Published on January 6, 2017
1. AN OVERVIEW OF MEDICAL RECORDS PREPAED BY: SOURAB BISWAS BBM(H) IN HM 5TH SEMESTER ROLL NO:43
2. CONTENT • Introduction • Objectives of medical records • Methodology • Data analysis • Problem identification • Recommendation • Bibliography
3. 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.
4. 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.
5. METHODOLGY A. 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
6. DATA ANALYSIS 5.1 5.05 4.48 5.0 4.88 4.81 4.88
7. 82 32 1452 47 62 JAN FEB MAR APR MAY JUNE
8. 0 1000 2000 3000 4000 5000 6000 JAN FEB MAR APRL MAY JUN JUL BED OCCUPANCY '16 ADM_ DIS_
9. 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 • •
10. 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.
11. BIBILOGRAPHY  Professional Standards and Guidelines – Medical Records September 2014; College of Physicians and Surgeons of British Columbia.page:3  Literature Review on Patient-Friendly Documentation Systems. page: 10-11  Management of patient information: trends and challenges in Member States, Global Observatory for eHealth Series, v. 6.page:15,17- 18  http://saltlake.amrihospitals.in