Transcript Evaluation of medical records

MEDICAL RECORDS
MANAGEMENT IN EYE
CARE SERVICES
1.EVOLUTION OF MEDICAL
RECORDS
History
Egyptian period:
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First real physician of record is
Imhotep.
Lived in pyramid age.
He was a grand vizier, chief
architect, and royal medical advisor
to a pharaoh before Christ.
History
Greek Period:
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Introduced scientific spirit into the
art of healing.
Aesculapius is the most venerated
physician of all times.
He is credited with curing many who
were so ill that they not were
expected to survive.
History
Greek Period:
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Hippocrates was the “Father of Medicine”
born in year 460 B.C.
He drew the rudiments of his medical
knowledge from the reports of cases
collected from Aesculapius at Cos.
During the period of 19th century,
Massachusetts General Hospital in Boston
has the distinction of having a complete
file of clinical records, with all cases
catalogued dating from the day it was
opened.
Development of Medical
Records
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To provide complete care to the patient,
the skills of many medical and allied
health specialists are required.
This team consists of physicians, nurses,
refractionsists, counselors and numerous
allied health personnel.
They inform and advise each other
through their entries in the records about
their findings, observations, opinions and,
treatment of the patient.
What is a Medical Record?
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Good medical care generally means a
good medical record.
Medical records store information
concerning the patient and his care.
Medical record must contain all relevant
details to clearly identify the patient, to
support the diagnosis, to justify the
treatment, and to record the results
accurately.
A written medical record must be
maintained on every person who has been
admitted to hospital.
Flow chart of out-patient Care
New Registration
Patient guided to vision room
Preliminary examination by doctor
Present illness, complaints & family history recorded
If needed, Refraction done
Patient undergoes B.P/Eye tension/Urine sugar test
If needed, dilation done
Patient sent for final examination & diagnosis
Glass prescription/Medicine prescription given
Patient sent home with follow-up advise
Uses of Medical Records
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To record the patient’s problem, history, and
treatment given either as out-patient or inpatient.
To form a bridge between the doctors and other
paramedical professionals contributing to patient
care.
To give continuity in treating the patient during
subsequent visits or admission.
To assist in protecting the legal interests of the
patient, the hospital, and the doctors.
To provide data for any research, study or
education.
To review the quality of treatment given by
doctors, nurses and other paramedical
professionals.
To provide data for any third party agencies
connected with the patient, doctor and hospital.
Value of Medical Records
To Patient
For
Teaching
Value of Medical
Records
For Research
Activity
To
Hospital
To Physician
Key points to remember
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The earliest records were primitive in form
and very different from the present Medical
records, but they served to record medical
achievements for later generations.
Mrs. Grace Whiting Myers was the first
president of the association of Records
Librarians of North America and honorary
president of the American Medical Records
Association.
A Medical record must be maintained on
every person who has been admitted to the
hospital as an in-patient, out-patient or as
an emergency patient.
Key points to remember
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The content of the Medical record is
developed as a result of the interaction of
the members of the healthcare team who
use it as a communication tool.
The purpose of Medical records is to serve
as a basis for continuity in the evaluation of
the patient’s condition and treatments.
Medical records are useful in protecting the
legal interests of the patients, the hospital,
and the doctors , and to provide data for
use in research and education.
Answer the following
1) Identify the following persons or
organizations.
- The first medical record librarian.
- The first Egyptian physician of record.
- The god of letters.
- The “Father of Medicine”
2) Trace the history of Medical records
through the Egyptian, Greek and GrecoRoman periods.
3) Identify six uses of medical records.
Answer the following
4) Discuss the value of medical record to
each of the following.
- The patient
- The Physician
- The hospital
5) Describe the development of medical
records in the hospital.