Medical Records

Standard MOI.9
The hospital initiates and maintains a standardized medical record for every patient assessed or
treated and determines the record’s content, format, and location of entries. (𝖯)

Standard MOI.9.1
The medical record contains sufficient information to identify the patient (also see IPSG.1), to
support the diagnosis, to justify the treatment, and to document the course and results of
treatment.
Intent of MOI.9 and MOI.9.1
Every patient assessed or treated in a hospital as an inpatient, outpatient, or emergency care
patient has a medical record. The medical record is assigned an identifier unique to the patient,
or some other mechanism is used to link the patient with his or her medical record. A single
record and a single identifier enable the hospital to easily locate patient medical records and to
document the care of patients over time.
The content, format, and location of entries for a patient’s medical record is standardized to
help promote the integration and continuity of care among the various practitioners of care to
the patient. The hospital determines the specific data and information recorded in the medical
record of each patient assessed or treated on an inpatient, outpatient, or emergency basis. The
medical record needs to present sufficient information to support the diagnosis, to justify the
treatment provided, to document the course and results of the treatment, and to facilitate the
continuity of care among health care practitioners. (Also see MMU.4.1)
Measurable Elements of MOI.9

q 1. A medical record is initiated for every patient assessed or treated by the hospital.

q 2. Patient medical records are maintained through the use of an identifier unique to the
patient or some other effective method. (Also see IPSG.1, ME 1)

q 3. The specific content, format, and location of entries for patient medical records is
standardized and determined by the hospital. (Also see ASC.7.2, ME 2; COP.2.2, MEs 1 and 5;
and PFE.2, ME 3)

Measurable Elements of MOI.9.1

q 1. Patient medical records contain adequate information to identify the patient. (Also see
IPSG.1)
q 2. Patient medical records contain adequate information to support the diagnosis. (Also see
AOP.1.1 and ASC.7, ME 3)
q 3. Patient medical records contain adequate information to justify the care and treatment.
(Also see AOP.1.2; AOP.1.7; COP.2.2, ME 3; and ASC.7, ME 3)
q 4. Patient medical records contain adequate information to document the course and results
of treatment. (Also see ACC.5.3; COP.2.1, ME 6; COP.2.3, ME 2; and ASC.5)
Standard MOI.10
The medical records of patients receiving emergency care include the time of arrival and
departure, the conclusions at termination of treatment, the patient’s condition at discharge,
and follow-up care instructions. (MOI)
Intent of MOI.10
The record of each patient receiving emergency care includes the arrival and departure times.
This information is captured for all emergency department patients, including those who are
discharged from the hospital, transferred to another facility, or admitted as inpatients.
Departure time may be when the patient physically leaves the emergency department to go
home or to another facility, or the time at which the patient is moved to another unit as an
inpatient. For patients who are discharged from the emergency department, the medical record
includes the conclusions at termination of treatment, the patient’s condition at discharge, and
follow-up care instructions. (Also see ACC.1.1, ME 5)
Measurable Elements of MOI.10

q 1. The medical records of all emergency patients include arrival and departure times.
q 2. The medical records of discharged emergency patients include conclusions at the
termination of treatment.
q 3. The medical records of discharged emergency patients include the patient’s condition at
discharge.
q 4. The medical records of discharged emergency patients include any follow-up care
instructions.
Standard MOI.11
The hospital identifies those authorized to make entries in the patient medical record. (𝖯)
Standard MOI.11.1
Every patient medical record entry identifies its author and when the entry was made in the
medical record.
Intent of MOI.11 and MOI.11.1
Access to information contained in the patient medical record is based on need and defined by
job title and function, including students in academic settings. An effective process defines
• Who has access to patient medical records;
• Which information in the patient medical record to which an individual has access;
• The user’s obligation to keep information confidential; (Also see MOI.2) and
• The process followed when confidentiality and security are violated.
One aspect of maintaining the security of patient information is to determine who is authorized
to obtain a patient medical record and to make entries into the patient medical record. The
hospital develops a policy to authorize such individuals. There is a process to ensure that only
authorized individuals make entries in patient medical records and that each entry identifies
the author of the entry and the date. The policy must also include the process for how entries
in the patient medical record are corrected or overwritten. The time of the entry is also noted,
such as for timed treatments or medication orders. (Also see IPSG.2.2; IPSG.4.1, ME 1; COP.2.2,
ME 6; MMU.4.2; and MOI.2)
Measurable Elements of MOI.11

q 1. Those authorized to make entries in the patient medical record are identified in hospital
policy.
q 2. There is a process to ensure that only authorized individuals make entries in patient
medical records. (Also see COP.2.2, ME 4 and MMU.4.2, ME 1)
q 3. There is a process that addresses how entries in the patient medical record are corrected
or overwritten.
q 4. Those authorized to have access to the patient medical record are identified in hospital
policy.
q 5. There is a process to ensure that only authorized individuals have access to the patient
medical record.

