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MEDICAL MEDICAL
DOCUMENTATION DOCUMENTATION
By By
PERUMAL CHINAYA AMN. PPN. PERUMAL CHINAYA AMN. PPN.
RMA. LLB( RMA. LLB(Hons Hons) ( ) (WoIverbampton WoIverbampton) CLP ) CLP
LegaI OIIIcer LegaI OIIIcer
MaIaysIan MedIcaI CouncII MaIaysIan MedIcaI CouncII
E E--maII: maII:
mmckkmyaboo.com mmckkmyaboo.com
perumaIxgmaII.com perumaIxgmaII.com
Webpage: www.mmc.gov.my Webpage: www.mmc.gov.my
MLulCAL 8LCC8uS
O A MEDICAL RECORD IS DOCUMENTED
INFORMATION ABOUT THE HEALTH OF AN
IDENTIFIABLE INDIVIDUAL RECORDED BY A
PRACTITIONER OR OTHER HEALTHCARE
PROVIDERS,EITHER PERSONALLY OR AT HIS OR
HER INSTRUCTIONS. IT SHOULD CONTAIN
SUFFICIENT INFORMATION TO IDENTIFY THE
PATIENT.
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MLulCAL 8LCC8uS
O Ii musi suppoii ile diagnosis based on lisioiy,
plysical examinaiion and invesiigaiions, jusiify ile
piofessional managemeni given, iecoid ile couise and
iesulis ileieof, and ensuie ile coniinuiiy of caie
piovided by piaciiiioneis and oilei lealilcaie
piovideis io ilai paiiiculai paiieni.
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MEDICAL RECORDS
MedIcaI records were bIstorIcaIIy regarded as aIde memoIrs Ior
pbysIcIans treatIng patIents and as essentIaI components to
patIent care. Tbey contaIned InIormatIon about tbe patIent, on
one part, and tbe pbysIcIan's opInIon and cIInIcaI judgment
wbIcb brougbt to bear on tbe patIent's management, on tbe
otber. Tbe understandIng tbat notes were essentIaI tooIs In
patIent care became weII estabIIsbed and evoIved to estabIIsb
tbe concept tbat medIcaI records were documents wbIcb
beIonged to tbe pbysIcIan and were tbereIore retaIned by bIm
In bIs pIace oI practIce. Based on tbIs concepts, tbe medIcaI
records were consIdered conIIdentIaI" documents In testImony
oI good medIcaI practIce and tbe InIormatIon tbereIn contaIned
consIdered prIvate" In observance oI etbIcaI doctor-patIent
reIatIonsbIp.
MLulCAL 8LCC8uS
O In piepaiing Medical iecoids, ile piaciiiionei musi leep in
mind ilai le is geneiaiing a documeni wlicl, wlile
iefleciing lis peisonal findings and managemeni of a
paiieni's illness in ile besi of iimes, can be demanded by
ile paiieni and ile couiis of law in maiieis of liiigaiion.
O Tleie is a need io exeicise cauiion in ile mannei and foim
of puiiing woids on papei (oi in ile eleciionic media) in
ile couise of managemeni of a paiieni. Ii is impeiaiive ilai
ile docioi is ai all iimes awaie ilai ile Medical Recoids is a
valuable documeni in paiieni caie wlicl maybe iead oi
disclosed subsequenily, and ileiefoie musi be compleie,
objeciive and compielensive.
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ReIated Issues: ReIated Issues:
a. a. Types oI MedIcaI DocumentatIon Types oI MedIcaI DocumentatIon
b. b. DeIInItIon DeIInItIon
c. c. Is Tbere A Need Ior DocumentatIon? Is Tbere A Need Ior DocumentatIon?
d. d. Tbe Content; Tbe Content;
e. e. OwnersbIp; OwnersbIp;
I. I. ReIeasIng ReportsJRecords; ReIeasIng ReportsJRecords;
g. g. HandIIng; HandIIng;
b. b. Storage PerIod; Storage PerIod;
I. I. WrItIng ReportsJReIerraI Letter; WrItIng ReportsJReIerraI Letter;
j. j. An 'IdeaI' DocumentatIon; and An 'IdeaI' DocumentatIon; and
k. k. An 'IdeaI' ReportJReIerraI Letter. An 'IdeaI' ReportJReIerraI Letter.
I. I. Consequences oI Breacb Consequences oI Breacb
m. m. PreventIng ProbIem wItb DocumentatIon PreventIng ProbIem wItb DocumentatIon
?
Record Record -- tbe cIInIcaI notes, etc tbe cIInIcaI notes, etc contInuatIon oI care; contInuatIon oI care;
Report Report -- summary oI tbe record summary oI tbe record care gIven; care gIven;
ReIerraI ReIerraI -- LetterJMemo LetterJMemo transIer oI care transIer oI care..
a. Types a. Types
b. Wby Is record KeepIng Important? b. Wby Is record KeepIng Important?
