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 could be legal
grounds for attacking the admissibility of the conclusions in court.