CHAPTER 1

Brian T. Harel, Brett A. Steinberg,

and Peter). Snyder

The Medical Chart:

Efficient InformationGathering Strategies and
Proper Chart Noting

The medical chart is a repository of clinically and researchoriented information regarding an individual patient. Thus, a
patient's medical history and responsiveness to various clinical
interventions (i.e., pharmacological, surgical, psychological, rehabilitative), as well as data that may be used in retrospective
clinical research studies, are contained within the chart. Having
this information in a single, standard format means that it may
serve as a vehicle of communication among all health care providers, documenting and coordinating, in a systematic and integrated manner, all care administered to an individual patient.
Without this vehicle of communication, the multidisciplinary
approach to patient care in a hospital setting would be impossible. Because of this, the medical chart also serves as a record of
care should any liability issues arise. With regard to psychiatric
issues such as suicide, for example, the medical chart would be
checked to ensure that proper assessment and precautionary
procedures were followed. More specific to neuropsychologists,
the medical chart serves to document the information that led
to any diagnosis we might offer, should concerns regarding an
evaluation arise.
Another aspect of liability involves the privacy and security
of a patient's medical chart. On April 14, 2003, the privacy
rule of the Health Insurance Portability and Accountability Act
(HIPAA), which was signed into law in August 1996, became

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active (U.S. Department of Health and Human Services, Office

of Civil Rights, 2003). The general goals of this legislation are
to protect previously ill Americans who change jobs or residences from losing their health insurance and to provide standards for the electronic transmission of medical information.
The second aspect of this legislation has direct relevance for
both the privacy and the security of electronically stored medical
information. Although a thorough discussion of HIPAA is beyond the scope of this chapter, there are two general points
that are directly relevant to our profession. The first is that
HIPAA regulations allow patients greater access to, and knowledge of, their own medical records. It is worth noting that psychotherapy notes are now considered protected health information and are more difficult for the patient to gain access to. The
second is that the implementation of HIPAA requires psychologists to receive additional training to be in compliance with the
privacy rule. The increased emphasis on maintaining privacy
and confidentiality, while at the same time allowing for increased patient access to their own records, means that clinicians
need to be very careful in both writing and protecting the security of their patient records.
Despite the changes that are taking place as a result of
technological advances in the storage and transmission of medical data, and the critical importance that the medical chart plays
in coordinating and documenting all facets of patient care, there
are relatively few sources of information that describe the basics
of proper chart review and chart noting for neuropsychologists
who practice in a hospital setting.
I. THE CHART REVIEW
Experienced neuropsychologists, like other hospital-based
health care specialists, have developed efficient strategies for
obtaining information from the medical chart that is pertinent
to their evaluations. The fact that the chart is a repository of
information from medical staff across a variety of disciplines
(e.g., neurologists, surgeons, physical and occupational therapists [PT/OT], and nurses) requires that the neuropsychologist
have a working knowledge of the language and techniques used
in other areas of health care. We are not suggesting that neuropsychologists be experts in other fields, but rather that they
be capable of conversing with patients' medical care providers
and that they have some understanding of the strategies and
techniques used in other disciplines (e.g., neurologic diagnosis,
patient management techniques, and strategies for providing

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11

day-to-day patient care). At the same time, however, neuropsychologists should be aware of the limits of their professional
competencies and thus be wary of Interpreting data outside of
their areas of expertise.
When reviewing the medical chart, it is also important to
keep general clinical issues in mind, such as psychosocial and
environmental factors, so that treatment recommendations will
be optimally effective. To do this, neuropsychologists must be
skilled at behavioral and psychological assessment and
intervention.
Although it may not be necessary to review all of the sections of the medical chart, it is important to be aware of the
various contents should the need arise to find specific data.
The following is meant to orient neuropsychologists to a few
of the most applicable sections of a typical chart by providing
brief descriptions of the pertinent information contained in
each section. Not all medical settings will use the same format,
however. (It is worthwhile to note that charts are full of medical
abbreviations and acronyms. The Appendix at the back of this
text provides a listing of the more common abbreviations, and
most hospitals publish their own lists of abbreviations that are
approved for use in medical charting at that institution.)
A. Sections of the Chart
1. Referral Information/History and Physical (H&P) contains
referral history, admission history, and results of physical examination.
2. Admission Data contains general consent form, initial
assessments and evaluations, social work intake/
psychosocial consult.
3. Pharmacy contains pharmacy orders.
4. Treatment contains admission protocol, treatment orders, physician order sheet.
5. Progress Notes contains problem list, progress notes for
all disciplines.
6. Consultations-Medical contains consultation records
for physician, physiatry, psychiatry, neurology,
psychology.
7. Evaluations/Assessments contains audiology, OT/PT
evaluations, pressure sore flowsheet, social work
evaluations.
8. Advance Directives contains power of attorney and probate papers.
9. Chemistry/Hematology/Urinalysis/Stool contains labs.

