One of the most important issues facing physician practices relates to the documentation of treatment/services. Often, medical record documentation is the best defense in liability suites. Medical records are used to: indentify the provider and the location of services provided; determine medical necessity; and claim accuracy.
According to the Kansas Board of Healing Arts K.A.R. 100-24-1, the medical record should, at minimum:
- Be legible
- Contain only those terms and abbreviations that are or should be comprehensible to similar licensees
- Contain adequate identification of the patient
- Indicate the dates any professional service was provided
- Contain pertinent and significant information concerning the patient's condition
- Reflect what examinations, vital signs, and tests were obtained, performed, or ordered and the findings and results of each
- Indicate the initial diagnosis and the patient's initial reason for seeking the licensee's services
- Indicate the medications prescribed, dispensed, or administered and the quantity and strength of each
- Reflect the treatment performed or recommended
- Document the patient's progress during the course of treatment provided by the licensee
- Include all patient records received from other health care providers, if those records formed the basis for a treatment decision by the licensee
- Each entry shall be authenticated by the person making the entry unless the entire patient record is maintained in the licensee's own handwriting
- Each patient record shall include any writing intended to be a final record, but shall not require the maintenance of rough drafts, notes, other writings, or recordings once this information is converted to final form. The final form shall accurately reflect the care and services rendered to the patient.
For purposes of implementing the healing arts act and this regulation, an electronic patient record shall be deemed a written patient record if the electronic record is authenticated by the licensee.
A hospital’s patient record, K.A.R. 28-34-9a, requires sufficient information to identify the patient clearly, justify the diagnosis and treatment, and document the results accurately. Each record, at minimum shall include:
- Notes by authorized hospital staff and individuals who have been granted clinical privileges, consultation reports, nurses’ notes, and entries by designated professional personnel
- Findings, and results of any pathological or clinical laboratory examinations, radiology examinations, medical and surgical treatment and other diagnostic or therapeutic procedures
- Provisional diagnosis, primary and secondary final diagnosis, a clinical resume and where appropriate necropsy reports.
- Each entry in each record shall be dated and authenticated by the person making the entry.
- Verbal orders, including telephone orders, should include the date and signature of the person recording them. The prescribing or covering practitioner should authenticate the order within seventy-two (72) hours of the patient’s discharge or thirty (30) days, whichever occurs first. Records of patients discharged should be completed within thirty (30) days following discharge.