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Submitted by:
Salve Boridas, R.N.
HEALTH CARE RECORDS – DOCUMENTATION AND MANAGEMENT
PURPOSE
The purpose of this policy is to:
Define the requirements for the documentation and management of health care records
across public health organizations’ (PHOs) in the public health system.
Ensure that high standards for documentation and management of health care records are
maintained consistent with common law, legislative, ethical and current best practice
requirements.
MANDATORY REQUIREMENTS
Documentation in health care records must provide an accurate description of each patient
or client’s episodes of care or contact with health care personnel. The policy requires that a health
care record is available for every patient / client to assist with assessment and treatment,
continuity of care, clinical handover, patient safety and clinical quality improvement, education,
research, evaluation, medico-legal, funding and statutory requirements.
Health care record management practices must comply with this policy.
IMPLEMENTATION
Chief Executives are responsible for:
Establishing mechanisms to ensure compliance with the requirements of this policy.
Ensuring health care personnel are advised that compliance with this policy is part of
their patient / client care responsibilities.
Ensuring line managers are advised that they are accountable for implementation of
this policy.
Ensuring implementation of a framework for auditing of health care records and
reporting of results.
Ensuring health care records are audited and results reported within the PHO.
Facility / service managers are responsible for:
Ensuring the requirements of this policy are disseminated and implemented in their
hospital / department / service.
Ensuring health care personnel within their facility / service have timely access to
paper based and electronic health care records.
Monitoring compliance with this policy, including health care record audit programs,
and acting on the audit results.
Health care personnel are responsible for:
Maintaining their knowledge, documentation and management of health care records
consistent with the requirements of this policy.
Ensuring they are aware of current information about the patient / client under their
care including where appropriate reviewing entries in the health record.
Policies and standards are important in medical record management to achieve a more-uniform
practice for effective medical records management. Standards and policies suggest two things
which are consensus and guides.
Policies and standards are crucial, but their application may not fit every possible situation
encountered, most especially where material resource is lacking. Hence, modifications which may
mean deviations from standards shall be warranted.
Modification should not deviate from the standard to the extent of adversely affecting the level of
performance and quality of patient care. The patient's record should contain complete and
accurate set of information to facilitate effective patient care and its evaluation.
1. STANDARDS
An accurate record is maintained to facilitate optimal patient care and allow for evaluation of
the care provided.
1.1 The record is sufficiently detailed to enable:
a) The patient to receive continuing care
b) Effective communication within the health team
c) The Attending Physician to have available information required for the consultation
d) Other medical practitioners and health personnel to assume the patient care e)
Concurrent or retrospective evaluation of patient care
1.2 Entries into the records are made only by duly authorized persons of the facility and are
dated and signed, containing designation.
1.3 All entries, including alterations, must be legible.
1.4 Only abbreviations and symbols approved by the Medical Record Committee are to be
used.
1.5 If possible, original copies of all reports made by medical, nursing, and allied health
professionals are filed in the record.
1.6 Each record should at least contain the following data:
a) A unique medical record number or reference
b) Patient's full name
c) Address
d) Date of birth
e) Sex
f) Person to notify in case of an emergency
1.7 An "ALERT' notation, for the conditions such as allergic responses and drug reactions, is
prominently displayed on the face sheet of the record.
1.8 The record contains a written admission diagnosis by the medical practitioner.
1.9 The record contains a patient's history, pertinent to the condition being treated, including
relevant details of:
a) Present and past medical history
b) Family history
c) Social considerations
1.10 A sufficiently detailed report of a relevant physical examination (PE), performed by a
medical practitioner, should be included for the purpose of admission.
1.11 Evidence that the patient has given informed consent is available.
1.12 Drug orders are written in the record by the medical staff.
1.13 Therapeutic orders and orders for special diagnostic test are noted in the record.
1.14 There is evidence in the medical record that patient care plans were made.
1.15 Progress notes, observations, and consultation reports are written by medical, nursing,
and allied health staff to record all significant events such as alterations in the patient's
condition and responses to treatment.
