Medical Record Review
Medical Record Review Special Records for Special Conditions—Failure to Thrive
Editors: Lawrence F. Nazarian, MD.
Some pediatricians construct complete and accurate records starting with blank sheets of paper. Others use a variety of forms that lend a predetermined structure to the recorded data. What matters is that the proper data are obtained, then laid out in a fashion that facilitates retrieval and interpretation.
Initiatives aimed at improving the quality and consistency of medical care naturally consider the clinical record a key element in the dispensing of such care. A properly structured chart makes it much easier for an auditor to tell if established criteria are being met. Beyond that function, a properly designed record can remind the clinician of appropriate diagnostic and therapeutic steps and make it more likely that the right data are garnered and written down. For a given condition, a specially designed form can function as an algorithm, guiding the practitioner through the management steps logically and without omission.
"Care map" is one term applied to medical record forms that guide, educate, and document at the same time. It is a challenging task to construct a proper care map, just as it is difficult to fashion a clear and useful clinical algorithm. The major problem lies in deciding what is correct management, especially when some aspects of care are controversial or literature to make unequivocal statements is inadequate.
