Lesson 1, Topic 1
In Progress

Purposes of Patient Records

May 1, 2021

The five basic purposes for accurate and complete patient records are: (1) documented communication; (2) permanent record for accountability; (3) legal record of care; (4) teaching; and (5) research and data collection.

The patient’s chart provides a concise, accurate, and permanent record of past and current medical and nursing problems, plans for care, care given, and the patient’s responses to various treatments. The record facilitates accurate communication and continuity of care among all members of the health care team. Recorded information is not as easily lost or altered as the spoken word. Proper charting covers all areas of patient needs and concerns: physical, emotional, psychological, social, and spiritual.

This permanent record is sometimes also used by various government and other agencies to evaluate the institution’s patient care, to justify cost reimbursement for care provided, and to establish or review accreditation. Current regulations require chart audits (review of specific chart components for completion and appropriateness) by officially appointed auditors (people appointed to examine patient charts and health records to assess quality of care). Auditors check to see whether all ordered care was charted as given and whether responses to specific care plan items and treatments are noted. Institutions have medical and peer review systems (an appraisal by professional coworkers of equal status). Peer review appraises the manner in which an individual nurse conducts practice, education, or research. Institutions also have specific procedures to provide for quality assurance, assessment, and improvement, which is an audit in health care that evaluates services provided and the results achieved compared with accepted standards. Accurate and legible records are the only means institutions have to prove that they are providing care to meet patient needs and established standards.

Cost reimbursement rates by the government plans (Medicare, Medicaid) are based on the prospective payment system of diagnosis-related groups (DRGs; a system that classifies patients by age, diagnosis, surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount) (CMS, 2013). Many private insurance companies now use similar illness categories when setting hospital payment rates. Institutions are reimbursed by insurance companies or government programs only for documented patient care. The payers carefully review various items in patient medical records, including the nursing notes (the form on the patient’s chart on which nurses record their observations, the care given, and the patient’s responses), when deciding whether the necessary and ordered care is being given or was given.

The patient chart or health record is a legal document; when necessary and appropriate, it is used in court proceedings. Although the physician or institution owns the original record, lawyers and courts are able to gain access to it; therefore, it is important to chart in a very detailed manner to protect those involved in inpatient care.
Patient health records are also used for teaching. Students in the health care professions learn more quickly and easily if examples of good charting are shared. Individuals also learn from their mistakes and the mistakes of others.

Patient records that involve research and data collection have many uses in the health field. For example, the government periodically publishes data on certain diseases and the effectiveness of new treatments. In addition, the pressure to contain or limit health care costs has made data regarding the usual length of hospitalization and the cost of treatment for specific illnesses or surgeries important for governmental and other health insurance providers.