Medical Records: What Needs to be Included from a Legal Standpoint?


Alex Fisher and Erin Tolbert, the creator of MidlevelU, discuss what needs to be included in medical records from a legal standpoint. The original article and video, published on MidlevelU, can be found here. Although Erin and Alex discuss medical record keeping in the context of nurse practitioners, the same advice applies to other health care providers, including physicians and physician assistants.

Included in this video are some suggestions for best practices that health care providers should use when prescribing controlled substances to back up their decision making and protect themselves from disciplinary action. These recommendations include:

  1. Document a complete social history including a history of drug and alcohol abuse.
  2. Get a pain management contract in place and maintain this as part of the patient’s medical record for individuals who are prescribed these types of medications on a long-term basis.
  3. Consider drug testing patients who are prescribed controlled substances. Make sure your practice has a protocol in place regarding next steps when drug test results are inconsistent with the patient’s prescribed medication regime.
  4. Discuss (and document!) pain management alternatives before prescribing narcotic medications. Regulatory boards like to see that patients have explored options aside from long term pain management with prescription drugs.
  5. Make use of state controlled substance medication prescribing databases before prescribing controlled substances. In some states this is required by law. Document that you have checked this record.
  6. Don’t prescribe without documentation. Even if you aren’t charging a patient for a visit where controlled substances are prescribed, medical documentation is required.