THE HOSPITAL AND
MEDICAL RECORDS
– Dandy Ahuruonye
INTRODUCTION
Records contain information that is critical in
making decisions.
They provide the details needed for us have proper knowledge
and guidance as we carry out certain functions in life, especially at the
workplace. One of those workplaces is the hospital.
The hospital, in some contexts, has been compared to the
human body.
Our bodies depend on the heart for continued function
because the heart controls the circulation of blood and oxygen, which keeps us
alive. If the heart stops, we stop!
With that explanation in view, I am going to look at the
hospital from the standpoint of the medical record, which is generally believed
to play the same role for the hospital as the heart plays for the human body.
HOSPITALS AND MEDICAL RECORDS
To put it simply, every hospital needs medical records, and
a medical records department.
The Importance of Hospital and Medical Records
Introduction
Records are essential for informed decision-making. They
provide crucial information that guides our actions, particularly in workplaces
such as hospitals. The hospital has, at times, been compared to the human body.
Just as the heart maintains the flow of blood and oxygen necessary for life,
medical records play a similarly vital role for the hospital. Without them, the
hospital cannot function properly.
The Role of Medical Records in Hospitals
Medical records serve as the “heart” of the hospital. They
contain details that are indispensable for the hospital's daily operations.
Through accurate and timely information, medical records ensure that the
hospital can serve its patients effectively and efficiently.
Identity and Patient Identification
With increasing globalisation, societies are blending into a
global community. As a result, people from diverse backgrounds may share the
same names, or have names that sound similar but are spelled differently (for
example, Brown and Browne, Catherine and Katherine). This presents challenges
for medical records personnel. Because medical records rely on the precise
spelling of names rather than pronunciation, they are crucial in accurately
identifying each individual patient.
The Role of Medical Records in the Outpatient Department
(OPD)
Medical records are invaluable for the day-to-day running of
health services. Most individuals visit the hospital because they are ill and
require medical attention. Many of these are repeat patients, and the Outpatient
Department (OPD) already holds their records, streamlining their care from the
moment they arrive. For those visiting the hospital for the first time, a new
record is created immediately, and this record instantly becomes significant.
Additionally, medical records help the OPD track how many patients are
scheduled for procedures on any given morning.
There are endless reasons why that is so.
REASONS WHY HOSPITALS NEED MEDICAL RECORDS
IDENTITY
As globalisation continues to engulf our planet, societies
are converging to form one global community.
The Importance of Medical Records in Hospitals
Medical Records: The Heart of the Hospital
Records are essential for informed decision-making and
provide the crucial information needed to guide actions in hospitals. The
hospital is often compared to the human body: just as the heart maintains the
flow of blood and oxygen necessary for life, medical records are vital for the
proper functioning of a hospital. Without medical records, the hospital cannot
operate effectively.
The Role of Medical Records in Daily Operations
Medical records serve as the “heart” of the hospital,
containing details indispensable for daily operations. Accurate and timely
information in these records ensures that the hospital can serve its patients
both effectively and efficiently.
Identity and Patient Identification
With increasing globalisation, societies are blending, and
people from diverse backgrounds may share names or have names that sound
similar but are spelled differently, such as Brown and Browne or Catherine and
Katherine. This presents challenges for medical records personnel. Since
medical records rely on the precise spelling of names rather than
pronunciation, they are crucial in accurately identifying each patient.
The Role of Medical Records in the Outpatient Department
(OPD)
Medical records are invaluable for the day-to-day running of
health services, particularly in the Outpatient Department (OPD). Most
individuals visit hospitals because they are ill and need medical attention.
Many are repeat patients, and the OPD already holds their records, streamlining
care from the moment they arrive. For first-time visitors, new records are
created immediately, and these records become significant right away.
Additionally, medical records help the OPD track how many patients are scheduled
for procedures on any given morning.
Reasons Why Hospitals Need Medical Records
There are countless reasons why hospitals need medical
records. Personal details in these records provide essential information such
as identity and age, which help medical teams deliver appropriate care to each
patient.
Among the many consequences of this development is that
people from unrelated backgrounds share same names, others have names that
sound alike but are spelled differently. E.g. Brown and Browne, Catherine and
Katherine, etc.
This situation creates a challenge for the medical records
personnel.
It is important to note, however, that because medical
records depend on the exact spelling of names and not their pronunciation, they
play a crucial role in the process of identifying each individual patient.
OPD
The Role and Importance of the Out Patient Department (OPD)
Medical Records
Purpose of Hospital Visits
Most individuals visit the hospital because they are unwell
and require medical attention. Many of these visitors are repeat patients, and
as such, the Out Patient Department (OPD) already possesses their medical
records, which facilitates a more efficient process upon their arrival.
Medical Records for New Patients
For those attending the hospital for the first time, a new
record is created for each individual on the day of their visit. These records
immediately become important and are integrated into the hospital’s system.
