MEDICAL RECORD Prof. Sulaiman Al-Shammari medical records and information 1.Why keep records?(functions?) 2.Problem oriented medical records(POMR) 3.Organising

MEDICAL RECORD

• Prof. Sulaiman Al-Shammari

medical records and information

1. Why keep records?(functions?)

2. Problem oriented medical records(POMR)

3. Organising the medical records

4. Storage of medical records

5. An information system for PHC

6. Arrangement of primary health care medical records

7. Sharing medical records with patients

Why keep records?(functions)

1.Why keep records?(functions)

*a permanent record of significant events

*unique continuing record of health and illness

WHAT IF

*no record of significant events

*lost record

*no past data

*accuracy not very high


*A medico-legal record

*important if complaint or legal action arises

*Both negative and positive findings are important (e.g.x-ray normal)


* A way of communicating with colleagues and other team members

* single-handed doctor needs to remind himself.

*PHCT (doctors on deputies and others)should be aware of main facts such as:

*past and present diagnoses

*current treatment

*allergies or warnings


*Jacket for hospital &laboratory reports &letters

*information needs to be accessible or it useless

So What to do with Bulky Records:

*A4 files are useful in this respect

*Throw useless or duplicated information

*Computerization


*A record of drugs prescribed

* accurate record of doses and quantity for :

*use within practice

*medico-legal and research(adverse reaction)


*an side memoire

*reminder for patient’s personal doctor

*what he told the patient ?

*what was in the back of his mind ?

*what he planned for next visit ?

*much of this is of short term value and can be discarded once the episode is :

*over

*summary completed

Problem Oriented Medical Record(POMR) - new move

- more logical particularly at the stage before a firm diagnosis

- help doctors to:

*see patient’s problem

*define his own problem

*avoid jumped to a diagnosis too early

pomr consist of:

1. Identifying particulars and background information(data base)e.g

-name, number etc - immunisation etc -health questionnaire

-patient to check accuracy

2. Clinical or progress notes

3. The problem list

4. The flow chart

5. The drug list

TYPES of MEDICAL RECORDS

• Traditional POMR• a)history a)subjective• b)examination b)objective• c)diagnosis c)assessment• d)investigation d)plan• e)treatment (i)tests• ( ii)treatment• (iii)patient education•

Organising the medical record• -continuation sheet• -summary sheet• -obstetric record • -child immunisation card • -child development record• -contraceptive record• -repeat prescription record• -hypersensitivities• -problem lists• -flow charts• -laboratory report sheets

These Stationery

• -is available from the health authority• -must be kept in a logical and agreed order• -fastened together by metal clip or staple atc• old continuation sheet can be summarised and then discarded.• redundant letters and reports can be destroyed.• *NB :time invested in an efficient record system pays off when the

doctor needs to retrieve information about the patient in an emergency:

• - design a system • - staff can use slack periods• - avoid generating bulky records without good reason• - throw away redundant information• - record of dead patients can be retuned to health authority

Legibilty

Notes must be legible

-typewritten

-dictated

Missing Notes

-Reasons*in doctor car or research

*misfiling

-during transfer from doctor to doctor

-Solution*a system for urgent transfer of medical record

*telephone call to previous doctor

*computer

*cooperation cards e.g. obstetric ,diabetic,geriatric patient

*a copy of summary sheet and database carried by the patient

*market out borrowed notes like library books.

Storage of Medical Records

Aim:quick and accurate retrieval of records

1.Main methods of Storage of MR*lateral or shelf filing -more space -easy access -misfiling can be reduced by colour coding or diagonal strip

2.Main methods of Storage of MR*rotary files -more efficient use of space -more confusing (not same fixed point) -coloured tape or card as starting point is helpful

3.Main methods of Storage of MR *cabinet files -may be satisfactory in small practice -time wasting -more likely to cause fatigue or injury -can be locked –advantage

4.Main Methods of Storage of MR * More elaborate and expensive system e.g -multi-stack lateral systems on rails -electrically operated banks of filing trays -advantage limited space

Filing methods

-small practice-alphabetical

-Large practice-numerical

-Colour coding by doctors

Family records-common family folder

-Family book or card

-Family chart

Confidentiality of MR and information

-strict policy and procedure

-Strict rule for access to medical records

*do NS,HV,MW,SW have access?

