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Medical Record

Rajesh Kumar Chaturvedi, Abha Mishra, Praveen Chaturvedi, Manaswi Chaubey

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Attribution-Non-commercial 4.0 International (CC BY-NC 4.0)

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Indian Journal of Legal Medicine 1(1):p 31-35, Jan-June 2022. | DOI: N.A

How Cite This Article:

Chaturvedi RK, Mishra A, Chaturvedi P. Medical Record. Indian Journal of Legal Medicine. 2022;1(1):31-35.

Timeline

Received : March 02, 2022         Accepted : April 07, 2022          Published : June 30, 2022

Abstract

Medical records are documents of a Health Institution and Medical Records department is the back bone of Health information system. Medical records can be used as a personal or impersonal document. Personal document is confidential and should not be released without the consent of the patient except in some specific situations. The impersonal documents have been used for research purposes as the identity of the patient is not revealed. As medical records form an important part of the management of a patient, so it is important for the doctors and medical establishments to properly maintain the records of patients. As we can see, medical record is an important component of the healthcare information system. As a patient, it is often time-consuming to complete intake forms, but they are very valuable pieces of information to hospital as well as for doctor. As a patient-focused approach, medical record is advantageous to both patients and providers; we must adopt problem oriented medical record (POMR) in present situation.

References

  • 1.   Mestri Shashidhar C, Gouda Hareesh S. Legal and ethical aspects of medical records – An Indian Perspective. Medico-Legal Update. 2009;9(2):16- 18.
  • 2.   Personal Health Records (PDF). CMS. April 2011. Archived from the original (PDF) on 2012-03-05. Retrieved 2012-04-14.
  • 3.   National Institute for Health. Nih.gov. Retrieved 2012-04-14.
  • 4.   American Health Information Management Association. Ahima.org. 2012-03-22. Retrieved 2012-04-14.

Data Sharing Statement

There are no additional data available.

Funding

This research received no funding.

Author Contributions

All authors contributed significantly to the work and approve its publication.

Ethics Declaration

This article does not involve any human or animal subjects, and therefore does not require ethics approval.

Acknowledgements

Information not provide.

Conflicts of Interest

The authors report no conflicts of interest in this work.

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Cite this article

Chaturvedi RK, Mishra A, Chaturvedi P. Medical Record. Indian Journal of Legal Medicine. 2022;1(1):31-35.

Licence:

Attribution-Non-commercial 4.0 International (CC BY-NC 4.0)

This license enables reusers to distribute, remix, adapt, and build upon the material in any medium or format for noncommercial purposes only, and only so long as attribution is given to the creator.

Received Accepted Published
March 02, 2022 April 07, 2022 June 30, 2022
DOI: N.A

Keywords

Medical recordsPOMR

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Timeline

Received March 02, 2022
Accepted April 07, 2022
Published June 30, 2022

licence

Attribution-Non-commercial 4.0 International (CC BY-NC 4.0)

This license enables reusers to distribute, remix, adapt, and build upon the material in any medium or format for noncommercial purposes only, and only so long as attribution is given to the creator.


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