An observational study of role of medical record department in tertiary care teaching hospital
Artigo
| IMSEAR
| ID: sea-217884
ABSTRACT
Background:
Medical record document explains all the details about the patient’s history, clinical findings, diagnostic test results, pre- and post-operative care, patient’s progress, and medication given. If written correctly, notes will support the doctor about the correctness of treatment. Aim andObjectives:
Our objective was to study effectiveness and utility of medical record department at our medical college affiliated tertiary care institution. Materials andMethods:
We did an observational study to determine various parameters of medical records such as consent, history and examination findings, pre-operative and intraoperative records, investigation documentation, nursing care chart, and concerned medical person’s signature. The study included 300 files. A medical record checklist was used as a tool for data collection. The study was conducted between January 2021 and January 2022. Data were collected, entered in Microsoft Excel spread sheet, and analyzed using percentage.Results:
Out of the 300 files, 186 files belonged to different surgical specialties while the rest were of non-surgical fields. It was found that nursing assessment document was present in 78%, while discharged card copy was found attached in 75.33% files. Furthermore, surgical safety checklist was found in 89.24%, while signature of faculty was absent in 38.3% files.Conclusion:
Medical record maintaining and keeping is an essential and vital part of health-care infrastructure, not only for data collection but also for calculating use of resources needed for better delivery of quality services to patients.
Texto completo:
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Índice:
IMSEAR (Sudeste Asiático)
Ano de publicação:
2023
Tipo de documento:
Artigo
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