Medical Documentation & Medical Records

8/13/2019 Medical Documentation & Medical Records

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Protect your

Problems with

your PEN1


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Objects

For care & treatment For documentation

For reimbursement

For medical education

For research

For communication

For follow up

For legal issues For Billing & Audit

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Reasons for poor records

Considered a time consuming bother

Cutting costs

Restaurant type medical service

No training

Doctor - shopping patients

Unless hit by litigation

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What is the Necessity ?

Practicing medicine now is hazardous & risky

Mutual faith replaced with mutual suspicion.

Practicing defensive medicine inevitable.

The best way to deal with Medical &Medicolegal problems is to prevent them

Medicine is a science of uncertainty and artof probability

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Several reasons to maintain records

Coordinative vehiclefor communication, all

case - related info, should be complete

Indicate good quality medical care Indicate good quality practitioner

Best defense for litigation

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Document should be

Correct Clear

Complete

Confidential Comprehensive

Collaborative

Contemporary

Consecutive Concise

Patient Centered

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Documentation Patient related

written and electronic health records

Audio and video tapes

Emails

Images (photographs and diagrams)

Observation charts

Check lists

Communication books

Shift/management reports

Incident reports

Clinicians personally or any other type or form ofdocumentation pertaining to the care provided

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Other Documents not pertaining to patients

Policies, procedures and protocols

Critical incident / occupational health and safetyreports

Statistical and research data

Reports related to service and funding agreements

Staffing rosters Personnel files

Performance appraisals

Clinical assessments Published reports/papers

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Minimum requirements Full Name

Age, Sex & Address Occupation, Educational status & Social

condition

Date, Time & Place

Consent History

General Examination with time & date

Special Examination with time & date Investigations

Diagnosis

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Periodic Observations

Treatment in detail

Instructions

Complications

Refer note

Remarks

Negative remarks Signature with qualification, designation &

Registration number

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Accurate Medical Records

Record of medical care

Comply with legal requirements, accreditation standards,and professional practice standards

Support and defend care

Advantages of Pre-printed documents Prompts clinician for key elements

Improves legibility

Standardizes content

Facilitates data collection, quality auditing

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Advantages of Electronic Documentation

software available

Less time consuming

Choose that is most user friendly

Trained staff in software use

Research possible from data

Medicolegal advantage

Record keeping

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Provisions regarding Medical

Documents

Certificates

Routine case records

Indoor case papers

Medico-legal case papers

Probable negligence cases

For library or public interest

patients rights

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Injury Certificate

Drunkenness Certificate

Sexual Offence Certificate Cause of Death Certificate

Age Estimation Certificate

Certificate for Leave/Extension of Leave/Commutation Leave

Fitness Certificate

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Registers

OPD Indoor

MLC

Birth & Death

Operative Procedure

Referred Cases

Discharge

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MEDICAL COUNCIL OF INDIA GUIDELINES ONMEDICAL RECORDS

Maintain indoor records in a standard proforma for 3

years from commencement of treatment (Section 1.3.1and Appendix 3).

Request for medical records by patient or authorizedattendant should be acknowledged and documentsissued within 72 hours (Section 1.3.2).

Maintain a register of certificates with the full details ofmedical certificates issued with at least one identification

mark of the patient and his signature (Section 1.3.3). Efforts should be made to computerize medical records

for quick retrieval (Section 1.3.4).

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Time period

* OPD records3 yrs

* Indoor case records5 yrs

* Medicolegal case30 yrs

Maintain Confidentiality of records

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Documents must be given to the patients as a matter ofright Discharge summary, referral notes, and death summary

Documents can be given after fulfilling the hospitalcriteria copies of inpatient files, records of diagnostic tests,

operation notes, videos, medical certificates, and duplicate

copies for lost documents Certain records cannot be given to patients without the

direction of the Court The outpatient register, inpatient register, and files of

medico-legal cases cannot be handed over to the patient orrelatives without the direction of the court

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There are certain situations where it is legal forthe authorities to give patient information.

during referral

when demanded by the court or by the police on awritten requisition

when demanded by insurance companies as

provided by the Insurance Act when the patienthas relinquished his rights on taking the insurance

when required for specific provisions ofWorkmen's Compensation cases, Consumer

Protection cases, or for Income tax authorities.

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