Medical Documentation

Introduction

Medical/health records form an essential part of a patient’s present and future health care.

• As a written collection of information about a patient's health and treatment, they are used essentially for the present and continuing care of the patient.
• In addition, medical records are used in the management and planning of health care facilities and services, for medical research and the production of health care statistics.

Examples include

• Bed head ticket (BHT)
• Investigation result
• ECG
• Consent
• Prescription slips or medication chart
• Medical certificate

Importance

• Provide information of patient and his illness' management as well as ensuring continuity of care.
• Provide evidence for billing and coding.
• The legal material used to protect both patient and health care professionals in the event of disagreement over care.

NOTE: If there is a medicolegal complain, it could be a case from 6 months to 1 year ago. Since we don't even remember what we eat this morning, it is vital to make proper medical documentation.

Key Reminders

Remember that if you did not write it means you did not do it.

When writing medical notes, we should ensure that each entry is as follows:

• Legible handwriting and correct spelling.
• Signed, with printed name and dated (date and time).
• Make sure the entry is succinct and informative (only those directly relevant to the patient's care), including both positive and negative findings.
• History, physical examination, investigation results, treatment plan and diagnosis.
• Incident affecting patient's treatment plan.
• Include any discussion of the issue with medical or nursing staff.
• Information conveyed to patient and/or relative.
• Patient's and/or relatives' responses and decision.
• Follows a chronological sequence.
• Correct way of cancelling entry. (Initial. Date. One line. Readable)
• Use only well-recognized abbreviations.
• Not be informal.
• Not directly criticize medical/nursing care.

Example: Handling Prescriptions which Require Clarification

According to Guide to Good Dispensing Practice, 2016, if an incomplete prescription or one which requires further clarification is received, attempts must always be made to contact the prescriber.

• If the prescriber can be contacted and is available on site, arrange for the incomplete/missing details to be inserted on the prescription by the prescriber.
• Remedial action for such prescriptions should be discussed with the prescriber prior to sending the prescription back to him/her.
• If the prescriber is not available to amend the prescription himself/herself, authorisation to make the change may be obtained verbally through the phone.
• The amendments to the prescription should be repeated back to the prescriber to ensure accuracy.
• The amendments should be documented on the prescription and endorsed with “prescriber contacted” (PC), dated and initialled by the pharmacist/person dispensing.

• If the prescriber cannot be contacted, patient should be informed and the prescription must be sent back to the prescriber with information on the clarification/action needed.

Prescriber should document any changes made to the patient’s medical record.

Example: Medication Counselling

Details of the counselling session including the issues encountered (e.g. language barrier) as well as plan (e.g. follow-up session) would need to be recorded in the bed head ticket and/or Pharmacy Information System (PhIS) as evidence and for future reference.

External Links

• WHO Medical Records Manual: A Guide for Developing Countries, 2006
  
• 5 Best Practices for Medical Documentation, 2021