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What is a medical chart?

Several terms are used interchangeably to describe a patient’s medical chart, including medical record, health record, and patient chart. All refer to a private medical record that contains systematic documentation of an individual patient’s important clinical data and medical history over time. Accurate, complete medical charts enable healthcare providers to make informed and appropriate decisions about optimal patient care.

A patient’s medical chart may contain different note types, documenting office or telemedicine visits (encounters) and patient calls, such as:

  • Consultation notes
  • Second-opinion notes
  • Progress notes
  • Nurse notes
  • Procedure notes
  • SOAP notes
  • Simple notes
  • Phone notes

Depending on the type of ambulatory practice– whether a solo practitioner or a member of a medical group that includes multiple practices—a patient’s chart may contain notes from one provider or from multiple providers who have seen the patient. On this page, we’ll discuss the different information and clinical data that may appear in patients’ medical charts.

What kind of information comprises a medical chart?

Medical charts contain documentation regarding a patient’s active and past medical history, including immunizations, medical conditions, acute and chronic diseases, testing results, treatments, and more. The purpose of medical charts is to provide clinicians with all necessary information to accurately diagnose, treat, follow, and in many cases, help to prevent medical conditions, disorders, and diseases.

The Practice Fusion electronic health record (EHR) system enables you to easily capture all the following information in your patients’ electronic medical charts, including what’s often called PAMI, referring to Problems, Allergies, Medications, and Immunizations:

  • Patient demographics, including date of birth (DOB), age, gender, race, ethnicity, preferred language, contact information, religion, education, and occupation. Documenting many of these demographics is required as part of fulfilling Medicare’s “Promoting Interoperability” (PI) measures, including gender, DOB, patient’s preferred language, race, and ethnicity. Fulfilling PI measures requires that demographics are captured via the EHR’s consolidated clinical document architecture (CCDA) in a visit’s continuity of care document (CCD) for electronic internal and external referrals. In addition, the PI measures also require that such demographics populate when patients view, download, and transmit via their Patient Portal accounts.)
  • Medical encounters, including initial consultations, second opinions, follow-up visits, routine check-ups, and visits for procedures. Medical encounters are included as clinical notes in C-CDA to facilitate data exchange electronically.
  • Developmental history, including growth charts and documentation regarding developmental milestones, e.g., language, motor, cognitive/intellectual, and social and emotional development
  • Current and past medications
  • Medication, food, and other allergies
  • Active Problems/Diagnoses, including acute and chronic conditions, diseases, and disorders
  • Past Medical History (PMH)
  • Past Surgical History (PSH), including surgery dates and reports
  • Family History, including history of certain conditions or diseases in family members (e.g., a history of dementia, cancer, heart disease, diabetes, epilepsy, etc.)
  • Social History, including marriage status, occupation, family situation, education, and habits, e.g., smoking status, alcohol consumption, diet, exercise, and sexual history. Capturing smoking status was part of Meaningful Use requirements and continues to be one of the Clinical Quality Measures (CMS 138v9) that you may report as part of the Merit-based Incentive Payment System (MIPS) requirements, called “Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention.”
  • Immunizations and dates, e.g., for influenza, pneumonia, COVID-19, shingles, and required pediatric vaccinations
  • Obstetric History, including pregnancies, any complications, and pregnancy outcomes

What other information is included in medical charts?

As discussed above, patient charts include office notes for every patient visit or encounter, which contain specific information based on the encounter type, including initial consultations, second opinions, follow-up visits, procedure visits, or encounters during which diagnostic testing takes place.

