Hospital Records

Hospital records Medical record Birth and death certificates ER record Out-patient record In-patient record Birth and death certificates Medical reports and certificates Reports of infectious diseases Registration of cancer patients

Medical record An orderly written document encompassing the patient’s identification data, health history, physical examination findings, laboratory reports, diagnosis, treatment and surgical procedures and hospital course

The record should contain sufficient data to justify the investigations, diagnosis, treatment, length of hospital stay, results of care and future courses of action.

Uses Means of communication among physicians, nurses and other allied health care professionals Reference for providing continuity in patient care Documentary evidence of care provided in the health care facility Informational document to assist in the quality review of patient care

Uses To protect the patient, physician, the health care institution and its employees in the vent of litigation To render clinical and administrative data required for budgeting, management, service development, planning, review, medical education and medical research To supply pertinent patient care information to authorized organizations and third party payers

Guiding principles Should cover the purpose, confidentiality, ownership substance and accessibility of the hospital record

Primary purpose Document the patient’s illness and treatment

Doctrine of confidentiality The hospital is obligated at times to withhold certain information as “confidential” in the absence of an appropriate consent on the part of the patient or in accordance with statutory provisions.

Policies for MDs regarding Release of Information Doctors and members of the allied health profession may review records of patients presently under their care Doctors who are members of the medical staff but not members of the medical team assigned to the patient should have a written authorization signed by the patient before they are given access to the record.

Ownership The medical record is the property of the hospital. Therefore, the hospital, subject to applicable legal provisions, may restrict the removal of the record from the medical record or hospital premises, determine who may have access to it and define the kind of information that may be taken from it.

Who has access to the medical record? Primary physician, Consultants hospital administrator resident, clinical clerks, interns * patient - can secure copies of tests, record of operation for purposes of insurance claims/benefits

Obligation to keep medical records “a physician must draw up a medical record for each person who consults him”

Physicians’ responsibilities in keeping Medical Records Do them promptly. Do them yourself. Note the date and time of each entry. Write legibly. Never “edit” an entry even for legibility

Physicians’ responsibilities in keeping Medical Records Record relevant facts – avoid vague and ambiguous statements Give opinion backed up by facts Derogatory, trivial comments about patients, or colleagues should never be recorded Record accurately.

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