MEDICAL RECORD DEPARTMENT POLICY PPT
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Management of Medical Records with the aims that Medical Records are readily retrievable
Feedback loop is established for continuous improvements of Health Indicators. Responsibility: Senior Medical Officer and Junior Clerk – Medical Records.
To develop good Medical Records (containing sufficient data written in sequence of events to justify the diagnosis, treatment and end result of all patients treated in a hospital)
keep them under safe custody
make the readily available as and when required for
The Patient. The Doctor Hospital Administrators.
Medico Legal Purposes. External Reporting.
1. For Patient, it Serves to document the clinical history and activities of patient treatment. Serves to avoid omission or repetition of diagnostic and therapeutic measures. Assists in continuity of Care even in future illness whether it requires attention in or out of the Hospital. Serves as evidence in Medico-legal Cases. Give necessary certification for employment purposes.
2. For The Doctor, it Assures quality and adequacy of diagnostic and therapeutic measures undertaken. Serves as an assurance of continuity of medical care. Evaluates Medical Practices.
Protection in litigation.