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1. Patient record
system
By- Rahul Dhaker
M.Sc. Nursing II year

2. Introduction

3. •The medical records is a clinical, scientific,
administrative and legal document relating to patient
care in which are records sufficient data written in
sequence of events to justify the diagnosis and warrant
treatment and the end result.

•The medical record benefits the patients, the doctor,
the hospital and public health authorities and
contributes to education and research.

4. Definition
•Medical records is defined simply as a systematic
documentation of patient’s personal and social
data, history of his or her ailment, clinical findings,
investigation, diagnosis, treatment given, and an
account of follow up and final outcome.

5. Cont…Definition
•A medical records document serves as: a
clinical document- listing the clinical
history. Physical examination, investigation,
nursing records, etc.

6. Characteristics Of Good
Medical Records

7. Cont…. Characteristics Of Good Medical Records
•Complete
•Adequate
•Accurate

8. Purpose and Scope of
Medical records

9. Cont…Purpose and Scope of Medical records
•Admission from
•Case sheet containing
•To the patient
•To the clinicians
•To the hospital and hospital administration
•To public health authorities
•To medical education and research

10. Benefits of Medical Records

11. Cont…
•Benefits of patient
•Benefits of Hospital
•Benefits of Doctor
•Benefits of Public health authorities
•Benefits of medical education and research

12. Function of medical
records department

13. •Planning developing and directing a medical record that
includes patient’s original clinical records and also the
primary and secondary records and indexes. These may
be in the central record room, the clinical service area,
adjunct department, to the outpatient department of the
hospital

•Maintaining proper facilities and services for accurate
and timely production, processing, checking, indexing,
filing and retrieval of medical records.

Cont…

14. •Developing a procedure for the proper flow of records
and report among the various services and departments,
including clinical services and the outpatient clinics
where they are needed.

•Developing a statistical reporting system that include
ward, consolidated daily census, outpatient department
activities, and statistics in relation to services such as
radiology, clinical laboratories and pharmacy.
Cont…

15. •Coding all diagnoses and operational according to
international classification of disease for statistical
purpose.
•Safeguarding the information in the medical
records against theft, loss, defacement, tampering
or use by unauthorized persons.
Cont…

16. •Determining in coordination with medical staff and
administrating the action to be taken in medico-
legal cases relating to the released of medical
records in a variety of situations and determining
the legality and ethical appropriateness of such
action of conformity with the laws of the land.
Cont…

17. Processing of
Medical Records

18. •Coding
•Indexing
•Storage and Retrieval of medical
records
•Filling system
Cont…

19. •Coding of the disease is done as per the
international classification of the disease;
for making nation and international
comparisons. This is to bring uniformity
in classification of the disease.
Cont…
Coding

20. •Alphabetical Indexing- Patients name
sequenced in alphabetical order.
•Disease index- The medical records, are of
patient having the same diagnosis is placed
at one place.
Cont…indexing
Indexing

21. •Unit indexing- unit wise indexing of medical records are
done like cardiology, nephrology or unit I or unit II of
surgery department.
•Physicians index- all patients treated by a particular
physician are indexed.
•Operation index- details of patients, who have undergone
surgery, are indexed.
Cont…indexing

22. Storage and Retrieval of medical
records
•Storage
•Compactness
•Easy accessibility
•Simplicity for understanding
•Elasticity for expansion
•Economical
•Easily retrievable
•Safety from fire, month insects and dampness.
•Controllability

23. Filling system
•Centralized system- All the medical
records whether OPD or IPD are filed in
medical records department of the hospital.

•Decentralized- In this system the OPDs
have their own records department. If a
patients is transferred from one department
to another department, the file is transferred
on loan basis.

24. Conclusion

25. Bibliography
•Syed Amin Tanish. Hospital and Health services,
Administration Principal & Practicrs. 1
st
edition. Oxford
University Press. Page No:- 317-322
•BM Sakharkar. Principal of hospital administration &
planning. 2
nd
edition. Jaypee brother medical publisher(P) Ltd.
Page no.- 223-230
•G.D. Kunders. Hospital facilities planning & management.
13
th
reprint 2011 Tata Mc Graw hill education private limited,
New Delhi. Page no.- 337-344
•D C Joshi and Mamta Joshi. Hospital administration. Jaypee
brother medical publisher(P) Ltd. Page no.- 309-317