Medical records are all documents & records which are prepared in one medical center or hospital and are kept in order of date, so to be used for subsequent cures of patient, if necessary, quantitatively and qualitatively. These documents are determining examinations and cures in different cases.
Medical documents are very useful for both patient and the hospital. The background of clinical records of a patient can be used in subsequent refers and prevents from wasting a patient’s time and money. Medical records can improve the management and programming of a hospital. They can be useful in evaluating the personnel. Today's hospital are not anymore archives of dusted files but a great meaning with significant improvement in line with internatonal technology. Power is in hand of those who have information.
In this hospital, the cases are given to unit of medical records after insurance works and settlement of account and are recorded in archive offices. The case is filled in the form of standard after delivery. It is coded with books of coding ICD10 and then recorded in a computer. ADS10 is a computer software for recent conditions. Before archives, they are corrected and incorrect cases are sent to related units for correction (quantitative and qualitative). They are sent back to unit of medical records after some time. It is necessary that all pages of a case are numbered and recorded in special registries. The date of its delivery and refer is determined. Case is then filed and the name of a patient is written on a file. The case which is archived isn’t ejected from archives at all and will be sent to another unit. doctors and other personnel of hospital write a demand to the chief for a review if needed, then medical records will be studied with the supervision of one who is responsible or one of their personnel.
In cases where a patient is hospitalized in a section and his/her previous records are needed, the case is sent to that section by delivery of demanding a patient’s case. a card of replacing case which is used for every section with one special color is put on a patient’s file and the second part of demand form is put in pocket of this card, and the case is retaken to archived after patient’s discharge.
Personnel:
Mrs. Bagherzabe Hosain abad: Receptionist & responsible for medical records and statistics
Mr. Shamsoldin Moradi: Receptionist
Mrs. Khosravifar: Associated in medical records
Mrs. Bahrami: in charge of archiving medical records
Mrs. Shafaee: Associated in medical records
Mrs. Z.Yaghobi: Associated in medical records
Mrs. Karee:Associated in medical records
Mrs.Rahchamani: Associated in medical records
Mrs Naseri: Associated in medical records
History of Medical Records Mashhad university of medical sciences Dr. sheikh hospital