Medical Record

Medical records are important documents that contain information

about a patient's health and medical treatment. The Joint
Commission on Accreditation of Hospitals (JCAH) recommends
that hospitals keep a medical record for every individual who is
evaluated or treated as an inpatient, emergency patient, or
hospital-based home care patient. Medical records should be
accurate, readily accessible, and arranged in a way that allows for
quick retrieval of information.
Purpose of Medical Records
Medical records help healthcare providers evaluate patient care.
They document the care plan and results for each patient. Medical
records also facilitate communication between healthcare
providers and support education, research, and legal protection.
A brief review of the medical record should provide a
comprehensive understanding of the patient's diagnosis and
progress.
Standardized Medical Record Format
Each hospital should develop and approve a standardized medical
record [Link] contain all the necessary information and are
organized in a way that makes it easy to find the information
needed.
Medical record may vary from institution to institution.
Essential Components of Medical Records
Medical records should contain the following essential
components:
1. Patient identification data
2. Medical history
3. Report of physical examination
4. Diagnostic and therapeutic orders
5. Clinical observations
6. Reports of procedures and tests
7. Results and conclusions of treatment
Documentation of Missing Information
If any information is missing in the above or more of the above ,
the reason should be documented.
Format of Medical Records
Mjority medical records are organized in a similar way. They are
divided into sections based on function, task, procedures, and
healthcare provider.
Common Sections of Medical Records
- Charting section (vital signs, medications, treatments)
- Physician's observations
- Nurse's notes
- Orders
- Diagnostic test results
- History and physical examination
- Consults and special procedures

Arrangement of Sections
Each section is arranged chronologically with the last entry
appearing first.
Problem-Oriented Medical Record (POMR) System
The POMR system is a different way of organizing medical
records.
Provide high quality patient care and utilize better existed medical
and paramedical [Link] demographic and economic
parameters that affects the medical practice and and record it for
computer based medical record system.
It focuses on the patient's problems and goals.
Individual Components of the Record(4P NMC
CILFD)
1. Physician's History and Physical (H&P)
2. Problem List
3. Physician's Orders
4. Physician's Progress Notes
5. Nurses Notes
6. Medication Administration Record
7. Clinical Graph
8. Intake and Output Record
9. Laboratory Reports
10. Flow Sheet
11. Diagnostic Reports
[Link]’s History and Physical (H&P)
1. Patient Information: Age, Sex, Race, Date of birth, Contact
info
1. Example: John Doe, 45, Male, 01/01/1978, 123-456-7890

2. Chief Complaints: Patient’s main problem, Reason,

Symptoms
1. Example: High blood sugar, Recent diagnosis, Fatigue,
thirst, frequent urination

3. History of Present Illness: Onset, Duration, Symptoms,

Severity, Triggers, Treatments
1. Example: Diabetes diagnosis 5 years ago, Gradual onset,
Fatigue, thirst, frequent urination

4. Previous Medical History: Past illnesses, Surgeries,

Medications, Allergies, Hospitalizations
 1. Example: High blood pressure, Cholesterol medication

5. Personal History: Marital status, Habits, Education, Living

conditions, Work history, Hazards
1. Example: Married, 2 children, Non-smoker, High school,
Office worker

6. Family History: Parents’ and siblings’ health, Hereditary

diseases
1. Example: Father had diabetes

7. Review of Systems: Symptoms or normal findings for each

organ system
1. Example: Fatigue, thirst, frequent urination, Skin: Normal,
Musculoskeletal: Normal

8. Physical Examination: Vital signs, General inspection,

Systematic examination
1. Example: Blood pressure 140/90, Blood glucose 200,
General inspection: Normal

9. Diagnosis/Summary: Established diagnoses, Possible

diagnoses, Further testing
1. Example: Diabetes management
[Link] List
1. List of patient’s health issues
2. Includes diagnoses, symptoms, and unclear findings
3. Each issue has a number and title
4. Updated regularly as patient’s condition changes
Example:

