Introduction

Medical record is a compilation of information related to health examination and treatment given to a patient. It includes documented data on present and past illnesses as well as treatment by healthcare personnel caring for the patient.

The purpose of the medical record is to record the facts or information related to a patient’s health history,it also emphasizes on the events leading to admission or visits to health facilities for continuity of care in the future.

Therefore, medical record is a document that is legally binding and the documented treatment information can be used as evidence in the court of law. It is also an important document for clinical or epidemiological study and research, production of health care statistic and a source of information for management, development and planning by Ministry of Health.

Characteristics Of Quality Medical Records

Quality medical records should have the characteristics of completeness of information and efficient records management system. Among those features are:

A. Document Or Records Produced Must Be Always Available When Needed

1. Using a folder for every patient who received treatment at the hospital (one patient one folder) will facilitate the tracing of records easily when needed.
2. Using only one registration number for each patient that is Master Registration Number (MRN) together with one attendance registration number, namely Encounter Number (RN) for each visiting episode of treatment.
3. Medical records must be systematically stored in Medical Records Storage Room using Terminal Digit Number.
4. Each record must have a checklist of the document and the documents need to be arranged in chronological sequence to facilitate the retrieval of information. All continuation sheets should have MRN and page number.

Example Of Folders Used In Hospitals

B. Accurate, Complete And Comprehensive Document

Every healthcare personnel involved in registration, examination and treatment of the individual must be aware that good quality medical record is essential and must contain sufficient data on the patient and treatment provided.

1. Patient Demographic Information

• The patient demographic information should contain the full name of patient as in identity card, identification number, registration number of patient (MRN / RN) followed by date of birth, age, sex, race, marital status, nationality, country residence, mailing address, next of kin, occupation and contact number.
• Accuracy of patient registration data is important for records keeping,tracing and tracking in a variety of purposes such as utilization of clinical or epidemiological research by age, gender, descent, nationality and so on.

2. Clinical Treatment Information

• When a patient being treated in the treatment room, all clinical information should be documented chronologically according to time, date, signature, name and designation stamp of healthcare team. The referral letter must be filed in the patient’s medical record.
• All documentation in the medical record should be accurate and adequate pertinent to the health care experiences of the patient including telephone conversation or verbal orders. All entries made must be related to health problems and treatment of the patient only.
• Surgical procedures that have been carried out must obtain a complete consent letter from the patient.                                                                

Incorrect Entry Struck Out With Impunity;

Date And Time Of Corrections Are Not Written. Date Of Corrections Done.

A Single Line Through The Incorrect Entry

Is Made But Without Initialed, Time And Date Of Corrections Done.

• All entries in the medical record are made in a way that they are not alterable. Any corrections must use a single line through the incorrect entry and are initialed and dated with time. Using correction materials or eraser is not allowed.
• The use of abbreviations is not recommended. If there is a reason to use an abbreviation, only abbreviations that have been approved by Ministry of Health Malaysia are allowed. Repeated or copy and paste information, symbols and abbreviations that are widely used in treatment written does not reflect the characteristic quality of the medical record.

Format PER.PD.302 and some abbreviations approved by MOH