University of Michigan Hospitals and Health Centers
Medical Record Requirements & Documentation Standards

Overview

• Medical Record – repository of information about the patient's life and health history, past and present illness, and all care and treatments provided/used in the care of the patient.
• Any information documented in any manner (dictated, created on-line, via email, written on paper, etc.) about the treatment of a patient constitutes the medical record, must be accessible to all care providers no matter where the care is provided or by what specialty.
• Components of the medical record:
• CareWeb – online record
• Problem Summary List (diagnoses, procedures, medications, allergies, health maintenance)
• Patient Demographics
• Documents (clinician dictations/documentation of care)
• Lab Results
• Rad/Nuc Results
• Other Results (EKG reports and tracings, Pulmonary Function Tests)
• Immunization Record
• Inpatient Medication Profile
• ED/OR/TB (Emergency, Anesthesia, Trauma Burn)
• Continuity (Growth Chart)
• Legal and Consents
• Create Document
• Discharge Navigator
• Results In-Box (OP Test Results)
• Notifications In-Box (Documents for review and signature)
• WatchChild/TraceView – OB Prenatal online record
• Paper record – paper documents not online.
• Microfilmed records – patient care provided prior to 1995.

Note: A list of all medical record document types and indication as to whether they are paper or electronic is maintained in CareWeb/Clinical Home Page, under References, Medical Records, “Medical Records Content and Location”.

• Additional purposes of the medical record;
• Supports reimbursement
• Provides data for benchmarking, outcomes research, and public health purposes
• Resource for healthcare practitioner education
• Document evidence of quality of patient care
• Serve as a legal business record

ACCESS TO A PATIENT'S MEDICAL RECORD

• Anyone who accesses a medical record (paper and electronic) should only do so because it is necessary for treatment, payment, and operations.
• It is not appropriate to look up friends, coworkers or a relative's information unless the subject has signed a release for the access.
• CareWeb maintains audit trails of all activity.
• Audits of who accessed what are done via patient request or according to a proactive audit policy and protocols.
• Inappropriate access may result in disciplinary action up to and including discharge.
• All paper records must remain on site and accessible to care providers.
• If a patient, parent, spouse, family member, attorney, outside caregiver, etc. requests information from a patient's record, refer them to Medical Information Services who handle all requests for release of medical information.

Medical Record Rules and Regulations

• Rules for the Medical Record come from Federal and State Laws, Regulatory Agencies, Third Party Payors, Institutional Policies, and Medical Staff By-Laws.
• Any medical information produced as a result of assessment and/or treatment of a patient within the UMHHC, or by faculty and other health care professionals operating as an agent of the UMHHC, must be made part of the UMHHC medical record and must meet all the associated laws, requirements, standards, and policies for medical records.
• UMHS/UMHHC Key Medical Record Policies:
• 03-09-001 Medical Record Description, Content and Requirements
• 03-09-002 Medical Record Forms (Paper and Electronic)
• 03-09-004 Release of Information
• 03-09-020 Electronic Signature
• 62-10-006 Inpatient Verbal Orders
• MIS - Correction and Amendment by a Clinician
• MIS - Patient Request to Amend Medical Record
• MIS - Dictation Number: Assignment of physician numbers to permit dictation
• Compliance with key medical record requirements are monitored by the Office of Clinical Affairs and Medical Information Services and reported institutionally and to federal and/or regulatory agencies as required. Failure to comply with medical record requirements is reported as appropriate to the Office of Clinical Affairs, the appropriate department head, residency director, service chief, attorney's office, privacy office, or UMHS/UMHHC executive officer.
• Failure to be in compliance with medical record documentation requirements may result in a letter to the personnel, and/or credentialing and privileging file, and/or sanctions by the Office of Clinical Affairs.

NOTE: The requirements listed in this document reflect legal requirements for a medical record. There are additional and more detailed requirements for professional billing, specifically regarding Attending Physician documentation and/or attestations. Information on Professional Billing Compliance can be found on the UMHS Compliance Website.