1. *Problem List*: 1. Diabetes, 2. High Blood Pressure

[Link]’s Orders
Doctor’s instructions for patient care
2. Includes:
1. Medications
2. Diet
3. Tests (lab, imaging, etc.)
4. Treatments (therapy, etc.)
5. Special handling (isolation, etc.)
3. May be written randomly or grouped by problem (POMR
system)
4. May use separate forms or books for medication requests
Example:
Physician’s Orders: Medication for diabetes, blood pressure check
[Link]’s Progress Notes
Daily update on patient’s condition
. Brief summary of:
1. Symptoms
2. Findings
3. Diagnosis
4. Treatment plan
Uses SOAP format (POMR system)

SOAP Format

1. *S*: Subjective (patient’s symptoms and complaints)

2. *O*: Objective (doctor’s observations and findings)
3. *A*: Assessment (doctor’s diagnosis and interpretation)
4. *P*: Plan (treatment and next steps)
Example:
1. *Progress Notes*: SOAP format –
1. *S*: Patient reports increased thirst
2. *O*: Blood glucose 200
3. *A*: Diabetes management
4. *P*: Adjust medication
[Link] Notes
Nurses write notes about a patient’s care. For example, a nurse
might write about giving a patient medication, how the patient is
feeling, and what the nurse thinks about the patient’s progress.
These notes help doctors and other healthcare providers
understand the patient’s condition and make decisions about their
care. Nurses write these notes at least once per shift, but they
may write them more often if the patient’s condition changes.
[Link] Administration Record (MAR)
A document that tracks the administration of medications to
patients, including:
1. Medication name
2. Dosage
3. Route (oral, IV, topical, etc.)
4. Time and date administered
5. Administered by (healthcare professional)
Exceptions:
1. Medications administered by physicians themselves (noted in
Physician’s Progress Report)
2. Medications given in operating or recovery rooms (recorded on
special departmental records)
[Link] Graph: A graphical representation of a patient’s
vital signs, monitored every 4-6 hours, including:
1. Temperature
 2. Pulse
3. Respiration
4. Blood pressure
5. Additional information (height, weight, intake/output
summary)

[Link] and Output Record: A document that tracks a

patient’s fluid balance, including:
1. Fluid intake (oral, parenteral)
2. Fluid output (urine, emesis, drainage, liquid stools)
3. Totals every 8 hours and 24-hour period
By maintaining accurate and up-to-date medical records,
healthcare teams can provide high-quality care and improve
patient outcomes.
[Link] repoert
Results of tests done in laboratories, including:
1. Blood tests (e.g., blood count, sugar level)
2. Urine tests (e.g., infection, kidney function)
3. Infection tests (e.g., culture, sensitivity)
[Link] Sheets:
A simple form to track:
1. Vital signs (temperature, pulse, blood pressure)
2. Medications (name, dose, time)
3. Test results (lab, imaging)
4. Physical changes (e.g., weight, appetite)
[Link] Reports:
Results of special tests, including:
1. X-rays (e.g., chest, bone)
2. Scans (e.g., liver, lung, CT, MRI)
3. Other imaging tests (e.g., ultrasound, angiography)
Medical Record a legal document
1. Medical records help healthcare providers share information
and give proper care.
2. Mistakes can happen, so double-check records to ensure
accuracy.
3. Accurate records prevent misinformation and omission,
ensuring continuity of care and informed decision-making.
Confidentiality of Medical Records
1. Patient information is private and protected by laws,
regulations and ethics.
2. Confidentiality varies by state, but healthcare providers must
safeguard patient information.
3. Electronic records have enhanced security to protect
confidentiality.
Legal Consequences of Negligence
1. Healthcare providers can be held liable for careless record-
keeping.
2. Negligence occurs due to:
1. Recording errors (e.g., incorrect lab results).
2. Not using records before care (e.g., allergy mistakes).
3. Not recording observations (e.g., medication reactions).
3. Negligence leads to legal action, fines and damage to
professional reputation.
Summary
1. *Medical Records Matter*: They help healthcare
professionals understand a patient’s health history, diagnoses,
and treatments.
2. *Pharmacists’ Role*: Pharmacists review records to prevent
harmful drug interactions and ensure safe medication use.
3. *Teamwork*: All healthcare professionals should know what’s
in medical records to communicate effectively and provide
coordinated care.