LegaI ProtectIon LegaI ProtectIon
MemoryJCommunIcatIon AId MemoryJCommunIcatIon AId
LegaI requIrement (ForensIc LegaI requIrement (ForensIc esp esp))
ProIessIonaI Standard oI PractIce ProIessIonaI Standard oI PractIce
Insurance RequIrement Insurance RequIrement
DIscbarge DecIsIons DIscbarge DecIsIons
SLaLus of 8ecords wlLhln
PealLhcare laclllLy
O MR aie io classified as "Confideniial" foi
adminisiiaiive puiposes
O Noimal foi vaiious giade of HCP landle medical
iecoids
O Impoiiani io impiess upon ilem ilai confideniialiiy is
mainiained ai all iimes
O Access only io ilose eniiiled
S
ueflnlLlon/urpose
O Medical Recoid is documenied infoimaiion aboui ile
lealil of a ideniifiable individual.
O Slould coniain enougl info io ideniify paiieni and
suppoii diagnosis based on lisioiy, plysical
examinaiion and invesiigaiions.
O Musi jusiify ile piofessional managemeni given,
iecoid ile couise and iesulis ileieof.
O Ensuie coniinuiiy of caie piovided by piaciiiioneis
and oilei HCP
O Weie lisioiically iegaided as SVWW[^_ foi
plysician iieaiing paiienis and as esseniial
componenis io paiieni caie.
9
ConL
O Undeisianding ilai ile noies weie esseniial iools in
paiieni caie
O Evolved io esiablisl ile concepi ilai medical iecoids
weie docus wlicl belonged io plysician
O MR weie consideied "confideniial" docus in iesiimony
of good medical piaciice
O Info ileiein coniained is consideied "piivaie" in
obseivance of eilical docioi-paiieni ielaiionslip
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Medlcal 8ecords and reporLs ln 2001 guldellnes
O Well lepi medical iecoids aie ile lall mail of good
medical piaciice. Paiieni caids slould iecoid all
ielevani info., plysical findings and diagnosis in ile
couise of paiieni managemeni. Sucl iecoids slould be
accuiaie, legible, compielensive and up-io -daie, and
coniiibuie io easy iecall of paiieni infoimaiion foi
coniinuiiy and follow up of paiienis, as well as fuiuie
iefeience sucl as piepaiing iepoiis.
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conL
O Invesiigaiion and iieaimeni slould be iecoided in
deiail, and in case of invasive pioceduies, ile
indicaiion foi, and ile naiuie of ile pioceduies musi
be cleaily documenied. Piopeily jusiified pioceduies
can be defended by peeis in ile eveni of liiigaiion, bui
wlen clinical noies aie sleicly, pooily made oui,
illegible, vague and ambiguous and supeiimposed
wiil deleiions and coiieciions ilis maybe difficuli.
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conL
O Similaily, noies and iecoids, ielaiing io opeiaiions and
invasive pioceduies slould be wiiiien cleaily, wiil
aiieniion io indicaiions, findings, ielevani deiails,
difficuliies encounieied and ile measuies ialen.
O Noies, once made oui, slould noi be eiased oi alieied,
oi new woids inseiied afiei a lapse of iime, as ilese
may indicaie defensive aciion by ile docioi in ile
eveni of unexpecied eveniualiiies in ile couise of
paiieni managemeni.
13
conL
O Foi paiienis wlo aie ai ligl iisl, paiiiculaily ilose
wlo aie aged and medically compiomised, ile
possible iisl of suigeiy and anesileiics need io be
explained cleaily io ile paiieni and]oi lis nexi of lin
and ilis musi be well ieflecied in ile noies.
O Ii is advisable ilai as fai as possible aciual quoiaiions
of paiienis be incoipoiaied in ile noie io avoid
paiienis denying wlai iianspiied ai an examinaiion
session.
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c. TIc Conicni. c. TIc Conicni.
O O Doctors cIInIcaI notes Doctors cIInIcaI notes
O O Emergency InIormatIon Emergency InIormatIon
O O HeaItb HIstory HeaItb HIstory
O O InjuryJRebabIIItatIon EvaIuatIon InjuryJRebabIIItatIon EvaIuatIon
O O DaIIy Treatment record DaIIy Treatment record
O O Insurance InIormatIon Insurance InIormatIon
O O Laboratory & Laboratory & HIstopatoIogIcaI HIstopatoIogIcaI reports reports
O O Drug prescrIptIons Drug prescrIptIons
O O Nurses report Nurses report
O O Consent Iorms Consent Iorms
O O OperatIng notesJ OperatIng notesJAnaestbetIc AnaestbetIc notes notes
1S
May also includc . May also includc .
O O SurgIcaIJx SurgIcaIJx--rayJMRI reports rayJMRI reports
O O CommunIcatIon Irom otber proIessIonaIs CommunIcatIon Irom otber proIessIonaIs
O O ReIease oI medIcaI InIormatIon Iorm ReIease oI medIcaI InIormatIon Iorm
O O PermIssIon to provIde medIcaI treatment PermIssIon to provIde medIcaI treatment
Iorm Iorm
O O ComputerIsed ComputerIsedJeIectronIc records JeIectronIc records
O O Record by otber HCP Record by otber HCP
O O PrIntout Irom PrIntout Irom monIterIng monIterIng equIpment (ECG, equIpment (ECG,
ECT ECT ect ect.) .)
