An electronic patient record should contain, at a minimum, the patient’s identification, medical history, consultations, prescriptions, test results, clinical reports and admission history, with a date and an author attached to every entry. The goal is simple: a clinician who has never met the patient should understand their situation within minutes. Here is the essential content, section by section, and a method for checking the quality of your records.
Key takeaways
- Seven sections form the core: identification, history, consultations, prescriptions, tests, reports and admissions.
- Every entry is dated and linked to its author.
- Reliable identification underpins everything else.
- Each professional only sees the information their role requires.
- A monthly check on a sample of records beats a rule nobody verifies.
The 7 sections of an electronic patient record
An electronic patient record is not a paper register copied onto a screen. It is the organised memory of the patient’s care, shared between registration, doctors, nurses, the laboratory and the pharmacy. The table below sets out the minimum content.
| Section | Essential content | What it is for |
|---|---|---|
| Identification | Surname, other names, sex, date of birth, phone, address, next of kin, cover (NHIS in Ghana, NHIA or HMO in Nigeria) | Finding the right patient and the right record |
| History | Medical and surgical history, known allergies, long-term medication | Making sure known information is not ignored |
| Consultations | Date, reason for visit, findings, diagnosis, decision | Following progress from one visit to the next |
| Prescriptions | Medicines, dosage, duration, prescriber | Knowing what was prescribed, by whom and when |
| Tests | Laboratory and imaging requests and results | Having results available when decisions are made |
| Reports | Operative, inpatient and discharge reports | Passing information to colleagues and to the patient |
| Admissions | Admission, ward, bed, transfers, discharge | Tracing the patient’s journey through the facility |
Example: a patient followed for a chronic condition at a clinic in Takoradi comes back after six months. The doctor on duty, who has never seen him, finds his history, his latest test results and his current treatment on a single screen. There is no need to take the full history again.
Identification: the foundation of the record
Every other section depends on identification. If the same patient has two records, their results and history are split, and the doctor decides on incomplete information. Set a written data-entry rule: surname first, spelling checked against an ID document where one exists, and phone number confirmed at every visit.
Example: a polyclinic in Abuja notices that reception sometimes records a patient’s everyday name instead of the name on their ID. The same patient then appears under two names. The rule “name on the ID first, everyday name as an addition” solves the problem. For more, see our article on unique patient identifiers and duplicate records.
Clinical data: history, consultations, prescriptions and tests
History that is up to date, not just filled in
History and known allergies should be visible as soon as the record opens and updated at every visit. An allergy noted in an old consultation, but missing from the dedicated section, is information lost.
Consultations with a consistent structure
Using the same template for every consultation makes notes easier to read: reason for visit, findings, diagnosis, decision, planned follow-up. Free text remains useful, but a shared structure lets a colleague find the essentials without reading everything.
Prescriptions and tests linked to the record
Every prescription and every test request is linked to the record, with the prescriber’s name. Laboratory and imaging results come back to the same record instead of circulating on loose sheets. Example: in a district hospital, a result filed in the right record saves the patient a second trip to the laboratory because the paper copy went missing. Our best practices for digital prescriptions cover this in detail.
Who writes what: traceability and confidentiality
An electronic patient record is only valuable if you know who wrote each entry and when. Every entry is dated and linked to an identified user. A correction never erases the original information: it adds to it, with the date and the author of the change.
Confidentiality follows the same logic. Registration needs administrative details, not the diagnosis. The laboratory needs test requests, not the full history. In Nigeria, the Nigeria Data Protection Act 2023 governs the processing of personal data, under the oversight of the Nigeria Data Protection Commission. In Ghana, the Data Protection Act 2012 (Act 843) plays a similar role, with the Data Protection Commission. We cover these obligations in our article on health data protection in West Africa.
Example: a clinic in Accra creates a personal account for every staff member and closes the shared “reception” account. When a data-entry error appears, the team now knows who to talk to about correcting it.
Check the quality of your records in 5 steps
A record-keeping rule is useless if nobody checks that it is applied. A simple monthly check is enough to help teams improve.
- Pick a small random sample of records of patients seen the previous month.
- Check the essential sections in each: complete identification, history filled in, structured consultation, prescriptions linked to their author, results present.
- Note the gaps in a simple grid, department by department.
- Present the findings at a department meeting, without blaming anyone.
- Set one or two improvements for the following month, then repeat.
Example: a medical centre in Tamale discovers during its first check that allergies are rarely recorded in the emergency department. It adds the question to the admission form, and the next check shows the improvement.
Patient records and MediFlow
MediFlow does not yet offer electronic patient records: this module is planned. Today, MediFlow covers on-call management (rosters, attendance, lateness, handovers, operational checks) and the stock room (catalogue, stock movements, inventories, batches, expiry dates, reorder alerts, stock-out forecasts).
The seven sections described in this article remain a good grid to assess any tool, and to organise your paper records now. The demo shows you the modules available and the status of the next ones.
Frequently asked questions
Does an electronic patient record completely replace paper files?
Not overnight. During the transition, old paper files stay archived and available. A common approach is to transfer the key medical history into the electronic record at the patient’s first visit after go-live, rather than re-entering everything at once.
How long must patient records be kept?
Retention periods depend on each country’s regulations and on the type of document. Check with your Ministry of Health and your national medical council, then write the rule you adopt into an internal procedure.
Who is allowed to view a patient’s record?
Only the professionals involved in the patient’s care, each according to their role. Registration sees administrative details, the laboratory sees the tests that concern it, and the treating doctor sees the clinical record. Shared accounts should be banned, because they make it impossible to know who viewed or changed what.
Want to see how MediFlow fits your facility? Request a free demo.