Patient record system

1. PATIENT RECORD
SYSTEM

2. DEFINITION
• IT IS A PERMANENT WRITTEN
COMMUNICATION THAT
DOCUMENTS INFORMATION
RELEVANT TO THE HEALTH CARE
MANAGEMENT

3. PRINCIPLES
• MINIMUM RECORDS
• REVIEW THE RECORDS PERIODICALLY
• SIMPLE , USEFUL , LEGIBLE
• CONFIDENTIAL

4. VALUE OF CLINICAL RECORD
•SCIENTIFIC AND LEGAL
•EVIDENCE FOR PATIENT CARE
MANAGEMENT
•LEGAL PROTECTION

5. PURPOSE
•PROVIDES INFORMATION ON
DISEASE CONDITION
•DATA FOR PLANNING AND
EVALUATION
•PLAN FOR FUTURE
•EVALUATION OF SERVICES
•RESEARCH

6. IMPORTANCE
•FOR INDIVIDUAL AND FAMILY
•FOR THE DOCTOR
•FOR THE NURSE
•FOR THE AUTHORITIES

11. CLASSIFICATION
•PAPER BASED ELECTRONIC
SYSTEM
•ELECTRONIC
DOCUMENTATION

12. (PAPER BASED DOCUMENTATION)TYPE
• PAPER BASED DOCUMENTATION SYSTEM
SOURCE ORIENTED METHOD (EG.ADMISSION RECORD)
PROBLEM ORIENTED METHOD (P.O.M.) (EG.LIST OF CLIENT PROBLEMS)
COMPONENTS
DATA BASE
PROBLEM LIST
PLAN OF CARE
PROGRESS NOTES
FORMAT
SOAP/ IER , PIE , DAR
CHARTING BY EXCEPTION(CBE)
GRAPHIC SHEETS AND FLOW CHARTS
VARIANCE CHARTING (EG,INCIDENT REPORTING )

13. ELECTRONIC
DOCUMENTATION
ELECTRONIC MEDICAL RECORDS (EMR’S)
&ELECTRONIC HEALTH RECORD
TYPES (ELECTRONIC MEDICAL RECORDS)
• DEPARTMENTAL
• INTERDEPARTMENTAL
• HOSPITAL EMR

14. HOSPITAL EMR
•INTER HOSPITAL EMR (TWO MORE
HOSPITAL)
•ELECTRONIC PATIENT RECORD(EPR)
(PARTICULAR HOPSITAL)
•COMPUTERISED PATIENT
RECORD(CPR)
•ELECTRONIC HEALTH CARE
RECORD(EHCR) (ALL HEALTH
INFORMATIONS)

15. • COMPUTERISED MEDICAL RECORD
(SCANNED IMAGES OF PATIENT’S
PAPER RECORDS.)
• DIGITAL MEDICAL RECORD (WEB
BASED RECORD CONTROLLED BY
HOSPITAL)
• CLINICAL DATA
REPOSITORY(STORE,THAT HOLDS
AND MANAGES CLINICAL DATA)

16. ELECTRONIC HEALTH RECORD
• TYPES
• THE AUTOMATED MEDICAL RECORD-(PAPER WITH SOME
COMPUTER GENERATED DATAS)
• THE COMPUTERIZED MEDICAL RECORD (CMR)(ELECTRONICALLY
AVAILABLE)
• ELECTRONIC MEDICAL RECORD (EMR)(CONNECTING PREVIOUS
LEVEL DATAS TO PRESENT SITUATION)
• ELECTRONIC PATIENT RECORD (EPR)(FROM MULTIPLE
INSTITUTIONS)
• ELECTRONIC HEALTH RECORD (EHCR)(ADDITIONAL
INFORMATION TO EPR)
• STRUCTURE
TIME ORIENTED EHR’S (CHRONOLOGICAL ORDER)
PROBLEM ORIENTED MEDICAL RECORD (POMR)

18. OBJECTIVES
• REVIEW PATIENT CARE,TAKE APPROPRIATE
DECISIONS
• PROVIDE AN ARCHIVAL AND LEGALLY
ACCEPTABLE METHOD
• TO PROVIDE MATERIAL FOR RESEARCHERS
• ACT AS A SOURCE OF INFORMATION FOR
HEALTH ADMINISTRATION
• FOR HOSPITAL AUDITING
• CARRY OUT THINGS IN RIGHT POSSIBLE
MANNER

21. VALUE OF NURSES CLINICAL
RECORD
•PROVIDE BASE LINE DATA FOR
FURTHER PLAN OF ACTIONS
•FOR DIAGNOSTIC AND TREATMENT
•TO EVALUATE THE WORKLOAD
•SCIENTIFIC AND RESEARCH
PURPOSE
•FOR LEGAL PURPOSE

24. OBJECTIVES OF REPORTING
• PRESENTS FACTUAL INFORMATION FOR
COMMUNICATION
• RECORDS USING FOR FUTURE REFERENCE
• PROVIDES NECESSARY INFORMATION TO
ALL RELATED TOPICS
• HELPFUL IN MEASURING PERFORMANCE
• PROVIDES VALUABLE AND
CONSTRUCTIVE SUGGESTION TO
MANAGEMENT

34. JOURNAL CONTENT
1.HOW TO KEEP GOOD CLINICAL RECORDS
JOURNAL OF EUROPEAN RESPIRATORY SOCIETY
ALEXANDER MATHIOUDAKIS ETAL..
-NEED OF KEEPING GOOD RECORDS
-ADVANTAGES OF KEEPING GOOD CLINICAL RECORDS AND THE
DISADVANTAGES OF POOR CLINICAL RECORDS
-BASIC DO’S AND DON’TS IN CLINICAL RECORD ENTRIES
2. DOCUMENTATION OF MEDICAL RECORDS IN HOSPITALS OF
MAZANDARAN UNIVERSITY OF MEDICAL SCIENCES IN 2014
JOURNAL OF ACADEMY OF MEDICAL SCIENCES OF BOSNIA AND
HERZEGOVINA
• BENYAMIN MOHSENI SARAVI ETAL..