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Manner of maklng Medlcal 8ecords
O Use of iniegiaied clinical noies is encouiaged
O Tle docioi and all oilei HCP involved in ile
managemeni of pi male coniempoianeous iecoid in
ile same coniinuaiion sleei
O Assisis in leeping diieci iiacl of ile daily
managemeni of paiieni
O Eniiy slould be piecise and legible and iecoid daie,
iime and pioceduie oi iieaimeni insiiiuied in
clionological sequence
O Slould be signed by peison maling ile eniiy wiil lis
ideniificaiion cleaily denoied
1?
aily Fccords aily Fccords
O O Many cbartIng tecbnIques Many cbartIng tecbnIques
O O Focus cbartIng Focus cbartIng
O O CbartIng by exceptIon CbartIng by exceptIon
O O Somewbat outdated by computer Somewbat outdated by computer
tecbnoIogy tecbnoIogy
O O ComputerIzed documentatIon ComputerIzed documentatIon
O O IndIvIduaIIzed IndIvIduaIIzed
O O commercIaI commercIaI
O O DIctatIon DIctatIon
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Tbe bospItaIJcIInIc? Tbe patIent? Tbe bospItaIJcIInIc? Tbe patIent?
MMC MMC -- Code oI ProIessIonaI Conduct: Code oI ProIessIonaI Conduct:
''It Is weII to remember tbat wbIIe It Is weII to remember tbat wbIIe tbe cIInIcaI notes and records tbe cIInIcaI notes and records
pbysIcaIIy resIde wItb tbe doctor and to tbe bospItaI pbysIcaIIy resIde wItb tbe doctor and to tbe bospItaI, , tbe tbe
InIormatIon tbereIn contaIned beIongs, moraIIy and etbIcaIIy to InIormatIon tbereIn contaIned beIongs, moraIIy and etbIcaIIy to
tbe patIent and to reguIatory autborItIes tbe patIent and to reguIatory autborItIes. Tbese documents . Tbese documents may may
be demanded be demanded by tbe patIent or bIs appoInted oIIIcers Ior varIous by tbe patIent or bIs appoInted oIIIcers Ior varIous
purposes, rangIng Irom need to seek second opInIon, to seek purposes, rangIng Irom need to seek second opInIon, to seek
Iurtber treatment eIsewbere, or Ior IItIgatIon. Iurtber treatment eIsewbere, or Ior IItIgatIon.
Doctors are obIIged to provIde comprebensIve MedIcaI Reports Doctors are obIIged to provIde comprebensIve MedIcaI Reports
wben requested by patIents or by tbe next wben requested by patIents or by tbe next--oI oI--kIn, In tbe case oI kIn, In tbe case oI
cbIIdren and mInors, or by tbe empIoyer wItb tbe patIent's cbIIdren and mInors, or by tbe empIoyer wItb tbe patIent's
consent. Any reIusaI or undue deIay In provIdIng sucb reports Is consent. Any reIusaI or undue deIay In provIdIng sucb reports Is
unetbIcaI.' unetbIcaI.'
d. Tbe OwnersbIp: d. Tbe OwnersbIp:
< 6JS2 < 6JS2 -- wItb compIete detaIIsJIorms wItb compIete detaIIsJIorms
Thcsc documcnts Thcsc documcnts may bc dcmandcd may bc dcmandcd by thc paticnt by thc paticnt
ov his appointcd oIIiccvs Iov vavious puvposcs, ov his appointcd oIIiccvs Iov vavious puvposcs,
vanging Ivom nccd to scck sccond opinion, to vanging Ivom nccd to scck sccond opinion, to
scck Iuvthcv tvcatmcnt c!scwhcvc, ov Iov scck Iuvthcv tvcatmcnt c!scwhcvc, ov Iov
!itigation. !itigation.
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octovs avc ob!igcd to pvovidc compvchcnsivc octovs avc ob!igcd to pvovidc compvchcnsivc
Mcdica! Rcpovts Mcdica! Rcpovts whcn vcqucstcd by paticnts ov by whcn vcqucstcd by paticnts ov by
thc ncxt thc ncxt--oI oI--kin, in thc casc oI chi!dvcn and kin, in thc casc oI chi!dvcn and
minovs, ov by thc cmp!oycv with thc paticnt's minovs, ov by thc cmp!oycv with thc paticnt's
conscnt. Any vcIusa! ov unduc dc!ay in pvoviding conscnt. Any vcIusa! ov unduc dc!ay in pvoviding
such vcpovts is uncthica!.' such vcpovts is uncthica!.'
