Organization management of medical records department part-1


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Organization management of medical records department part-1

  2. 2. ORGANIZATION OF MEDICAL RECORDS INTRODUCTION What is record ? Record is a written document or something setting down in writing. But What is medical record ? The information set down in writing pertaining in thepatients illness, history ,treatment and end result known as medical record. T.Keshavarao Mob.9880569550
  3. 3. Functions of Medical RecordAct as a communication between Patients and PhysicianImmediate clinical care of the patient.Future care of the patient.Utilization for clinical or epidemiological purposes.Act as Documentary evidence in Legal purposes.Source of nomination for management & Planning.Principles & Policies of Medical Records.Orient Patient care.Establish a basis for the evaluation of Medical Record Programme.To help estimate current & future staff , equipment and other requirements.Improve decision making by reducing the number of arbitrary or conflictingdecisions.Certain Policies should be standardized. T.Keshavarao Mob.9880569550
  4. 4. Purpose of Medical RecordPatient Care.1. Medical record are an aid to the treatment. Communication within the facility (Inside the hospital) Communication within the facility (one hospital to another Hospital)2. Medical record act as a mediator physician and other health care professionals individual patient care.Education. Medical records use to made retrospective review.Research. Providing data to Clinical, health services administrative point of view. Retrospective and Prospective information for future.Statistics. Morbidity statistics for prophylactic action purpose. Utilization statistics T.Keshavarao Mob.9880569550
  5. 5. EvaluationEasily evaluate the Medical care.Programme Surveillance (Monitoring)Individual PlanningAdministrative Management (Planning. Budged. Organizing. Controlling)Legal Aspects. Furnishing documentary evidence of the course of the patient illness andtreatment during each and every treatment visit or hospitalization. T.Keshavarao Mob.9880569550
  6. 6. BRIEF HISTORY OF MEDICAL RECORDS MEDICAL RECORD KEEPING of sick and injury is not a new procedure of the country. The history of medical records runs parallel with the history of the medicine. STONE AGE > In the stone age as in Spain the peoples were recorded the surgical notes of amputation of fingers in walls have been explained graphically about 2500 bc. > Caves and temples of Ajanta , Ellora and Buddhist stupas of Amaravathy & Nagarjuna konda also ample evidence of medical records. > Indian medical practice documentation found in “Athervaveda” > First Indian medicine text book is “Atreyasamhita” > “Agnivesasamhita & “Agnivesasamhita” also documented art of healing. > First Indian surgery text book is “Susrutasamhita” T.Keshavarao Mob.9880569550
  7. 7. Egyptian periodIn Egypt author “Thoth “ created 6 medical subject books. They discussed humanbody diseases & diseases of opthal & gynaecology instruments, drugs. Another Egypt physician “Imhotop”He has authourship of “Papyrus which isancient Medical documents dealing with surgical subjects. It is roll over 15 feetand long 13 inches wide made up 12 sheets usual size. It is written both sidesand consists 48 cases of clinical surgeries.Greek PeriodIn Greek scientist “Hippocrates” known as Father of medicine. He written severalvolumes of medicine books like patient history, symptoms & physical science ofdiseases. His books translated many languages.Greco-RomanIn Rome physician “Galen” has first realized the function of arteries and containblood. He was maintained bedside records.Mohammedian Period“Rhases” treats smallpox and measles and were kept few medical records. T.Keshavarao Mob.9880569550
  8. 8. 19th CENTURY The famous Massachusetts general Hospital at Boston (USA) was opened andmaintained Medical record Library and appointed first Qualified Medcial RecordLibrarian Mrs. Grace Whiting Myers (1859-1957) The first record written in ink in folio volumes of 18 length and 12 wide 2 ½thick bound in boards covered with dark red leather. The records show the daysprior to the discovery of Ether, 164 patients undergone surgery and following itsintroduction 487 patients were operated upon. This fact alone proves the value ofkeeping for medical records for research and statistical purposes.20th CENTURYIn 1902 The American Hospital Association discussed Medical Records for the firsttime at a convention. The problem brought out and discussed elaborately thatthere was no uniformity in methods. As a result American Medical Record Association convention developed themedical record standardization.1930 AMRA published medical record news bulletin.1935 Medical records education programmed starts at Boston,Newyark,Chicago.1952 Ist International Medical Record conference held in London. T.Keshavarao Mob.9880569550
  9. 9. Medical Records in IndiaIn 1950s importance was given for medical records development in India.In 1957 Dr.J.R.McGibbony (Rock feller Foundation.USA) visited India and herecommended to establish well developed MRDs in India.1961 the Govt of India DGHS appointed Mudaliar committee for establishment ofMRDs.1962 CMC Hospital Vellore was Started MRT & MRO courses.1966 Govt of India DGHS Starts well organized MRD in JIPMER Puducherry.28 th February 1973 (DGHS CBHI) MRT Training and 1978 MRO Trainingprogramme started at Safdarjung hospital.New Delhi.1977 MRO Course & 1979 MRT course (DGHS CBHI) started at JIPMER Puducherry. T.Keshavarao Mob.9880569550