Operational Significance of Medical Records
Medical records are essential to the OPD in tracking the
number of patients scheduled for procedures on specific mornings. This
information aids in managing patient flow and allocation of medical resources.
Contents and Utility of Patient Records
Personal details maintained in these records provide the
medical team with critical information, including:
Identity
Age
Gender
Allergies
Current medication
Any known illnesses
In some instances, a comprehensive medical history
These details support the medical team in delivering
appropriate care tailored to each patient's needs.
Medical records are invaluable sources of information
required for the day to day running of the health service.
The reason why most people go to the hospital is because
they are ill and therefore need medical attention. Many of those patients are
repeat patients and so the Out Patient Department already have their records
and that accelerates matters right from their arrival.
Nevertheless those who are attending that hospital for the
first time would have a record created for each of them on the day, and such
records become so important right away.
Additionally Medical records help the OPD to know how many
patients are booked in for procedures for a certain morning.
The personal details in the record help the medical team to
know such crucial information as:
Identity
Age
Gender
Allergies
Current medication
Any known illnesses, and in some cases, a comprehensive
medical history.
With all that information, the doctor or nurse would know
the answer to the most important questions like; who, when, how, why, and what.
By answering those questions, she now knows the medication
to, or not to administer, and on which patient.
If emergencies arise, the same record would help the
hospital personnel to contact the patient’s next of kin.
TESTS AND RESULTS
It scares me to think of a situation where the results of
another person’s blood test are used as a guide in treating me at the hospital!
But that is what might happen if there were no medical records, because then
there would be a mix up in names and dates of birth. It means, for example,
that the medical team might initiate a treatment for cancer or ulcer on a
patient who is suffering a minor cold.
On the other hand, if there are medical records, such a
scenario could hardly ever be imagined.
The Importance of Medical Records in Hospitals
Personal and Medical Information
Medical records contain vital details about each patient,
such as gender, allergies, current medications, any known illnesses, and
sometimes a comprehensive medical history. This information enables doctors and
nurses to answer essential questions: who, when, how, why, and what. By having
these answers, healthcare professionals can determine the correct medication to
administer or avoid, and identify the appropriate patient for each treatment.
In emergencies, medical records are instrumental in helping hospital personnel
contact a patient’s next of kin.
Tests and Results
The absence of accurate medical records in a hospital can
lead to dangerous mistakes, such as mixing up patients' identities and using
another person’s blood test results for treatment. Such errors could result in
a patient being treated for conditions they do not have, like cancer or ulcers,
instead of something minor like a cold. Properly kept medical records prevent
these scenarios and ensure that patients receive the correct diagnosis and
treatment.
Statistical Insights for Hospital Management
Statistics derived from medical records are crucial for
making managerial, financial, and planning decisions in hospitals. By analysing
these records, managers and medical staff can observe trends such as whether a
particular disease is increasing or decreasing, identify patterns in illnesses,
and assess patient recovery rates by different doctors. Additionally, they can
evaluate the effectiveness of certain drugs, monitor repeat patient rates for
specific illnesses, and investigate the reasons behind these trends. With all
this information, hospital administrators are better equipped to make decisions
regarding staffing needs, drug usage, and potential changes in treatment
protocols.
Looking to the Future
Statistics from medical records provide a clear view of the
past and present situations in the hospital, enabling more informed predictions
and decisions about future needs and improvements.
STATISTICS AND PLANNING
Statistics provide some of the most important information
for a hospital in making managerial, financial, and planning decisions. By
looking into medical records, hospital managers, and medical personnel are able
to know whether:
A particular disease is rising or decreasing
There is a pattern in an illness
Patients are recovering faster after being treated by a
particular doctor or not
Certain drugs are effective or not, the hospital has a high
percentage of repeat patients with a certain illness, and why, etc.
Armed with all these statistics from medical records, the
managers would then be in the best position to make important decisions, like,
whether there is the need for more doctors and or nurses, whether there is the
need to change, or even phase out certain drugs or not, etc.
Statistics help to see what a situation has been in the
past, what it is as at present, and so enable one in deciding what might be the
possible situation in the future.
The Importance of Medical Records in Hospitals
Tests and Results
The absence of medical records in a hospital can result in
dangerous mistakes, such as confusing patients' identities and using another
person's test results for treatment. This could lead to serious situations,
like prescribing cancer or ulcer treatments to someone who only has a minor
cold. However, when accurate medical records are maintained, such mix-ups are
highly unlikely.
Statistics and Planning
Medical records provide essential statistics that guide
hospital management in making decisions about operations, finances, and
planning. By analysing these records, hospital staff can determine whether
particular diseases are increasing or decreasing, identify patterns in
illnesses, and assess how effective certain doctors and drugs are in patient
recovery. They can also discover if there is a high percentage of repeat
patients for specific illnesses and investigate the reasons behind it. With
this information, managers are better equipped to make decisions such as hiring
more staff or deciding whether to change or discontinue certain medications.
