1. Hospital Records

2. 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

3. 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

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

5. 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

6. 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

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

8. Primary purpose
Document the patient’s illness and treatment

9. 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.

10. 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.

11. 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.

12. 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

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

14. 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

15. 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.

16. thank you !!!