For a consultation or follow-up visit, the provider’s office visit note will include note sections with all information relevant to the patient’s care, such as the following:

  • Chief Complaint (CC) is a concise medical term or phrase describing the primary problem that led the patient to seek medical attention. The chief complaint enables the provider to focus on the priority for that day’s encounter while assessing the patient, direct the type of additional history to obtain, and drive appropriate physical examination regarding the reported problem.
  • History of Present Illness (HPI) describes the progression of the patient’s present illness from initial symptoms to present day.
  • Review of Systems (ROS) is a listing of questions organized by organ system to identify malfunctioning and disease. ROS documentation indicates the patient’s answers to such questions vs. the physical examination note section (see below), where the provider documents what he or she observes through seeing, hearing, or measuring during examination.1
  • Physical Examination may include use of a stethoscope to evaluate heart rhythm and valvular function, percussion to detect abnormal fluid and evaluate size and borders of organs, and determination of pulse rate, height, and weight.
  • Vital Signs may include the patient’s blood pressure, heart rate, respiratory rate, and more.
  • Results may include lab results and imaging reports received electronically from lab or imaging interfaces, result documents uploaded to the patient’s chart, or results added to a patient’s chart manually.
  • Orders may include prescriptions, referral orders, lab testing, imaging studies, specific ordered procedures, and more.
  • Assessment and Plan, where the former includes diagnostic conclusions, and the latter discusses the provider’s recommended plan for treatment.

When documenting in the Practice Fusion EHR, you can pull forward data from the patient’s chart into a new encounter note, including active medical history, PMH, PSH, family history, current medications, and allergies.

Additional note types in a patient’s chart may include SOAP notes and Simple notes (non-SOAP) notes. SOAP notes have separate sections for the Subjective, Objective, Assessment, and Plan sections, whereas Simple notes have one free-text field that comprises the body of the note.2

The Subjective section is the first heading of a SOAP note and describes the personal thoughts and feelings of the patient or a person close to him or her. The Objective section, which documents objective information obtained during the patient’s encounter, may include vital signs, laboratory and imaging results, additional diagnostic data, physical exam findings, and review of documentation from other healthcare providers.2

Who has access to medical charts?

The Health Insurance Portability and Accountability Act (HIPAA)’s Privacy Rule gives individuals rights over their health information and sets limits and rules on who is able to view and receive medical information. In addition, HIPAA gives patients and personal representatives of patients (healthcare proxies) the right to access their medical records from their healthcare providers and health plan upon request. It also allows patients or healthcare proxies to ensure the accuracy of all information in their medical records and to identify any inaccuracies that require correction. The Privacy Rule is applicable to all forms of an individual’s protected health information (PHI), including oral, written, or electronic.3

How can Practice Fusion enhance your practice’s medical charts?

EHRs such as Practice Fusion have enabled more and more practices to move from paper medical charts to electronic/digital medical records. They have helped healthcare providers share medical notes and other chart data securely and quickly with all those involved in a patient’s care. This includes other ambulatory practices, hospitals, laboratories, imaging centers, clinics, and, of course, patients themselves, with such increasing interoperability streamlining and enhancing patient care.

Practice Fusion supports other care-related activities through various interfaces and provides functionality that enables querying to identify specific patient populations, engaging in quality management efforts, and conducting outcomes reporting.

The use of EHRs also provides additional benefits, including the following:

  • Reduces the incidence of medical errors in charts by improving the accuracy and quality of medical records and enhancing coordination of care among healthcare providers
  • Makes patients’ medical records easily accessible, reducing duplication of tests and delays in diagnosis or treatment that could result in potential harms
  • Enables patient access to Patient Portals, such as Patient Fusion, which allows patients to easily view their medical records. Patient portals also give patients and/or their healthcare proxies the ability to view, download, and transmit their patient health record data directly from the patient portal.

Click here to learn more about the Practice Fusion EHR.

References:

  1. American Academy of Professional Coders (AAPC). Knowledge Base: How to distinguish ROS from Exam. September 4, 2012. Accessed on September 15, 2021. https://www.aapc.com/blog/21038-distinguish-ros-from-exam-to-prevent-double-dipping
  2. Podder V, Lew V., Ghassemzadeh S. SOAP notes. StatPearls (Internet). Last updated: September 3, 2020. Accessed on September 15, 2021. https://www.ncbi.nlm.nih.gov/books/NBK482263/
  3. Office for Civil Rights. Your rights under HIPAA. Last updated: November 2, 2020. Accessed on September 15, 2021. Your Rights Under HIPAA | HHS.gov