Introduction to Health Care System
1.0 INTRODUCTION
1.1.1 BACKGROUND
The explosion of information technology has opened a new realm of communication and information technology. This has given enlightenment and development to many fields which affect our lives directly or indirectly, these does not exclude medical record system. A medical record in general is a systematic documentation of a single patient's long-term individual medical history and care. The term 'Medical record' is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient's health history. (Moyle, 1976).
The information contained in the medical record allows health care providers to provide continuity of care to individual patients. It also serves as a basis for planning patient care, documenting communication between patient, the health care provider and any other health professional contributing to the patient's care, thereby assisting in protecting the medical needs. Personal health records combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care system. In addition, the medical record may serve as a document to educate medical students / resident physicians, to provide data for internal hospital auditing and quality assurance, and to provide data for medical research (Mersey Care NHS Trust, 2003).
A patient's individual medical record identifies the patient and contains information regarding the patient's entire case history. The health records as well as any electronically stored variant of the traditional paper files contain proper identification of the patient. Further information varies with the individual medical history of the patient. ("Use of Electronic Health Records in U.S. Hospitals," New England Journal of Medicine, March 25, 2009).
Medical record can be in two forms, paper based medical record, and electronic medical record. The former is the present system
1.1.1 BACKGROUND
The explosion of information technology has opened a new realm of communication and information technology. This has given enlightenment and development to many fields which affect our lives directly or indirectly, these does not exclude medical record system. A medical record in general is a systematic documentation of a single patient's long-term individual medical history and care. The term 'Medical record' is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient's health history. (Moyle, 1976).
The information contained in the medical record allows health care providers to provide continuity of care to individual patients. It also serves as a basis for planning patient care, documenting communication between patient, the health care provider and any other health professional contributing to the patient's care, thereby assisting in protecting the medical needs. Personal health records combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care system. In addition, the medical record may serve as a document to educate medical students / resident physicians, to provide data for internal hospital auditing and quality assurance, and to provide data for medical research (Mersey Care NHS Trust, 2003).
A patient's individual medical record identifies the patient and contains information regarding the patient's entire case history. The health records as well as any electronically stored variant of the traditional paper files contain proper identification of the patient. Further information varies with the individual medical history of the patient. ("Use of Electronic Health Records in U.S. Hospitals," New England Journal of Medicine, March 25, 2009).
Medical record can be in two forms, paper based medical record, and electronic medical record. The former is the present system