AN OVERVIEW OF MEDICAL RECORDS

PREPAED BY: SOURAB BISWAS BBM(H) IN HM

5TH SEMESTER ROLL NO:43

CONTENT• Introduction• Objectives of medical records• Methodology• Data analysis• Problem identification• Recommendation• Bibliography

INTRODUCTION• A medical record, health record is a

systematic documentation of a Patient's medical history and care.

• The term 'Medical record' are comprises of the total of each patient's health history.

• Medical records can be defined as an orderly written document encompassing the patient identification data.

OBJECTIVES OF MEDICAL RECORDS

• To understand present and past health status.

• To claim work man compensation.• To assist in medical treatment during

hospitalization or thereafter.• To understand the record management

system.• To monitor the quality improvement of

patient care.

METHODOLGYA. Research design: • In this presentation research design

highlights the following areas, these include:

• 1.The nature of the study.• 2. The purpose of the study.B. Data collection:• Two way data have been collected:• 1. Primary data: Personal interview• 2. Secondary data: Journals of Medical

records

DATA ANALYSIS

AVERAGE LENGTH OF STAYJAN FEB MAR APRL MAY JUN JUL

5.15

5.05

4.48

5.01

4.88

4.81

4.88

82

32145247

62

STATISTICS OF LIVE BIRTH

JAN

FEB

MAR

APR

MAY

JUNE

BED OCCUPANCY RATE

JAN FEB MAR APRL MAY JUN JUL0

1000

2000

3000

4000

5000

6000

BED OCCUPANCY '16ADM_DIS_

PROBLEM IDENTIFICATION

• Fire sensors should be checked for proper functioning

• More staffs needed in the department for better work flow

• Record shelves are needed• Fire drills should be conduct within the

department• Unique identification must be given to

each records• •  

RECOMENDATION• The medical record system in each

medical/health institution should be computerized with appropriately designed software.

• All the technical functionaries in the medical record department be trained through the prescribed training programmes.

• There should be clear guidelines for period of retention of medical records for both outpatient and inpatient departments.

BIBILOGRAPHY[1] Professional Standards and Guidelines –

Medical Records September 2014; College of Physicians and Surgeons of British Columbia.page:3

 [2] Literature Review on Patient-Friendly Documentation Systems. page: 10-11

 [3] Management of patient information: trends and challenges in Member States, Global Observatory for eHealth Series, v. 6.page:15,17-18

[4] http://saltlake.amrihospitals.in• •