Part Two

- Medical Files

Policy Name

Standardized and consistent content of the patient's medical file

Policy Number

Issue date and number

Review Date

Number of pages

Artificial kidney unit

Policy for uniform and consistent content of the patient's medical file

The Purpose:

Familiarity of staff with the consistent composition of the patient’s medical record.

Politics:

· Having a medical record for every patient examined and treated.

· The fixed composition of the patient’s medical record contains sufficient information such as:

◾ Identify the patient by name - address - file number

◾ Allows for continuity of care

◾ Confirm the diagnosis

◾ Justification for treatment

◾ Documentation of treatment steps and results

· The components of medical records for patients in the hospital are standardized and have a specific format, and doctors and nurses are committed to using the forms in optimal use and they contain:

◾ Writing treatment orders in a unified manner and in the same place.

· Department nurses are obligated to familiarize the patient with all patient record forms, which contain:

◾ Patient’s name is four-digit number

· Test reports, rumors, the medical report, and a copy of the discharge summary are included in the patient’s file.

· The medical team corrects or amends one of the data recorded in the medical record by placing parentheses around the inaccurate data, taking into account ensuring that it is still possible to read it, sign in front of it, and record the date and time of making the correction, as it is not permissible to erase or delete incorrect data.

· The availability of data related to the consultations as evidence that the consulting physician reviewed the patient’s medical record and the results he reached when conducting the medical examination on him, as well as the consulting physician’s opinion and recommendations.

· Issuing verbal diagnostic and therapeutic orders to qualified nursing personnel. The orders must be signed within twenty-four (24) hours, and all orders must bear the date, time, signature, and procedures applied.

· The clinical data recorded in the medical record and any other data and signatures are clear and legible.

· Send a referral form with the patient when he is transferred to another hospital, while keeping a copy in the patient’s file.

· Giving the patient a discharge summary with complete information

Procedures:

· Nursing staff members ensure that the file contains the following data upon entry:

· Patient’s full name - uniform number - age

· Name, address and telephone number of a relative of the patient or someone who can be contacted in case of emergency.

· Nursing staff members do the following:

· Writing the patient’s full name and uniform number on all pages of the medical file.

· Recording the patient’s vital signs and medical condition in the vital signs register and the nursing staff’s observations register

· Modify the treatment implementation plan according to the doctor’s amendment on the doctor’s orders page.

· Doctors do the following:

· Complete the patient examination record and the record contains the following data:

· The type of allergy the patient suffers from, if any.

· Whether the patient suffers from any chronic infectious disease such as hepatitis C

· Diagnosis when the patient is admitted to the hospital

· The patient’s complete medical history: previous, current, and family medical history

· A detailed statement of the patient’s clinical examination, a statement of the results drawn, and the action plan

· Mention the results of laboratory tests and x-rays

· Clearly write the type of treatment applied on the doctor’s orders page.

· Request all required examinations or tests on the Clinical Progress page

· Record all types of routine and special follow-up, consultations and treatments appropriately on the appropriate forms.

· Take notes on the development of the condition at least daily for patients with serious conditions, as well as for patients whose conditions are difficult to diagnose or control their clinical problems. Notes of the development of the condition must also be recorded at the time of the observation to allow for continuity of care and the possibility of transferring the patient from one department to another. Also, as much as possible, it must be determined Each of the problems that the patient suffers from should be clearly stated in the case progress notes and linked to the orders issued regarding it, as well as the results of examinations and treatment. On the other hand, comprehensive notes about the development of the condition during the surgical procedure and immediately after the completion of the surgery must be recorded in the record. This is done for the purpose of providing correct information for use by any caregiver who subsequently assumes responsibility for caring for the patient

· Writing all operating reports immediately after the end of the surgical operation, provided that they include the patient’s full name, medical file number, date of the surgical operation, diagnosis before and after the surgical operation, the name of the surgeon and his assistant, the name of the surgical operation, and a detailed statement of the results and methods used during the operation and anesthesia. The samples taken, the amount of fluid secreted, complications, reasons for surgery, and the patient’s condition before the operation.

