An overview of medical records

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Information about An overview of medical records

Published on January 6, 2017

Author: s1o9u9r4ab



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 [1] Professional Standards and Guidelines – Medical Records September 2014; College of Physicians and Surgeons of British [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.,17- 18 [4]

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