Medical records 101: A basic guide for resident doctors

Posted by dashboard at March 16, 2020 2:39 pm Blog
Medical records 101: A basic guide for resident doctors

Getting to grips with medical records and their maintenance is one of the key skills that every doctor should learn in their first years.

They give you the information you need to treat patients with a high level of care, ensure you only spend time on necessary examinations and procedures, and even protect you against medical complaints.

In a word, they’re important. Here’s what you need to know to begin mastering medical record creation, maintenance and transfer.


What should be in medical records?

Generally speaking, the information included in a medical record will be all relevant information related to the patient’s care.

This includes:

  • Relevant clinical findings
  • Clinical decisions made
  • Information given to the patient
  • Any drugs or other treatments prescribed

Within this information, there will be distinctions between acute or emergency care, long-term patient care and management. For example, a chronic condition would be noted as separate from an emergency issue, and any illnesses/injuries that appear together would be listed as co-morbidities.

These medical records will also include negative findings (e.g. no sign of heightened cholesterol), making it easier to exclude a diagnosis or preclude an additional examination.

There will also generally be communication information, such as “safety net” advice dictating when the patient has been asked to return to the hospital, as well as any referrals to secondary care (and communication between primary and secondary).

A rule of thumb is that records should be comprehensive enough to explain the rationale of underlying clinical management decisions.


When should they be changed?

These records should be updated at each consultation, at the time they are relevant or provided as soon as possible afterwards. This ensures the information remains accurate and nothing is forgotten during a busy hospital day.


Who should see medical records?

Medical record confidentiality is a significant issue in the mind of both doctors and patients.

Generally speaking, remember these key facts:

  • Only relevant staff members need to see medical records, not everyone who works at the hospital.
  • Patients are normally allowed to view their medical records, as the information provided belongs to the patient. However, there are times when this allowance is overridden by other factors. If in doubt, refer to your senior’s direction or speak with a medicolegal advisor.
  • If in doubt, don’t share medical records and consult with your supervisor.


How to transfer medical records

If your patient leaves your care, you may need to transfer their medical records.

As an RMO, you likely won’t need to deal with this particular aspect directly, but it is still valuable to know the process.

Firstly, should medical records be requested, they don’t always need to be dealt with immediately. However, they should be handled within 20 days or as soon as reasonably practicable, and there are times when they may be required urgently—in which case they should be dealt with immediately.

These records can be transferred physically or, as is more common nowadays, electronically. Regardless of the method used, there must be a way of tracking when they are sent and the receipt of delivery. This might involve using registered mail if sending physically, to ensure the records can be traced should they go missing.

Lastly, hospitals keep medical records for at least 10 years, from the date of the patient’s last treatment at the facility.

However, there are additional factors that affect the exact retention time, including DHB protocol and the type of record. If in doubt, refer to a senior doctor or speak to a medicolegal advisor.

Once transferred, your care facility will generally retain a copy of these records as well.


More information

For more detailed information about making and keeping medical records, you should read this guide from the Privacy Commissioner.

It has all the nitty-gritty on what information can be used in medical records, how they should be transferred, and many other details that doctors should keep in mind in their work.

 


 

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