A Study of the Medical Record Department’s Experience, Competence, and Application at a Tertiary Care Hospital

Introduction:The primary source of health information for a patient is medical record data. Thus, accurate, complete, and properly recorded patient data are important to provide the best treatment. The workload of the hospital may be reduced and operate more effectively in the hospital if staff members have the necessary knowledge, awareness, and desired clinical abilities, together with an understanding of medical records. Materials and Methods: From January 1 to December 31, 2017, the study was carried out at Tertiary Care Hospital Medical Record Department (MRD). The staff was evaluated for their competency and skill gaps using questionnaires. The complete use of the medical records was then evaluated per quarter for a year. Results: The staff showed adequate understanding of the various questions about medical records. Over the year, there was the highest utilization of files from the MRD, with medicine and obstetrics and gynecology in broad specialties and the department of cardiology with nephrology having the highest utilization in superspecialties. Conclusion: The job environment was pleasant for the staff, and the questionnaire revealed adequate knowledge. Increased satisfaction among MRD staff members, as well as among doctors, nurses, paramedics, and patients, may be related to the utilization being greater in MRD that has been scientifically designed, well‑planned, and appropriately structured, with the best physical amenities

Medical Record Keeping for Quality Patient Care: An Observational Study

Introduction:Effective management of medical records is essential for delivering high‑quality treatment. The location, architecture, and personnel of a medical records department (MRD) can considerably impact its operational efficiency. This study seeks to examine hospital MRD and establishes whether its current configuration is suitable for effective medical record management. Materials and Methods: The descriptive method was utilized to evaluate the MRD of the hospital. The review analyzed the department’s physical layout, personnel, workload, training programs, and available equipment. The study also evaluated the influence of government and business restrictions on MRDs operations. Results: It was determined that the MRD of the hospital had an appropriate physical layout, with divisions positioned in optimal locations. The department’s personnel levels were adequate, with twenty employees managing the patient population’s workload. The analysis determined that the department required extra photocopiers and scanners to boost operational efficiency. In addition, the study underlined the significance of adhering to policies, protocols, and established processes in ensuring efficient workflow. Conclusion: The analysis concludes that the hospital MRD has an adequate physical layout, staffing levels, and task management. However, the present equipment could be enhanced to increase operational efficiency. The study also emphasizes the importance of adhering to policies, protocols, and written processes to ensure the department’s efficient workflow. The outcomes of this study may inform future decisions on MRD management in other health‑care organizations, especially those subject to comparable government and commercial regulations