Protect your Problems with your PEN

 Objects For care & treatment For documentation For reimbursement For medical education For research For communication For follow up For legal issues

For Billing & Audit

Reasons for poor records

Considered a time consuming bother

Cutting costs
Restaurant type medical service No training

Doctor - shopping patients

Unless hit by litigation

What is the Necessity ?

Practicing medicine now is hazardous & risky Mutual faith replaced with mutual suspicion. Practicing defensive medicine inevitable.

The best way to deal with Medical & Medicolegal problems is to prevent them
Medicine is a science of uncertainty and art of probability
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Several reasons to maintain records

Coordinative vehicle for communication, all

case - related info, should be complete

Indicate good quality medical care

Indicate good quality practitioner

Best defense for litigation

 Document should be
Correct

Clear
Complete Confidential Comprehensive Collaborative Contemporary Consecutive Concise Patient Centered
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Documentation
Patient related
written and electronic health records Audio and video tapes

Emails
Images (photographs and diagrams) Observation charts Check lists

Communication books
Shift/management reports Incident reports Clinicians personally or any other type or form of

documentation pertaining to the care provided

 Other Documents not pertaining to patients Policies, procedures and protocols Critical incident / occupational health and safety

reports Statistical and research data Reports related to service and funding agreements Staffing rosters Personnel files Performance appraisals Clinical assessments Published reports/papers

 Who? What? When? Why? How?

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 Minimum requirements Full Name Age, Sex & Address Occupation, Educational status & Social condition Date, Time & Place Consent History General Examination with time & date Special Examination with time & date Investigations Diagnosis
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 Periodic Observations Treatment in detail Instructions Complications

Refer note
Remarks Negative remarks

Signature with qualification, designation &

Registration number

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 Accurate Medical Records

Record of medical care Comply with legal requirements, accreditation standards,

and professional practice standards Support and defend care

Advantages of Pre-printed documents
Prompts clinician for key elements Improves legibility Standardizes content Facilitates data collection, quality auditing

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Advantages of Electronic Documentation

software available Less time consuming

Choose that is most user friendly

Trained staff in software use

Research possible from data

Medicolegal advantage

Record keeping

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 Provisions regarding Medical

Documents
Certificates Routine case records Indoor case papers Medico-legal case papers Probable negligence cases For library or public interest patients rights

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 Injury Certificate Drunkenness Certificate Sexual Offence Certificate Cause of Death Certificate Age Estimation Certificate Certificate for Leave/Extension of Leave/

Commutation Leave Fitness Certificate

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 Registers
OPD Indoor MLC Birth & Death Operative Procedure Referred Cases Discharge

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MEDICAL COUNCIL OF INDIA GUIDELINES ON MEDICAL RECORDS Maintain indoor records in a standard proforma for 3 years from commencement of treatment (Section 1.3.1 and Appendix 3). Request for medical records by patient or authorized attendant should be acknowledged and documents issued within 72 hours (Section 1.3.2). Maintain a register of certificates with the full details of medical certificates issued with at least one identification mark of the patient and his signature (Section 1.3.3). Efforts should be made to computerize medical records for quick retrieval (Section 1.3.4).
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 Time period

* OPD records 3 yrs * Indoor case records 5 yrs * Medicolegal case 30 yrs

Maintain Confidentiality of records

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 Documents must be given to the patients as a matter of

right
Discharge summary, referral notes, and death summary

Documents can be given after fulfilling the hospital

criteria
copies of inpatient files, records of diagnostic tests,

operation notes, videos, medical certificates, and duplicate copies for lost documents
Certain records cannot be given to patients without the

direction of the Court

The outpatient register, inpatient register, and files of

medico-legal cases cannot be handed over to the patient or relatives without the direction of the court

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 There are certain situations where it is legal for

the authorities to give patient information. during referral when demanded by the court or by the police on a written requisition when demanded by insurance companies as provided by the Insurance Act when the patient has relinquished his rights on taking the insurance when required for specific provisions of Workmen's Compensation cases, Consumer Protection cases, or for Income tax authorities.

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