Electronic medical record - essential for healthcare system.

ABSTRACT

In recent years, medical record-keeping has evolved into a science which is increasingly using computers and digital technology to fulfill the needs of clinicians, researchers, administrators, legal regulatory agencies and insurance companies. Medical records are important because ‘people forget and record remembers. The Medical Record Department, which is entrusted with storage, analysis and retrieval of records, plays a key role in management, planning, medical audits, policy decisions and research in any institution. Further, the information provided by this department to the health authorities of the city, state and country forms the basis on which several health-related decisions are taken at those levels. Medicolegally these records are to be preserved for, fix time periods depending on type of cases, so proper storage and damages to the conventional paper based records is emerging as a big issue to institutions. A hospital should follow well established procedures meticulously; update them regularly including the use of Information Technology for having sound Electronic Medical record Department. The transformation of conventional medical records to electronic medical records, certain Technical features and standard are to be observed strictly. In turn, this will provide more reliability, Transparency and accuracy in Medical Records. This will generate great amount of confidence in our patients, Insurance Companies, TPAs and Accreditation bodies. Electronic Medical record will be first step towards “Paperless Hospital”.