What can go wrong when handling a patient’s medical record?
If a mistake is made when handling a patient’s medical file, it might result in huge consequences for the patient, your facility, and your reputation.
The Medical Records Department maintains the patient’s medical records.
It explains the patient’s history, diagnostic test results, pre-and post-operative care, patient progress, and medication.
You must probably be wondering what’s the big deal and how it can help you?
Well, these records will support the accuracy of the physician’s evaluation if they are properly organized and documented.
Imagine the days when keeping track of our medical records required digging through a variety of files.
It was difficult to locate the patients’ histories of treatments and medications.
But do you want to know what’s the best part?
Thanks to the biggest advancement in this field, Electronic Health Records (EHR).
With the help of EHR, we can keep track of critical medical information and discover it quickly when needed! Medical
Records Department uses EHR to record a patient’s medical information.
In this blog, we will tell you the objectives of the Medical Record Department and the importance of documenting your medical records.
What Do You Mean by Medical Records?
Medical records include a patient’s demographic data (name, address, age, gender, etc.), medical history, test results, vaccines, and other important medical information.
The terms “medical record,” “health record,” and “medical chart” are frequently used interchangeably.
They refer to both the physical and electronic medical records, as well as the patient’s whole medical history.
Both the doctor and his patients benefit from a thorough medical record.
It is critical for the doctor to accurately document how the patient is treated while in his care.
Medical record keeping has evolved into a science.
If the medical records are of good quality, the majority of medical negligence claims can be rejected.
The main reason for the significance of correct, current medical records is that “They Can Save Lives.”
Keeping accurate records is the only way for the doctor to verify that the treatment was given correctly.
Sometimes, medical records are the sole trustworthy source of data.
Perhaps they are far more reliable than a memory!
Information Included in Medical Records
Healthcare professionals can better treat patients with access to thorough and accurate medical records.
Since it can aid in diagnosis and treatment, each and every piece of information is essential.
Modern medical records typically include self-reported information, such as:
Contact Information
- Name and address
- Phone numbers
- Emergency contact details
Lifestyle Habits
- Food eating habits
- Behavioral patterns
- Smoking habit
- Alcohol/ Drugs usage
Medical History
- Blood group
- Major diagnosis: any illness/disease
- Lab Tests results
Vaccination Details
- Preventive Measures
- Immunizations
- Vaccine dose
Family Medical History
- Genetic conditions
- Birth defects
- Physical and Mental illness
Allergies and Reactions
- Skin conditions
- Weak or rapid pulse
- Trouble in breathing
- Nausea or Vomiting
Major Diagnosis
- Accidents
- Operations and recovery
Disorders
- Eating disorders
- Personality disorder
- Depression, bipolar disorder, and other mood disorders
Treatment Plans
- Identifying the treatment methods
- The goal of the treatment
- Duration of treatment
- Possible side effects
Preventive Care
- Routine check-ups
- Regular counseling
Patients and their healthcare providers should maintain the security of all paper and electronic records.
Dates, times, attending medical staff, admitting and discharge reports, prescriptions, and any other relevant medical and lab results should all be included in the description of medical reports.
The Main Objectives Of The Medical Record Department (MRD)
A vital part of patient care is the hospital’s medical records division, which maintains the medical records of each patient who has taken its services.
It assists in running hospitals effectively and is crucial to patient quality care and health promotion.
Every hospital now has an MRD department, which offers various services to patients.
Here, We are outlining the main objectives of the Medical Record Department;
MRD Helps in Retrieving the Medical Record Very Fast
Medical Record Department uses Computerized Document Management System(DMS).
Without affecting the original data, DMS scans all patient information that was written while they were hospitalized, including consent, daily medicines, nursing sheets, and everything else.
It will facilitate quick retrieval of medical records.
It Helps Prepare the Statistics
In addition to keeping medical records, the department also gathers data from all other departments and creates statistics that help organize and plan hospital services.
MRD Systematically Documents the Patient’s Medical History
A patient’s medical history and the hospital care they received are systematically documented in their medical record.
Patients, their family members, healthcare professionals, hospital administration, government agencies, public health agencies, research organizations, etc., can all benefit from the information that has been collected and organized in this way.
It Protects the Patient’s Confidentiality
MRD is in charge of preserving medical records consistently and expertly to protect patients’ privacy while providing caregivers with sufficient access to support the delivery of high-quality patient care.
MRD Is Cost-Effective and the Best Tool to Convey the Message
Medical records are the most effective communication method with your doctor and the best tool for helping them understand your needs and requirements.
Electronic medical records have become more cost-effective and enable better patient outcomes with the use of information technology.
MRD Helps to Analyze the Data Quickly
Most of the time, we may not be able to provide our doctors with the information they genuinely need to diagnose us.
Alternatively, if our medical history is given to them, they can analyze the data and make an accurate identification and decision to choose the best treatment option.
MRD Ensures Seamless Integration of Medical Information Across the Institution
MRD’s goal is to ensure that medical information is seamlessly integrated throughout the institution.
MRD guarantees the security and privacy of the data by keeping up-to-date, accurate, and detailed health records.
The MRD Guarantees That the Medical Records Are Regularly Updated
Medical records must be updated periodically from an administrative and medical care perspective.
Any patient’s life will experience changes at some point, whether it’s a new address, last name, diagnosis, or treatment plan.
These adjustments must be documented so that a patient can be located in case of an emergency.
MRD Ensures That Medical Records Are Accessible to Emergency Department Staff in Times of Need
The emergency department staff can benefit from accurate medical records for both emergencies.
If a patient is unable to recall or is unsure of their current prescriptions, a well-maintained medical record can provide the specific details, preventing any potential drug interactions.
If the patient has a serious injury, is unconscious, or has an unidentified condition, a study of the patient’s medical records can also help a medical professional give the patient proper care.
In Medical-Legal Cases, Medical Records Can Be Used as an Evidence
When a patient or a relative claims medical negligence, the judicial system primarily looks for documentation proof.
This is frequently the most crucial piece of evidence when there is a claim of negligence, and it will determine whether the doctor will be found guilty or not.
MRD Takes Other Policies Into Consideration
The Medical Records Department’s (MRD) primary goal is to quickly provide patient medical records to various hospital units, allied with other needs such as:
- Observing the actual patient
- Medical study
- For insurance cases, personal injury lawsuits, workmen’s compensation claims, criminal cases, and property cases.
- Medical, dental, or paramedical education
- Regarding any malpractice actions
- For medical audit
Medical professionals can better manage their patients and collaborate with other medical specialists by maintaining medical records.
This is essential to ensuring that each patient receives proper care while taking into account their individual histories.
Final Words
Medical records often include patient self-reported data as well as notes from doctors regarding diagnosis, care, and therapies.
However, there is plenty more to it.
We want to make sure everyone knows how crucial medical records are.
By doing this, we wish to inspire everyone to communicate truthfully each time they seek medical advice.
These records provide details on a patient’s medical background, current medications, and previous treatments.
This makes it essential to maintain accurate and consistent medical records over time.
It’s not too late to start tracking all your medical data.
If you have kids, you should also start keeping track of the various doctors, consultations, procedures, and surgeries your child has had.
Additionally, ask for copies of any reports and outcomes.
Doctors can give your child the greatest care if they have accurate records.
