Medical Record Maintenance

Good medical records – whether electronic or handwritten – are essential for the continuity of care of your loved ones. For health professionals, good medical records are vital for further clinical analysis, treatment, and in defending a complaint or clinical negligence claim. The presence of a complete, updated, and accurate medical record can make a great difference in the handling of not only seniors falling sick but also for all age groups.

What are medical records?

The HPCSA (Health Professions Council of South Africa) defines a medical record as “any relevant record made by a health care practitioner at the time of, or subsequent to, consultation and/or examination or the application of health management”. Appropriate record-keeping is recognized as an important component of professional standards all over the globe.

Medical records cover a set of documents and reports that are generated as a result of patient care.

1. Hand-written prescription 
2. Hand-written notes giving by the physician (if available)
3. Hand-written notes of the previous doctors whom the patient consulted earlier (if available)
4. The family medical history of the patient will be collected by 60plusindia.com and maintained
5. Immunization history
6. Computerized data of the history of the patient (additional)
7. The discharge summary from hospitals
8. Referral letters between doctors pertaining to the patient. 
9. Lab Reports and other Physical Examination Reports ( eg: X-ray films and reports, Scan reports and films -  Ultrasound Scan image and report,  be it CT scan, or MRI Scan (Cds), ECG traces and ECHO images and reports - Treadmill and Angiogram report and CDs, etc. If softcopy is available, we will maintain the same also.)
10. Document all decisions made by the family, any discussions, the information is given, relevant history, etc. will also be maintained in the medical record.
11. Any health insurance policy taken - details will be maintained 

For the safety and confidentiality of the patient's medical records, all the hand-written notes need to be signed and dated. Any corrections or changes must be clearly shown as an alteration and should end with the date of the amendment and the name of the person doing changes along with his signature. 

National Accreditation Board for Hospitals and Healthcare  Providers (NABH) April 2020 supports Patient and family rights in including access to their clinical records. 

Risks can never be eradicated, even with the best practices. They can only be reduced. Good record-keeping helps to maintain best-practice, aiding clear communication between professionals and family, and helps in setting the best practice that has to be followed.

A Complete and well-organized informative medical record is essential for good medical practice and continuity of care. They are necessary for a healthcare professional’s defense against a claim or complaint as well and can also reflect the quality of care provided.