Medical record documentation is integral to good patient care, not only in providing the caregiver's opinion regarding diagnosis, course of illness, current problems and management, but also facilitating continuity of care among health care professionals. According to NIH Clinical Center policy, outpatient and inpatient encounters by licensed independent providers are to be documented in the electronic medical records system (CRIS) at least daily for inpatients (twice weekly for behavioral health inpatients) and following each outpatient encounter. For medical records to be meaningful to patient care, entries must be current and accurate. Copying materials from prior progress notes, outpatient notes and admission/discharge summaries may be irrelevant to current patient status or worse, perpetuate errors that may adversely impact patient care.
Health care providers will provide documentation in CRIS that is concise, current, problem-focused and informative to other staff who contribute to patient care, at a frequency consistent with Clinical Center policy. Institute clinical directors are responsible for enacting a quality improvement program that includes a patient record review to ensure high quality medical documentation as well as an opportunity for instructing trainees.