Personal Knowledge

The second requirement is 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. The medical records transcriptionist need not have any personal knowledge of the medical records that person is transcribing from the physician's dictation; it is necessary only that the physician doing the dictation have personal knowledge of the subject matter of the entry. The physician must then verify the transcription and sign it.

The personal knowledge requirement is generally not a problem for the nursing staff. The nurses actually rendering the care should be the ones to record the care in the chart. Even if the nurse directly rendering the care does not enter the record of the care into the chart, if that nurse personally informs the person making the entry, there is no problem with the personal knowledge exception.

The requirements of personal knowledge becomes more difficult to fulfill with regard to the members of the medical staff, particularly in teaching institutions. In some situation, a physician may write discharge notes and discharge summaries for a colleague. If that physician has not personally cared for the patient, however, it is arguable whether the entries that are made satisfy the personal knowledge requirement. 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 can arise, however, when the physician draws conclusions about the patient's condition on discharge using only the data in the record. Even though those conclusions are made a part of the medical record in the discharge summary, there 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. For this reason, the hospital must be careful to specify that the treating physician be the physician who dictates the discharge summary and any other parts of the medical record that require conclusions about the patient's condition. (This problem is discussed in greater detail in the chapter on accreditation requirements.)