All medical records, paper or electronic, should be organized in a uniform and orderly manner. They should be:

Legible
All contents of the medical record, including scanned or faxed documents, must be legible so that essential patient information can be accurately and clearly communicated to healthcare professionals involved in the care and treatment of the patient. Not only can illegible or unclear documentation put the patient at risk for medical errors, it may cause a jury to view you in a negative light. During a trial, it is not uncommon for a plaintiff’s attorney to hand the defendant physician a copy of the patient’s medical record and ask the physician to read a selection. It can be extremely detrimental to the defense of the case if the physician cannot read his/her own writing or a scanned document or determine the meaning of the note. Keep in mind that a printout of a patient’s chart may look different from the electronic version.

Chronological
Your documentation will be more easily understood when it is both sequential by date and logical in process. Use the SOAP format to record the patient’s Subjective complaints, your Objective observations, your Assessment, and your treatment Plan. Ask yourself this question: Is there a logical process presented in the record for coming to this treatment decision?

Concurrent
Document in the patient’s medical record as soon as possible after an event or observation is made when your memory of the event or observation is fresh and your documentation is more likely to be accurate. Documentation that is made at or near the time of the event or observation is more likely to be perceived as credible by a jury.

Any necessary late entries or addendums to the medical record should be clearly noted as such with the date and time the entry was made and the date and time for which the entry refers and authenticated by the individual making the entry.

Accurate
It is of major importance that the content of patients’ medical records be accurate. Inaccuracies, discrepancies, or inconsistencies in the medical record, such as documentation of an ulcer on the right foot when the ulcer was on the left foot, can lead to adverse events. Inaccuracies can lead to miscommunication between you and the patient, you and your staff, or you and another physician, and could be problematic if you must defend your care in court. They can also cause a jury to question the credibility of the entire record.
Check your entries into the medical record immediately after documentation to make sure they accurately reflect the patient’s condition, your assessment, treatment provided, orders, patient instructions, etc.

Additionally, make sure you have documented in the correct patient’s medical record. All pages of the medical record, both paper and electronic, should contain at least two patient identifiers, such as the patient’s name and medical record number.

Objective
Documentation should be free from conjecture or speculation. By documenting things you saw (e.g., bleeding, deformities, wounds), heard (e.g., the patient’s statements, moaning), felt (e.g., skin temperature, motion at a fracture site), or smelled (e.g., malodorous drainage, alcohol on the patient’s breath), the patient’s medical record will be specific and objective.

Specific
Medical record documentation should be specific and factual. If a patient brings a lawsuit against you, many times you will not be able to remember specific events. You will have to rely on your documentation to support that you rendered the standard of care. If your documentation is not specific, your defense will be hampered. Avoid generalizations, vague statements, or speculation in your documentation.

Complete
The patient’s medical record should contain a complete story from the patient’s initial visit to the last visit. Anyone reading the patient’s medical record should be able to identify exactly:

• The care and treatment you rendered to the patient

• Your decision-making process for the care and treatment you provided, including the reason for any deviation from standard treatment

• The patient’s progress, or lack of progress, with treatment

• The outcome of your treatment

• Clinically relevant

Physician office policies and procedures should specify who may document in patient medical records based on the staff member’s licensure, certification, or professional experience. Anyone documenting in the medical record should be trained and competent in fundamental documentation practices and legal documentation standards.

Each medical record entry should indicate the date and time of the entry and be authenticated by the author. Authors are responsible for the completeness and accuracy of their entries in a medical record. Once the record has been authenticated, the document should be considered locked from any editing. Any additions or corrections should be applied only through an addendum or amendment and clearly marked as such. Any clinical information supplied by another person to the author of an entry should be clearly attributed to the source.

If documentation of patient care is entered for another provider, the entry should include the name of the person who entered the information and the date of the entry. Then the entry should be authenticated and dated by the actual provider of care.

All transcriptions should be reviewed, signed, and dated with the date of the review by the dictating doctor to ensure accuracy of the information. Transcriptions should contain the date the patient was seen, the date of dictation, and the date of transcription.

