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Lecture for
4th year medical students Salman bin Abdulaziz University Kharj on
May 7, 2013 by Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard),
DrPH (Harvard)
1.0 TYPES OF RECORDS
1.1 Hospital information systems
Medical records departments
collect, store, and access information used for health care, financial or
administrative reasons. SOAPIE, the acronym for problem-oriented medical
recording, stands for Subjective complaints, Objective complaints, Assessment,
Plan, Intervention, and Evaluation. The electronic medical record (EMR) enables
clinical data net-working, direct on-line data entry from terminals in wards,
record linkage, and record integration. Audio recordings, video recordings,
photographs, and other types of images are considered part of the medical
record. Hospital records are analyzed for process and outcome performance
indicators, planning and projections, cost analysis, assessing access and
affordability, and surveillance.
1.2 Public health information systems
Health care information is used
for decision making, problem solving, and planning. It is sourced from
demographic data, morbidity data, morbidity data, health care utilization,
hospital care records, outpatient treatment records, environmental monitoring,
occupational monitoring, health care activities, needs assessment, disease
registers, health surveys, injury and accident monitoring, and vital
statistics.
1.3 Disease registries with cancer as an example
Cancer registration is continuing
and systematic collection of data on reportable neoplasms. The data is
comprehensive including socio-demographic, clinical, laboratory, radiological,
and treatment variables. The hospital cancer registry helps physician in follow-up
of patients, sends data to outside registries (community, regional, or national
cancer registries), and is used for hospital-based epidemiological studies
(incidence and prevalence, immediate causes of death, survival, and treatment).
The hospital cancer registry is a good source of controls for case control
studies of cancer etiology. Disease registries are also available for other
diseases.
2.0 OWNERSHIP OF RECORDS
The ownership of the records is
not clear. Do they belong to the patient, the caregiver that wrote them, or the
institution? Using the law of property, a product belongs to the person who
made it. In this case, the doctor is the 'maker' of all the medical facts that
are written and should be the acknowledged owner of the records. However the patient is the owner of the facts
in the record. The patient is also the only person involved who has most to
lose if records are misused and therefore should have control in the form of
ownership. The contents of the medical records cannot be revealed without the
express permission of the owner of the information. Although the patient owns
records in the sense that their contents cannot be disclosed without consent,
the physician has physical custody of the records.
3.0 CONFIDENTIALITY OF MEDICAL RECORDS
Privacy and confidentiality are
balanced against the need for timely information by caregivers. In a modern
medical environment, many records are generated about each patient. These prove
a challenge as far as keeping of secrets is concerned because many people can
access them. Besides their use in medical care, the records can be used for
medical education, medical research, and for legal purposes. Specific legal and
ethical guidelines govern the release of these records.
4.0 QUALITY OF RECORDS
Quality control is needed to
eliminate inaccuracy and inconsistencies. Records must be clear and legible.
Records must be complete. It is an offense to omit significant information.
Each record must be dated and timed. It is an offense to alter records after
they have been written. Some information can be omitted from the general record
for example information about adoption. Records should be kept secure and their
security should be assured. Security of records may be compromised during
transfer from one place to another or when there is a change of the staff who
have physical custody.
5.0 RETENTION OF RECORDS
Medical records have to be
retained because they may be referred later for purposes of medical treatment
or for litigation. They however cannot be retained for ever because that is
costly. There are therefore regulations on how long each type of record can be
kept.
6.0 ACCESS TO RECORDS
The patient has a right of access
to his or her records at any time.