MEDICAL RECORD

2. MEDICAL RECORD • Prof. Sulaiman Al-Shammari

3. medical records and information • Why keep records?(functions?) • Problem oriented medical records(POMR) • Organising the medical records • Storage of medical records • An information system for PHC • Arrangement of primary health care medical records • Sharing medical records with patients

4. Why keep records?(functions)

5. 1.Why keep records?(functions) *a permanent record of significant events *unique continuing record of health and illness WHAT IF *no record of significant events *lost record *no past data *accuracy not very high

6. 2.Why keep records?(functions) *A medico-legal record *important if complaint or legal action arises *Both negative and positive findings are important (e.g.x-ray normal)

7. 3.Why keep records?(functions) * A way of communicating with colleagues and other team members * single-handed doctor needs to remind himself. *PHCT (doctors on deputies and others)should be aware of main facts such as: *past and present diagnoses *current treatment *allergies or warnings

8. 4.Why keep records?(functions) *Jacket for hospital &laboratory reports &letters *information needs to be accessible or it useless So What to do with Bulky Records: *A4 files are useful in this respect *Throw useless or duplicated information *Computerization

9. 5.Why keep records?(functions) *A record of drugs prescribed * accurate record of doses and quantity for : *use within practice *medico-legal and research(adverse reaction)

10. 6.Why keep records?(functions) *an side memoire *reminder for patient’s personal doctor *what he told the patient ? *what was in the back of his mind ? *what he planned for next visit ? *much of this is of short term value and can be discarded once the episode is : *over *summary completed

11. Problem Oriented Medical Record(POMR) - new move - more logical particularly at the stage before a firm diagnosis - help doctors to: *see patient’s problem *define his own problem *avoid jumped to a diagnosis too early pomr consist of: 1. Identifying particulars and background information(data base)e.g -name, number etc - immunisation etc -health questionnaire -patient to check accuracy 2. Clinical or progress notes 3. The problem list 4. The flow chart 5. The drug list

12. TYPES of MEDICAL RECORDS • Traditional POMR • a)history a)subjective • b)examination b)objective • c)diagnosis c)assessment • d)investigation d)plan • e)treatment (i)tests • ( ii)treatment • (iii)patient education

13. Organising the medical record • -continuation sheet • -summary sheet • -obstetric record • -child immunisation card • -child development record • -contraceptive record • -repeat prescription record • -hypersensitivities • -problem lists • -flow charts • -laboratory report sheets

14. These Stationery • -is available from the health authority • -must be kept in a logical and agreed order • -fastened together by metal clip or staple atc • old continuation sheet can be summarised and then discarded. • redundant letters and reports can be destroyed. • *NB :time invested in an efficient record system pays off when the doctor needs to retrieve information about the patient in an emergency: • - design a system • - staff can use slack periods • - avoid generating bulky records without good reason • - throw away redundant information • - record of dead patients can be retuned to health authority

15. Legibilty Notes must be legible -typewritten -dictated

16. Missing Notes -Reasons *in doctor car or research *misfiling -during transfer from doctor to doctor -Solution *a system for urgent transfer of medical record *telephone call to previous doctor *computer *cooperation cards e.g. obstetric ,diabetic,geriatric patient *a copy of summary sheet and database carried by the patient *market out borrowed notes like library books.

17. Storage of Medical Records Aim:quick and accurate retrieval of records

18. 1.Main methods of Storage of MR *lateral or shelf filing -more space -easy access -misfiling can be reduced by colour coding or diagonal strip

19. 2.Main methods of Storage of MR *rotary files -more efficient use of space -more confusing (not same fixed point) -coloured tape or card as starting point is helpful

20. 3.Main methods of Storage of MR *cabinet files -may be satisfactory in small practice -time wasting -more likely to cause fatigue or injury -can be locked –advantage

21. 4.Main Methods of Storage of MR * More elaborate and expensive system e.g -multi-stack lateral systems on rails -electrically operated banks of filing trays -advantage limited space

22. Filing methods • small practice-alphabetical • Large practice-numerical • Colour coding by doctors

23. Family records • common family folder • Family book or card • Family chart

24. Confidentiality of MR and information • strict policy and procedure • Strict rule for access to medical records • *do NS,HV,MW,SW have access? • *are they permitted to take them to their office ? • *are doctors ,staff and their families medical records filed separately under moreSecure conditions ? • locked filing cabinets or rooms • Cleaning only when staff are present • MR and reports should not be left unattended.

25. Patients views on records • trust doctor or other staff • Access to notes • Access of police and others to notes • Computerised records and confidentiality

26. Logs and registers of practice activity • for assessment of workload • Efficient day-to-day running of service • Examples: • 1.log of patients seen by each doctor • 2.register of hospital appointment requested • 3.register of hospital transport requests • 4.register of x-rays requested • 5.register of deaths • 6.day book for recording messages • 7.log of practice nurse’s workload

27. An information system for PHC The basic raw material: -consultations per annum -other items of serves (eg prescriptions ,telephone contacts) -laboratory tests -x-ray reports -referrals to hospital -admissions to hospital

28. The records has to serve the needs of: 1.preventive medicine-at risk groups 2.quality control-patient recall, performance review 3.practice planning administration and finance 4.education-doctors ,staff, trainee ,patients 5.research

29. *different coloured cards for males and females including name address date of birth & arranged in birth date order -must be kept up to date -what use is it? 1.checking child health screening or immunisation of children up to age 5 2.checking rubella immunisation of 11 year old girls 3.preparing lists for cervical screening of women aged 35-65(year intervals) 4.preparing lists for hypertension screening 5.Preparing an age-sex profile of the practice. 6.preparing an age-sex profile of the practice.

