Dr Puneet Kumar Misra
The patient records is not a simpleaggregate data of itsillness or stay in the hospital, it contain the information of its chief complaint with diagnosis , management andtreatment,it is a valuable document of data which provide the information to thehealth system to make the futureplanning of treatment and add to development of the health unitsfor advance and better care of patientsby the research and medical audit
Key words- patient records, health system, data, information,
Distinction between Data and Information
There is more than a subtle semantic difference between “data”, “information” and “intelligence”. Data consists of discrete observations of attributes or events that carry little meaning when considered alone; data as collected from operating health care systems or institutions are inadequate for planning. Data need to be transformed into information by reducing them, summarizing them and adjusting them for variations, such as the age and sex composition of the population so that comparisons over time and place are possible. It is the transformation of information through integration and processing with experience and perceptions based on social and political values that produces intelligence. Data that are not transformed into information and information that is not transformed into intelligence to guide decision-makers, policy-makers, planners, administrators and health care personnel themselves are of little value.
Medical records is a scientific, clinical ,administrative and legal document relating to patient care and Medical records are a means of recording details about a patient’s care and communicating that information between healthcare professionals. The information contained within the medical records can also be used to monitor service activity, and for audit and research purposes. It is therefore essential that records are clear, accurate and legible, and that they are made contemporaneously. In providing good clinical care it must:
- Keep clear, accurate and legible records, reporting:
- The relevant clinical findings
- He decisions made
- The information given to patients
- Any drugs prescribed
- Any other investigation or treatment
- Make records at the same time as the events you are recording or as soon as possible afterwards.
Structure and Content of Standard Medical Record
A recent consultation process has shown that over 90 per cent of doctors think that there should be structured documentation across the NHS (National Health Service ). In a project funded by NHS Connecting for Health, the Royal College of Physicians (RCP) Health Informatics Unit has developed profession-wide standards for the structure and content of hospital patient records, and these have been approved by the Academy of Medical Royal Colleges. Standards have been developed for the following types of patient record:
- Hospital admission record
- Handover document
- Discharge summary.
Hospital Admission Record
The doctor completing the record should note down their name, grade and contact details, and also (in the UK) their GMC number (which acts as a unique identifi er). A detailed description of the type of information that applies under each heading, together with a sample pro forma, is available on the Health Informatics Unit for the hospital admission record described below.
HOSPITAL ADMISSION RECORD – HEADINGS (REPRODUCED WITH PERMISSION FROM THE HEALTH INFORMATICS UNIT, RCP, LONDON)
! Responsible consultant! Clerking doctor ! Source of referral ! Time and date patient seen ! Time and date of clerking ! Patient’s location ! Reason for admission and presenting ,complaints ! History of each presenting complaint ! Past medical, surgical and mental health history ! Medication record ! Current medicationsm ! Relevant previous medications ! Relevant legal information ! Mental capacity ! Advance decisions to refuse treatment ! Lasting power of attorney or deputy ! Organ donation ! Allergies and adverse reactions ! Risks and warnings ! Social history ! Lifestyle ! Social and personal circumstances ! Services and carers ! Family history ! Systems enquiry ! Patient’s concerns, expectations and wishes
! Observations and findings ! General appearance ! Structured scales ! Vital signs ! Mental state ! Cardiovascular system ! Respiratory system ! Abdomen ! Genitourinary ! Nervous system ! Musculoskeletal system ! Skin ! Problem list and/or differential diagnosis ! Relevant risk factors ! Discharge planning ! Management plan ! Summary and interpretation of fi ndings ! Next steps ! Special monitoring required ! Resuscitation status ! Information given to the patient and/or authorized Representative ! Investigations and initial procedures ! Person completing clerking Doctor’s name ! Grade ! Doctor’s signature ! Specialist registrar/senior review ! Post-take ward round
Patient handovers occur when a patient’s care is transferred between different consultants or between on-call teams (e.g. at weekends or at night). The handover process is often poorly done, with little or no documentation as part of the process. To maintain good patient care, safety and communication, it is important to ensure that key information is handed over between teams and that a written record of this information is available.
It is important that discharge summaries include the information that general practitioners (GPs) want and need. As well as details pertaining to the patient’s admission, the discharge summary must include details of future plans with clear and specific information about any future actions that may be required by the hospital, GP and allied health professionals.
The handover document and discharge summary are also having the many specific heading for provide the information regarding patient illness and treatment.
Generic standards are those that apply to all forms of medical record keeping. In 2007 the Health Informatics Unit of the Royal College of Physicians (RCP), London, published 12 standards
Generic standards for medical record keeping
- The patient’s complete medical record should be available at all times during their stay in hospital
- Every page in the medical record should include the patient’s name, identifi cation number (NHS number2) and location in the hospital
- The contents of the medical record should have a standardized structure and layout
- Documentation within the medical record should reflect the continuum of patient care and should be viewable in chronological order
- Data recorded or communicated on admission, handover and discharge should be recorded using a standardized proforma (This standard is not intended to mean that a handover proforma should be used for every handover of every patient, rather that any patient handover information should have a standardized structure.)
