An In-depth View of Medical Documentation & Medical Records. By our faculty at AIILSG, Ahmedabad; respected DR RAVI BHISE. Just to share his excellence and knowledge for utmost help to health science and medical students through the medium of internet.
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Content
“Protect your Problems with your PEN”
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Objects For care & treatment For documentation For reimbursement For medical education For research For communication For follow up For legal issues
For Billing & Audit
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Reasons for poor records
Considered a time consuming bother
Cutting costs
Restaurant type medical service No training
Doctor - shopping patients
…Unless hit by litigation
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What is the Necessity ?
Practicing medicine now is hazardous & risky Mutual faith replaced with mutual suspicion. Practicing defensive medicine inevitable.
The best way to deal with Medical & Medicolegal problems is to prevent them
Medicine is a science of uncertainty and art of probability
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Several reasons to maintain records
Coordinative vehicle – for communication, all
case - related info, should be complete
Indicate good quality medical care
Indicate good quality practitioner
Best defense for litigation
Communication books
Shift/management reports Incident reports Clinicians personally or any other type or form of
documentation pertaining to the care provided
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Other Documents not pertaining to patients Policies, procedures and protocols Critical incident / occupational health and safety
reports Statistical and research data Reports related to service and funding agreements Staffing rosters Personnel files Performance appraisals Clinical assessments Published reports/papers
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Who? What? When? Why? How?
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Minimum requirements Full Name Age, Sex & Address Occupation, Educational status & Social condition Date, Time & Place Consent History General Examination with time & date Special Examination with time & date Investigations Diagnosis
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Accurate Medical Records
Record of medical care Comply with legal requirements, accreditation standards,
and professional practice standards Support and defend care
Advantages of Pre-printed documents
Prompts clinician for key elements Improves legibility Standardizes content Facilitates data collection, quality auditing
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Advantages of Electronic Documentation
software available Less time consuming
Choose that is most user friendly
Trained staff in software use
Research possible from data
Medicolegal advantage
Record keeping
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Provisions regarding Medical
Documents
Certificates Routine case records Indoor case papers Medico-legal case papers Probable negligence cases For library or public interest patient’s rights
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Injury Certificate Drunkenness Certificate Sexual Offence Certificate Cause of Death Certificate Age Estimation Certificate Certificate for Leave/Extension of Leave/
Commutation Leave Fitness Certificate
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Registers
OPD Indoor MLC Birth & Death Operative Procedure Referred Cases Discharge
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MEDICAL COUNCIL OF INDIA GUIDELINES ON MEDICAL RECORDS Maintain indoor records in a standard proforma for 3 years from commencement of treatment (Section 1.3.1 and Appendix 3). Request for medical records by patient or authorized attendant should be acknowledged and documents issued within 72 hours (Section 1.3.2). Maintain a register of certificates with the full details of medical certificates issued with at least one identification mark of the patient and his signature (Section 1.3.3). Efforts should be made to computerize medical records for quick retrieval (Section 1.3.4).
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Time period
* OPD records – 3 yrs * Indoor case records – 5 yrs * Medicolegal case – 30 yrs
Maintain Confidentiality of records
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Documents must be given to the patients as a matter of
right
Discharge summary, referral notes, and death summary
Documents can be given after fulfilling the hospital
criteria
copies of inpatient files, records of diagnostic tests,
operation notes, videos, medical certificates, and duplicate copies for lost documents
Certain records cannot be given to patients without the
direction of the Court
The outpatient register, inpatient register, and files of
medico-legal cases cannot be handed over to the patient or relatives without the direction of the court
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There are certain situations where it is legal for
the authorities to give patient information. during referral when demanded by the court or by the police on a written requisition when demanded by insurance companies as provided by the Insurance Act when the patient has relinquished his rights on taking the insurance when required for specific provisions of Workmen's Compensation cases, Consumer Protection cases, or for Income tax authorities.