ENGLISH MEDICAL RECORD

CREATED BY :
1. NI WAYAN ARI RAHAYUNI (010)
2. KADEK INDAH DWIJAYANTI (011)
3. PUTU AYU SUADNYANI (012)
4. NI PUTU ANGGI WIDYASARI (013)
5. LUH MADE MAS SWANDEWI (014)
6. GUSTI AGUNG AYU DIVASYA S. (016)
7. I GUSTI AYU INTAN SETYARI (016)
8. NI WAYAN LITA PERDANI (017)
9. LUH GEDE SUMIARI (018)

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN DENPASAR
JURUSAN KEPERAWATAN
PRODI NERS
2021
 ENGLISH MEDICAL RECORD

A. Medical Record Definition

A medical record is a collection of data compiled on a patient to assist in
the clinical care of present and future illness. By clinical care is meant treatment
by doctors, nurses and others in the health team, in a hospital, an outpatient clinic,
or primary care by a family doctor. As a document, the medical record is not only
a repository of information, it is also a continuing record which acts as a means of
communication between members of the health team.
A good medical record serves the interest of the medical practitioner as
well as his patients. It is very important for the treating doctor to properly
document the management of the patient under his care. Medical record keeping
has evolved into a science. The key to dispensability of most of the medical
negligence claim rest with the quality of the medical records. Record
maintenance is the only way for the doctor to prove that the treatment was
carried out properly.
Medical records are often the only source of the truth. They are likely to
be far more reliable than memory. The management and preservation of the
hospital records in Indian context present a very gloomy picture. Despite the
intensive effort at national and international level, the fundamental health care
needs of the population of the developing countries are still unmet. The lack
of basic health data renders difficulties in formulating and applying a rational
for the allocation of limited resources that are available for patient care and
disease prevention.
It is recommended that more efforts should be made by the
institutions/hospital managements, all clinicians and medical record officer to
improve the standard of maintenance and preservation of medical records. In this
article, we are discussing the various aspects of the medical record management.

B. Values of the medical record

1. To the patient
a. It facilitates continuity and excellence of care, if all details of all treatments,
 both previous and current, rerecorded in it. It may save repetition of X-ray and
pathology examinations which is often necessary if all notes on all previous
investigations and treatments are not available to the doctor at the most recent
admission or outpatient consultation.
b. It can give valuable supportive evidence, if needed, in court cases.
2. To the doctor
a. He can review his cases, e.g., to reconsider therapy he has been giving for a
certain disease, etc.
b. With the assistance of the medical record staff, and a good disease index or
operation index, he can have selected for him groups of medical records
relating to a certain disease operation - for research purposes.
c. The medical record, as evidence, can also help him in a court case.
3. To the hospital
a. The medical record forms a book of facts on medical staff competence and
shows whether their efforts, supported by hospital facilities, i.e., staff and
equipment, are in accordance with reasonable expectations in a clinical
medical service.
b. From an accurate and complete medical record, discharge analysis statistics
can be drawn and these can be used by the hospital's management in
estimating and planning for present and future patient services.
c. A complete medical record can be of immense value in a litigation suit
brought against the hospital.
4. Education
The medical record is invaluable for teaching of medical, paramedical and
nursing students. "This record shows what the patient complained of", when
explaining the symptoms of a particular disease and how it was treated.

C. Purposes or uses of the medical record

A medical record is not an end in itself and its design should reflect the uses
it is to be given. For each level or type of health care facility, consideration
should be given to the use, if any, that will be made of the record for:
1. Patient care: communication within facility; communication between facilities
2. Education: disciplines involved (e.g., physicians, nurses, etc.); use to be made
(retrospective review of records, recording by students on affiliation, inservice
education) ; patient education
3. Research: clinical, health services (administrative); retrospective, prospective
4. Evaluation: patient care evaluation; programme surveillance (monitoring)
5. Statistics: morbidity statistics; utilization statistics (service statistics)
6. Administration/- management: data on costs, productivity, drug and supply
utilization.

