Medical Records Management

Medical Records Management

Imagine that a former patient of your hospital files a lawsuit against your hospital. The charge leveled against your medical center is 'the mysterious disappearance of the plaintiff's medical records'. He claims that his medical registration and the files that record the previous treatments undergone by him are nowhere to be found. The entire hospital is put on alert as all the administrative personnel are ordered to locate the 'particular file'. Countless hours are lost in this process; the room where the medical records are kept, has an appearance similar to a town hit by a tornado or an avalanche. Panic and anxiety soar high, and the tedious process of 'hunting' for the file results in the wasting of time, energy and money. Question: Could this unpleasant situation have been avoided? Answer: a resounding 'yes'.

The ability to manage medical information effectively, is evocative of the ability to deliver great care In most of the low income countries, the majority of the hospitals or medical centers are understaffed and the patients are usually cramped in a limited space. Particularly in emergency cases, registering the patients' files can be a daunting ordeal. To avoid chaotic or unpleasant situations from arising, effective medical records management is of paramount importance.

Medical records management pertains to the: planning, controlling, directing, organizing, training, promoting and other managerial activities related to the creation, maintenance, use and disposition of medical records to achieve adequate and proper documentation of a health care organization's policies and transactions. To effectively carry out these functions, every hospital or health care center must have personnel trained in developing and maintaining fully integrated information management, data storage, protection and recovery programs. In other words, it is one of the prime responsibilities of the medical organizations and centers to take all necessary steps for safeguarding patient information.

Storing health care information and protecting that data is an ever increasing challenge for administrators and IT professionals. Moreover, the documents should be stored in such a manner so as to be easily retrieved for future use. In recent years, electronic medical-records are rapidly replacing the documents in paper form. It is note-worthy that the patient data or the medical-record must incorporate: the patient's past medical history, age, gender, source of income, number of family members in an individual household, previous surgeries and any possible complications as a result of that particular surgery.

In a typical health care organization, hundreds to thousands of medical and support staff need to access patient data to do their jobs. The significant aim in this regard would be to effectively enforce access control to hospitals information systems( for ensuring patient privacy), without hampering medical care efficiency and effectiveness. This can be attained by only allowing the participants the medical-record personnel, hospital administrators and clinical staff- to view the confidential patient files.

A simple computer database is also of immense importance to manage patient information, standardized medical records forms and processes, and for safeguarding enhanced human resource management efforts. Medical-records accessibility and completeness ensures physician satisfaction, thereby allowing the physician to concentrate on the treatment of the patient's illness; rather than worrying about unorganized medical records management. Therefore, a commendable manner of managing medical records is one of the hallmarks for guaranteeing the patient's confidence in a health care organization.

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_(By Nancy E Fraser).