1.16 The front sheet is completed at the time of discharge or as soon as the relevant
information is available. It contains all relevant diagnoses and procedures using the
terminology of a current revision of the International Classification of Diseases (ICD).
1.17 A discharge summary for each patient should be completed within 48 hours of patient's
discharge, with a copy remaining- in the medical record. The discharge summary should at
least include the following:
a) Discharge diagnosis
b) Procedures performed
c) Follow-up arrangements
d) Therapeutic orders
e) Patient instructions (where necessary)
When a patient is transferred to another facility, a discharge summary should accompany
him/her.
1.18 When an autopsy is performed, a provisional diagnosis is noted in the medical record within
72hours and the medical record is completed within 15 days following the death. A copy of
the autopsy report is filed in the medical record.
2. RECORD COMPLETION
2.1 The medical record should be completed within 48 hours after the discharge of the
patient.
2.2 History and PE should be completed within 24 hours after admission.
2.3 An incomplete chart, not completed within 15 days after patient's discharge, shall be
considered a delinquent chart.
2.4 The attending physician has the final and major responsibility for completeness and
accuracy of the data entry in the record. He is also encouraged to raise the level of quality
of the individual health record and sustain a high level of recording.
2.5 Residents and interns may be delegated the duty of recording medical information as
history, PE, and discharge summaries. Their entries have to be reviewed, corrected, and
countersigned by the attending physician.
2.6 The Medical Record Practitioner assists the attending physician in reviewing records for
completeness by checking for omissions and discrepancies and helps ensure that medical
records comply with set policies and standards.
3. RELEASE OF INFORMATION
Release of health information is a very sensitive issue in several respects. The confidentiality of the
medical record should always be the concern of people involved in the release of health
information.
3.1 General Policies
3.1.1 The hospital shall safeguard all information contained in the health record against
loss, destruction, or unauthorized use.
3.1.2 All information in the health record shall be treated as confidential and shall be
disclosed only to authorize individuals.
3.1.3 It shall be the policy of all government hospitals not to use the medical record in any
way which will jeopardize the interest of the patient. But the hospital may use the
record to defend itself against any accusations.
3.1.4 The release of information is delegated to the supervisor of the MRS. But in cases
where the medical record practitioner encounters problems regarding the release of
information, the matter should be referred first to the Administrative Officer (AO), or
to the Chief-of Hospital (COH) for proper solution.
3.1.5 No release of information with clinical value shall be done without written consent
from the patient himself.
3.1.6 The medical record is the physical property of the hospital. However, since the
information written on the record is the patient's personal history, he/she also has a
right to the said record. In cases where litigation is likely to happen and is intended
against the hospital or any other personnel of the health care facility, the Medical
Director/COH may refuse or deny access to the record even with the patient's written
authorization, until the court declares otherwise.
3.1.7 Request for medical certificate or clinical information when the patient is still confined
shall be referred to the attending physician.
• Should the AP decide to release the certificate while the patient is still confined, a
Certificate of Confinement shall be issued.
• No certificate of confinement shall be issued where the patient concerned is already
discharged, instead, a medical certificate shall be issued.
• No medical certificate shall be released without the signature of the Chief of
Professional Staff and the hospital seal.
• On the other hand, no medico-legal certificate shall be released without the
signature of the Director/COH and the hospital seal.
3.1.8 Information of no clinical value can be disclosed by the staff of the health care facility.
However, hospital policy should first be consulted and utmost care taken into
consideration before the release of non-clinical information. Such information includes the
following:
• Name
• Address
• Attending physician
• Name of relative with patient during admission
• Admission and discharge dates
3.1.9 Where the patient is a minor, consent of either one of the parents or the legal
guardian shah be secured before any information of clinical significance is released.
3.1.10 The medical record shall not be taken out of the hospital premises except on court
orders. Those authorized to do research and studies shall use the records inside the
MRS.
3.1.11 Incomplete medical records shall be referred to the attending physician before
entertaining any request to access and review the medical record.