D. Uses of medical records

There are two ways in which a medical record can be USED.
1. As a Personal Document, i.e., relating to a particular patient, as an individual.
a. On admission - when a patient is to be admitted, the staff of the medical
record department (MRD) should produce any existing medical record so that
it may be taken to the ward at the same time as the patient. Special
arrangements may be necessary for the production of records relating to
patients admitted outside normal hours.
b. On admission of the patient to another hospital - a copy of his clinical
discharge summary should be sent, on that hospital's request for information.
c. On OP attendance - when a patient is to attend an outpatient clinic, the staff of
the MRD should produce any existing medical record, so that it will be
available to the clinician when he sees the patient.
2. As an Impersonal Document
The major use here is for basic data for research. In this case, the identity
of the individual is of no interest, rather it is the disease, operation, or other
variable which is under study that is important. This is legitimate use of the
records, for patients' benefit and so records can be freely released for it to
members of the hospital's own staff. Doctors from outside the hospital can use the
records for this purpose too, but must first have written authorization from the
hospital because it is the hospital which is the owner of the records. When the
record is used as an impersonal document care should be taken so that the
individual patient cannot be identified in any report or publication.
E. Structure of medical records
Structure of the record At present, there are two basic ways in which a
medical record can be structured: the traditional way and the problem oriented
medical record. In the traditional medical record, data are organized according to
their separate sections for physician notes, laboratory reports, nursing notes etc. is
also known as the source-oriented record or disease-oriented record. source, with
This record The problem oriented medical record (POMR), as the name implies,
is structured in function of the patient's problems. The POMR has four basic
components:
1. The data base formed by the initial data collected through the history (which
should include a medical and social profile of the patient); physical
examination; laboratory and X-ray examinations, etc. The data base should be
complete and uniform, that is, the minimum set of data to be collected for
each type of patient should be established.
2. The problem list. All the patient's problems - medical, social, psychiatric, etc.
-derived from the data base are entered on a list, assigning a number to each
problem. The problems can be expressed as diagnoses, symptoms,
physiologic findings, etc. depending on what the data will support. Diagnostic
suppositions or impressions are not recorded. The problem list is placed at the
front of the record and serves as an index.
3. The plans. Once the problems have been identified, a plan should be
developed for each one which indicates the actions proposed to clarify the
diagnosis, to initiate therapeutic measures, and to educate the patient. Each
plan is identified with the problem number and title.
4. Progress notes. Each narrative progress note is clearly identified with the
number and title of the problem to which it refers. These progress notes are
structured into four parts: (S) Subjective data which is what the patient
relates; (O) Objective data; (A) Assessment, interpretation, or impression; and
(P) Plan which covers the same points as the initial plans. Progress notes can
also be recorded on flow sheets in which the items of interest to be followed
are listed on one axis with columns or graphs used to record how each of
these items progresses. (See also Part II, Section 1.6) It should be noted that
 the only special form that is needed to put this type of record into practice is
the problem list.

F. Content of record
The health record should support the philosophy of care Which the
country wishes to provide. The record should therefore be designed to reflect the
health priorities, the activities to be carried out, and the identity and status of the
health personnel responsible for the care given. A first step must be to define the
functions to be performed at each level of care and what recording is required. As
a minimum, each record should contain:
1. Sufficient information to identify the patient (the items required will depend
on varying factors such as cultural patterns) ;
2. Date of contact;
3. Reason for contact (complaint or control);
4. Findings;
5. Treatment and recommendations.

G. Altering Medical Records

While writing the medical notes, as far as possible do not overwrite. If the
change is needed, strike the whole sentence. Do not leave ambiguity. Make a habit
of signing if change is made. Preferably put the date and time below the signature.
Attempting to obliterate the erroneous entry by applying the whitener or
scratching through the entry in such a way that the person cannot determine what
was written originally written raises the suspicion of someone looking for
negligent or inappropriate care.
1. Do not alter the notes retrospectively. If something written was inaccurate,
misleading or incomplete then insert an additional note as a correction.
2. Entries in a medical record should be made on every line. Skipping lines leave
the room for tampering with the records.
3. Amend on electric record by striking through rather than deleting and
overwriting the original entry. After insert- ing the new note, add date, time
and doctor name.
4. Correction of the personal identification data of the patient like name, age,
father/husband name, and address should only be made on the basis of
affidavit attested by notary or 1st class magistrate.

H. Who has Access to Medical Records?

1. Medical records are the property of the hospital or patient’s medical
practitioner. It is a confidential communication of the patient and cannot be
released without his permission.
2. All patients have right to access their records and obtain copy of those records.
3. Patient’s legal representative has the right to those records as long as patient
has signed a release of records to accompany any request from the legal
representative.
4. Other health care providers have the right to the records of the patient, if they
are directly involved in the care and treatment of the patient.
5. Parents of a minor also have access to patient’s medical records.
6. Medical records are usually summoned in a court of law in certain cases like-
road traffic accident, medical negligence, insurance claim etc.
7. The impersonal documents have been used for research purposes as the
identity of the patient is not revealed. Though the identity is not revealed, the
research team is privy to patient records and a cause of concern about the
confidentiality of the information. Recently a need has been felt to regulate the
need of medical research, effectively restricting the manner in which this type
of research is conducting. An ethical review is required for using the patient’s
data.

I. Release of Records
1. Request for medical records by patient or authorized attendant should be
acknowledged and documents should be issued within 72 hours.
2. Maintain the register of certificates with the detail of medical records issued
with at least one identification mark of the patient and his signature.
3. Effort should be made to computerize the records for quick retrieval.
4. Certain document must be given to the patient as a matter of right. Discharge
summary, referral notes, or death summary are important document for the
patient. Therefore, these documents must be given without any charge for all
including patients who discharge them- selves against medical advice.
5. Doctors are not under any obligation to produce or surrender their medical
records to the police in the absence of valid court warrant.
6. A subpoena to produce clinical records is a form of court order. Failure to
comply is in contempt of court and may be punished. Medical records which
are subpoenaed are to be made over to the court and not to the solicitor who
sought the subpoena.

