Series: Understanding MSDS | Post 18 of 52
Standard 6 (IMS-1) | Indicator 15 | Category: YELLOW (80% required)
Four Men Named Muhammad Akram
Dr. Rukhsana Iqbal had kept a patient register at her family clinic in Gujrat since the day it opened. Her receptionist, Kashif, wrote one line per patient: name, age, and a word about the complaint.
The PHC assessor turned the pages slowly.
“Doctor, a patient named Muhammad Akram came to you in March with high blood pressure. Could you show me his record?”
Kashif searched. There were four entries for Muhammad Akram between February and April. None had a father’s name. None had a serial number. Two had no age, and one had no complaint written at all. Nobody could say which of them, if any, was the man with high blood pressure, or whether all four were the same person.
Across the sampled pages, most lines had no address, contact number or treatment.
“The register exists,” the assessor said. “But it cannot tell me who anyone is.”
With the deficiency well beyond one in five records, Indicator 15 was scored as not met.
What Indicator 15 Requires
The indicator reads: Every patient’s record has a unique identifier and particulars for identification.
The surveyor checks that a system of record keeping, computerised or manual, is in place. Each patient record should contain:
- Serial number and date
- Name, and parentage or husband’s name
- Age and gender
- Address, and CNIC or contact number
- Symptoms or provisional diagnosis
- Treatment provided or advised
- Referrals, if any
The manual provides a suggested format in columns, including date, time, unique number, name, parentage, age, gender, weight, address, allergy, symptoms and history, findings and treatment.
One Patient, One Number
The guidelines state that all documents of a patient must be consistently labelled with one unique number, so that each patient has only one record number, one clinical record and no duplicates. A computer or manually generated serial number is described as the easiest and most accurate method.
The manual separates patient characteristics that do not change, such as full name, CNIC number, gender, date of birth, father’s first name and mother’s first name, from those that do. Address and age can change, so they are not permanent identifiers. Birthplace should not be used.
How Long Records Are Kept
Patient records should be maintained in the clinic for at least one year for general records. Records of vital events are kept lifelong, and medico-legal cases for 12 years or longer, as required. Where another law requires longer retention, that law applies.
How It Is Scored
This is a YELLOW indicator with three possible outcomes.
Fully met: the patient record is maintained as described.
Partially met: the record is maintained, but the information is deficient by about 20% only.
Not met: no record is maintained, or the deficiency is more than 20%.
Why It Matters
The manual describes the purpose of the clinical record as preserving the truth. A complete and accurate record protects the legal interests of both the patient and the doctor. When a question arises about the care given, the record is the evidence. A register that cannot tell one Muhammad Akram from another cannot defend anyone.
What Dr. Rukhsana Changed
She replaced the old register with a new one ruled into columns following the manual’s suggested format. Every new patient now receives a serial number at the reception, written on the register and on the patient’s slip.
Kashif was told to ask every patient for the father’s or husband’s name and a contact number or CNIC. Returning patients bring their slip, and the same number is used again, so a patient’s visits stay under one number.
Dr. Rukhsana began writing the provisional diagnosis, treatment and any referral in the register herself at the end of each consultation.
At reassessment, the assessor picked five patients at random. Each could be traced by number across every visit. Indicator 15 was fully met.
A Quick Self-Check
- Does every patient have one unique number that stays the same on every visit?
- Does each record include parentage or husband’s name, age, gender, address and CNIC or contact number?
- Are symptoms or provisional diagnosis, treatment and referrals recorded?
- Could you find a specific patient’s record from three months ago in under a minute?
- Are old records retained for at least one year, and longer for vital events and medico-legal cases?