THE PURPOSE OF A MEDICAL RECORD

1. THE PURPOSE OF A MEDICAL RECORD

2. THE PURPOSE OF A MEDICAL RECORD • Planning and Continuity of Treatment. • The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a civilian organization that reviews and accredits all military and civilian hospitals, defines the purpose of the medical record. • According to the JCAHO, the medical record is intended to serve as the basis for planning patient care. • The medical record provides for continuity in the evaluation of the patient's condition and treatment.

3. Planning and Continuity of Treatment. • If a patient gets sick repeatedly, health care providers can look back at what happened the last time and/or how the patient reacted to medication. • If a patient breaks his or her leg more than once, the first set of radiographs can be compared to the second set.

4. THE PURPOSE OF A MEDICAL RECORD • Documentation. • A medical record provides documentary evidence. • It describes the course of the patient's medical evaluation and treatment. • It provides a record of any changes in condition. (A change in condition might be profuse bleeding from a laceration, which is subsequently stabilized upon stitching.)

5. Documentation. • The medical record reflects changes in a patient's condition that may occur in the hospital, as an outpatient (ambulatory care), during an emergency hospital visit, or in a hospital administered home care program.

6. THE PURPOSE OF A MEDICAL RECORD • An Efficient Means of Communication for Health Care Providers. • A medical record documents communication between responsible practitioners and any other health care professionals responsible for the patient's care. • For example, consider an x-ray technologist who takes radiographs and initials the number of films taken.

7. An Efficient Means of Communication for Health Care Providers. • By making these entries, the radiographer is not only documenting his or her actions, but also communicating with the physician. • The physician does not have to walk over and talk to the radiographer about every patient he or she sees. • It would be inefficient and time-consuming to do so. Thus, the record provides an efficient means of communication.

8. THE PURPOSE OF A MEDICAL RECORD • Protection of Legal Rights. • The medical record is a legally valid source of accurate information on the patient, the responsible practitioner, and the hospital. • As such, it can be used to protect the legal rights of the parties involved.

9. THE PURPOSE OF A MEDICAL RECORD • Data Source. • The medical record is a useful source of data for continuing education programs and research.

10. Data Source. • For example, the number of cases of spinal meningitis reported in 1949, the symptoms reported, and the treatment provided can be determined by a quick review of the medical records. Of course, all names would have to be deleted from information extracted from the medical records to protect the patients' privacy.

11. إرسال السجل الطبى للمحكمة • رغم ان السجل الطبى مصمم لحفظ معلومات المريض بالدرجة الاولى  إلا انه قد يطلب للمحكمة لإستخدامة من قبل القضاه كبينة و دليل فى بعض القضايا مثال ذلك قضايا التأمين ومن يلتزم بدفع تكاليف العلاج  و القضايا الجنائية  .

12. ويستحوذ السجل الطبى على ثقة القضاه لأن المعلومات المدونة فية موثقة وذات مصداقية عالية  و تتمتاز بالتجرد و الحياد  و مبنية على اسس علمية .

13. يجب عند تقديم السجل الطبى للمحكمة إتباع ما يلى : 1- تسجيل الطلب الوارد من المحكمة فى سجل خاص بذلك 2- تجهيز السجل الطبى المطلوب 3- مراجعة السجل الطبى المطلوب و التأكد من إكتمالة من كافة الجوانب و الشكليات اللازمة 4- إذا كان السجل موجودا على الكمبيوتر فيجب طباعة نسخة منها و التوقيع عليها

14. 5- استدعاء الطبيب المختص المشرف لمراجعة السجل و التأكد من عدم وجود معلومات يمكن إساءةفهمها و القيام بتفسيرها . 6- حصر الوثائق و النماذج الطبية الاخرى المطلوبة مثل صور الاشعة و سجل المحاسبة . 7- عدم إرفاق الاوراق الادارية و النسخ المكررة. 8- ترقيم الصفحات  و وضع عدد الصفحات على السجل من الخارج.

15. كيف يتم إرسال السجل الطبى للمحكمة ؟ • لا يرسل السجل الى المحكمة بالبريد و إنما يرسل مع احد الاطباء او مع رئيس قسم السجلات الطبية و إذا ارادت المحكمة الإحتفاظ بالسجل فيؤخذ من المحكمة إشعار بالاستلام .