Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                
Scribd Logo
Upload

Welcome to Scribd!

  • 684 views

    Medical Records

    Uploaded by

    pdamodar2007
    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.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd

    Medical Records

    Uploaded by

    pdamodar2007
    684 views17 pages
    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.

    Original Title

    MRD

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PPT, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    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.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    684 views17 pages

    Medical Records

    Uploaded by

    pdamodar2007
    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.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 17

    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

    You might also like