18 Nov Medical Record Documentation Standards: Best Practices

Medical Record Documentation Standards: Best Practices

Maintaining clear, accurate, and up-to-date medical records is essential to facilitating high-quality patient care. Proper documentation also simplifies treatment for future physicians, helps insurers expedite claims, ensures services are billed correctly, and maintains healthcare providers’ legal defensibility.

However, different healthcare providers can have varying approaches to recordkeeping. This is why medical record documentation standards are a must across clinic, hospital, and telehealth settings.

From upholding data accuracy to ensuring compliance, these widely accepted standards are the key to maintaining useful, accurate, and legally-compliant medical records.

What Are Medical Record Documentation Standards?

Medical record documentation standards are the common regulations that guide how physicians, clinics, and providers collect and keep patient information. They outline what data to note during clinical visits, how to add it to medical records, and what it communicates to future providers working with a given patient.

Documentation standards ultimately give healthcare providers a framework to work from when assessing patient conditions. While providing care, they can lean on preset documentation guidelines to ensure their reporting is:

• Accurate – Accuracy is the law when submitting claims to publicly-funded healthcare programs including Medicare and Medicaid. Accuracy not only ensures legal defensibility but also helps other providers understand patient conditions, expedites clinical services, and improves the quality of care. 

• Consistent – Different physicians may have varying ideas of what information is relevant, how much to report about a specific issue, and how to document an observation. Documentation standards uphold reporting consistency across providers, physicians, and patients. 

• Legally defensible – Failing to properly document key patient data is more than just unprofessional medical practice—it’s a major deviation from (and potential breach of) commonly held standards of care. Following established documentation standards gives providers a steady legal defense if their reporting is called into question.

Medical record documentation standards are the purview of a variety of national, state, and private organizations. On a federal level, standards are set by agencies like the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission, a national nonprofit that monitors and assesses healthcare practice, accreditation, and reporting. 

Like all other aspects of healthcare, the Health Insurance Portability and Accountability Act (HIPAA) also governs medical record documentation. 

Core Elements of Proper Documentation

Exact reporting standards can vary by state and even differ within specific state-run programs. Regardless, the CMS, HIPAA, Joint Commission, and other governing bodies offer consistent guidance for medical documentation, including:

• Patient identification – Every page of a patient’s medical record should include their full name or identification number.

• Provider notes – Providers should note all significant illnesses and medical conditions on the record. They should also list medication allergies and adverse reactions or, if none are known, indicate so. Past medical history should be easily identified and understood from consulting a patient’s record.

• Timelines – Attending physicians should note the advice and potential outcomes they provide the patient, including timelines for follow-up care, calls, or visits.

• Signatures – All entries into a patient’s medical records must contain the author’s identification. This can be a handwritten signature, unique identification number, or initials. 

• Legibility – The record must be legible to someone other than the writer. Misunderstanding documentation can lead to improper treatment, potentially harming the patient and reducing their quality of care.

• Chronological order – All entries to a patient’s medical record must be dated. Documentation should also be kept in chronological order to expedite clinical understanding and provide care based on the most recent, accurate assessments of the patient’s health. 

These standards apply whether records are kept physically on paper files or digitally in the form of Electronic Health Records (EHRs) and Electronic Medical Records (EMRs). When using digital records, it’s also important to: 

• Turn off auto-fill and keyword features that may lead to inaccurate reporting

• Ensure each note is individually timestamped, even if it’s in the same continuous document as other clinical visits

• Initial or otherwise identify the editor each time the patient’s record is altered

While most healthcare providers follow some form of these rules, there are still a few commonly made mistakes during medical record documentation. 

Common Documentation Errors and Their Consequences

The most pervasive mistakes facing medical record documentation include:

• Incomplete notes – Attending Physician Statements (APSs) should detail all the symptoms and conditions the patient presents, rather than just their primary complaint. Incomplete notes can lead to misunderstandings, misdiagnoses, and improper treatment.

• Missing signatures – Without a signature accompanying reports, future providers won’t know who to consult for explication or clarification of a patient’s records.

• Inaccurate dates – Mislabelled dates can lead to misunderstanding about a patient’s progress with a specific illness or condition.

These and other errors deviate from generally accepted medical documentation standards. They can also lead to issues with:

• Billing – Incomplete notes may not accurately represent a patient’s health status or capture all of the clinical procedures the attending physician performs. This may lead to billable items being left off the final statement or hold-ups in insurance approvals as providers seek clarification on patient conditions. 

