8 USES OF HOSPITAL RECORDS III

Types Of Medical Records

Next, let us consider the types of hospital records and the all important question of how to manage hospital records.

There are two basic types of records found in any hospital. These are clinical records and administrative records. Records could also be classified as paper records and electronic records (shown above).

     

The single most important record is the Patient’s case notes. This contains valuable information like the patient’s biodata, medical history, family and social history, investigation reports, patient’s summaries etc.

Patients indexes and registers are also considered a “must have” for any hospital. The Master Patient Index (MPI) is a compilation of all the patients’ indexes. The MPI is a very useful aid for finding/retrieving patient’s case notes.

I won’t go into much detail about the other types of hospital records. 

Tips On Managing Hospital Records

The first thing you need is a records manager who will be charged with the responsibility of managing the different types of hospital records in your facility.  Next, the records manager must be properly trained and re-trained. You will also need to expose your records clerks, nurses and other staff to periodic training in records management.

If you have the means, you may decide to install hospital management software and use electronic records. However, you must get your paper records right before installing any software. It is advisable to first perfect paper records, manage it efficiently for at least 6 months before you bring in software engineers to install electronic record systems.

On a lesser scale, if your records manager is proficient in the use of MS-Excel, he can transcribe your paper records into digital form before you get good record software installed. This can be done daily, weekly or monthly.

Specifically, every doctor should take note of the following when writing in patient’s case notes.

1. Write legibly

Take a little extra time and care to write legibly in paper records. While you may be able to read your own handwriting, can anyone else? A lot of recording errors occur when your staffs try to read and record the information you previously wrote.

2. Include the date and time

Dated and timed hand-written notes will be invaluable if a claim arises several years later. Such details will clarify the sequence of events during your treatment of the patient, even though you may not be able to remember clearly what happened. With electronic records, the time and date will be automatically recorded. A friend of mine who is a Pediatric Surgeon ‘escaped’ litigation 2 years ago because his operation notes were detailed.

3. Avoid abbreviations

What does PID mean? Prolapsed intervertebral disc or pelvic inflammatory disease?  What about  RTI? Road traffic injury or respiratory tract infection? It may be clear to you, but could be ambiguous to others. If you must use abbreviations, limit them to those approved in your workplace.

4. Do not alter an entry or disguise an addition

Clinical notes should be made at the time of treatment or as soon as possible afterwards. If it transpires that the notes are factually incorrect, for example, an entry has been made in the wrong patient’s records, then the amendment must make this clear. Errors should be scored out with a single line so the original text is still legible and the corrected entry written alongside with the date, time and your signature. Never try to insert new notes.  Tampering with records can lead to MDCN investigations.

5. Avoid unnecessary comments

Offensive, personal or humorous comments are unprofessional, often misunderstood and could damage your credibility. Patients have a right to access their records and a flippant remark in the notes might be difficult to explain.

6. Please check dictation and reports

Letters dictated and then typed up later by a secretary should be checked, corrected and signed by the doctor who dictated them. Errors can arise due to problems with the quality of recording or simple misunderstandings of medical terminology. You will need to see, evaluate and initial every report or letter before it is filed in the patient’s records.

Final Thoughts

On a final note, good records management is an important variable in the successful management of any hospital. A short article like this cannot extensively address all the issues involved. This article is meant to stimulate you to seek more knowledge on records management. While you may not have the time to train your staff, you can expose them to routine private training sessions. 

See you soon.