Standard 3.8 Maintaining medical records.

Standard 3.8 Maintaining medical records.

Medical records are maintained in accordance with the provisions of policies and procedures.

Community health centers are required to maintain medical records containing patient care data and information needed for patient care and these medical records can be accessed by health care workers, management, and parties outside the organization who are given access rights to medical records for the benefit of patients, insurance, and other interests in accordance with statutory regulations.

a. Criterion 3.8.1

The management of medical records is carried out in accordance with statutory provisions.

1) Main Thoughts:

a) Medical records are the main source of information regarding the process of patient care and development, so they become an important communication medium. In order for this information to be useful and support ongoing patient care, medical records must be available during patient care and at all times needed and maintained to always record the latest developments in the patient's condition.

b) Medical records are maintained in accordance with statutory provisions. Medical records are files that contain notes and documents regarding patient identity, examinations, treatment, procedures and other services that have been provided to patients. Medical records must be made in writing, complete and clear or electronically.

c) It is necessary to standardize (1) diagnosis codes, (2) procedure/action codes, and (3) symbols and abbreviations that are and should not be used, then their implementation is monitored to prevent errors in communication and delivery of patient care and to be able to support the collection and data analysis.

The standardization must be consistent with the applicable standards according to the provisions.

d) Doctors, nurses, midwives and other care providers jointly agree on the contents of medical records in accordance with the information needs that need to be provided in the implementation of patient care.

e) Maintaining medical records is carried out sequentially from the time the patient is admitted until the patient goes home, is referred, or dies, which includes activities

(1) patient registration;

(2) distribution of medical records;

(3) fill in medical records and complete clinical information;

(4) data processing and coding; (5) financing claims;

(6) medical record storage;

(7) quality assurance;

(8) release of health information; And

(9) destruction of medical records

f) Drug effects, drug side effects, and allergic events are documented in the medical record.

g) If a history of drug allergies is found, the allergy history must be documented as clinical information in the medical record.

h) Medical records are filled in by every doctor, dentist and/or health worker who carries out individual health services.

i) If there is more than one doctor, dentist and/or health worker in one health facility, medical records are created in an integrated manner.

j) Every note in the medical record must be complete and clear, including the name, time and signature of the doctor, dentist and/or health worker providing the service sequentially according to the time of service.

k) In the event that an error occurs in recording medical records, the doctor, dentist and/or health worker

others can make corrections by crossing out one line without removing the corrected note, then initialing and the date; In the event that additional words or sentences are required, initials and dates are required.

l) Outpatient medical records contain at least:

(1) patient identity;

(2) date and time;

(3) anamnesis results, including at least complaints and disease history;

(4) disease;

(5) results of physical examination and medical support;

(6) diagnosis;

(7) management plan; (8) treatment and/or action;

(9) other services that have been provided to the patient

(10) approval and rejection of action if necessary;

(11) for dental case patients equipped with a clinical odontogram; And

(12) name and signature of the doctor, dentist and/or health worker providing health services.

m) Inpatient medical records contain at least:

(1) patient identity;

(2) date and time;

(3) anamnesis results, including at least complaints and disease history;

(4) results of physical examination and medical support;

(5) diagnosis;

(6) management plan;

(7) treatment and/or action;

(8) informed consent if necessary;

(9) records of clinical observations and treatment results;

(10) discharge summary;

(11) name and signature of the doctor, dentist and/or health worker providing health services;

(12) other services that have been provided by certain health workers;

(13) for dental case patients equipped with a clinical odontogram; And

(14) the name and signature of the doctor, dentist, or certain health worker who provides health services.

n) Medical records for emergency patients are filled in in the form of:

(1) patient identity;

(2) conditions when the patient arrives at the health service facility;

(3) the identity of the patient introducer;

(4) date and time;

(5) anamnesis results, including at least complaints and disease history;

(6) results of physical examination and medical support;

(7) diagnosis;

(8) management plan;

(9) treatment and/or action;

(10) a summary of the patient's condition before leaving the emergency unit and follow-up plans;

(11) name and signature of the doctor, dentist and/or health worker providing health services;

(12) means of transportation used for patients who will be transferred to other health service facilities; And

(13) other services that have been provided to patients.

o) The Community Health Center determines and implements a policy for storing medical record files and other data and information. The storage period for medical records, data and other information related to patients is in accordance with applicable laws and regulations to support patient care, management, legally valid documentation, education and research.

p) Policies regarding storage (retention) of medical records are consistent with the confidentiality and security of such information. Medical record files, data and information can be destroyed after exceeding the storage period in accordance with statutory regulations, except for discharge summaries and approval of medical procedures.

2) Assessment Elements:

a) Maintaining medical records is carried out sequentially from the time the patient is admitted until the patient goes home, is referred, or dies, including activities

(1) patient registration;

(2) distribution of medical records;

(3) fill in medical records and complete clinical information;

(4) data processing and coding;

(5) financing claims;

(6) medical record storage;

(7) quality assurance;

(8) release of health information;

(9) destruction of medical records; And

(10) including a history of drug allergies,

carried out in accordance with established policies and procedures (R,D,O,W).

b) Medical records are filled in completely and in legible writing and must include the name, time of examination, and signature of the doctor, dentist and/or health worker who carries out the individual health service; If there are errors in recording in the medical record, corrections are made in accordance with the provisions of the laws and regulations (D, O, W).