My last article discussed the general organization and categories of information contained in a patient’s hospital chart. The contents are largely required by law. This article describes the sources of law which define the records that must be kept and the information those records must contain.
The laws, rules, and regulations describing the types of records a hospital must maintain are complex and come from several sources.
Arizona hospitals are licensed by The Arizona Department of Health Services and most are accredited by the Joint Commission on Hospital Accreditation (JCAHO). JCAHO prescribes categories of records and types of information each facility must maintain in each patient’s chart. JCAHO also describes how hospitals must aggregate and analyze the information in patient records. Those requirements are contained in the JCAHO Hospital Accreditation Standards and Statements of Intent, which it publishes annually. More specifically, the section on medical information systems addresses these issues.
The Arizona Administrative Code also requires hospitals to maintain specified records and information in patient records. Those regulations are contained in Sections R9-10-101 et. seq. and R9 – 10 – 201 of the code.
Medicare has regulations which apply to all hospitals where Medicare recipients receive care. See 42 CFR 482.1 et. seq., generally, and 42 CFR 482.24, more specifically. Collectively, these regulations are known as the Medicare conditions of participation.
Each institution has its own rules, regulations, policies and procedures for what must be included in a patient’s chart. These are frequently the result of work by a medical records committee which works with hospital employees and administrators to write rules about hospital records and monitor employee compliance with the record keeping rules.
Arizona has a statutory definition of an adequate medical record. ARS 32 – 1401 requires that records must support the diagnosis, justify the treatment and describe the patient response to the treatment with sufficient detail that a health care provider knowing nothing about the patient could assume the patient’s care if needed.
Anyone who has tried to read a hospital chart may be surprised to learn that writing legibly, using a legible signature and using a single line through to legibly correct any errors are near universal requirements. The chart allows providers who are present at different times to communicate with each other and the personal shorthand scribbles each provider adds to the chart can create confusion and cause miscommunication. Anyone wanting to improve their ability to read medical records might consider getting, Improving Your Chart Reading Skills, written by Malcolm Rosenberg, RN.
To complicate the problem, information about a patient’s hospital care may not all be in the patient’s chart.
For example, when a surgeon removes tissue from a patient, it is routinely sent to the pathology laboratory for analysis. If the surgeon is interested in a particular subject, a written question may be sent with the specimen. That written question may help us understand what was important to the surgeon at the time of surgery. That note might be on a scrap of paper, or it might be on a requisition form which the hospital pathology laboratory provides to the surgeons. In either case, it will almost never be in the patient’s chart. It may be in a working file in the pathology lab, but unless someone knows to ask for it from the pathologist or from the pathology laboratory, it will not come to light.
Many specialized services provided by hospitals for their patients are in fact provided by companies hired by the hospital to provide those services. The pathology lab may be owned and operated by ABC pathology. The radiology service may be provided by a group of radiologists who are employed by XYZ radiology. The same is true of the doctors in the emergency department. They all appear to be employees of the hospital, but they often are separate companies with their own records.
If the service to be performed is needed quickly, a preliminary result may be called from one specialist to another. There may not be a written record of the call in the patient’s chart. There may, however, be a short note of the call in the department or there may be a record of the time a call was made to the operating room if the time of the call becomes important.
If the time a patient required resuscitation becomes important, there will likely be a record of when the code team was paged. If the anesthesiologist on the code team was not present at the time, perhaps his billings or an intraoperative anesthesia note will explain why he was unavailable.
The best way to learn what records remain in the hospital but outside the patient chart is to work with someone who already knows and can help you clearly identify what you need to know.
The information in the patient’s chart and elsewhere in the hospital will almost always provide the information you need to evaluate your case realistically. Learning how to read and interpret it is time well spent.