1. PATIENT RECORD
SYSTEM

2. DEFINITION
Patient record is a permanent written
communication that documents
information relevant to the
healthcare management.

3. PRINCIPLES IN KEEPING RECORDS
 Minimum records
 Review the records periodically
 Simple, useful, legible
 Confidential

4. VALUE OF THE CLINICAL RECORD
 Scientific and legal
 Evidence for patient care
management.
 Legal protection to hospital, doctors
and nurses.

5. PURPOSE OF RECORDS
 Provides information on clients
medical condition, socio economic,
psychological and environmental
factors.
 Data for programme planning and
evaluation
 Plan for future
 Evaluation of services
 research

6. IMPORTANCE OF RECORDS
FOR INDIVIDUAL AND FAMILY
oHistory of client
oContinuity of care
oLegal evidence
oUsed as a research and teaching tools

7. FOR THE DOCTOR
As a guide for diagnosis , treatment, follow
up and evaluation of services
Indicate progress and continuity of care
Self evaluation of medical practice
Protect in legal issues
For teaching and research

8. FOR THE NURSE
documentation of services rendered
Planning and evaluation of services for future
Guide for professional growth
Enable to judge the quality and quantity
of work done
Communication tool
Plan for future

9. FOR THE AUTHORITIES
oStatistical control
oAdministrative control
oFuture references
oDocumentary evidence of
care

10. TYPES OF PATIENT RECORD SYSTEM
 Dedicated patient health records
 Paper based record system
 Hybrid and paper record system
 Health summaries

11. PATIENT HEALTH RECORD SYSTEM
CONTAINS……..

12. Electronic patient record system

13. DEFINITION
“An electronic health record is a systematic
collection of electronic health information about
an individual, that is in digital format and is
capable of being shared across different health
care setting.”

14. ADVANTAGES
 Information can be used and shared fastly
 Could be accessed independently
 Save time and improving patient care
 Can be integrated with other initiatives
 Improve quality and efficiency of care
 Increases patient safety
 Shared decision making
 More efficient, accurate transferability of records

15. ISSUES IN PATIENT RECORD SYSTEM
 Access
 Data protection
 Staff efficiency
 Security and privacy
 trust

16. TECHNICAL FEATURES
 Digital formatting
 Track care
 Trigger warning and reminders
 Send and receive orders , reports
and results

17. TECHNICAL INFORMATION EXCHANGE
 Technical and social framework
 Reporting to public health
 E prescribing
 Sharing lab results

18. PATIENT CONSIDERATIONS
 quality
 costs
 software quality and usability
deficiencies
 unintended consequences
 intended consequences

19. LEGAL ISSUES
privacy and confidentiality
technical inter operability
 liability

20. THANK YOU