Introduction and Definition
Medical records form an essential part of a patient’s present and future health care. As a written collection of information about a patient’s health and treatment, they are used essentially for the present and continuing care of the patient. In addition, medical records are used in the management and planning of health care facilities and services, for medical research and the production of health care statistics (Medical Record Manual. A Guide for Developing Countries, World Health Organization, 2006).
Medical ethically it is classified as confidential. The health facilities should uphold confidentiality and security of the information contained in it and ensuring no modifications made by health care providers.
Documenting patient information in medical records must be complete as it is legally binding.
Items that need to be addressed by health personnel in documenting the patient’s medical records include:
- Ensuring a complete notes, clear, easy to read with the time and date of record, along with the doctor’s stamp and sign.
- Each examination and treatment information.
- Amendments cannot be done arbitrarily. Mistakes need to be rectified neatly by strike through, where the new written information should be accompanied by the signature of the doctor with the date and time the correction is made. Eraser or liquid paper usage is prohibited.
- The only-approved abbreviations by the Ministry of Health are allowed to be used.
- Discharge summary is prepared when patient discharged is planned.
- Ministry of Health forms and formats are used.
- Documents are arranged according to chronology example episodes of admission / visit to facilitate the search of the documents,
- Each page in the progress notes must record patient’s name, identity card number and page number to ensure there is safety of patient information.
Who Owns the Medical Record?
The purpose of the patient’s medical record was to record all facts and information relating to the patient’s health history. The emphasis is on the causes that make the patient to seek treatment should be given. The aim is to ensure the continuity of patient care. Thus, medical record must always be available where it can be accessed immediately at any time required when patients come to hospital as to facilitate service rendered by the doctor.
Medical records also have intermediary’s role amongst doctors and other medical practitioners whenever referrals are made.Although the patient may be never treated by the particular doctor at the time of the previous treatment, that doctor can illicit the clinical history of the patient from the records. It will help in treating the patient effectively.
If the medical records are kept by the patient as their property, a doctor may have difficulty in retrieving information in a short time as to ensure the best treatment to the patient. The timely and accurate health data and information that are urgently needed by the doctor may be obtained through medical records that are kept in the hospital. Along with the slogan Ministry of Health “ready to assist” the hospital strives to ensure the best health services provided to the patients.
In addition, statistical data can be collected and analyzed for the purpose of health planning and development. This is in line with the Ministry Of Health objective in ensuring the best service delivery to the people as well as consolidates and strengthen the quality of health care.
Researchers can be benefited through the data and information as well as drugs derived from the patient’s medical record. This is in line with the continuous spectrum of preventive care, awareness, treatment, rehabilitation and palliative approach where all the methods should be based on scientific studies and proven practices and best practices. This will definitely improve the expertise, skills and knowledge through the development of continuous training to health officials.
The patient’s medical record also serves as education document for medical students or doctors, data provision for auditing and certifying the quality of the hospital as well as for research and development of health.
As medical records are the property of the hospital it is always secured and will not be amended. The medical records department was established to carry out tasks related to the management of medical records inclusive the tasks of receiving, registration, filing, production, movement and disposal.
The information in the patient’s medical record is the patient’s right but it is the property of the hospital. Some of the information in medical records cannot be disclosed to the patient because of the confidentiality. The hospital has the authority to determine whether the information can be disclose or otherwise such as, information obtained from third parties and the opinions or intellectual views of doctors based on the results of tests conducted. However, patients are allowed to know the information about diseases, treatments and medicines given to him while he receives treatment in the form of medical reports rather than an actual copy of the patient record.
However, all requests for information are still subjected to the rules set by the Circular of Director General of Health 16/2010.
The reasons generally that makes medical records are not the property of the patients but own by the hospitals are because of the various needs and interests in providing health information, treatment given to patients, the tests conducted and the data that is useful in planning and developing the quality of health care and treatment.
- Pekeliling Ketua Pengarah Kesihatan Bil.17/2010, Garispanduan Pengendalian dan Pengurusan Rekod Perubatan Pesakit Bagi Hospital-Hospital dan Institusi Perubatan
- Berita Harian, Isnin 6 Januari 2014
- Medical Record Manual. A Guide For Developing Countries, World Health Organization, 2006
- Pelita Brunei, Isnin 6 Januari 2014 , Seminar Profesional Kesihatan Bersekutu 2013 (Allied Health Professional Seminar 20l3)
|Last Reviewed||:||11 August 2017|
|Writer||:||Pn. Sharifah Shazliha Binti Sulaiman|
|Translator||:||Pn. Hasnah Binti Ismail|
|Accreditor||:||Pn. Oni Saifura Binti Osman|