3 Key Aspects of Medical Records and Documentation

Medical records and documentation play an important role in the delivery of healthcare and serve a critical function in routine clinical operations. Essential details of the record include a patient’s medical and social history, comorbidities, drug allergies, presenting complaints, signs, and symptoms derived from a careful physical examination, differential diagnoses, and treatment plan.

Accurate documentation in the medical record optimizes patient well-being and helps promote continuity of care and patient satisfaction. Federal and state regulations like HIPAA and the Affordable Care Act, address virtually every facet of health record content, security, storage, access, and disposal. Though medical records and documentation have huge scope, in this article, we covered 3 key aspects of them.

Retaining Medical Records

Retaining well-maintained patient records helps physicians ensure continuity of care and protect against any future professional liability claims. The availability of accurate records also provides protection against licensing board complaints and peer review inquiries and can help when responding to investigations by governmental compliance agencies. The potential for billing audits by the Centers for Medicare and Medicaid Services (CMS) or commercial third-party payers provides further motivation to create and store complete documentation.

The Centers for Medicare and Medicaid Services (CMS) and other governmental entities have policies on storing and retaining records. Federal legislation, such as the HITECH Act, has added another dimension to retention requirements.

Professional Liability Actions

The medical record including specialty referrals, progress notes, and laboratory results is usually the key evidence in a professional liability action. The record is critical in helping the provider recall events that might have occurred years earlier. It is an independent document that establishes facts at a time when there was no pending conflict or other motivation to shade or otherwise embellish the circumstances at issue.

In the event of civil litigation, the medical record is considered reliable and credible because it was created during the normal course of business by the physician, hospital, advanced practice provider, or clinic personnel at or near the time of the event in question. Judges and juries generally regard medical records as the most trustworthy and probative piece of evidence.

When introduced as independent documentary evidence, a well-documented medical record is a powerful defense to offset patient allegations that a physician was negligent in making medical decisions and providing treatment.


Upon receiving notice that a malpractice suit is about to commence or has already been filed, physicians must ensure the safety and integrity of the patient’s medical record. Any changes made to the medical record after learning of a lawsuit raise questions about the provider’s truthfulness, motives, and the quality of the medical care. Forensic document experts are frequently called to testify that a paper record has been augmented or altered. In situations in which a practitioner has an EHR, counsel will retain information technology experts to conduct a metadata audit.

The audit provides a complete analysis of every keystroke (including additions, deletions, and changes) and when the entries were made, by whom, and how long a document was open for review and revision. Changes to either a paper record or an EHR—including corrections, deletions, late entries, and addenda, are readily discoverable, patently obvious, and usually deleterious to a successful defense. If experts discover that the medical record has been altered, it can also expose the physician to punitive damages and result in a medical board investigation.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. We keep on sharing billing, coding, documentation guidelines, and updates for provider education. In this article, we shared the excerpt of ‘The Defensible Medical Record’ just for reference. If you are looking for any assistance in medical billing for your practice, contact us at info@medicalbillersandcoders.com/ 888-357-3226

Published By - Medical Billers and Coders
Published Date - Apr-25-2022 Back

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