Medical Records
Dr. Yousif E. Elgizouli
MRCGP (UK),JMHPE
Family Medicine Consultant & Trainer
Organization is the power of the day; without
it, nothing is accomplished.
~ Sophia Palmer
From A Daybook for Nurses: Making a Difference Each Day
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
The session has two parts
»Theoretical Part
»Practical Part
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.
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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
Emails
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”
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
Why good records are important?
• Past and present medical conditions
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.
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.
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.
Patient Medical Records (cont.)
Patient
Education
• Test results
• Health issues
• Treatment
instructions
Additional Uses of
Patient Records
Research
Quality of
Treatment
• Peer review
• Teaching
• Source of data
•Health-care
analysis and
policy decisions
Emails and text messages
• These should be included in a patient’s records. If you
want to communicate with patients using emails or
texts, make sure that there is a robust system in place
for including them in the medical records.
• Be cautious about using emails, as confidentiality
can be a problem. You should ensure you have the
patient’s consent before sending text messages.
Information included in patient
record

– Name and address
– Health-care needs
– Occupation
– Medical treatment
plan
– Current complaint
– Past Medical History
– Response to care
– Lab and radiology
& reports
Patient Charts: Standard Chart Information
Patient Registration Form

Date

Patient demographic information
 Age,
DOB
Address

Financial information

Emergency contact
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
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.
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
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
Initiating and Maintaining
Patient Records
Completing medical
history forms
Documenting
test results
Initial
Interview
Examination,
preparation,
and vital signs
Documenting
patient
statements
The Six Cs of Charting
Client’s words –
Do not interpret patient’s words
Clarity – Precise descriptions / medical terminology
Completeness – C
Fill out forms completely
onciseness – To the point / approved abbreviations
Chronological order –
Legal issues
confidentiality – Follow
guidelines
Types of Medical Records
Source-Oriented Medical
Records
Problem-Oriented Medical
Records
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Conventional approach
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Information is arranged
according to who supplied
the data
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Problems and treatments are on
the same form
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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

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 Documentation
The treatment plan to correct the illness or problem
The impression of the patient’s problem that
leads to diagnosis
lan
What the physician observes
during the examination
Information
the patient
tells you
ssessment
bjective data
ubjective data
Apply Your Knowledge
Label the following items as either (S) “subjective” or
(O) “objective.”
ANSWER:
____
S headache
____
O pulse 72
____
O vomited x 3
____
S nausea
____
O skin color
____
O respirations 16, labored
____
S chest pain
____
S poor appetite
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
Appearance, Timeliness, and
Accuracy of Records (cont.)
 Timeliness
 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
Appearance, Timeliness, and
Accuracy of Records (cont.)
Accuracy
Check information carefully
Never guess or assume
 Double-check accuracy findings and instructions
 Make sure most recent information is recorded
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
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.
Patient Signature
mm/dd/yyyy
Date
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
Referral Letter
• A way of communication to other health care
provider.
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Shared care system
It must be part of the documentation in PMR
Must had feedback from the referred authority
Educational tool
Release of Records (cont.)
• Special cases
– Divorce
• Legal guardian of
children (may be one
or both parents)
– Death
• Next of kin
• Legally authorized
representative
• Confidentiality
– 18-year-olds
• Considered
adults
• Must have
written consent
to release their
Legal and records
ethical
principle:
Protect patient’s right to
privacy at all times.
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
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.
PMR Assignments
GA
• 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
GB
- Why we should keep good patient medical
records?
- PMR should be kept secure, but when you
release patient information (records)?
GC
- 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?