Question

What type of information should NEVER be included in a medical record?

Answer 1

A medical record is a collection of information related to a patient and his or her health care. Medical records will be created and maintained in the regular course of time. This should be done in accordance with the policies, made by a concerned person. The person creating the record should have knowledge of the acts, events, opinions or diagnoses relating to the patient. They must maintain accuracy and prepared in a timely manner. The records should be made at or around the time indicated in the documentation. If there is an apparent disparity between what is said or written and the actual facts in medical records credibility gap occurs. The medical record act as the important mode of communication between medical personnel and it has a legal value.

The main purposes of medical records are:

It provides a clear medical image and details of the patient from birth to death
- Continuity of care can be maintained
- It contains the documentary evidence of the course of healthcare, evaluation and treatment
- Medical records will assist concerned personnel in diagnosing, treating, and tracking the changes and patterns of patient's health
- Has a statistical value, health matters such as births, deaths and communicable diseases

The medical record can be maintained in an electronic medical record system or a physical record.

                       

                        The data that should be excluded from the medical record

                       

• Unofficial records: like the personal health records managed and maintained by the patient
• Unprofessional comments:
• Material that is not relevant to patient care: like the debate of staffs on patient condition and care
• Avoid inappropriate observations
• Personal judgments of the caring person
• Never include attempts at humour.
• Illegible data
• Overwritten data
• Discriminatory remarks including socio-economic information (can include only if relevant to patient care).
• Arguments/conflicts with other staffs regarding
• Subjective statements: Be non-prejudiced while making records regarding prior treatment or poor outcomes presented as facts.
• Do not write anything to help or point the health care personnel as in case of an adverse event.
• Avoid inclusion of incident reports