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Most doctors dislike paperwork – especially that involved
in entering information in medical records. Thus, while most
surgeons enjoy operating, many treat documenting the medical
details in the record as a painful chore which they would
rather not do. This often means that entering data into the
medical chart is delegated to a junior or inexperienced assistant,
as a result of which it is often not done well.
Remember that the medical record serves many purposes
, and its primary function is to plan for patient
care. However, from the risk management perspective,
the medical record is a crucial element in preventing
and minimizing malpractice litigation. Ultimately,
it serves as the basis for the defense of malpractice
claims and lawsuits. Medical records which are poorly
maintained, incomplete, inaccurate, illegible or
altered, create doubt about the treatment given
to a patient, and can be a major medical-legal liability.
By contrast, proper documentation in the medical
record creates a legal document which accurately
and completely reflects the care provided to a patient
and, in a courtroom setting, it may be likened to
a witness whose memory is never lost.
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While keeping good records is simply a matter of common sense,
the mnemonic OLFACTORY, which stands for : Original, Legible,
Factual, Accurate, Complete, Timely, Objective, Rationale
and Yours, will help you to define a “good” medical
record.
It is helpful to follow a system when making notes in the
medical record, to ensure that all important information has
been recorded. The SOAP system ( which stands for Subjective
( the patient’s history); Objective ( examination findings);
Assessment and Plan ) is popular in many hospitals, and is
easy to implement. Preprinted medical records can help to
establish consistent documentation , ensuring you do not forget
to record important information. They can also help to save
your time when entering data.
When writing orders in the chart, it can be helpful
to remember the following headings ( the mnemonic
being ADCA VAN DIMS) , to ensure that important
orders are not overlooked. Every doctor should develop
their own systematic method to ensure completeness.
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Admission
Diagnosis
Condition
Allergies
Vital signs
Ambulation
Nursing care
Diet
IV fluids
Lab tests
Medications
Special orders ( such as occupational therapy or consultations
requested)
Each and every page of a patient record should be clearly
labeled with the patient's complete name and medical record
number. Anyone making an entry in a patient's chart should
do so only on hospital approved medical record forms and then
only with pen rather than pencil. Use only hospital accepted
medical abbreviations and terminology. Associated records
and tests such as EKG's, EEG's, fetal monitoring tracings,
etc., should all be properly labeled with the patient's name
, medical record number, the date and time.
All entries in the medical record should be dated, the time
they were made noted, and should be signed by the person making
the entries. Progress notes should indicate that the patient
was kept informed of his or her condition, as well as the
treatment plan. Document all instances of patient non-compliance
or refusal of recommended treatment and that the patient was
informed of potential consequences. Many courts take the view
that if it an event is not documented, it did not happen !
Patient records should never be altered. One should not erase,
obliterate or attempt to edit notes previously written. All
corrections, late entries, entries made out of time sequence,
and addenda should be clearly marked as such in the record,
and should be dated and timed on the day they are written
and signed. Draw a single line through any erroneous chart
entry and write "error" with the date and time,
as well as your initials.
Don’t forget that the information you enter
on a patient’s record is open to public scrutiny.
Good medical notes are an excellent way of showing
other doctors your clinical skills and competence.
It’s also a good idea to go over the medical
record with your patient, so that he understands
exactly what you have entered and what it means.
It’s helpful to ask patients to fill out
their own medical history form before they see
you. This allows them to review their own medical
history; and also ensures that they do not forget
important details. Such a structured patient interview
form can help to improve the quality of medical
care you provide. Many clinics mail such a form
to the patient so they can fill it at home before
coming in; while others now offer such forms online,
so they can be emailed and checked before the
actual visit. This helps you to make more efficient
use of your time ! Busy doctors often ask their
assistants to take the history; and while
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this saves your time, it’s important that you review
the facts carefully with the patient yourself.
While some doctors still laboriously hand-write
all their medical notes, it’s very cost-effective
to have pre-printed medical record sheets or templates.
You can design these yourself, customised for
the medical problems you see most commonly. This
will allow you to improve accuracy, because you
record all the important clinical details for
each patient; ensure legibility; and save you
time, because it minimizes your handwriting.
You need to develop a system of keeping your patient’s
records safely and securely. While this can be
an additional burden, it’s well worth your
while. Not only will it make it much easier for
you to provide better care to your patients, your
patients will also feel much more comfortable,
knowing that you have all their medical details
at the tip of your fingertips. The following suggestions
will help you store your patient’s medical
records safely.
1. Implement an efficient filing system . Charts
can be filed by the patient’s last name,
date or code – use whatever works for you
!
2. All records must stay in the clinic. Don't
bring charts home - you are likely to leave them
in your home or your car.
3. Practice what you preach. Your staff should
have full permission to let you know when you
are remiss in your chart duties.
4. Adapt to new technology. Computers and voice
recognition systems are great for simplifying
documentation.
5. Discipline yourself - charts should be completed
by the end of the day.
By taking an organized approach to the problem,
you and your staff won't be spending half the
day looking for missing or misplaced records !
Many lawyers recommend that medical records be
kept indefinitely. Older records can be archived
and stored on microfilm or CD-ROM. However, do
remember that even though the medical record is
the property of the clinic, patients have a right
to see their own records.
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In the USA, doctors often dictate their findings
onto a tape, which is then “transcribed”
by a medical transcriptionist. This is very useful,
and many Indian companies are now rushing to offer
this service . Right now, it’s mostly hospitals
in the USA which use this service, but many Indian
hospitals will start using this soon. However,
voice recognition software will most probably
make most transcriptionists redundant very soon.
Keeping medical records on computers ( Electronic
Medical Records, EMR) has been a major advance
and many software packages are available now which
allow doctors to do this efficiently. Not only
is the information much easier to fill in , it
also ensures
legibility and completeness – and the records
are easier to retrieve. Computer-based records
are also very useful for medical research, since
it’s easier to analyse them. However, many
doctors have poor typing skills, and many are
still computer-shy. The introduction of sophisticated
voice recognition programs in the near future
will soon allow doctors to “talk to their
computers” , making data entry for medical
record-keeping much easier for them. However,
computerized medical record handling does also
carry certain downsides, such as the issues of
privacy and confidentiality, and these still need
to be resolved.
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