- Patient medical charts display a patient’s key medical information so practitioners can make more accurate diagnoses and develop treatment plans with better outcomes.
- The information found in patient charts includes demographics, medications, family history and lifestyle.
- All medical professionals involved in a patient’s care can access the patient’s chart, though the chart technically belongs to the patient.
- This article is for medical professionals looking to understand all the ins and outs of patient charts.
In a way, patient charts are the crux of the medical industry. They substantially increase the likelihood of positive patient outcomes and give medical professionals the general patient profiles they need to develop meaningful treatment plans. Virtually every reputable medical practitioner uses them to guide their clinical decision-making. Read on to learn why patient charts matter and how you can use them.
What is a patient medical chart?
A patient medical chart, commonly referred to as just a patient chart, is a complete and total record of a patient’s clinical data and medical history. Typically, patient charts include vitals, medications, treatment plans, allergies, immunizations, test results, patient demographics, diagnoses, progress notes and reports. All information in patient charts comes from nurses, lab technicians, physicians and other practitioners involved in the patient’s care.
The importance of patient charts
Proper patient care involves addressing a patient’s symptoms in the context of the big picture. Patient charts are that big picture. The comprehensive patient data they provide gives you all the information you need to make proper diagnoses, prescribe appropriate medications, order appropriate bloodwork and set up robust treatment plans. Without patient charts, even highly experienced doctors can misdiagnose patients or set up treatment plans that yield no results.
Additionally, medical billers and coders rely on the information in patients’ charts to generate medical claims. Claims are then submitted to payers like insurance companies in order for practices to collect the money they are owed for services rendered. Without a comprehensive medical chart, it is virtually impossible for medical billers to effectively do their job. [Looking to improve how you track patient charts? Read more on how to choose an EMR system for your practice]
What information is included in a patient chart?
A typical patient chart includes the following information:
- Demographics. This data is important to have since a patient’s race and gender can predispose them to certain conditions.
- Medications. When you know which medications a patient is taking, you’ll know whether you should increase or decrease their dosages. You’ll also have an easier time deciding whether additional medications are needed.
- Allergies. Prescribing medications to which a patient is allergic is obviously a bad choice. However, if you don’t know the patient’s allergies, you could easily make this mistake.
- Family history. This information matters, since seemingly innocuous symptoms or lab results can indicate the earliest phases of a condition common in the patient’s bloodline.
- Medical history. Knowing when a patient last saw primary care physicians and specialists gives you a timeline that’s key to determining which treatments have and haven’t worked.
- Immunizations. You can likely rule out certain illnesses as causes of a patient’s symptoms if the patient is vaccinated against the pathogen or otherwise immune.
- Surgical history. If a patient has had a certain type of surgery in the past, then perhaps some of their current symptoms pertain to unexpected consequences from that surgery.
- Lifestyle. Knowing a patient’s lifestyle factors such as smoking, occupation, alcohol use and exercise level can help you make more accurate diagnoses.
- Developmental history. Especially in pediatrics, motor skill disorders and learning disabilities could tie into a patient’s current symptoms.
- Pregnancies, if applicable. Pregnant patients may be unable to take certain medications, and some symptoms are more common in the weeks and months after pregnancy.
Key takeaway: Patient charts include demographics, medications, allergies, family and medical histories, immunizations, surgical history, lifestyle details, developmental history, and pregnancies.
What should be added to a patient chart during encounters?
During each patient encounter, practitioners should add the following to the patient’s chart:
- Reason for visit. Simply describe the patient’s symptoms and other complaints.
- Present diagnoses. Indicate whether the patient is visiting you after a recent diagnosis or is showing up with brand-new complaints.
- Physical exam notes. Record any exams you performed and what you observed during those exams. You should also record the patient’s vitals.
- Treatment plan. If you’ve given the patient a diagnosis, record it. Same goes for if you’ve started the patient on a treatment plan. List each and every part of your plan in as much detail as possible.
- Lab and test orders. Note any labs and other tests, such as X-rays and MRIs, that are part of the treatment plan.
- Lab and test results. If you ordered labs and tests for the patient before your current encounter, list the results here and explain what they could mean.
- Prescriptions. Jot down the names and dosages of any medications you’ve given the patient as part of their treatment plan. Be sure to indicate how many times per day the patient should take their medication.
- Progress notes. Describe how well the patient is responding to their treatment plan and what remaining steps you expect will be needed to relieve the patient’s symptoms. If your current encounter is the patient’s first time expressing these complaints, note that instead.
FYI During a patient encounter, you should add the patient’s symptoms, diagnoses, physical exam notes, treatment plans, lab and testing info and results, prescription, and treatment progress to their chart.
Example of a patient chart
Patient charts vary in appearance based on the EHR system (also known as an EMR system) your practice uses. Below is an example of what patient charts look like in athenahealth’s EMR system. For a closer look, read our review of athenahealth’s medical software, which includes its EMR system athenaClinicals.
Digital charts like these can usually be customized by healthcare providers to suit their preferences. Most EMR systems also offer the ability to create templates and favorites lists, making it easier to navigate to frequently used tools, diagnoses, prescriptions and lab orders. Healthcare providers are also able to send these charts securely to other healthcare providers when needed, cluing in a patient’s other care teams on relevant information your practice might have uncovered during their last visit.
On the other hand, a paper chart might look like this:
Medical professionals highly encourage EMR use over paper charts. The Centers for Medicare & Medicaid Studies (CMS) previously offered incentives to encourage adoption; however, organizations that fail to meaningfully implement medical software now face penalties to Medicare and Medicaid reimbursements. To learn more about why EMR software is superior to conventional paper charts and why regulators are pushing for mass adoption, visit our reviews of the best EMR software providers.
Who has access to patient medical charts?
Patients can access their own charts via the patient portal, as can any nurses, lab technicians, physicians and other medical personnel involved in their care. However, the chart ultimately belongs to the patient even if it’s stored in your EMR, as patient charts contain sensitive patient information. Patients can thus demand their medical records from you at any time or grant access to anyone they desire. They can also demand that you rectify any inaccuracies.
Did you know? Technically, a patient chart belongs to the patient.
EMRs and patient medical charts
By definition, EMRs are digitized versions of traditional patient medical charts. These digitized versions make the information in a patient chart significantly easier for all your medical staff to quickly access. Instead of rifling through paper records, you can just load your EMR on your computer or phone, open your medical software platform and then access your patient charts.
EMR patient charts are also better for comprehensive care, as everyone involved in the patient’s care can add their encounter notes to the same digital document. Then, when the next medical professional encounters the patient, they’ll have all the information they need, ordered chronologically, to properly care for the patient. The result is a more thorough, streamlined care experience for patients and providers alike.
Technically, EMR describes solely digital patient charts, whereas EHR – with which EMR is often used interchangeably – describes EMR and additional tools for improving patient care and communicating with other healthcare providers. These tools include electronic prescribing and lab ordering, as well as telehealth technology and interoperability measures for communications with specialists and physicians outside your practice.
In short, EMR includes solely patient charts, and EHR makes EMR easier for practices to work with. To learn more, read the Business News Daily guide to EMR vs. EHR.