Principles of Medical Record Documentation

2011; Issue 4

All Articles

The medical record has many purposes, for instance: it serves as a communication tool for a wide variety of players; it chronologically documents the plan of care for the patient; and aids the doctor in the defense of a medical liability claim. Regardless of whether you are using paper or electronic medical records the following principles apply.

General Principles of Medical Record Documentation:

  • Medical records should be complete and legible.
  • Documentation of each patient encounter should include:
    • Reason for encounter and relevant history.
    • Appropriate history and physical exam in relationship to the patient's chief complaint.
    • Review of lab, x-ray data and other ancillary services, where appropriate.
    • Assessment, clinical impression, diagnosis and plan for care.
    • Past and present diagnoses should be accessible to the treating and/or consulting physician.
    • The reasons for and results of x-rays, lab tests, and other services should be documented or included in the medical record.
    • Relevant health risk factors should be identified.
    • The patient's progress, including treatment, change in treatment, change in diagnosis and patient non-compliance should be documented.
  • The written plan of care should include:
    • Treatments and medications.
    • Referrals and consultations.
    • Patient/family education.
    • Specific instructions for follow-up.
  • Documentation should support the intensity of the patient evaluation and/or treatment.
  • All entries should be dated and authenticated.
  • All patient contacts need to be documented in the medical record. This includes:
    • Scheduled appointments.
    • Office visits.
    • Missed appointments.
    • No-show appointments.
    • Telephone conversations.
    • Patients calling with any clinically relevant information.
    • Prescriptions refills.
    • Advice or instructions given.
Upon a written request of a patient, his attorney or authorized representative, or pursuant to a written authorization, a provider shall furnish to the person making such request a copy of the patient's health record, including but not limited to, bills, x-rays and copies of laboratory reports, prescriptions and other technical information used in assessing the patient's health condition. (CGS 20-7c(c))

The provider must supply the health record within the 30 days of request. (CGS 20-7c(c))

When can a provider withhold this information?
By law, a provider can withhold medical information from a patient if he reasonably determines that the information would be detrimental to the patient's physical or mental health or would likely cause the patient to harm himself or someone else. In such a case, the provider can supply the information to an appropriate third party, or another provider, who can release it to the patient. (CGS 20-7c(d))

Is there a cost to obtain medical records?
A provider can charge up to 65 cents per page, including any research fees, handling fees or related costs, and the cost of first class postage, if applicable, to furnish the patient's health record. Also, the provider can charge a patient the amount necessary to cover the costs of materials for providing a copy of an x-ray. (CGS 20-7c(c))
A provider cannot charge for supplying a health record if the person documents that it is necessary to support a Social Security claim or appeal. (CGS 20-7c(c))

Can a patient's medical record be released to another provider?
If the patient asks in writing, a provider must furnish a copy of the patient's health record to another provider. This includes x-rays and copies of lab reports, prescriptions, and other technical information used in assessing the patient's condition. The written request must specify the name of the provider who is to receive the record. The patient is responsible for the reasonable costs of providing the information. (CGS 20-7d)

What happens when a health care provider dies or retires?
A provider who terminates a practice (or his executor or responsible relative in the case of death) must inform patients by notice published in a local newspaper and a letter sent to each patient within the past three years before the date the practice was discontinued. The patients' medical records must be kept for 60 days after the notice. Sec.19a-14-44

Medical Record Retention Schedule
The Connecticut Public Health Code (Sec. 19a-14-42) states, "medical records, pathology slides, EEG and ECG tracings are to be retained for a period of seven (7) years from the last date of treatment. In the event of death of the patient, the medical record is to be retained for a period of three (3) years. Lab reports and PKU reports must be kept for at least five (5) years. X-ray films must be kept for a period of three (3) years." Those records that may, in your estimation, become part of a legal action should be maintained for as long as possible.

Sec 19a-14-43 Exceptions. "Nothing in these regulations shall prevent a practitioner from retaining records longer that the prescribed minimum. When medical records for a patient are retained by a health care facility or organization, the individual practitioner shall not be required to maintain duplicate records and the retention schedules of the facility or organization shall apply to the records. If a claim of malpractice, unprofessional conduct, or negligence with respect to a particular patient has been made, or if litigation has been commenced, then all records for that patient must be retained until the matter is resolved. A consulting health care provider need not retain records if they are sent to the referring provider, who must retain them. If a patient requests his records to be transferred to another provider who then becomes the primary provider to the patient, then the first provider is no longer required to retain that patient's records."


Do patients have access to their medical records?
Yes. Physicians must provide patients with a copy of their medical records upon the patient's request. Records can be requested by a patient, the patient's parent (if a minor) or legal guardian, or, with patient authorization, by another physician or any person authorized by the patient.
Patients are entitled to a copy of their complete records, including records transferred from previous physicians. The health provider must supply the health record within the 30 days of request.

Is there a cost to obtain medical records?
Physicians may charge for the cost of copying and providing medical records, but the rate must be reasonable. G.L. c. 111 § 70

A reasonable rate is no more than:

$15.00 per request; $0.50 per page for the first 100 pages; and $0.25 per page for every page over 100; Actual cost for postage; and Actual cost for the copying of x-rays and other records not reproducible by ordinary photocopying. Providers may charge one fee for the entire record. The flat fee may be more than $15.00 so long as it is not greater that the per-page cost.

A provider cannot charge for supplying a health record if the person documents that it is necessary to support a Social Security claim or appeal. G.L. c. 111 § 70 and 243 CMR 2.07 (13) (d)

Medical Record Retention Schedule
Physicians must maintain patient records for a minimum of seven years from the date of the last patient encounter or until the former patient reaches age nine. Medical records must be kept in a manner that permits the patient or a successor physician access to the records. 243 CMR 2.07 (13)(a)
A retiring physician, his successor, or the estate of a deceased physician must maintain patient records for seven years from the date of the last patient encounter.

For more information CLICK HERE.

New Hampshire

Do patients have access to their medical records?
Yes, STATE LAW, RSA 332-I, allows patients to obtain a copy of their medical records for a limited charge. A physician is required to release the medical record within 30 days from the receipt of the signed release from the patient. In the case of a medical emergency, the record should be provided as soon as possible.

RSA 332-I states the following:

"All medical information contained in the medical records in the possession of any health care provider shall be deemed to be the property of the patient. The patient shall be entitled to a copy of such records upon request. The charge for the copying of a patient's medical records shall not exceed $15 for the first 30 pages or $.50 per page, whichever is greater; provided that copies of filmed records such as radiograms, x-rays, and sonograms shall be copied at a reasonable cost." The licensee may charge the actual cost of duplication for X-rays or other color photographs.

Medical Record Retention Schedule
NEW HAMPSHIRE BOARD OF MEDICINE RULES state that a licensee shall retain a copy of all patient medical records for at least 7 years from the date of the patient's last contact with the licensee, unless, before that date, the patient has requested that the file be transferred to another health care provider.

For more information CLICK HERE.