MEDICAL RECORD

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MEDICAL RECORD

• Prof. Sulaiman Al-Shammari

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• medical
  records and information
• Why keep records?(functions?)
• Problem oriented medical records(POMR)
• Organising the medical records
• Storage of medical records
• An information system for PHC
• Arrangement of primary health care medical
  records
• Sharing medical records with patients

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Why keep records?(functions)
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1.Why keep records?(functions) a permanent
record of significant events unique continuing
record of health and illness WHAT IF no
record of significant events lost record no
past data accuracy not very high
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2.Why keep records?(functions) A medico-legal
record important if complaint or legal action
arises Both negative and positive findings are
important (e.g.x-ray normal)
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3.Why keep records?(functions) A way of
communicating with colleagues and other team
members single-handed doctor needs to remind
himself. PHCT (doctors on deputies and
others)should be aware of main facts such
as past and present diagnoses
current treatment allergies or warnings
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4.Why keep records?(functions) Jacket for
hospital laboratory reports letters information
needs to be accessible or it useless So What
to do with Bulky Records A4 files are useful in
this respect Throw useless or duplicated
information Computerization
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5.Why keep records?(functions) A record of
drugs prescribed accurate record of doses and
quantity for use within practice
medico-legal and research(adverse reaction)
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6.Why keep records?(functions) an side
memoire reminder for patients personal doctor
what he told the patient ? what was in
the back of his mind ? what he planned for
next visit ? much of this is of short term
value and can be discarded once the
episode is over summary completed
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Problem Oriented Medical Record(POMR) -
new move - more logical particularly
at the stage before a firm diagnosis -
help doctors to see
patients problem define his own
problem avoid jumped to a
diagnosis too early pomr consist of
1. Identifying particulars and
background information(data base)e.g
-name, number etc - immunisation etc
-health questionnaire
-patient to check accuracy 2.
Clinical or progress notes 3. The
problem list 4. The flow chart
5. The drug list
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TYPES of MEDICAL RECORDS

• Traditional
  POMR
• a)history
  a)subjective
• b)examination
  b)objective
• c)diagnosis
  c)assessment
• d)investigation d)plan
• e)treatment
  (i)tests
• 
  ( ii)treatment
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  (iii)patient education

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Organising the medical record

• -continuation sheet
• -summary sheet
• -obstetric record
• -child immunisation card
• -child development record
• -contraceptive record
• -repeat prescription record
• -hypersensitivities
• -problem lists
• -flow charts
• -laboratory report sheets

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These Stationery

• -is available from the health authority
• -must be kept in a logical and agreed order
• -fastened together by metal clip or staple
  atc
• old continuation sheet can be summarised and
  then discarded.
• redundant letters and reports can be
  destroyed.
• NB time invested in an efficient record system
  pays off when the doctor needs to retrieve
  information about the patient in an emergency
• - design a system
• - staff can use slack periods
• - avoid generating bulky records without good
  reason
• - throw away redundant information
• - record of dead patients can be retuned to
  health authority

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Legibilty Notes must be legible
-typewritten -dictated
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Missing Notes -Reasons in
doctor car or research misfiling -during
transfer from doctor to doctor -Solution a
system for urgent transfer of medical record
telephone call to previous doctor computer coo
peration cards e.g. obstetric ,diabetic,geriatric
patient a copy of summary sheet and database
carried by the patient market out borrowed notes
like library books.
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Storage of Medical Records Aimquick and
accurate retrieval of records
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1.Main methods of Storage of MR lateral or
shelf filing -more space -easy access
-misfiling can be reduced by colour coding
or diagonal strip
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2.Main methods of Storage of MR rotary files
-more efficient use of space -more confusing
(not same fixed point) -coloured tape or card
as starting point is helpful
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3.Main methods of Storage of MR cabinet files
-may be satisfactory in small practice -time
wasting -more likely to cause fatigue or
injury -can be locked advantage
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4.Main Methods of Storage of MR More
elaborate and expensive system e.g
-multi-stack lateral systems on rails
-electrically operated banks of filing trays
-advantage limited space
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• Filing methods
• small practice-alphabetical
• Large practice-numerical
• Colour coding by doctors

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• Family records
• common family folder
• Family book or card
• Family chart

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• Confidentiality of MR and information
• strict policy and procedure
• Strict rule for access to medical records
• do NS,HV,MW,SW have access?
• are they permitted to take them to their
  office ?
• are doctors ,staff and their families medical
  records filed separately under more Secure
  conditions ?
• locked filing cabinets or rooms
• Cleaning only when staff are present
• MR and reports should not be left unattended.