Then appropriate mechanisms could be put in place to prepare
for that possible outcome.
The Importance of Medical Records in Hospital Operations
Billing and Payment Responsibilities
The hospital’s finance department requires clarity on who is
responsible for settling the bills incurred by patients. Some patients lack
insurance coverage and must pay their hospital expenses directly, while others
have partial or full insurance coverage. Medical records are vital for helping
the finance team determine the appropriate payer. Depending on the patient’s
type of insurance, invoices may be sent either to the individual or to their
insurance company, in full or in part. These processes ultimately inform audit
conclusions regarding which accounts have been settled and which remain
outstanding.
Identification and Death Certification
For deceased patients, identification relies on information
contained in existing medical records. These records form the foundation for
preparing and issuing accurately named death certificates.
Teaching and Research Applications
Demographic details found in medical records can reveal
changes occurring within the patient community. Such information may indicate
evolving trends in age, ethnicity, language, and the emergence of new or
previously unknown diseases.
The Importance of Medical Records in Hospital Operations
Billing and Payment Responsibilities
The finance department of a hospital relies on medical
records to determine who is responsible for paying patient bills. Some patients
do not have insurance coverage and must pay their hospital expenses themselves.
Others may have partial or complete insurance coverage. The details within
medical records help the finance team identify the appropriate payer, whether
it is the individual patient or their insurance company, depending on the type
of insurance held. These procedures support the audit process, clarifying which
accounts have been settled and which remain outstanding.
Identification and Death Certification
For patients who have passed away, identification is based
on information found in their medical records. These records serve as the
foundation for preparing and issuing accurately named death certificates.
Teaching and Research Applications
Demographic data in medical records provides insight into
shifts within the patient community. This information can reflect changes
related to age, ethnicity, language, and the emergence of new or previously
unknown diseases.
BILLING, AUDIT AND CERTIFICATES
The hospital’s finance department needs to know who is
paying the bill incurred by the patient.
Some patients do not have any insurance cover and so would
have to pay their hospital bills by themselves, while others have some sort of
insurance cover. The medical records help the finance department to decide who
will pay the bills. The bill may have to be sent to the individual, or to the
insurance company, either in part or whole, depending on the type of insurance
cover the patient has.
These would eventually lead to audit conclusions as to who has
and has not paid their bills.
The identification of a deceased patient relies on their
existing medical records, which then serves as the basis for the creation and
subsequent issuing of a properly named death certificate.
TEACHING AND RESEARCH
The demographic details in medical records could indicate
that the patient community is changing in terms of:
Age
Ethnicity
Language
New and previously unknown diseases
The findings might lead to some scientific research and
experiments. New clinical methods could be developed and adopted, which in turn
would create the need for teaching and training the medical student, medical
staff, and other hospital personnel.
COURT CASES
The medical record has been known to be a source of evidence
in litigation. The potential evidence contained is so powerful that cases are
won or lost due to their absence.
The Essential Role of Medical Records in Hospitals
Every detail within a medical record holds significance for
the hospital. Whether the information is stored on paper, electronically, or in
electromagnetic formats, it must be carefully retained. The integrity and
completeness of these records are central to hospital operations.
The Role of Medical Records Personnel
The medical records department is as vital as the records it
maintains. The personnel in this department are entrusted with the crucial
responsibility of managing and safeguarding all medical records. Each hospital
must ensure the presence of a dedicated medical records department, whose staff
diligently care for and protect the records under their supervision. Without
their efforts, records would not exist.
Consequences of Missing Records
The absence of records results in the absence of:
Identity
Medical history
Social history
Test results
Diagnosis
Without these elements, there is no information, no guidance
for medical care, and ultimately, no possibility of treatment. Therefore, in
the absence of records, a hospital cannot function.
The medical records in the hospital are therefore referred
to as the heart of the hospital, and rightly so, as they are sources of key
information that help hospitals to cure sick people.
CONCLUSION
The foregoing shows just how important the medical record is
to any hospital. Every piece of information in any medical record is important
and must be retained, be it in paper, electronic, or electromagnetic form. This
is where the role of the medical records personnel comes into play. The medical
records department is as important as the medical records themselves, because
its staffs are invested with the responsibility of managing and keeping the
records.
Each hospital must have a medical records department, and
each department must do their best to keep and look after the records under
their care. If they did not, then there would be no records!
If there are no records, there are;
No identity
No medical history
No social history
No test results
No diagnosis
Without the above, there would be no information, no medical
guidance possible, and then there would be no treatment. Because of these
therefore, there would be no hospital.
©2006 Dandy Ahaoma Ahuruonye
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