Characteristics of good Medical Record:

-A good medical record possesses several key characteristics that are essential for efficient
and effective healthcare management.
-These characteristics collectively contribute to the quality and reliability of a medical
record, thereby supporting safe and effective healthcare delivery.
- These characteristics are:

1. Accuracy:

The information recorded should be precise, complete, and free from errors. It should reflect
the patient's medical history, symptoms, diagnoses, treatments, and outcomes accurately.

2. Completeness:

The medical record should contain all relevant information pertaining to the patient's
healthcare, including personal details, medical history, laboratory results, diagnostic reports,
treatment plans, progress notes, and follow-up care.

3. Timeliness:

The medical record should be updated in a timely manner, reflecting the most recent patient
encounters, test results, treatments, and any changes in the patient's condition. This ensures
that healthcare providers have access to the most current information when making clinical
decisions.

4. Clarity and Organization:

The record should be well-organized and easy to navigate. It should use clear and concise
language, standardized medical terminology, and headings to facilitate quick and accurate
retrieval of information.

5. Confidentiality and Security:

Patient confidentiality is of utmost importance. A good medical record should adhere to

strict privacy and security protocols, ensuring that patient information remains confidential
and protected from unauthorized access or disclosure.

6. Accessibility:

The medical record should be easily accessible to authorized healthcare providers involved
in the patient's care. This includes physicians, nurses, specialists, and other healthcare
professionals who require access to the information to provide appropriate and coordinated
care.

7. Legibility:

All entries in the medical record should be legible and easily understandable. Illegible
handwriting or unclear documentation can lead to misunderstandings or errors in patient
care.
8. Consistency:

The medical record should maintain consistency in terms of format, terminology, and
abbreviations. This helps to avoid confusion and misinterpretation of information.

9. Auditability:

A good medical record should be auditable, meaning that any changes or alterations made to
the record should be transparent and traceable. This ensures accountability and helps
maintain the integrity of the information.

10. Integration and Interoperability:

Ideally, the medical record should be part of an integrated healthcare information system,
allowing for seamless exchange of information between different healthcare providers and
systems. This promotes continuity of care and avoids duplication of efforts.

Sequence of Medical Record:

A medical record typically contains a variety of information related to a patient's healthcare.
While the specific contents may vary depending on the healthcare provider and the patient
condition, here are some common elements found in a medical record:

A. Patient still in hospital

1. Personal Information:(Identification Sheet)

This includes the patient's name, address, contact details, date of birth, gender, and
emergency contact information.
The identification sheet is used as both a clinical and an administrative
document. It provides a quick view of diagnosis of the patient's condition.

2. Vital Signs:

Vital signs such as blood pressure, heart rate, respiratory rate, temperature, and oxygen
saturation are recorded to assess the patient's overall health status.

3. Medical History:

This section covers the patient's past and current medical conditions, including any
chronic illnesses, surgeries, allergies, significant family history of disease, and
medications taken.
4. Physical Examination:

This section details the findings of the healthcare provider's physical examination, including
observations, palpations, and auscultations.

5. Laboratory and Diagnostic Tests:

Results of laboratory tests, such as blood tests, urine tests, imaging studies (X-rays, MRIs,
etc.), and other diagnostic procedures, are documented here.

6. Progress Notes:

These are records of each visit or encounter with the healthcare provider, including a
summary of the discussion, assessment of the patient's condition, any changes in treatment
plan, and response to treatment.
Each provider is responsible for the content of his /her notes.

7. Medication Record:

Information about the medications prescribed to the patient, including the name, dosage,
frequency, and duration of use.
It also lists any medication allergies.
Nurses are responsible for documenting medication information.

8. Treatment Plans:(Operative Report)

This section outlines the recommended treatments, procedures, surgeries, for the patient's
Condition, the surgeon is responsible for the operative report, this report contains the names
of surgeons and assistants.

9. Consultation and Referral Reports:

If the patient was referred to a specialist or received a consultation, the reports and
recommendations from those healthcare professionals may be included in the medical
record.

10. Consent Forms:

Any signed consent forms for specific procedures or treatments are typically included in the
record.

11. Pathology Report:

Describes tissue removed during any surgical procedure. The pathologist is responsible for
this report.
 12. Discharge Summary:

If the patient was admitted to a hospital, a discharge summary may be present, outlining the
reason for admission, treatment received, and instructions for follow-up care.

B. After discharge of the patient:

1. Front sheet.
2. Summary sheet (final diagnosis, disease and operation codes).
3. Consents for treatment.
4. Legal documents (request for information).
5. Discharge summary.
6. Admission notes.
7. Clinical progress notes.
8. Nurses progress notes.
9. Report.
10. Pathology report.
11. Other reports(x-ray).
12. Medication order.

The responsibility for Medical Records:

the responsibility for medical records is a shared effort among healthcare providers,
healthcare organizations, health information management professionals, patients, and
regulatory authorities.

Here are the key stakeholders involved:

1. Healthcare Providers:

The primary responsibility for creating and maintaining medical records lies with healthcare
providers, including physicians, nurses, and other healthcare professionals. They are
responsible for documenting the patient's medical history, examination findings, diagnoses,
treatments, and other relevant information during the course of their care. Providers should
ensure that the records are accurate, complete, and up-to-date.

2. Healthcare Organizations:

Healthcare organizations, such as hospitals, clinics, and medical practices, also have a
responsibility for the management of medical records. They establish policies and
procedures for record-keeping, implement systems for electronic or paper-based record
storage, and ensure the security and privacy of the records. The organizations may have
designated staff, such as medical records administrators or health information
management professionals, who oversee the maintenance and access of medical records.
3. Health Information Management Professionals:

These professionals have specialized training in managing medical records and health
information. They are responsible for tasks such as record coding, release of information,
record retention, and ensuring compliance with legal and regulatory requirements. They play
a vital role in maintaining the integrity and confidentiality of medical records.

4. Patients:

Patients also have a role in the management of their medical records. They should provide
accurate and updated information about their medical history, medications, and allergies to
healthcare providers. Patients have the right to access and request copies of their medical
records, and they should notify healthcare providers if they identify any errors or
discrepancies in their records.

5. Regulatory Authorities:

Government agencies and regulatory bodies may establish guidelines and regulations
regarding the management of medical records. They ensure compliance with privacy laws,
data security standards, and other regulations related to health information management.
These authorities may conduct audits and inspections to assess the handling of medical
records by healthcare organizations.

Reference:

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Harcourt, K., Fitzgerald, P., Payne, T.H., Stametz, R. and Delbanco, T., 2020. The
views and experiences of clinicians sharing medical record notes with patients. JAMA
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