12 Harel, Steinberg, and Snyder

10. Microbiology contains labs.

11. X-Ray contains cardiac rhythm sheet, echocardiogram,
electrocardiogram (EKG), electromyography (EMG),
modified barium swallow results, sleep study, x-ray,
and neuroimaging data.
12. Care Plan/Critical Path contains individual treatment
plan (IIP), patient care plan, and behavior management plans (BMPs).
B. Steps for Reviewing the Chart

As the previous section indicates, the medical chart stores data

that can be used to develop a conceptual framework within
which the neuropsychological assessment results can be interpreted. For example, review of the chart might reveal information regarding psychoactive medications that could be influencing test performance or affecting the patient's symptoms in
a way that might not otherwise be readily apparent. Therefore,
we offer several suggested steps to more efficiently direct the
neuropsychologist's review of the chart:
1. Clarify the referral question. This will help to guide the
review of the medical chart in an organized and efficient
manner. If, for example, a patient is referred for evaluation following a stroke, the neuroimaging and PT/OT
notes may yield information regarding the arterial territory and functional consequences, respectively, of the
vascular event.
2. Read through the initial history and physical examination (H&P), which generally contains the following
components (for a more detailed review, see Blumenfeld, 2002):
a. Chief complaint (CC) contains presenting complaint
along with brief pertinent background data.
b. History of present illness (HPI) contains complete history
of current illness that brought patient to hospital.
c. Past medical history (PMH) contains information
about prior medical and surgical problems.
d. Review of systems (ROS) contains brief review of
medical systems (e.g., head, eyes, neurologic, and
OB/GYN).
e. Family history (FHx) contains a list of immediate relatives and any family illnesses.
f. Social and environmental history (SocHx) contains information about work history, family relationships,
and so on.

The Medical Chart

3.

4.

5.

6.

7.

13

g. Medications and allergies contains lists of current medications as well as allergies.

h. Physical exam contains information about general appearance, vital signs (temperature, pulse, blood pressure, and respiratory rate), HEENT (head, eyes, ears,
nose, and throat), neck, back and spine, lymph
nodes, breasts, lungs, heart, abdomen, extremities,
nervous system, reproductive system, and skin.
i. Results of lab studies contains data from diagnostic
tests (e.g., blood work, tissue biopsy, and radiological tests).
j. Assessment and plan contains brief summary along
with diagnosis and suggested interventions.
Review reports pertaining to relevant neuroimaging
studies (computed tomography [CT], magnetic resonance imaging [MRI], single photon emission computed
tomography [SPECT], position emission tomography
[PET], and cerebral angiography). Also, read any available electroencephalography (EEG) or neurosurgical reports available in the chart.
Review laboratory data for abnormally high or low critical blood or urine test values, for liver function tests, as
well as for positive results of drug screen tests. (Chapter 3
of this book provides a review of how such important
laboratory studies should be read and interpreted by the
neuropsychologist.)
Review current medications and dosages as well as
whether the patient recently has been taken off or
started on a medication that might have a negative
impact on neuropsychological functioning.
Review prior consultation reports from the medicine,
neurology, radiology, neurosurgery, psychiatry, and
physiatry services. In particular, it may be useful to focus
on the initial and most recent reports so as to have a
sense of current functioning as well as progress made
to date. (Chapter 2 of this book provides a review of
the organization and writing of standard neurological
consultation and progress notes. In addition, references
are included at the end of the present chapter.)
Review progress notes from other relevant disciplines,
such as nursing, nutrition, social work, and OT/PT.
These notes are useful because they may provide a fairly
detailed description of the patient's behavior on admission, level of cooperation with hospital staff, arousability
and alertness, as well as any socially inappropriate or

