Medical Records

Published on March 2017 | Categories: Documents | Downloads: 43 | Comments: 0 | Views: 345
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Medical Records is the data or documents contains health information of the patient in hospitals handled by the authorized person and can be access by certain kept personal and confidential in any government or private protect the privacy of the patients as long as the main

the

people. It must be order to

hospitals in

customer of the hospitals. In the

academic term, medical records management is the planning, controlling, organizing, training, promoting and the other managerial activities related to the creation, maintenance and use and disposition of medical care organizations¶ protected by legal records to achieve adequate and proper documentation of a health policies and transactions. The confidentiality of medical information is

law. Information can only be released with authorization from the patient or their

guardian. The law requires that the authorization be accompanied by the patient¶s

signature and the date the request is being authorized. All the medical records in the hospitals are kept in their own department to avoid any misdiagnose condition that can brings to fatal

consequences. By that, the privacy of those medical records must become the important issue in any hospitals in the world. WHAT IS IN MEDICAL RECORDS? Medical records are created when receive treatment from a health professional physician, nurse, dentist, chiropractor, or psychiatrist. Records may include such medical as a

history, details about lifestyle such as smoking or involvement in high-risksports, and family medical history. In addition, medical records contain laboratory test results, medications prescribed and reports

that indicate the results of operations and other medical procedures.The record could also the result of genetic testing used to predict health. Other than that, they might include information about participation in research projects. Information you provide on applications for disability,life or accidental insurance with private insurers or government programs can also become part of medical file.

Besides information about physical health, these records may include information about relationships, sexual behavior and substance abuse and even the private that come with psychotherapy. Information from your medical admission to educational institutions and

family

thoughts and feelings

records may influence credit,

employment. It may also affect ability to get health

insurance or the rates pay for coverage. More importantly, having others know intimate details about life may mean a loss of dignity and autonomy. Essentially, electronic medical records (EMRs) exist in electronic format instead of paper. The effort lies in transitioning conventional records to electronic format so that the known advantages and flexibility of EMRs can be harnessed the main purpose of clinical care and research is to discern patterns and modify treatment according to changing parameters, be they weight, blood pressure, plasma glucose or serum lipids. EMRs are µenabling technology¶ although they are neither easy nor low-cost implement. Benefits include reduced errors, improved clinical care, universal access to records, besides administrative ease of scheduling and billing. From an administrative and policy viewpoint, they result in improvement of quality, competitiveness,

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