Medical Records - An Insight to a Patient's Health

Sharad Gaikwad
October 12, 2012 — 1,177 views  
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In the world of medicine, innumerable patients walk the lobbies of the hospital strutting along possessing different diseases, defects or even disabilities. It is a dire necessity to systematically organise and arrange their history and details under the watchful eye of the concerned health provider and their/its jurisdiction. Medical records are methodical compilation of patient's details, doctors and drugs administered, symptoms, prescriptions etc. This procedure is vital for the reference of the patients past history in association with their present condition. These records must be stored and disposed off in an appropriate manner so as to avoid any unauthorized access to patient's personal details. Impeachment of a patients' confidentiality can result in legal proceedings against the concerned hospital or healthcare organisation.

These records can also include pre-operative notes, administrative notes, post-operative notes and procedural notes to imply the different techniques adopted upon the concerned individual. These records can be manually managed by handwritten notes or can be stored electronically with the patient's proper identification. At time the online transmission of these records can hamper a patient's integrity if a hacker intends to gain unauthorized entry. Records of this sort must be standardized and written in accordance to an individuals' basic stature.

Audio transcription is the process of transforming patient records into documented context which can be stored electronically in a database or large data warehouse. This procedure is implemented by a transcriptionist that listens to the patients details via the Dictaphone or a digital recorder. Transcription companies utilise this method to accumulate and store the patients' necessary technicalities. It has proven to inculcate methodologies sufficing to the requirements of the healthcare sector worldwide. Using the internet as a medium, medical transcription has materialized into a mode of generating jobs in India. This has created a platform for a certain population to revive a career in the healthcare sector.

Medical transcription companies implement the process of Audio transcription. This methodology depicts that correspondence via secure communication line which helps hospitals create dozens of job ventures to individuals. These people who apply prefer working from the luxury of their own living room in contrast to an office environment. These are created work in an alliance to with a hospital but are independently functional. This form of transcription has unburdened hospitals of the load of recording and filing patient records. Medical records are essential for prioritising the patient's details and history as per the doctor's requirements. These records contain A to Z information necessary before discharging or admitting a patient into the hospital. All the hospital staff and experts associated with the individual can have access to their records. These records are like a summary of all data required to be known by the healthcare provider. The need of the hour is to create a system that is robust and diligent, which will safeguard patient information by making sure no unknown imposter can retrieve the recorded information. The security of these records is vital to keep the reputation of the hospital intact and untarnished.

Sharad Gaikwad