As the repository of all patient’s records, the Medical Record Section (MRS) provides data to the hospital staff directly responsible in patient care management as well as information to decision-makers that serves as management tool for sensible planning and evidence-based decision-making.
- The MRS has to ensure an organized system of measuring quality patient care with sufficient data written in sequence of events in order to justify the diagnosis and warrant the treatment and end results.
- The processing, analyzing, maintaining and safekeeping of all medical records created or maintained in the hospital, in the course of giving medical care to patients, shall be the main responsibility of the section.
- There must be a medical records for each patient confined / treated in the hospital.
- Documentation in the medical record should reflect the patient’s physical condition and the orders and care provided from admission to discharge.
- Documentation should reflect observation and should be objective and non-judgmental.
- There should be a standard format for medical record documentation which should include demographics and assessment data.
- A chart of records should be maintained for each patient. This shall include all consultations or admissions to the hospital, discharge summaries and quality documentation by the physician and other inter-disciplinary team members who participated in the care of the patient.
- All documentation must be legible and written in ink or typewritten.
- Documentation should be completed within 48 hours after the patient is discharged.
- A written History and Physical Examination should be completed upon consultation or within 24 hours after the patient is admitted for confinement.
- To ensure quality documentation, there should be a Medical Record Committee (MRC) which shall review and revise, if necessary, the medical record forms.
- Use of abbreviations in writing the diagnosis shall not be allowed, but use of symbols with an explanatory legend by authorized personnel may be allowed with the approval of the hospital management.
- Short forms like laboratory and other result forms should be securely fastened to the records to prevent loss.
- Since the medical record is a legal document, no form shall be detached once it is filed in the chart.
- There should also be no erasure of any sort. To correct an error, draw one single line through the information to be corrected or changed, and affix initial and date, then write the correct entry near the information to be corrected.
- In cases where the patient wants some data corrected, especially sociological data, it should not be done on the original entry but should appear as an amendment in another sheet of the same form.
- The chart shall contain all original copies of examination results, operations and other required forms.
- The medical record is the physical property of the hospital. However, since the information written on the records is the patient’s personal history, he/she also has a right to the said records.