“Let the Record Speak . . .”: The Power of the Medical Record

• The medical record is the essential primary document for health care communication and data storage.
• In a claim of malpractice, the medical record is prima facie evidence and may offer a defense.
• The justification for coding at any level must be substantiated by the medical record documentation.
• Any unauthorized use of personal health information is subject to civil and criminal liabilities.
• A patient is entitled to a right of access (a copy), upon request, to their personal medical record including diagnostic reports such as laboratory results and x-rays, monitoring reports, instructions, and an accounting of charges.

Nurse practitioners (NPs) know the medical record is their essential source for clinical information and that a medical record accompanies every patient and each encounter is documented. As a primary legal document, the medical record is usually the best source of evidence. In addition, it communicates and stores data including protected health information. Legal implications innate in documentation relating to reimbursement, fraud and abuse, and data breach are key areas impacting NP practice. The aims of this article are to enhance NPs’ understanding by exploring some essential functions of the medical record, thereby decreasing their risk of liability.