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Medical Records:Purpose, Use and

Value

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Definition

set of information about health status of a patientwhich acts as a media to establish effectivecommunication within a treatment provided

presents medical history and status of the patientwhich also have educational and research value

can also be used as a tool for follow-up andsupervising treatment procedures in the community.

accurate, valid, updated

physicians, nurses and/or clerical staff and thewhole treatment provider team

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Content

admission anddischarge summary

medical history andphysical examination

physician's order

progress note

laboratory reportattachment

radiology report

electrocardiogramattachment

consultation request

vital signs

composite graphic chartfluid balance chart (24

hours)

pre-operation care

anesthesia record

operation report

pathology report and

unit summary sheet.

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Uses

A Demographic information(including unit number, patient's nameand family name, father name, date ofbirth, location of birth, address andphone number)

B Administrative informationadmission information (including dateof admission, admitting physician,

ward, room and bed number)

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Uses

C Diagnostic and treatment procedures

(including physical examination,laboratory and radiological tests, medicalorders and surgical interventions)

D Identification information of diagnosisand treatment provider (name and familyname of physician and nurse, signature,seal, date and time)

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Uses

1. Patient Management and Services

2. Financial Reimbursement

3. Management Planning4. Utilization Review and Quality Assurance

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Uses

5. Research

6. Legal Affairs

7. Education

8. Accreditation

9. Public Health

U.S. Office of Personnel Management, Medical RecordsAdministration Series GS-0669 TS-102 March 1991

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Patient care management

- to diagnose and treat illnesses and documentmedical care services provided the patient.

- Documents the course of the patients illnesses and

treatment during each episode care

- Communicates between the physician and other health

professionals providing care to the patient

- Informs health professionals providing subsequent care

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Patient care management

To the Patient

- Medical records contain regarding a patients pastand present health

- It presents documentation by health professionals ofthe patients current condition in the form of

physical findings, results of diagnostic andtherapeutic procedures and the patients responses

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Financial reimbursement

substantiate insurance claims of health facilities andpatients and to ensure reimbursement under local

and national medical programs

To insurance companies

- Information pertaining to patients illness and injurycan be given to the insurance company uponpresentation of patients authorization to releaseinformation

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Planning and marketing

help administrative and medical staff in planningservices and determining resources

identifies data necessary for selecting and

promoting facility services

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Legal affairs

Provides data to assist in protecting the legal interests of

the patient, the physician and the health care facility

To government agencies

- pending claims by a patient

- Information from the records requested by a governmentagency is not allowed without the patients authorizationor a written request signed by the facility head. If suchagencies desire to review the record, a subpoena shouldbe served to the hospital.

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Legal affairs

To employer of patient

- Employer without authorization from the patient is

not entitled to information except for the dates ofadmission and discharge

- It is permissible to transmit information

confidentially to a company physician caring for thepatient after hospital discharge, but suchinformation is not the property of the personneldepartment or the company management

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Legal affairs

To news media

- All calls and inquiries from any type of news, mediawill be referred to the patients relations office

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Education

to provide actual case studies for the education ofhealth professionals

To educators, research and public healthofficials

- data which can assist health professionals and

students in to learn about patient care and diseaseprocesses

- Used in furthering medical research by supplying adatabase evaluating the effectiveness of treatments

for specific diseases

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Education

provide data for reporting vital events such as birthsand deaths to the public health agency in each cityor municipality

provide data for reporting certain diseases such ascommunicable diseases existing in each locality inaccordance with the requirements set to protect thehealth of the individual and the public

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Accreditation

to provide the factual data necessary foraccreditation and licensure.

To the health care facility

- Provides data of the performance of healthprofessionals working in the health care facility

- Evaluates use of the facilities resources such asspecial diagnostic equipment and services offeredby the facility

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Accreditation

Used in surveys by licensing, certifying, and

accrediting agencies in evaluating care which thefacility provides, and determining compliance withstandards by the respective agencies

For continued participation in health insuranceprograms, the medical records maintained by afacility are reviewed to determine compliance withstandards regarding medical content

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Public health

to identify disease incidence to formulate plans toimprove the overall health of the nation or world.

Statistics can be developed as the data gatheredfrom the records to document the need of the

municipality or city, national and world healthprograms

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Ownership

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Date Activity Topic

Nov. 24 Lecture Use & Ownership

Dec. 1 No ClassDec. 8 Reporting 1 Resp. Admin & Rec. Dept.

Dec. 15 Reporting 2 Resp. Med/Nur Staff & Rec.Com

Jan. 5 Reporting 3 Data Coll. & Assembly

Jan. 12 Reporting 4 Rec. Flow & Health Info Sys

Jan. 19 Reporting 5 Filing & Storage

Jan. 26 Quiz Review for Midterms

Feb. 2 Midterms and short disc. on guidelines

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