Labs, diagnostic tests, consultation reports, etc. should likewise be signed and dated by the prescribing doctor to indicate the doctor reviewed the report and the date of the review.

An initial history and physical should be performed and documented at the initial visit prior to the initiation of care and/or treatment.

The patient should complete a medical, social, and family history and provide information pertaining to the current problem for which they are seeking podiatric care. Once the patient completes the form, the provider should review the form with the patient and establish evidence of your review, such as placing your initials and date of review on the form or documenting that you reviewed the medical, social, and family history with the patient in the patient’s medical record.

The patient information form should include:

• Name
• Date of birth
• Sex
• Phone numbers
• Address
• Emergency contacts
• Insurance Information
• Names of individuals to whom you may relay the patient’s health information
• Preferred pharmacy
• The patient’s primary language
• The name and phone number of the patient’s primary care doctor
• Prescriptions – a list of all medications the patient is currently taking, including prescriptions, over-the-counter medications, and herbal supplements
• Allergies* – current allergy information should be displayed in an easily accessible, prominent location
• Psychosocial history
• Family medical history

*If the patient does not have any known allergies, document the absence of allergies. Allergy information is to be verified and recorded at each patient contact, including telephone discussions for medication refills.

A sample “New Patient Information” form is available here.

Once you have reviewed the patient information form with the patient, then a thorough initial history and physical should be performed and documented, including a list of prior surgeries and hospitalizations with reason and dates.

The history and physical documentation should include: 

• A review of systems
• The chief complaint and a chronological description of the development of the patient’s present problem from onset to present
• A problem list that contains current information pertaining to chronic, acute, or significant conditions (the list should identify the date of occurrence or discovery and the date of resolution)
•  Pain level with and without activities
• Lower extremity examination and current clinical condition with a diagram to mark areas affected by current or recurring problem
• Objective findings
• The patient’s expectations and goals for treatment
• Who was present in the treatment room with the patient, if applicable (i.e., spouse/family member/friend)
• The presence or absence of functional limitations
• Your diagnosis or impression
• The treatment plan, including diagnostic and radiologic tests and results
•  Treatment administered and anticipated frequency and duration of treatment
• Treatment results, including complications
• Your prognosis
• Any medication or therapy ordered, and copies of the prescriptions and/or referrals given to the patient
• Whether or not any special procedures are anticipated
• Education provided
• Instructions for follow-up

A sample “New Patient Information (Dr. Use Only)” form is available here.

Standard components of a progress note should include:

•  Date and time of service
• Chief complaint
• Subjective information provided by the patient (HPI, symptom changes, response to treatment, pain level, pertinent positives and negatives)
• Objective information like measurable or observed findings (vitals, physical exam, wound measurements, imaging/lab results, gait, photos if applicable)
• Assessment and status of condition
• Treatment plan
• Patient response/tolerance
• Patient education and any non-adherence
• Medical decision-making thought process

Templates are valuable tools for enhancing the efficiency of documentation, but it is essential to ensure that each template utilized incorporates all required elements. Sections such as patient information, history and physical examination, progress notes, wounds and lesions, and pre/intra/postoperative care detail the documentation standards for their respective areas within the medical record. Furthermore, information recorded should be pertinent to the patient's visit and treatment plan; extraneous or unrelated details should be omitted from the documentation.

In addition to adhering to these documentation guidelines, it is important to regularly review and update templates to reflect current best practices and regulatory requirements. This ongoing process helps ensure that records remain accurate, comprehensive, and compliant with industry standards. 

A description of each wound should be documented at each visit. Adequately describe all wounds and include:
•    Location
•    Specific size measurements
•    Accurate grading
•    Drainage
•    Odor
•    Redness
•    Swelling

Additionally, lesions should be carefully described to include the precise location, size/dimensions, and color. The lesion’s surface features should also be described.

