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The functionality of medical records by Sharad Gaikwad
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The functionality of medical records |
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Health
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Medicine is a field that is formulated to help ailing patients but lately the administrative hassles and paper work has doubled the strain on the hospital personnel. The administrative task included maintaining patient records, arranging the matter and systematically organizing the data to allow future access in case the need arises. Medical records of a patient comprises of his history of illnesses, symptoms, obstetric information as well as his personal details. The doctor requires these records to study the illness of the person and keep a written or documented proof of the patient’s association with the hospital. These records tend to have confidential information that can create havoc if leaked out by an unauthorized handler, hence care must be taken that the confidentiality of the patient and his backdrop remains intact. These records are like the medical biography of a patient and contain all the information about the medical complexities of the concerned individual. The documents must be transcribed and stored in electronic format or they can be manually arranged by the hospital staff. The security to safeguard the information must be undertaken in whatever medium the records are stored in. if electronically stored then the records must be protected by firewalls while if manually arranged then care must be taken that the access is not made available to a third party with devious intentions. Doctors play a major part in the record assimilation and compilation of the patient’s information. The medical expert uses a mechanism called medical dictation to store the details of the concerned patient. These dictations are usually recorded in Dictaphones or digital recorders. Apart from the Hippocratic Oath, doctors have a personal interest to improve the health and well being of their patients. Hence a recorded version of the patient’s information can help easy access to the records if case the doctor requires it during further sessions with the patient. These dictations allow the medical examiner to freely process his thoughts and recommendations without interruption by a third party. These dictations are later passed n to medical transcriptionists to make the necessary conversions. Hospitals encourage the doctors to use digitization while preparing notes as storage becomes easier and loads of paperwork is subsequently discarded. Medical records contains operative as well as pre operative information of a patient that can be accessed by the concerned doctor to make a decision to what method he should adopt. These records are converted by medical transcriptionists that convert audio files to textual documents. Medical dictations play a major role in the transcription process as the documents can only be formulated if the dictations are apt and offer clarity to the receiver. These dictations help the doctor keep track of an individual’s growth, betterment and development. Records and dictations are activities that formulate a major component of the administration section of the hospital as one cannot function without the other. As the importance for safeguarding these two components have increased, techniques are adopted to preserve the confidentiality of the records.
Related Articles -
Medical dictations, Medical Letters, Transcriptionists, Medical Transcripts, Medical services outsourcing, Medical transcription companies,
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