MEDICAL RECORDS

Dr Nakwagala
INTRODUCTION
• EFFECTIVE MANAGEMENT OF MEDICAL RECORDS IS PIVOTAL IN
HEALTH SERVICE DELIVERY

• INNEFECTIVE MANAGEMENT CAN LEAD TO SERIOUS CONSEQUENSES

• VARIOUS ETHICAL ISSUES ARISE

DEFINITION
• A MEDICAL RECORD IS ANY MEDIA IN WHICH INFORAMTION IS
STORED THAT PROVIDES DATA ON HEALTH INFORMATION OF A
PATIENT
TYPES OF MEDICAL RECORDS
• TRADITIONAL HARD COPIES
• PHOTOGRAPHS
• XRAYS
• ULTRASOUND IMAGES
• VIDEO RECORDING OF A HISTORY TAKING EXERCISE
• VIDEO OF A COUNSELING EXERCISE
• ELECTRONIC COPIES IN TEXT
• AUDIO TRACTS
Modern trends
• Increased use of digital platforms

• Increased data sharing among institutions

• Increased use of records for research

• Increased use for legal purposes

UTILITY OF MEDICAL RECORDS
• Traditional medical care
• Referral of medical care
• Sourveniors
• Identity
• Criminal investigations
• Legal issues
• Health Research
QUALITIES of a good medical record
• ORIGINAL
• LEGIBLE
• VALID
• DURABLE
• RETRIEVABLE
• TRANSFORMABLE
• COMPREHENSIVE
COMMON ISSUES IN MEDICAL RECORDS MANAGEMENT

• Poor source documentation practices

• Poor storage and archival
• Falsification
• Fabrication
• Non documentation
• Lack of privacy and confidentiality
• Forgeries
• Misuse for other claims like malingering and official absences from regular
duties
• Poor referral
• Patients misuse
• Anauthorised access and use