Medıcal Records Management and Hospıtal Applıcatıon

Abstract

Medical records make an important resource that can be used for evidence of medical care given to the patient and for evaluating quality of provided service. Therefore it’s very important exactly and regularly certificate, in details and on time, any services provided to individuals whose disease is suspicious, to patients, to injured person and to people who gave birth. Any patient records in hospitals contain data with high capacity about the human health. These data are checked, preserved and commented for different purposes. Each comment and basic information is archived in order to be reached in case of need. During this work any improvements made in medical reports of any foundation hospital were retrospectively examined with a casual method. Between 2004 and 2013, 350 patient files for every year and totally 3500 patient files from cardiology, cardiovascular surgery, orthopedics, neurology, transplantation, general surgery and pulmonology departments have been examined. In their observations doctos noted that the examined medical records most of the records have been incompletely filled in. The ratio of filling medical records that in the period between 2004 and 2007 years made 80%, in the period between 2007 – 2010 – 2013 raised to 94%, where the audits of JCI ac creditation and of the Ministr y of health were realized. Consequently: an improvement in medical records has been noticed during the years where JCI accreditation audits have been realized.