Documentation of patient care: an often underestimated responsibility.

Abstract

There is increasing societal concern about retention and retrieval of information about individuals; advances in technology have enlarged the means for storing and communicating personal information. Not surprisingly, some of this concern is directed toward medical records. Questions have arisen about ownership of and access to medical records, as well as their content. This column focuses solely on some basic issues pertaining to the content of medical records.Information in a patient's medical record can be used as a basis for decisions concerning his insurance coverage or payments, employment, eligibility for educational or benefit programs, or the outcome of a lawsuit. Thus, the law generally recognizes the patient's right to control the access to his medical record by third parties.Because of the permanence and potential importance of a patient's medical record, health professionals frequently raise questions about what to include in the record, who should write in a patient's chart, where and how to make corrections, and how to document specific problems such as patient injury or concerns about the quality of care the patient is receiving.