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Medical record

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Head of Unit : Parisa Jahandideh

Since medical documents and the information included in them represent very precious and reliable leverages in policy-making and planning of the healthcare administrators, due diligence should be undertaken in modifying, improving and progressing them and this is contingent upon the identification of medical documents units in the healthcare centers, as well as identifying the strengths and weaknesses and taking action to revise and improve them. Identifying the medical documents unit and its capabilities does not simply include investigating each and every form used to record data and function as a resource for retaining useful information. But it also includes the assessment of the performance of the constituents of the medical documents unit, each of which partly contains the process of collection, ordering, proper saving, classification in line with the unit’s information, proper retention of the information and medical and healthcare stats which constitute the basis of logical reasoning in the type of services offered, playing an effective role in the subsequent predictions.

The medical documents unit, which works to offer services to the patients, doctors, hospital administrators, provide educational and research services, maintain the desirable remedial and healthcare services quality, preserve the rights of the patients and maintain standards, is considered to be one of the most important parts of the hospital and follows these goals:

  • Establishing an efficient and monolithic system to retain the complete dossiers of the patients
  • Providing the statistics of the diagnostic and clinical actions done and their interpretation and analysis
  • Preparing and collecting the patients’ indices in order to find the medical dossiers in case of frequent referrals
  • Preparing and collecting the indices of surgeries and diseases to help with research and development
  • Preparing the summary of medical dossiers to help the legal authorities with the issuance of decrees

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The value of medical dossier for the hospital

From the point of view of the hospital, medical dossiers contain data that include observations done by the physician and the outcome of the treatment of the patient. Through the medical dossiers, the hospital will aim at analyzing the quality and quantity of the services offered. As a result, the highest value of the medical documents lies with diagnosis and determining the reasons of treatment. It’s highly likely that the patient might die and his or her death may be because of the reasons that are preventable. In such cases, the medical documents of the patient will be particularly considered by the hospital in order to research the reason of the death. It’s noteworthy that for the hospital, the importance of death is not less than the disease itself as in today’s modern medicine, it’s not sufficient to only know that the patient has been treated and is released. Today, the hospital is responsible for reviewing and determining the results originating from the treatment of the patient and its reasons. If the outcome of the treatment is the recovery of the patient, the hospital and the medical staff should know what role they have played in this recovery.

A brief description of the activities of the unit

  • Assigning codes to the medical dossiers of the patients based on primary diagnosis over the course of treatment, final diagnosis, surgeries and other medical actions and external triggers (accidents, plagues and poisoning) based on the international coding of disorders book
  • Getting the daily statistics from the units and controlling them by completing the monthly statistics of clinical treatment (separated by sections), hospital infections, sample diseases, clients, hospital activities and sending them to the treatment deputy

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Description of the activities of the archiving of medical documents unit

  • Keeping the dossiers of patients in the relevant files based on archiving standards
  • Responding to the clients to deliver the documents required by the complementary insurances
  • Responding to the clients to deliver the documents required by the medical commission or Public Conscription Organization
  • Sending the documents required by the forensic medicine in accordance with the verified instructions
  • Sending the documents required by the Organization for Civil Registration in accordance with the verified instructions
  • Responding to the clients and taking care of the affairs related to the veterans, families of the martyrs and the Relief Foundation

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 رشت، گلسار، بلوار سمیه، خیابان 142

کد پستی: ۶۳۱۱۱-۴۱۶۵۷


پیاده سازی و اجرا: تجارت الکترونیک پارس داتام | میزبانی وب: آپتایم هاست