*are they permitted to take them to their office ?

*are doctors ,staff and their families medical records filed separately under more Secure conditions ?

-locked filing cabinets or rooms

-Cleaning only when staff are present

-MR and reports should not be left unattended.

Patients views on records

-trust doctor or other staff

-Access to notes

-Access of police and others to notes

-Computerised records and confidentiality

Logs and registers of practice activity

-for assessment of workload

-Efficient day-to-day running of service

-Examples:

1.log of patients seen by each doctor

2.register of hospital appointment requested

3.register of hospital transport requests

4.register of x-rays requested

5.register of deaths

6.day book for recording messages

7.log of practice nurse’s workload

An information system for PHC

The basic raw material:

-consultations per annum

-other items of serves (eg prescriptions ,telephone contacts)

-laboratory tests

-x-ray reports

-referrals to hospital

-admissions to hospital

The records has to serve the needs of:

1.preventive medicine-at risk groups

2.quality control-patient recall, performance review

3.practice planning administration and finance

4.education-doctors ,staff, trainee ,patients

5.research

*different coloured cards for males and females including name address date of birth & arranged in birth date order-must be kept up to date

-what use is it?

1.checking child health screening or immunisation of children up to age 5

2.checking rubella immunisation of 11 year old girls

3.preparing lists for cervical screening of women aged 35-65(year intervals)

4.preparing lists for hypertension screening

5.Preparing an age-sex profile of the practice.

6.preparing an age-sex profile of the practice.

Age-sex register

-identify people at risk

What is it?

*NB:unless there is active preventive medicine or research taking place in the practice the labour of preparing the register is not cost effective.

*the disease index (diagnostic index)

-list of patients with certain disease

-notes can be colour tagged

Clinical and drug information

-come from many sources*memories or notes from medical school or post graduate lectures

*consultants RECOMMENDAIONS

*medical journals

*text books

*drug company promotion

*government publications and circulars

*audio or video cassettes

*computerised date system

References

1.management in general practice by peter pritchard et al

2.oxford general practice

Arrangement of primary health care MR 1.initial patient profile

2.referrals

3.problem list

4.primary care

*physicians notes )

*yellow coloured page )in chronological order

*pink coloured page )

5.diabetes mallitus flow chart

6.hypertension flow chart

7.other specialities notes

*obstetetrice and gynaecology *ophthalmology ENT

8.accidents and emergency notes

9.nutrition clinic notes

10.lab results:

*histopathology *cytology *blood grouping *hematology *clinical biochemistry yellow red blue green brown

*serology *virology *general microbiology *parasitology *urine

11.reports

*endoscopy

*xray

*u/s

*ECG

SURNAME

MSWDA FIRST NAME

DOB

1930

OCCUPATION TAXY DRIVE

ETHNIC GROUP

PLACE OF BIRTH

(SPECIFY COUNTRY)RELIGION

YEAR SMER(INC MONTH) CURRENT DRUGS: DRUG SENSITIVITY

LAST BP

STEROIDS ANTICOAGULANTS ORAL CONTRACEPTION CYTOTOXICS

-----------------------

URINE WEIGHT SMOKER/NON SMOKER

YEAR PROBLEM

1938 CHICHEN POX

1940JAUNDICE-HOSBITAL 40 DAYS(VHA)

1942 APPENDECTOMY

1950 HAEMATURIA?CAUE

1950 MARRIED

1952

HAEMATURIA SCHISTOSOMIASIS(MANSONI AND HAEMATOBIUM)

19553RD DAUGHTER MENTALLY RETARDED(MICROCEPHALY)

1966ELDEST SON DIED AGED16 YEARS RTA

1967MULTIPLE COMPLAINTS?ASSOCIED WITH ABOVE

1980 HAEMATEMESIS CIRRHOSIS

1986 COMPENSATED LIVE FAILURE

SURNAME

MSWDA FIRST NAME

DOB

1930

OCCUPATION TAXY DRIVE

ETHNIC GROUP

PLACE OF BIRTH

(SPECIFY COUNTRY)RELIGION

YEAR SMER(INC MONTH) CURRENT DRUGS: DRUG SENSITIVITY

LAST BP

STEROIDS ANTICOAGULANTS ORAL CONTRACEPTION CYTOTOXICS

-----------------------

URINE WEIGHT SMOKER/NON SMOKER

YEAR PROBLEM

1938 CHICHEN POX

1940JAUNDICE-HOSBITAL 40 DAYS(VHA)

