January 2009 Notes from Asia-Pacific

Medical Records
 
A medical record is a powerful tool.  It systematically documents a patient's medical history and treatment.  In theory, this tool enables doctors, nurses and hospital staff to provide good continuity of care to patients; in practicality, that is not always the case.

Three problems typically arise with medical records, which can lead to poor continuity of care and to even worse outcomes—medical errors.  After visiting many hospitals across the Asia-Pacific region, I have noticed three medical record issues plaguing our hospitals: timeliness of entries, legibility, and completeness.  After speaking to other JCI regional office directors, I learned that our region is not alone in battling these common problems.

Timeliness is crucial when recording information into a medical record.  Following a medical assessment, JCI standards require that information needs to be recorded within 24 hours at most or within the time frame stipulated by the hospital (which ever comes first).  I often recommend that staff surpass these standards—rather than meet them—by committing to record information into a medical record within 12 hours after assessment.  

For legibility, common misconception would lead one to assume that doctors are the culprits, but in my experiences, legibility is a problem among all groups, including nurses and allied health care staff.  

For hospitals using electronic medical records (EMRs), legibility is not a relevant issue; however, EMRs supply their own set of challenges.  I will be providing tips to help solve these problems in a future article.

In terms of completeness, medical records need to provide sufficient information so other staff can understand the patient’s diagnosis and treatment in addition to which test have been administered.  Typically in Asia, doctors and staff have been accustomed to writing very little, which makes it hard for the next shift to understand what needs to be done. Continuity of care will ultimately suffer. 

Paul Chang
pchang@jcrinc.com