Medical record keeping for quality patient care: An observational study

S. Rudresh, Sherry P Mathew
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Abstract

Introduction: Effective management of medical records is essential for delivering high-quality treatment. The location, architecture, and personnel of a medical records department (MRD) can considerably impact its operational efficiency. This study seeks to examine hospital MRD and establishes whether its current configuration is suitable for effective medical record management. Materials and Methods: The descriptive method was utilized to evaluate the MRD of the hospital. The review analyzed the department's physical layout, personnel, workload, training programs, and available equipment. The study also evaluated the influence of government and business restrictions on MRDs operations. Results: It was determined that the MRD of the hospital had an appropriate physical layout, with divisions positioned in optimal locations. The department's personnel levels were adequate, with twenty employees managing the patient population's workload. The analysis determined that the department required extra photocopiers and scanners to boost operational efficiency. In addition, the study underlined the significance of adhering to policies, protocols, and established processes in ensuring efficient workflow. Conclusion: The analysis concludes that the hospital MRD has an adequate physical layout, staffing levels, and task management. However, the present equipment could be enhanced to increase operational efficiency. The study also emphasizes the importance of adhering to policies, protocols, and written processes to ensure the department's efficient workflow. The outcomes of this study may inform future decisions on MRD management in other health-care organizations, especially those subject to comparable government and commercial regulations.
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高质量病人护理的医疗记录保存:一项观察性研究
导读:有效的医疗记录管理对于提供高质量的治疗至关重要。医疗记录部门(MRD)的位置、架构和人员会极大地影响其操作效率。本研究旨在检验医院MRD,并确定其目前的配置是否适合于有效的病案管理。材料与方法:采用描述性方法对医院的MRD进行评价。审查分析了该部门的物理布局、人员、工作量、培训计划和可用设备。该研究还评估了政府和企业限制对mrd运营的影响。结果:确定医院MRD物理布局合理,科室布置在最佳位置。该部门的人员水平是足够的,有20名员工管理病人群体的工作量。分析确定,该部门需要额外的复印机和扫描仪,以提高运作效率。此外,该研究强调了在确保有效工作流程方面遵守政策、协议和既定程序的重要性。结论:分析认为医院MRD具有适当的物理布局、人员配备水平和任务管理。不过,现有的设备可以加以改进,以提高作业效率。该研究还强调了遵守政策、协议和书面流程以确保部门高效工作流程的重要性。本研究的结果可为其他医疗机构,特别是那些受政府和商业法规约束的医疗机构,未来的MRD管理决策提供参考。
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