Informed consent discussions need to be conducted with patients, and documented, for any treatment or procedure that has the potential for risk. This results in the patient’s educated decision either to pursue or refuse certain treatments or procedures. While people other than the physician may perform administrative tasks, such as obtaining the patient’s signature on a form, handing out an educational pamphlet or showing a video, it is the physician’s responsibility to complete the actual consent process.

Any doubts about the necessity of obtaining a special consent from the patient should be resolved in favor of obtaining consent. If any element of informed consent (diagnosis, procedure, risks, benefits, etc.) changes after the patient signs a consent form, another informed consent discussion should take place, and another form should be signed.

The following information should be discussed with the patient and documented in the medical record:

1. The nature of the patient’s illness, the diagnosis, the proposed treatment plan, and the prognosis.

2. A description of the recommended procedure or treatment and its purpose.

3. The probable outcome, particularly if it is difficult to predict, and the patient’s expected post-procedure/treatment course.

4. The possible risks and side effects, the potential benefits, as well as the potential complications of the procedure or treatment.

5. Reasonable alternative methods of treatment or non-treatment including the risks, benefits, complications, and the prognosis associated with each alternative or with non-treatment.

A sample “Informed Consent” form is available here.

A patient has the right to refuse treatment. However, it is the responsibility of the physician to make sure the patient’s decision to refuse treatment is an informed decision. If a patient refuses a recommended plan of treatment, it is important that you undergo and document an “informed refusal” discussion with the patient.

Provide the patient with specific, detailed information regarding the recommended treatment including the benefits and risks of the treatment and any risks of not undergoing the treatment. Additionally, discuss with the patient reasonable alternative treatment possibilities and the risks and benefits of each.

All discussions and educational efforts should be documented in the patient’s medical record along with the fact that the patient was made aware and understands the risks of non-compliance with the recommended plan of treatment. To potentially further reduce the practitioner’s liability in the event the patient suffers a poor outcome as a result of the non-compliance, the practitioner may consider formally terminating their relationship with the patient.

A sample “Refusal of Care” form is available here.

Documentation of surgery performed in the office should reflect compliance with federal and state requirements or guidelines, if applicable, or with the standard of care. It should include:

• Pre-operative assessment, including the pre-operative diagnosis and rationale for surgery, and surgical clearance by appropriate medical specialist, if indicated
• The patient’s written informed consent
• Verification of the patient’s identity, the surgery to be performed, and the site of the surgery just prior to performance of the surgery
• Appropriate patient assessment and monitoring (according to the type of anesthesia/analgesia/sedation administered) during the surgery
• The name, dose, and route of any anesthetics and/or medications administered
• The patient’s vital signs prior to, during, and immediately following the surgery
• Specimens or tissue collected and disposition (e.g., sent to pathology)
• Placement of drains, hardware, etc.
• Dressings applied
• The times the surgery began and ended
• Operative report, including:
  • Technical procedures performed
  • Post-operative diagnosis
  • Name(s) of surgeon and assistants, if any
  • Sharps, instrument, and sponge counts, if applicable
  • Any complications
• A copy of written discharge instructions given to the patient, including: 
  • Procedure performed
  • Information regarding potential complications
  • Telephone number(s) to call if questions or complications arise
  • Instructions for medications and pain management
  • Other instructions (e.g., non-weight bearing, use of ice packs, dressings, etc.)
  • Date and time of follow-up visit
  • The name of person accompanying patient, if applicable

It is important to refer patients in a timely manner if the patient is not responding to care and/or treatment. Additionally, thoroughly document all referrals for consultations, lab work, diagnostic testing, etc. that you feel are necessary for the ongoing care and treatment of the patient.

Documentation should include:
•    The reason for the referral
•    The name of the referral doctor, lab, or other healthcare provider
•    The phone call or letter to the referral doctor/order for lab work, testing, etc.
•    The date of the appointment
•    Patient instructions/education
•    Date of receipt of the referral report
•    Date you reviewed the referral report
•    Follow-up actions taken if the referral report is not received in a timely manner
•    The date you reviewed the referral report with the patient
•    Your discussion of the results with the patient
•    The plan for future treatment
•    The name of the provider who will be assuming future care of the patient if other than you
•    Any follow-up actions taken based upon the referral report

Patient education 
Patient education and instructions should be documented in the medical record. All patient education, pre-operative or post-operative packets or checklists given to a patient should be signed by a patient and scanned to your medical record before the patient leaves with the documentation.  Any non-adherence to the education and instructions should be documented as well, including observations and patient statements.