Medical Record Content

Requirements for the content of the medical record derive from standards and/or requirements from the Medical Staff By-Laws, the JCAHO Standards for Management of Information, the Centers for Medicare & Medicaid Services Conditions of Participation, UMHS/UMHHC Policies and Procedures, Third Party Payers, and State and Federal Regulations. The detailed requirements are extensive and detailed in above policies. Key requirements are listed below.

1. General Requirements for all medical records:

• Admission History and Physical including: physical, psychological and social status, goals of treatment and treatment plan.
• Evidence of known advance directives with provisions documented.
• In the absence of an advance directive, the substance is documented in the record.
• For the patient with no advance directive, documentation that they were provided with information and an opportunity to provide one.
• Evidence of informed consent for procedures, etc.
• All diagnostic and therapeutic orders
• Documentation in progress notes of reasons for tests or medications ordered;
• Operative and Procedure notes
• Daily progress notes
• Pain assessment (initial and ongoing) with the patient's specific pain score;
• Consultation reports;
• Allergies to foods and medicines;
• A nutritional screen within 24 hours, and when warranted, an assessment of nutritional status
• A functional screen within 24 hours, and when warranted, an assessment of functional status;
• A functional assessment for every patient referred for rehabilitation services;
• All relevant diagnoses established during the course of care;
• All co-morbid conditions upon admission, such as diabetes, CHF, etc;
• Any referrals and communications made to external or internal care providers and to community agencies;
• Conclusions at termination of hospitalization;
• Discharge instructions to the patient and family; and
• Discharge summaries, or a final progress note or transfer summary. This summary must include:
• Documentation of emails containing patient-provider or provider-provider communication regarding the patient or the patient's care.
• Telephone consultations and/or triage.
• Patient-generated information (for example, information entered into the record over the Web or in pre-visit computer systems), if applicable.

2. Daily Inpatient Visits: must be documented through daily progress notes or orders, except for rehabilitation services which are required to document 5 days a week.

3. Operative and Invasive Procedure documentation requirements:

• Surgical consent including: risks, benefits, and alternatives prior to procedure
• Pre-anesthesia assessment
• Pre-op plan for anesthesia
• Prior to induction, the patient is re-evaluated for anesthesia
• Before beginning any invasive procedure in the OR, diagnostic area, or at the bedside, a “time out” must be taken to verify the correct patient (name and birth date), correct procedure, correct side and site. The “time out” must be documented. In the OR the timeout is documented in the on-line anesthesia record. In diagnostic areas and for bedside procedures the time out is documented on the sedation record or in progress notes.
• Post-operative monitoring and documentation that includes:
• Operative reports
  • A brief operative note is entered in the medical record immediately after the procedure.
  • The detailed operative report is dictated shortly after the procedure.

4. Pediatric patients:

• Developmental age
• Growth Chart and/or documentation of length/height, head circumference, and weight (may be documented in CareWeb)
• Immunization status (immunizations are documented in CareWeb)

5. Ambulatory Care:

• a Problem Summary List (PSL), documented in CareWeb, must be initiated by the third visit including:
  • Known significant medical diagnoses and conditions
  • Known significant operative and invasive procedures ( UMHHC procedures are automatically downloaded)
  • Known adverse and allergic reactions
  • Known long-term medications, including current prescriptions, over-the counter-drugs, and herbal preparations.
  • Health Maintenance information may also be entered
• PSL information should be included in dictated documents using the term “Updates to Problem Summary List” in the dictation. PSL information may also be added on-line at any time via CareWeb.
• The Prescription Writer function in the PSL can be used to generate printed prescriptions from the medication list ready for signature.
  

6. Emergency Care

• Documentation if a patient leaves Against Medical Advice (AMA).
• Conclusions at the termination of treatment, including final disposition, condition at discharge and instructions for follow-up care, treatment, and services.

