Personal Knowledge

Personal Knowledge

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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