Imagine that a former patient of your hospital sued your hospital. The punishment against your medical center is the mysterious disappearance of the plaintiff’s medical records. He claims that his medical registration and files that record the previous treatments he processed are now in place. The entire hospital is on alert, as all administrative staff are ordered to find a specific file. In this process, countless hours are lost; the room where medical records are stored has a form similar to a city affected by a tornado or avalanche. Panic and anxiety soar high, and the tedious process of “hunting” since the file leads to a depletion of time, energy and money. Question: Is it possible to avoid this unresolved situation? The answer is:
The ability to effectively manage medical information is caused by the ability to exercise great care. In most low-income countries, most hospitals or medical centers are understaffed and patients are usually closely related in a confined space. In particular, in emergency cases, patient registration files can be difficult to test. To avoid chaotic or unpleasant situations from an organization, effective management of medical records is of paramount importance.
Medical records management refers to: planning, controlling, directing, organizing, teaching, programming, and other management activities related to creating, maintaining, using, and disposing of medical documentation to ensure adequate and proper documentation of health organization policies and transactions. To effectively perform these functions, each hospital or medical center must have staff trained to develop and support fully integrated information management, data storage, protection and recovery programs. In other words, one of the main responsibilities of medical organizations and centers is to take all necessary measures to protect patient information.
Storing medical information and protecting data is an increasingly difficult task for administrators and IT professionals. In addition, documents should be stored in such a way that they can be easily retrieved for future use. In recent years, electronic medical records have quickly replaced paper documents. It should be noted that patient data or a medical record should include: a patient's history, age, sex, source of income, number of family members in an individual household, previous operations, and any possible complications resulting from this particular operation.
In a typical health organization, hundreds and thousands of medical and support staff must access patient data to perform their duties. A significant goal in this regard will be to effectively ensure access to hospitals for information systems (to ensure patient confidentiality) without interfering with the effectiveness and efficiency of medical care. This can be achieved only by allowing members of the medical and control staff, hospital administrators and clinical staff to view patient confidential files.
A simple computer database is also of paramount importance for managing patient information, standardized forms and processes of medical records and for ensuring more effective human resource management efforts. The availability and completeness of medical records ensures the satisfaction of the physician, thereby allowing the physician to focus on the treatment of the patient’s illness; and not worry about the unorganized management of medical records. Thus, the commendable way of managing medical records is one of the hallmarks of ensuring patient confidence in a healthcare organization.
