Patient record system

By- Rahul Dhaker M.Sc. Nursing II year

Introduction

 The medical records is a clinical, scientific, administrative and legal document relating to patient care in which are records sufficient data written in sequence of events to justify the diagnosis and warrant treatment and the end result.
The medical record benefits the patients, the doctor, the hospital and public health authorities and contributes to education and research.

Definition
Medical records is defined simply as a systematic documentation of patients personal and social data, history of his or her ailment, clinical findings, investigation, diagnosis, treatment given, and an account of follow up and final outcome.

ContDefinition

A medical records document serves as: a clinical document- listing the clinical history. Physical examination, investigation,

nursing records, etc.

Characteristics Of Good Medical Records

Cont. Characteristics Of Good Medical Records

Complete Adequate Accurate

Purpose and Scope of Medical records

ContPurpose and Scope of Medical records

Admission from Case sheet containing To the patient To the clinicians To the hospital and hospital administration To public health authorities To medical education and research

Benefits of Medical Records

Cont

Benefits of patient
Benefits of Hospital

Benefits of Doctor
Benefits of Public health authorities Benefits of medical education and research

Function of medical records department

Cont

Planning developing and directing a medical record that includes patients original clinical records and also the primary and secondary records and indexes. These may be in the central record room, the clinical service area, adjunct department, to the outpatient department of the hospital Maintaining proper facilities and services for accurate and timely production, processing, checking, indexing, filing and retrieval of medical records.

Cont

Developing a procedure for the proper flow of records and report among the various services and departments, including clinical services and the outpatient clinics where they are needed. Developing a statistical reporting system that include ward, consolidated daily census, outpatient department activities, and statistics in relation to services such as radiology, clinical laboratories and pharmacy.

Cont

Coding all diagnoses and operational according to

international classification of disease for statistical

purpose.
Safeguarding the information in the medical

records against theft, loss, defacement, tampering

or use by unauthorized persons.

Cont

Determining in coordination with medical staff and

administrating the action to be taken in medico-

legal cases relating to the released of medical

records in a variety of situations and determining

the legality and ethical appropriateness of such

action of conformity with the laws of the land.

Processing of Medical Records

Cont

Coding
Indexing Storage and Retrieval of medical

records
Filling system

Cont

Coding
Coding of the disease is done as per the
international classification of the disease; for making nation and international

comparisons. This is to bring uniformity

in classification of the disease.

Contindexing

Indexing
Alphabetical Indexing- Patients name
sequenced in alphabetical order. Disease index- The medical records, are of

patient having the same diagnosis is placed

at one place.

Contindexing

Unit indexing- unit wise indexing of medical records are done like cardiology, nephrology or unit I or unit II of surgery department. Physicians index- all patients treated by a particular physician are indexed. Operation index- details of patients, who have undergone surgery, are indexed.

Storage and Retrieval of medical records Storage

Compactness Easy accessibility Simplicity for understanding Elasticity for expansion Economical Easily retrievable Safety from fire, month insects and dampness. Controllability

Filling system
Centralized system- All the medical records whether OPD or IPD are filed in medical records department of the hospital.
Decentralized- In this system the OPDs have their own records department. If a patients is transferred from one department to another department, the file is transferred on loan basis.

Conclusion

Bibliography
Syed Amin Tanish. Hospital and Health services, Administration Principal & Practicrs. 1st edition. Oxford University Press. Page No:- 317-322 BM Sakharkar. Principal of hospital administration & planning. 2nd edition. Jaypee brother medical publisher(P) Ltd. Page no.- 223-230 G.D. Kunders. Hospital facilities planning & management. 13th reprint 2011 Tata Mc Graw hill education private limited, New Delhi. Page no.- 337-344 D C Joshi and Mamta Joshi. Hospital administration. Jaypee brother medical publisher(P) Ltd. Page no.- 309-317