A record of health information uniquely assigned to a single person generated by one or more encounters and maintained in written paper base or electronic format, or a combination of both,. The health record connects the physicians and other caregiver’s entries. Included-but not limited to – in this information are patient demographics, progress notes, problems, medications, medical history, and post-operative summary (if applicable), laboratory data, radiology reports and discharge summary.
check and analyze the components parts of the Medical Record to ensurethat it is complete, adequate and accurate and its available at all times for legitimate needs of the patients, the hospital, and the Physician.
A review of medical record entries for inconsistencies and omissions which may signify that the medical record is inaccurate or incomplete.
Completing the medical records, which are deficient in number of forms or contents as per the established standard. The medical record staff reviews each case and notes down the deficiencies and (doctors visit the MRD weekly and complete them) verify with concerned staff.
The cardinal rule for analyzing records is to verify that the patient’s name and medical record number is reflected on each report (Patient identification or addressograph)