How Effective Is Your Medical Documentation?

Medical-RecordMedical record-keeping is all about documentation! Our paper-based health records demand quality, and should therefore be more legible and complete.

In India, medical records are still primarily paper-based. Each one is a detailed account of a patient’s health history, which includes current illness, clinical findings, and treatment, among other information. It is very important that the treating doctor properly documents patients’ clinical data and medications prescribed. Often, we encounter that the record is not legible because of the use of abbreviations and bad handwriting. Essentially, each record is a patient’s medical story, taking us through their past to lead us to the currently presenting illness or condition of health.

Variation in Documentation Practices

A common occurrence is that there is a lot of variation in medical record-keeping. Hospitals design their own formats and follow their own policies to maintain patient data. The process of keeping medical records in hospitals is very comprehensive and exhaustive.
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A typical record may include the following:

  • Health history and past physical examinations, with medications and diagnostic results
  • Operative notes, pre- and post-surgery records and consent
  • Obstetric record
  • Nursing notes
  • Discharge summary with prescription(s)
  • ICU and CCU records

Medical record rooms of hospitals have heaps of patient files stored. Looking through these patient files, it is very common to still find much variation in recording by different doctors even in the same hospital. Usually, there is a team of doctors that participates in patient care in the hospitals. Therefore, it is very important that the hospital management conducts training for the resident doctors and nurses in maintaining medical records to ensure they are complete and error-free. Such practices help to maintain quality in medical record-keeping.

Doctors in private practice also need to follow formats and record data properly. However, it is commonly seen that patients’ medical records in private practices consist of only a prescription and a few comments. India has many regional languages, so for easy understanding, we find that the doctors use local language in private practice.

All these factors lead to marked variation in medical record-keeping and hamper the quality of the data maintained. Medical records should be easily accessible, and it would be ideal for them to be complete and accurate. They are essential for follow-up and future reference, as well as for scientific evaluation (1). Thus, medical records form an integral part of patient management.

Maintaining quality in medical records is also important in terms of utilizing the data for research studies. The comprehensive data helps for medico-legal purposes and insurance companies. Being that the medical record is documented evidence, it can be presented as proof in the court of law. It is the only proof of treatment provided to the patient.

Medical Council of India (2002) provides the following regulations for medical records (2):

  1. Hospital records must be maintained for 3 years from the date of commencement in the standard proforma
  2. The request of the record by the patient/legal authority should be acknowledged and the record furnished within 72 hours
  3. A Registered medical practitioner shall maintain a Register of Medical Certificates giving full details of certificates issued along with one identification mark and signature
  4. Efforts shall be made to computerize medical records for quick retrieval

(Click here for complete details from the MCI.)

The proforma provided by the MCI is basic and adequate. It can be downloaded from their website. The Food and Drug Administration recently issued a revised prescription format, effective starting May of 2014 (3). It includes the following:

  • Doctor’s full name, qualifications, address, contact number, doctor’s stamp and signature
  • Date & prescription serial number
  • Patient’s name, address, and weight
  • Drugs with generic names in capital letters, drug strength, dosage and duration

Medical record-keeping is an art and a science, if doctors can follow the basic rules laid down by the regulatory bodies. This detailed account goes a long way in reducing medical errors and ensuring patient safety and rights. So, doctors, as we move on to electronic records in the future, let us adopt good clinical documentation practices.

AK Valimbe Dr.Ashwini Valimbe, Health IT Consultant, US and Indian healthcare domain. Expertise in health outcomes, EMR, Meaningful Use and Comparative Effectiveness Research. Current interests includes designing and implementation of simple tools for private clinics in India and physician education to adopt technology and transform healthcare.

References (click to show/hide)

  1. Medical Records and issues in Negligence. Joseph Thomas, Indian J Urol. 2009 Jul-Sep; 25(3): 384–388
  2. Code of Ethics Regulations, 2002. http://www.mciindia.org/RulesandRegulations/CodeofMedicalEthicsRegulations2002.aspx
  3. Docs told to write detailed & easy-to-read prescriptions. Times of India. Mar 2014. Available at: http://epaper.timesofindia.com/Default/Scripting/ArticleWin.asp?From=Archive&Source=Page&Skin=TOINEW&BaseHref=TOIPU/2014/03/15&PageLabel=4&EntityId=Ar00401&ViewMode=HTML


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3 Comments

  1. Jayaraj Govindaraj
    Posted Jul 2014 at 2:26 am | Permalink

    Very useful guidelines.
    Combating this serious issue, we have to comply and not feign ignorance, as many of us try to excuse ourselves. The Ethics & Practice of proper medicare must be a part of the revised curriculum in all UG & PG courses in medicine.
    Kudos for having highlighted this problem.
    jayarajg

  2. Arun Kumbhat
    Posted Sep 2014 at 3:27 pm | Permalink

    The Medical Record isn’t generated or maintained for a variety of factors – Time constraints and volume of patients. lack of convenient tools and of course avoiding the avoidable by not linking prescription to diagnosis.
    Better tools would go a long way in mitigating this.
    Am working on this

  3. Meenu Sagar
    Posted Apr 2015 at 6:09 pm | Permalink

    Very useful n informatic.maintenance of medical records is the need of day today practice.if you want good n stress freelife always dedicate few time to complete your medical records.

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