1942 APPENDECTOMY

1950 HAEMATURIA?CAUE

1950 MARRIED

1952

HAEMATURIA SCHISTOSOMIASIS(MANSONI AND HAEMATOBIUM)

19553RD DAUGHTER MENTALLY RETARDED(MICROCEPHALY)

1966ELDEST SON DIED AGED16 YEARS RTA

1967MULTIPLE COMPLAINTS?ASSOCIED WITH ABOVE

1980 HAEMATEMESIS CIRRHOSIS

1986 COMPENSATED LIVE FAILURE

CLINCAL

NOTES

SURNAME(BLOCK LETTERS)

FORENAME(BLOCK LETTERS)

ADDRESS DATE OF BIRTH

NURSES AND HEALTH VISITORS RECORDS

SURNAME (BLOCK LETTERS)

FORENAMES(BLOCK LETTERS)


MOUNT SHEET

X-RAY AND

PATHOLOGY

INVESTIGATIONS

SURNAME(BLOCK LETTERS)

FORENAME(BLOCK LETTERS)


ADVANTAGES OF SHARING MR WITH PTs1.PATIENTS CAN CHEEK ACCURACY OF INFORMATION COLLECTED

2.PATIENTS BECOME AWARE OF DOCTOR KNWLEDGE AND PERCEPTION OF THE PROBLEM WICH MAY LEAD TO INCREASE UNDERSTANDING AND

COMLIANCE.

3.PATIENTS CAN CONATANTLY REVIEW THEIR HEALTH PROBLEM.

4.IMPROVE COMMUNICATION BETWEEN DOCTOR AND PATIENTS AND GIVE CHANCE FOR AUTONOMY AND FURTHER NEGOTIATION.

5.PREVENTS DOCTOR FROM WRITING ANY HARSH PERSONAL COMMENTS.

6.FORCE THE DOTOR TO WRITE ACCURATE INFOEMATION SO THAT THE NOTES BECOME MORE MEANINGFUL AND PRECISE

7.REDUCE MYSTIFICATION BY ASSURING THE PATIENT THAT NOTHING IS CONCEALED.

DISADVANTAGES OF SHARING MR WITH PTs1.INACCURATE NOTES IN THE MEDICAL RECORDS MAY DIMINISH PATIANTS CONFIDENT IN HIS DOCTOR.

2.PATIENTS WITH SERIOUS DISEASES MAY NOT PREFER KNOW ABOUT PROGNOSIS OF THEIR ILLNESS.

3.KNOWING THE DIAGNOSIS MAY CAUSE ANXIETY

4.DISCLOSURE OF INFORMATION ABOUT RELATIVES MAY BREACH CONFIDENTIALITY

5.IT MAY STOP DOCTORS WRITING HIS OWN COMMENTS ABOUT THE PATIENTS PERSONALITY CHARACTER OR BEHAVIOUR(eg IMMATURE OR INADEQUATE PRESONALITY ,PSYCHOPATH)WHICH MAY BE VITAL INFORMATION TO RECORD.

6.DIAGNOSIS MAY LEAD TO FALSE LABELLING AND(eg ALCOHOLIC NEUROTIC)

7.INFORMATION MAY BE MISINTERPRETED OR OFFEND AND FRIGHTEN PATIENTS LUMP IN BREST VERSUS CARCINOMA.

8.IT MAY INCREASE MEDICO LEGAL ACTIVITIES

MEDICAL RECORDS

PATIENT REGISTERED POPULATION

AGE-SEX REGUSTER(IND:SOCIAL CLASS ETHNIC GROUP)

INTERACTIONDOCTORTHEAM AND NHS RESOURCES

CLINCAL AND DRUG INFORMATION DISEASE INDEX

UTILIZATION LOG

RECALL SYSTEM

IMMUNIZATION FILE

INDEX OF REFERRAL AND SELF HELP AGENCIES

REFERRALS TO HOSBITAL

LABORATORY AND X-RAY

REPEAT PRESCRIPTION CONTROL

FLG MODEL OF A MEDICAL INFORMATION SYSTEM (FROM METCALFE 1982)

THANK YOU

organising the medical record

-continuation sheet

-summary sheet

-obstetric record

-child immunisation card

-child development record

-contraceptive record

-repeat prescription record

-hypersensitivities

-problem lists

-flow charts

-laboratory report sheets

these stationery:

-is available from the health authority

-must be kept in a logical and agreed order

-fastened together by metal clip or staple atc

old continuation sheet can be summarised and then discarded.

redundant letters and reports can be destroyed.

