Medical Record Documentation, Where We
Stand?
Amer EItwati Ben Irhuma,*
"Knowing
is not enough; we must apply. Willing is not enough; we must do."
"Johann von Goethe "
Keywords: medical file,
medical documentation, medical record.
Introduction:
Medical record
documentation is required to record pertinent facts, findings, and observations
about an individual's health history including past and present illnesses,
examinations, tests, treatments, and outcomes. The medical record chronologically
documents the care of the patient and is an important element contributing to
high quality care.1
Medical records
are one of the primary sources of evidence used by the court in deciding
whether a physician is liable for malpractice. Incomplete records can be devastating
to the defense of a claim; as far as the court is concerned, if it's not in the
medical record, it simply did not happen. Sloppy or inaccurate documentation can
create the impression that the medical care rendered was less than professional.
The medical
record you prepare today may be reviewed by others, both within and outside the
hospital or practice. And the accuracy and completeness may be questioned or
discussed and you may be asked to justify your record-keeping methods and
practices by non-medical personnel.
Problems with communication, and in particular documentation, have been widely recognised as major contributing factors in the occurrence of sub-optimal patient outcomes. The treating medical officer is responsible for diagnosis, establishing a treatment plan and facilitating ongoing care. It is vital that documentation regarding these aspects is adequate if intended results are to be achieved. The best protection from liability is good prehospital care." And, "The best protection in a malpractice proceeding is good documentation".2
Problems with communication, and in particular documentation, have been widely recognised as major contributing factors in the occurrence of sub-optimal patient outcomes. The treating medical officer is responsible for diagnosis, establishing a treatment plan and facilitating ongoing care. It is vital that documentation regarding these aspects is adequate if intended results are to be achieved. The best protection from liability is good prehospital care." And, "The best protection in a malpractice proceeding is good documentation".2
Purposes:
Medical record
should have clear and objective purposes to serve. The medical record:3
1. Preserves basic
patient information
2. Justifies
treatment
3. Allows
continuity of care
4. Satisfies
regulatory requirements
5. Provides data for quality control and research
6. Is a documentary evidence of evaluation, treatment,
change in condition, etc.
7. Is a communication tool between clinicians.
Medical Record
Documentation Standards
Complete and
well - documented medical records are essential to effective and confidential
patient care. In general, medical records should be well organized and contain
only one member record per chart. Medical records should be kept in a secure
and confidential area and must be available to the practitioner during patient visits.
The standards for medical record documentation are listed below:
• Each and every page in the medical record should contain
the patient's name or ID number.
• Personal/biographical data should include date of birth,
gender, address & home telephone number.
• All entries in the medical record should be dated.
• All entries in the medical record must be legible.
• All entries in the medical record should contain author identification.
• Significant illnesses and medical conditions must be
indicated on the problem list.
• Medication allergies & adverse reactions should be
prominently noted in the record. If the patient has no known allergies or
history of adverse reactions, this must be appropriately noted in the record.
• Past medical history should include serious accidents,
operations and illnesses.
• There should be appropriate notations concerning the use
of cigarettes.
• Each visit should contain appropriate subjective and
objective information pertinent to the patient's presenting complaints.
*) Dean, Faculty of Medicine, Sebha University ,
Sebha , Libya
• A complete initial physical examination should be recorded
in the medical record.
• Appropriate laboratory and other studies are ordered and
completed.
• Working diagnoses should be noted to be consistent with
findings.
• Treatment plans should be consistent with diagnosis.
• Progress notes should have a notation regarding follow-up
care, calls or visits.
• There should be evidence of appropriate use of
consultants.
• If consultation is requested, there should be a note from
the consultant in the record.
• Abnormal laboratory(s)/imaging study results must have an
explicit notation in the record of follow-up plans.
• An appropriate immunization history must be noted in the
record for both adults and children.
• As applicable, there should be evidence of compliance with
public health reporting requirements relating to communicable disease.4
Principle Of
Medical Record
For medical record
to be up to standard it has specific principle to follow, and the record must
be Accurate, Complete, Legible, Objective, Comprehensive Signed, Timed, and
Dated, and as it's being said An accurate, complete, legible medical
record IMPLIES accurate, complete, organized assessment and management.
Accurate: Do NOT
speculate about patient or incident, Document facts, observations only WRITE IT
RIGHT.
Complete: for the
medical record to be complete it should include all requested information. If
you look for something and it isn't there, document its absence. Failure to
document implies failure to consider, (IF IT ISN'T DOCUMENTED, IT WASN'T DONE).
Legible: If you cannot
read the report, you may be unable to determine what happened. Documents
presented in court must "speak for themselves". If a document cannot
be deciphered, the court has the right to ignore it altogether. (If the report
is sloppy, others will assume that the care was equally sloppy).
Objective: medical
documentation is a fact sheet which should include
measurable information, and supportive, reproducible observations.2
measurable information, and supportive, reproducible observations.2
Record Date and
Time of:
All entries, Consultation notification, All orders, All informed consents.
Failing to document times implies lack of concern about the time factor.
Medical Record
Documentation, Where We Stand?
The medical
record system in our hospitals lacks the principle of record documentation, and
the variation in record documentation methods among hospitals in Libya Achill 's tendon of the
health care administration.
I think it is
about time to take care of our way to document our practice and be prepared to
face the increasing accountability the profession imposes on us. This can not
be achieved if we don't recognize how big the problem is, and confess about the
careless behavior of this crucial and vital issue.
CONCLUSION:
As
responsibility grows so does accountability. There are few, if any, professions
that bear more responsibility than the medical profession. With this huge
responsibility there is strict accountability. What does this accountability
mean to the average physician, nurse, hospital, or other health care provider?
It means that proper documentation and record keeping can be as important as
providing proper care.
References:
1. "Documentation Guidelines for Evaluation and
Management Services", American Medical Association, HCFA-May, 1997
3. https://www.excellusbcbs.com/wps/wcm/
resour ces/rile/eb74f54c5a727c6/Standards%20 Medi-cal %20Record%20Review.pdf.
4. NCQA 2004/2005 Standards and Guidelines for the
Accreditation of MCOs. Ql 13: Standards for Medical Record Documentation.
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