Medical Record (WHO)

 

Medical Records – WHO Guidelines Overview

1. Definition

A medical record is a systematic documentation of a patient’s medical history and care, created by healthcare professionals to ensure continuity, safety, and quality of care.

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2. Key WHO Recommendations

✅ Completeness and Accuracy

• Should include identification data, medical history, physical examination findings, diagnostic test results, treatment plans, progress notes, and discharge summary.

• Entries should be legible, dated, timed, and signed by the responsible healthcare provider.

✅ Confidentiality

• Patient information must be kept confidential, shared only with authorized personnel, ensuring compliance with data protection laws and ethical standards.

✅ Accessibility

• Records must be readily available to authorized users for patient care, audits, research, and legal purposes.

✅ Standardization

• Use standard formats and terminologies for consistency (e.g., ICD coding for diagnosis).

✅ Retention and Preservation

• Records should be retained for an adequate period (varies by country; usually at least 5-10 years after the last visit or death).

• Should be stored securely to prevent damage, loss, or unauthorized access.

✅ Electronic Health Records (EHR)

• WHO encourages adoption of EHR systems for better integration, data analysis, and continuity of care while ensuring data security.

✅ Patient Rights

• Patients have the right to access their medical records, request corrections if needed, and understand their care plan.

✅ Legal and Ethical Considerations

• Records are legal documents and can be used as evidence in courts.

• Must adhere to ethical guidelines, local laws, and institutional policies

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 Essential Components in Medical Records

✔ Patient identification (name, age, sex, ID)
✔ Presenting complaints and history
✔ Examination findings
✔ Diagnostic test results
✔ Diagnosis (provisional and final)
✔ Treatment plans and orders
✔ Progress notes (daily updates)
✔ Operative and procedure notes
✔ Consent forms
✔ Nursing notes
✔ Discharge summary
✔ Follow-up plans