ASSIGNMENT -01

MEDICAL RECORDS

Ø The medical record is somewhat describe the systematic documentation of a
single patient's medical history and care across time within one particular health care
provider's jurisdiction.
• essential tool for the family physician.
• Needed for good quality patient care in family practice like continuing care of patients over
a long period of time.
• Informations organized in a systematic and logical manner.
• It contain all the relevant information regarding the patient’s present and past medical
problems, family history and social circumstances.
• The information will show potential problems and whole idea about the patient in the
future to the family physician.

Purpose of a medical record

1. Useful in the day to day management of acute illness.
2. Useful in the long term management of chronic illness.
3. Helps to communicate facts about the patient to a new doctor who may be acting for the regular
family physician.
4. Useful in preventive care and identification of risk factors eg. decline in the rate of growth of a child .-
as indicated in the child health development record or a family history of ischaemic heart disease in a
patient with hypertension.
5. Useful for research eg. retrospective surveys.
6. Useful for clinical audit to evaluate the quality of medical care.
7. Useful for medico-legal purposes.

Characteristics of a good medical record

1) The indexing and filing system should be organised in a way that makes retrieval of the medical
record quick and simple.
2) The size of the medical record should be such that it could be easily stored.
3) The contents should be organised and structured so that recording is simple and retrieval of
information is quick and easy.

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4) Should contain all the relevant information about the patient’s medical and health problems
such as diagnoses, results of investigations, treatment, referral, hospitalizations etc.
5) Entries should be clearly written, accurate and legible. A doctor who cannot read his own notes
when called upon to do so in a court of law, will not make a good impression.
6) Abbreviations which are easily understood by other doctors such as BP, UTI could be used.

Types of Medical Records

01) classification according to storage
• paper based (physical) records
• computer based (electronic) records.


02) classification according to content
• family medical records
• individual medical records.

Components in the medical records

v Patient identification & demographic data
v Present complains
v Informed consent for treatment & procedure
v Admission nursing history
v Family history
v Physical examination finding
v Medical history
v Tentative history
v Medical diagnosis
v Therapeutic order
v Treatment given
v Medical progress notes
v Supportive care given
v Reports of diagnosis studies
v Final diagnosis
v Patient education
v Summary of operative procedures
v Discharge plan and summary
v Any specific instructions

Ethical issues in medical records

PRIVACY AND CONFIDENTIALITY

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v In whatever form medical records should be maintained as confidential documents

v should not be accessible to anyone other than the doctor;but in multi disciplinary team
they all can access for the professional need only.
v Patients are entitled to have access to their own medical records
v In Family Practice, if a patient requests to be shown his or her record or wishes to
receive a copy, the doctor is obliged to do so.
v For a patient to have his or her medical records is also useful when a patient has to go
into an emergency care unit or when the patient falls ill while visiting another town or
country.
v In some countries patients using Smart Card which carries his or her personal health
informations.
v the right of an individual to keep information about themselves from being disclosed to
others; the claim of individuals to be let alone, from surveillance or interference from
other individuals, organizations or the government.
v Information of a patient should be released to others only with the patient's permission
or allowed by law.
v When a patient is unable to do so because of age, mental incapacity the decisions about
information sharing should be made by the legal representative or legal guardian of the
patient.
v Information shared as a result of clinical interaction is considered confidential and must
be protected.
v Information from which the identity of the patient cannot be ascertained for example,
the number of patients with breast carcinoma in a government hospital, is not in this
category.
v Although controlling access to health information is important, but is not sufficient for
protecting the confidentiality. Additional security steps such as strong privacy and
security policies are essential to secure patient's information.

SECURITY BREACHES

v Security breaches threaten patient privacy when confidential health information is made
available to others without the individual's consent or authorization.
v Security measures such as firewalls, antivirus software, and intrusion detection software
must be included to protect data integrity.
v Specific policies and procedures serve to maintain patient privacy and confidentiality.
v A security officer must be designated by the organization to work with a team of health
IT experts.
v Routine random audits should be conducted on a regular basis to ensure compliance with
hospital policy.
v All system activity can be tracked by audit trails. This includes detailed listings of
content, duration and the user; generating date and time for entries and logs of all
modifications to EHRs.

