documentation of the casese

1. By
Dr . Shaymaa Kotb
Master degree from Alazhar university
M RCSI , RCSEng , RCSEd ,RCPSG
DOCUMENTATION OF THE CASES

2. OUTLINES
PURPOSE OF RECORDING
IMPORTANCE OF DOCUMENTATION
DOCUMENTATION IS EVIDENCE
 STANDARD OF DOCUMENTATION
LEGAL ASPECTS
ELECTRONIC RECORDING
CONFEDENTIALITY

3. PURPOSE OF RECORDING
Planning
Organization
Co-ordination
Control of Health services

4. IMPORTANCE OF DOCUMENTATION
 Good documentation is central to good clinical
practice
 Key for documentation : must keep clear,
accurate and legible records
A single source of truth , saves time and energy
Documentation cuts down duplicative work

5. DOCUMENTATION IS MY BEST FRIEND

6. IMPORTANCE OF CLINICAL DOCUMENTATION
protect your patients.
 Good documentation promotes patient safety
Vital means of communication between dr and pt
 Empower the healthcare providers to plan the
treatment, thus improving the overall quality of
healthcare services.
Clinical records also provide data for use in audit
and research

7. DOCUMENTATION = EVIDENCE

8. DOCUMENTATION = EVIDENCE

9. STANDARDS OF DOCUMENTATION
Must have the patient’s ID number
should be dated and timed with the 24-hour clock.
Name of patients’ data , it must include:
Date of birth
The contact number,
Employer, address,
Marital status.

10. STANDARDS OF DOCUMENTATION
The medical conditions or illnesses of the patients.
On top of everything, the potential adverse
reactions
 Medication allergies must be outlined.
The past medical history
Somking state
Alcohol state

11. IDENTIFICATION OF STANDARD OF
DOCUMENTATION
Education & Awareness
Reviewing the Information
Declaration of Legal Health Records
Authentication, Dating, And Timing (in a written
form)

12. LEGAL ASPECTS
Misinterpretation
Medical Errors
Malpractice Claims in Medicine
Unauthorized Access

13. LEGAL ASPECTS
Don’t erase or use white –out
Don’t write critical comments ( don’t blame on your
colleagues)
Correct all errors promptly
Spell correctly
Record all facts
Be accurate about time
Avoid vague statement

14. ELECTRONIC RECORDS
use of electronic records overcome many problem.
Doctors have a duty to write legibly.
The ability to find information at any times
 Storage problems associated with the current
paper-based clinical notes
Financial Issues(cost)
Provide clear guidance for medical students

15. CONFDENTIALITY = DON’T DISCUSS WITHOUT PURPOSE

16. “COURT BELIEVES YOUR DOCUMENTS ONLY”

17. CONFIDENTIALITY = SECRETS

18. REFERENCES
 .General Medical Council. Good Medical Practice.
London: GMC; 2013.
The Royal College of Surgeons of England.
Guidelines for Clinicians on Medical Records and
Notes. London: RCS; 1994.
The Royal College of Physicians. Generic Medical
Record Keeping Standards. London: RCP; 2009.

20. THANK YOU
•
By
• Dr. shaymaa kotb