 Introduction of Medical Record:

 Meaning,
 Definition
 Significance of medical record;

Unit-I  Value of medical records to

 patient,
 hospital,
 doctors,
 medical education and
 research,

 Characteristics of good medical Record,

 Issues related to medical record
  Systematic documentation of a single patient's
medical history and care across time within one
particular health care provider's jurisdiction

Meaning  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.
  medical record n.
A chronological written account of a patient's exa
mination and treatment
Definition 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.
  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,
Significance 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
  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.

continued  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.
  Handwritten clinical notes X-ray films and other
imaging records
 Computerized/electronic
clinical records  Photographs
 Emails  Videos and audio
recordings
Clinical records include a  Scanned records
wide variety of  Printouts from monitoring
 Text messages (both
equipment, particularly in
documents generated outgoing from the
anesthesia and obstetrics,
which includes: NHS/professional and
A&E and ICU
incoming from patients)
 Consent forms.
 Correspondence between
health professionals
 Laboratory results
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
  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
Patient personnel, admittance and discharge reports,
prescriptions, and any other related medical and lab
reports.
  Data building
 Legal importance
 Trends in diseases

Hospital  Census
 Use of medicines/ surgeries most performed/
instruments

 Financial decisions based on consumption data

  Biographical data including any history of alcohol use,
drug abuse, and smoking, in addition to physical
exams, allergies, medications, and any adverse
reactions.
Doctors  Preventive therapies such as immunizations and
screenings.
  Case Studies
 History of previously done interventions- failed and
worked ones

Medical  Provides a base for practical (more than theory in

books)
Education  Most current information available
 Verified data on certain things available for projects/
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/
Research 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.
  PROOF OF WORK DONE
 FOR CURRENT AND FUTURE PLANNING
 DISEASE /PROCEDURE INCIDENCES
 OUT PATIENT TURN OUT
Research  BED OCCUPANCY RATE
(Statistics)  AVERAGE LENGTH OF STAY
 DEATH RATE
 DEATHS UNDER 48 hrs.
 DEATHS MORE THAN 48 hrs.
 Good Medical Documentation in
Record Medical Records

• Accurate • Legible
• Complete • Readable
• Timely • Acceptable
Characteristics
• Contents • Timely
of good medical • Chronology • Consent recorded
Record • Continuity • Error free
• Promptness • Reproducible
• Authentication
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.
 The records should:

 Serve specific needs.  Be worth their cost.

 Have specific objectives  Be related directly to
and purposes. tabulations and reports
 Be kept to a minimum that will stem for them.
w.r.t. number, scope and  Be available when
content. needed.
 Be designed for least  Be considered valuable
expensive handling. by supervisors and lines
 Be up-to-date. management.
 1. Deficiencies like:
 Improper terminology
 Different diagnosis 2. Legal issues related to
 Procedures not recorded (E)MR
 Wrong forms 3.Ethical Issues

Issues related to  Missing Progress Notes ______”_______

 Name, Date, and Time to be (confidentiality/ consent in

medical record recorded situations)
 Poor medical follow up
 Repetition of investigations
 Mixing up of cases
 Delay in MR coding, statistics
 TPA settlements
 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
PROBLEMS  5. Unwanted records must be destroyed .
FACED  6. Record storage entail into 2 stages. A. Moving the records
(Maintenance from active to inactive file and from there to storage room. B.
Destruction and disposal of the unimportant records
issues)  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.