Record Keeping and Documentation

Law, rules and regulations, not Alerts, specify the requirements for practice and violating them constitutes professional misconduct. Not adhering to this Alert may be interpreted as professional misconduct only if the conduct also violates pertinent law, rules and regulations, some citations of which are listed at the end of this Alert.

Health care professionals must maintain proper documentation that accurately reflects the evaluation and treatment of the patient, consistent with the appropriate levels of care. Clinical notes serve several important purposes including:

  • ensuring comprehensive and consistent patient care
  • improving communication with other professionals
  • facilitating reimbursement from insurance carriers
  • helping to protect licensees against litigation
  • standardizing clinical documentation in support of research.

As a competent and prudent practitioner, the initial entry in a patient record should ordinarily include a comprehensive case history documenting an examination of symptoms, past history, family history, past surgeries, traumas, and previous and current medication. You should maintain thorough and accurate records and notes that reflect your care, treatment and interaction with each patient.

Your patient records should include a consistent method for documenting results of care as well as patient outcomes. Forms such as the Oswestry, Neck Pain Index, Visual Analog Scales, or Pain Diagrams may assist in standardizing and objectifying your patients' subjective reports of conditions. These assessments also can be used to monitor the progress of your patients.

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Citations of Pertinent Law, Rules or Regulations:

Last Updated: April 7, 2014