A survey on the management of medical records and their availability for epidemiological study (author's transl)

Abstract

In order to determine the availability of medical records for epidemiological study, questionnaires were sent to all the medical and surgical wards of hospitals in Kyushu, Japan in 1968. Questions included items on storage and retrieval systems of medical records, and description of information available for epidemiological study.Eleven hundred and twenty-two questionnaires out of 1, 321 were returned and analyzed. Three hundred and forty-two (30.5%) of medical and surgical wards have kept their medical records for 10 years or more. Only 120 (10.7%) had medical record librarians. Almost none of the hospitals had adopted the unit file system. Five hundred and twenty one (46.4%) wards out of 1, 122 had some kind of indices. Name indices and discharge date indices were common in the wards where the indices were compiled.Information for follow-up was recorded routinely on the medical records, i. e., 271 (24.2%) wards for permanent address, 354 (31.6%) wards for address of family or relatives. However, medical findings of x-ray, E. C. G., etc., were well described on the records.In summary, it would not be easy to obtain information from medical records preserved in hospitals for epidemiological study, because of short-term custody of medical records, lack of suitable management systems for medical records, incompleteness of retrieval systems and lack of follow-up information. Recently it is well recognized by workers in medical areas, however, that management of medical records should be improved, not only for medical research but also for hospital management. Therefore, in the near future, the information from medical records could be fully utilized.