Fundamentals of Medical Record Documentation Marta Rorat MD

Fundamentals of Medical Record Documentation Marta Rorat, MD, Ph. D Medical Law Department

Medical record documentation – a file of documents which carry any medical information about a patient/patients

Who owns the medical record documentation? ENTITY PROVIDING MEDICAL SERVICES Who own the information? ENTITY PROVIDING MEDICAL SERVICES (CAN NOT FREELY DISPOSE THE INFORMATION) What about the patient? HE HAS THE RIGHT TO GET FULL INFORMATION

• 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 Act of 6 November 2008 on Patient Rights and the Patient Rights Ombudsman Ordinance of the Minister of Health of 21 December 2010 on the types, scope and templates of medical records and methods of their processing

• Patient right to get medical record documentation about his/her health condition and provided medical services • Entity providing medical services obligations: running, storing, proper sharing (following the Act of 6 November 2008 on Patient Rights and the Patient Rights Ombudsman, art. 24), safety, archiving, destroying • Two possibilities of keeping medical records: in paper or/and electronic versions

TYPES OF MEDICAL RECORDS individual internal collective external

INDIVIDUAL INTERNAL • • medical history (history of health and/or illness) newborn form individual nursing care form individual midwifery care form support visit form (newborns) social interview form (environmental, family) immunisation form

Statements that should be attached to the individual internal medical documentation: 1. Patient’s written statement to authorize his/her relatives to aquire information about health condition and provided medical services 2. Patient’s written statement to authorize his/her relatives to have access to medical record documentation 3. Consent form for medical services

INDIVIDUAL EXTERNAL • • referral to hospital or other entity referral to the diagnostics, consultations or treatment pregnancy form child health booklet hospital treatment information vaccination booklet certificates, judgements, and medical opinions

COLLECTIVE ⟳ ⟳ ⟳ the book of hospital admissions and discharges the book of admission denials and outpatient consultations given in the emergency room the list of patients waiting for health care financed from public funds records of patients admissions the medical reports book the nursing reports book records of interventions the operating room book the labour ward book records of newborns the diagnostic laboratory book

MANDATORY DATA INCLUDED IN THE MEDICAL RECORDS § identification of the entity providing health care services § identification of the patient (name, address, date of birth, gender, children under 1 year of age - PESEL/ series and mother's ID; data of the legal representative of the child) § identification of the person providing health care services § information on health condition, disease and the diagnostic, therapeutic, nursing or rehabilitation processes (health service applied, conducted diagnosis, recommendations, certificates, treatment dosing, etc. ) § date of registration § signature of the person making registration § other information required by separate regulations

MANDATORY DATA INCLUDED IN THE MEDICAL RECORDS § § § § general health condition information on taken therapeutic, diagnostic, nursing, rehabilitation actions diagnosis recommendations information on issued medical opinions and certificates information on prescribed drugs - including dosing, time of treatment type of information on health condition provided to the patient

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 nursing records neonate observation records fever records medical orders records of anesthetic course diagnostic tests results consultation records surgical protocols medical emergency treatment card physical therapy card discharge card perioperative control card

MEDICAL HISTORY contains 1) medical interview and physical examination 2) lab test results and consultations 3) patient's pain intensity and other features (pain scale), treatment and efficacy 4) observation card 5) medical orders and their performance 6) nursing and doctor’s observations

DISCHARGE CARD contains 1) 2) 3) 4) diagnosis (in Polish) and ICD-10 number all lab test results and consultations performed treatment recommendations for further treatment, nutrition, hygiene, life style 5) the period of temporary work incapacity 6) information on drugs including dosing, the numer of packages 7) planned date of reffered consultations

DEATH 1) date and hour of death 2) the diseases causing death a) primary b) secondary c) direct cause of death 3) brain death protocol issued by comission 4) information on autopsy 5) information on obtained cells, tissues or organs

The rules of running medical records documentation • legible records, in chronological order, immediately after providing • • medical service the patient’s name and surname on each numbered page medical records in Polish removing of records and documents is strictly prohibited (in case of a mistake you should cross it out, explaind the reason, give the date and signature) information on the person taking the records protecting the documentation from disclosure to an unauthorized person protecting the documentation from being destroyed ICD 10

The time of archiving medical records documentation 20 lat 22 lata (children under 2 years of age) 30 lat (death due to injury or poisoning) 10 lat (X-rays) 5 lat (others)

The entities entitled to access medical records documentation the patient /legal representative/ authorized person controllers Pension Institution (ZUS); the National Health Fund (NFZ) court/prosecutor professional liability spokesman public authorities; national and regional consultant another health care institution insurance company– with patient’s agreement

INSIGHT Medical records access forms ORIGINAL COPIES

The consequences of medical records incorrect completing disciplinary liability professional liability civil liability criminal liability

Act of 6 June 1997 The Penal Code - 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 significance shall 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, he shall be subject to the penalty of deprivation of liberty for a term of between 6 months and 8 years.

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.

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.