What? Who? Me!‪!‬

The medical record is the single, tangible tool that can be used to accurately access reflect the quality of medical care rendered to patients in a hospital. Judgment of the medical record should be made only by qualified members of the medical staff, who serve on its reviewing committees: medical record, medical audit, and tissue. In addition, the medical record should serve as a scientific teaching tool in the education of interns and residents, as well as in the continuing education of practicing physicians.

To ensure quantitative and qualitative completeness of the medical record, the medical staff of the Barberton Citizens Hospital has set policies in its rules and regulations governing these records. The responsibilities of the attending and house physician are made explicit. The reviewing committees are obliged to insure adherence to these policies.

The medical record librarian and her staff, upon receipt of the chart from the floor, grade it for clerical deficiencies. Factors such as the quantity of progress notes, presence or lack of consultation notes, completeness of history or physical examination should not be left to the discretion of the medical record department personnel. Such elements are only to be judged by physicians. However, in instances of obvious deficiency, the medical record librarian should seek the opinion of the chairman of the medical record committee. He should then decide what steps, if any, should be taken.

The policies concerning medical records in the rules and regulations are set before the medical staff. They need only be followed to produce good records that are a true picture of the care being rendered. However, it must be reemphasized that the ultimate responsibility for providing a good medical record rests with the physician of record. Members of the house staff, nursing service, and many other paramedical personnel assist him in the care of his patient; nevertheless, it is he who must authenticate the accurate recording of this care.