Need for Medical Records

Ranjith Kumar.M
Free Hospital Incharge
Aravind Eye Care System

Good medical care generally means a good medical record, while an inadequate medical record generally reflects poor medical care. Medical record is the who, what, why, where, when, and how of patient care during hospitalization. It stores the knowledge concerning the patient and his care. The medical record contains information acquired in a doctor patient relationship which is generally considered to be confidential and privileged communication. Medical record contains sufficient information to clearly identify the patient, to justify the diagnosis and treatment and to results.

Purpose of the medical record:
The medical record is the property of the hospital and is maintained for the benefit of the patient, the physician, and the hospital.

The Purpose of the medical record are to:

  1. Provide a means of communication between the physician and other professionals contributing to the patients care.
  2. Serve as a basis for planning individual patient care.
  3. Furnish documentary evidence of the course of the patients illness and treatment during each hospital admission.
  4. Serve as a basis for analysis, study and evaluation of the quality of care rendered to the patient.
  5. Assist in protecting the legal interest of the patient, hospital, and physician.
  6. 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.

To the Patient
The physician describes the patients present and past state health and analyses the present illness in terms of diagnosis and prognosis. The medical record serves as a reference. When a patient requires subsequent hospitalizations with the same or another illness, and with or without a change of physician, the medical record of previous hospitalization will enable the physician to review and analyze the previous illness and treatment and make judgments as to the course of treatment to be followed.

To the Hospital
The medical record is of value to the hospital in evaluating the competency of the medical staff and the end results of treatment. It provides as a means of measuring whether or not the efforts of the physicians are in accordance with reasonable expectations of modern scientific medicine. The medical record is also of value to the hospital medico-legal purposes.

To the Physician
The medical record is helpful to the physician in caring for a patient during subsequent hospitalization. Physician may wish to review all cases which he has had in the hospital during a given time or he may wish to like to follow-up the patient has been called for consultation in a given period.

For Medical Research and Teaching
Scientific research the medical record is indispensable. Case studies supply a practical and reliable source of material for the advancement of medical care. The medical record is valuable in all teaching programs. It is a source document for medical fact relative to disease, treatment, care and results.

Statistical reporting by Medical Record:
Statistics are facts set down as figures. These figures must serve their purpose, they must be relevant, and they must be reliable if anyone is to evaluate them accurately and to make decisions from them. Statistics involve collection, analysis, interpretation, and presentation of facts as numbers. The medical record department needs a broader knowledge of statistical methods and reasoning. Hospital statistics are compiled to give the information needed for effective hospital administration, and to provide proper patient care. The medical record department is the logical place to collect and compile statistical data concerning utilization and medical services rendered throughout the hospital. Developing a program for collection of statistical data, emphasis must be placed a routine, systematic collection and recording of meaningful information. The medical record statistics should be collected in the aspect of both Quantitative and Qualitative.

Uses of medical record:
The medical records are used to:
  1. Document the course of the patients illness and medical treatment as an inpatient or an outpatient.
  2. Communicate between the physician and other professionals contributing to patient care.
  3. Provide continuity of patient care on subsequent admission of the patient.
  4. Review, study, and evaluate patient care by hospital or medical record committees.
  5. Provide data for third parties concerned with the patient other physicians and hospitals, insurance companies or prepayment agencies, compensation carriers, attorneys, government agencies.
  6. Provide data to assist in protecting the legal interest of the patient, the hospital and the medical staff.
  7. Provide clinical data for research, study, and education.