Hospital records management solution

Hospitals deal with the life and health of their patients. Good medical care relies on well-trained doctors and nurses and on high-quality facilities and equipment. Good medical care also relies on good record keeping. Without accurate, comprehensive up-to-date and accessible patient case notes, medical personnel may not offer the best treatment or may in fact mis-diagnose a condition, which can have serious consequences. Associated records, such as X-rays, specimens, drug records and patient registers, must also be well cared for if the patient is to be protected. Good records care also ensures the hospital's administration runs smoothly: unneeded records are transferred or destroyed regularly, keeping storage areas clear and accessible; and key records can be found quickly, saving time and resources. Records also provide evidence of the hospital's accountability for its actions and they form a key source of data for medical research, statistical reports and health information systems. It is still common in many hospitals to give each department total autonomy in the management of its records. Unfortunately, this decentralisation of records care often leads to poorly designed filing systems, loss of information, premature destruction or unnecessary retention of records and ultimately to inefficiency and wasted resources. Above all, patient care will be adversely affected if correct records are not maintained or if records are inadequately managed or if there is no means of co-ordinating the care the same patient receives in different departments. A structured and effective records management programme, covering all departments and all records irrespective of media, should be the aim of every hospital. A comprehensive records programme will help to ensure that staff have access both to clinical information and to administrative records on a wide range of issues, including policy, precedents, legal rights and obligations, personnel, finance, buildings, equipment and resources. Besides controlling records needed for current business, the programme will ensure that the hospital can meet its legal and financial obligations and can defend its actions when necessary. Managing Hospital Records addresses the specific issues involved in managing clinical and non-clinical hospital records, indicating where particular approaches are needed to meet the specific requirements of a records service within a hospital environment. While Managing Hospital Records is primarily concerned with the records of general hospitals, much of its content is also applicable to the management of records in other health care facilities, such as long-stay hospitals, mission hospitals, sanatoria, community clinics and local health centres.

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