Health care has become one of India's fastest growing sectors in the past decade. A multitude of private players have entered this market, combining to offer high-quality health care and service in world-class hospitals and nursing homes all over India. It has been recognised that a professional approach to hospital administration and better resource allocation will go a long way to ensure both quality and cost-effectiveness in health care in India. The second edition of this successful book contains a well-planned collection of writings on modern hospital management. Revised and updated, it also contains two new chapters that discuss and highlight new developments in this field. The book spans a wide range of issues in modern hospital management, and provides all the necessary knowledge required to set up and run a modern-day hospital efficiently and as an economically viable business. The book also looks at " Customer experience management " Computer-aided diagnosis " Waste management " Financial management " Maintaining medical records " Medical audits " Managing human resources
Chapter 11: Medical Records
Memories fade People lie Witnesses die But Medical Records live on for ever.
A medical record is defined as a clinical, scientific, administrative and legal document relating to patient care in which sufficient data is written in the sequence of events to justify the diagnosis, treatment and the end results.
The medical record today is a compilation of the pertinent facts relating to a patient's health history, including past and present illness or illnesses, and treatment prescribed by health professionals contributing to the patient's care. The medical record should be compiled chronologically and should contain sufficient data to identify the patient, support the diagnosis or the reason for the treatment, justify the treatment and accurately document the result.
The medical record professional must ensure that ...