Further to the acceptable norm for medical record contents, and qualified by the JCI Standard MCI.19.1 which states that “The patient clinical record contains sufficient information to identify the patient, to support the diagnosis, to justify the treatment, to document the course and results of treatment, and to promote continuity of care among health care practitioners”, HIM/MR practitioners in Malaysia need to take note that the Malaysian Medical Council (MMC) recommends the following items which may make up the contents of a patient’s medical record – perhaps other countries also have similar guidelines :
- Doctor’s clinical notes
- Recording of discussion with patient/next of kin regarding
disease/management/possible use of tape recording for such discussions - Referral notes to other specialists for consultation/co-management
- Laboratory reports
- Imaging records and reports
- Clinical photographs
- Drug prescriptions
- Nurses’ reports
- Consent forms
- Operation notes/anaesthetic notes
- Video recordings
- Printouts from monitoring equipment
- Correspondence with other healthcare professionals
- Computerised/electronic records
- Recordings of telephone consultations.
Source: mmc.gov.my/v1/
