SAVEETHA ENGINEERING COLLEGE

DEPARTMENT OF MEDICAL ELECTRONICS

(MD8751)

HOSPITAL TRAINING

MEDICAL RECORDS/ TELEMETRY DEPARTMENT

SUBMITTED BY,

MONIKA J

212217119023

MEDICAL ELECTRONICS

SAVEETHA ENGINEERING COLLEGE

Thandalam, Tamil Nadu, India.

The Medical Records Department (MRD) prime objective is the provision of patient Medical Records
in a timely manner to different hospital units in order to assist clinicians, allied health professionals and
other hospital staff in the provision of quality care to patients. In addition, MRD is responsible for
maintaining medical records in a standardized and professional manner in order to protect patient
confidentiality while allowing adequate access to providers in order to promote quality patient care.

Therefore, MRD has become an essential department in every hospital, which provides multiple
services not only to the patients but also to running a hospital efficiently and plays a key role in health
promotion and patient care quality.

The terms medical record, health record, and medical chart are used somewhat interchangeably to
describe the systematic documentation of a single patient's medical history and care across time within one
particular health care provider's jurisdiction.

The medical record includes a variety of types of "notes" entered over time by health care
professionals, recording observations and administration of drugs and therapies, orders for the
administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and
accurate medical records is a requirement of health care providers and is generally enforced as a licensing
or certification prerequisite.

Fig-1: Medical record

The terms are used for the written (paper notes), physical (image films) and digital records that exist
for each individual patient and for the body of information found therein.

Medical records have traditionally been compiled and maintained by health care providers, but
advances in online data storage have led to the development of personal health records (PHR) that are
maintained by patients themselves, often on third-party websites. This concept is supported by US national
health administration entities and by AHIMA, the American Health Information Management Association.
In 2009, Congress authorized and funded legislation known as the Health Information Technology for
Economic and Clinical Health Act to stimulate the conversion of paper medical records into electronic
charts.
The department also provides numerous functions and services:
➢ Creation, storage and maintenance of patient’s medical record.
➢ Reporting of statistical data to the Department of Health and Hospital Executives.
➢ Monitoring the quality of medical record content.
➢ Maintaining a patient’s right to confidentiality and privacy by adhering to information
release guidelines and ensuring records are kept in a secure environment.
➢ Clinical coding.
➢ Forms design.
➢ Management of policies on health privacy, patient registration, records management and
archiving, and medical record documentation.

Fig-2: Medical record in software

MEDICAL HISTORY

The medical history is a longitudinal record of what has happened to the patient since birth. It
chronicles diseases, major and minor illnesses, as well as growth landmarks. It gives the clinician a feel for
what has happened before to the patient. As a result, it may often give clues to current disease state. It includes
several subsets detailed below.
SURGICAL HISTORY
The surgical history is a chronicle of surgery performed for the patient. It may have dates of
operations, operative reports, and/or the detailed narrative of what the surgeon did.
OBSTETRIC HISTORY
The obstetric history lists prior pregnancies and their outcomes. It also includes any complications of
these pregnancies.
MEDICATIONS AND MEDICAL ALLERGIES
The medical record may contain a summary of the patient's current and previous medications as well as
any medical allergies.
FAMILY HISTORY
The family history lists the health status of immediate family members as well as their causes of death
(if known). It may also list diseases common in the family or found only in one sex or the other. It may also
include a pedigree chart. It is a valuable asset in predicting some outcomes for the patient.
SOCIAL HISTORY
The social history is a chronicle of human interactions. It tells of the relationships of the patient, his/her
careers and trainings, and religious training. It is helpful for the physician to know what sorts
of community support the patient might expect during a major illness. It may explain the behaviour of the
patient in relation to illness or loss. It may also give clues as to the cause of an illness (e.g. occupational
exposure to asbestos).
HABITS
Various habits which impact health, such as tobacco use, alcohol intake, exercise, and diet are
chronicled, often as part of the social history. This section may also include more intimate details such as
sexual habits and sexual orientation.
IMMUNIZATION HISTORY
The history of vaccination is included. Any blood tests proving immunity will also be included in this
section.
GROWTH CHART AND DEVELOPMENTAL HISTORY
For children and teenagers, charts documenting growth as it compares to other children of the same
age is included, so that health-care providers can follow the child's growth over time. Many diseases and
social stresses can affect growth, and longitudinal charting can thus provide a clue to underlying illness.
Additionally, a child's behaviour (such as timing of talking, walking, etc.) as it compares to other children of
the same age is documented within the medical record for much the same reasons as growth.

MEDICAL ENCOUNTERS

Within the medical record, individual medical encounters are marked by discrete summations of a
patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms.
Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by
a specialist often take an exhaustive form, detailing the entirety of prior health and health care. Routine visits
by a provider familiar to the patient, however, may take a shorter form such as the problem-oriented medical
record (POMR), which includes a problem list of diagnoses or a "SOAP" method of documentation for each
visit. Each encounter will generally contain the aspects below:
CHIEF COMPLAINT
This is the main problem (traditionally called a complaint) that has brought the patient to see the doctor
or other clinician. Information on the nature and duration of the problem will be explored.
HISTORY OF THE PRESENT ILLNESS
A detailed exploration of the symptoms the patient is experiencing that have caused the patient to seek
medical attention.
PHYSICAL EXAMINATION
The physical examination is the recording of observations of the patient. This includes the vital signs,
muscle power and examination of the different organ systems, especially ones that might directly be
responsible for the symptoms the patient is experiencing.
ASSESSMENT AND PLAN
The assessment is a written summation of what are the most likely causes of the patient's current set of
symptoms. The plan documents the expected course of action to address the symptoms (diagnosis, treatment,
etc.).