Medical Records in Practice
Keeping medical records is the responsibility of every medical unit, both public and commercial. Meticulously completed documentation is crucial for patient treatment, and can be used as support in the event of (sometimes unjustified) complaints.
The purpose of keeping medical records should be considered in two ways. On one hand, it is an activity that supports the daily work of staff. The documentation is intended to reflect the activities that are performed in medical institutions within the framework of provided services, such as consultations, recommendations and decisions on further stages of treatment. Specialists use the data provided on an ongoing basis to maintain the continuity of treatment and improve the quality of services offered in the future.
On the other hand, keeping medical records fulfills the legal requirement to document the process of providing health and medical services. The legal basis in Poland for this is the Act of 6 November 2008 on patients’ rights, the Patient Rights Ombudsman, and the Regulation of the Minister of Health of 6 April 2020.
Characteristics of paper documentation
In the case of paper-based documentation, it should be remembered to supplement it each time immediately after delivering healthcare. The documentation must include data from both the patient and the healthcare provider. If you have received a referral from another medical unit, you should also complete the documentation with the reason for the referral and the doctor who issued it.
It is also worth noting some important facts concerning the keeping of medical records in paper form, resulting from the Minister’s regulation:
- Each entry shall be legible and in chronological order
- The person making the annotation in the patient’s documentation must include their signature
- Entries cannot be deleted from medical records
- In the event of an incorrect record, a reference shall be made as to the cause of the error, together with the date and signature of the person making the annotation.
- Any deletions should be described accordingly, as in the case of an error
Characteristics of documentation in electronic form
The rules for keeping medical records in electronic version are specified in the Regulation of the Minister of Health of 6 April 2020 on the types, scope and models of medical records and how they are processed. It details conditions that should be met by the ICT system processing medical documentation in a given institution.
Among all the system functionality requirements listed in the Regulation, it is worth mentioning:
- Protection of documentation against damage, loss and unauthorized access
- Integrity of the content of the documentation and metadata, meaning protection against changes (exception: changes made in compliance with established and documented procedures)
- Identification of the person issuing the alert and providing health care services, together with documentation of changes in the documentation and metadata
- The assignment of information features to the relevant types of documentation
- The provision (including electronic export) of documentation or part thereof specified in the regulation, in the format in which it is processed (xml or pdf)
- Possibility to print documentation
Interestingly, if there is a need to include documents in an electronic way in paper form, such as the results of tests carried out in other units, they should be digitally reproduced and only in this version should be included in the IT system.
Structured medical records with the help of Optimed NXT Cloud
Are you looking for a support system ideal for your clinic? Our Optimed NXT Cloud is perfect for clinics and medical offices. It is an HIS-class (hospital information system) system which, thanks to the use of cloud technology, provides quick and convenient access to medical documentation or current information about the resources of the facility.
With Optimed NXT Cloud, managing the unit, registering patients, and maintaining electronic medical records (EDM) becomes easy and fun. Complete your data with just a few clicks, add scans of paper medical records as attachments, and store all data securely in the cloud. You can also extend the service with system integrations such as Znany Lekarz, Laboratorium, PZU and Compensa.
Would you like to learn more about the solution and get to know our detailed offer? Do not hesitate to contact our consultant.