30. Age-sex register -identify people at risk What is it?

31. *NB:unless there is active preventive medicine or research taking place in the practice the labour of preparing the register is not cost effective. *the disease index (diagnostic index) -list of patients with certain disease -notes can be colour tagged

32. Clinical and drug information -come from many sources *memories or notes from medical school or post graduate lectures *consultants RECOMMENDAIONS *medical journals *text books *drug company promotion *government publications and circulars *audio or video cassettes *computerised date system

33. References 1.management in general practice by peter pritchard et al 2.oxford general practice

34. Arrangement of primary health care MR 1.initial patient profile 2.referrals 3.problem list 4.primary care *physicians notes ) *yellow coloured page )in chronological order *pink coloured page ) 5.diabetes mallitus flow chart 6.hypertension flow chart 7.other specialities notes *obstetetrice and gynaecology *ophthalmology ENT 8.accidents and emergency notes 9.nutrition clinic notes 10.lab results: *histopathology *cytology *blood grouping *hematology *clinical biochemistry yellow red blue green brown *serology *virology *general microbiology *parasitology *urine

35. 11.reports *endoscopy *xray *u/s *ECG

41. ADVANTAGES OF SHARING MR WITH PTs 1.PATIENTS CAN CHEEK ACCURACY OF INFORMATION COLLECTED 2.PATIENTS BECOME AWARE OF DOCTOR KNWLEDGE AND PERCEPTION OF THE PROBLEM WICH MAY LEAD TO INCREASE UNDERSTANDING AND COMLIANCE. 3.PATIENTS CAN CONATANTLY REVIEW THEIR HEALTH PROBLEM. 4.IMPROVE COMMUNICATION BETWEEN DOCTOR AND PATIENTS AND GIVE CHANCE FOR AUTONOMY AND FURTHER NEGOTIATION. 5.PREVENTS DOCTOR FROM WRITING ANY HARSH PERSONAL COMMENTS. 6.FORCE THE DOTOR TO WRITE ACCURATE INFOEMATION SO THAT THE NOTES BECOME MORE MEANINGFUL AND PRECISE 7.REDUCE MYSTIFICATION BY ASSURING THE PATIENT THAT NOTHING IS CONCEALED.

42. DISADVANTAGES OF SHARING MR WITH PTs 1.INACCURATE NOTES IN THE MEDICAL RECORDS MAY DIMINISH PATIANTS CONFIDENT IN HIS DOCTOR. 2.PATIENTS WITH SERIOUS DISEASES MAY NOT PREFER KNOW ABOUT PROGNOSIS OF THEIR ILLNESS. 3.KNOWING THE DIAGNOSIS MAY CAUSE ANXIETY 4.DISCLOSURE OF INFORMATION ABOUT RELATIVES MAY BREACH CONFIDENTIALITY 5.IT MAY STOP DOCTORS WRITING HIS OWN COMMENTS ABOUT THE PATIENTS PERSONALITY CHARACTER OR BEHAVIOUR(eg IMMATURE OR INADEQUATE PRESONALITY ,PSYCHOPATH)WHICH MAY BE VITAL INFORMATION TO RECORD. 6.DIAGNOSIS MAY LEAD TO FALSE LABELLING AND(eg ALCOHOLIC NEUROTIC) 7.INFORMATION MAY BE MISINTERPRETED OR OFFEND AND FRIGHTEN PATIENTS LUMP IN BREST VERSUS CARCINOMA. 8.IT MAY INCREASE MEDICO LEGAL ACTIVITIES

43. MEDICAL RECORDS THEAM AND NHS RESOURCES DOCTOR INTERACTION PATIENT REGISTERED POPULATION AGE-SEX REGUSTER(IND:SOCIAL CLASS ETHNIC GROUP) CLINCAL AND DRUG INFORMATION DISEASE INDEX UTILIZATION LOG REFERRALS TO HOSBITAL RECALL SYSTEM IMMUNIZATION FILE LABORATORY AND X-RAY INDEX OF REFERRAL AND SELF HELP AGENCIES REPEAT PRESCRIPTION CONTROL FLG MODEL OF A MEDICAL INFORMATION SYSTEM (FROM METCALFE 1982)

44. THANK YOU

45. organising the medical record -continuation sheet -summary sheet -obstetric record -child immunisation card -child development record -contraceptive record -repeat prescription record -hypersensitivities -problem lists -flow charts -laboratory report sheets these stationery: -is available from the health authority -must be kept in a logical and agreed order -fastened together by metal clip or staple atc old continuation sheet can be summarised and then discarded. redundant letters and reports can be destroyed. *nb :time invested in an efficient record system pays off when the doctor needs to retrieve information about the patient in an emergency: - design a system - staff can use slack periods - avoid generating bulky records without good reason - throw away redundant information - record of dead patients can be retuned to health authority

46. Storage of medical records Aim:quick and accurate retrieval of records Main methods 1.lateral or shelf filing -more space -easy access -misfiling can be reduced by colour coding or diagonal stripe 2.rotary files -more efficient use of space -more confusing (not same fixed point) -coloured tape or card as starting point is helpful 3.cabinet files -may be satisfactory in small practice -time wasting -more likely to cause fatigue or injury -can be locked –advantage 4. More elaborate and expensive system e.g -multi-stack lateral systems on rails -electrically operated banks of filing trays -advantage limited space

48. Hypertension and Referral System Prof. Sulaiman Al-Shammari Department of Family & Community Medicine , College of Medicine King Saud University , Riyadh, Saudi Arabia

50. Hypertension management Mainly outpatient First contact doctor Usually PHC physician Sometime specialist in outpatient setting To lesser extent as inpatient