A Medical Record is a collection of recorded facts concerning a particular patient and is the documentary evidence of the care given to the patient.
To be complete, the Medical Record must contain sufficient information to clearly identify the patient, to support the diagnosis, justify the treatment and to record the results accurately.
Providing the best medical care to the patient and providing materials for
a) Teaching and Training
b) Service Statistics
d) Appraisal of Medical Practice
e) Legal Requirements
This is the basement of Medical Records Communication and ethics.
Six Excellent Guidelines For Hospital Staff is
b) Commitment to Service
Information, Communication and Technologies can really impact and improve the quality of care that we render to our patients. Management of patient information during the administration of emergency care is essential to avoid adverse events and assist in decision making.
Studies have shown that proper implementation has got significant benefits in improving better patient safely. The shared EMR is important when there is a multi disciplinary management of the patient and different care providers are involves.
Definition of Communication
The process by which we understand others and in turn endeavour to be understood by them
Communication is an interaction and should lead to
4. Growth--------->Medical Records is a process.
Process of Communication
“People Forget, Record Remember”
Perception of the Listener (Patients, Colleagues, Co-Workers)
Why Communivation Important ?
Medical Records is a Master Communication- What makes formal organizational communication effective
Clear, comprehensive and thorough documentations
Medical Records is a key part of Information & Transformation
Types of Non-Verbal communication
Tone and volume of voice
Medical Record-good interpersonal relationship should start within the department. To do this he must have qualities of fairness, dependability and dedication and should command the respect of the employees under him
By -> Motivation of the individual
Building Of Team Work.
Communication is the process of passing information to others, and understanding others, and good communication is essential for good relationships with good communication - misunderstandings can be avoided or cleared. The Medical Record professional as a manager should develop communication skills and be always willing to understand his subordinate problems.
The Medical Records department can contribute much to good public relations; contact with the public should leave a good impression. Special care must be exercised in the release of information.
Aspects of Effective of Communication
“When we do the same things in the same way we get the same results. When we do the same things in the same way and expect better results. We have symptoms of insanity”. -Stephen Corey
“Some men see things as they are and ask why?
Dream of things that never were, and ask why not?
-George Bernard Shaw
To be a Good Communicator, you must be a Good Listener
Mental process of Receiving, Understanding, Responding is the foundation of Medical Records Ethics
The quality of formal and informal communication among the staff of a Healthcare Organization is closely linked to that between staff and patients. Effective internal communication is essential for successful external communication.