Medical Records Dr Yousif E Elgizouli MRCGP UK

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

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

Learning Objectives Ø Recognize the importance of PMR Ø Identify different types of PMR Ø Describe different contents and sections of PMR Ø Describe common approaches to documenting information. Ø Confidentiality issues Ø Write the SOAP format in PMR Ø Identify different format of referral letters Ø Identify some of Primary Care Forms.

The session has two parts » Theoretical Part » Practical Part

What are medical records? • Medical records include any information created by a health professional in connection with the care of a patient, e. g. • • • Handwritten medical notes Computerized 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

Good Medical Records Ø Should be clear, Ø Accurate and legible, Ø Comprehensive & report all relevant clinical findings, Ø Should be timely

Good medical records • Good medical records summarized 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 investigations or treatment • Who is making the record and when

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

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.

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.

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.

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

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.

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

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

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

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.

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

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

Initiating and Maintaining Patient Records Completing medical history forms Documenting test results Initial Interview Examination, preparation, and vital signs Documenting patient statements

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

Types of Medical Records Source-Oriented Medical Records n n Problem-Oriented Medical Records Conventional approach n Information is arranged according to who supplied the data n Problems and treatments are on the same form Difficult to track progress of specific events POMR records make it easier to track specific illnesses Information included Database n Problem list n Educational, diagnostic, and treatment plans n Progress notes n

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

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

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

Appearance, Timeliness, and Accuracy of Records (cont. ) 6 Timeliness 6 Record all findings as soon as they are available 6 For late entries, record both original date and current date 6 Record date and time of telephone calls and information discussed 6 Retrieve file quickly in event of an emergency

Appearance, Timeliness, and Accuracy of Records (cont. ) þAccuracy þCheck information carefully þNever guess or assume þ Double-check accuracy findings and instructions þ Make sure most recent information is recorded

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

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 Information to MOH/ Insurance I authorize Dr. X to release my healthcare information to the above-named ministry /insurance company. Patient Signature mm/dd/yyyy Date

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

Release of Records (cont. ) • 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 Legal and ethical principle: records Protect patient’s right to privacy at all times.

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

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

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.

Arrange 8 Subgroups

The Forms • - Medical Record Problem List SG-1 Data Base SG-1 Encounter Form SG-2 Laboratory Request SG-3 CT / MRI Request SG-4

The Forms • • • Female Infant Growth Chart SG-5 Consultation Request SG-6 Referral to Accident & Emergency SG-7 Injection/Dressing Request -8 Sick Leave Form SG-9