Medical Records

MEDICAL RECORDS

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Introduction

·       Medical Records are the legal documents providing a chronicle of a patient’s medical history and care

·       Members of healthcare team that can make entries in medical records are

o   Consultants

o   Nurses

o   Technicians

o   RMOs

·       Medical records includes a variety of notes entered over time by the healthcare professionals

 

Uses, Components, Labelling, Issue, Functions & Process of Medical Records

·       Uses

o   To document the course of illness & treatment

o   Communicate between attending doctor and other healthcare professionals

o   Collection of health statistics

o   Legal matters & Court cases

o   Insurance cases

·       Components

o   Identification summary sheet

o   Consent for treatment

o   Legal documents

o   Discharge summary

o   Admission notes

o   Clinical progress notes

o   Nurse progress notes

o   Operation report

o   Investigation reports (X-ray, USG, CT etc.)

o   Orders for the treatment and medications with signature of the doctor & nursing staff

·       Labelling

o   Patients name

o   Patients medical record number

o   Year of the last attendance

·       Issue of Medical Records

o   A UHID (Unique Hospital Identification Details) given to a medical record

o   UHID should be issued in a straight numerical order

o   In a computerized system the UHID is auto generated

o   UHID is permanent

·       Functions

o   Filling of records

o   Retrieval of records

o   Completion of records after discharge

o   Coding disease

o   Completion of statistics

o   Release of information in MLCs

·       Process

o   Nursing until keeps the patient records after the discharge of the patient

o   A list of patient record is prepared and given to the MRD with patient case sheet

o   Checking of records

o   Sorting of records

o   Tied the records & place them in racks after labelling

 

Retrieve, Sequence, Completion, Release, Retention, Responsibility and Quality Indicators of MRD

·       Retrieve

o   The retrieve form is filled up by the concerned person

o   After approval from MS, given to MRD officer

o   MRD officer gives the person the record in duplicate & notes down the number of pages in the form & takes signature

o   After giving the records back, the person signs on that form

·       Sequence

o   Information & identification sheet

o   Clinical notes

o   Diagnostic reports

o   Blood transfusion notes

o   Nurse notes

o   Informed consent

o   X-ray films are stored separately

·       Completion

o   Consent form for treatment has been signed by the patient

o   Patient identification details are correct and entered on all forms

o   Doctors have recorded all essential information

o   Doctors have signed and dated all clinical entries

o   Front sheet has been completed and signed by the attending doctors

o   Nurse have recorded and signed all daily notes

o   All orders for the treatment have been recorded in the medication form and signed

o   Medication administration has been recorded and signed

o   Anaesthesia form has been completed and signed

o   Operation form has been completed and signed

o   Diagnostic reports have been attached

o   Discharge/referral summary is dully filled and signed

·       Release of Information in MLC

o   Requests from lawyers are usually registered

o   Date of receipt of request recorded by the hospital administration and forwarded to the MRD for processing

o   Medical record is located and the patient signature checked against the signature on the consent form in the medical record

o   Information request is identified

o   Attending doctor is asked to write a report

o   If a discharge summary is already in the records, it is checked and a copy is made

o   Discharge summary will save the doctor having to write a new report

o   MRD officer notices the hospital administration that the report has been sent

·       Retention

o   OPD Records (5 years)

o   IPD Records (10 years)

o   MLC Cases (30 years)

·       Responsibilities of MRD Officer

o   Management of MRD

o   Development, analysis and technical evaluation of clinical records

o   Development of secondary records (indexes)

o   Preservation of medical records

o   Development of statistics

o   Assistance to medical staff

o   Cooperation with all other departments

o   Pest control measure in MRD at equal intervals

·       Quality Indicators of MRD

o   Are medical records filed promptly?

o   Is the file room clean and tidy?

o   Are master patient index cards filed?

o   Are the medical records complete?

o   Are medical record form filed in the correct order?

o   Are medical records coded correctly?

 

Ethical and Legal Responsibilities

·       Ethical Responsibilities

o   Put saving of life and promotion of health above all else

o   Make every effort to keep patient as comfortable as possible and to preserve life when possible

o   Respect patient’s choice to die peacefully and with dignity (advanced directive)

o   Treat all patients equally (avoid bias, prejudice, and discrimination)

o   Provide care for all persons to the best of your ability

o   Maintain competent level of skill consistent with occupation

o   Maintain confidentiality –Gossiping about patients is ethically wrong

o   Avoid immoral, unethical, or illegal practice Rules of Ethics (cont)

o   Show loyalty to patients, co-workers, and employer

o   Be sincere, honest and caring

·       Legal Responsibilities

o   Avoid Malpractices

§  Providing improper or unprofessional treatment or care

§  Ex: doctor amputating the wrong limb in surgery

§  Nurse prescribing medication or performing minor surgery

§  Liability insurance is available to health care professionals to protect them in such events

§  The cost, particularly for physicians has become a financial burden for the professional

§  Some states have higher malpractice rates than others, prompting physicians to move to other states with lower rates

o   Avoid Negligence

§  Failure to provide care that is normally expected of a person equally trained in that particular situation, resulting in injury to the patient

§  EX: Ordered side rails left down and patient falls from bed

§  Using or not reporting defective equipment that injures patient

§  Patient develops infection from poor sterile technique by the nurse

§  Patient burned from bath water that was too hot

§  Negligence by a healthcare provider is malpractice

o   Informed Consent

§  Permission granted by a person of sound mind of legal age after the procedure and all risks have been explained in term the patient understands

§  Procedures requiring written consent:

·       Surgery

·       Invasive diagnostic tests

·       Treatment of minors

·       Side rail releases (if doctor order)

o   Verbal Consent

§  Permission is granted after procedure has been explained to patient

§  Ex: giving an injection, taking a blood pressure, drawing blood for a lab test, starting an IV, performing physical exam

