Policy Who has the authority to write to a patient’s medical file

Policy: 

the medical team of nurses and attending physicians is authorized to write in the patient's medical file with their clear and legible names and their job title, provided that the information is clear and in a legible font, with the date and hour written.

Purpose: 

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

Actions:

* The members of the nursing staff, when recording their performance in the patient files, are obliged to write their names (Triple name) and record the date and hour.

* When registering in patient files, doctors are obliged to write their names (Triple name), use cliches, write the date and hour.

* All researches, examinations and treatments that require the patient to sign from the attending physician with the writing of his Triple name and his seal.

* The person doing the medical and Radiological analyzes signs the results of the analyzes and the Radiological reports with his Triple name or his aclash and writing the date and hour.

Responsible members of the nursing 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

Politics:

* 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 access the medical record and the data allowed to access them .

Purpose: -

maintaining and protecting the confidentiality of the patient's information and data .

Actions:-

* All hospital staff sign a declaration of confidentiality of patient information .

Conditions under which information in the medical file is allowed to be viewed :-

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

· In the case if the student is sick himself or his legal representative or external bodies such as (administrative prosecution - Public Prosecution-inspection bodies-Ministry of Health ), the hospital director or medical director will review the application and provide information in one of the following ways :

  ◾ Verbally .

  ◾ A photocopy of the original from the file.

  ◾ Summary of the case .

  ◾ The original file, and in this case, a representative from the hospital will forward the file and return it after the end of the decision .

· In case the patient is transferred to another hospital, the specialist fills out the transfer form with a summary of the case( diagnosis - reason for transfer ) .

· In case of requesting a medical report on a case, the patient or his legal representative submits an oral request to the medical records office official to address the Attending Physician to write the report on the case, which is done on the same day and delivered to the applicant .

* The hospital has the right to withhold some of the patient's medical information in the event that the information represents harm to the patient, such as ( the patient's knowledge of the nature of the patient's pathological condition may affect his psychological condition and lead to deterioration of his condition ).

* List of authorized persons to view the medical file at the hospital :

     ◾ The doctor in charge of the case .

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

     ◾ The nurse in charge of the case .

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

     ◾ The director of the hospital .

     ◾ Medical director .

     ◾ Coordinator of quality and performance improvement .

     ◾Judicial and supervisory authorities and the Ministry of health when needed .

     ◾ Medical Statistics Officer .

     ◾ The accounts officer.

Persons authorized to view	اThe 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	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 employees of the hospital.

Forms: declaration of confidentiality of information

Preparation	Review	The trust