MEDICAL RECORDS IN

FAMILY PRACTICE
Suryani Tawali
 Objectives
• At the end of the session, students are
expected to be able to :
1. Explain the purpose of a medical
records in daily practice.
2. Explain the Source Oriented Medical
Record.
3. Explain the Problem oriented medical
record.
 Objectives
4. List items included in the medical
records
5. Discuss why keeping medical records.
6. Explain the P SOAP acronym of
keeping records of patients.
 What is medical records ?
• A record of patients health conditions

LEGAL BASIC : PERMENKES NO. 749a thn

1989
 What is included in a medical
record ?
• Personal info: age, sex, occupation, training,
family...
• Risk factors: tobacco, alcohol, life styles...
• Allergies and drug reactions
• Problem list
• Disease history: diseases, operations. . .
• The disease process: main problem, history,
exam, lab.
• Management plan: advice, education,
medication. . .
• Progress notes: in the P S O A P format
Why keeping medical records?
• Helps in medical decisions
(is the size of a lymph node or nodule
increasing with time?)
• Helps to share responsibility with the
patient
• Legal obligation.
• Protects the patient as well as doctor
in front of the court
• Useful to produce health statistics
• Provides epidemiological data
• Assists practice management
• Useful in QI activities
• Is a communication tool
 TYPES OF MEDICAL RECORDS

1. Source Oriented Medical Record

(SOMR)
2. Problem Oriented Medical Record
(POMR)
 SOMR
– Data taken from the source are recorded as
they are
(Source: patient, relative, laboratory etc.)
– Easy and fast to record

– Flexible
– Omitting information is highly possible
– Difficult to access the information
 POMR
• Structure is defined in advance.
• The patient with problem is in the
focus
• It is systematic
• Data is easily accessible
• Not flexible. Recording information is
difficult and time consuming
• Problem PSOAP
– Everything the patient reports and doctor’s
findings which are regarded as problems
• Subjective
– History of the problem; what the patient
feels or thinks about the problem
• Objective
– Doctors findings related with the problem
• Assessment
– Evaluation of the problem; the diff.
diagnosis
• Plan
– Prescription, consultation, advice, control
visit...
 Source Oriented Medical Record
Patient -Source-Oriented Medical
Visits Record
21 February 1996: dyspnea, coughing and fever. Dark defecation.
PE: BP 150/90, pulse 95/min, Fever: 39.3 oC.
Ronchi +, no abdominal tenderness.
Medications: 64 mg Aspirin/day.
Possible acute bronchitis and cardiac decompensation.
Possible bleeding due to Aspirin.
Rx: Amoxicilline 500 mg 2x1, Aspirin 32 mg/day.

4 March 1996: no cough, slight dyspnea, defecation normal.

PE: light rhonchi, BP 160/95, pulse 82/min.
Rx: Aspirin 32 mg/day.

Lab
21 February 1996: ESR 25 mm, Hb 7.8, Fecal occult blood +.
4 March 1996: Hb 8.2, Fecal occult blood :-.
X-ray
21 February 1996: Chest x-ray: no atelectasis, light cardiac
decompensation findings
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 Problem Oriented Medical Record
Problem 1: Coughing
21 February 1996
S: dyspnea, coughing, fever.
O: pulse 95/min, Fever: 39.3 oC.
Rhonchi+. ESR 25 mm.
Chest x-ray: no atelectasis, light
cardiac decompensation findings.
A: Acute bronchitis.
P: Amoxicilline 500 mg 2x1.
4 March 1996
S: no coughing, slight dyspnea.
O: pulse 82/min. Slight rhonchi.
A: minimal bronchitis findings.
Problem 2: Dyspnea
21 February 1996
S: Dyspnea.
O: Rhonchi+, BP 150/90 mmHg.
Chest x-ray: no atelectasis, slight
cardiac decompensation findings.
A: Slight decompensation findings.
4 March 1996
S: slight dyspnea.
O: BP: 160/95, pulse 82/min.
A: No decompensation.
Problem 3: Dark colored defecation

21 February 1996
S: Dark feces. Using Aspirin 64 mg/day.
O: No abdominal tenderness, rectal exam revealed no blood, Hb 7.8 mg/dl. Fecal
occult blood +
A: Possible intestinal bleeding due to Aspirin.
P: Decrease Aspirin dose to 32 mg/day.

4 March 1996
S: Defecation normal.
O: Fecal occult blood -
A: No intestinal bleeding symptoms.
P: Continue Aspirin dosage 32 mg/day
 Rules in keeping medical records
1. Each page in the record contains the patient’s name or ID number.
2. Personal biographical data include the address, employer, home and work
telephone numbers and marital status.
3. All entries in the medical record contain the author’s identification. Author
identification may be a handwritten signature, unique electronic identifier
or initials.
4. All entries are dated.
5. The record is legible to someone other than the writer.
6. Significant illnesses and medical conditions are indicated on the problem
list.
7. Medication allergies and adverse reactions are prominently noted in the
record. If the patient has no known allergies or history of adverse
reactions, this is appropriately noted in the record.
8. Past medical history (for patients seen three or more times) is easily
identified and includes serious accidents, operations and illnesses. For
children and adolescents (18 years and younger), past medical history
relates to prenatal care, birth, operations and childhood illnesses.
9. For patients 12 years and older, there is appropriate notation concerning
the use of cigarettes, alcohol and substances (for patients seen three or
more times, query substance abuse history).
10. The history and physical examination identifies appropriate subjective and
objective information pertinent to the patient’s presenting complaints.
11. Laboratory and other studies are ordered, as appropriate.
12. * Working diagnoses are consistent with findings.
13. * Treatment plans are consistent with diagnoses.
14. Encounter forms or notes have a notation, regarding follow-up care, calls or
visits, when indicated. The specific time of return is noted in weeks, months
or as needed.
15. Unresolved problems from previous office visits are addressed in
subsequent visits.
16. There is review for under - or over utilization of consultants.
17. If a consultation is requested, there a note from the consultant in the record.
18. Consultation, laboratory and imaging reports filed in the chart are initialed by
the practitioner who ordered them, to signify review. (Review and signature
by professionals other than the ordering practitioner do not meet this
requirement.) If the reports are presented electronically or by some other
method, there is also representation of review by the ordering practitioner.
Consultation and abnormal laboratory and imaging study results have an
explicit notation in the record of follow-up plans.
19. There is no evidence that the patient is placed at inappropriate risk by a
diagnostic or therapeutic procedure.
20. An immunization record (for children) is up to date or an appropriate history
has been made in the medical record (for adults).
21. There is evidence that preventive screening and services are offered in
accordance with the organization’s practice guidelines.
 Legal Problems

• Not recorded = Not done !

 In order to prevent legal
problems:
• Record everything you do (including phone
consultations)
• Apply guidelines (according to the country legal
basic)
• Don't use erasable pencils
• Don’t use humiliating expressions
 Do not use vague expressions such as “the
patient feels well”

 If you need to make changes just strike through

and record also the date of change

 If you stated that the patient is not cooperative

give the reason

 If patient rejects a procedure or test, mention it

and give the reason why you requested it
 Follow-up Charts

• It is practical to use follow-up charts for

chronic diseases
– DM,
– Hypertension
– Obesity
–…
 Charts - Obesity

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