An overview of medical records
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Transcript of An overview of medical records
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• •