IDEAS home Printed from https://ideas.repec.org/h/spr/sprchp/978-981-97-3879-3_17.html
   My bibliography  Save this book chapter

Medical Records

In: Health Care Management: Principles and Practice

Author

Listed:
  • Syed Amin Tabish

    (Sher-i-Kashmir Inst. of Medical Sciences)

Abstract

Healthcare systems are highly complex, fragmented, and use multiple information technology systems. A good medical record serves the interest of the medical practitioner as well as his patients. Objectives of maintaining of medical records are monitoring of the actual patient, medical research, medical/dental or paramedical education, for insurance cases, personal injury suits, workmen’s compensation case, criminal cases, and will cases, for malpractice suits, and for medical audit and statistical studies. It is very important for the treating doctor to properly document the management of the patient under his care. Medical record keeping has evolved into a science. The key to dispensability of most of the medical negligence claim rest with the quality of the medical records. Record maintenance is the only way for the doctor to prove that the treatment was carried out properly. Medical records serve several essential purposes in healthcare, acting as a vital tool for both patients and healthcare providers. The key functions of medical records include continuity of care, communication among providers, legal documentation, regulatory compliance, billing and reimbursement, quality assurance and improvement, research and public health, and patient empowerment. Medical records are foundational to modern healthcare, enhancing the safety, efficacy, and quality of patient care while supporting administrative and legal functions within the healthcare system. Medical record consists of personal information, medical history, clinical notes, medications, immunization records, test results, treatment plans, progress notes, reference and consultations, and billing information. Types of medical records are: Electronic health record (EHR): Electronic medical record (EMR) and personal health record (PHR).

Suggested Citation

  • Syed Amin Tabish, 2024. "Medical Records," Springer Books, in: Health Care Management: Principles and Practice, chapter 0, pages 357-368, Springer.
  • Handle: RePEc:spr:sprchp:978-981-97-3879-3_17
    DOI: 10.1007/978-981-97-3879-3_17
    as

    Download full text from publisher

    To our knowledge, this item is not available for download. To find whether it is available, there are three options:
    1. Check below whether another version of this item is available online.
    2. Check on the provider's web page whether it is in fact available.
    3. Perform a search for a similarly titled item that would be available.

    More about this item

    Statistics

    Access and download statistics

    Corrections

    All material on this site has been provided by the respective publishers and authors. You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:spr:sprchp:978-981-97-3879-3_17. See general information about how to correct material in RePEc.

    If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.

    We have no bibliographic references for this item. You can help adding them by using this form .

    If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your RePEc Author Service profile, as there may be some citations waiting for confirmation.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: Sonal Shukla or Springer Nature Abstracting and Indexing (email available below). General contact details of provider: http://www.springer.com .

    Please note that corrections may take a couple of weeks to filter through the various RePEc services.

    IDEAS is a RePEc service. RePEc uses bibliographic data supplied by the respective publishers.