Although proper charting of medical and treatment information has always been important for medical malpractice prevention, it is now also important as a compliance measure for billing fraud issues. The old rule in medical malpractice was that if it was not in the chart, it was not done. Auditors looking for insurance or Medicare fraud use the same standard: if the medical necessity of the care is not documented along with the care, then the bill for the care is fraudulent. In the best case, the medical care practitioner will have to refund the amount paid. In the worst case, there is a $5,000 fine per fraudulent bill, plus jail time.

The most important information is the basic patient data. The chart must contain enough information for a medical care practitioner unfamiliar with the patient to provide appropriate care. This should include physiological information, therapeutic information, and any special patient characteristics such as allergies or handicaps. This information should be summarized on a cover sheet. There are several acceptable styles for providing this summary, but they share an emphasis on rapid identification of abnormal findings, the recording of problems that will require attention on future visits, and a way to ensure that the physician is notified if the patient misses a follow-up visit.

The record should also contain family and legal information. For minors, the names of the parents or guardians should be in the chart, and a prominent notation as to who is legally able to consent to the child’s care. Most important, the chart should note any special legal constraints, such as a parent who is not allowed to consent to care, who is not allowed to pick up the child from the clinic, or who is not allowed to have access to the child’s medical information. If patients have a living will or durable power of attorney, this should be noted in the chart and a copy attached, if available. Adult family information—spouses, children, significant others—should be recorded and a note made if other members of the family are patients of the practice. The medical care practitioner may review the other patients’ charts to look for medically significant information, such as the risk of spreading infectious diseases between family members. However, the medical care practitioner must not share one adult’s medical information with another without the patient’s consent. If there is consent to share information, it should be in writing and filed in the chart. If the medical care practitioner believes that a patient may endanger others by spreading disease, then the proper response is to report this to the public health authorities and ask for their help and advice.