One of the most basic elements of a clinical record is full and complete identification of the provider, the office, and the patient. Whether the record is paper to be scanned into an electronic medical record (EMR) or paper forms stored in a physical file, best practice is a complete ID on each and every page of the chart.
- The provider should be identified by name, professional designation, physical address and telephone number.
- The patient should be identified with a full name and date of birth or other unique identifier such as a health record number.
- The author of the note should be clearly identified and include a verifying signature. Note: If forms are two-sided, each side should have complete identification.
Some providers complain, “Why the over-kill? I know who my patients are.” It’s true that, while the chart is in the provider’s office and under their control, everything may be clear. However, when copies are made for another health care provider, an insurance company, or even an attorney and the provider or patient’s ID is not on every side of the paper record, the receiver may not be able to tell for certain that a piece of the record is from the provider or pertains to their patient. A completely identified record with a full signature or validated electronic signature is an unassailable legal record. Also, mishaps happen. If records are vandalized, misplaced, or even just fall to the floor, proper identification of each page will allow successful reassembling of the files.
If you use an EMR system, check your software settings to ensure proper ID is printed on every page. If you are printing commonly used forms – such as a patient intake form – always allow space for the patient name and DOB or other unique ID on each page. Make sure that the clinic address and phone number is included on each page. In multiple provider offices make sure to identify the provider seeing that patient.
The best practices described here are endorsed by many health care organizations, regulatory agencies (e.g., NCQA) and state authorities. Want more information on record keeping or other best practices for integrative healthcare providers? Search “best practices” on this site to read more in this series of articles.