Medical Records. Dr. Yousif E. Elgizouli MRCGP (UK),JMHPE Family Medicine Consultant & Trainer. Organization is the power of the day; without it, nothing is accomplished. ~ Sophia Palmer From A Daybook for Nurses: Making a Difference Each Day. Learning Objectives.
Dr. Yousif E. Elgizouli
Family Medicine Consultant & Trainer
~ Sophia Palmer
From A Daybook for Nurses: Making a Difference Each Day
Additional Uses of
Documenting test results
Examination, preparation,and vital signs
Documenting patient statements
Maintain patient privacy
Client’s words –
Completeness – C
Chronological order –
Do not interpret patient’s words
Precise descriptions / medical terminology
Fill out forms completely
To the point / approved abbreviations
The treatment plan to correct the illness or problem
The impression of the patient’s problem that leads to diagnosis
What the physician observes during the examination
Information the patient tells you
Release of Informationto MOH/ Insurance
I authorize Dr. X to release my healthcare information to the above-named ministry /insurance company.
mm/dd/yyyyPatient Signature Date
Legal guardian of children (may be one or both parents)
Next of kin
Legally authorized representative
Must have written consent to release their records
Legal and ethical principle:Protect patient’s right to privacy at all times.Release of Records (cont.)
- Include how you think the advantages and disadvantages of each record format affect everyday work; remember to think about retrieving records as well as filing them
- Why we should keep good patient medical records?
- PMR should be kept secure, but when you release patient information (records)?
- What are the differences between manual (paper) & electronic medical records, mention advantages and disadvantages of each?
- Hanan-25-Years old teacher consult you with a severe episodic headache 2 months ago, her headaches are associated with nausea & vomiting, often at the right side of the head. She felt that since 4 Years, her mother has similar headaches.