7. Psychiatry and/or Behavioral Health Services - document the following:

• History of mental, emotional, behavioral, and substance abuse problems; their occurrence; and treatment
• Current mental, emotional and behavioral functioning, including a mental status examination
• Maladaptive or problem behaviors
• Psychosocial assessment
• When appropriate, legal assessment, vocational or education assessment.

8. Psychosocial services for alcoholism, and other drug dependencies - must document:

• History of alcohol, nicotine, and other drug use, including age of onset, duration, intensity, patterns of use, and consequences,
• Types of previous treatment and responses to that treatment,
• History of mental, emotional, and behavioral problems; their co-occurrence with substance use problems; and their treatment,
• History of biomedical complication associated with alcohol, nicotine, or other drug use and the patient's level of awareness of the relationships between these behavioral conditions and his or her pattern of substance use,
• A psychosocial assessment.

9. Restraints for the medical/surgical patient
Follow requirements set forth in UMHHC Restraint policy #62-01-001.

• Orders must be written in the medical record within 24 hours of initiation of a restraint.
• Orders are written on the Restraint Assessment Order Sheet or restraint order sticker. Written orders must be based on an examination of the patient by a physician and documented each time the order is renewed including:
  • Rationale for use of restraint
  • Modification of the treatment plan to include restraint
  • Expected result when restraint is initiated

10. Restraint/Seclusion for Behavioral Management:
Follow requirements set forth in UMHHC policy #62-01-002 Restraint and Seclusion for Behavior Management.

• Order written immediately before or after application.
• Order must be time limited, not to exceed 4 hours for adults, 2 hours for 9 – 17 years of age, 1 hour for less than 9 years of age.
• Re-examination by physician required after 8 hours for adults, 4 hours for children.

11. Outside Information: provided by another provider or health care institution, especially test results, etc. may also be included in the medical record.

Electronic medical record requirements
Detailed requirements found in UMHHC policy # 03-09-001 Medical Record Description, Content and Requirements. Key points for electronic medical records include:

• Must enable a printed copy with all appropriate content, identification of patient, identification of organization, document title, on every page.
• Must indicate who entered what information and include electronic authentication via level 2 sign-on and password.
• Prohibit removal of any information once signature has been applied.

Requirements for Completeness and Timeliness
All documentation must be completed according to UMHHC policy, Medical Staff By-Laws, external regulatory agency requirements, and third party payer requirements:

• Admission History and Physical – 24 hours from admission .
• Surgical History and Physical – within 30 days of procedure , if greater than 7 days updated .
• Discharge Summary – recommended to be done within 2 days of discharge to support continuity of care. Required to be done within 30 days of discharge.
• Operative Report – handwritten note immediately after surgery . Dictated note as soon as possible after surgery and no later than 30 days after surgery.

Compliance with timeliness of discharge summaries, admission histories and physicals, operative reports and all electronic signatures on all dictated documents are tracked by MIS and deficiencies are reported to the Office of Clinical Affairs. The information is utilized in the annual evaluation of physicians. Sanctions are imposed for non-compliance.

• All entries (notes, orders, consults, etc.) in the medical record (paper or electronic) must include date and signature (handwritten or electronic via password) of the person making the entry.
• Physicians and other Licensed Independent Practitioners must also include their UMHHC four or five digit identification code with their signature.
• Rubber stamp signatures or copy and paste signatures are not permitted.
• For certain entries such as verbal/telephone orders and restraint orders, date and time are required.
• The By-Laws require an Attending co-signature on Operative Reports, Discharge Summaries, and frequently enough on progress notes to indicate personally identifiable medical service.

Verbal/telephone orders

• State law requires that all Inpatient Verbal Orders and/or Telephone Orders are countersigned and dated by the physician by the next day .
• Any physician familiar with the patient may sign the Verbal/Telephone Order.
• Outpatient verbal/telephone orders must be signed by the next visit or physician entry into the medical record.
• Staff taking the order must write the name of the person giving the order, date and time, and sign their name.
• The order must be read back to the physician to verify the information.
• Verbal orders that are signed, but not dated, fail to meet the requirements.