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Cwnershlp of Medlcal 8ecords
AL common law Lhe ownershlp of documenLs generally vesLs wlLh Lhe
person who wroLe or prepared Lhe documenL 1herefore medlcal
records ln Lhe form of noLes belongs Lo Lhe docLor Powever where
Lhe paLlenL had made a paymenL as ln Lhe case of x'rays lab resulLs
eLc Lhen Lhe properLy ln Lhese documenLs rlghLfully belong Lo Lhe
paLlenL by vlrLue of Lhe conLracL
neverLheless Lhe MMC's guldellnes sLaLes LhaL" whlle cllnlcal noLes
and records physlcally belong Lo Lhe docLor Lhe lnformaLlon Lhereln
belongs morally and eLhlcally Lo Lhe paLlenL and legally Lo Lhe paLlenL
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Access Lo Medlcal 8ecords and Medlcal 8eporLs
CovernmenL PosplLals
A Medlcal 8eporL ls a publlc documenL as medlcal
offlcers are members of Lhe publlc servlce
under sec 74 of Lhe Lvldence AcL 1930
publlc documenLs are documenLs formlng Lhe acLs or
records of Lhe acLs of publlc offlcers
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under sec 76 of Lhe LA lf a person has Lhe rlghL Lo lnspecL a
documenL Lhen he should be supplled wlLh a copy of Lhe documenL
on paymenL of a prescrlbed fees A person has a rlghL Lo lnspecL a
documenL lf he has an lnLeresL ln Lhe documenL and Lhe lnspecLlon ls
necessary for Lhe proLecLlon of hls own lnLeresLs
rlvaLe PosplLals and uocLors ln rlvaLe racLlce
racLlLloners are obllged Lo provlde Lhelr paLlenLs wlLh a
comprehenslve medlcal reporL
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aLlenL's Medlcal 8ecord
O .(i) A paiieni's medical iecoid is ile piopeiiy of a
piivaie lealilcaie faciliiy oi seivice.
O (:) No paiieni's medical iecoid slall be ialen oui fiom
ile faciliiy oi seivice excepi undei a couii oidei, a
copy of ile iecoids slall be ieiained by ile piivaie
lealilcaie faciliiy oi seivice and ile oiiginal iecoids
slall be ieiuined io ile piivaie lealilcaie oi faciliiy oi
seivice ai ile end of ile pioceedings foi wlicl ile
iecoids weie diiecied io be piocuied.
O Piivaie Healilcaie Faciliiies and Seivices Regulaiions
:oo
2S
olsons AcL 1932 and uangerous urugs
AcL 1932 prescrlbes sLrlngenL
requlremenL over Lhe purchase
sLorage prescrlpLlon and supply of
polsons and dangerous drugs
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LA8LLS
O Undei ile Poisons Regulaiions i:, labels musi be
affixed io dispensed medicine.
O Ii is advisable io label lab specimens and x'iays wiil
ile ielevani deiails io avoid mix up.
2?
e) e) Record oI Dangerous & ControIIed Drugs Record oI Dangerous & ControIIed Drugs::
O It Is a GMP to maIntaIn stock Inventory oI aII medIcInes In tbe
IacIIIty.
O HC personneI are requIred by IegIsIatIon to maIntaIn proper
records oI tbe prescrIptIon oI dangerous and controIIed drugs,
and a stock Inventory. FaIIure to compIy Is a serIous oIIense.
(PoIson Act 19SS)
O AvoId prescrIbIng babIt-IormIng medIcInes In Iarge quantItIes as
It may Iead to substance abuse as weII as tbe rIsk oI overdose In
unstabIe patIents.
O Never use abbrevIatIons;
O Secure DDA cabInet keys.
O O Never Issue prescrIptIon or medIcaI sIck Ieave wItbout Never Issue prescrIptIon or medIcaI sIck Ieave wItbout
examInIng tbe patIent IIrst and makIng reIevant notes In tbe examInIng tbe patIent IIrst and makIng reIevant notes In tbe
patIent records. patIent records.
O O Never pre Never pre--sIgn prescrIptIon sIIps (or certIIIcates) as tbese may sIgn prescrIptIon sIIps (or certIIIcates) as tbese may
be mIsused by unautborIsed persons In your absence. be mIsused by unautborIsed persons In your absence.
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Tbe OrIgIn: Tbe OrIgIn:
derIved Irom varIous sources derIved Irom varIous sources::
Tbe patIent Tbe patIent
Tbe personneI Tbe personneI -- may IncIude IncrImInatIng, may IncIude IncrImInatIng,
comments, personaI opInIon, judgment, etc comments, personaI opInIon, judgment, etc
ReIatIvesJ ReIatIvesJSpouse Spouse
DocumentatIon DocumentatIon -- tbe InIo wrItten tbe InIo wrItten --
omIssIon andJor commIssIon, styIes, omIssIon andJor commIssIon, styIes,
ambIguIty, IegIbIIIty, etc. ambIguIty, IegIbIIIty, etc. (InterpretatIon?) (InterpretatIon?)
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e. ReIeasIng ReportJRecords: e. ReIeasIng ReportJRecords:
Tbe Consent: Tbe Consent:
* * Consent Irom tbe 'Source' Consent Irom tbe 'Source'
* TbIrd Party Requests; * TbIrd Party Requests;
# Deceased # Deceased SpouseJs? ReIatIonsbIp beIore tbe SpouseJs? ReIatIonsbIp beIore tbe
demIse? demIse?
# Young cbIIdren # Young cbIIdren Fatber Fatber? Motber? GuardIan? ? Motber? GuardIan?
# Tbe Letter oI Consent # Tbe Letter oI Consent GenuIne? GenuIne?
# PreIerabIy # PreIerabIy -- court order court order
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I. HandIIng I. HandIIng -- to ensure conIIdentIaIIty: to ensure conIIdentIaIIty:
Tbe OveraII Manager Tbe OveraII Manager -- ensures an EIIectIve ensures an EIIectIve
SecurIty System (guIdeIInesJprotocoIs) to SecurIty System (guIdeIInesJprotocoIs) to
prevent Improper dIscIosures prevent Improper dIscIosures
Tbe Person Tbe Person--In In--cbarge at varIous IeveIs cbarge at varIous IeveIs boIds boIds
prIme responsIbIIIty prIme responsIbIIIty -- ensurIng protectIon oI ensurIng protectIon oI
InIormatIon and documentsJIIIes. InIormatIon and documentsJIIIes.