Writing a summary of discharge or death in all medical files of patients admitted to the hospital, which includes:

· Check-in and check-out dates

· Initial diagnosis - final diagnosis

· Analysis

· Actions taken

· Prescription drugs and other treatments

· Patient condition and next stop upon discharge

· Discharge instructions, including food, medication and follow-up instructions

· The name of the doctor who discharged the patient

· Fill out the referral form as follows:

· Reason for referral

· The required means of transportation and follow-up

· Description of the condition

· next station

· The emergency patient’s medical file contains:

· Patient arrival time and discharge time

· Final results at the end of treatment

· Patient’s condition upon discharge

· The patient’s destination upon discharge

· Medical care instructions for patient follow-up

· Documentation of the discharge order from the treating physician

Administrator:

· Nursing staff and medical staff.

Models:

· Patient records – content of the medical file for each department.

The reviewer :

· Medical records guide for the Ministry of Health.

Preparation	Review	The trust

The policy of who has the authority to write in the patient’s medical file

Policy Name	The policy of who has the authority to write in the patient’s medical file		Policy Number
Issue date and number		Review Date	Number of pages
Section	Artificial kidney unit

Politics:

The medical team, including nurses and treating doctors, is authorized to write in the patient’s medical file their names, clear and legible, and their job titles, provided that the information is clear and in legible handwriting, with the date and hour written.

The purpose:

Determine who has the authority to write in the medical file.

Procedures:

· When recording their performance in patient files, nursing staff members are obligated to write their names (first name) and record the date and hour.

· When registering in patient files, doctors are obligated to write their names (first name), use scribbles, and write the date and hour.

· All research, examinations and treatments requested for the patient must be signed by the treating physician, with his name written in three letters and his stamp.

· The person performing the medical tests and x-rays signs the results of the tests and x-ray reports with his or her full name or his own letter and writes the date and hour.

Administrator:

Nursing staff and medical staff.

Preparation	Review	The trust

The policy of who has the right to view the patient’s medical file to ensure the confidentiality of the information.

Policy Name	Who has the right to view the patient’s medical file to ensure the confidentiality of the information?		Policy Number
Issue date and number		Review Date	Number of pages
Section	Artificial kidney unit

Policy: The medical record is considered a legal document and therefore its confidentiality must be maintained, and this confidentiality is the basis of the legal aspect of the medical record.

· Establish controls to maintain the confidentiality of information and determine who has the right to view the medical record and what data they are permitted to view.

Purpose: Maintaining and protecting the confidentiality of patient information and data.

Procedures:

· All hospital employees sign a declaration of confidentiality of patient information.

Circumstances in which access to information in the medical file is permitted:

· If the file is requested from the medical team to view the patient’s examinations or information of clinical value, the doctor writes a request to extract the previous file in the current file, the doctor signs it clearly and with the date, then submits the file to the medical records official to extract the medical file.

· In the event that the sick applicant is himself, his legal representative, or external parties such as (the Administrative Prosecution - the Public Prosecution - Inspection Bodies - the Ministry of Health), the hospital director or medical director shall review the request and provide the information in one of the following ways:

◾ Orally.

◾ An exact copy of the file.

◾ Summary of the case.

◾ The original file. In this case, a representative from the hospital will refer the file and return it after the decision on it is completed.

· In the event that the patient is transferred to another hospital, the specialist doctor fills out the transfer form, which includes a summary of the case

(Diagnosis - reason for transfer)

· In the event of requesting a medical report on a case, the patient or his legal representative submits a verbal request to the official of the Medical Records Office to contact the treating physician to write the report on the case. This is done on the same day and delivered to the applicant.

· The hospital has the right to withhold some medical information about the patient in the event that the information represents harm to the patient, for example

(The patient’s knowledge of the nature of the patient’s medical condition may affect his psychological state and lead to a deterioration in his condition).

· List of persons authorized to view the hospital’s medical file:

◾ The doctor responsible for the case

◾ Doctors from other departments who are consulted about the patient’s condition.

◾ The nursing staff responsible for the case

◾ The patient or his legal representative with the authorization of the patient

◾ Hospital director

◾ Medical Director

◾ Quality and performance improvement coordinator

◾ Judicial and supervisory authorities and the Ministry of Health when necessary.