- Every entry in the medical record should be dated, timed (24 hour clock), legible and signed by the person making the entry. The name and designation of the person making the entry should be legibly printed against their signature. Deletions and alterations should be countersigned, dated and timed
- Entries to the medical record should be made as soon as possible after the event to be documented (e.g. change in clinical state, ward round, investigation) and before the relevant staff member goes off duty. If there is a delay, the time of the event and the delay should be recorded
- Every entry in the medical record should identify the most senior healthcare professional present (who is responsible for decision making) at the time the entry is made
- On each occasion the consultant responsible for the patient’s care changes, the name of the new responsible consultant and the date and time of the agreed transfer of care should be recorded
- An entry should be made in the medical record whenever a patient is seen by a doctor. When there is no entry in the hospital record for more than four (4) days for acute medical care or seven (7) days for long-stay continuing care, the next entry should explain why(The maximum interval between entries in the record would in normal circumstances be one day or less. The maximum interval that would cover a public holiday weekend, however, should be four days.)
- The discharge record/discharge summary should be commenced at the time a patient is admitted to hospital
- Advance Decisions to Refuse Treatment, Consent, Cardio-Pulmonary Resuscitation decisions must be clearly recorded in the medical record. In circumstances where the patient is not the decision maker, that person should be identified e.g. Lasting Power of Attorney.
The common set of the form which complete the need of the standard medical record and used in the hospital setup are. 1) Admission record form 2) Front sheet or identification and summary sheet 3) discharge summary record form 4) history record form 5) physical examination form 6) doctors orders form 7) doctors progress note 8) medication charts 9) nurses bedside record (TPR chart & Input-Output chart) 10) informed consent form 11) laboratory and x-ray request and report form 12) birth and death certificate 13) some special other form i.e. operation record form, pre-anaesthesia report ,pregnancy and labour record.
A prescription is a means by which a prescriber communicates the intended plan of treatment to the pharmacist who dispenses a medicine and to a nurse or patient who administers it. It should be precise, accurate, clear and legible. The two main kinds of prescription are those written, dispensed and administered in hospital and those written in primary care (in the UK by a GP), dispensed at a community pharmacy and self-administered by the patient. The information supplied must include:
- the date
- the identification details of the patient
- the name of the drug
- the formulation
- the dose
- the frequency of administration
- the route and method of administration
- the amount to be supplied (primary care only)
- the instructions for labelling (primary care only)
- the prescriber’s signature.
Steps in good prescribing
- Make a diagnosis
- Consider factors that might influence the patient’s response to therapy (age, concomitant drug therapy, renal and liver function etc.)
- Establish the therapeutic goal*
- Choose the therapeutic approach*
- Choose the drug and its formulation (the ‘medicine’)
- Choose the dose, route and frequency
- Choose the duration of therapy
- Write an unambiguous prescription (or ‘medication order’)
- Inform the patient about the treatment and its likely effects
- Monitor treatment effects, both beneficial and harmful
- Review/alter the prescription
*These steps in particular take the patient’s views into consideration to establish a therapeutic partnership (shared decision-making to achieve ‘concordance’).
Uses of basic medical record data for information to utilization of hospital service -The patient’s medical record is a primary source of statistical data. The medical record provides information such as admission and discharge dates, age, sex, diagnoses, operations and procedures, attending physician, consultants, expected payer, etc, and given indices .
Admission and Discharge details of patients calculate the following indices of hospital service.
- Average Daily Census is the average number of patients in the hospital at a given time per day and is expressed as
Sum of daily census for a given period
Number of calendar days in the period
b) Bed Occupancy Rate is the proportion of in –patient bed occupied i.e. the ratio of actual patient days to the maximum possible patients days (based on bed complement) during any given period, expressed as a percentage .It is calculated by the formula
Average daily Census x 100
Bed complements (i.e. total authorized beds)
c) Average Length of Stay (ALS) is the average number of days of service that is rendered to each discharge patient during the given period of time . It is calculated by the formula
Total no . of patient days during a given period of time
Total no of the in-patient discharged (including death ) during that period
d) Turnover interval or “T” interval is the average period in days a bed remain vacant between one discharge and another admission. It is a very sensitive index of hospital utilization it is calculated by the formula
maximum patient days – actual patient days during a given period
no of discharges (including death ) during that period
The T value may be negative or positive
Negative value is indication of over utilization of bed or bed deficiency
Positive value is indication of under utilization of bed or bed excess
e) Bed turnover rate is an important and major of hospital utilization index .it gives the net effect of changes in occupancy rate and ALS. it is calculated by the formula
No of discharged for a given period of time
Average bed count for that period of time
- The first important uses of patient medical record data about the health information of patient.
- To measure the health status of the people and to quantify their health problems and medical and health care needs
- For local, national and international comparisons of health status. For such comparisons the data need to be subjected to rigorous standardization and quality control
- For planning, administration and effective management of health services and programmes
- For assessing whether health services are accomplishing their objectives in terms of their effectiveness and efficiency
- For assessing the attitudes and degree of satisfaction of the beneficiaries with the health system,
- For research into particular problems of health and disease.
- Analysis of the medical record provide the retrospect details of the medical care
- According to ISI (1982) the space required for 500 beds hospital is approx 273 sq meters
- The system of medical records can either be centralized (both OPD & IPD at central place) or decentralized (OPD & IPD separately)
The all above fact shows that each patient medical record is not only important for the particular patient, it also important for the whole social and medical community for future development and benefit of health care system ,therefore the medical; record are the accurate, adequate, complete and retrievable in nature.
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Dr Puneet Kumar Misra B.Sc, BHMS
Lecturer, Practice of Medicine
Govt Pt J LN H M C Kanpur