A health record must be maintained for every individual who is assessed or treated. Although Edna Huffman’s classic Health Information Management1 book is no longer in print, her definition of the purpose and use of a health record still holds true today. She states, “The main purpose of the medical record is to accurately and adequately document a patient’s life and health history, including past and present illnesses and treatments, with emphasis on the events affecting the patient during the current episode of care.” Huffman goes on to say, “The medical record must be compiled in a timely manner and contain sufficient data to identify the patient, support the diagnosis or reason for health care encounter, justify the treatment and accurately document the results.” According to Abdelhak’s Health Information: Management of a Strategic Resource,² the health record serves five purposes:

1. Describes the patient’s health history

2. Serves as a method for clinicians to communicate regarding the plan of care for the patients

3. Serves as a legal document of care and services provided

4. Serves as a source of data

5. Serves as a resource for healthcare practitioner education

The patient’s health record in today’s environment may be maintained in several formats or hybrids. The traditional health record consists of documentation on paper prepared by healthcare providers that describes the condition of the patient and the plan and course of treatment. As the world advances through electronic forms of documentation, paper notes become more and more obsolete. Most health records are currently in a state of transition. Some paper documentation and some transcribed or electronically stored documentation may be available. Some facilities have actually achieved a predominantly electronic health record. One of the advantages of storing the record electronically is that many users are able to access the record at the same time. Whether in electronic, paper, or hybrid form, documentation serves as the basis of a health record.

The Centers for Medicare and Medicaid Services (CMS) has provided physicians with General Principles of Medical Record Documentation.3

Medical records should be complete and legible

The documentation of each patient encounter should include:

• Reason for encounter and relevant history

• Physical examination findings and prior diagnostic test results

• Assessment, clinical impression, and diagnosis

• Plan for care

Date and legible identity of the observer

The rationale for ordering diagnostic and ancillary services (if not documented, should be easily inferred)

Past and present diagnoses should be accessible for treating and/or consulting physician

Appropriate health risk factors should be identified

Patient’s progress, response to changes in treatment, and revision of diagnosis should be documented

Current Procedural Terminology (CPT) and International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes reported on health insurance claim forms should be supported by documentation in the medical record

Sections of the Health Record

Every facility has its own policies and procedures regarding the organization of the health record. Records will differ slightly depending upon the course of the patient’s condition and treatment. If a record were to be organized similarly to a novel that tells a story, the elements discussed in the next sections would be included.

See Figure 2-3 for an example of a history and physical form (H&P).

Physician Orders

This is the area of the record in which the attending physician, as well as physician consultants, gives directives to the house staff and to nursing and ancillary services. Physician orders are dated, timed, and signed and become part of the record. Verbal orders by physicians are guided by medical staff regulations. See Figure 2-4 for an example of handwritten physician orders and Figure 2-5 for an electronic physician order.

Progress Notes

Progress notes are a record of the course of a patient’s hospital care. They are usually written by the attending physician (Figure 2-6, A). Academic medical centers may have notes written by medical students, interns, and residents, as well as attending physicians and consultants. Some facilities have integrated progress notes, which allow individuals from several disciplines to write in the same area of the record. An integrated progress note may include notes written by dietitians, physical therapists, respiratory therapists, and nurses.

Progress notes written by the attending physician are recorded on a daily basis; the frequency of such note taking is governed by medical staff regulations. These notes describe how the patient is progressing and put forth the plan of care for the patient. In an electronic patient record, these notes may be dictated and transcribed or typed by physicians themselves. Physicians are usually taught to document progress notes according to the SOAP format. SOAP stands for the following: