For each of the qualities listed below, please describe the consequences if the quality is missing from the medical record?Accuracy Accessibility...

The Medical Record is used for clinical communication and
care planning.  Health care companies, employers, payers and patients, use information
in the medical record.  It documents the basis for care and treatment of the patient. 
It must include documentation to support payment for services.  It must protect the
legal interests of the patient and the doctor.  Finally, the medical record provides
data usable in medical research.

Here is your list of
factors and the consequences if they are missing from the medical
record:

Accuracy:  It goes without saying that accuracy is
crucial.  Incorrect information or data in the medical record can lead to treatment
errors, patient harm and even death.

Accessibility:  The
medical record must be accessible to all members of the health care team in order for
each team member to participate correctly in the care of the patient.  It must also be
available to the health insurance company to ensure proper payment for medial
services.

Comprehensiveness:  The medical record must be
complete and comprehensive.  It must reflect a full and thorough medical “work-up” of
the patient, and show all needed supporting tests, X-rays and examinations so that
another health care worker could, if necessary, determine the correct diagnosis and
treatment.  The medical record is the only permanent source of information about the
evaluation, testing and treatment of the patient.  Without a complete medical record,
the medical examinations and tests lose their
value.

Consistency:  It is important for the practitioner
to be consistent in her medical record keeping.  This means that she creates a proper
medical record as described herein for each and every patient
encounter.

Currency:  Medical records must be created at
the time of patient encounter.  It does no good to see and diagnose a patient without
documenting the visit.  For example, if a patient is examined and found to have a
penicillin allergy, it is dangerous and unacceptable to fail to document this
immediately on the patient chart.

Definition:  This term is
somewhat vague with respect to the medical record.  Surely, however, it is important
that descriptions and diagnoses are clearly defined in the medical record so that other
practitioners can use the record to reach the correct conclusion about the patient’s
condition and treatment.

Granularity:  This term is not
ordinarily considered a quality of the medial
record.

Precision:  Like definition, precision of
terminology (and consistency thereof) should occur throughout the medical
record.

Relevancy:  The record should contain all
information needed to establish and confirm the diagnosis and proper treatment of the
patient.  It should NOT contain irrelevant and extraneous material.  Nor should the
medical record contain subjective information about the patient that has nothing to do
with her care.  It should never contain personal, derogatory comments about the
patient.  Information that might infer that the physician is biased against the patient
for some reason must be omitted.

Timeliness:  See
“currency” above.

Please see the reference for a treatise
on Maintaining Accuracy and Compliance in the Medical Record.