Medical Record and its Importance

Records may be termed as any information and documents kept in a systematic, scientific and easy ways that help to receive the required data at the time of necessity.

Similarly, Medical record is also a systematized way of storing the required data, information and other relevant documents with the objective of making easy availability of necessary data at the time of its need.

Medical record consists of name of patient, address, age, sex, occupation, disease, modes of diagnosis and recommendations made the after by the concerned doctor in course of undergoing treatment. It helps patients to acquire the right and apt treatment. Moreover, it acts as a tool for the doctor who is looking into the patient.

When we talk of the development of medical record, we have to go back to the seventeenth century. In 1752 A.D. Benjamin Franklin set up a incorporated Hospital in Philadelphia in United State of America. This hospital is presently known as Pennsylvania Hospital. He introduced medical record by preparing file of special cases on which patients' name, admission date, discharge date etc. were written. In the same way, another hospital was opened in Boston in 1821 A.D. where a typical method of keeping relevant data was initiated. Separate files were opened for different individual patients in order to keep records. This process proved to be more helpful in finding the necessary data regarding the patients. Besides this, it helped in acquiring important facts that could make easier to take care for patients and to conduct the proper research work.

With the passage of time Medical record has been a backbone for developing a new dimension in the health sector in each of the countries in the world.

It has been indispensable for countries for continuing the research works, to deliver the appropriate health services to the patients, create the skilled manpower and to enhance the goodwill of the nation as well. Considering the significance of medical record, no hospitals and health centers are opened without establishing a separate and well-equipped medical record sections. Apart from this, provisions for imparting the required knowledge to the persons working in medical record section have also been made. For this purpose, some institutions that impart special training have also been set-up. Such training centers seem to have been established even in India.

Taking into account of importance of medical record the World Health Organization has introduced International Classifications of Disease in 1946 AD with the view of integrating the proper diagnosis systems and formulating the true and factual data on the basis of medical records kept by all the health entities.

Accordingly WHO has initiated ICD-10 which has laid emphasis on caring for patients and finding out the causes of disease. Moreover, it tries to explain the ways to be resorted against nurse, doctor and other health workers who works under estimation and with carelessness. This helps to check the errors committing either with intention or with ignorance. In addition to this it has made provision for mentioning Morbidity, Mortality, and Cause of Death. It gives more emphasis on the injuries owing to external accidents. It has made mandatory to explain about the cause of accident and the effects it has created upon him. This provision has somewhat helped the country minimize the accidents of such kind.

If we talk of history of Medical record in Nepal, no institutionalized development of medical record can be realized so far. It doesn't mean that medical record is entirely neglected. In some hospitals, there are distinct medical record sections. But these sections have not been well equipped and operated well to meet the entire satisfaction. Instead these are working as only name registration section.

Though no any concrete efforts are made by the government in this sector yet some hospitals are seen alert in this regard. They have developed their own ways for giving due importance on medical records but the efforts made have not been abundant. Tribhuvan University Teaching Hospital and B. P. Koirala Lions for Ophthalmic Studies Center can be taken as for example.

We are on the verge of 21st century. We should also thrive to implement the proper medical recording system as adopted by the developing and developed countries in the world.

It would be a timely approach to establish a sound medical record department at government level which ought to be entrusted with all the powers for regulating, managing and operating all the necessary functions.

We cannot undermine the relationship between the doctors of concerned authority and the people requiring medical treatment. Medical record, no doubt, may be regarded as a supportive hand in such matters. It helps doctors as well as patients to get informed of the ailments and plans and procedures adopted incourse of conducting treatment. Medical record can also be regarded as such device that might help the governing body, health institution and person concerned in easily and timely availability of required information without any dilly-dally.

A patient as well as doctor may derive the respective file/information in case of necessity as legal evidence. Medical record therefore refers to as a complete file prepared for each patient with all clinical records.

It acts as a means of providing necessary data in connection with the health of people and the brunt of specific diseases at the specific places to the health sectors including the nation.

On the basis of good management of medical record, one can easily obtain the ways of rendering services, standard of service, diagnosis pattern, style of treatment and managerial functioning pursued by the concerned health institutions.

Medical record plays a pivotal role in such organizations, which are specially involved in research-work as well as imparting health education to the people. With the help of it the standard and efficiency of the product there from can be appraised. Besides this, one can easily ascertain the quality of service being delivered by the expertise manpower and one can easily receive data pertaining to health of people in order to conduct research work.

Since there must be a name and signature of concerned doctor who is involved in the treatment of any patient in medical record, more caution is necessarily taken, incourse of treatment. As result a patient may derive a right treatment after quick and meaningful diagnosis of disease. This helps not only the patients in receiving the good health but also the doctors in keeping his/her good will.

A good arrangement of medical record is instrumental for the concerned bodies in understanding the pressure / concentration of patients, nature of disease and all the personal details of patient. Due to easy access to these invaluable facts and figure the organization can make some alternations in its existing plans and policies and formulate some additional policies in case of urgency and directives so as to deliver better and more standardized service in the upcoming years.

Medical record is note - worthy for the country in several aspects. Since medical record contains various facts like-personal details of patient, illness, diagnosis, modus operandi used to find out the disease, seriousness of diseases, medicines being used by patients in the recommendation of his/her attending doctors and even the clear names and signature of attending doctors, the nation can attain the health relating information through thorough check up of such medical records. The government can avail of such records in the direction of making short as well as long term health strategies. An integrated study of medical records available in all the hospitals and health centers will contribute towards knowing the health condition of people, ailment stricken areas, cause and effects of disease, availability of health workers as well as physical facilities and resources in order of delivering the appropriate health service to the people.

Through the study of medical record, preventive measures are to be timely adopted in order to save people from being ill. The reason behind it is that the epidemics and other disease tending to spread can conveniently be well informed in time.

The proportion of doctors to patients, the nature of disease and its repercussions, the number of doctors associated with certain disease, urgency of specialized service and the number of beds available at certain place compared with its actual requirement and so on are some other prominent facts as can be easily obtained through this.

In Conclusion systematic medical record plays a vital role in the field of delivering proper health services to the people.

Ram Kumar Karki

B.P. Koirala Lions Center for Ophthalmic Studies Center

Institute of Medicine, Tribhuvan University

P.O. Box 8750, Kathmandu Nepal

Ph. No. 422694 / 95, Office; 372771 Res.