• Legal cases – In legal cases that require medical proof, incomplete, improperly dated, or inaccurate records can disqualify documentation from meeting evidentiary standards. 

• Compliance – Improper documentation can defy CMS and HIPAA standards, and failure to comply with these guidelines can result in a $50,000 penalty per violation with an annual maximum penalty of $1.5 million.

Alongside fines, improper documentation also risks malpractice and the ensuing legal consequences. It can also lead to claim denial, as insurers may not deem a procedure as medical necessity without a full picture of the patient’s health. 

Industry Regulations and Compliance Requirements

As noted, the CMS is the governing body responsible for overarching documentation standards, and HIPAA is the key piece of legislation guiding medical practice. Together with state laws, they cover most of the guidelines mentioned above while also outlining key expectations for data security and privacy, including:

• Data usage authorization – Healthcare providers and other entities must obtain explicit permission to utilize a patient’s medical data in any form other than for treatment, payment, and healthcare operations.

• The disclosure of Protected Health Information (PHI) – PHI is the privilege of the patient and their care providers. It’s only to be shared with patient consent, due to legal orders, or under other specific circumstances. Otherwise, sharing medical documentation—including patient reports—is subject to criminal and civil charges.

• The safeguarding of PHI – Alongside willful disclosure, HIPAA also covers accidental releases of PHI via data breaches and other causes. Following unauthorized access to medical records, affected patients and the Secretary of breaches must be notified. If more than 500 individuals are affected, the media must also be notified.

Despite HIPAA’s privacy mandates, there are instances where healthcare providers, insurers, or lawyers need to access a patient’s medical records. In such situations, they can file a retrieval request and, if approved, gain access to the information they need.

How Retrieval Partners Support Compliance

Using medical records retrieval solutions, rather than requesting EHRs and EMRs on your own, helps and HIPAA compliance. That’s because trustworthy medical record retrieval services offer compliant request management portals to prevent accidental violations of established regulations. 

In addition, compliant requests often require follow-ups, form submissions, and a record of transferred documents. All this takes time away from your primary operations, making a retrieval partner essential for:

• Medical record retrieval for lawyers – Retrieval partners deliver records to evidentiary standards with the ability to search by date or keyword, reducing the administrative burden on legal firms and improving their ability to efficiently review documentation.

• Medical record retrieval for insurance companies – Retrieval partners expedite the request process, allowing claims to move more quickly toward underwriting and assessment. This efficiency also expedites clinical care and helps providers achieve faster, more favorable patient outcomes. 

• Medical record retrieval for healthcare organizations – Healthcare organizations need patient information as soon as possible, but often don’t have the time to deal with complex retrieval requests and drawn-out follow-ups. Retrieval services leverage their close relationships with large national providers to expedite record requests, allowing healthcare providers to access EHRs and EMRs sooner.

In addition, working with a retrieval partner enhances record accuracy by ensuring the right documents reach the approved parties as they’re needed. 

Setting the Standard for Documentation Excellence

Medical record documentation standards require physicians to keep complete, consistent, accurate, and legible notes. Each page should be organized in chronological order and include both patient and physician identifiers. Maintaining properly documented medical records in this way improves care quality, helps future physicians understand patient conditions, and ensures a provider’s legal defensibility.

Just as medical documentation needs to be legally compliant, so too do record access requests. Fortunately, American Retrieval provides standards-based records access for lawyers, insurers, and healthcare organizations alike. With strict adherence to HIPAA and close industry connections, we ensure speedy, secure access that aligns with federal, state, and local regulations. And with over 30 years of experience, we’re the most trusted partner in the industry.

Contact American Retrieval today to learn more about what a partnership could look like.

Sources: 

Centers for Medicare and Medicaid Services. Medicaid Documentation for Medical Professionals. https://www.cms.gov/medicare-medicaid-coordination/fraud-prevention/medicaid-integrity-education/downloads/docmatters-medicalprof-factsheet.pdf. 

National Library of Health. Fundamentals of Medical Record Documentation. https://pmc.ncbi.nlm.nih.gov/articles/PMC3010959/. 

National Committee for Quality Assurance. Guidelines for Medical Record Documentation. https://wpcdn.ncqa.org/www-prod/wp-content/uploads/2018/07/20180110_Guidelines_Medical_Record_Documentation.pdf. 

American Medical Association. HIPAA violations & enforcement. https://www.ama-assn.org/practice-management/hipaa/hipaa-violations-enforcement. 

United States Department of Health and Human Services. Summary of the HIPAA Privacy Rule. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html.