Policy: 

Staff familiarity with the established composition of the patient's medical record .

Purpose :

* The presence of a medical record for each patient who has been examined and treated.

* The established composition of the patient's medical record contains sufficient information such as:

◾ Identify the patient by name – address-file number.

◾ Allows continuity of care .

◾ Confirm the diagnosis .

◾ Justification of treatment.

◾ Documentation of treatment steps and results .

* The components of the medical records of patients in the hospital are unified and specific in form, and doctors and nurses are committed to using the forms optimally and contain:

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

* The nursing departments are committed to familiarizing the patient with all patient record forms, including:

Quadruple patient name-unified number

* It is done with examination reports, rumors, medical report and a copy of the discharge summary of the patient's file .

* The medical team corrects or amends one of the data recorded in the medical record by putting brackets around inaccurate data, taking into account ensuring that it can still be read, signing in front of it and recording the date and time of Correction, where it is not permissible to erase or delete erroneous data .

* Availability of consultation data as evidence that the consultant reviewed the patient's medical record and the results he reached when signing the medical examination, as well as the consultant's opinion and recommendations .

* Issuing oral diagnostic and therapeutic orders to a qualified nurse .orders must be signed within twenty-four (24) hours and all orders must bear the date , time, signature and applicable procedures.

* 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, keeping a copy of the patient's file.

* Give the patient an updated discharge summary .

Actions:

The nursing staff members make sure that the file contains the following data when entering :

* Quadruple patient name-unified number-age .

* Name, address and phone number of a relative of the patient or who can be contacted in case of emergency.

* The nursing staff members do the following:

* Write the name of the quadruple patient and his unified number on all pages of the medical file .

* Registration of vital signs and the patient's satisfactory condition with the vital signs register and the nursing notes register

* Modify the treatment implementation plan according to the doctor's modification 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 suffered by the patient, if any .

· Whether the patient has any chronic infectious disease such as hepatitis .

* Diagnosis when the patient is hospitalized .

* The patient's complete medical history: previous, current and family medical history .

* A detailed statement of the clinical examination of the patient and a statement of the results and the action plan.

* Mention the results of laboratory tests and radiology

* 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 follow-up, consultations, routine and special treatments appropriately in the appropriate forms.

* Take notes of 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, and notes of the development of the condition should be recorded at the time of observation to allow continuity of care and the possibility of transferring the patient from one department to another, as well as On the other hand, comprehensive notes on the development of the condition during the surgery and immediately after the completion of the surgery should be made in the medical record in order to provide correct information for use by any caregiver who takes responsibility for the care of the patient afterwards

* Write all the reports of the operations immediately after the end of the surgical operation, including the patient's name, medical file number, date of the surgical operation, pre-and postoperative diagnosis, the name of the surgeon and his assistant, the name of the surgical operation, a detailed statement of the results and methods used during the operation, anesthesia, samples taken, the amount of fluids secreted, complications, and The reasons for the surgery and the patient's condition before the operation.

Writing a discharge or death summary in all medical files of hospitalized patients, including

  ◾ Entry and exit dates .

  ◾ Preliminary diagnosis-the final diagnosis .

  ◾ Analysis .

  ◾ The actions that took place .

  ◾ Medical drugs and other treatments .

  ◾ The patient's condition and the next stop at discharge .

 Exit instructions include food, medication and follow-up instructions . 

  ◾ The name of the doctor who discharged the patient .

Completing the referral form as follows:

  ◾ The reason for the referral

  ◾ The required means of transition and follow-up

  ◾ Case description

  ◾ The next stop

The medical file of the emergency patient contains :

  ◾ Patient arrival time and discharge time .

 Final results at the time of completion of treatment.

  ◾ The patient's condition at discharge .

  ◾ The patient's destination at discharge .

  ◾ Medical care instructions for patient follow-up .

  ◾ Document the order of discharge from the Attending Physician .

Responsible: members of the nursing and medical staff .

Forms: patient records-the content of the medical file for each department.

References: directory of medical records of the Ministry of Health .