E-ISSN 2231-3206 | ISSN 2320-4672
 

Original Research 


An observational study of role of medical record department in tertiary care teaching hospital

Gunjan P Tank, Parag Tank, Poojan Shah.

Abstract
Background: Medical record document explains all the details about the patient’s history, clinical findings, diagnostic test results, pre- and post-operative care, patient’s progress, and medication given. If written correctly, notes will support the doctor about the correctness of treatment.

Aim and Objectives: Our objective was to study effectiveness and utility of medical record department at our medical college affiliated tertiary care institution.

Materials and Methods: We did an observational study to determine various parameters of medical records such as consent, history and examination findings, pre-operative and intraoperative records, investigation documentation, nursing care chart, and concerned medical person’s signature. The study included 300 files. A medical record checklist was used as a tool for data collection. The study was conducted between January 2021 and January 2022. Data were collected, entered in Microsoft Excel spread sheet, and analyzed using percentage.

Results: Out of the 300 files, 186 files belonged to different surgical specialties while the rest were of non-surgical fields. It was found that nursing assessment document was present in 78%, while discharged card copy was found attached in 75.33% files. Furthermore, surgical safety checklist was found in 89.24%, while signature of faculty was absent in 38.3% files.

Conclusion: Medical record maintaining and keeping is an essential and vital part of health-care infrastructure, not only for data collection but also for calculating use of resources needed for better delivery of quality services to patients.

Key words: Medical Record; Tertiary Care; Data Collection


 
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How to Cite this Article
Pubmed Style

Tank GP, Tank P, Shah P. An observational study of role of medical record department in tertiary care teaching hospital. Natl J Physiol Pharm Pharmacol. 2023; 13(1): 138-142. doi:10.5455/njppp.2023.13.10486202219112022


Web Style

Tank GP, Tank P, Shah P. An observational study of role of medical record department in tertiary care teaching hospital. https://www.njppp.com/?mno=120363 [Access: February 01, 2023]. doi:10.5455/njppp.2023.13.10486202219112022


AMA (American Medical Association) Style

Tank GP, Tank P, Shah P. An observational study of role of medical record department in tertiary care teaching hospital. Natl J Physiol Pharm Pharmacol. 2023; 13(1): 138-142. doi:10.5455/njppp.2023.13.10486202219112022



Vancouver/ICMJE Style

Tank GP, Tank P, Shah P. An observational study of role of medical record department in tertiary care teaching hospital. Natl J Physiol Pharm Pharmacol. (2023), [cited February 01, 2023]; 13(1): 138-142. doi:10.5455/njppp.2023.13.10486202219112022



Harvard Style

Tank, G. P., Tank, . P. & Shah, . P. (2023) An observational study of role of medical record department in tertiary care teaching hospital. Natl J Physiol Pharm Pharmacol, 13 (1), 138-142. doi:10.5455/njppp.2023.13.10486202219112022



Turabian Style

Tank, Gunjan P, Parag Tank, and Poojan Shah. 2023. An observational study of role of medical record department in tertiary care teaching hospital. National Journal of Physiology, Pharmacy and Pharmacology, 13 (1), 138-142. doi:10.5455/njppp.2023.13.10486202219112022



Chicago Style

Tank, Gunjan P, Parag Tank, and Poojan Shah. "An observational study of role of medical record department in tertiary care teaching hospital." National Journal of Physiology, Pharmacy and Pharmacology 13 (2023), 138-142. doi:10.5455/njppp.2023.13.10486202219112022



MLA (The Modern Language Association) Style

Tank, Gunjan P, Parag Tank, and Poojan Shah. "An observational study of role of medical record department in tertiary care teaching hospital." National Journal of Physiology, Pharmacy and Pharmacology 13.1 (2023), 138-142. Print. doi:10.5455/njppp.2023.13.10486202219112022



APA (American Psychological Association) Style

Tank, G. P., Tank, . P. & Shah, . P. (2023) An observational study of role of medical record department in tertiary care teaching hospital. National Journal of Physiology, Pharmacy and Pharmacology, 13 (1), 138-142. doi:10.5455/njppp.2023.13.10486202219112022