Medical Record

Function- 4 stakeholders (Patient, Doctor, Hospital, Government)

For Hospital (SAW)- Statistic, Allocation, Workload.

Features (USIA)- Unique, Specific, can be Index, can be Arranged.

Policy (CARTE`)- Complete, Accurate, Reliable, Timeliness, Ethical

Numbering System

Serial #- Given at Inpatient or outpatient

Unit #- Given at every services or transaction

Serial Unit #- Unique, can be tracked back

Standard Page- Vital, Consent, Admission, Doctor, nursing, medication, Xray, Lab, Transaction, Discharge.

Reporting- Index, Registers

Index (main source of information of for disease-treatment)

Register (main source of information for services-transaction)

Function of Medical Record

1- WAS:

Workload, Analysis, Statistic

2- POLICE

Budget, record, population, program, prevalence, epidemiology

3- Stored, post-analysis, retrieval

Medical record is core unit in the Health Information System