Fundamentals of Medical Record Documentation

1. Fundamentals of Medical Record Documentation Marta Rorat, MD, PhD Medical Law Department

2. Medical recorddocumentation – a file of documentswhichcarryanymedicalinformationabout a patient/patients

4. Act of 5 December 1996 on Professions of Doctor and Dentist • The Code of Medical Ethics • Act of 29 August 1997 on the Protection of Personal Data

5. Patientrightto get medicalrecorddocumentationabouthis/herhealthcondition and providedmedical services • Entityprovidingmedical services obligations: running, storing, propersharing(following the Act of 6 November 2008 on Patient Rights and the Patient Rights Ombudsman, art. 24), safety, archiving, destroying • Twopossibilities of keepingmedicalrecords: in paperor/and electronicversions

7. medicalhistory (history of health and/orillness) • newborn form • individualnursingcareform • individualmidwiferycare form • supportvisit form (newborns) • social interview form (environmental, family) • immunisationform

8. 3. • 2. Statementsthatshould be attached to the individualinternalmedicaldocumentation: Patient’swrittenstatement to authorizehis/herrelativesto aquireinformationabouthealthconditionand providedmedical services Patient’swrittenstatement to authorizehis/herrelativesto haveaccess to medicalrecorddocumentation Consent form for medical services

9. referral to hospital or other entity • referralto the diagnostics, consultations or treatment • pregnancyform • childhealth booklet • hospitaltreatmentinformation • vaccination booklet • certificates, judgements, and medicalopinions

10. the book of hospitaladmissions and discharges • the book of admission denials and outpatient consultationsgiven in the emergency room • the list of patients waiting for health care financed from public funds • records of patients admissions • the medical reportsbook • the nursingreports book • recordsofinterventions • the operating roombook • the labourwardbook • records of newborns • the diagnostic laboratorybook

11. identification of the entity providing healthcareservices • identification of the patient (name, address, date of birth, gender, children under 1 year of age - PESEL/ series andmother's ID;data of the legal representative of the child) • identification of the person providing health careservices • information on healthcondition, disease and the diagnostic, therapeutic, nursing or rehabilitationprocesses(healthservice applied, conducteddiagnosis, recommendations, certificates, treatment dosing, etc.) • date of registration • signature of the person makingregistration • otherinformationrequired by separateregulations

12. general healthcondition • information on taken therapeutic, diagnostic, nursing, rehabilitation actions • diagnosis • recommendations • information on issued medical opinions and certificates • information on prescribeddrugs - including dosing, time of treatment • type of information on healthconditionprovided to the patient

13. MEDICAL HISTORY includes the synthesized information on: • date and reason for patient’s admission to the hospital • the course of hospitalisation • the patient’s discharge • ADDITIONAL DOCUMENTATION: • individual nursingrecords • neonateobservationrecords • feverrecords • medical ordersrecords • records of anestheticcourse • diagnostic testsresults • consultationrecords • surgical protocols • medical emergency treatmentcard • physical therapycard • discharge card • perioperativecontrol card

15. 1) medical interview and physicalexamination 2) lab test results and consultations 3) patient's pain intensity andother features (painscale), treatment and efficacy 4) observationcard 5) medicalorders and their performance 6) nursing and doctor’sobservations

16. diagnosis (in Polish) and ICD-10 number • all lab test results and consultations • performedtreatment • recommendations for furthertreatment, nutrition, hygiene, life style • the period of temporaryworkincapacity • information on drugsincludingdosing, the numer of packages • planneddate of refferedconsultations

17. dateand hour of death • the diseasescausingdeath • a) primary • b) secondary • c) directcause of death • 3) braindeathprotocolissued by comission • 4) information on autopsy • 5) information on obtainedcells, tissuesororgans

18. legiblerecords, in chronological order, immediatelyafterprovidingmedical service • the patient’sname and surname on eachnumberedpage • medicalrecords in Polish • removing of records and documentsisstrictlyprohibited (in case of a mistakeyoushould cross it out, explaind the reason, give the date and signature) • informationon the person takingthe records • protectingthe documentation from disclosure to anunauthorizedperson • protectingthe documentation from beingdestroyed • ICD 10

22. The consequences of medical recordsincorrect completing

23. Act of 6 June 1997 The PenalCode-Offence Against The Credibility Of Documents Article 271. § 1. A public official or other person authorised to issue a document, who certifies an untruth therein, with regard to a circumstance having a legal significanceshall be subject to the penalty of deprivation of liberty for a term of between 3 months and 5 years. § 2. In the event that the act is of a lesser significance, the perpetrator shall be subject to a fine or the penalty of restriction of liberty. § 3. If the perpetrator commits the act specified in § 1 in order to gain material or personal benefit, heshall be subject to the penalty of deprivation of liberty for a term of between 6 months and 8 years.

24. Article 276. Whoever destroys, damages or renders unfit for use, or conceals, or removes a document to which he has no exclusive right of disposition shall be subject to a fine,the penalty of restriction of liberty or the penalty of deprivation of liberty for up to 2 years.

25. Article 270. § 1. Whoever, with the purpose of using it as authentic, forges, or counterfeits or alters a document or uses such a document as authentic shall be subject to a fine, the penalty of restriction of liberty or the penalty of deprivation of liberty for a term of between 3 months to 5 years. § 2. The same punishment shall be imposed on anyone, who fills in a form bearing someone else's signature, contrary to the will of the signatory and to his detriment or indeed uses such a document.