Health Record Guidelines - Dubai Health Authority

Table of ContentsAcknowledgment 31. Scope 42. Purpose 43. Definitions 44. Acronyms 6SECTION ONE: GENERAL REQUIRMENTS 71. Facility Record Keeping Requirements 72. Health Record Contents and Electronic Format 73. Telephone or Verbal Orders 74. Methods of Documentation 8SECTION TWO: SPECIFIC HEALTH RECORDS REQUIRMENTS 95. Health Records Contents 96. Informed Consent 107. In Patient Health Records Contents 108. Surgical Contents 119. Medical Contents 1110. Nursing Records 1111. Obstetric Content 1212. Newborn Content 1313. Discharge Summary 1314. Patient Access and Release of Patient Information 1315. Records Detail with Negative Impact 1416. Emergency Record 1417. Record completion 1418. Changes, Corrections, or Other Modifications in Health Record 1419. Retention of Health records 1520. Destruction of Health records 1521. Compliance with these guidelines: 16References 17Health Record Guidelines Page 2 of 17 Ref. No. HRD/HRS/FRU010