**Wbo SubmIts AppIIcatIon? Wbo SubmIts AppIIcatIon?
Wbo ReceIves AppIIcatIon? Wbo ReceIves AppIIcatIon?
**Mode oI AppIIcatIon Mode oI AppIIcatIon
**Mode oI RepIy Mode oI RepIy
}}
GenuIne sIgnature? GenuIne sIgnature?
Correct Person? Correct Person?
*Issues! *Issues!
In person? In person?
Post? Post?
3 3
rd rd
Party? Party?
EIectronIc? EIectronIc?
LlmlLaLlon erlods
a no llmlLaLlon for crlmlnal or dlsclpllnary cases Lo be kepL Llll
resolved
bClvll cases 3 years lnvolvlng publlc auLhorlLles
cCLhers LlmlLaLlon AcL 1933/ ubllc AuLhorlLles roLecLlon AcL
1943 applles
l1orL and breach of conLracL noL ln wrlLlng 3 years
ll8reach of conLracL ln wrlLlng 6 years
lllMedlcal negllgence prlvaLe medlcal LreaLmenL Lo be heard
wlLhln 6years of daLe of ln[ury governmenL wlLhln 3years
lv laLal accldenL wlLhln 3 years of deaLh
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reservaLlon of 8ecords
Medlcal 8ecords may be preserved for
a Medlcal reasons for LreaLmenL and managemenL of paLlenLs
bLegal reasons
CourL cases Llll concluded
c SLaLuLory requlremenLs
l Crlmlnal rocedure Code
ll revenLlon and ConLrol of lnfecLlous ulsease AcL 1988
lll LlmlLaLlon AcL 1933
lv ubllc AuLhorlLles roLecLlon AcL 1943
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LxcepLlonal slLuaLlons
Mlnors and persons of unsound mlnd Llme does noL run whlle
dlsablllLy exlsLs
ln cases of mlnors records have Lo preserved Llll Lhe age of
ma[orlLy whlch ls 18 years
lL ls generally advlsable LhaL medlcal records should be
preserved/kepL/sLored safely for aL leasL 8 years ln prlvaLe
hosplLal and 3 years ln governmenL hosplLals
34
3S
MedIco-LegaI Aspects OI MedIcaI
Reports
1. Tbe Purpose OI Tbe Report
2. Wbat Is To Be Done?
3. Wbo Wants Tbe Reports?
4. Wbat SbouId Be In Tbe Reports
36
b. WrItIng Report: b. WrItIng Report:
Wbo sbouId wrIte? Wbo sbouId wrIte?
Record & ReIerraI Ietter: Record & ReIerraI Ietter:
# tbe Doctor In cbarge # tbe Doctor In cbarge
Report: Report:
# Tbe # Tbe 'MaIn' 'MaIn' HeaItb Care ProvIder? HeaItb Care ProvIder?
# Everybody? # Everybody?
# Anybody # Anybody -- HOJMOJSpecIaIIsts? Nurses? HOJMOJSpecIaIIsts? Nurses?
SIster? PbysIotberapIstJRadIoIogIst, etc SIster? PbysIotberapIstJRadIoIogIst, etc
# For MedIcoIegaI cases (or potentIaI) # For MedIcoIegaI cases (or potentIaI) -- consuIt consuIt
your LegaI AdvIsor your LegaI AdvIsor FIRST FIRST! !
(KIV Breacb oI Consent) (KIV Breacb oI Consent)
3?
MedIcaI Act 19?1: MedIcaI Act 19?1:
preIerabIy tbe practItIoner treatIng tbe patIent preIerabIy tbe practItIoner treatIng tbe patIent ((&&
based on tbe avaIIabIe records based on tbe avaIIabIe records))
In tbe event In tbe event -- tbe 'maIn' provIder Is not avaIIabIe tbe 'maIn' provIder Is not avaIIabIe --
Wbo Is tbe next best person? Wbat CrIterIa? Wbo Is tbe next best person? Wbat CrIterIa?
Note Note -- tbe wrIter tbe wrIter -- be prepared to testIIy In court. be prepared to testIIy In court.
SectIon 2?. MedIcaI certIIIcate: SectIon 2?. MedIcaI certIIIcate:
''No oer11]1oo1e or o1er dooumen1 requ1red bg ong No oer11]1oo1e or o1er dooumen1 requ1red bg ong
ur111en 1ou 1o be s1gned bg o du1g quo11]1ed med1oo1 ur111en 1ou 1o be s1gned bg o du1g quo11]1ed med1oo1
proo1111oner g1ven o]1er 1e oommenoemen1 o] 11s proo1111oner g1ven o]1er 1e oommenoemen1 o] 11s
Ao1 so11 be vo11d un1ess s1gned bg o ]u11g reg1s1ered Ao1 so11 be vo11d un1ess s1gned bg o ]u11g reg1s1ered
med1oo1 proo1111oner.' med1oo1 proo1111oner.'
