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Onil Pereyra, ENG
Pablo Wagner, MD
Guarionex Robiou, ENG
Healthcare is a very important part of our society and it is imperative for healthcare providers to do their jobs in an efficient and effective manner. The main reason for maintaining medical records is to ensure continuity of care for the patient.
AbstractMedical records are the documentation of the medical histories of patients. They includes the following information: demographics and personal circumstances of the patient, such as the name, birth date, age, civil status, etc. They also list the diseases, sickness and growth landmarks of the patient, as well as his allergies and preferences.
Hospitals and health care providers, need the medical information so they can give continuous care to the patient. This continuity of care should not stop in case the patient transfers to another hospital or chooses another doctor. The previous hospital or doctor is required to turnover the medical records of the patient, so the new hospital or doctor can continue monitoring his health.
Doctors depend on this to come-up with better diagnostics of a sickness or disease. They need these records to avoid prescribing medications that can otherwise produce ill-effects to the patient instead of being a cure for the sickness. They also need it to give advice to patients with a weak disposition, so they can avoid possible contraction of diseases or illness he is vulnerable from. In times of emergency, for example, if the patient is unconscious, his medical records are all that the hospital or doctor can use as reference.
- Onil Pereyra
- Guarionex Robiou
- Pablo Wagner
- To increase medical service delivery capacity 20% in 12 months
Good medical records summarise the key details of every patient contact. Clinical records should include:
- Relevant clinical findings
- The decisions made and the actions agreed, and who is making the decisions and agreeing the actions
- The information given to patients
- Any drugs prescribed or other investigation or treatment
- Who is making the record and when.
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