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potentially hazardous behaviors. When possible, it is

also useful to briefly interview the nursing staff prior to
the examination.
8. Note the schedule of appointments, as this is likely to
influence the patient's ability to perform optimally during neuropsychological testing. For example, several
hours of FT will likely affect a patient's performance on
testing that occurs immediately afterward.
II. THE PROGRESS NOTE
The progress note serves as a more immediately accessible summary of the most salient points of the evaluation. Ultimately,
a progress note should give the reader (e.g., attending physician)
sufficient information regarding the implications of the evaluation so that appropriate care can be provided. Because the progress note functions as a brief summary of the neuropsychological
evaluation, it should be written as soon after the evaluation
takes place as is reasonably possible. (For maximum usefulness
in patient care and in disputes about liability, notes should
include the dates and times that they were written.) Although
we discuss the general types of information that should be included in the progress note, each facility has its own tradition
and culture for writing progress notes.
Initially, we clearly state the reason for the evaluation,
including the referral source and question. In much the same
way that the referral question directs the review of the medical
chart, the referral question should direct the way the note is
written (e.g., the language used and specific issues addressed).
Behavioral observations and judgments about the validity of
the results are then presented. We typically highlight the salient
test findings by addressing each functional domain with a oneor two-sentence summary of performance. (To keep this brief,
it is important to focus on neurocognitive domains rather than
on individual test scores. We may, however, include IQ scores
to provide a quantitative frame of reference for the reader's
interpretation of other findings.) In addition to the neuropsychological test report data, we include data regarding psychological functioning (e.g., risk of harm to self or others, level of
arousal, level of cooperation during examination, and mood
and affect). This is followed by a brief summary of our diagnostic
impressions and the implications of the results as they relate
to the original referral question. If it is appropriate, the prognosis
can also be discussed in terms of time since injury or onset of
the disease, treatment progress, efficacy of medication(s), and

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15

what is currently known about the condition. Furthermore,

recommendations that can be readily implemented and are of
an immediate nature are included. Finally, as a courtesy, we like
to thank the referral source for the opportunity to participate
in the patient's care.
Once a progress note is written, it immediately becomes
part of that patient's medical record. It is important to remember
that this record is regarded as a legal document and that once
information is entered into the record, it becomes permanent.
For this reason, if an error is made while writing (e.g., a misspelling or an incorrect drug name), it should not simply be scratched
out or covered with correction fluid (e.g., White-Out). Instead,
the error should be crossed out, the correct word should be
printed above or next to it, and the writer's initials should be
signed in the same place. If an error is discovered after an entry
is complete then a new entry should be entered into the record.
This new entry should identify the date, time, and nature of
the error that was discovered; it should provide the correct information; and a note should be placed at the location of the old,
erroneous note indicating that an error was found and when
the revision was added. Finally, it is worth noting that neatly
written progress notes are more likely to be useful and to be
appreciated by colleagues.
III. THE FUTURE OF MEDICAL RECORDS
Although the electronic storage and transmission of medical
charts has engendered concerns regarding privacy and security
(as is apparent by the enactment of HIPAA), it also offers considerable possibility. As records become electronic documents, several potential benefits may improve patient care. The first is
that information will become accessible more quickly and be
available to a greater number of health care professionals. In
addition, search engines will allow for a more interactive experience between the medical staff and the medical chart. For instance, algorithms designed to seek out and compare information within the chart will be able to offer "suggestions" as to
what type of antidepressant should be used based on information about the patient's current medications, sleep and eating
habits, response to a similar class of drugs taken in the past,
diagnoses, and so on. In response to the advancement in computer technology, for example, Rollman et al. (2001) evaluated
the utility of providing screening and feedback for the initial
management of major depression to primary care physicians via
electronic medical records. Rollman et al. found that "electronic

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notification of the depression diagnosis can affect the primary

care provider's initial management of major depression"
(p. 197). That is, when provided with such electronic notification, the primary care providers were found to respond more
rapidly and to manage their patients closely from that point
forward. Of course, future research will be needed to determine
to what extent this will improve clinical outcomes.
IV. CONCLUSION
This chapter provides a basic overview of how to thoroughly
review inpatient medical charts and how to responsibly convey
clinical impressions and recommendations through effective
chart noting.
BIBLIOGRAPHY
Blumenfeld, H. (2002). Neuroanatomy through clinical cases. Sunderland, MA: Sinauer Associates.
Rollman, B. L., Hanusa, B. H., Gilbert, T., Lowe, H. J., Kapoor,
W. N., & Schulberg, H. C. (2001). The electronic medical
record: A randomized trial of its impact on primary care
physicians' initial management of major depression. Archives
of Internal Medicine, 161, 189-197.
U.S. Department of Health and Human Services, Office for Civil
Rights. (2003). Medical privacy: National standards to protect
the privacy of personal health information. Retrieved April 11,
2003, from http://www.hhs.gov/ocr/hipaa/