RECORD is a in scripted information (regardless of physical format) that can be retrieved at any time. It includes all original documents, letters, photographs, books, blueprints, sound & video recordings and electronic data.
MEDICAL RECORD: The medical record is a clinical, scientific, administrative, & legal document relating to patient care. Here data written in the sequence of events to identify and locate the patient and justify the diagnosis, the treatment given and the final outcome.
The record contains observations regarding the patient history, physical condition, investigations, line of treatment, daily progress diagnosis and discharge/death summary, and cause of death.
The presentation discusses how the records are created, how it moves and finally where it is stored and the various aspects of good record keeping.
MEDICAL RECORD: The medical record is a clinical, scientific, administrative, & legal document relating to patient care. Here data written in the sequence of events to identify and locate the patient and justify the diagnosis, the treatment given and the final outcome.
The record contains observations regarding the patient history, physical condition, investigations, line of treatment, daily progress diagnosis and discharge/death summary, and cause of death.
"In view of this record carries importance not only to patient but also to the hospital, doctor and court of law as a legal document. It is also used for teaching, training, and medical research.
Looking in to the importance of medical records, its documentation, preservation and safety is very essential.This needs a group of specially trained and dedicated team of workers for its maintenance."
The presentation discusses how the records are created, how it moves and finally where it is stored and the various aspects of good record keeping.
