Law And Rules Regarding Medical Record

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LAW AND RULES REGARDING





MEDICAL RECORD








JULIE JAMES ABDULLAH

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Learning Outcome


















01 02 03









Explain the List essential Describe mechanism

importance of elements of to correct and

accurate and proper documentations in maintain medical

documentation of medical records records

medical records

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Introduction

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• A series of Acts give patients the right to see

their medical notes [health records], medical
reports, personal data held on computer and

their personal file held by the social services














Patient & Their Medical

Notes

Guideline of The Malaysian Medical Council

MMG GUIDELINE 002/2006


MEDICAL RECORDS


AND


MEDICAL REPORTS

Malaysian Medical Council

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Medical Records












• Documented information about the health of an identifiable individual recorded by a
practitioner or other healthcare professional, either personally or at his or her

instructions.






• It should contain sufficient information

➢ to identify the patient, support the diagnosis based on history, physical
examination and investigations, justify the professional management given, record

the course and results thereof, and ensure the continuity of care provided by

practitioners and other healthcare workers to that particular patient.

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Medical Records












• Medical records cover an array of documents that are generated as a result of

patient care. These include:

• Hand-written contemporaneous notes taken by the health care practitioner


• Notes taken by previous practitioners attending health care or other health care

practitioners, including a typed patient discharge summary or summaries


• Referral letters to and from other health care practitioners

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Medical Records








• Laboratory reports and other laboratory

evidence such as histology sections, cytology
slides and printouts from automated

analysers,


➢ X-ray films and reports, ECG traces, etc


• Audio visual records such as photographs,

videos and tape-recordings


• Clinical research forms and clinical trial data


• Other forms completed during the health
interaction such as insurance forms, disability

assessments and documentation of injury on

duty


• Death certificates and autopsy reports


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Medical Records












• Provide the most important defence tool in a malpractice suit.


• If it is not documented, it is not done.


• Illegible records are a curse upon the profession


• Illegible orders and prescriptions are a curse upon the patient

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Medical Records












• Medical Reports are documents prepared by a practitioner on a patient based on

Medical Records.

➢Opinion by an Expert may also be part of a Medical Report.

➢Practitioners are obliged to provide comprehensive medical reports when

requested by patients or by the next of kin, in the case of children or minors,

or by the employer with the patient’s specific consent.

➢Any refusal or undue delay in providing such reports is unethical.

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IMPORTANCE OF ACCURATE AND


PROPER DOCUMENTATION OF MEDICAL



RECORDS






Proper Documentation

Proper And Accurate Medical Documentation

Medical Records Requirements By Law In Registered Or Licensed Private Healthcare Facilities

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i. Proper



Documentation






• Proper documentation of case notes,
lab results, x-ray etc.


• Although there are no legislations in

Malaysia to compel doctors/hospitals

to give these documents to the

patient, in the event that they are
required to release these documents

when the case goes for trial,

nonproduction will be detrimental to
the case.










Example of Electronic Patient’s Report

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i. Proper Documentation












a. Good quality medical records are an essential component of safe and effective

healthcare

• Understand your obligation in making adequate medical records

• Learn tips for record-keeping





b. Good medical records – whether electronic or handwritten are essential for the

continuity of care of your patients.

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i. Proper Documentation












c. For health professionals, good medical records are vital for defending a

complaint or clinical negligence claim

• they provide a window on the clinical judgment being exercised at the time.






d. The presence of a complete, up-to-date and accurate medical record can make
all the difference to the outcome.

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i. Proper Documentation









Tips for - record keeping






• Always date and sign your notes, whether written or on computer.


• Don’t change them.

➢If you realise later that they are factually inaccurate, add an amendment.


• Any correction must be clearly shown as an alteration, complete with the date the

amendment was made, and your name.


• Making good notes should become routine.

• Document all decisions made, any discussions, information given, relevant history, clinical

findings, patient progress, investigations, results, consent and referrals.

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i. Proper Documentation












Tips for - record keeping






• Medical records can contain a wide range of material, such as handwritten notes,
computerised records, correspondence between health professionals, lab reports, imaging

records, photographs, video and other recordings and printouts from monitoring

equipment.






• Do not write offensive or gratuitous comments – eg, racist, sexist or ageist remarks.

