A medical chart is a confidential document that contains detailed and comprehensive information on an individual and the care experience related to that person.
The purpose of a medical chart is to serve as both a medical and legal record of an individual's clinical status, care, history, and caregiver involvement. The specific information contained in the chart is intended to provide a record of a person's clinical condition by detailing diagnoses, treatments, tests and responses to treatment, as well as any other factors that may affect the person's health or clinical state.
Every person who has a professional relationship with a health-care provider has a medical record. Because most people have such relationships with more than one health professional or caregiver, most people actually have more than one medical chart.
The terms medical chart or medical record are a general description of a collection of information on a person. However, different clinical settings and systems utilize different forms of documentation to achieve this purpose. As technology progresses, more institutions are adopting computerized systems that aid in clearer documentation, enhanced access and searching, and more efficient storage and retrieval of individual records.
New uses of technology have also raised concerns about confidentiality. Confidentiality, or personal privacy, is an important principle related to the chart. Whatever system may be in place, it is essential that the health care provider protect an individual's privacy by limiting access only to authorized individuals. Generally, physicians and nurses write most frequently in the chart. Documentation by the clinician who is leading treatment decisions (usually a physician) often focuses on diagnosis and prognosis, while the documentation by members of the nursing team generally focuses on individual responses to treatment and details of day-to-day progress. In many institutions, the medical and nursing staff may complete separate forms or areas of the chart specific to their disciplines.
Other health-care professionals that have access to the chart include physician assistants; social workers; psychologists; nutritionists; physical, occupational, speech, or respiratory therapists; and consultants. It is important that the various disciplines view the notes written by other specialties in order to form a complete picture of a person and provide continuity of care. Quality assurance and regulatory organizations, legal bodies, and insurance companies may also have access to the chart for specific purposes such as documentation, institutional audits, legal proceedings, or verification of information for care reimbursement. It is important to know about institutional policies regarding chart access in order to ensure the privacy of personal records.
The medical record should be stored in a pre-designated, secure area and discussed only in appropriate and private clinical areas. All individuals have a right to view and obtain copies of their own records. Special state statutes may cover especially sensitive information such as psychiatric, communicable disease (i.e., HIV), or substance abuse records. Institutional and government policies govern what is contained in the chart, how it is documented, who has access, and policies for regulating access to the chart and protecting its integrity and confidentiality. In those cases in which individuals outside of the immediate care system must access chart contents, an individual or personal representative is asked to provide permission before records can be released. Individuals are often asked to sign these releases so that caregivers in new clinical settings may review their charts.
Thorough training is essential prior to independent use of the medical chart. Whenever possible, a new clinician should spend time reviewing the chart to get a sense of organization and documentation format and style. Training programs for health care professionals often include practice in writing notes or flow charts in mock medical records. Notes by trainees are often initially cosigned by supervisors to ensure accurate and relevant documentation and document-appropriate supervision.
Documentation in the medical record begins when an individual enters the care system, which may be a specific place such as a hospital or professional office, or a program such as a home health-care service. Frequently, a facility will request permission to obtain copies of previous records so that they have complete information on the person. Although chart systems vary from institution to institution, there are many aspects of the chart that are universal. Frequently used chart sections include the following:
These general categories may be further divided by individual facilities for their own purposes. For example, a psychiatric facility may use a special section for psychometric testing, or a hospital may provide sections specifically for operations, x ray reports, or electrocardiograms. In addition, certain details such as allergies or do not resuscitate orders may be displayed prominently (for instance, with large colored stickers or special chart sections) on the chart in order to communicate uniquely important information. It is important for health care providers to become familiar with the charting systems in place at their specific facilities or programs.
It is important that the information in the chart be clear and concise, so that those utilizing the record can easily access accurate information. The medical chart can also aid in clinical problem solving by tracking an individual's baseline, or status on admission or entry into an office or health care system; orders and treatments provided in response to specific problems; and individual responses. Another reason for the standard of clear documentation is the possibility that the record may be used in legal proceedings, when documentation serves as evidence in exploring and evaluating a person's care experience. When medical care is being referred to or questioned by the legal system, chart contents are frequently cited in court. For all of these purposes, certain practices that protect the integrity of the chart and provide essential information are recommended for adding information and maintaining the chart. These practices include the following:
Several methods of documentation have arisen in response to the need to accurately summarize a person's experience. In the critical care setting, flow records are often used to track frequent personal evaluations, checks of equipment, and changes of equipment settings that are required. Flow records also offer the advantages of displaying a large amount of information in a relatively small space and allowing for quick comparisons. Flow records can also save time for a busy clinician by allowing for the completion of checklists versus requiring written narrative notes.
Narrative progress notes, while more time consuming, are often the best way to capture specific information about an individual. Some institutions require only charting by exception (CBE), which requires notes only for significant or unusual findings. While this method may decrease repetition and lower required documentation time, most institutions that use CBE notes also require a separate flow record that documents regular contact with a person. Many facilities or programs require notes at regular intervals even when there is no significant occurrence, i.e., every nursing shift. Frequently used formats in individual notes include SOAP (subjective, objective, assessment, plan) notes. SOAP notes use an individual's subjective statement to capture an important aspect of care, follow with a key objective statement regarding the person's status, a description of the clinical assessment, and a plan for how to address individual problems or concerns. Focus charting and PIE (problem-intervention-evaluation) charting use similar systems of notes that begin with a particular focus such as a nursing diagnosis or an individual concern. Nursing diagnoses are often used as guides to nursing care by focusing on individual care-recipient needs and responses to treatment. An example of a nursing diagnosis is fluid volume for someone who is dehydrated. The notes would then focus on assessment for dehydration, interventions to address the problem, and a plan for continued care such as measurement of input and output and intravenous therapy.
Current medical charts are maintained by members of the health care team and usually require clerical assistance such as a unit clerk in the hospital setting or records clerk in a professional office. No alterations should be made to the record unless they are required to clarify or correct information and are clearly marked as such. After discharge, the medical records department of a facility checks for completeness and retains the record. Similar checks may be made in professional office settings. Sometimes, the record will be made available in another format, i.e., recording paper charts on microfilm or computer imaging. Institutional policies and state laws govern storage of charts on- and off-site and length of storage time required.
A major potential risk associated with medical charts is breach of confidentiality. This must be safeguarded at all times. Other risks include loss of materials in a chart or incorrectly filing a chart so that subsequent retrieval is impeded or impossible.
All members of a health-care team require thorough understanding of the medical chart and documentation guidelines in order to provide competent care and maintain a clear, concise, and pertinent record. Health-care systems often employ methods to guarantee thorough and continuous use and review of charts across disciplines. For example, nursing staff may be required to sign below every new physician order to indicate that this information has been communicated, or internal quality assurance teams may study groups of charts to determine trends in missing or unclear documentation. In legal settings, health care team members may be called upon to interpret or explain chart notations as they relate to a specific legal case.
Medical charts are made of paper or other materials. They are subject to deterioration or loss. Transporting them may cause lifting injuries, but not lead to disease or death.
There are no alternatives for medical charts. Alternative mediums exist for paper records. These include fixing images on plastic media (photographs or x rays) or electronic storage. The latter can include magnetic tape or computer disks.
See also Health history ; Physical examination ; Talking to the doctor .
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L. Fleming Fallon, Jr, MD, DrPH
All members of a health-care team or individuals who render professional health-care services usually make entries into medical records. Healthcare records are maintained in hospitals or other clinical settings and professional offices. Insurance companies and corporations may maintain limited health-care records or obtain copies of records created by other health-care providers.