Abstract

In the growth of scientific medicine, medical records have played an important role as a tool and basis for planning patient care besides medical education, research and legal protection. The author wish to share with congress participants, the experience gained in eight nations, having served at the national level as Senior Medical Record Consultant Adviser and visiting WHO Consultant, in Kuwait, Saudi Arabia, Bahrain, Qatar, UAE, Oman, Afghanistan and India. The blueprint for development of medical records included three phases. The first phase surveyed the existing status of medical records. The second phase suggested appropriate systems, policies and procedures, trained personnel, and organized the medical record departments. The third phase implementation of EHR, education, training, and monitoring. During this phase, the author undertook the study of importance of medical records. Problems of Medical Records, there was no clear concept of Medical Record System earlier. In some hospitals MRD’s were so poorly organized, missing records, non-availability of laboratory and radiology reports resulted in creation of new records and new investigation orders, on each visit by the patient and there was no continuity in patient care. There was repetition of doctor’s work like history documentation, physical examination, investigations and prescribing drugs, the hospital patient care services were chaotic with much confusion and duplication of work. While developing software, most important aspect is meticulous preparation of domain of all functions, EHR related interoperable and accreditation standards, classification of diseases list, alerts, reminders, and clinical decision support systems for quality improvement, have to be incorporated. The theme “ What are the Medical Records for?” have to examined 360 degrees to incorporate all required characteristics stated above in the EHR that would meet the need of 21st Century.

Key words: medical records, role, EHR, healthcare delivery, 21st century