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• Patients views on records
• trust doctor or other staff
• Access to notes
• Access of police and others to notes
• Computerised records and confidentiality

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• Logs and registers of practice activity
• for assessment of workload
• Efficient day-to-day running of service
• Examples
• 1.log of patients seen by each doctor
• 2.register of hospital appointment requested
• 3.register of hospital transport requests
• 4.register of x-rays requested
• 5.register of deaths
• 6.day book for recording messages
• 7.log of practice nurses workload

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An information system for PHC The basic raw
material -consultations per annum -other items
of serves (eg prescriptions ,telephone
contacts) -laboratory tests -x-ray
reports -referrals to hospital -admissions to
hospital
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The records has to serve the needs
of 1.preventive medicine-at risk
groups 2.quality control-patient recall,
performance review 3.practice planning
administration and finance 4.education-doctors
,staff, trainee ,patients 5.research
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different coloured cards for males and females
including name address date of birth arranged
in birth date order -must be kept up to
date -what use is it? 1.checking child health
screening or immunisation of children up to age
5 2.checking rubella immunisation of 11 year old
girls 3.preparing lists for cervical screening
of women aged 35-65(year intervals) 4.preparing
lists for hypertension screening 5.Preparing an
age-sex profile of the practice. 6.preparing an
age-sex profile of the practice.
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Age-sex register -identify people at risk What
is it?
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NBunless there is active preventive medicine or
research taking place in the practice the labour
of preparing the register is not cost
effective. the disease index (diagnostic
index) -list of patients with certain
disease -notes can be colour tagged
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Clinical and drug information -come from
many sources memories or notes from medical
school or post graduate lectures consultants
RECOMMENDAIONS medical journals text
books drug company promotion government
publications and circulars audio or video
cassettes computerised date system
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References 1.management in general practice by
peter pritchard et al 2.oxford general practice
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Arrangement of primary health care MR 1.initial
patient profile 2.referrals 3.problem list
4.primary care physicians notes
) yellow coloured page )in chronological
order pink coloured page ) 5.diabetes
mallitus flow chart 6.hypertension flow chart
7.other specialities notes obstetetrice and
gynaecology ophthalmology
ENT 8.accidents and emergency notes 9.nutrition
clinic notes 10.lab results histopathology
cytology blood grouping hematology
clinical biochemistry yellow red blue green
brown serology virology general
microbiology parasitology urine
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11.reports endoscopy xray u/s ECG
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SURNAME MSWDA FIRST NAME DOB 1930
OCCUPATION TAXY DRIVE ETHNIC GROUP PLACE OF BIRTH (SPECIFY COUNTRY)RELIGION
YEAR SMER(INC MONTH) CURRENT DRUGS DRUG SENSITIVITY
LAST BP STEROIDS ANTICOAGULANTS ORAL CONTRACEPTION CYTOTOXICS -----------------------
URINE WEIGHT SMOKER/NON SMOKER
YEAR PROBLEM
1938 CHICHEN POX
1940 JAUNDICE-HOSBITAL 40 DAYS(VHA)
1942 APPENDECTOMY
1950 HAEMATURIA?CAUE
1950 MARRIED
1952 HAEMATURIA SCHISTOSOMIASIS(MANSONI AND HAEMATOBIUM)
1955 3RD DAUGHTER MENTALLY RETARDED(MICROCEPHALY)
1966 ELDEST SON DIED AGED16 YEARS RTA
1967 MULTIPLE COMPLAINTS?ASSOCIED WITH ABOVE
1980 HAEMATEMESIS CIRRHOSIS
1986 COMPENSATED LIVE FAILURE

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SURNAME MSWDA FIRST NAME DOB 1930
OCCUPATION TAXY DRIVE ETHNIC GROUP PLACE OF BIRTH (SPECIFY COUNTRY)RELIGION
YEAR SMER(INC MONTH) CURRENT DRUGS DRUG SENSITIVITY
LAST BP STEROIDS ANTICOAGULANTS ORAL CONTRACEPTION CYTOTOXICS -----------------------
URINE WEIGHT SMOKER/NON SMOKER
YEAR PROBLEM
1938 CHICHEN POX
1940 JAUNDICE-HOSBITAL 40 DAYS(VHA)

