Medical Record Science

Corse semester (1434/1433)

Presented By: Murad younis RN,MS

University Of TabukMedical record

department

Out line At the end of this presentation, the student

should able to:

• Brief history of medical record.

• Introduction to medical record science.

• Medical record department structure.

• List unit that contain to medical record department.

• The main complication in the medical record department.

Out line

• The rout of organization and content of medical record.

• Designing and general rule of medical record.

*AL DEPERGH Design.

*LORANS WED Design(P.O.M.R).

Jopdescrption to manger of medical record.

Brief history• The medical Record was started with beginning in

old medicine.

• The U.K the first called as medical record since 1912, then development step by step by time, the actually development in 1969 by lorans.

• He make the basic modern to medical record, thin started the classification system of record and stored the file record, after that the computerization system establish this is the actually steps in developing history.

Brief history• Thin starting using the microfilm and

microfation.

• Finally the medical record now a day electronic record and generally to don’t used the paper and pencil so we depend on electronic method rather than not paper method.

DEFINITION Medical Record

• “ Medical record as a clinical, scientific ,administrative , and legal document relating to patient care in which are recorded sufficient data written in the sequence of events to justify diagnosis and warrant treatment and end results” Mc Gibony

It has various uses toPatientsDoctorsHospitalTeachersStudentsFor research workNational & International agenciesORIGIN :-

The inpatient Medical Record in originated at the admission office based on the admission order made by the clinician or at ER Dept. and various OPDs of the Hospital.

• At present the Medical Record Dept. has Medical Record Officer Medical Record Technicians Medical Record Clerks Medical Record Attendants.• The Reception, Enquiry and Admission office functions

round the clock under the charge of Medical Record Officer.

• Presently only inpatients records are maintained in the Medical Record Department.

• Registration work of OPDs are also managed by the Medical Record Officer.

• Statistical information about the functioning of OPDs is regularly submitted by the Medical Record Officials in the Medical Record Deptt.

The unit of administration of medical rescored

• 1- Save unit .

• 2-Statical unit.

• 3-Secretary and reporting unit.

• 4-Admation patient officer.

• 5-Reciption in out department clinical.

• 6-Reciption in emergency room department.

• 7-Central of computer system.

The main complication with employment in medical record

• Careless the manager officer to give the worker good continuous education and training program.

• Put the worker in bad envermental and UN appraperat setting.

The main complication with employment in medical record

• Unappriparat the equipment and technology beside the level of technical worker.

• Careless in Put the good person in good place.

• Careless in motivations worker.

The rout of organization and content of medical record

• First rout

Prepare medical record according to sours and time frequently .

Scand rout

Prepare medical record according to used comprehensive to development the health status patient and treatment ,and diagnosis and medical note ..

The rout of organization and content of medical record

• There'd rout

Prepare the contain record according to health complain.

This depended on loranse it make the medical record to four part.

1-Basic medical data.

2-list of health complain.

According to loranse

3-pramiry planning for complain .

4-Dector note to development health status.

Medical record department structure

• The medical record administration `organized as :-

1- Centralization System.

2- Decentralization System Under Supervisor The Centralization System.

3-Compined System.

Centralization SystemOrganized

• Easy to organized and can be retain back as need.

• Have supervisor technical and administration on the worker.

• Work group as one tem.

Centralization SystemOrganized

• To make sure to open the one file for patient.

• Low in space area work, lower in human worker(personal), lower economical costly.

• Easy to add the modern technology in this system.

Decentralization System

• Store the record in clinical department it helped the speed work in health care system

• To make sure the confidential privacy to information.

• To be oriented about miss take inside the clinic and disadvantage.

Decentralization System

• Over to need the human personal qualification .

• High costly.

• Frequent open the file

Combined System

• Decreeing in mistake during work.

• Good method used in clinical department to cover the gap.

• Make more than medical record to same patent.

• High in equipment and resource including in personal.

• Using high space in work use.

• make a Combination in role and worker.

The factor to be selecting the appropriate system

1- Hospital mainfstrction.

2-The size of hospital.

3- The costly.

4-Reped to work complitionment.

5-Number of worker.

AL DEPERGH DESIN

According to AL Depergh design it used six type of card ready:

1-sumarize medical it is first paper then record vacation in lower paper.

2-famly history and personal ,enogram to 3rd generation.

3-card to record the follow up visit (D.M,HTN)

AL DEPERGH DESIN

5- Card to descriptive health condition.

6- data base to filling according questioner for patient.

Can be added any paper to this system as need.

LORANS WED(P.O.M.R)

According to lorans wed the file must be counting on :

*personal data.

*progress note.

*health problem list.

*medication list.

*flow chart.

LORANS WED(P.O.M.R)

• This is system called problem oriented medical record(P.O.M.R).

• And used in international clinic in world wide because it is :

*easy to use.

*flexible.

*can be monitor and assess to contain.

The flow chart of inpatient Medical Record for example

Central Admission Office

Wards

Medical Record Department

1. Assembling

2. ADMN. &

Discharge analysis

3. Storage Area

After completion of Records

Hospital statistics prepared Monthly/Yearly

Medical Record is filled for perusal of Patients/claims/research purposes.

The Jop Description To Manger OF Medical Record Department

1- To monitor the record follow up and open new files.

2- To monitor on employment the medical record department.

3-development the work performance to all department.

4-make good envermental to employment to increasing performance and achieve target goal.

5-To make sure that patient recording according to policy.

The Jop Description To Manger OF Medical Record

Department

6-To make sure that have no mixing file.

7-corrdination and follow-up the next visit in accuracy work,proble solver.

8-improve the quality inside the clinic .

General rule of organizing the medical record

1- you must the cover of medical record including on thickness of paper.

2-you must prefer to fix by plastic to save the cared patent.

3-It is very important to put main list including on paper used.

4-put the color to indicated to type record file.5-used special paper to investigation.6-you must to be in same size.

THANK YOU