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Indian Journal of Legal Medicine 1(1):p 31-35, . | DOI:
Review Article
Medical Record
Rajesh Kumar Chaturvedi , Rajesh Kumar Chaturvedi1 , Abha Mishra2 , Praveen Chaturvedi3 , Manaswi Chaubey4
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Indian Journal of Legal Medicine 1(1):p 31-35, . | DOI:
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Rajesh Kumar Chaturvedi, Abha Mishra, Praveen Chaturvedi, et al. Medical Record. Indian Journal of Legal Medicine. 2020;1(1):31-
35.
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Abstract
Medical records are documents of a Health Institution and Medical Records department is the back bone of Health information system. Medical records can be used as a personal or impersonal document. Personal document is confidential and should not be released without the consent of the patient except in some specific situations. The impersonal documents have been used for research purposes as the identity of the patient is not revealed. As medical records form an important part of the management of a patient, so it is important for the doctors and medical establishments to properly maintain the records of patients. As we can see, medical record is an important component of the healthcare information system. As a patient, it is often time-consuming to complete intake forms, but they are very valuable pieces of information to hospital as well as for doctor. As a patient-focused approach, medical record is advantageous to both patients and providers; we must adopt problem oriented medical record (POMR) in present situation.
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Authors and Affiliatione
- Rajesh Kumar Chaturvedi
, - Rajesh Kumar Chaturvedi1
, - Abha Mishra2
, - Praveen Chaturvedi3
, - Manaswi Chaubey4
,
Conflicts of Interest
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| Received | N/A |
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| Published | N/A |