A lot goes into maintaining accurate and compliant medical records, from storing them for a certain period of time to ensuring that you’ve documented medical necessity in every file. And one factor that should never be left behind is ensuring that your medical records are legally compliant.

Check out seven Do’s and five Don’ts to follow to ensure that you’re compliant with the medical records regulations.

7 Medical Recordkeeping Do’s

1. DO record the patient’s identification (date of birth, name, medical record number) on each page of the chart and use a separate file for each family member. Although this makes sense on the surface, experts say charts are often intermingled between family members, particularly when a mother and baby are seeing the doctor.
2. DO record the complete date on each entry (dd/mm/yyyy). This is easier if you’re using an EMR, but for providers who write or dictate notes, the provider may add the date, but not the year — or may even forget the date or write the wrong one.
3. DO sign each entry with your name, title and credentials. This includes anyone who is providing services and documenting in the medical record. At some practices, the doctor signs medical records, but other staff members — such as X-ray technicians— actually performed the service. The X-ray technician should be signing notes for any services they perform.
4. DO review all pre-populated information and carry-over documentation — and then make updates — so you avoid accusations of cloned notes. Pre-populating information in your EMR might be convenient, but it can get you into legal trouble if you just carry over prior notes every time. Medical records should not all be identical, and things like the chief complaint, plan of care and other areas must always be unique.
5. DO write legibly and use only standard abbreviations. Providers who are writing notes should be sure that anyone reading them can comprehend them easily, without anyone’s assistance in trying to discern what they say. In addition, avoid using abbreviations that aren’t widely understood. For instance, “HPI” is well known as “history of present illness,” but if your practice often uses “RV” to mean “rhinovirus,” then that’s an abbreviation that should be avoided, since others reading it wouldn’t know what it meant.
6. DO ensure that notes entered by someone other than the provider are reviewed and approved by the provider. If someone else is putting information into the medical record for the provider, such as gathering details and entering them, the provider must review the information and approve it before signing the record. If a scribe is being used, they should have their own credentials and sign the record.
7. DO fill in any blanks, recording both negative and positive information. If you’re using a template and there are blanks, make sure that you are filling in all of those blanks, even if it’s just to note that an item isn’t applicable. You want to make sure that anyone reviewing your record wouldn’t assume you simply skipped an item accidentally.

5 Medical Records Don’ts

1. DON’T use white out, erase, or obliterate a chart entry in any way. Always cross out wrong information, and then date and initial that deletion, along with a note on why it was changed.
2. DON’T use subjective comments about a patient. Instead, quote the patient’s words and describe the patient’s behavior in an objective manner. For instance, instead of writing “Patient is difficult,” you might write, “Patient said she didn’t want to take the medication ‘because she is suspicious of pharmaceutical companies.’”
3. DON’T use names without describing their role in the patient’s future care. For instance, you might say, “I referred the patient to Dr. Jane Doe for allergy testing” instead of “referred patient to Dr. Jane Doe.”
4. DON’T criticize the care that the patient received from another provider. Instead of saying “Dr. Jones erroneously determined the patient had a spiral fracture but he was clearly wrong,” you might say, “The previous X-ray described a spiral fracture, but our radiologist’s interpretation indicates the patient has a simple fracture.”
5. DON’T lock down a chart before it has been checked for both accuracy and completeness (of all entries). Ensure that the chart is accurate, that the provider signed and dated it, and that you have confirmed the contents of it before sending the chart out to be billed.

Every medical record must be legally compliant if you want to avoid audits and fines. Healthcare attorney Amanda L. Waesch, Esq., can help during her online training, Protect Against Medical Documentation Errors, Audits and Fines. Register today!

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