OVERVIEW OF MEDICAL
RECORDS
Deenadayalan Sekar
Head of Medical Informatics
Prime Healthcare Group LLC
United Arab Emirates
INTRODUCTION
Medical record, health record and medical chart
is systemic documentation of a patients’ medical
history and care across time within one particular
health care providers jurisdiction.
Definition
The health record is a legal document that should
accurately outline the total needs, care and
management of patients. It facilitates
communication, decision making and evaluation of
care in addition to protecting the legal interests of
the patient, healthcare professionals and the health
facility.
STORAGE
Storage equipment for medical records
generally is the property of the health care
provider the information contained is the
property of the patient, and is shared with
caregivers to significantly contribute to
patient care.
BASIC "RULE" OF DOCUMENTATION
• "IF YOU DIDN'T WRITE IT, IT DIDN'T GET DONE!“
• “IF IT WASN’T WRITTEN, IT WASN’T DONE”
• "IF YOU DIDN'T ENTER IT, IT DIDN'T GET DONE!“
• “IF IT WASN’T ENTERED, IT WASN’T DONE”
PURPOSE
Serves as a mean
• To identify the patient
• Justify the treatment
• Support the diagnosis
• Document the patient’s progress and results of treatment
• Provides continuity of patient care and serves as a means of communication
• Serve as document to educate medical students / resident physicians
• Provide data for internal hospital auditing and quality assurance
• Provide data for medical research.
• Justify third party payment
• Support for malpractice litigation
• Infection control monitoring
MRN Means
Medical Record Number is a unique
identification Number of the Patient.
Maintenance Of Medical Records
Requires Security Measures To Prevent
From Unauthorized Access.
ONLY AUTHORIZED STAFF TO MAKE ENTRIES
➢ MEDICAL STAFF
➢ NURSING STAFF
➢ HOSPITAL ADMINISTRATION
➢ CUSTOMER RELATION OFFICER / PRO
➢ SOCIAL WORKERS
➢ ALLIED HEALTH PROFESSIONALS
MRD WORK FLOW
OPD CONSULTATION
REGISTRATION MEDICAL
RECORDS
Direct Admission OP
Recei
ADMISSION
COUNTER Planned Admission
ve
STATI
IP
STICS
QUERIES
Assembling
WARD Hospital Statistics
STATISTICS for Govt.
1. DOCTOR QUERIES Deficiency Checking
1. CONSULTATION 2. PATIENT QUERIES Medico Legal
2. ICU 3. OTHER DEPARTMENTAL
QUERIES ICD CODING
3. WARD TRANSFERS 4. EXTERNAL QUERIES
4. OT
5. INVESTIGATIONS
Data Entries /
6. TREATMENT Scanning
7. MEDICINES
Filing
8. ANY OTHER
ADMINISTRATION
Retrieval
DISCHARGE
Issu
e
OPD CONSULTATION /
FOLLOW UP / RESEARCH /
ADMISSION
MEDICAL RECORDS
DOCUMENTATION
REQUIREMENTS
SUFFICIENTLY COMPLETE
• Records of the course of treatment and hand writing
sufficiently legible to other care givers.
• All handwriting shall be in blue / black permanent ink
that is legible when photocopied or scanned.
• Each page within the medical record shall be identified
with Prime Hospital name & Logo, the patient’s name
and file Number.
CORRECTION
Errors if made shall be marked by drawing
one line through the errors write the letter
“e” dating and initiating it.
Documentation must be
➢Identified
▪ Write information complete and legible.
▪ State patient identification information on each sheet.
▪ Pain Score is required in each entry.
▪ Sign and Seal is mandatory requirement for all entries.
➢Dated(Day, Month, Year)
▪ At the beginning of each entry.
➢Timed
▪ Each entry must be timed. (24 hrs format)
AUTHENTICATION
• The signature of clinician with stamp/
license number after each new entry.
• Signature of the attending nurse with staff
id is must in all the entries in the medical
file.
RELEASE OF PATIENT
INFORMATION
PURPOSE:
To ensure that patients information is
released as per rights of the patient and
compliant with government regulation.
1. Unless prior informed consent has been given by the
patient, no information should be released about his/ her
treatment
2. No information can be given over the telephone.
3. If the patient is less than 21 years of age the parent
may give consent for release of information.
1. If the patient is physically, mentally incapable the patients
guardian may give consent to release the information.
2. The original files are strictly not to be taken out of the
hospital.
3. Original files can be transferred to other hospital by the
written permission from medical director/ hospital administrator.
1. Reports requested by the patient during the
consultation: a copy of the reports can be given to the
patient with the treating doctors approval after getting
his/her signature for receiving the reports.
2. A Physician / NOK / Insurance Companies / Employer
who is not a staff of Prime Hospital must obtain patient
authorization to check the file.
Thank you for your Attention
Contact Number / WhatsApp: +971-556953714
Email: [email protected]