3.1.12 In cases where the patient is in critical condition and does not have someone with
him/her to give consent, the medical record practitioner shall release, information only
after consultation with the Director/COH.
3.1.13Verbal request for clinical information shall be discouraged in favor of written
requests.
3.1.14The staff of the Medical Social Service (MSS) shall have access to the medical records
for purposes of establishing patient classification. They may also reveal the social content
of the record to organize and reputable social agencies who have a legitimate reason for
inquiry.
3.1.15 Information may be released to other health care facilities, upon written request, that
the patient is now under care.
3.1.16 Hospital management may, at its discretion, permit the use of medical records for
research and studies, only stressing that no information which will directly identify the
patient shall be published.
4. POLICIES FOR DOCTOR'S RELEASE OF INFORMATION
4.1 Doctors and members of the allied health profession may review records of patients
presently under their care.
4.2 Doctors who are members of the medical staff but not members of the team assigned
to the patient shall be armed with a written authorization signed by the patient before
they are given access to the record.
4.3 The privilege against disclosure belongs to the patient and not the treating physician,
therefore, the patient has the right to claim for it or waive it. In which case, the doctor's
approval is technically not necessary. But it would be a good practice to notify the
doctor prior to release of any information, as a sign of courtesy.
4.4 The hospital management may permit use of the medical record for research and
studies, the medical record being the physical property of the hospital. The hospital may
also withhold access to the medical record until a subpoena is issued.
4.5 Outside doctors intending to do some research/studies in a particular hospital shall seek
the written approval of the management before they are given access to the medical
record.
4.6 Insurance company doctors shall need proper written authorization from the patient, or
a duly accomplished insurance waiver, before they are given access to medical record.
4.7 Company physicians who are presently caring for a patient shall be given medical
information only upon presentation of a formal request addressed to the MRS.
4.8 Consultants shall have access to records of patients referred to them.
4.9 Resident doctors and the rest of the medical staff may request the MRS for records
'needed for their research and studies. But in cases where there is suspicion that their
wish to access will jeopardize the right of the patient, doctor-and the institution, access
shall be denied by the medical record staff.
4.10 It shall be the responsibility of the attending physician to inform his patient about his
medical condition.
Advances in health care delivery gave rise to what is known as the "team care approach" to health
care delivery. This requires a wider range of health professionals who might have a legitimate
need for access to information from the medical record. In this sense, institutions should formulate
guidelines to restrict access to records to those who are only actually involved in the care of a
particular patient.
REQUEST FOR INFORMATION FROM THE MEDICAL RECORD FOR RESEARCH AND
STUDIES
Health care facilities are said to own the medical records, but legally, the "privilege against
disclosure belongs to the patient and nobody else." In a hospital setting, proper notification of the
attending physician, prior to the release of information is ideal, in order to protect the legal
interest of the doctor and the hospital as well.
In cases of research and studies, the hospital management may decide on who can and who shall
not be given access to the medical record, the record being the hospital's physical property. While
the hospital may give access to a patient's medical record for research, study, and publication, the
court of law emphasizes the need to protect the identity of the patient, which explains why the
name of the patient is not mentioned in these published reports.
“If you think of the medical record first and foremost as clinical communication that you
documented carefully, you need not panic if the court subpoenas it. However, if you think only of
legal implications or document to protect yourself, your part of the medical record will sound self-
serving and defensive. Such documentation tends to have a negative impact on a judge and jury”
(Lippincott, Williams & Wilkins, 2008).
The medical record, also called the patient’s record or the chart, serves four major purposes.
1. Acts as a vehicle for communication among members of the healthcare team.
2. Documents compliance with standards of care and standards of various accrediting
organizations such as TJC and the state health department.
3. Documents compliance with standards that must be met for reimbursement by a third party
payor such as Medicare, Medicaid, or another insurance carrier.
4. Documents that patient care meets safe, effective, and legal requirements.
Documentation Standards
All aspects of care that standards mandate must be documented as evidence that care was
provided.
