This document discusses medical records, including their definition, benefits, characteristics, components, storage, and ownership. Medical records provide an orderly documentation of a patient's health information and justify medical care. They benefit patients by documenting their health history, hospitals by aiding management and protecting against legal action, and public health authorities by providing morbidity and mortality statistics. Electronic medical records can increase efficiency but also raise privacy and security issues. Overall, medical records are an important tool for patient care, research, and administration of healthcare services.

1. MEDICAL RECORDS
Professor S. A. Tabish

2. Definition
• An orderly written document
encompassing the patient’s
identification data, health history,
physical examination findings, the
surgical procedures, and hospital
course.
• When complete it should contain
sufficient data to justify the
investigation, diagnosis, treatment,
length of hospital stay, result of care,
future course of action.

3. Benefits to Patient
• Document the story of patient
• Avoids repetition of diagnosis &
treatment
• Assists in the continuity of care in
the event of future illness
• Serves an evidence to support or
to refute the legal questions that
arise

4. Benefits to Hospital
• Provides the management with
statistical information necessary for
decision making regarding the
utilization of resources
• Furnishes documentary evidence for
purposes of evaluation of hospital care
in terms of quantity, quality and
adequacy (medical audit)
• Protects the hospital in the event of
legal action

5. Benefits to Pub Health Authorities
• Gives morbidity & mortality
statistics
• Helps PH Authorities to plan
the prevention and social
measures to meet the needs of
the community

6. Medical Education & Research
• Since recorded observations and
case-studies are the basis of all
clinical research, medical records
become invaluable in all research
and teaching programs

7. Characteristics of Good MR
• Complete: sufficient data to
identify the patient, justify
diagnosis and warrant treatment
and outcome
• Adequate: all necessary forms
and all relevant clinical information
• Accurate: capable of quantitative
analysis

8. Functions
•Outpatient
•Inpatient (MR Library)
•Accident & Emergency

9. Components of MRD
• Assembling
• Quantitative Analysis
• Basic Records (summary sheet/face sheet,
admission record card)
• Deficiency check
• Completion of incomplete records
• Coding
• Indexing
• Analysis & statistics
• Reporting of communicable diseases
• Numbering: filing patient records

10. Central Records Department
Assembling:
TPR, physician’s order, nurses
bed side record, special
reports-lab, anesthesia, x-ray
reports; history & physical
exam.; progress report; record
of admission; summary sheets

11. Numbering
• Serial numbering: patient receives a new
number on each admission
• Unit number system: patient is given
number on his first admission in the
hospital. He retains the number on all
subsequent admissions
• Serial-Unit Numbering: same as serial
numbering but the records are brought
forward and filed under the latest number

12. Filing System
• Decentralized system: same
as numbering system but
records are brought forward
and filed under the latest
number
• Centralized System: All
records are filed together
within a central department

13. Methods of filing
• Horizontal: papers are inserted in
the files or folders and the
folders are kept in horizontal
position, one upon the other
• Vertical filing: files are placed
vertically or in a standing upright
position. It facilitates ready
reference, economical, scope for
expansion

14. Storage
How long MR will be preserved:
Inpatient: upto 10 years
Outpatient: upto 5 years
Medicolegal: upto 10 years

15. Ownership of MR
•MR is the property of the
hospital and not of the
patient, the clinical
department or the
attending doctor

16. Electronic MR
• Decreased paper work
• Save time and effort
• Reduce costs
• Increase accuracy and
completeness
• Improve quality
• Improve management of care
• Disadvantage: security & privacy
problems

17. Electronic MR
• Stored in digital format
• Can be seen and used in more
than one locations at a time
• Can be replicated
• Can be processed
automatically

18. Smart Cards
• With features like smart cards and
hot-disking, appliances allow
Hospital employees to work in new
ways.
• Users insert credit card-size smart
cards into the Appliances' built-in
card readers to log in to the system,
providing strong security without the
need to memorize passwords.

19. Smart Card
• Doctors and nurses use smart
cards to obtain information from
thin clients located by patients'
bedsides
• Smart cards can also be used as
ID badges, or with barcode
technology for purchasing.

20. T H A N K Y O U
V e r y m u c h