Measurable Elements of MOI.11.1

q 1. The author can be identified for each patient medical record entry. (Also see IPSG.2.2;
COP.2.3, ME 2; ASC.5, ME 2; and MOI.11.1.1)
q 2. The date of each patient medical record entry can be identified. (Also see IPSG.2.2)
q 3. The time of each patient medical entry can be identified. (Also see IPSG.2.2)

Standard MOI.11.1.1
The hospital has a process to address the proper use of the copy-and-paste function when
electronic medical records are used. (𝖯)
Intent of MOI.11.1.1
The use of the copy-and-paste function in the clinical documentation done by health care
practitioners is becoming a common practice as more and more hospitals adopt electronic
medical record systems. This practice of duplicating information within the same patient
medical record or moving it across multiple records can have several advantages, including
enhancing the efficiency of documentation and improving communication between
practitioners. However, these benefits must be weighed against the potential risks to the
integrity of the patient medical record.
There are many examples of inaccurate information documented in a patient’s medical record,
some causing severe adverse or sentinel events because the information pasted was not
reviewed and updated to reflect the patient’s current condition or changes in the patient’s
personal information; for example, outdated weight information used for dose calculation of
chemotherapeutic agents. Additional risks as it relates to the use of copy-and-paste include the
following:
• Repetitive information, which makes it difficult to identify the current information
• Inability to identify the author or intent of the documentation (Also see MOI.11.1, ME 1)
• Inability to identify when the documentation was first created
• Duplication of information that results in false information
• Internally inconsistent progress notes
The integrity of the patient medical record is critical to the quality and safety of patient care, as
this is the principal tool for communication between health care practitioners and facilitates
medical decision making, clinical follow-up, transitions of care, and medication ordering and
dosing. (Also see ACC.3) Hospitals using electronic medical records must be aware of the risks of
using copy-and-paste and implement measures in collaboration with health care practitioners
to ensure that this process does not lead to unintended consequences that may result in
patient harm.
There are a number of actions that hospitals can take to help prevent copy-and-paste errors in
electronic medical records, including the following recommendations:
• Develop a process addressing the proper use of copy-and-paste to ensure compliance with
governmental, regulatory, and industry standards.
• Provide comprehensive training and education on proper use of copy-and-paste to all staff
who document in the electronic medical record.
• Monitor compliance with the use of copy-and-paste guidelines, and institute corrective action
as needed.
Measurable Elements of MOI.11.1.1

q 1. The hospital develops a process to address the proper use of copy-and-paste when
electronic medical records are used.
q 2. The hospital provides education and training on the proper use of copy-and-paste to all
staff who document in the electronic medical record.
q 3. The hospital monitors compliance with the use of copy-and-paste guidelines and
implements corrective action as needed.
q 4. The hospital develops a process to ensure that the accuracy of the electronic medical
record is monitored. (Also see MOI.12)
Standard MOI.12
As part of its monitoring and performance improvement activities, the hospital regularly
assesses patient medical record content and the completeness of patient medical records.
Intent of MOI.12
Each hospital determines the content and format of the patient medical record and has a
process to assess medical record content and the completeness of medical records. (Also see
MOI.11.1.1, ME 4) That process is a part of the hospital’s performance improvement activities
and is carried out regularly. Patient medical record review is based on a sample representing
the practitioners providing care and the types of care provided. The review process is
conducted by the medical staff, nursing staff, and other relevant clinical professionals who are
authorized to make entries in the patient medical record. The review focuses on the timeliness,
completeness, legibility, and so forth of the record and clinical information. (Also see MOI.4, ME
6) Medical record content required by laws or regulations is included in the review process. The
hospital’s medical record review process includes medical records of patients currently
receiving care as well as medical records of discharged patients.
In addition, medical records from outpatient, inpatient, and other services provided to patients
are included in the review. A representative sample means medical records from all services
and not a specific sample size; however, it should make sense for the organization. For
example, random sampling and selecting approximately 5% of medical records may achieve a
representative sample. (Also see MOI.4, ME 6)
Measurable Elements of MOI.12

q 1. A representative sample of medical records that includes active and discharged medical
records and inpatient and outpatient medical records, is reviewed at least quarterly or more
frequently as determined by laws and regulations.
q 2. The review is conducted by physicians, nurses, and others authorized to make entries in
patient medical records or to manage patient medical records.
q 3. The review focuses on the timeliness, legibility, and completeness of the medical record.
(Also see MMU.4, ME 2)
q 4. Medical record contents required by laws or regulations are included in the review process.
q 5. The results of the review process are incorporated into the hospital’s quality oversight
mechanism.