patient record system is a method to stored

Patient records

1. patient record system

2. DEFINITION A patient record system is a clinical information system that collects, stores, and makes available clinical data to help deliver patient care. Or According to National institute of health “A patient record is the repository of information about a single patient. This information is generated by health care professionals as a direct result of interaction with a patient or with individuals who have personal knowledge of the patient (or with both)”.

3. CLASSIFICATION: Paper based documentation system Electronic documentation

4. Paper based documentation type: 1. Source oriented method ( eg.admission record): Source-oriented (SO) charting is a narrative recording by each member (source) of the health care team charts on separate records. ADVANTAGES : Seeing a Patient’s Progress According to Each Care Specialty.  Visualizing Notes in the Order They Were Written.   Tracking Progress Across the Multidisciplinary Team for Coordinated Discharge.   Ease of Use for Individual Disciplines.   Detailed    Documentation .  

5. Disadvantages 1. Difficulty Finding Up-to-date Information in Complex Cases.   2. Fragmented Data Among Treating Providers.  3. Limited Cross-Referencing and Silo-Writing.   4. Inconsistency in   Documentation  Styles.   5. Increased Risk of Errors.   6. Time-Consuming Data Compilation.  

6. 2. Problem oriented method ( p.o.m .) ( eg.list of client problems): Problem-oriented documentation (POMR) is a method of note-taking that helps with clinical thought processes and is used to manage and communicate patient information in a medical office.  The Four (4) Basic Components 1 .  Database.  2. Problem List.   3. Plan of Care 4. Progress Notes

7. Advantages Enhance communication between members of the medical team Increase the quality of care Reduce the chances of making serious mistakes Help healthcare practitioners identify patterns Improve coordination of care Improve patient outcomes 

8. Disadvantages 1. Varied Ability to Use the Charting Format. 2. Constant Vigilance Required 3. Inefficiency Due to Repetition 4. Time-Consuming 5. Learning Curve.  

9. 3. PIE (Problems, Interventions, and Evaluation) Problems (P).  Identifies and lists the patient’s health issues or  nursing diagnoses . Interventions (I).  Records the specific actions taken to address the identified problems. Evaluation (E).  Documents the patient’s response to the interventions and the effectiveness of the care provided.

10. Advantages 1. Efficient    Documentation 2. Enhanced Continuity of Care.   3. Focused and Relevant Information.   Disadvantages Potential for Oversight.   Learning Curve.   Detail Management

11. 4. Focus Charting: Focus Charting is a documentation method designed to prioritize the patient’s concerns, needs, and strengths in the healthcare record. Components : Client-Centered Focus Three Columns for Recording DAR Format: Data, Action, Response

12. Advantages Patient-Centered Care Clarity and Organization.   Enhanced Communication Comprehensive    Documentation DISADVANTAGES Training Requirements Time-Consuming Risk of Incomplete    Documentation

13. 5. Charting by Exception Charting by Exception (CBE) is a documentation system that focuses on recording only abnormal or significant findings, or exceptions to established norms. Components : 1. Flow Sheets 2. Standards of Nursing Care 3. Bedside Access to Chart Forms

14. Advantages 1. Efficiency 2. Clarity 3. Reduced Redundancy 4. Enhanced Focus on Patient Needs.   Disadvantages : 1. Risk of Missing Details 2. Dependence on Accurate Baselines 3. Training Requirements 4. Potential for Complacency

15. Computerized Documentation Computerized documentation systems have been developed to manage the vast amount of information required in modern healthcare. These systems leverage technology to facilitate the documentation process, enhance accuracy, and improve access to patient information.

16. Benefits

17. Advantages

18. Disadvantages

19. Medical Record Department

20. FUNCTION OF MEDICAL RECORDS DEPARTMENT Planning developing and directing a medical record that includes patient’s original clinical records and also the primary and secondary records and indexes. Maintaining proper facilities and services for accurate and timely production, processing, checking, indexing, filing and retrieval of medical records. 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.

21. Continue… 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. 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.

22. PROCESSING OF MEDICAL RECORDS

23. CODING 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.

24. INDEXING: 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. 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.

25. STORAGE AND RETRIEVAL OF MEDICAL RECORDS : Compactness Easy accessibility Simplicity for understanding Elasticity for expansion Economical Easily retrievable Safety from fire, moth , insects and dampness. Controllability

26. 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 OPD save  their own records department. If a patients is transferred from one department to another department, the file is transferred on loan basis.

27. NEW OPD REGISTRATION TECHNIQUE UNDER AYUSHMAN BHARAT DIGITAL MISSION:

28. CONCLUSION A patient record system is a type of clinical information system, which is dedicated to collecting, storing, manipulating, and making available clinical information important to the delivery of patient care. The central focus of such systems is clinical data and not financial or billing information.

29. BIBLIOGRAPHY Jogindra vati ; principles and practice of nursing management and administration jaypee publications;648-655 Deepak. k et al; A comprehensive textbook on nursing management emmess publications;2013;555-559 Basavanthappa B T;. Nursing administration. Ist edn . New Delhi: Jaypee brothers;2000. Alamellu ; Newer trends in management of nursing services and education. health science publishers first edition 2017;

30. Net reference Electronic patient records and innovation in health care services PB ELBERG - International journal of medical informatics, 2001 – Elsevier www. pubmed.com www.wikepedia.com https://www.ausmed.com/cpd/articles/record-keeping-documentation