Phone calls
All phone calls and voicemails should be documented and should include:
•    Date and time of call.
•    The name of the person to whom you are speaking.
•    The name and title of the person in your office making/receiving the call.
•    The reason for the call (In detail and quoting the patient).
•    Your orders, if applicable.
•    Advice or information given.
•    Appointment offered, cancelled  and/or scheduled, if indicated.

When you speak with a patient via phone, it is best to document on the same day the phone call occurred. 

Electronic Communications
You must follow all HIPAA Privacy and Security rules in relation to electronic communication with patients. It is recommended that you obtain informed consent from the patient to communicate with them electronically. Accordingly, if a doctor chooses to communicate electronically, there must be clear disclaimers about response times. All electronic communications need to be included in the patient’s chart whether the communications are emails, text messages on a cell phone or portal communications. Do not be cavalier or unprofessional in your responses and respond in a timely fashion.  Finally, if patients send photos to you electronically, it is best to have the patient come into the office or advise the patient to go to the emergency room for evaluation rather than providing care based off a photo. 

Social Media 
Social media activity associated with the practice presents professional, reputational, and legal risks. All online communications must comply with HIPAA, ethical standards, and applicable laws. Guidelines to follow:

•    Only authorized individuals may post on behalf of the practice.
•    Protected Health Information (PHI) must never be disclosed in any format, including images, comments, or indirect identifiers.
•    Content should be educational, factual, within the scope of practice, and consistent with accepted clinical standards.
•    Content should not include information or testimonials that appear to provide a 100% guarantee (for example: 100% success rate performing minimally invasive bunionectomy).
•    Providers and staff should avoid offering individualized medical advice through public platforms.
•    Staff must receive training on confidentiality, professional boundaries, and appropriate online conduct.
•    All advertising for your practice must adhere to state law and requirements.

Online Reviews
Online reviews require careful handling to avoid HIPAA violations and escalation of disputes. Guidelines to follow:

•    Do not confirm a patient relationship or reference specific treatment in public responses.
•    Responses should remain general, professional, and invite the reviewer to contact the office privately.
•    Evaluate negative reviews internally for potential quality improvement opportunities.
•    Document and escalate any threatening, defamatory, or repeated concerning online interactions according to risk management protocols.
•    Save the negative review provided by a patient (many times the patient will delete the review later and your lawyer may need it).
•    Forward the negative review to your malpractice carrier if the patient had a bad outcome.

A sample “Email Consent” form is available here.

As soon as possible after discovering an unexpected outcome, document the event in the patient’s medical record. Documentation of unexpected outcomes should be factual. The documentation should not contain subjective comments, blame, or speculation about what happened.

After you have disclosed the facts to the patient and/or family, document the information discussed, including:
•    Date, time, and place of the disclosure.
•    The names of those present.
•    Your plans for subsequent treatment.

Please contact PICA’s Risk Management Department for assistance with the disclosure discussion if one takes place. Contact us for advice on how best to proceed by calling (800) 251-5727 or emailing PICARM@ProAssurance.com.

Error Correction

For errors in paper records, draw a single line through the erroneous entry, taking care not to render the erroneous information unreadable, and make the correct entry next to it. All corrections should be initialed and dated. For electronic records, the office should have policies and procedures based on the system used and on how to make an error correction appropriately in the medical record.

Late Entry

A late entry applies to documentation within the medical record that is entered after the point of care. To make a late entry in paper records, go to the next available space in the record, document the current date and time, reference the entry as a late entry for the date the entry should have been made, document the appropriate information, then date and sign the note. For electronic records, the office should have policies and procedures based on the system used and on how to make a late entry correctly in the medical record. The late entry should be clearly noted as a late entry and include the date and time the entry was made.

