Session 3

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Medical record is a clearly and accurately written description of patient condition, illness and treatment of a disease.

Medical records systems are either manual or electronic systems that are used to organise and catalogue information regarding treatments, general health conditions or other data that is relevant to patients.

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Medical records includes

Name

Gender

Age of the patient

Contact information for next of kin or other persons authorized to receive information about the patient.

Notes on any allergies are also documented.

If the patient has some type of insurance or some kind of health care discount plan, and other relevant details are also kept in the patient file.

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Doctor’s visits

Patient hospital stays

Surgical procedures

Medication prescribed on a short- or long-term basis

Most systems include spaces where physicians, nurses and other authorized medical personnel can enter notes relevant to each event where medical care was given to the patient

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Case records

These are records initiated for patients who get admitted into the wards or who continuously attend the various consultant clinics.

The information that is contained in the case can be expressed verbally, graphically, diagrammatically or in a tabular form (depends on the person who is taking in the information).

The range of documents to be included in the case record also depends on local requirements, although certain documents will be common to all health facilities.

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Includes all the cards that are used in the outpatient departments, for example, casualty cards, ante-natal cards, immunization cards and any other card that may be used in the out-patient departments.

Diagnostic records

These include notes on lab investigations, radiology and pathology.

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Psychiatric records

Maintained differently from the general records according to the mental health act.

Tuberculosis (TB) records

Maintained in order to identify the affected population.

Since it is an infectious disease notification must be made to the medical officer or health officer (a register is maintained for this notification).

Copies of the notification of new cases are sent to the TB and Leprosy clinic.

A unit record is opened for this patient and the information contained in it should be very comprehensive.

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The records belonging to these patients are supposed to be kept for long periods and therefore the case folder must be made of strong material to resist wear and tear.

The notes should be written in full scaps instead of A4 size papers.

Radiotherapy records

All radiotherapy cases are supposed to be registered nationally for follow up.

All patients’ radiotherapy records are kept in the patient’s hospital record with one unit number and maintained at the national cancer registration unit.

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Treatment

The health record is first and foremost of value in the present and future treatment of the patient.

The individual record is a reminder to the specialists, clinician, nurse, social workers or health technicians of what he or she has personally observed during the patient’s illness and can assist in prescription of future treatment.

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It provides or should provide complete history of the patient so that all facts that might be important are permanently available for reference at any time.

A complete record prevents duplication of work, effort and facilitates future care of the patient.

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Health statistics and information gathered from the health record can be used to plan for future programs and service.

It is important that statistics/information is accurate and disseminated promptly to the users.

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Accurate recording of observations can provide useful information for research purposes.

If medical record is used for research, it should contain basic information required for achieving the goals of research.

Teaching

Health records can be used as an educational tool or instrument.

Good quality health records facilitates effective learning of students

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Complete health records increase efficiency in health service to the public, avoiding dissatisfaction, facilitates fair settlement of claims and enhances capacity to answer enquiries about the work.

Record should be designed to capture necessary information needed for its purpose

It is important for the record to meet the requirements of both the clinician and the records personnel.

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The legal requirements affecting health records will concentrate on

Confidentiality of patient records

Ownership of patient records

Security and disclosure of information

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Information concerning a patient is confidential and should not be disclosed to any unauthorized person.

If members of the health facility staff improperly disclose any information concerning a patient, the patient can sue the health facility and the responsible officer.

To minimize risks, it is suggested that the health facility should have a policy of confidentiality regarding patients’ health information.

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There are five main categories under which contents of patient’s records can be disclosed.

Consent by the patient, which can be verbal or written consent

If there is a court order

In transferring patients between health facilities, clinics or doctors in the interest of the patient

Notification of infectious diseases, births and deaths registration and notification of poisons and chemicals

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The records do not belong to the patients even if the fees have been paid.

The records belong to the various health facilities that have created them.

In the case of government health facilities they belong to the government.

Case records of private health facilities belong to the health facilities because they have contributed to the creation of records.

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The folder should be made of strong material with holders to keep the forms and records intact

Contents of the health records folder include

Front sheet or identification sheet

Clinical history sheet

Surgical operation chart

Anaesthetic record

Temperature, pulse and respiration (T.P.R) chart

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Consent forms

Report forms

Clinical photographs

In-patient summary

Correspondence

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This is the area where all the patient’s social demographic details are recorded from the pre-registration form, for example, patient names, address, sex, age.

The back side should be provided to record signs and symptoms of patient conditions.

A section on this side is provided to record the consultants/clinicians’ names or a clinic the patient has attended or wards him/her has been admitted.

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Provides space for clinicians to write patients history.

Continuation sheet-They are continuation of history sheets or treatment sheets.

Prescription chart-This chart makes formal provision for the doctor to prescribe medicine for inpatients or outpatients.

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Special forms are provided on which operations may be recorded.

Normally contain sections in which the names of all surgeons and anaesthetists taking part in the operation are recorded, may be provision for special remarks (for example drainage, blood loss information and recovery treatment).

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Anaesthetic record forms contain records of anaesthetic drugs given to the patient during the operation and immediate postoperative period.

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One type of temperature chart is the twice-daily chart for the recording of the routine observations of morning and evening temperatures.

Urine and stool details are usually recorded at the foot of the T.P.R. chart.

A second type is the 4-hourly temperature chart used to record vital signs of serious patients.

This is frequently printed on coloured paper, or in coloured ink, to make it noticeable.

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Many reports which are smaller than the size of most forms have to be filed in the folder.

Usually attached to a report mount sheet.

These mount sheets vary in designs and the method of attachment.

The reports attached on a mount sheet are consent form, laboratory results, radiological pictures and others.

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Written consent has to be obtained for all operative procedures.

For minor operations like tubeligation, vasectomy (sterilization procedures), for post mortems examination.

The consent has to be obtained from patient, relative or parent (for less than 16 years old).

Consent for testing and counselling for HIV.

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All investigations – laboratory (haematology, biochemistry, bacteriology, histology), cardiology, radiological results, in some sort of report form that will have to be filed into the patient’s record folder

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When a patient has an interesting condition, a clinical photograph may be taken.

In plastic surgery where the patient may pass through several stages of treatment, a photograph is often taken at intervals to record progress.

Photographs may be kept centrally in the medical photographic department, but they are frequently filed in the patient’s folder, either mounted on a card or in a special plastic holder with pockets for the storage of a series of smaller photographs or slides.

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This is a form where patient’s information on discharge is recorded.

It is used for follow up purposes.

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Copies and originals of all communications about patient’s health information or condition must be filed in the patient’s record folder.

These may include referral letters.

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Medical record is a clear, accurate and comprehensive written description of patient condition, illness and treatment of a disease.

Types of health records include case records, outpatient records, diagnostic records and special health records.

Legal aspect of health records involves confidentiality, disclosure of information and ownership.

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What are the types of health records?

What are the uses of health records?

Where are we supposed to keep special health records in the health facility.

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