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Medical Records

The document defines medical records and their importance. Medical records consist of clinical data documenting a patient's history, examinations, diagnoses, treatments, and outcomes. They serve as clinical, scientific, administrative, and legal documents. Good medical records are complete, adequate, and accurate. Records are important for patient care, hospitals, doctors, and public health authorities. Electronic medical records (EMRs) provide longitudinal, integrated patient information across care settings.

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1K views

Medical Records

The document defines medical records and their importance. Medical records consist of clinical data documenting a patient's history, examinations, diagnoses, treatments, and outcomes. They serve as clinical, scientific, administrative, and legal documents. Good medical records are complete, adequate, and accurate. Records are important for patient care, hospitals, doctors, and public health authorities. Electronic medical records (EMRs) provide longitudinal, integrated patient information across care settings.

Uploaded by

pdamodar2007
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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Medical Records

Definition

 Clinical, scientific, administrative and


legal document relating to patient care
consisting of data written in sequence to
justify diagnosis and warrant treatment.
 Characteristics - adequately informative,
highly scientific, and legally protective
 It can be simply defined as a systematic
documentation of a patient's personal
and social date, history of his ort ailment,
clinical findings, investigations,
diagnoses, treatment given and an
account of follow up and final outcome
A medical record serves as:

 A clinical document- listing the clinical


history, physical examination,
investigations, nursing records
 A scientific document- because it is used
to study the patient’s condition and
progress through scientifically practices
medicine and for research
 A administrative document- it helps
administrative control, planning of
services, budgeting, improving quality of
care, hospital statistics
 A legal document- admissible under
Indian Evidence Act in courts in
defending malpractice suits, hospitals
and its clinicians
Importance
 To patient – diagnosis , treatment, evidence,
 To hospital – statistical data, evaluation of
care and quality, legal protection
 To doctor – assures quality, continuity of care,
self evaluation, education and research
 To public health authorities – mortality and
morbidity statistics, plan preventive measures,
evaluate health status
Good medical record

 Complete in form- sufficient data to


identify the patient, justify diagnosis,
treatment, follow up and outcome
 Adequate in content- with all necessary
forms, all clinical information and
 Accurate in facts- capable of quantitative
analysis
Types

 Out patient records


 In patient records
Medical record department
 Receiving and assembling in chronological
order
 Deficiency check – delinquent M R
 Completion desk
 Coding desk
 Indexing desk – disease, physician, unit
 Analysis desk
 Numbering and filing
 Storage
Ownership

 Personal document – confidential and


privileged document, when info can be
released, to relatives, to press, to
insurance, police, courts
 Impersonal document – education,
research, public health
Filing

 Recommended size- 8 x 11
 Properly organizing the documents of
each patient
 Identifying each record. Indexed
alphabetical, numerical, serial unit,
terminal digit
 Placing the record file in cabinets/ shelf
Retention

 Need for patient – 10 years


 Medico legal: inpatient- 10 years,
outpatient- 5 years
 Teaching/ research- 5-10 years
Other functions
 Assembling of records
 Patient Index
 Coding (ICD for disease, to provisional
diagnosis (at the time of admission), to death
certificate)
 Indexing (diagnostic)
 Filing (with tracer card)
 Reporting to the government agencies about
health statistics
EMR
 An EMR is electronically maintained
information about an individual’s lifetime
health status and health care
 Not mere automated health forms, it
encompasses information in all media forms
 EMR system facilitates capture,storage,
processing, communication, security and
presentation of non-redundant health data.
EMR

 Paper based record is admission


centered
 EMR is longitudinal, patient-focused and
integrated delivery system
 Provides flexibility, search ability, and
Decision Support System
EMR

 Customizable
 Serves multiple legitimate users
 Care continuum
 Life long health status
 Integrated
 Effective Management Information
System
 Universal Accessibility
 Informed Decision Making
 Specialty Specific Customization
 Ensured Compliance
 Interpretive Reporting
 Integrated Workflow
 Scope for Research Initiatives

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