1942 APPENDECTOMY
1950 HAEMATURIA?CAUE
1950 MARRIED
1952 HAEMATURIA SCHISTOSOMIASIS(MANSONI AND HAEMATOBIUM)
1955 3RD DAUGHTER MENTALLY RETARDED(MICROCEPHALY)
1966 ELDEST SON DIED AGED16 YEARS RTA
1967 MULTIPLE COMPLAINTS?ASSOCIED WITH ABOVE
1980 HAEMATEMESIS CIRRHOSIS
1986 COMPENSATED LIVE FAILURE

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CLINCAL NOTES SURNAME(BLOCK LETTERS) FORENAME(BLOCK LETTERS)
ADDRESS DATE OF BIRTH
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NURSES AND HEALTH VISITORS RECORDS SURNAME (BLOCK LETTERS) FORENAMES(BLOCK LETTERS)
ADDRESS DATE OF BIRTH
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MOUNT SHEET X-RAY AND PATHOLOGY INVESTIGATIONS SURNAME(BLOCK LETTERS) FORENAME(BLOCK LETTERS)
ADDRESS DATE OF BIRTH
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ADVANTAGES OF SHARING MR WITH PTs 1.PATIENTS CAN
CHEEK ACCURACY OF INFORMATION COLLECTED 2.PATIENTS
BECOME AWARE OF DOCTOR KNWLEDGE AND PERCEPTION
OF THE PROBLEM WICH MAY LEAD TO INCREASE
UNDERSTANDING AND COMLIANCE. 3.PATIENTS CAN
CONATANTLY REVIEW THEIR HEALTH PROBLEM. 4.IMPROVE
COMMUNICATION BETWEEN DOCTOR AND PATIENTS AND
GIVE CHANCE FOR AUTONOMY AND FURTHER
NEGOTIATION. 5.PREVENTS DOCTOR FROM WRITING ANY
HARSH PERSONAL COMMENTS. 6.FORCE THE DOTOR TO
WRITE ACCURATE INFOEMATION SO THAT THE NOTES
BECOME MORE MEANINGFUL AND PRECISE 7.REDUCE
MYSTIFICATION BY ASSURING THE PATIENT THAT
NOTHING IS CONCEALED.
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DISADVANTAGES OF SHARING MR WITH PTs 1.INACCURATE
NOTES IN THE MEDICAL RECORDS MAY DIMINISH
PATIANTS CONFIDENT IN HIS DOCTOR. 2.PATIENTS WITH
SERIOUS DISEASES MAY NOT PREFER KNOW ABOUT
PROGNOSIS OF THEIR ILLNESS. 3.KNOWING THE
DIAGNOSIS MAY CAUSE ANXIETY 4.DISCLOSURE OF
INFORMATION ABOUT RELATIVES MAY BREACH
CONFIDENTIALITY 5.IT MAY STOP DOCTORS WRITING HIS
OWN COMMENTS ABOUT THE PATIENTS PERSONALITY
CHARACTER OR BEHAVIOUR(eg IMMATURE OR INADEQUATE
PRESONALITY ,PSYCHOPATH)WHICH MAY BE VITAL
INFORMATION TO RECORD. 6.DIAGNOSIS MAY LEAD TO
FALSE LABELLING AND(eg ALCOHOLIC
NEUROTIC) 7.INFORMATION MAY BE MISINTERPRETED OR
OFFEND AND FRIGHTEN PATIENTS LUMP IN BREST VERSUS
CARCINOMA. 8.IT MAY INCREASE MEDICO LEGAL
ACTIVITIES
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MEDICAL RECORDS
THEAM AND NHS RESOURCES
PATIENT
INTERACTION
DOCTOR
REGISTERED POPULATION
AGE-SEX REGUSTER(INDSOCIAL CLASS ETHNIC GROUP)
CLINCAL AND DRUG INFORMATION
DISEASE INDEX
UTILIZATION LOG
REFERRALS TO HOSBITAL
RECALL SYSTEM
IMMUNIZATION FILE
LABORATORY AND X-RAY
INDEX OF REFERRAL AND SELF HELP AGENCIES
REPEAT PRESCRIPTION CONTROL
FLG MODEL OF A MEDICAL INFORMATION SYSTEM (FROM
METCALFE 1982)
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THANK YOU
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organising the medical record -continuation
sheet -summary sheet -obstetric record
-child immunisation card -child development
record -contraceptive record -repeat
prescription record -hypersensitivities
-problem lists -flow charts -laboratory
report sheets these stationery -is
available from the health authority -must be
kept in a logical and agreed order -fastened
together by metal clip or staple atc old
continuation sheet can be summarised and then
discarded. redundant letters and reports can
be destroyed. nb time invested in an efficient
record system pays off when the doctor needs to
retrieve information about the patient in an
emergency - design a system - staff can use
slack periods - avoid generating bulky records
without good reason - throw away redundant
information - record of dead patients can be
retuned to health authority
46
Storage of medical records Aimquick and
accurate retrieval of records Main
methods 1.lateral or shelf filing -more space
-easy access -misfiling can be reduced by
colour coding or diagonal stripe 2.rotary files
-more efficient use of space -more
confusing (not same fixed point) -coloured
tape or card as starting point is
helpful 3.cabinet files -may be satisfactory
in small practice -time wasting -more
likely to cause fatigue or injury -can be
locked advantage 4. More elaborate and expensive
system e.g -multi-stack lateral systems on
rails -electrically operated banks of filing
trays -advantage limited space
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Hypertension and Referral System Prof.
Sulaiman Al-Shammari Department of Family
Community Medicine , College of Medicine King
Saud University , Riyadh, Saudi Arabia
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Hypertension management

