A chronological written account of a patient’s examination and treatment that includes the patient’s medical history and complaints, the physician’s physical findings, the results of diagnostic tests and procedures, and medications and therapeutic procedures.
The information contained in the medical record allowshealth care providers to determine the patient’s medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient’s care.
In addition, the individual medical record may serve as a document to educate medical students resident physicians, to provide data for internal hospital auditing quality assurance and to provide data for medical research
In addition, the individual medical record may serve as a document to educate medical students/resident physicians, to provide data for internal hospital auditing and quality assurance, and to provide data for medical research
Digitalization of medical records
Medical records are maintained by Straight Numeric numbering system for both outpatients and inpatients. All inpatients files are fully digitalized now.
Diagnostic Medical Coding is being done for all the patient medical record by using ICD-10 Procedural coding is done for all the procedures by using CPT (current procedural terminology).
As medical record professionals, we are dedicated to unfailing reliability in meeting each request and duty asked of us. We pledge to empower our staff through continuous education and upgrading of our skills and thus enhance the quality of our communication, participation and interaction with physicians and others in meeting the health information needs of this hospital and the communities it serves.