Medical Documentation & Medical Records

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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

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 Document should be
 Correct

 Clear
 Complete  Confidential  Comprehensive  Collaborative  Contemporary  Consecutive  Concise  Patient Centered
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Documentation
 Patient related
 written and electronic health records  Audio and video tapes

 Emails
 Images (photographs and diagrams)  Observation charts  Check lists

 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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 Periodic Observations  Treatment in detail  Instructions  Complications

 Refer note
 Remarks  Negative remarks

 Signature with qualification, designation &

Registration number

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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.

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