Lecture by Professor Omar Hasan Kasule Sr. for Year 2 medical students at Universiti Brunei Darussalam

1.0 TYPES OF RECORDS

1.1 Hospital information systems

Medical records departments collect, store, and access information used for health care, financial or administrative reasons. SOAPIE, the acronym for problem-oriented medical recording, stands for Subjective complaints, Objective complaints, Assessment, Plan, Intervention, and Evaluation. The electronic medical record (EMR) enables clinical data net-working, direct on-line data entry from terminals in wards, record linkage, and record integration. Audio recordings, video recordings, photographs, and other types of images are considered part of the medical record. Hospital records are analyzed for process and outcome performance indicators, planning and projections, cost analysis, assessing access and affordability, and surveillance.

1.2 Public health information systems

Health care information is used for decision making, problem solving, and planning. It is sourced from demographic data, morbidity data, morbidity data, health care utilization, hospital care records, outpatient treatment records, environmental monitoring, occupational monitoring, health care activities, needs assessment, disease registers, health surveys, injury and accident monitoring, and vital statistics.

1.3 Disease registries with cancer as an example

Cancer registration is continuing and systematic collection of data on reportable neoplasms. The data is comprehensive including socio-demographic, clinical, laboratory, radiological, and treatment variables. The hospital cancer registry helps physician in follow-up of patients, sends data to outside registries (community, regional, or national cancer registries), and is used for hospital-based epidemiological studies (incidence and prevalence, immediate causes of death, survival, and treatment). The hospital cancer registry is a good source of controls for case control studies of cancer etiology. Disease registries are also available for other diseases.

2.0 OWNERSHIP OF RECORDS

The ownership of the records is not clear. Do they belong to the patient, the caregiver that wrote them, or the institution? Using the law of property, a product belongs to the person who made it. In this case, the doctor is the 'maker' of all the medical facts that are written and should be the acknowledged owner of the records.  However the patient is the owner of the facts in the record. The patient is also the only person involved who has most to lose if records are misused and therefore should have control in the form of ownership. The contents of the medical records cannot be revealed without the express permission of the owner of the information. Although the patient owns records in the sense that their contents cannot be disclosed without consent, the physician has physical custody of the records.

3.0 CONFIDENTIALITY OF MEDICAL RECORDS

Privacy and confidentiality are balanced against the need for timely information by caregivers. In a modern medical environment, many records are generated about each patient. These prove a challenge as far as keeping of secrets is concerned because many people can access them. Besides their use in medical care, the records can be used for medical education, medical research, and for legal purposes. Specific legal and ethical guidelines govern the release of these records.

4.0 QUALITY OF RECORDS

Quality control is needed to eliminate inaccuracy and inconsistencies. Records must be clear and legible. Records must be complete. It is an offense to omit significant information. Each record must be dated and timed. It is an offense to alter records after they have been written. Some information can be omitted from the general record for example information about adoption. Records should be kept secure and their security should be assured. Security of records may be compromised during transfer from one place to another or when there is a change of the staff who have physical custody.

5.0 RETENTION OF RECORDS

Medical records have to be retained because they may be referred later for purposes of medical treatment or for litigation. They however cannot be retained for ever because that is costly. There are therefore regulations on how long each type of record can be kept.

6.0 ACCESS TO RECORDS

The patient has a right of access to his or her records at any time