Off-Chart Records
Poor organization, combined with illegible handwriting, leads many medical care providers to use temporary notes, such as index cards, to coordinate care. These notes are used as a source of immediate information. Entries in the official medical record may be written long after the care is delivered. Given the added dimension of hindsight, it is impossible to avoid slanting entries to reflect what should have happened, as opposed to what did happen. This is legally dangerous because it is difficult to maintain consistency in entries that are biased by hindsight. It is very damaging if a patient’s attorney can discredit the record through internal inconsistencies and thereby raise questions about the good faith of the providers, as well as the quality of care.
Physicians in training and nurses maintain most extra-chart records. Residents often use 3×5-inch index cards with a brief history, the attending physician, recent test results, pending test results, and what needs to be done next. Residents keep their own cards, and these may be passed on at shift change or may serve as a memory jogger to fill in the new residents in charge, who transfer the information to their own set of cards.
Nursing personnel keep elaborate extra-chart bedside records. Individual nurses keep personal notes, and often the nursing service maintains a centralized extra- chart recordkeeping system. These records exist outside both legal and administrative control. The records are kept in pencil, and old data are erased to make room for new data, ensuring that decisions are based on current information. This process of creating and erasing temporary records also carries over to the processing of physician orders, which are transcribed from the medical record into the extra-chart record. Once in the extra-chart system, it is easy to erase or mark out orders as they are performed.
From a patient care perspective, extra-chart records provide a way to coordinate patient care and provide ready access to laboratory test results. But these records are deficient in that they provide no historical information. Extra- chart records inevitably corrupt the accuracy of the chart itself because the extra-chart record becomes the record that is filled out first, with the chart becoming a secondary record, filled out when time allows. Secondary records often reflect what should have been done rather than what was done. This causes medical problems if the extra-chart system breaks down (someone loses the index cards, for example) and legal problems if the care is challenged in court.
Physicians should never use off-chart records. All patient information must originate in the chart and be transferred to notecards or other temporary records from the chart. If notes are made separate from the chart, these notes should be glued into the chart. They should not be copied over into the chart. Notepaper with strippable adhesive should never be used for keeping medical notes. If they are inadvertently used, they should be glued into the chart with a permanent adhesive.