Medical Histories Medical Records

1. Medical Histories & Medical Records Keeping Important Medical Data on Our Patients & Using that Data to Help in Care

2. Medical Records - Then & Now The Paper Record Readable Writing Availability Tracking Getting Data in to the Record in a Timely Manner Moves with Patient

3. Medical Records - Then & Now Where did that record go ? Putting in all the floating data slips ! Getting the record off to different clinics ! Doing chart reviews

4. Medical Records - Then & Now Where did all those records go after a patient died ? Can I find the record in the dead record file room ?

5. Medical Records - Then & Now The coding room jungle Getting the ICD-9 codes correct Setting up for billing Doctor, Medical Student & Resident Reviews & Sign-Offs

6. Medical Records - Then & Now The new medical filing room Where did all those folders go ? Hello Y2K !!!!

7. Medical Records - Then & Now Entering the lab data No longer by hand and floating files Direct data entry in to the electronic medical record

8. Medical Records - Then & Now The student and resident offices on the hospital wards and in the clinics Search and reviewing patient data Entering information

9. Medical Records - Then & Now At the Nurses�Station Students Residents Nurses Pharmacists Social Service Calling in from outside the hospital

10. Medical Records - Then & Now 85% electronic data management Multiple access points - simultaneously Able to access via modem or Interent Can review data from outside hospital Remaining hurdles - Phys Ex & Progress Notes How about an Internet Medical Record