About the Book

Traditional Medical record, organization & management Procedures

1. History of Medical Records Administration 1 Medical history The Basic Components of a Complete Medical Record 2. Role of Medical Record in Health Care Delivery Problem-Oriented Medical Records (POMR) Database Complete Problem List Initial Plans Daily Progress Notes 3. Legal Aspects of Medical Records and Electronic Health Records impact of the consumer protection act in medical field Medical malpractice/negligence Documentation of the medical records Indian Penal Code 23 Legal aspects of Electronic Health Record (EHRs) EHR audit trail performance, criteria and functionalities 4. Medical Audit Guidelines for completion of medical records Completion of records legally speaking clinical or clerical 5. International Statistical Classification of Diseases-10 History Design of ICD-10 Codes Other icd classification systems Icd-10-cm tabular list of diseases and injuries Icd-10-pcs-chapter-wise breakup-icd-10 procedure code 6. Hospital Information System Basic management cycle / Revenue cycle management in hospitals Categories of information systems in hospital What are the source of health information? Managing information systems Information needs in the hospital Information at the ministry Security and protection of information Mogli’s ready reckoner for counting hospital days 7. How to Economize Health Service Expenditure Health Service expenditure 8. Organization and Management of the Medical Record Department Organization Organization and functions Personnel requirements and job descriptions Space requirements Equipment requirements Merits and demerits of different types of filing shelves Background information required for organizing a medical record department Commissioning of medical record service Periodical evalution of medical record organizational needs evalution of medical record services 9. Medical Record Procedures central registration and appointment section Outpatient clinic Accident and emergency (casualty) service Admissions office Ward Processing of outpatient records Processing of inpatient records Hospital statistics Filing and retrieving of patient files and x-rays Medical record library-general