➢Only include things that are relevant to the health record.

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i. Proper Documentation












Tips for - record keeping






• Remember patients have a right to access their own medical records under Promotion of Access
to Information Act (PAIA), No 2 of 2000.






• Risks can never be eradicated, even with best practice, only reduced.

➢ Good record-keeping helps to maintain best practice, aiding clear communication between

professionals, and demonstrates that best practice has been followed.

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i. Proper Documentation












Tips for - record keeping






• Complete, contemporaneous and well-organised medical records are essential for good medical
practice and continuity of care. They are necessary for a healthcare professional’s defence

against a claim or complaint and can be seen to reflect the quality of care provided.






• Appropriate record-keeping is recognised as an important component of professional standards.

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ii. Proper And Accurate Medical Documentation












• All Medical Documents are legally supportive documents in a court hearing.


• Properly justified procedures can be defended by peers in the event of conflict or litigation, but
when the notes are poorly made and suspicious, this may be difficult.


• Courts have a tendency to believe the memory of a patient rather than that of a doctor/nurse

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ii. Proper And Accurate Medical Documentation









• Complete and accurate medical recordkeeping can help ensure that your patients get the right

care at the right time.

➢At the end of the day, that's what really matters. Good documentation is important to

protect you the provider. Good documentation can help you avoid liability and keep out of
fraud and abuse trouble.






• The Importance of Accurate Medical Records
Because of their detailed information, most records can help pinpoint where mistakes occurred.

In effect, they can help provide patients with better care.






• After malpractice claims, accurate records might even help settle the claim

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iii. Medical Records Requirements By Law In


Registered or Licensed Private Healthcare Facilities










• All medical document are legally supportive documents in a court hearing


• Properly justified procedures can be defended by peers in the event of conflict or litigation, but
when the notes are poorly made and suspicious, this may be difficult


• Courts have a tendency to believe the memory of a patient rather than that of a doctor/nurse


• Medical records requirements by law in registered or licensed private healthcare facilities

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Essential Elements Of Documentations



In Medical Records

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Elements Of Documentations In Medical Records












• Doctor’s clinical notes


• Recording of Discussion with patient /next of kin regards disease/ management (with witness) /
Possible use of tape recording for such discussions


• Referral Notes to other specialist(s) for consultation/management


• Laboratory & Histopathological reports


• Imaging records and reports


• Clinical Photographs


• Drug Prescriptions

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Elements Of Documentations In Medical Records












• Nurses’ Reports


• Consent Forms, At-Own-Risk Discharge Forms


• Operation Notes/Anaesthetic Notes


• Video Recordings


• Printouts from monitoring equipment (e.g. Electro-cardiogram, Electroencephalogram)


• Letters to and from other health professionals


• Computerized/electronic records


• Recordings of telephone consultations/instructions relevant to the care of the patient

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What are the elements of the medical record?












• The medical history, includes the following components


➢patient demographics e.g., the patient's name, birth date, address, phone number, gender,

race, and marital status and the name of the attending physician.

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Patient identification












• Failure to correctly identify patients - result in medication errors, transfusion errors, testing

errors, wrong person procedures, and the discharge of infants to the wrong families.





• Patient Safety Agency reported 236 incidents and near misses related to missing wristbands or

wristbands with incorrect information.

➢Between November 2003 and July 2005, the United Kingdom National

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Mechanism to Correct and Maintain



Medical Records

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Mechanism To Correct And Maintain Medical




Records





Put a single line

through the Do not place
Do not omit
erroneous entry or significant facts inaccurate

incorrect entry. information

Initial and date it.





Dating record as
Mention the error Do not attempt to though it were

in subsequent deceive through written at an earlier

entries alteration
time










Do not use Do not erase or Altering someone
correction fluid obliterate anything else’s records

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Mechanism To Correct And Maintain Medical Records












• Provide documentary evidence

➢Written evidence carries more weight than oral evidence

➢Good Record = Good Defence


➢Bad Record = Bad Defence

➢No Record = NO DEFENCE

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Medical documentations are

importance in healthcare.

These not only will protect the
patients but as well protection

of the healthcare providers.
Summary




Accuracy in reporting is only

way to protect either patient
or staff from any medical legal

action.