Introduction to Medical Records

In
health care organizations, medical records the principal repository of patient’s
health care information, so every health organization needs a medical records department
that is organized and staffed to provide adequate information (Perspective
Health Information Management, 2006).

Medical
record is permanent documentation of history and progress of a patient medical
care. Records are used for continuity of a patient’s care, verification of
insurance claims, as a legal business document outlining the course of a
patient’s medical care, to provide statistical and factual information for
hospital administration, licensing and other regulatory bodies and medical
research. (Pickett 2011).
The
role and importance of records to any organization cannot be over emphasized.
Records are not only generated and received almost on a daily basis, they
constitute the tonic that keeps the organization in all aspects of its
operation and existence. Information is crucial to all spheres of human
endeavor. (Miller, 2003).
Personnel
(secretaries and filling clerks) who maintain the registry, systems with
filling cabinets containing the paper evidence of medical records are inadequate
and in fact ignorant of their responsibilities.
The
health record department is confronted with long waiting times for patients,
overtime for doctors and nurses during clinic sections, and workloads for its
counter personnel’s previous studies (Huang, 1994) show that long waiting times
are important dissatisfaction for patients. According to doctors and
Personnel’s,
overtime and peak workload are potential threats for the quality of care and
the quality of labour. Hence this project focuses on lack of adequate health
records personnel, a problem to appointment system in health records practice.
Stanfield
(2005) view that the information, the administrators need in the smooth running
of health institution is buried in records which constitute an essential
instrument of administration without which operational processes and functions
cannot be executed  in the health care
institution.
Afolabi
(1999) asserted that records, management practice in Nigeria has number of
problems which may include insufficient skilled and experienced records management
personnel and possibly, low priority of records management in the scheme of
things.
In
the opinion of Awe (2000) the problems of records management can be viewed from
the prospective of government, hospital management and the staff as their
action and activities can lead to effective or ineffective records management.
References
Afolabi,
O. (1999) Educational Archivists and Record Management in Africa: Annual
Conference Procedure of the society of Nigeria, Archivist, Lagos: SNA, pp.
61-67
Awe, F.
A. (2000). Principles and Practice of Record Management Course in Lagos State
Public Service, November 7-11. Magodo: Staff Development Centre.
Huang, J.
(1994). A Cost Effective Way of Reducing Outpatient Clinic Waiting Times
Millasr,
M. (2003). The right to information; the right to records, the relationship
between Record Keeping, Access to information, and Government Accountability.
CHRI contribution available.
Perspective
Health Management (2006). Health Information Management. Pub Med Central
Journalist. Available http//www.Medical.com/record.
Retrieved 18-3-2013.
Pickett,
Y. (2011). Health Record Practice in Health Care Institution.
Stansfield,
S. (2005) Structuring Information and Incentives to improve Health. Bulleting
of the World Health Organization. 
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