This document discusses patient record systems, including their definition, principles, value, and importance for individuals, doctors, nurses, and authorities. It describes different types of record systems such as dedicated, paper-based, hybrid, and electronic. Electronic patient record systems are defined as digital collections of health information that can be shared across settings. The advantages include faster access and sharing of information to improve patient care, quality, and safety. Issues around access, data protection, security, and privacy are discussed.

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