Medical Records

1. Medical Records Dr. Yousif E. Elgizouli MRCGP (UK),JMHPE Family Medicine Consultant & Trainer

2. Organization is the power of the day; without it, nothing is accomplished. ~ Sophia Palmer From A Daybook for Nurses: Making a Difference Each Day

3. Learning Objectives • Recognize the importance of PMR • Identify different types of PMR • Describe different contents and sections of PMR • Describe common approaches to documenting information. • Confidentiality issues • Write the SOAP format in PMR • Identify different format of referral letters • Write a referral letter

4. The session has two parts • Theoretical Part • Practical Part

5. What are medical records? • Medical records include any information created by, or on behalf of, a health professional in connection with the care of a patient, e.g. • Handwritten medical notes • Computerised records • Correspondence between health professionals • Laboratory reports • X-ray films and other imaging records • Videos and other recordings • Printouts from monitoring equipment • Text messages • Emails

6. Good Medical Records • Doctors should “keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigation or treatment” and “make records at the same time as the events you are recording or as soon as possible afterwards”

7. Good medical records • Good medical records summarise the key details of every patient contact. Clinical records should include: • Relevant clinical findings • The decisions made and the actions agreed, and who is making the decisions and agreeing the actions • The information given to patients • Any drugs prescribed or other investigation or treatment  • Who is making the record and when

8. Why good records are important? • Past and present medical conditions

9. Continuity of care • Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. Adequate medical records enable you or somebody else to reconstruct the essential parts of each patient contact without reference to memory. • They should therefore be comprehensive enough to allow a colleague to carry on where you left off.

10. Complaints and claims • Many clinical negligence claims are indefensible because there are problems with the medical records, whether they are inaccurate, illegible, too brief, or simply missing. • You may have done nothing wrong but, unless the medical records support this, it can be difficult to defend a claim.

11. Research and clinical audit • Good medical records can help to improve standards of patient care. Auditing medical records is an important part of the research, and records should be written in a way that helps this.

12. Patient Medical Records (cont.) Additional Uses of Patient Records Quality ofTreatment Patient Education • Peer review • Teaching • Health-care analysis and policy decisions Research • Test results • Health issues • Treatment instructions • Source of data

13. Emails and text messages • These should be included in a patient’s records. If you want to communicate with patients using emails or texts, make sure that there is a robust system in place for including them in the medical records. • Be cautious about using emails, as confidentiality can be a problem. You should ensure you have the patient’s consent before sending text messages.

14. Name and address Occupation Current complaint Past Medical History Health-care needs Medical treatment plan Response to care Lab and radiology & reports Information included in patient record 

15. Patient Charts:Standard Chart Information • Patient Registration Form • Date • Patient demographic information • Age, DOB • Address • Financial information • Emergency contact

16. Standard Chart Information (cont.) • Past medical history • Illnesses, surgeries, allergies, and current medications • Family medical history • Social history (diet, exercise, smoking, use of drugs and alcohol) • Occupational history • Current patient complaint recorded in patient’s own words

17. Standard Chart Information (cont.) • Physical examination results • Results of laboratory and other tests • Records from other physicians or hospitals • Include a copy of the patient consent.

18. Standard Chart Information (cont.) • Doctor’s diagnosis and treatment plan • Treatment options and final treatment list • Instructions to patient • Medication prescribed • Comments or impressions • Operative reports, follow-up visits • These are part of the continuous patient record • Document calls made to and from the patient

19. Standard Chart Information (cont.) • Informed consent forms • Verify that the patient understands procedures, outcomes, and options • Patient may withdraw consent at any time • Hospital discharge summary forms, if any • Information summarizing the patient’s hospitalization • Instructions for follow-up care • Physician signature

20. Initiating and Maintaining Patient Records Completing medical history forms Documenting test results Initial Interview Examination, preparation,and vital signs Documenting patient statements Maintain patient privacy during interview

21. The Six Cs of Charting C Client’s words – Clarity – Completeness – C onciseness – Chronological order – confidentiality – Do not interpret patient’s words Precise descriptions / medical terminology Fill out forms completely To the point / approved abbreviations Legal issues Follow guidelines

