Health Record Content and Documentation
What the record must contain
Health record content is shaped by federal Conditions of Participation, state licensure law, accreditation standards, and facility policy. A complete record documents patient identification, consent, history and physical, assessments, orders, progress notes, diagnostic and therapeutic services, operative and procedure reports, nursing notes, medication administration, discharge summary and instructions, and authentication by the responsible practitioner.
Know the difference between the legal health record (whatever the organization designates as its official record of care) and the designated record set under HIPAA, which is broader and includes billing and claims records used in decisions about the patient. The provider owns the medium; the patient owns rights of access to the information.
Timeliness and authentication: accreditation standards require the organization to define timeframes; they do not impose one universal deadline. Verbal and telephone orders must be documented and countersigned per policy. Late entries are labeled late, dated and timed when entered, and never backdated. Corrections are made by addendum or single-line strike-through with initials and date - never by obliteration or deletion.
Release of information: a valid authorization states who, what, to whom, purpose, expiration date, signature, and right to revoke. Psychotherapy notes, substance use disorder records (42 CFR Part 2), and behavioral health/HIV information carry extra protections.
Worked example: a patient requests an amendment. The covered entity must act within 30 days (one 30-day extension allowed), either making the amendment or issuing a written denial with appeal rights. Rule of thumb: consent to treat is not authorization to disclose.
Traps: 'the EHR is the legal health record' (false); assuming a fixed 30-day authentication deadline; confusing retention statutes (state law often controls) with accreditation rules.