The medical record

The medical record serves many purposes but its primary function is to plan for patient care and to provide for continuity in information about the patient's medical treatment.

  

As a permanent record, the patient's medical record informs other health care providers both inside and outside the hospital about the medical history of the patient. In addition, the medical record:

• provides information which serves as the basis for financial reimbursement to hospitals, health care providers and patients;
  
  
• serves as a legal document for use by an injured patient against other parties or for use in other legal proceedings;
  
  
• is used by hospital quality assurance and peer review committees, State licensing agencies, State regulatory agencies, and other entities in accessing the quality of patient care by hospitals and health care providers;
  
  
• is a key portion of accreditation processes.
  
  
• can be used in clinical research (via retrospective review)
  

From the risk management perspective, the medical record is a crucial element in preventing and minimizing the potential adverse consequences of malpractice litigation. Ultimately, it serves as the basis for the defense of malpractice claims and lawsuits. Medical records which are poorly maintained, incomplete, inaccurate, illegible or altered, create questions of fact regarding the treatment given to a patient. Patient's attorneys often institute malpractice lawsuits when they believe the questions of fact created by incomplete and poorly documented medical records will cause a jury to find liability against a hospital and/or health care provider.

Proper documentation in the medical record creates a legal document which accurately and completely reflects the care provided to a patient and, in a courtroom setting, it may be likened to a witness whose memory is never lost. It serves to correlate, for all involved, important patient information regarding the treatment rendered and the patient's treatment plan, and is the means by which a level of communication is achieved among all health care providers involved in the patient's care.