Public Health Law Map - Beta 5 - Medical and Public Health Law Site

the charts must kept in such as way as to preserve all the relevant data so that the
medical care practitioner who treats the patient can try to make sense out of the
previous care.
3. Maintaining the Records
Medical records are business records and are admitted as evidence under the hearsay
rule exception for business records. As such, medical records are subject to the
specific legal requirements for keeping records that may be used in court: (1) the
record must be made in the regular course of the business; (2) the record must be
kept by a person who has personal knowledge of the act, event, or condition being
recorded; (3) the record must be made at or near the time that the recorded act, event,
or condition occurred or reasonably soon thereafter; and (4) the record must be kept
in a consistent manner, according to a set procedure.
a) Readability
An illegible medical record is doubly damaging to a physician: it obscures
necessary information, and it makes the physician who wrote the entry look less
than professional. A favorite strategy of plaintiffs’ attorneys is to make
enlargements of illegible medical records and use them to belittle the defendant
physician in front of the jury. Despite the jokes about physicians’ handwriting,
juries are not tolerant of illegible records.
The best way to ensure that records are legible is to dictate them. This may be done
on a pocket tape recorder while the physician is still with the patient or immediately
after. In all cases, the dictation should be done before the physician sees another
patient. If recordkeeping is delayed, it is inevitable that entries will be lost or
distorted. The tape should be transcribed daily and the transcription entered into the
chart. This entry may be made by affixing the actual typescript to the medical
record. If a computer or memory typewriter is used for the transcription, then the
entry, after proofing, may be printed on the chart page itself.
Handwritten notes should always be made in the chart in case the transcription is
delayed or lost. The transcribed notes should not be pasted over the handwritten
notes; both sets of notes are part of the legal record and must be preserved. If the
chart entries are not dictated, all entries should be made in black ink—never in
pencil. It is best if they are printed, but legible cursive handwriting is acceptable.
The records should be spot-checked for legibility from time to time. Taking the
time to write one legible sentence makes for a better record than a hastily scrawled
page of illegible notes.
b) Altered Records
It is important to be consistent in the keeping of records. The essence of a credible
record is that it appears to have been maintained in the regular course of business.
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