AIIMS Delhi NO- 2019
Nursing Management
Hard
Patient's Medical record with all essential information is responsibility of:
Appeared in: AIIMS Delhi NO- 2019
Explanation
- The Medical Superintendent is the head of the hospital's medical administration and holds the ultimate responsibility for all institutional operations.
- This includes overseeing the Medical Records Department (MRD) and ensuring the entire system for creating, storing, securing, and retrieving patient records is effective and compliant with legal standards.
- While individual healthcare providers contribute to the record, the Superintendent is accountable for the integrity and management of the records as a whole.
- This overarching responsibility includes establishing record-keeping procedures, training staff, and ensuring patient confidentiality is maintained at an institutional level.
Why Other Options Were Wrong
- Option A: The patient is the subject of the medical record and has rights to access it, but they are not responsible for its official maintenance, storage, or security.
- Option B: The term 'Director' is too vague. A hospital may have many directors (e.g., Nursing Director, Finance Director). 'Medical Superintendent' is the specific title for the administrative head of a hospital responsible for such matters.
- Option C: The treating doctor is responsible for the clinical accuracy and completeness of the information they enter into the record. However, their responsibility is primarily for the content of the documentation, not the overall administrative and legal management of the hospital's entire record system.
Related Visual
Clinical Relevance
- Nursing practice connection: Use the key finding related to Administrative and Legal Responsibility for Medical Records to guide bedside assessment, documentation, and the next nursing action.
- Proper medical record management is fundamental to patient safety, ensuring continuity of care, and preventing medical errors.
- Accurate and complete records are a healthcare provider's best legal defense in cases of alleged malpractice. They serve as the official evidence of the care provided.
- What if? If a court subpoenas a patient's record for a legal case, the request is formally handled by the hospital administration under the authority of the Medical Superintendent, not by the individual treating doctor. This highlights the institutional nature of the responsibility.
How to Approach the Question
- First, identify the core of the question: it asks about the overall 'responsibility' for the medical record, not just who writes in it.
- Consider the scope of each role. A 'Patient' is the subject, not the manager. A 'Director' is too general.
- Differentiate between the 'Treating doctor' and the 'Medical superintendent'. The doctor has a direct, content-level responsibility. The superintendent has a higher-level, systemic, and administrative responsibility.
- Recognize that questions about institutional policy, legal compliance, and overall management usually point to the highest administrative authority listed.
- Select the option that represents the ultimate accountability for the entire system, which in a hospital setting is the Medical Superintendent.
Concept Tested & Keywords
- Concept Tested: Administrative and Legal Responsibility for Medical Records
- Stem keywords: Patient's Medical record, essential information, responsibility
- Lead-in keywords: responsibility of
Question ID
Q9hJnriEOgr8kk549LcwQY
Reference Book
E6 Principles and Practice of NURSING Management Leadership for BSc Nursing 3rd Edi Jogindra Vati — Subpart B (pp 340-678 of 1017) pp. 320-322, 319-321
E6 Kaplan Sadock's Synopsis of Psychiatry-2022 (pp 1-3768 of 3768) p. 108-110
Practise the full AIIMS Delhi NO- 2019
Attempt every question from this paper in a timed mock, then review the full solution for each one.
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