§  Patient may withdraw consent at any time

§  Never perform a procedure on a patient without consent

 

Confidentiality

§  All information given to health personnel by a patient is considered privileged communication, and by law must be kept confidential

§  Health care records are also considered privileged communications

§  Discuss patient information only with immediate supervisor

§  Do not discuss with:

o   Other patients

o   Relatives and friends of the patient

o   Visitors to the hospital

o   Representatives of news media

o   Fellow workers, except when in conference

o   Your own relatives and friends

§  A medical facility, a physician, or health care worker can be fined, sued, or lose their job for sharing nay information about patients with others

§  Information cannot be told to anyone without written consent of the patient

§  The consent should state the following:

o   What information is to be released

o   To whom the information is to be given

o   Any time limits

 

Preparation of Miscellaneous Medical Reports

§  Preparing medical reports requires attention to detail, accuracy, and adherence to ethical and legal standards.

§  The specific format and content of medical reports may vary depending on the type of report and the medical specialty involved.

§  Here's a general guide on how to prepare miscellaneous medical reports:

 

1. Patient Information:

Begin with the patient's demographic information: name, age, gender, and any relevant identification numbers.

Include the date of the report.

 

2. Medical History:

Provide a brief summary of the patient's medical history, including relevant past illnesses, surgeries, and family medical history.

Highlight any chronic conditions, allergies, or medications.

 

3. Chief Complaint:

Clearly state the reason for the medical report. Include the patient's main symptoms or concerns.

 

4. Present Illness:

Detail the current health status, focusing on the symptoms, their onset, duration, and any factors that worsen or alleviate them.

Include relevant information about lifestyle factors, such as diet, exercise, and habits.

 

5. Physical Examination:

Document the findings of the physical examination, including vital signs (e.g., blood pressure, heart rate), general appearance, and specific organ systems examined.

Note any abnormalities or significant findings.

 

6. Diagnostic Tests and Results:

Include the results of any diagnostic tests performed, such as blood tests, imaging studies, or other relevant investigations.

Provide normal reference ranges for comparison if applicable.

 

7. Diagnosis:

Clearly state the diagnosis based on the available information.

Include any differential diagnoses considered and the rationale for the final diagnosis.

 

8. Treatment Plan:

Outline the recommended treatment plan, including medications, procedures, lifestyle modifications, or other interventions.

Specify the frequency and duration of treatment.

 

9. Prognosis:

Provide an assessment of the patient's prognosis, considering the nature of the condition and the effectiveness of the chosen treatment plan.

 

10. Follow-up Recommendations:

Suggest any necessary follow-up appointments, tests, or monitoring.

Indicate when the next medical review is advised.

 

11. Conclusion:

Summarize the key points of the report.

Reiterate the importance of follow-up and compliance with the treatment plan.

 

12. Signature and Credentials:

Include the name, signature, and professional credentials of the healthcare provider responsible for the report.

 

13. Confidentiality:

Ensure that patient confidentiality is maintained throughout the report.

 

14. Language:

Use clear, concise, and jargon-free language that can be understood by patients and other healthcare professionals.

 

15. Legal and Ethical Considerations:

Adhere to legal and ethical guidelines governing medical documentation in your jurisdiction.

 

§  Remember that the specific requirements for medical reports may vary, so it's important to follow any guidelines or templates provided by your institution or regulatory body.

 

General Principles for Complete Documentation in Medical Records

§  Certainly! Creating complete and accurate medical documentation is crucial for patient care, legal purposes, and effective communication among healthcare professionals.

§  Here are some general principles for complete documentation in medical records:

 

Legibility:

 

Ensure that all entries are clear and legible. Illegible handwriting can lead to misinterpretation and potential errors in patient care.

 

Timeliness:

Document information promptly after the event occurs to capture details accurately. Delayed documentation can lead to forgetfulness and compromise the quality of the medical record.

 

Objectivity:

Be objective and unbiased in your documentation. Stick to the facts and avoid subjective language or personal opinions.

 

Clarity and Conciseness:

Use clear and concise language to convey information. Avoid unnecessary jargon or overly technical terms that may be difficult for non-specialists to understand.

 

Completeness:

Include all relevant information about the patient's condition, treatment, and response to interventions. Document any changes in the patient's status and the reasoning behind clinical decisions.

 

Relevance:

Focus on information that is relevant to the patient's current condition, treatment, and overall healthcare. Irrelevant details may clutter the medical record and make it harder to extract essential information.

 

Accuracy:

Ensure that all information is accurate and reflects the actual events. Inaccurate documentation can lead to incorrect diagnoses and inappropriate treatments.

 

Consistency:

Maintain consistency in your documentation style. Use the same terminology and abbreviations consistently throughout the medical record.

 

Authentication:

Sign and authenticate all entries with your credentials. This helps to establish accountability and confirms the authorship of the documentation.

 

Patient-Centered Approach:

Clearly document the patient's complaints, symptoms, and concerns. In addition to clinical data, consider including information about the patient's preferences, values, and goals of care.

 

Confidentiality:

Adhere to patient privacy laws and regulations. Avoid disclosing sensitive information to unauthorized individuals.

 

Communication:

Use the medical record as a tool for communication among healthcare team members. Clearly document any instructions given or received, as well as consultations with other specialists.

 

Emergency Situations:

In emergency situations, document the events as soon as possible, even if it means providing initial information on a temporary basis.

 

Follow Organizational Policies:

Familiarize yourself with and adhere to the documentation policies and procedures of your healthcare organization.

§  Remember that accurate and complete medical documentation is essential for providing quality patient care, ensuring legal compliance, and facilitating effective communication among healthcare professionals.

 

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