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 patient’s 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.

Cont…Definition

• 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

Cont…Purpose 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

• Planning developing and directing a medical record that includes patient’s 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.

Cont…

Processing of Medical Records

• Coding

• Indexing

• Storage and Retrieval of medical

records

• Filling system

Cont…

• 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.

Cont…

Coding

• 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.

Cont…indexing

Indexing

• 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.

Cont…indexing

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