Medical Records: Purpose, Use and Value

• set of information about health status of a patient which acts as a media to establish effective communication within a treatment provided • presents medical history and status of the patient which also have educational and research value • can also be used as a tool for follow-up and supervising treatment procedures in the community. • accurate, valid, updated • physicians, nurses and/or clerical staff and the whole treatment provider team

Definition

admission and discharge summary medical history and physical examination physician's order progress note laboratory report attachment radiology report electrocardiogram attachment

consultation request vital signs composite graphic chart fluid balance chart (24 hours) pre-operation care anesthesia record operation report pathology report and unit summary sheet.

Content

• A – Demographic information (including unit number, patient's name and family name, father name, date of birth, location of birth, address and phone number) • B – Administrative information – admission information (including date of admission, admitting physician, ward, room and bed number)

Uses

• C – Diagnostic and treatment procedures (including physical examination, laboratory and radiological tests, medical orders and surgical interventions)

• D – Identification information of diagnosis and treatment provider (name and family name of physician and nurse, signature, seal, date and time)

Uses

1. 2. 3. 4.

Patient Management and Services Financial Reimbursement Management Planning Utilization Review and Quality Assurance

Uses

5. 6. 7. 8. 9.

Research Legal Affairs Education Accreditation Public Health

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

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to diagnose and treat illnesses and document medical care services provided the patient. Documents the course of the patient’s 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

Patient care management

• To the Patient - Medical records contain regarding a patient’s past and present health - It presents documentation by health professionals of the patients’ current condition in the form of physical findings, results of diagnostic and therapeutic procedures and the patients responses

Patient care management

• substantiate insurance claims of health facilities and patients and to ensure reimbursement under local and national medical programs

• To insurance companies - Information pertaining to patient’s illness and injury can be given to the insurance company upon presentation of patients’ authorization to release information

Financial reimbursement

• help administrative and medical staff in planning services and determining resources • identifies data necessary for selecting and promoting facility services

Planning and marketing

• 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 government agency is not allowed without the patients’ authorization or a written request signed by the facility head. If such agencies desire to review the record, a subpoena should be served to the hospital.

Legal affairs

• To employer of patient - Employer without authorization from the patient is not entitled to information except for the dates of admission and discharge - It is permissible to transmit information confidentially to a company physician caring for the patient after hospital discharge, but such information is not the property of the personnel department or the company management

Legal affairs

• To news media - All calls and inquiries from any type of news, media will be referred to the patient’s relations office

Legal affairs

• to provide actual case studies for the education of health professionals

• To educators, research and public health officials - data which can assist health professionals and students in to learn about patient care and disease processes - Used in furthering medical research by supplying a database evaluating the effectiveness of treatments for specific diseases

Education

• provide data for reporting vital events such as births and deaths to the public health agency in each city or municipality • provide data for reporting certain diseases such as communicable diseases existing in each locality in accordance with the requirements set to protect the health of the individual and the public

Education

• to provide the factual data necessary for accreditation and licensure. • To the health care facility - Provides data of the performance of health professionals working in the health care facility - Evaluates use of the facilities resources such as special diagnostic equipment and services offered by the facility

Accreditation

• Used in surveys by licensing, certifying, and accrediting agencies in evaluating care which the facility provides, and determining compliance with standards by the respective agencies • For continued participation in health insurance programs, the medical records maintained by a facility are reviewed to determine compliance with standards regarding medical content

Accreditation

• to identify disease incidence to formulate plans to improve the overall health of the nation or world. • Statistics can be developed as the data gathered from the records to document the need of the municipality or city, national and world health programs

Public health

Ownership

Class Schedule

Date Nov. 24 Dec. 1 Dec. 8 Dec. 15
Jan. Jan. Jan. Jan. 5 12 19 26

Activity Topic Lecture Use & Ownership No Class Reporting 1 Resp. Admin & Rec. Dept. Reporting 2 Resp. Med/Nur Staff & Rec. Com Reporting 3 Data Coll. & Assembly Reporting 4 Rec. Flow & Health Info Sys Reporting 5 Filing & Storage Quiz Review for Midterms

Feb. 2 Midterms and short disc. on guidelines

Date Feb. 9 Feb. 16
Feb. 23 Mar. 2 Mar. 9 Mar. 16 Mar. 23

Activity Topic Reporting 6 Release & Control of Med Info Reporting 7 Quantitative Analysis Reporting 8 Qualitative Analysis No Class Lecture Medical Terminologies Reporting 9 Class. Of Diseases &Indexing Reporting 10 Lecture Recap Case Presentation

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