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.
Citations of Pertinent Law, Rules or Regulations:
- Education Law, section 6509(9) - "unprofessional conduct"
- Public Health Law, section 18 - "access to records"
- Regents Rules, part 29.2(a)(3) - "failing to keep records"