1. Family Medicine Consultant & Trainer
Medical Records
Dr. Yousif E. Elgizouli
MRCGP (UK),JMHPE
Family Medicine Consultant & Trainer

2. Organization is the power of the day; without it, nothing is accomplished.
~ Sophia Palmer
From A Daybook for Nurses: Making a Difference Each Day

3. Learning Objectives Recognize the importance of PMR
Identify different types of PMR
Describe different contents and sections of PMR
Describe common approaches to documenting information.
Confidentiality issues
Write the SOAP format in PMR
Identify different format of referral letters
Write a referral letter

4. The session has two parts
Theoretical Part
Practical Part

5. What are medical records?
Medical records include any information created by, or on behalf of, a health professional in connection with the care of a patient, e.g.
Handwritten medical notes
Computerised records
Correspondence between health professionals
Laboratory reports
X-ray films and other imaging records
Videos and other recordings
Printouts from monitoring equipment
Text messages s

6. Good Medical Records
Doctors should “keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigation or treatment” and “make records at the same time as the events you are recording or as soon as possible afterwards”

7. Good medical records
Good medical records summarise the key details of every patient contact. Clinical records should include:
Relevant clinical findings
The decisions made and the actions agreed, and who is making the decisions and agreeing the actions
The information given to patients
Any drugs prescribed or other investigation or treatment 
Who is making the record and when

8. Why good records are important?
Past and present medical conditions

9. Continuity of care
Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. Adequate medical records enable you or somebody else to reconstruct the essential parts of each patient contact without reference to memory.
They should therefore be comprehensive enough to allow a colleague to carry on where you left off.

10. Complaints and claims
Many clinical negligence claims are indefensible because there are problems with the medical records, whether they are inaccurate, illegible, too brief, or simply missing.
You may have done nothing wrong but, unless the medical records support this, it can be difficult to defend a claim.

11. Research and clinical audit
Good medical records can help to improve standards of patient care. Auditing medical records is an important part of the research, and records should be written in a way that helps this.

12. Patient Medical Records (cont.)
Additional Uses of
Patient Records
Quality of Treatment
Patient Education
Peer review
Teaching
Health-care analysis and policy decisions
Research
Test results
Health issues
Treatment instructions
Source of data

13. Emails and text messages
These should be included in a patient’s records. If you want to communicate with patients using s or texts, make sure that there is a robust system in place for including them in the medical records.
Be cautious about using s, as confidentiality can be a problem. You should ensure you have the patient’s consent before sending text messages.

14. Information included in patient record
Name and address
Occupation
Current complaint
Past Medical History
Health-care needs
Medical treatment plan
Response to care
Lab and radiology & reports

15. Patient Charts: Standard Chart Information
Patient Registration Form
Date
Patient demographic information
Age, DOB
Address
Financial information
Emergency contact

16. Standard Chart Information (cont.)
Past medical history
Illnesses, surgeries, allergies, and current medications
Family medical history
Social history (diet, exercise, smoking, use of drugs and alcohol)
Occupational history
Current patient complaint recorded in patient’s own words

17. Standard Chart Information (cont.)
Physical examination results
Results of laboratory and other tests
Records from other physicians or hospitals
Include a copy of the patient consent.

18. Standard Chart Information (cont.)
Doctor’s diagnosis and treatment plan
Treatment options and final treatment list
Instructions to patient
Medication prescribed
Comments or impressions
Operative reports, follow-up visits
These are part of the continuous patient record
Document calls made to and from the patient

19. Standard Chart Information (cont.)
Informed consent forms
Verify that the patient understands procedures, outcomes, and options
Patient may withdraw consent at any time
Hospital discharge summary forms, if any
Information summarizing the patient’s hospitalization
Instructions for follow-up care
Physician signature

20. Initiating and Maintaining Patient Records
Completing medical
history forms
Documenting test results
Initial
Interview
Examination, preparation, and vital signs
Documenting patient statements
Maintain patient privacy
during interview

21. The Six Cs of Charting C Client’s words – Clarity – Completeness – C
onciseness –
Chronological order –
confidentiality –
Do not interpret patient’s words
Precise descriptions / medical terminology
Fill out forms completely
To the point / approved abbreviations
Legal issues
Follow guidelines

22. Types of Medical Records
Source-Oriented Medical Records
Problem-Oriented Medical Records
Conventional approach
Information is arranged according to who supplied the data
Problems and treatments are on the same form
Difficult to track progress of specific events
POMR records make it easier to track specific illnesses
Information included
Database
Problem list
Educational, diagnostic, and treatment plans
Progress notes

