Code of Practice for Private Hospitals, Nursing Homes and Maternity ...

Chapter 10
Medical Records
10.1 Overview
A comprehensive medical record is maintained for each patient. The
record is a contemporaneous record of all treatment provided by all
health professionals. It enables the health team to provide continuing
care to the patient. Please refer to the section of “Medical Records” in the
“Professional Code and Conduct” issued by the Medical Council of
Hong Kong.
10.2 General Requirements
10.2.1 All medical records are accurate, sufficiently detailed, legible,
current, complete and organised to enable -
(i) the medical practitioner responsible for the patient to
provide continuing care to the patient, to review the
diagnostic and therapeutic procedures performed and the
patient’s response to treatment;
(ii) another medical practitioner to assume the care of the
patient at any time or at times of emergency; and
(iii) the retrieval of information required for review and quality
assurance activities.
10.2.2 The patient’s name in full, patient / hospital number or
alternative identifier are displayed conspicuously on the record
sheet for easy identification. The record of the patient comprises
the following but not limited to -;
(i) notes of all medical practitioners, allied health
professionals and their identification, who have attended
the patient in the establishment, e.g. admission notes,
consultation notes and progress notes;
(ii) prescription order form;
(iii) observation charts and fluid balance charts;
(iv) drug charts and history of allergy;
(v) reports of laboratory, radiological and diagnostic
services;
(vi) films or clinical photos;
(vii) consent forms;
Code of Practice for Private Hospitals, Nursing Homes and Maternity Homes 42