Medical Records and the Law

Content Requirements 37(C) physical examination report;(D) provisional diagnosis;(E) diagnostic and therapeutic reports on laboratory test results,X-ray findings, any surgical procedure performed, anypathological examination, any consultation, and any otherdiagnostic or therapeutic procedure performed;(F) orders and progress notes made by the attending physicianand when applicable by other members of the medical staffand allied health personnel;(G) observation notes and vital sign charting made by nursingpersonnel; and(H) conclusions as to the primary and any associated diagnosis,brief clinical resume, disposition at discharge to include instructionsand/or medications and any autopsy findings on ahospital death. 13A few states, however, have regulations that specify only broad areasof information required in a medical record. 14 The Hawaii regulationsprovide that the “medical records shall clearly and accurately documenta patient’s identity, the diagnosis of the patient’s illness, treatment, ordersby medical staff, observations, and conclusion concerning the patient.”15 As the minimum state standard for medical records, otherstates simply adopt the accreditation requirements of the Joint Commissionon Accreditation of Healthcare Organizations ( Joint Commission)16 or the Medicare Conditions of Participation for Hospitalsrequirements. 17Healthcare providers seeking to participate in federal reimbursementprograms must satisfy federal regulations governing conditions ofparticipation in those programs, which also impose record maintenancerequirements. Regulations issued by the Department of Healthand Human Services, Centers for Medicare & Medicaid Services(CMS) require specific categories of healthcare providers to maintain13Ill. Admin. Code tit. 77, § 250.1510(b)(2).14See, e.g., Regs. Conn. State Agencies § 19-13-D3(d).15Haw. Admin. R. § 11-93-21(c).16See, e.g., R.I. Code R. 14-090-007 § 25.7; Rules and Regulations for the Licensure ofHospitals in Virginia, 12 Va. Admin. Code § 5-410-370.17See, e.g., 105 Code Mass. Regs. 130.200 (2004).