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v When there is inappropriate access to a medical record, the system can yield information
about the name of the individual gaining access; the time, date, screens accessed and the
duration of the review.
v This information is useful when determining whether the access is the result of an error
or an intentional, unauthorized view.
v Outside vendors create special privacy issues. Employee-only access to the EMR
requires any external vendor to access and navigate the record under the authorization
and oversight of an employee.

SYSTEM IMPLEMENTATION

v Health care organizations encounter major challenges in the course of EHR

implementation these challenges result in wasted resources, frustrated providers, loss of
confidence by patients and patient safety issues. The development, implementation, and
maintenance of EHRs requires adequate funds and the involvement of many individuals,
including clinicians, information technologists, educators, and consultants.
v Hospitals and health care institutions are making improvements without significant
clinician engagements. Many EHR implementation projects fail because they
underestimate the importance of one or more clinician to serve as opinion leaders for
providers in the clinic. Thus, clinician must guide colleagues in understanding their roles
in the implementation and enlisting their involvement in tasks as EHR selection,
workflow design, and quality improvement.
v Clinical personnel often have little knowledge of the clinic's workflow and the roles
others play in care delivery. This blind spot results in inadequate planning for successful
implementation. Without identifying a standardized best practice method to do the work,
every user is left to struggle. Clinics should map and standardize their workflows before
EHR selection.
v When any two systems are integrated, an interface is created. By the user interface, we
mean an interface between the user and the computer system. These interfaces are
critical to the overall success of the implementation process. Interface issues are the
greatest system risk because these failures can be invisible initially. Lack of systemic
consideration of users and tasks often results in poor user interface. Poorly designed user
interface account for unintended adverse consequence leading to decreased time
efficiency, poor quality of care and increased threat to patient safety. Improperly
designed user interface fail to deliver the much needed quality of care, which lead to user
dissatisfaction. The faulty user interface issue, which was small earlier on, increases over
a period of time that leads to abandonment of EHR. Maintenance and testing of these
interfaces on a routine basis is essential in controlling this major risk. Practice disruption
during EHR implementation can negatively impact the quality of care or endanger
patient safety along with financial loss.

DATA INACCURACIES

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v Integrity assures that the data is accurate and has not been changed. EHRs serve as a way
to improve the patient's safety by reducing healthcare errors, reduce health disparities
and improve the health of the public.

v However, concerns have been raised about the accuracy and reliability of data entered
into the electronic record.
v Inaccurate representation of the patient's current condition and treatment occurs due to
improper use of options such as “cut and paste”. This practice is unacceptable because it
increases the risk for patients and liability for clinicians and organizations.
v Another feature that can cause a problem in the data integrity is the drop down menu
and disposition of relevant information in the trash. Such menus limit the choices
available to the clinician who in a hurry may choose the wrong one leading to major
errors.
v Clinicians and vendors have been working to resolve software problems to make EHRs
both user-friendly and accurate.

Future organization of a recording system

❖ An easily retrievable , efficient filing system will be developed.
❖ An alphabetical filing system will be developed.Here, each patient will be given a registration
number which
starts with the first letter of the surname,followed by a number given in serial or chronological
order. The patients could be given cards with their registration numbers with instructions to
bring them when they come to visit the doctor again.
The number on the card will enable the files to be retrieved easily without looking at the
register, provided the files have been stacked in serial order on the shelf.

Computer based vs paper based medical record

Computer based medical Paper based medical records
records
patient’s datas are stored Patient’s datas are recorded
in softwares. in paper based files and
register
The initial setup will have this method takes more
some cost ,,but in the long costly in the long run.
run the expense would
decrease significantly.
No need of physical space Need physical space
One person in enough to More than one employees
maintain needed for maintenance

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More privacy is maintained Comparatively less privacy

Information is readily Takes longer time to search
available the file.
can be shared with other Cannot be shared instantly
doctors instantly to other doctors in
emergency
No need big changing Data has to be copied &
process to share(electronic mailed or converted to
transmission or direct access electronic format via
to the storage system.) scanning or email for sharing.
Anti-virus software and Natural disaster ,theft,
regular backups reduce the physical damage and
risk of losing record misplacement can lead to
loss of medical records
Need to expertise and Training on using a software
training to use the software. is not needed
Can be protected by Can’t protect from others
passwords from miss using

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