J Maxillofac Oral Surg. 2011 Sep; 10(3): 199–202. Medical records are the document that explains all detail about the patient’s history, clinical findings, diagnostic test results, pre and postoperative care, patient’s progress and medication. If written correctly, notes will support the doctor about the correctness of treatment. Inspite of
knowing the importance of proper record keeping in India, it is still in the initial stages. Medical records are the one of the most important aspect on which practically almost every medico-legal battle is won or lost. This article discusses the various aspect of record maintenance. Keywords: Medical record, Law, Alteration, Maintenance A good medical record serves the interest of the
medical practitioner as well as his patients. It is very important for the treating doctor to properly document the management of the patient under his care. Medical record keeping has evolved into a science. The key to dispensability of most of the medical negligence claim rest with the quality of the medical records. Record maintenance is the only way for the doctor to prove that the treatment was carried out properly. Medical records are often the only source of the truth. They are likely to
be far more reliable than memory. The management and preservation of the hospital records in Indian context present a very gloomy picture. Despite the intensive effort at national and international level, the fundamental health care needs of the population of the developing countries are still unmet. The lack of basic health data renders difficulties in formulating and applying a rational for the allocation of limited resources that are available for patient care and disease
prevention. It is recommended that more efforts should be made by the institutions/hospital managements, all clinicians and medical record officer to improve the standard of maintenance and preservation of medical records. In this article, we are discussing the various aspects of the medical record management. Monitoring of the actual patient Medical research Medical/dental or paramedical education For insurance cases, personal injury suits, workmen’s compensation case, criminal cases, and will cases For malpractice suits For medical audit and statistical studies Altering Medical Records
Who has Access to Medical Records?
Release of Records
Care while Issuing certain Medical RecordsPrescriptionThe prescription should be preferably on the OPD slip of the institution or on the letter pad of the doctor. Drug company or chemist prescription pad should never be used. Prescription must contain—patient’s name, age, sex, address and institution/hospital name. Prescribed drug should be preferably in capital letter or else clearly visible. One should mention its strength (especially in paediatric age group), its dose frequency, duration in days, and total quantity (number of tablets and capsules). Below the main drug, also mention other instructions of precautions and what to avoid. If any investigation is advised, do not forget to mention it on the prescription slip and call the patient after the investigation. If patient fails to keep follow up date and if then some complication occurs, then patient is also considered negligent (contributory negligence) [1]. ReportsAll reports i.e. lab investigation, X-ray reports, ultrasound reports, computed tomography (CT-scan)/magnetic imaging resonance (MRI) reports, and histo-pathological reports should be issued by a qualified person. Biopsy report should preferably be issued in duplicate so that the referring doctor/hospital can keep the original copy. If the pathologist does not give a duplicate copy the referring doctor should get it xeroxed and should be handed over to the patient. Referral NotesAlways keep the carbon copy of referral note especially in case of critically ill patient. Referral note should mention the date and time of writing the note. Also write the treatment given. Discharge CardConsultant in-charge should himself fill or supervise the discharge card. Condition of the patient on the admission, investigation done, the treatment given and detail advice on discharge should be written on discharge card. Operation notes if mentioned have to be correct otherwise just mention the name of the operation and give separate note in detail if asked for. If any complication is expected after discharge ask the patient to report immediately. Instructions while discharge must be very clear and elaborative. Keep in mind that abbreviations may not be understood by others. Also do not use code messages, sarcasm or poor opinion to the patient. CertificatesA medical certificate is defined as a document of written evidence vouching for the truth of a fact as determined by the doctor issuing such a document. If medical certificate is admitted in a court of law as evidence and is proved to be false, the issuing doctor is liable for punishment. While issuing a medical certificate following things should be kept in mind,
How Long to Maintain the Records
How to Destroy the Records
Hard Copy OnlyComputers are now widely used in institution/hospitals for electronic patient records but still hard copy is required for following documents [1]
Problem of Record ManagementThere are many problems faced by institution/hospital for the proper maintenance of the records. 1. Constant revision of the outdated form is needed [2]. 2. Always trained personnel are needed for the maintenance [2]. 3. Inactive records need storage at appropriate place [7]. 4. There must be a need of determination of record retention [7]. 5. Unwanted records must be destroyed [8]. 6. Record storage entail into 2 stages. A. Moving the records from active to inactive file and from there to storage room. B. Destruction and disposal of the unimportant records [8]. There are various type of damage which may be found in paper documentation like-aged paper may become weak, colour alteration from white to yellow, dirt and dust may be present on the surface, insect and fungus is a big threat for the records, if paper is kept folded, it may become weak at the crease, dampness and water leakage in storage room also destroy the paper. Proper Preservation of the Medical RecordsCollect all the records and classify them according to the different section [7]. Protect the records from insect attack. Spray insecticide or place naphthalene balls over shelves to preserve the records. Plan a periodical checking for the records [3]. Proper care should be observed while handling the records. Fire extinguisher should be available in record room. Protect all records from dampness, water, and from hot and dry climate [8]. Records should be kept in dust free area. Windows and ventilators should be properly covered with frames as safeguard against sabotage. Destroy the records as per the regulation established for retention of records. ConclusionMedical records form an important part of a patient management. It is important for the doctor and medical establishment to properly maintain the records of the patient for 2 important reasons. First one is that it helps in proper evaluation of the patient and to plan treatment protocol. Second is that the legal system relies mainly on documentary evidence in cases of medical negligence. Therefore, medical records should be properly written and preserved to serve the interest of doctor as well as his patient. References1. Behere SB. Doctor & law. Dr People. 2010;2(7):11–14. [Google Scholar] 2. Singh S, Sinha US, Sharma NK. Preservation of medical records—an essential part of health care delivery. IIJFMT. 2005;3(4):1–8. [Google Scholar] 4. Baldwa M. Practical definition of medical negligence. Dr People. 2010;2(7):5–10. [Google Scholar] 5. Basu RN, Bose TK. Medico-legal aspect of clinical and hospital practice. Mumbai: English Edition Publishers; 2005. pp. 86–89. [Google Scholar] 6. Navarange JR. Medical negligence. Dr People. 2009;2(4):4–7. [Google Scholar] 7. Modi CD. Organisation and management. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2001. pp. 348–361. [Google Scholar] 8. Agarwal OP, Barkeshli M. Conservation of books, manuscript and paper documents. Lucknow: INTACT; 1997. pp. 25–48. [Google Scholar] Articles from Journal of Maxillofacial & Oral Surgery are provided here courtesy of Springer Which of the following records are kept indefinitely?Vital papers such as financial reports and legal documents are considered permanent records and are kept indefinitely in a secure file (see Table 8-1).
When patient records can be eliminated they must be completely destroyed This is accomplished by?are those of patients whom the doctor has not seen for 6 months or longer. HIAA recommends to keep records for at least 2 years. destroyed them by shredding or though a professional destruction service.
What is medical record management Chapter 43 quizlet?What is medical record management? The process of controlling and handling medical records from the time a record is created until it is places in permanent storage or destroyed. ( 1009)
|