Unit 4 DB - Records Storage and Maintenance - Medical Records

Running head : UNIT

Unit 4DB - Records Storage and Maintenance - Medical Records

Name

University

Unit 4DB - Records Storage and Maintenance - Medical Records

Medical records are the written reports , results of laboratory tests photographs and video tapes relating to the patient 's physical conditions , symptoms , manifestations , and treatment . These are usually -based records that are kept in Medical Records Sections of hospitals and other healthcare organizations . Due to technological advancements , health or medical records are now being transferred to computer-based system . These are now called Electronic Health Records (EHR

The

transfer of -based records to computer-based system should have to first undergo a process wherein the -based records are scanned into an electronic management system , usually the computer , with the application principles for -based records . The computer unit to be used must be of standard quality and efficient equipment . The computer program used to generate the record must be reliable and functioning properly , and records should be stored in a format that only a computer can process

With regards to the record itself , the records should always show factual information and written in factual statements . All record entries must be legible and made in black ink to facilitate clear photocopying . Clinical data from other facilities should be well-defined as to whether the data is in its entirety or abstracted and should be evaluated the clinician . The name of the patient and medical record number must be stated on every page of the health record . Timeliness and chronology of entries must be properly...