J. Care while Issuing certain Medical Records

1. Prescription
The prescription should be preferably on the OPD slip of the institution or
on the letter pad of the doctor. Drug company or chemist prescription pad should
never be used. Prescription must contain—patient’s name, age, sex, address and
institution/hospital name. Prescribed drug should be preferably in capital letter or
else clearly visible. One should mention its strength (especially in paediatric age
group), its dose frequency, duration in days, and total quantity (number of tablets
and capsules). Below the main drug, also mention other instructions of
precautions and what to avoid. If any investigation is advised, do not forget to
mention it on the prescription slip and call the patient after the investigation. If
patient fails to keep follow up date and if then some complication occurs, then
patient is also considered negligent (contributory negligence).
2. Reports
All reports i.e. lab investigation, X-ray reports, ultrasound reports,
computed tomography (CT-scan)/magnetic imag- ing resonance (MRI) reports,
and histo-pathological reports should be issued by a qualified person. Biopsy
report should preferably be issued in duplicate so that the refer- ring
doctor/hospital can keep the original copy. If the pathologist does not give a
duplicate copy the referring doctor should get it xeroxed and should be handed
over to the patient.
3. Referral Notes
Always keep the carbon copy of referral note especially in case of
critically ill patient. Referral note should mention the date and time of writing the
note. Also write the treatment given.
4. Discharge Card
Consultant in-charge should himself fill or supervise the discharge card.
Condition of the patient on the admission, investigation done, the treatment given
and detail advice on discharge should be written on discharge card. Operation
notes if mentioned have to be correct otherwise just mention the name of the
operation and give separate note in detail if asked for. If any complication is
expected after discharge ask the patient to report immediately. Instructions while
discharge must be very clear and elaborative. Keep in mind that abbreviations
may not be understood by others. Also do not use code messages, sarcasm or poor
opinion to the patient.
5. Certificates
A medical certificate is defined as a document of written evidence
vouching for the truth of a fact as determined by the doctor issuing such a
document. If medical certificate is admitted in a court of law as evidence and is
proved to be false, the issuing doctor is liable for punishment. While issuing a
medical certificate following things should be kept in mind,
a. Medical certificate should be on institution/doctor letter pad.
b. Date, time, and place should be mentioned.
c. Issue it only for legitimate purpose and only when necessary.
d. It has to be true and clear without any ambiguity.
e. There should be an identification mark of the patient, preferably a thumb
impression.
f. Period of illness should be clearly mentioned.
g. Diagnosis disclosure of the diagnosis should be only after the patient’s express
consent, unless required by the law
h. Doctor should maintain the duplicate copy of every certificate.
K. How Long to Maintain the Records
1. Ideally records of adult patient are maintained for 3 year.
2. 21 year for neonatal patient (3 + 18 year).
3. For children 18 year of age + 3 year.
4. For mentally retarded patient forever till hospital/ institution is working.
5. From income tax point of view for 7 years.

L. How to Destroy the Records

1. Public notice of destroying the records in English news paper and in one
vernacular paper mentioning the specific date up to which destruction will be
sought.
2. Give a time limit of 1 month for taking away records for those who want the
records with written consent.
3. After 1 month destroy the records up to date specified except for following
a. Where litigation is going on.
b. Where future trouble is expected.
c. Mentally ill or retarded patient.
d. Pre-litigation process of notice exchange is going on.

M. Hard Copy Only

Computers are now widely used in institution/hospitals for electronic
patient records but still hard copy is required for following documents.
1. Consent need to be on hard copy.
2. Referral to doctor need hard copy.
3. Police case need hard copy.
4. Certificate of fitness should be on hard copy.

N. Problem of Record Management

There are many problems faced by institution/hospital for the proper
maintenance of the records.
1. Constant revision of the outdated form is needed.
2. Always trained personnel are needed for the maintenance
3. Inactive records need storage at appropriate place
4. There must be a need of determination of record retention.
5. Unwanted records must be destroyed
6. Record storage entail into 2 stages :Moving the records from active to
inactive file and from there to storage room and destruction and disposal of
the unimportant records.
There are various type of damage which may be found in paper
documentation like-aged paper may become weak, colour alteration from white to
yellow, dirt and dust may be present on the surface, insect and fungus is a big
threat for the records, if paper is kept folded, it may become weak at the crease,
dampness and water leakage in storage room also destroy the paper.

O. Proper Preservation of the Medical Records

Collect all the records and classify them according to the different section.
Protect the records from insect attack. Spray insecticide or place naphthalene balls
over shelves to preserve the records. Plan a periodical checking for the records.
Proper care should be observed while handling the records. Fire extinguisher
should be available in record room. Protect all records from dampness, water, and
from hot and dry climate. Records should be kept in dust free area. Windows and
ventilators should be properly covered with frames as safeguard against sabotage.
Destroy the records as per the regulation established for retention of records.
Examples of medical records form: