Chart Notes, Case Histories, and Test Reports

Abstract

The patient’s treatment record is one of the most important clinical documents to which the intern will contribute. It is a comprehensive account of all diagnostic and treatment activities that are pertinent to a patient’s care. The treatment record functions as a clinical log that is used for the documentation of services, and communication among professional staff. Aside from its clinical utility, the treatment record also is a legal document that can be reviewed by third-party payers or review committees, subpoenaed by a court, and, in many states, made available to the patient or his parent or guardian. As clinical facilities, all internship sites maintain treatment records, and all will advocate certain customs and procedures for the documentation of services. While there may be some variation in the documentation required by different sites, much of what is contained in the treatment record is bound by state laws, professional standards, and regulations set forth by utilization review groups. Most treatment records are composed of hand-written notes and typed reports. However, the computerization of clinical facilities has led to the development of patient records that are maintained and stored on electronic media (e.g., optical disk). These forms of records are gaining more widespread use because they are cost and space efficient, and they can be used in the construction of patient databases that can be searched, reviewed, and statistically analyzed.