How Effective Is Your Medical Documentation?

Medical-RecordMedical record-keeping is all about documentation! Our paper-based health records demand quality, and should therefore be more legible and complete.

In India, medical records are still primarily paper-based. Each one is a detailed account of a patient's health history, which includes current illness, clinical findings, and treatment, among other information. It is very important that the treating doctor properly documents patients' clinical data and medications prescribed. Often, we encounter that the record is not legible because of the use of abbreviations and bad handwriting. Essentially, each record is a patient's medical story, taking us through their past to lead us to the currently presenting illness or condition of health.

Variation in Documentation Practices

A common occurrence is that there is a lot of variation in medical record-keeping. Hospitals design their own formats and follow their own policies to maintain patient data. The process of keeping medical records in hospitals is very comprehensive and exhaustive.

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  1. Jayaraj Govindaraj
    Posted Jul 2014 at 2:26 am | Permalink

    Very useful guidelines.
    Combating this serious issue, we have to comply and not feign ignorance, as many of us try to excuse ourselves. The Ethics & Practice of proper medicare must be a part of the revised curriculum in all UG & PG courses in medicine.
    Kudos for having highlighted this problem.

  2. Arun Kumbhat
    Posted Sep 2014 at 3:27 pm | Permalink

    The Medical Record isn’t generated or maintained for a variety of factors – Time constraints and volume of patients. lack of convenient tools and of course avoiding the avoidable by not linking prescription to diagnosis.
    Better tools would go a long way in mitigating this.
    Am working on this

  3. Meenu Sagar
    Posted Apr 2015 at 6:09 pm | Permalink

    Very useful n informatic.maintenance of medical records is the need of day today practice.if you want good n stress freelife always dedicate few time to complete your medical records.

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