22. Types of Medical Records

23. Medical Records: SOAP Documentation • Orderly series of steps for dealing with any medical case • Lists the following • Patient symptoms • Positive signs • Diagnosis • Suggested treatment SOAP

24. SOAP Documentation P lan A ssessment O bjective data S ubjective data The treatment plan to correct the illness or problem The impression of the patient’s problem that leads to diagnosis What the physician observes during the examination Information the patient tells you

25. ANSWER: S O O S O O S S Good Job! Apply Your Knowledge Label the following items as either (S) “subjective” or (O) “objective.” ____ headache ____ pulse 72 ____ vomited x 3 ____ nausea ____ skin color ____ respirations 16, labored ____ chest pain ____ poor appetite

26. Appearance, Timeliness, and Accuracy of Records • Neatness and legibility • Use a good-quality pen • Blue ink is preferred (differentiates original from copy) • Highlight critical items such as allergies • Handwriting must be legible • Make corrections properly

27. Appearance, Timeliness, and Accuracy of Records (cont.) • Timeliness • Record all findings as soon as they are available • For late entries, record both original date and current date • Record date and time of telephone calls and information discussed • Retrieve file quickly in event of an emergency

28. Appearance, Timeliness, and Accuracy of Records (cont.) • Accuracy • Check information carefully • Never guess or assume • Double-check accuracy findings and instructions • Make sure most recent information is recorded

29. Appearance, Timeliness, and Accuracy of Records (cont.) • Computer records • Accuracy is also important with electronic records • Advantages • Can be accessed by more than one person at a time • Can be used in teleconferences • Useful for tickler files • Security concerns • Protect patient confidentiality

30. Release of Records • Records are property of physician • Contain confidential patient health information • Must have patient’s written consent to release • Exceptions: cases of contagious disease or court order Release of Informationto MOH/ Insurance I authorize Dr. X to release my healthcare information to the above-named ministry /insurance company. mm/dd/yyyyPatient Signature Date

31. Release of Records (cont.) • Procedures for releasing records • Obtain a signed and newly dated release form authorizing the transfer of information, and place it in the patient’s record • Make photocopies of original materials • Copy and send only documents covered in the release authorization • Call to confirm receipt of materials

32. Referral Letter • A way of communication to other health care provider. • Shared care system • It must be part of the documentation in PMR • Must had feedback from the referred authority • Educational tool

33. Special cases Divorce Legal guardian of children (may be one or both parents) Death Next of kin Legally authorized representative Confidentiality 18-year-olds Considered adults Must have written consent to release their records Legal and ethical principle:Protect patient’s right to privacy at all times. Release of Records (cont.)

34. In Summary • Medical assistants must properly prepare and maintain patient records • There are several methods for documentation, but regardless of method, records must be complete, legible, current, accurate, and professional • Properly maintain, correct, update, and release patient medical records

35. Altering medical records • If you discover a mistake, insert an additional note as a correction • Do not change the original medical record unless the information is factually incorrect. • If you discover a mistake, insert an additional note as a correction. Make it clear that this is a new note, not an attempt to tamper with the original record. • A patient may ask for some information to be deleted from the record. Notes should only be amended if the original information was inaccurate, misleading or incomplete. If it is changed, include a note, signed and dated, to say that the incorrect information was altered at the patient’s request.

36. PMR Assignments G A • Summarize, in 250 to 300 words, the differences among source oriented records, problem oriented records, and integrated records.  - Include how you think the advantages and disadvantages of each record format affect everyday work; remember to think about retrieving records as well as filing them

37. G B - Why we should keep good patient medical records? - PMR should be kept secure, but when you release patient information (records)?

38. G C - What are the differences between manual (paper) & electronic medical records, mention advantages and disadvantages of each? - Hanan-25-Years old teacher consult you with a severe episodic headache 2 months ago, her headaches are associated with nausea & vomiting, often at the right side of the head. She felt that since 4 Years, her mother has similar headaches. • No other sinister symptoms • Vital signs (T: 36.6 C, BP: 110/70, PR: 88) • O/E: Sinuses free, cervical movements intact • You prescribed NSAIDs tablets & you offered her a headache diary for 2/12 to confirm or refute your hypothesis. • Today she brings the diary. • Put this information in a SOAP format?