• Mainly outpatient
• First contact doctor
• Usually PHC physician
• Sometime specialist in outpatient setting
• To lesser extent as inpatient

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Management Options

• Continuous fellow up
• Referral
• Shared care

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Definition of Referral

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Definition of Referral

• The practice of sending a patient to another
  program
• or practitioner for services
• or advice which the referring source is not
  prepared to provide

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Determinants of referral
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Determinants of referral

• KAP of referring physician
• Health system set up
• Availability accessibility of facilities
• Investigations
• Treatment
• Procedures
• CME purposes
• Patient satisfaction

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• Indications for specialist referral

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Suggested indications for specialist referral
(BSH)

• 1.Urgent treatment needed
• Accelerated hypertension (severe hypertension and
  grade III-IV retinopathy)
• Particularly severe hypertension (gt 220/120 mm
  Hg)
• Impending complications (for example, transient
  ischaemic attack, left ventricular failure)

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Suggested indications for specialist referral
(BHS)

• 2.Possible underlying cause
• Any clue in history or examination of a secondary
  cause, such as hypokalaemia with increased or
  high normal plasma sodium (Conn's syndrome)
• Elevated serum creatinine
• Proteinuria or haematuria
• Sudden onset or worsening of hypertension
• Resistant to multidrug regimen ( 3 drugs)
• Young age (any hypertension lt 20 years needing
  treatment lt 30 years)

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Causes of Hypertension (SHMS)

• Sleep Apnea.
• Drug Induced.
• Chronic Renal Disease.
• Primary Aldosteronism.
• Renovascular Disease.
• Chronic Steroid Therapy and Cushings syndrome.
• Pheochromocytoma.
• Coarctation of Aorta.
• Thyroid or Parathyroid Disease.

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Suggested indications for specialist referral
(BHS)

• 3.Therapeutic problems
• Multiple drug intolerance
• Multiple drug contraindications
• Persistent non-adherence or non-compliance

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Suggested indications for specialist referral
(BHS)

• 4.Special situations
• Unusual blood pressure variability
• Possible white coat hypertension
• Hypertension in pregnancy

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Other Indications

• Ophthalmology Assessment.
• Dietician.
• Lifestyle Modification.

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Referral to group therapy

• Health center guidance
• Learn together
• Support each other
• Toward healthy life style

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Questionable Indications

• Lab
• Imaging
• ECG.

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Outcome of Referral

• Investigations done
• Treatment given
• Procedures preformed
• Clear plan provided through feedback
• Caution of long appointment with specialists

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Cost-effectiveness
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Cost-effectiveness

• Overcrowding of specialist clinic
• Increasing cost
• May lead to low interest
• May lead to Loss of skills

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Thank you