3S
DuratIon DuratIon -- <6JS2 <6JS2 upon receIpt oI compIete upon receIpt oI compIete
appIIcatIon by a practItIoner appIIcatIon by a practItIoner
DeIay DeIay -- AdmInIstrator AdmInIstrator -- VIcarIousIy IIabIe? VIcarIousIy IIabIe?
Payment Payment -- IoIIow tbe scbeduIe IoIIow tbe scbeduIe
CertaIn AdmIn Procedures CertaIn AdmIn Procedures
VettIng by 3 VettIng by 3
rd rd
PartIes (e.g. LegaI AdvIsors) PartIes (e.g. LegaI AdvIsors)
Ensure consent Irom patIent Ensure consent Irom patIent
e.g. No consent e.g. No consent no report! no report!
KIV to: KIV to:
a. ensure proper guIdeIIne a. ensure proper guIdeIIne -- avaIIabIe & ImpIemented avaIIabIe & ImpIemented
b. amend tbe consent Iorm ~ e.g. namIng tbe recIpIent b. amend tbe consent Iorm ~ e.g. namIng tbe recIpIent
TIc Imoriancc of TIc Imoriancc of 'Corrcci Punciuaiion'. 'Corrcci Punciuaiion'.
dear jobn I want a man wbo knows wbat Iove Is aII dear jobn I want a man wbo knows wbat Iove Is aII
about you are generous kInd tbougbtIuI peopIe wbo about you are generous kInd tbougbtIuI peopIe wbo
are not IIke you admIt to beIng useIess and InIerIor are not IIke you admIt to beIng useIess and InIerIor
you bave ruIned me Ior otber men I yearn Ior you I you bave ruIned me Ior otber men I yearn Ior you I
bave no IeeIIngs wbatsoever wben we're apart I can be bave no IeeIIngs wbatsoever wben we're apart I can be
Iorever bappy wIII you Iet me be yours jane Iorever bappy wIII you Iet me be yours jane
39
EXERCISE EXERCISE
Note: Note: You are onIy aIIowed to Insert commas, You are onIy aIIowed to Insert commas,
IuII IuII--stops and a questIon mark. stops and a questIon mark.
eor Jon eor Jon,,
1 uon1 o mon uo Knous uo1 1ove 1s 1 uon1 o mon uo Knous uo1 1ove 1s.. A11 obou1 gou ore A11 obou1 gou ore
generous generous,, K1nd K1nd,, 1oug1]u1 peop1e 1oug1]u1 peop1e,, uo ore no1 11Ke gou uo ore no1 11Ke gou..
Adm11 1o be1ng use1ess ond 1n]er1or Adm11 1o be1ng use1ess ond 1n]er1or.. You ove ru1ned You ove ru1ned
me. For o1er men me. For o1er men,, 1 georn 1 georn.. For gou For gou,, 1 ove no ]ee11ngs 1 ove no ]ee11ngs
uo1soever uo1soever. . Wen uere opor1 Wen uere opor1,, 1 oon be ]orever oppg 1 oon be ]orever oppg..
W111 gou 1e1 me be W111 gou 1e1 me be? ?
Yours Yours, , Jone Jone..
40
Dear Jobn Dear Jobn,,
I want a man wbo knows wbat Iove Is aII about I want a man wbo knows wbat Iove Is aII about..
You are generous You are generous,, kInd kInd,, tbougbtIuI tbougbtIuI.. PeopIe wbo are not PeopIe wbo are not
IIke you admIt to beIng useIess and InIerIor IIke you admIt to beIng useIess and InIerIor. . You bave You bave
ruIned me Ior otber men ruIned me Ior otber men. . I yearn Ior you I yearn Ior you.. I bave no I bave no
IeeIIngs wbatsoever wben we're apart IeeIIngs wbatsoever wben we're apart.. I can be Iorever I can be Iorever
bappy bappy.. WIII you Iet me be yours WIII you Iet me be yours? ?
Jane Jane..
$Ic Ias no rigors or sIaling cIills, lui Icr Iusland siaics sIc was vcry
Ioi in lcd lasi nigIi.
TIc clvic cam will lc donc laicr on iIc floor.
Paiicni Ias iwo iccnagc cIildrcn, lui no oiIcr alnormaliiics.
$lin. $omcwIai alc lui rcscni.
TIc aiicni was io Iavc a lowcl rcscciion. Howcvcr, Ic iool a jol as a siocl
lrolcr insicad.
TIc lal icsi indicaicd alnormal lovcr funciion.
Eaminaiion of gcniialia rcvcals iIai Ic is circus sizcd.
DoiI lrcasis arc cqual and rcaciivc io ligIi and accommodaiion.
I saw your aiicni ioday, wIo is siill undcr our car for Iysical iIcray.
$Ic siaicd iIai sIc Iad lccn consiiaicd for mosi of Icr lifc uniil sIc goi a
divorcc.
Fccial caminaiion rcvcalcd a normal sizc iIyroid.
Occasional, consiani, infrcqucni IcadacIcs.
Paiicni Iad wafflcs for lrcalfasi and anorcia for luncI.