All sources of documentation standards and requirements emphasize:
Ongoing assessment
• Patient teaching, including the patient’s response to teaching and indication that the
patient has learned.
• Response to all medications, treatments, and interventions.
• Relevant statements made by the patient. Your organization’s P&P are the standard
against which your practice is judged in a court of law or in any disciplinary proceeding.
Entries into organization documents or the health record (including, but not limited to, provider
orders) must be:
• Accurate, valid, and complete;
• Authenticated; that is, the information is truthful, the author is identified, and nothing has
been added or inserted;
• Dated and time-stamped by the persons who created the entry;
• Legible/readable; and
• Made using standardized terminology, including acronyms and symbols.
For electronic records the history of audited changes must be retained and the replacement
note linked to the note flagged as “written in error”. This provides the viewer with both the
erroneous record and the corrected record.
The Joint Commission has endorsed the Institute for Safe Medication Practices List of Error-Prone
Abbreviations. The ISMP list is also endorsed by the Federal Drug Administration (FDA), and the
National Council for Medication Error Reporting and Prevention (NCCMERP).
A trailing zero may be used only when required to demonstrate the level of precision of the value
being reported, such as for laboratory results, imaging studies that report the size of lesions, or
catheter/tube sizes. It may not be used in medication orders or other medication-related
documentation
Consider the following as a "Do Use" list:
• Use mL instead of cc.
• Write out the word: unit.
• Use mcg instead of: μ.
• Use less than and greater than instead of < and >.
Late Entries
When the medical record is unavailable or when you remember further information to
document, you will need to make a late entry. Document the time of your entry. Within the
body of your note indicate the time of the occurrence to which you are referring.
However, entering pertinent information is better done late than never. Shorter lengths of stay
on inpatient units may increase the likelihood of the need for late entries. Follow your
organization’s policy for making late entries.
The safest, most legally defensible practice is to document at frequent intervals, and particularly
after any emergency, unusual, or complicated events. When you absolutely cannot do so,
make notes and document carefully into the medical record at your earliest opportunity.
The most widely accepted procedure for correcting errors has been to draw a single line through
error and note “mistaken entry,” “error,” or the error notation that is required by your
organization, followed by the date and your initials. Since your signature follows the original entry,
your initials are sufficient unless organizational policy requires otherwise.
HOWEVER, consult your organization’s policy regarding correction of errors. Some organizations
have discontinued and prohibited the use of the terms “error” or “mistake” because of the possible
interpretation that an error occurred in patient care and not simply in making a documentation
entry.
Never erase an entry or use correction fluid, liquid paper, or “white out.” If you need to replace
several words, you may need to add an addendum sheet and follow the procedure for late entries.
Frequency of documentation
The frequency of documentation entries should conform to the following as minimum
requirements.
Labels
Non-permanent adhesive labels should be avoided. Where considered essential the label
must be relevant to the patient / client and placed so that all parts of the health care record are
able to be read and patient / client privacy maintained.
Anaesthetic reports
Ministry of Health, NSW, 2017. “Health Care Records - Documentation and Management”. 73 Miller
Street North Sydney NSW 2060. Retrieved from http://www.health.nsw.gov.au/policies/
Department of Health, 1994. “Hospital Medical Records Management Manual”. San Lazaro
Compound, Rizal Avenue, Sta. Cruz, Manila, Philippines. Second Edition.
Case Di Leonardi, Bette. June 1, 2012. “Professional Documentation: Safe, Effective, and Legal”
Copyright © 2009 by RN.com
The Joint Commission (TJC). (2012a). Hospital National Patient Safety Goals effective January 1,
2012. Oakbrook, IL: TJC. Retrieved from http://www.jointcommission.org/assets/1/6/NPSG_
Chapter_Jan2012_HAP.pdf
American Nurses Association (2010b) ANA’s principles for nursing documentation: Guidance for
Registered Nurses. Silver Spring, MD: ANA, Nursebooks.org.