The Medical Records are written tool of communication used by the members of the medical and allied medical staff in the efficient and effective management of patient. It serves as a source material for analysis, evaluation, education, research and studies of the quality medical care rendered. The medical record is also considered as the fundamental building blocks in the development of health information systems.
Duties and Functions of Medical Records Section
• The general function of the medical records section is to provide an organized system of measuring quality patient care and to ensure that sufficient data is written in sequence of events to justify the diagnosis, warrant the treatment and end result.
• Maintain all medical records in accordance with the principle and practice of efficient and effective medical records management.
• Maintain comprehensive numbering and register (e.g., Admission diagnosis and discharge summary, Operative Record, (O.R.) Delivery Room (D.R.), Out Patient Department (OPD) and Emergency Room (ER), and birth and death register. These are important record for patient identification and also considered as indispensable retrieval tools.
• Review records for completeness and accuracy, coding of diseases, operation, and special therapies according to approved nomenclature and classification
• Maintain a comprehensive and up to date record for hospital patients to ensure that all relevant information on each patient is collected, placed in the record, and filed in the record accordingly.
• Collect and compile data and produce statistical reports required by the Department of Health (DOH) and respective hospital management.
• Respond to all subpoena and medico legal cases directed to the hospital.
• Maintain and safeguard the confidentiality of the medical records.
• Provide records, upon request, for patient’s attendance to OPD and the ward.
• Ensure that all report and results are promptly and accurately filed in the corresponding patient record.
• Participate in research activities and studies conducted by doctors and authorized researcher by providing needed data and other information.
• Prepare different report as required.
*Issue pertinent medical documents within the prescribed period provided that the representative will present proof of relationship to the concerned patient.