23. Medical Records: SOAP Documentation
Orderly series of steps for dealing with any medical case
Lists the following
Patient symptoms
Positive signs
Diagnosis
Suggested treatment
SOAP

24. SOAP Documentation P A O S lan ssessment bjective data ubjective data
The treatment plan to correct the illness or problem
The impression of the patient’s problem that leads to diagnosis P
lan
What the physician observes during the examination A
ssessment
Information the patient tells you O
bjective data S
ubjective data

25. Apply Your Knowledge S O Good Job!
Label the following items as either (S) “subjective” or (O) “objective.”
____ headache ____ pulse 72
____ vomited x 3 ____ nausea
____ skin color ____ respirations 16, labored
____ chest pain ____ poor appetite S O
ANSWER:

26. Appearance, Timeliness, and Accuracy of Records
Neatness and legibility
Use a good-quality pen
Blue ink is preferred (differentiates original from copy)
Highlight critical items such as allergies
Handwriting must be legible
Make corrections properly

27. Appearance, Timeliness, and Accuracy of Records (cont.)
Record all findings as soon as they are available
For late entries, record both original date and current date
Record date and time of telephone calls and information discussed
Retrieve file quickly in event of an emergency

28. Appearance, Timeliness, and Accuracy of Records (cont.)
Check information carefully
Never guess or assume
Double-check accuracy findings and instructions
Make sure most recent information is recorded

29. Appearance, Timeliness, and Accuracy of Records (cont.)
Computer records
Accuracy is also important with electronic records
Advantages
Can be accessed by more than one person at a time
Can be used in teleconferences
Useful for tickler files
Security concerns
Protect patient confidentiality

30. Release of Information to MOH/ Insurance
Release of Records
Records are property of physician
Contain confidential patient health information
Must have patient’s written consent to release
Exceptions: cases of contagious disease or court order
Release of Information to MOH/ Insurance
I authorize Dr. X to release my healthcare information to the above-named ministry /insurance company.
mm/dd/yyyy Patient Signature Date

31. Release of Records (cont.)
Procedures for releasing records
Obtain a signed and newly dated release form authorizing the transfer of information, and place it in the patient’s record
Make photocopies of original materials
Copy and send only documents covered in the release authorization
Call to confirm receipt of materials

32. Referral Letter A way of communication to other health care provider.
Shared care system
It must be part of the documentation in PMR
Must had feedback from the referred authority
Educational tool

33. Release of Records (cont.)
Confidentiality
18-year-olds
Considered adults
Must have written consent to release their records
Special cases
Divorce
Legal guardian of children (may be one or both parents)
Death
Next of kin
Legally authorized representative
Legal and ethical principle: Protect patient’s right to privacy at all times.

34. In Summary
Medical assistants must properly prepare and maintain patient records
There are several methods for documentation, but regardless of method, records must be complete, legible, current, accurate, and professional
Properly maintain, correct, update, and release patient medical records

35. Altering medical records
If you discover a mistake, insert an additional note as a correction
Do not change the original medical record unless the information is factually incorrect.
If you discover a mistake, insert an additional note as a correction. Make it clear that this is a new note, not an attempt to tamper with the original record.
A patient may ask for some information to be deleted from the record. Notes should only be amended if the original information was inaccurate, misleading or incomplete. If it is changed, include a note, signed and dated, to say that the incorrect information was altered at the patient’s request.

36. PMR Assignments
G A
Summarize, in 250 to 300 words, the differences among source oriented records, problem oriented records, and integrated records. 
- Include how you think the advantages and disadvantages of each record format affect everyday work; remember to think about retrieving records as well as filing them

37. G B - Why we should keep good patient medical records?
- Why we should keep good patient medical records?
- PMR should be kept secure, but when you release patient information (records)?

38. G C
- What are the differences between manual (paper) & electronic medical records, mention advantages and disadvantages of each?
- Hanan-25-Years old teacher consult you with a severe episodic headache 2 months ago, her headaches are associated with nausea & vomiting, often at the right side of the head. She felt that since 4 Years, her mother has similar headaches.
No other sinister symptoms
Vital signs (T: 36.6 C, BP: 110/70, PR: 88)
O/E: Sinuses free, cervical movements intact
You prescribed NSAIDs tablets & you offered her a headache diary for 2/12 to confirm or refute your hypothesis.
Today she brings the diary.
Put this information in a SOAP format?