Patient Record System....

 

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 

 

Cont… 

• 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, ro om, 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.

a statistical system that include • Developing ward, consolidated dailyreporting census, outpatient department activities, and statistics in relation to services such s uch as radiology, clinical laboratories and pharmacy.

 

Cont… 

• Coding all diagnoses and operational accordin according g to international classification of disease for statistical

purpose.

• Safeguarding the information in the medical records against theft, loss, defacement, defacement, tampering or use by unauthorized persons.

 

Cont… 

• Determining in coordination with medical staff and administrating the action to be taken in medicolegal 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.

 

Cont…indexing

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.

 

Cont…indexing

indexing- unit wise indexing of medical records are • Unit indexingdone like cardiology, nephrology or unit I or unit II of  surgery department.

• Physicians indexindex- all patients treated by a particular physician are indexed.

• Operation indexindex- 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 whetherdepartment OPD or IPD arehospital. filed in medical records of the

• 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 h ospital 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