A. Aim:
1. To establish guidelines for the contents, maintenance, and confidentiality of patient Medical Records that meets the requirements of DHA.
2. To maintain patient medical records, in order that individual practitioners and maintain the highest standard of professionalism and effectiveness in documenting the patient care provided
B. Purpose:
1. All employees are provided with complete and comprehensive information regarding documenting requirements for the best quality medical record.
2. To provide current information on the care and condition of the patient.
3. To be headed with standardized patient identification information.
4. To document communication/ contact with the patients family/ related to treatment or care
5. To include any
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Medical/Dental Abbreviations: Non approved abbreviation must not be used on the medical records.
A list of the approved medical and dental abbreviations on medical records should be available and accessible to all the medical staff at the facility. 12 Patient transfer and Referral
o The patient and the outpatient care facility have the right to change or transfer the patient care responsibility from one healthcare professional to another with clear justification. o Patients and their families have the right for knowledge and health education in order to assist them to participate in care and take decisions about their health status. o All information relevant to a patient should be readily available to authorized healthcare professionals or in the event that a patient is transferred.
Transfer order:
The transfer of a patient from one service to another and / or from one physician to another requires that transfer order be written on the physician’s notes.
The order must be legibly timed, dated and signed.
Transfer note:
A transfer note must be written in the physician notes for transfers between services within the