Complete Medical Records Help Ensure Patient Safety

Patient safety is everyone’s responsibility. What can you do?

In the office setting, clear and complete information in the medical record reduces the risk of a miscommunication that could result in patient harm. Set up practices and standards that support excellent medical record documentation.

• Be certain that each medical record includes current allergies and refer to this section whenever the patient has an office or telephone visit.
• The patient’s record should contain a past medical history as well as an up-to-date list of medications and chronic conditions. Having this information available when providing care reduces the risk that the patient will be prescribed a medication or treatment that is contraindicated.
• Include information from other physicians, hospitals, home care agencies, or skilled nursing facilities in the form of a filed correspondence or progress note to ensure safe coordination of care.
• All written documentation must be legible both within the medical record and in any communications provided to the patient or about the patient.

Maintaining a complete and comprehensive medical record for each patient is a safe practice.

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