Medical Records: Intro, importance, characteristics & issues

Unit-I
 Introduction of Medical Record:
 Meaning,
 Definition
 Significance of medical record;
 Value of medical records to
 patient,
 hospital,
 doctors,
 medical education and
 research,
 Characteristics of good medical Record,
 Issues related to medical record

Meaning
 Systematic documentation of a single patient's
medical history and care across time within one
particular health care provider's jurisdiction
 A MR is clear, concise, and accurate history of
patient’s life and illness, written from the health
and medical point of view. The story of patient’s
illness narrated by the patient, observations made
by nurses and the comments and treatment given by
the doctors are recorded in the medical record. Thus,
the MR comprises three general sections.

Definition
 medical record n.
A chronological written account of a patient's exa
mination and treatment
that includes the patient's medical history and co
mplaints, the physician’s
physical findings, the results of diagnostic tests a
nd procedures, and
medications and therapeutic procedures.

Significance
 To reconstruct the essential parts of each patient contact,
without the need to refer to memory
 Easier for health professionals to carry on where a
colleague left off
 Need for continuity of care for the patient is the main
reason
 For defending a complaint or clinical negligence claim,
given the insight that they provide into the clinical
judgment that was exercised at the time
 Not only relevant clinical findings, but also the decisions
made and agreed actions, in addition to who is making
and agreeing these decisions
 Include the information that patients have been given,
any prescribed drugs or other treatment or investigation
and who is making the record and when

continued
 The Medical Record is useful to the Patient for
his/her further follow-up and treatment.
 The Medical Record safeguard the Physicians
and Surgeons from the integrity.
 The Medical Record is useful for Teaching for
Postgraduates and undergraduates.
 The Medical Record is useful for Research
purpose
 The Medical Record is useful for the Health
Programme for controlling the epidemic
diseases.
 The Medical Record is useful to the
Administrator to manage the Hospital and use
this as yardstick for controlling the Hospital.

Clinicalrecordsincludea
widevarietyof
documentsgenerated
whichincludes:
 Handwritten clinical notes
 Computerized/electronic
clinical records
 Emails
 Scanned records
 Text messages (both
outgoing from the
NHS/professional and
incoming from patients)
 Correspondence between
health professionals
 Laboratory results
 X-ray films and other
imaging records
 Photographs
 Videos and audio
recordings
 Printouts from monitoring
equipment, particularly in
anesthesia and obstetrics,
A&E and ICU
 Consent forms.

What is a medical record ?
• It is a document containing sufficient data written in
sequences of events to justify the diagnosis, and
warrant the treatment given and the end results.
Importance of medical record:
• Contributes professional care rendered to the patient.
• Reflect the quality care rendered by the institution.
Differentiation of the medical record:
• In-patient record.
• Out-patient record.
• Emergency record

Medical Records: Intro, importance, characteristics & issues

Patient
 Significant illnesses and medical conditions, including
documentation on lab findings, diagnoses, and
treatment plans.
 Paperwork to document services performed by medical
professionals including dates, times, attending medical
personnel, admittance and discharge reports,
prescriptions, and any other related medical and lab
reports.

Hospital
 Data building
 Legal importance
 Trends in diseases
 Census
 Use of medicines/ surgeries most performed/
instruments
 Financial decisions based on consumption data

Doctors
 Biographical data including any history of alcohol use,
drug abuse, and smoking, in addition to physical
exams, allergies, medications, and any adverse
reactions.
 Preventive therapies such as immunizations and
screenings.

Medical
Education
 Case Studies
 History of previously done interventions- failed and
worked ones
 Provides a base for practical (more than theory in
books)
 Most current information available
 Verified data on certain things available for projects/
research

Research
 Provides primary and secondary data for literature
review and studies like cohort studies/ case-control
studies
 Reflects changes in trends in healthcare
 Statistically calculable data on descriptive diseases/
cases
 Quality and quantity data
 Also helps in concluding hospital’s internally required
facts based decisions like which specialties to be
started/ closed/ how many physicians/ nurses required/
patient complain trend- quality program/ operations
research, etc.

Research
(Statistics)
 PROOF OF WORK DONE
 FOR CURRENT AND FUTURE PLANNING
 DISEASE /PROCEDURE INCIDENCES
 OUT PATIENT TURN OUT
 BED OCCUPANCY RATE
 AVERAGE LENGTH OF STAY
 DEATH RATE
 DEATHS UNDER 48 hrs.
 DEATHS MORE THAN 48 hrs.

Characteristics
ofgoodmedical
Record
Good Medical
Record
• Accurate
• Complete
• Timely
• Contents
• Chronology
• Continuity
• Promptness
• Authentication
Documentation in
Medical Records
• Legible
• Readable
• Acceptable
• Timely
• Consent recorded
• Error free
• Reproducible

Essentials of MRM:
• Comprehensive: the records should be
such as can be easily understood when
retrieved for planning, policy making and
decision making. The language used
should be simple and legible.
• Properly planned: The records are
screened at regular intervals of time to
remove or discard the information not
required for future. In this way, we can
reduce the paper work to 25%. This
would indirectly help us in locating the
desired information quickly.
• Economical: we should manage the
records economically so that we may
achieve more with minimal efforts.
• Accurate: the records should be
accurate; otherwise its utility would
be doubtful.
• Timely: the time taken in retrieving
the information should be as short as
possible. Reducing retrieval time is
essential for effective Material
management.
• Classification: Records must be
classified to be of practical use. The
classification is done either on basis of
subjects or chronology.

Therecordsshould:
 Serve specific needs.
 Have specific objectives
and purposes.
 Be kept to a minimum
w.r.t. number, scope and
content.
 Be designed for least
expensive handling.
 Be up-to-date.
 Be worth their cost.
 Be related directly to
tabulations and reports
that will stem for them.
 Be available when
needed.
 Be considered valuable
by supervisors and lines
management.

Issuesrelatedto
medicalrecord
1. Deficiencies like:
 Improper terminology
 Different diagnosis
 Procedures not recorded
 Wrong forms
 Missing Progress Notes
 Name, Date, and Time to be
recorded
 Poor medical follow up
 Repetition of investigations
 Mixing up of cases
 Delay in MR coding, statistics
 TPA settlements
2. Legal issues related to
(E)MR
3.Ethical Issues
______”_______
(confidentiality/ consent in
situations)

PROBLEMS
FACED
(Maintenance
issues)
There are many problems faced by institution/hospital for the
proper maintenance of the records.
 1. Constant revision of the outdated form is needed .
 2. Always trained personnel are needed for the maintenance
 3. Inactive records need storage at appropriate place .
 4. There must be a need of determination of record retention
 5. Unwanted records must be destroyed .
 6. Record storage entail into 2 stages. A. Moving the records
from active to inactive file and from there to storage room. B.
Destruction and disposal of the unimportant records
 There are various type of damage which may be found
in paper documentation like-aged paper may become
weak, colour alteration from white to yellow, dirt and
dust may be present on the surface, insect and fungus
is a big threat for the records, if paper is kept folded, it
may become weak at the crease, dampness and water
leakage in storage room also destroy the paper.

Medical Records: Intro, importance, characteristics & issues

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Medical Records: Intro, importance, characteristics & issues