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The health care delivery system is the organization of all health care facilities, providers and ancillary services that are necessary to serve patients. Health is not merely the absence of disease but also protection from factors which predispose to disease. The World Health Organization has defined health as the status of complete physical, mental and social well-being.
Modern definitions of health care are influenced by many factors such as the advances in medical sciences, new technology, increased life spans, and societal expectations. The patient of today expects personal attention, explanations of problems, assurance of relief and satisfaction of complaints. The health care delivery system does not have the resources or the capabilities to meet the expectations of every patient served. With serious consequences for the health of any nation, the situation becomes more complex as government expands its role in health care and patient expectations continue to grow.
Health care is delivered mainly through primary care centres, secondary care and tertiary care institutions. The primary health care centres deal with patients whose medical conditions may be managed with relative ease on an outpatient basis, the secondary care is usually managed in acute care hospitals and tertiary care generally requires the resources of a sophisticated medical centre.
Health care facilities are built and maintained for the benefit of patients. Failure to retain accurate, timely and complete medical records results in negligence in the institutional responsibility to patients and the community as a whole for adequate records generate statistics vital for societal review, planning, and allocation of health care resources. In recent years, the great strides in the field of medicine have emboldened and encouraged the peoples of developing countries to abandon their superstitions and avail themselves of institutional medicine. The modern hospital is viewed as a haven of relief of health care problems. Good medical records are essential for rendering efficient patient care at a minimum cost. Therefore, increasing attention is bestowed upon the proper administration of medical record departments. A scientifically formulated medical record not only provides vital statistical information but assists the efficient provision of patient care and enables the analysis of the quality of patient care services.
Medical record can be defined as an orderly written document encompassing the patient’s identification data, health history, physical examination findings, laboratory reports, diagnosis, treatment and surgical procedures, and hospital course. When complete, the record should contain sufficient data to justify the investigations, diagnosis, treatment, length of hospital stay, results of care and future courses of action.
The purposes of the medical record are:
1. To provide a means of communication among physicians, nurses and other allied health care professionals.
2. To serve as an easy reference for providing continuity in patient care.
3. To furnish documentary evidence of care provided in the health care facility.
4. To serve as an informational document to assist in the quality review of patient care.
5. To protect the patient, physician, as well as me health care institution and its employees in the event of litigation.
6. To render clinical and administrative data required for budgeting, management, service development, planning, review, medical education and medical research.
7. To supply pertinent patient care information to authorized organizations and third party payers.
1. Evaluating the competency of the medical, nursing and ancillary staff (quality assurance)
2. Justifying the results of treatment
3. Medicolegal purposes
4. Defense in malpractice suits
5. Basis for preparing operating budgets
6. Administrative control over functional activities
7. Basis for distribution of expenses when computing costs of operation.
8. Statistical data to assist in controlling bed allocation, infection and mortality rates, and length of stay.
9. Planning of additional facilities, staff and equipment as well as improving medical education and patient care.
1. Medical science is dynamic: New techniques, new methods and new medications
2. Conduct research to meet own country’s needs
3. Research results are shared by others
4. Medical records of present and past help in concurrent, prospective and retrospective research
5. Learn simple and better ways to deal with problems
6. Control health care costs
7. Find better drugs and techniques
8. Improve quality of services
9. Implementation of the teaching program
10. Essential for medical education
11. Medical students require lot of practical training besides theoretical classes
12. Clinical practice in art of history taking, proper physical examination and writing treatment notes
13. Teacher is able to teach and guide better
14. In the absence of teacher, student can learn techniques and methods of dealing with different cases.
15. Learn traits of teacher through well documented record.
16. Student learns from his mistakes.
17. Even senior staff learn from records.
18. Records are full of documented facts of live cases, which are better than a written textbook
19. Undergraduates and postgraduates benefit
1. Depend on information
2. Allocate budget, staff and equipment
3. Plan and construct hospitals and health centres in required locations
4. Determine the type of health services required
5. Monitor all hospitals and health institutions
6. Exchange expertise from other nations
7. Collaborate with international organizations
8. Develop medical and allied health service education.
1. Responsible for assisting and guiding nations
2. Control infectious diseases and epidemics
3. Provide assistance to needy nations and accepting assistance from countries which have surpluses
4. Exchange experts and specialists
5. Send medical supplies and other items to needy countries
6. Need reliable information from all countries to achieve global healthier living
Medical records are frequently summoned to court in the following cases:
1. Insurance cases
2. compensation
3. Personal injury suits
4. Malpractice suits
5. Probate cases
6. Notification of birth and death
7. Criminal cases
8. Medical reports and certificates
Database contains a history of the present illness, administrative information, chief complaint, past medical and surgical history, family history, social history, patient profile (the patient’s daily activities of living), review of systems—in explicit terms arranged in a logical manner, laboratory reports, X-ray reports, and so forth. The database can be obtained manually or via computerized processing.
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Email : info@shahealthcare.org
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