◾ Medical Statistics Officer

◾ Accounts Officer

Persons authorized to view	The nature of the data allowed to be accessed
Hospital Manager	All medical and financial reports
Medical Director	All medical reports
Administrative and Financial Director	All financial and administrative reports
Physician	Follow up on examinations and write a treatment plan
[A doctor from another department in case of consultation	Medical examinations and reports
Responsible nursing staff members	Implementing doctor's orders and implementing treatment
Pharmacists	Dispense treatment
Doctors and laboratory chemists	Carrying out the required analyses
Doctors and radiology technicians	Conducting x-ray examinations and writing reports
Quality team	All contents of the medical file
Medical Records Committee	All contents of the medical file

Responsible: All hospital employees.

Forms: Declaration of confidentiality of information

Preparation	Review	The trust

Policy for protecting medical records and information from loss, damage, tampering, and unauthorized use or access

Policy name	Protecting medical records and information from loss, damage, tampering, and unauthorized use or access		Policy Number
Issue date and number		Review Date	Number of pages
Section	Artificial kidney unit

Politics:

Protecting medical records and information from loss, damage, tampering and unauthorized use

The Purpose:

Ensuring that the medical file is preserved from loss or damage and ensuring that the patient’s medical information is preserved so that it can be retrieved when needed.

Procedures:

The hospital’s medical records room meets the following specifications:

Ventilation is adequate

Lighting is adequate

Fire protection

Intact storage shelves

Offices for workers

Access to the file storage area is not permitted to anyone other than authorized persons (patient affairs employees only).

The medical records office official keeps the patient's medical records on the shelf in the order of the month for each department.

The Medical Records Office official shall repair all records with loose papers or torn covers immediately before the important information recorded in them is exposed to further loss or damage.

The official in the medical records office keeps all reports related to diagnosis, examinations, etc., such as medical reports, laboratory results, etc., in the medical file, except for radiology, which is kept in the radiology department.

There is a record of requests in the place where files are kept, which includes the borrowed files and the person borrowing the file from the people authorized to view the file.

The medical records clerks assigned to work in the filing area are responsible for maintaining the cleanliness of the area and the neat order of files on the shelves.

Administrator:

Medical records office

Preparation	Review	The trust

Policy for disposing of medical files and the duration of keeping records and files

The purpose:

Disposing of medical files through legal means and clarifying the legal period for keeping records and files.

Politics:

· Dispose of records within the specified period in accordance with regulations and laws.

· Dispose of records completely to prevent anyone from viewing them or extracting identical copies of them.

· Records may not be disposed of except based on an administrative order issued by the hospital director general.

Procedures:

· Inactive medical records may be disposed of after a certain period of time determined by the Ministry of Health guidelines.

· Records scheduled for disposal should be registered according to the patient's name, medical file number, and last date of activity.

· The records must be completely destroyed to prevent anyone from viewing them or extracting duplicate copies of them.

· The medical records official and clerk, on the first of December of each year, review the medical records to extract what has expired and is worthy of being permanently disposed of, in accordance with the guiding policies of the Egyptian Ministry of Health website.

· The medical records officer shall keep all records related to lawsuits or other investigations of a confidential or serious nature and shall not dispose of them until after the lawsuits are completed.

· On the first of January of each year, the medical records official examines the dispensed documents and after verifying the authenticity of the dispensed documents, they are packed into bags by the department’s workers to be delivered to the Health Affairs Directorate for disposal in accordance with the ‘archives regulations’.

· The following is the schedule for maintaining medical files and records.

· Below is the schedule for maintaining medical files and records.

· Schedule for maintaining medical records
· Name of the medical record	· The period of retention of the original record · In years	· As of the date of	· Using the computer for permanent preservation
· Log in and out	2	· Recording the last case	No
· Emergency department record	2	· Recording the last case	No
· Operation log	2	· Recording the last case	No
· Record of radiology examinations	2	· Recording the last case	No
· Record of laboratory tests	2	· Recording the last case]	No
· Any other record	2	· Recording the last case	No

· Schedule for maintaining medical files
· The topic	· Retention period in years	· As of the date of	· Using the computer for permanent preservation
· The patient’s medical file	5	· Last patient review]	No
· X-ray films	5	· The patient’s last imaging request	No

Administrator:

· Medical Records Department

· the reviewer:

· Ministry of Health Medical Records Guide

· Guiding policies for the Egyptian Ministry of Health website.

Preparation	Review	The trust