Sign and Date here!!!

Verbal order use and compliance are monitored and reported monthly to Medical Staff leadership.

Abbreviations and Symbols

The UMHHC has determined that the following abbreviations are not to be used and are prohibited as part of the National Patient Safety Goals.

Permanency of Entries

• All entries in the medical record regardless of form or format must be permanent (paper or electronic records).
• For hand-written entries, a ball-point pen with permanent blue or black ink should be used.

Correction or Amendment to the Medical Record

There will be times when documentation problems or mistakes occur and changes or clarifications will be necessary. Proper procedures must be followed in handling these situations. At no time is it permissible to cross-out, obliterate or remove a previous entry in the medical record (paper or electronic). UMHHC Policy “Correction and Amendment to the Medical Record by a Clinician provides detailed instructions. Key points are:

• Draw line through entry (thin pen line). Make sure that the inaccurate information is still legible.
• Initial and date entry.
• State reason for the error (i.e. in the margin or above the note if room).
• Document the correct information.
• If there is not enough room at original entry, enter the correct information on the next available line/space documenting the current date and time and referring back to the incorrect entry.
• Do not obliterate or otherwise alter the original entry by blacking out with marker, using white out, writing over an entry, etc.

2. Correcting an electronic/computerized document after signature/authentication:

• Original document must remain.
• Dictated documents can have an addendum dictated and/or electronically entered and authenticated. See CareWeb Help page, Caregiver Tools, Electronic Signature.
• In situations where there is a hard copy printed from the electronic record, the hard copy must also be corrected.

3. Making a Late Entry

• Identify the new entry as a "late entry"
• Enter the current date and time – do not try to give the appearance that the entry was made on a previous date or an earlier time.
• Identify or refer to the date and incident for which late entry is written.

4. Entering an Addendum/Clarification:
For paper documents:

• Document the current date and time.
• Write "addendum" or “clarification” and state the reason for the addendum/clarification referring back to the original entry.
• Identify any sources of information used to support the addendum/clarification.
• When writing an addendum/clarification, complete it as soon after the original note as possible.

For electronic documents:

• For dictated documents, go to the CareWeb Help page, Caregiver Tools, Electronic Signature, Create a Document Addendum, and follow the instructions.
• Addendums/Clarifications must be done using the Create Document function in CareWeb.

It is considered willful falsification and illegal to go back and complete and/or fill-in signature "holes" on medication and treatment records or other graphic/flow records in the medical record.

Patient Amendments to their Record
A patient has the right to request an amendment to their record. UMHHC Policy #01-04-330 Patient Request to Amend the Medical Record details the process. Key Points:

• Any request by a patient for amendment should be directed to Medical Information Services for management. MIS will in turn, work with the clinician involved.
• Patient must request amendment in writing and provide a reason to support a requested amendment.
• The UMHHC must act on the individual's request for an amendment no later than 60 days after receipt (a 30 day extension may be granted if the patient is notified). Once the amendment request has been reviewed,
• UMHHC must inform the patient if the amendment was granted in whole or in part.
• If all or a portion of request denied, UMHHC must provide patient with written reason for denial. The patient has the right to make a written statement of disagreement with the denial that will become part of the medical record. UMHHC can also document a rebuttal statement.
• When releasing/disclosing information pertaining to the disagreement, the written statement by the patient and the rebuttal by UMHHC must be included.

Patient Care Orders

• PRN medication orders must contain the indication for use;
  example-Tylenol 325 mg PO PRN for pain.
• All orders must be signed, dated and include the clinicians identification number
• A ball-point pen with blue or black ink should be used to document in the medical record. The ink should be permanent

SECURITY AND CONFIDENTIALITY
Refer to UMHHC Policy # 01-04-002 Confidentiality of Patient Information

For additional information related to Medical Record documentation see CareWeb/Clinical Home Page, References, Medical Records, or contact Medical Information Services at 734-936-5340.