MEDICAL RECORDS
DEPATMENT
PRASOON BANERJEE (19MBMH17)
BYAGARI DHIVYANI (19MBMH16)
CH. SHRAVAN KUMAR (19MBMH15)
CONTEN INTRODUCTION
HISTORY
OBJECTIVES
PURPOSES
VALUES OF THE MEDICAL
RECORDS
TS
STAFFING (FOR 500 BEDDED HOSPITAL)
INTRODUCTION
Medical Records are a clinical, scientific, administrative and legal
document relating to patient care in which sufficient data is
recorded by trained observers as per sequence of events to
justify the diagnosis and therapy, giving the results thereof are
in accordance with reasonable expectation of present day
scientific medical care. It is in other words a performance
barometer of the hospital.
HISTORY
First Medical Record Unit was established in 1667 at ST.
BARTHOLOMEW’S HOSPITAL, ENGLAND.
Followed by practice of maintaining patient register in
PENNSYLVANIA HOSPITAL, USA in 1792.
Idea of proper medical records in form of standardized inpatients
records came in USA from the AMERICAN COLLEGE OF
PHYSICIANS and AMERICAN COLLEGE OF SURGEONS in the last
quarter of the 20th century.
In India BHORE COMMITTEE (1946) first stressed the importance
of keeping medical records.
HISTORY
Reiterated by MUDALIAR COMMITTEE in 1962.
Subsequently, HEALTH AND HOSPITAL REVIEW COMMITTEE (JAIN
COMMITTEE and RAO COMMITTEE) highlighted poor state of
medical records and recommended the establishment of a
proper Medical Records Section in each hospital.
With technical advancement, computers are extensively used for
record generation, analysis and retrieval.
OBJECTIVES
1. To maintain a central system of complete medical record of
all patients.
2. To serve as effective managerial tool for future planning.
3. To provide data for quality check, medical research and
education.
4. To fulfil the legal requirements.
PURPOSES
Provide a means of communication between the physician and
other professionals contributing to the patients care.
Serve as a basis for planning individual patient care.
Furnish documentary evidence of the course of the patient’s
illness and treatment during each hospital admission.
Serve as a basis for analysis, study and evaluation of the quality
of care rendered to the patient.
Assist in protecting the legal interest of the patient, hospital, and
physician.
Provide clinical data for use in research and education.
VALUE OF THE MEDICAL RECORD
The patient medical record is a form of document, a historical
record, the content of which may not only aid in diagnosis of a
specific case, but may aid in the treatment of another case, and it
is also a legal value. It is a verdict that Patient forgets and Records
remember. By let us know the real value that contributes to the
patient, the hospital, the physician, and for research and teaching.
VALUE OF THE MEDICAL RECORD
To the Patient
It describes the patients present and past state health.
It serves as a reference.
It serves to avoid omission or unnecessary repetition of diagnostic and
treatment measures.
It assists in continuity of care in the event of future illness.
Provides necessary information for insurance, contributory health schemes or
for the employment purposes.
VALUE OF THE MEDICAL RECORD
To the Doctor
Assurance of quality, quantity and adequacy of diagnostics and therapeutic
measures undertaken.
An assurance of orderly continuity of medical care.
Evaluation of medical practice.
An aid in research and the continuing education of health professionals.
A protection in the event of legal question.
VALUE OF THE MEDICAL RECORD
To the Hospital
Document the type and quantity of work undertaken and accomplished.
Furnish proof of the type and quantity of care rendered to the patient.
Evaluate the proficiency of the individual doctor, for administration and clinical
purposes.
Evaluate the services of the hospital in terms of accepted norms and standards.
Protect the hospital in the event of legal matters.
Assist in future program planning.
VALUE OF THE MEDICAL RECORD
Medical Education and Research
Recorded observations are the basis for all clinical research.
Further the education of doctors and other health personnel.
Medical records supply pertinent data for the use by public health authorities
for control of diseases.
SOLE SOURCE OF HEALTH INFORMATION
Direct
patient
care
Doctors,
nurses,
others
The
Governme
Patient’s
Planning, nt Health
medical
Legal, Care
record –
Issues, agencies,
source of
protection Health
informatio
insurance
n
Indirect
care
House
keeping,
Business
office, etc.
STAFFING (FOR 500 BEDDED HOSPITAL)
• MEDICAL RECORD OFFICER ADMISSON AND INQUIRY
1
OFFICE
• MEDICAL RECORD TECHNICIAN • ASST. MEDICALRECORD
4 OFFICER
1
• CLERKS
3 • MEDICAL RECORD TECHNICIAN
5
• PEON
1
• MEDICAL RECORD ATTENDANT
• STATISTICIAN 4
1
• RECEPTIONIST
5
STAFFING (FOR 500 BEDDED HOSPITAL)
CENTRAL RECORD OFFICE
• ASST. MEDICAL RECORD OFFICER
1
• MEDICAL RECORD TECHNICIAN/ ASST.
8 MEDICAL RECORD TECHNICIAN
• MEDICAL RECORD ATTENDENTS
8
• STATISTICAL ASST.
5
MEDICAL RECORDS DEPARTMENT