*nb :time invested in an efficient record system pays off when the doctor needs to retrieve information about the patient in an emergency:

- design a system

- staff can use slack periods

- avoid generating bulky records without good reason

- throw away redundant information

- record of dead patients can be retuned to health authority

Storage of medical records

Aim:quick and accurate retrieval of records

Main methods

1.lateral or shelf filing

-more space

-easy access

-misfiling can be reduced by colour coding or diagonal stripe

2.rotary files

-more efficient use of space

-more confusing (not same fixed point)

-coloured tape or card as starting point is helpful

3.cabinet files

-may be satisfactory in small practice

-time wasting

-more likely to cause fatigue or injury

-can be locked –advantage

4. More elaborate and expensive system e.g

-multi-stack lateral systems on rails

-electrically operated banks of filing trays

-advantage limited space

Hypertension and Referral System

Prof. Sulaiman Al-ShammariDepartment of Family & Community

Medicine , College of Medicine King Saud University , Riyadh, Saudi Arabia

Rule of Halves of Hypertension

Not Aw are

No Treat.

Not Contr.

Controlled

Hypertension management

Mainly outpatient

First contact doctor

Usually PHC physician

Sometime specialist in outpatient setting

To lesser extent as inpatient

Management Options

• Continuous fellow up

• Referral

• Shared care

Definition of Referral

Definition of Referral

The practice of sending a patient to another program

or practitioner for services

or advice which the referring source is not prepared to provide

Determinants of referral

Determinants of referral

KAP of referring physicianHealth system set up

Availability & accessibility of facilities Investigations Treatment ProceduresCME purposesPatient satisfaction

Indications for specialist referral

Suggested indications for specialist referral (BSH)

1.Urgent treatment needed • Accelerated hypertension (severe hypertension and

grade III-IV retinopathy)

• Particularly severe hypertension (> 220/120 mm Hg)

• Impending complications (for example, transient ischaemic attack, left ventricular failure)

Suggested indications for specialist referral (BHS)

2.Possible underlying cause • Any clue in history or examination of a secondary

cause, such as hypokalaemia with increased or high normal plasma sodium (Conn's syndrome)

• Elevated serum creatinine• Proteinuria or haematuria• Sudden onset or worsening of hypertension• Resistant to multidrug regimen ( 3 drugs)• Young age (any hypertension < 20 years; needing

treatment < 30 years)

Causes of Hypertension (SHMS)

• Sleep Apnea.• Drug Induced.• Chronic Renal Disease.• Primary Aldosteronism.• Renovascular Disease.• Chronic Steroid Therapy and Cushing’s

syndrome.• Pheochromocytoma.• Coarctation of Aorta.• Thyroid or Parathyroid Disease.


3.Therapeutic problems

• Multiple drug intolerance

• Multiple drug contraindications

• Persistent non-adherence or non-compliance


4.Special situations

• Unusual blood pressure variability

• Possible white coat hypertension

• Hypertension in pregnancy

Other Indications

• Ophthalmology Assessment.

• Dietician.

• Lifestyle Modification.

Referral to group therapy

• Health center guidance

• Learn together

• Support each other

• Toward healthy life style

Questionable Indications

• Lab

• Imaging

• ECG.

Outcome of Referral

• Investigations done

• Treatment given

• Procedures preformed

• Clear plan provided through feedback

• Caution of long appointment with specialists

Cost-effectiveness

Cost-effectiveness

• Overcrowding of specialist clinic

• Increasing cost

• May lead to low interest

• May lead to Loss of skills

Thank you

Documents

MEDICAL RECORD Prof. Sulaiman Al-Shammari medical records and information 1.Why keep records?(functions?) 2.Problem oriented medical records(POMR) 3.Organising