Common medical record-keeping questions

Common medical record-keeping questions: "Common medical record-keeping questions

By Claire Turcotte, Esq.

Published December 2006

* React to this article in the Discussion Forum.



Most physician practices have policies and procedures, whether formal or informal, for maintaining, producing and retaining medical records. Often things are done 'the way we have always done them.' While this approach is probably adequate most of the time, many physician practices remain unclear about certain legal requirements affecting medical record-keeping. As a result, they are not confident that their current practices meet legal requirements. To help address this problem, this article clarifies many commonly ill-understood aspects of medical record-keeping.

What is Included in a Medical Record? Surprisingly, just what constitutes the 'medical' record is often a point of confusion for physician practices. Under Pennsylvania law a medical record is all 'clinical information pertaining to the patient which has been accumulated by the physician, either by himself, or through his agents.' According to the Pennsylvania Medical Society, the patient’s medical record includes results of diagnostic tests, x-rays, physician notes, and any records from prior treating or consulting physicians. This means that when a patient brings records from one physician to another physician, those records should become part of the latter physician’s medical record. In addition, Pennsylvania law does not expressly include a patient’s billing or business records in the medical record. As a result, some practices elect to maintain business records separately from medical records."