Paiicni was sccn in consuliaiion ly r. $miiI, wIo fcli wc sIould sii on iIc
aldomcn and I agrcc.
41
Excerpts Irom MedIcaI Records
Tbe IoIIowIng quotes were taken Irom actuaI medIcaI records,
as dIctated by pbysIcIans.
bttp:JJwww.drIbbIegIass.comJJokesJmedIcaI-records.btm
Dy iIc iimc Ic was admiiicd, Iis raid Icari Iad siocd, and Ic was fccling
lciicr.
Paiicni Ias cIcsi ain if sIc lics on Icr lcfi sidc for ovcr a ycar.
On iIc sccond day iIc lncc was lciicr and on iIc iIird day ii Iad comlcicly
disacarcd.
TIc aiicni Ias lccn dcrcsscd cvcr sincc sIc lcgan sccing mc in 1983.
TIc aiicni is icarful and crying consianily. $Ic also acars io lc dcrcsscd.
iscIargc siaius. Alivc lui wiiIoui crmission.
HcaliIy-acaring dccrcii 69-ycar-old malc, mcnially alcri lui forgciful.
TIc aiicni rcfuscd an auiosy.
TIc aiicni Ias no asi Iisiory of suicidcs.
TIc aiicni circd on iIc floor uncvcnifully.
Paiicni Ias lcfi Iis wIiic llood cclls ai anoiIcr Iosiial.
TIc aiicni's asi mcdical Iisiory Ias lccn rcmarlally insignificani, wiiI only
a 40-ound wcigIi gain in iIc asi iIrcc days.
$Ic slicd on iIc icc and aarcnily Icr lcgs wcni in scaraic dircciions in
carly cccmlcr.
Dciwccn you and mc, wc ougIi io lc allc io gci iIis lady rcgnani.
TIc aiicni was in Iis usual siaic of good IcaliI uniil Iis airlanc ran oui of
gas and crasIcd.
$Ic is numl from Icr iocs down.
TIc slin was moisi and dry.
Paiicni was alcri and unrcsonsivc.
WIcn sIc fainicd, Icr cycs rollcd around iIc room.
42
43
I. An 'IdeaI' MedIcaI DocumentatIon: I. An 'IdeaI' MedIcaI DocumentatIon:
1. 1. WrItten by tbe person wbo executed tbe orders; WrItten by tbe person wbo executed tbe orders;
2. 2. In cbronoIogIcaI order In cbronoIogIcaI order -- IndIcate reasonJs II IndIcate reasonJs II
deIay Is unavoIdabIe; deIay Is unavoIdabIe;
3. 3. WrIte entrIes sbortIy aIter care provIded; WrIte entrIes sbortIy aIter care provIded;
4. 4. LegIbIy wrItten; LegIbIy wrItten;
S. S. WrItten wItb permanent Ink; WrItten wItb permanent Ink;
6. 6. DescrIbe patIent care DescrIbe patIent care -- aII reIevant IIndIngsJ aII reIevant IIndIngsJ
actIonsJ InactIons actIonsJ InactIons -- botb + & botb + & --JomIssIon & JomIssIon &
commIssIon & aII cbanges In condItIon; commIssIon & aII cbanges In condItIon;
?. ?. Tbe groundsJjustIIIcatIons Tbe groundsJjustIIIcatIons -- actIonJInactIon; actIonJInactIon;
S. S. Be FactuaI & SpecIIIc Be FactuaI & SpecIIIc -- Use patIent quotes; Use patIent quotes;
9. 9. AII reIevant IIndIngsJactIonsJInactIons AII reIevant IIndIngsJactIonsJInactIons -- botb botb
posItIve & negatIveJomIssIon & commIssIon; posItIve & negatIveJomIssIon & commIssIon;
44
Cont . Cont .
10. 10. DeIeted approprIateIy and sIgned; DeIeted approprIateIy and sIgned;
11. 11. WrIte wbat you say (AvoId conIusIng quotes) WrIte wbat you say (AvoId conIusIng quotes)
12. 12. Document compIaIntsJneedsJresoIutIons; Document compIaIntsJneedsJresoIutIons;
13. 13. Care In usage oI abbrevIatIons; Care In usage oI abbrevIatIons;
14. 14. No ambIguousJuncIear words; No ambIguousJuncIear words;
1S. 1S. No IncrImInatIng remarks; No IncrImInatIng remarks;
16. 16. For every entry For every entry -- IdentIIy tIme, date & sIgn IdentIIy tIme, date & sIgn
It wItb name & desIgnatIon rubber It wItb name & desIgnatIon rubber--stamped; stamped;
1?. 1?. IndIcate patIentJcaregIvers response to IndIcate patIentJcaregIvers response to
teacbIng; teacbIng;
1S. 1S. INDICATE URGENCY! INDICATE URGENCY! -- II necessary II necessary
4S
An 'IdeaI' MedIcaI An 'IdeaI' MedIcaI RecordJReIerraI Letter RecordJReIerraI Letter
SbouId IncIude: SbouId IncIude: (Adopted by MMC) (Adopted by MMC)
For ALL MedIcaI DocumentatIon: For ALL MedIcaI DocumentatIon:
1. 1. PatIent ID PatIent ID
2. 2. AdmIssIon AdmIssIon -- Date and tIme Date and tIme
3. 3. CIInIcaI bIstory; CIInIcaI bIstory;
4. 4. CIInIcaI IIndIngs; CIInIcaI IIndIngs;
S. S. Summary oI InvestIgatIons; Summary oI InvestIgatIons;
6. 6. DIagnosIsJDIagnoses; DIagnosIsJDIagnoses;
?. ?. Summary oI procedures carrIed out Summary oI procedures carrIed out -- Dates & tImes; Dates & tImes;
S. S. Drugs & otber medIcaments prescrIbed; Drugs & otber medIcaments prescrIbed;
9. 9. PatIent progress wbIIe under care; PatIent progress wbIIe under care;
10. 10. PatIent condItIon Iast seen by tbe doctor; and PatIent condItIon Iast seen by tbe doctor; and
11. 11. FutureJFurtber PIan FutureJFurtber PIan
For ReIerraI: For ReIerraI:
12. SuggestIonJs . ( 12. SuggestIonJs . (INDICATE URGENCY! INDICATE URGENCY!))
Tbe practItIoner: Tbe practItIoner:
O O CIvIIJCrImInaI ActIon CIvIIJCrImInaI ActIon
PossIbIe RemedIes: PossIbIe RemedIes:
InjunctIon to RestraIn BreacbJFuture Breacbes InjunctIon to RestraIn BreacbJFuture Breacbes
Damages In LIeu oI InjunctIon Damages In LIeu oI InjunctIon JaII JaII
O O CIvII Servant CIvII Servant
DIscIpIInary ActIon DIscIpIInary ActIon
Demoted, ExpeIIed, ReprImanded, etc. Demoted, ExpeIIed, ReprImanded, etc.
O O ProIessIonaI ReguIatory AutborIty: ProIessIonaI ReguIatory AutborIty:
PossIbIe RemedIes PossIbIe RemedIes by ReIevant ProIessIonaI ReguIatory BodIes: by ReIevant ProIessIonaI ReguIatory BodIes:
DeregIstered, Suspended, ReprImanded, etc. DeregIstered, Suspended, ReprImanded, etc.
O O PersonaI: PersonaI:
InIamous IeeIIngs? GuIIt, Remorse, PIty, etc InIamous IeeIIngs? GuIIt, Remorse, PIty, etc
46
CONSEQUENCES OF BREACH: CONSEQUENCES OF BREACH:
((esp. c esp. consent & conIIdentIaIIty) onsent & conIIdentIaIIty)
Tbe patIent: Tbe patIent:
O O Court ActIon Court ActIon
tbe compIexItIes oI tbe IegaI system In brIngIng a tbe compIexItIes oI tbe IegaI system In brIngIng a
successIuI cIaIm successIuI cIaIm
O O SuIIerIngs: SuIIerIngs:
PbysIcaI PbysIcaI -- dIsabIIItyJIes, deIormItIes, etc. dIsabIIItyJIes, deIormItIes, etc.
EmotIonaI EmotIonaI -- anger, anger, dIstrust, suIcIde, etc. dIstrust, suIcIde, etc.
SocIaI SocIaI -- dIvorce, 'outcasted', 'rIdIcuIed', etc dIvorce, 'outcasted', 'rIdIcuIed', etc
FInancIaI FInancIaI -- rebab. burden, empIoyment, Income, etc. rebab. burden, empIoyment, Income, etc.
Tbe OrganIsatIon: Tbe OrganIsatIon:
O O Image Image BusIness, etc. BusIness, etc.
O O LItIgatIon, etc. LItIgatIon, etc.
Tbe ProIessIonaI ReguIatory AutborIty: Tbe ProIessIonaI ReguIatory AutborIty:
O O Image tarnIsbed Image tarnIsbed
O O DIscIpIInary ActIon DIscIpIInary ActIon
Otbers: Otbers:
O O FamIIIes and reIatIves. FamIIIes and reIatIves.
O O Country's Image. Country's Image.
4?
Avoiding Prollcm wiiI Any ocumcniaiion. Avoiding Prollcm wiiI Any ocumcniaiion.
1. 1. Proper Cbeck Proper Cbeck
2. 2. Counter Cbeck Counter Cbeck
3. 3. Cross Cbeck Cross Cbeck
4. 4. DoubIe Cbeck DoubIe Cbeck
S. S. FInaI Cbeck FInaI Cbeck
6. 6. 'CHECK 'CHECK--MATE'! MATE'!
4S
BE WARY OF POTENTIAL BE WARY OF POTENTIAL
LITIGATION LITIGATION -- AT ALL TIMES! AT ALL TIMES!
ubllc ServanL framlng an lncorrecL record
Sec. :i Penal Code.
Public seivani claiged wiil ile piepaiaiion of any
iecoid oi oilei wiiiing, fiames ilai iecoid oi
wiiiing in a mannei wlicl le lnows io be
incoiieci, wiil inieni io cause ,oi le is lilely io
cause loss oi injuiy io ile public oi any peison slall
be punisled wiil impiisonmeni foi a ieim wlicl may
exiend io iliee yeais, oi wiil fine,, oi wiil boil.
49
O THANK YOU
Any quesiions?
S0

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