The requirement that the entry be made by someone who has personal knowledge of
the event being recorded or that the information be transmitted directly to the
person making the entry from someone who has personal knowledge allows a
physician to dictate notes to be transcribed and put in the chart. The
transcriptionist need not have any personal knowledge of the medical care
rendered because he or she is getting the information from someone who is
familiar with the care given.
The requirement of personal knowledge is a problem in teaching institutions. In
some cases, a physician may write chart notes and summaries for a patient he or
she has not personally cared for or discussed with the physician who did care
for the patient. If the recording physician does nothing more than summarize
data already in the medical record, there will be no problem with the personal
knowledge requirement, because the physician, by reviewing the record, will
have personal knowledge of the data in the record.
Problems arise when the physician draws conclusions about the patient's
condition based on data in the record. Although these conclusions are
incorporated in the medical record, they are not based on personal knowledge of
the patient's condition. This failure of personal knowledge would be legal
grounds for attacking the admissibility of the conclusions in court.
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