Checklist

The initial review is best carried out by using a checklist. Since the checklist does not require the evaluation of medical decisions, it can be utilized by nonphysician reviewers, such as medical records department personnel. This type of review is very useful in documenting a failure to comply with basic record-keeping protocols. But it provides information only about failure to document medical decisions; it does not judge the quality of the decisions that are made. Even in its limited purpose, the checklist type of review is of little use if it is not done promptly.

Once a patient is discharged from the hospital, there few additions to the chart are allowed. Discharge summaries may be prepared, and orders that do not require a countersignature within 24 hours may be signed; but there should be no additions to the orders, progress notes, and other parts of the record that are kept in chronological order. To be effective, the review of the record must be done soon after discharge to detect late entries. In the rare cases where there is a valid reason to amend a record, this should never be done in such a way as to obscure the original entry. The original entry may be struck out with a single line so that it is still legible and the new entry inserted. Any added entries must be signed and dated. Since the hospital is the custodian of the records, it must protect them from tampering, regardless of the intent of the person making the changes.

Many physicians see the medical record as a required legal document, with little bearing on patient care. From this point of view, it does not matter if an order is countersigned within 24 hours or after six months. It is only the final appearance of the chart that is of concern. From the hospital's point of view, it will be impossible to monitor the care that a patient receives if the chart can be revised after the treatment is rendered. While this is discussed in greater detail in the chapters on medical records, it must be emphasized here that an essential part of monitoring is making the distinction between entries made at the time care is rendered and entries after the patient's discharge, it may be necessary to ask the nursing staff to line off each day's entries to determine if the records are being properly kept.