The purpose of the Singhania Clinic & Therapy Centre (SCTC) Medical Records policy is:
- To ensure that documentation of patient health information is performed in a manner that meets generally accepted medical practices and complies with mandatory regulatory and accrediting standards;
- Details the requirements for ensuring the confidentiality, security and integrity of patient health information;
- Specifies the essentials for maintaining medical records, to support decision making, enhance the continuity of patient care, and improve patient care and outcomes.
This policy is applicable to all SCTC physicians, nurses, clerical and administrative personnel who have access to or handle electronic and/or written (hard copy) medical records.
- The restricted access to data and information to individuals who have a need, a reason, and permission for such access.
- An individual’s right to personal and informational privacy, including for his or her health care records.
- Informed Consent: In the general practice environment consent is almost always implied by participation. If there is a situation where it is felt that a patient is in a situation where participation is not deemed to be appropriate evidence of informed consent then an attempt will be made to obtain informed consent in writing. A process of communication between a patient and physician that results in the patient’s authorization or agreement to undergo a specific medical intervention. It includes the principle that a physician has a duty to inform his or her patients about the nature of a proposed treatment, procedure, test, or research, the risks and benefits, the likelihood of success, alternative treatment or procedure and the risks involved, and the risks and benefits of not receiving or undergoing treatment. A patient, concerned for his or her own welfare and faced with a choice of whether or not to undergo the proposed treatment, test, or research, may then balance the probable risks against the probable benefits.
POLICY: All EMR regulations will apply in 2021.
- SCTC shall initiate, maintain and secure a medical record in accordance with the procedures described in this policy for every patient who registers for care and who may be assessed, treated and provided care or services by its practitioners.
- All members of staff who are specifically authorized by SCTC management may access medical records or view patient health information that may be considered confidential. Any breach of patient confidentiality is regarded by the management of SC as gross misconduct which may result in disciplinary action or termination.
- The following SCTC staff members have access to view, edit and proofread all medical records on SC premises: Dr. Rajeshree Singhania, Rebecca Grisdale, Christina Antony, Adah Nyro, Anjna Kumari, Dr. Deepa Bapat.
- 4.3 The medical record is the property of SCTC. Medical records or parts of a record may only be removed from the premises of SCTC by Dr. Rajeshree Singhania or as required by the legal authorities or Dubai Health Authority.
- It is the responsibility of all practitioners and other individuals at SCTC identified in this medical records policy as those authorized to have access to the medical records to adhere to this policy.
- SCTC Clinical Administrator is the assigned Custodian of Medical Records and is responsible for ensuring that security and confidentiality of medical records are maintained within the scope of her job description.
- The Directors of SCTC shall ensure the availability of sufficient staff and other resources to maintain a sustainable record keeping system.
- It is the responsibility of Dr. Singhania and her staff to ensure patient medical records are completed in a legible and timely manner in keeping with the requirements of this policy.
- The Directors of SCTC shall ensure compliance to all regulatory requirements concerning the security, confidentiality and integrity of patient health information. The Directors shall oversee the medical records review process to ensure record content is entered and completed in a timely, accurate, legible and authenticated manner.
Content of Medical Records
- SCTC medical records shall include sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results of treatment, and promote continuity of care from SCTC practitioners and any other healthcare provider who may subsequently provide care to the patient.
All SCTC medical records must include the following at minimum:
- Full name, address, and date of birth of the patient
- Patient’s MRN on each page of the paper record
- List of allergies with associated drug reactions or ‘No Known Drug Allergies’ or ‘None Known’. NOTE. The EMR will alert any allergies entered on opening the record once the system is in place. Medical record files are to have a red allergy sticker affixed to the front if patient has known allergies.
- Any written report received from another healthcare professional referring the patient to include referring healthcare professional’s name and address
- Date of each professional encounter with the patient.
