Chapter 2: Overview of the Health Record

Overview of the Health Record

The health record, whether paper-based or in electronic format, should contain sufficient information to justify the patient's diagnosis, treatment, and services rendered. Documentation in the record should explain the patient's progress including the response to therapy, medication, or care rendered. Health records play the following roles in supporting the healthcare industry²:

• Serve as a communication tool that facilitates ongoing care and treatment of the patient

• Justify reimbursement for hospitals and other healthcare practitioners

• Serve as a legal document describing the healthcare services provided

• Serve as a resource for research and education

• Support clinical decision-making

• Provide information for evaluating the quality of care provided

• Serve as a source of data for outcomes research

Maintaining a Health Record

Health records are kept in one of three formats: paper format, electronic format, or a combination of both formats, known as a hybrid health record. Health records are maintained by all entities that provide health care to patients. Physicians, dentists, chiropractors, podiatrists, optometrists, nurses, physical therapists, occupational therapists, hospitals, urgent care centers, rehabilitation centers, skilled nursing facilities, residential facilities, emergency care facilities, home healthcare agencies, behavioral health facilities, and correctional facilities are required to maintain a health record for each patient. Documentation requirements and the type of record maintained vary according to the type of facility and provider. Documented medical information links all aspects of the healthcare delivery system; so all healthcare providers must document information to meet the needs of the patient and to comply with the laws and regulatory standards.³

Maintaining a health record for patient encounters and documenting the care provided are mandatory. Over the decades, healthcare has become increasingly complex, resulting in the need to have documentation that is accurate, timely, and legible. Regulatory agencies such as The Joint Commission, the Commission on Accreditation of Rehabilitation Facilities (CARF), the Accreditation Association for Ambulatory Healthcare (AAAHC), the American Osteopathic Association (AOA), the National Committee on Quality Assurance (NCQA), and the American Accreditation Healthcare Commission (AAHC) are just a few of the accrediting agencies that have standards for health records and documentation. Attaining accreditation signifies that the institution has made a commitment to having high standards for performance improvement and quality improvement.⁴

The federal government became more involved in health care in 1965 with the establishment of the Social Security Act, of which Medicare was a component. Medicare is a health insurance program for persons over the age of 65, persons under the age of 65 with certain disabilities, and individuals with end-stage renal disease requiring dialysis or a kidney transplant.⁵ Standards for health record content and documentation for federal patients are established by the Centers for Medicare & Medicaid Services (CMS), a division of the federal Department of Health and Human Services.

The health record must contain information to justify admission and continued ...