Medical Record Documentation Requirements

Having a complete and thorough medical record will make it more accessible for a patient to receive adequate care. A medical record that is missing required documents could make it easier for the patient to be misdiagnosed, possibly putting the patient’s life in danger. Therefore, having the required documents in the medical record will make it easier for the doctor to provide a diagnosis and is essential for the overall care of the patient.

Patient Information

• The patient information section is the first section of a medical record. The information must be up-to-date because it contains valuable contact information for the patient. The patient information must include the patient’s contact information, Social Security number and insurance information. In addition, it must have an emergency contact name and number.

Medical History

• The medical history is not only required, but it is one of the most important files located inside the medical record. It contains information about the patient’s past illnesses, diagnosis and surgeries. Additionally, it lists medications the patient is taking or has taken in the past, thus giving the next doctor an overview of previous procedures, complications and prognosis.

Imaging Reports

• The imaging reports contain pictures, X-rays, MRIs and other imaging or video tests performed on the patient. Each imaging report is usually accompanied by a doctor’s note or expert diagnosis.

Privacy Notice

• A valid and signed copy of a Health Insurance Portability and Accountability Act notice is required inside a medical record. The act prevents the release of medical information to unauthorized parties.

Doctor's Notes

• To complete a medical record, a summary of a patient's visits to the doctor’s office or hospital is required. The doctor's note may include a summary of the visit, a list of symptoms the patient was experiencing at the time of the visit, as well as the doctor’s diagnosis and prognosis of the patient.