- Address of the patient
- Guardian’s name, telephone number and email address
- Referring person or party
- Immunization records
- Record of the patient assessment by SCTC nurse/physician, including:
- Vital signs and pain levels
- Past Medical and surgical Histories
- Chief complaint(s)
- Mental, behavioural and emotional assessment, including the risk for patient abuse and neglect
- Patients’ nutritional and functional needs when applicable
- Particulars of each medical examination and/or review of systems
- Note of any investigations ordered and results of the investigations
- A record of the disposition of the patient, including:
- Indication of each treatment prescribed or administered
- Professional/educational advice given
- Particulars of any referral made by SCTC physicians
- A record of any incident related to the patient’s medical care that affected him/her even if no harm occurred or even if the incident negatively affected the patient. Examples include patient was given the wrong medication even if no harm occurred the incident should be documented in the patient’s medical record. Another example would be a patient was given wrong dosage or vaccination.
- The content of medical records after each patient encounter reflect the following:
- List of tests to be done
- Appropriate relevant history
- Appropriate physical examination
- Psychoeducational tests and test result
- Family history
- Other specific tests
- Input from school
- Input from parents
- Provisional diagnosis
- Treatment plan
- Medication file
- Therapy File
- All the above patient information is to be recorded in the patient medical file within a 3 month time frame from the patient’s first visit.
Modification of Medical Records
- Changes may be made to a medical record entry. All changes to the EMR made after the initial entry has been saved will be recorded and the original entry will be viewable by recalling the corrected entry (see EMR procedure manual)?
- The date, time, nature, reason and correction or other modified entry is documented and signed by the practitioner.
- The head nurse may be assigned responsibility for the security of the medical record files in the absence of the clinic manager
Confidentiality and Release of Patient Medical Information
- Information from the medical record is only disclosed if required by law, by DHA or as determined by standards of professional healthcare practices.
- Patients or their legal representative are to be provided access to their medical record at their request and under the guidance of their physician who can explain the content of the record. Patients may be provided a copy or a summary of their relevant health information at their request. Such requests are to be made in writing by the patient or their legal representative preferably on the SCTC ‘Request for patient health information’ form. Copies of patient health information will be provided to a third party only upon the written request of the patient or their legal representative which is to include an attached signed copy of the patient’s identification (passport, national identification). The person authorized to receive the record is required to show similar proof of identity and a copy is to be retained by the clinic. In the case of requests for a copy of the full medical record or when a medical summary is requested patients should be informed that this may require up to 2 days to complete. It is strictly forbidden to provide patient health information without the explicit consent of the patient to any other party other than those permitted by law or regulation.
- SCTC shall report to DHA patient health information as required and in accordance with UAE and DHA regulations and requirements.
Retention of Medical Records
- SCTC shall comply with and adopt the regulatory requirements of DHA Medical Records Policy Retention section which are as follows:
- The medical records shall be retained for a period of a minimum of ten (10) years after the date of last entry into the record for U.A.E Nationals.
- Once scanned, the medical records shall be retained for a period of a minimum of ten (5) years after the date of last entry into the record for Expatriates.
- The medical records of medico-legal cases shall be retained for a minimum of twenty (20) years and destroyed.
- The medical records of deceased patients shall be stored for 5 years and destroyed.
Transfer of Medical Records
- Original medical records are the property of SCTC and are not to be removed. If an SCTC practitioner relocates or ceases to practice at SC the medical records remain in the custody of SCTC.
- In case SCTC plans to cease operation all medical records under its custody will be managed in accordance with DHA regulations and shall be maintained for a minimum of two years. During that period, SCTC shall inform DHA about its decision and shall either keep the records with a designated custodian at the same SCTC contact information or shall transfer custody of the record to the patient after notification.
Destruction of Medical Records
- SC shall retain its medical records as specified in 6.6.1 after which it will be considered for destruction.
- Approved destruction method for the hard copy medical record is shredding and electronic full deletion (electronic shredding) for the EMR. Once the medical record is identified for destruction IMC will attempt to notify patients prior to the destruction of their records either through SMS or email. Patients will be notified two months in advance. Should there be no reply from the patient after two weeks then a reminder will be sent within six weeks after which the medical record will be destroyed.