 hours

Resident

Progress note (to include a statement about with which attending the case was discussed)

Attending physician

Writes a progress note

Writing requirements

All eligible staff must write legibly and apply the following requirements when writing in charts:

Writes in black ink
Exception: Nurses use red ink to write telephone orders, sign off physician orders and document patient allergies.

Writes each entry immediately following the previous entry without leaving any blank space between the entries

In case of error, draws a single line through the erroneous words and write the word ERROR above the entry followed by initials of the person making the error and correcting. Do not: Erase or use whiteout (liquid paper) in the medical record

Enters the actual date and time that the note and order is written on both the progress note and the order

Signs the legal name as shown in the employee roster and writes the license initials on every timed entry on every page s/he has written

Uses only the approved symbols and abbreviations when s/he writes in the medical record for progress noting
Exception: Does not use symbols or abbreviation in the final diagnosis or on the face sheet, unless the abbreviation is listed as a DSM-IV TR Plus diagnosis.
Physician order: Does not use drug abbreviation

Medical record inclusion

Every medical record must include the following:

Time

Required Documentation

Admission

An admitting diagnosis with valid reason for admission

General consent to admission and the attending physician diagnosis and treatment

Pertinent history and physical examination (H&P) for new admissions that must be recorded no later than 24 hours of admission

H&P prior admission: If a medical staff member of JCAHO accredited health care organization performed the H&P within the past 30 days, then a legible copy of it can be placed in the medical record.

Initial orders that are written at the time of admission

Treatment

Consent to Treatment with Psychoactive Medications form that the patient signs under the direction of the attending physician prior to treatment with psychoactive medications

Progress notes that the physician writes at the time of observations to permit continuity of care and transferability

Patient problems: The physician should clearly identify and correlate patient's clinical problems with specific orders and the results of tests and treatment.

Master Treatment Plan reviews as required.

Consultation reports that show the following:

The consultant pertinent findings on examination

The consultant opinion and recommendations

Reports of procedures, tests, and results

Example: Clinical laboratory reports, radiology and nuclear examinations, and other diagnostic and therapeutic procedures

Discharge

The discharge summary if required.

Related standards

The Joint Commission : Information Management, Medical Staff, Provision of Care

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Harris County Psychiatric Center University of Texas Health Science Center