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MRD

The document discusses the medical records department of a hospital. It provides an introduction to medical records, their history and importance. It outlines the objectives and purposes of maintaining proper medical records. The value of medical records to patients, doctors, hospitals, education and research is described. Staffing requirements for a 500 bedded hospital are listed, including roles such as Medical Record Officer, Technicians, Clerks and a Statistician.

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Prasoon Banerjee
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560 views17 pages

MRD

The document discusses the medical records department of a hospital. It provides an introduction to medical records, their history and importance. It outlines the objectives and purposes of maintaining proper medical records. The value of medical records to patients, doctors, hospitals, education and research is described. Staffing requirements for a 500 bedded hospital are listed, including roles such as Medical Record Officer, Technicians, Clerks and a Statistician.

Uploaded by

Prasoon Banerjee
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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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

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