Addendum

An addendum is a type of late entry used to provide additional information in conjunction with a previous entry. Addendums should be made as soon as possible after the original entry. To enter an addendum in paper records, go to the next available space and document the current date and time, write “addendum” and state the reason for the addendum, referring back to the original entry date, as well as identify any source(s) of information used to support the addendum (e.g., lab report), and date and sign the note. For corrections to electronic records after the entries have been locked, make an addendum to the record as described above. The original unaltered document should remain as part of the electronic record.

Amendments

An amendment is documentation meant to clarify health information within a health record. Amendments should be made as soon as possible after the need for clarification is identified and should clearly state the current date and time the amendment is made.
Federal law gives patients the right to request that their medical records be amended to correct incomplete or incorrect information, per HIPAA Privacy Rules. The patient must submit a written request for the amendment. Once the request has been submitted, the doctor must review the request to determine if the request should be granted. The doctor may deny the patient’s request if they determine that the information is subject to the request:

1. Was not created by the doctor’s office, unless the individual provides a reasonable basis to believe that the originator of the medical record is no longer available to act on the requested information
2. Would not be available to the patient for inspection (see HIPAA Privacy Rules for exceptions to a patient’s right to access protected health information)
3. Is accurate and complete

 

If the doctor denies the patient’s request for amendment, the doctor must provide the patient with a written explanation of the denial. The patient will then have the right to file a statement of disagreement or to request that the practice include the individual’s request for amendment and the denial letter with any future disclosures of the medical record subject to the request. If the doctor agrees to amend the record, they should enter an addendum to the record stating the change was made at the request of the patient.

AI-assisted documentation tools (e.g., transcription software, ambient listening systems, note generators) may improve workflow efficiency; however, the provider retains full responsibility for the accuracy and completeness of the medical record.

AI Guidelines
•    AI tools support, but do not replace, clinical judgment.
•    All AI-generated content must be reviewed, edited, and verified before finalizing the record.
•    The medical record should reflect AI assistance when applicable.
•    Clinical reasoning must be documented independently and not rely solely on AI summaries.
•    Practices must confirm HIPAA compliance and data security protections with AI vendors.
•    Conduct periodic audits of AI-assisted documentation to ensure accuracy and compliance.

Suggested Additions to the Notice of Privacy Practices
As part of your care, clinical photographs and AI-assisted documentation tools may be used to support accurate and complete medical recordkeeping. These tools assist with documentation but do not replace clinical judgment. All information collected is maintained in accordance with applicable privacy and security regulations.

The FDA maintains a public resource called the AI-Enabled Medical Devices List (also referred to as the AI/ML-Enabled Medical Device List). You can access it here:
Artificial Intelligence-Enabled Medical Devices (FDA)

Healthcare providers are responsible for maintaining medical records for a period of time consistent with applicable federal health record retention requirements, state laws or regulations pertaining to retention of health information, and accreditation agency retention standards. This means that the specific length of time for which medical records must be kept may vary depending on the governing jurisdiction and the type of healthcare facility. Providers should establish clear policies and procedures to ensure that records are securely stored and can be easily retrieved when necessary. It is recommended that a local attorney, familiar with such matters, be consulted when developing medical record retention policies. Additionally, it is important to periodically review and update record retention practices to remain in compliance with any changes in laws or accreditation requirements. Failure to adhere to proper retention guidelines can result in legal consequences, compromised patient care, or loss of accreditation status.

Unless longer periods of time are required by state or federal law, records of adult patients should be retained for a minimum of 10 years after the most recent encounter and records of minor patients should be retained to the age of majority plus the state statute of limitations or 10 years after the most recent encounter, whichever is longest.

When selling or leaving a podiatric practice, it is best dealt with by obtaining legal counsel in your home state that deals with employment agreements and state rules regarding length of time and appropriate manners of maintaining record access and storage. 

More information on retirement and group practices can be found here:

• Retirement: Record Retention & Patient Communication

• Risk Management FAQs