Management of Medical Records: Facts and Figures for Surgeons

Bali, Amit; Bali, Deepika; Iyer, Nageshwar; Iyer, Meenakshi

doi:10.1007/s12663-011-0219-8

Cited by 56 publications

(36 citation statements)

References 2 publications

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“…Challenges of inadequacy in medical recording keeping and data retrieval further compound the hassles faced by a researcher to conduct clinical studies. [ 17 ] (Note: This factor was not evaluated in our study.)…”

Section: Discussionmentioning

confidence: 99%

Motivators and barriers to research among doctors in the Indian medical scenario: A cross-sectional study from Karnataka, India

Shanmukhappa¹,

Abraham²,

Venkatesh

et al. 2020

J Family Med Prim Care

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Background: The fundamental principles of healthcare practices and policies are derived from good quality research. Doctors collectively are a source of vast sums of invaluable information. This information if effectively utilized can improve and strengthen the healthcare system. Our study provides a comprehensive overview of the ecosystem of an Indian medical researcher. Objectives: To understand (1) the obstacles faced by medical professionals (2) the challenges encountered at various steps (3) the gaps in research knowledge and (4) the means to rectify them. Method: Doctors from medical schools, hospitals, and in private practices were approached. Data were collected through online and physical questionnaire. Data were analyzed and studied. Results: The total number of participants in this study is 212. Case reports (51.9%) and case-control studies (51.14%) are the most frequently conducted types of research. Lack of access to research journals (43.9%) and absence of proper guidance or mentorship (37.39%) are the commonly faced challenges among individuals who have pursued research, whereas busy schedule is the top-cited reason for not pursuing research (34.24%) and discontinuing research (57.4%). Coordinating time schedule with mentees is a challenge for mentors (49.2%). Doctors also face the greatest difficulty (48.12%) and delay (47.4%) in the publication process. On the other hand, personal interest (60.15%) and job requirement (46.61%) are the top facilitators for research. A small percentage has or knows someone that has plagiarized (21.32%) or falsified data (33.49%). Most of the doctors agree that research experience should be a mandatory part of undergrad training (81.6%). Conclusion: We believe interest, impact and importance of research can be the best developed and emphasized in the training years. Institutional support, adequate mentorship and an uplifting research environment can go a long way in motivating the doctors and tackling the challenges they face.

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Section: Discussionmentioning

confidence: 99%

Motivators and barriers to research among doctors in the Indian medical scenario: A cross-sectional study from Karnataka, India

Shanmukhappa¹,

Abraham²,

Venkatesh

et al. 2020

J Family Med Prim Care

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“…Therefore, medical records should be properly written and preserved to serve the interest of doctor as well as his patient. 6,10 Clinical audit requires an inquisitive mind and thoughtful planning and documentation. When done effectively, results in benefits beyond measure and provides best of the treatment available having a scientific backing and improving the quality of care.…”

Section: Discussionmentioning

confidence: 99%

Clinical Audit and Record Keeping Guide for Improving Patient Care

Motimath¹,

Baliga²,

Sharma³

2017

jebmh

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BACKGROUND Maintaining records and documentation of all aspects of patient's dental care is considered as the legal responsibility and professional duty of the dental surgeon. Complete dental records consist of documents pertaining to history of present illness, clinical examination, diagnosis, treatment plan, treatment provided and prognosis. Record maintenance helps in all the aspects of practice whether providing appropriate treatment or medicolegal defence. MATERIALS AND METHODS We conducted thorough research of documents pertaining to patients who reported to the Department of Oral and Maxillofacial Surgery, KLES V.K. Institute of Dental Sciences, Karnataka, India, between 2015-2016.Their records were maintained in the prescribed format followed by entry in a register about the records, diagnosis, treatment which was crosschecked by a consultant daily.The record consist of several different elements, which include written notes, radiographs, study models, referral letters, consultants reports, clinical photographs, results of special investigations, drug prescriptions, laboratory prescriptions, patient identification information and a comprehensive medical history. Timely auditing was done to evaluate the quality of care provided with constant refinement of the protocols RESULTS The audit of the records done in our department showed the common mistakes in recording history by the trainees. We recorded common postoperative complications seen with different procedures and treatment protocols.Wherever required protocols and follow ups were changed to minimise them. With the help of this audit, we were able to compare new treatment modalities and were able to provide best possible care which was also cost effective. CONCLUSION This article highlights the importance of dental records and how it helps in improving patient care, especially in developing countries where this habit is to be inculcated from roots now. It gives an insight into the possible success rates to be encountered by general dental practitioners by continuous review and audit of their work especially benefitting when applied at level of institution.

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“…Medical records are those documents that explain all details about the patient's history, clinical findings, diagnostic test results, pre and postoperative care, patient's progress and medication. [ 16 ]…”

Section: Importance Of Recordsmentioning

confidence: 99%

Medico-legal and ethical issues in anaesthesiology profession

Shinde

Parak

Bhati

et al. 2021

Indian Journal of Anaesthesia

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Extant legislation, professional and societal ethics provide fundamental guidance to professionals in practising their profession. Legal rules are enforced by courts of law whereas rules of ethics are enforced by professional bodies like the Medical Council of India (now National Medical Commission). In this article, we explore some of the principal guidelines that regulate medical ethics. The role of informed written consent is vital in safeguarding the patient as well the doctor's interests; the approach for getting consent will differ depending on patient and procedure. Medical records document every aspect of the patient's history and details of the procedure and are the only means to settle disputes as they provide legitimate, real-time and accurate details of events that have occurred in the past. Although not explicitly listed as a 'service' in the Consumer Protection Act (CPA), healthcare-related complaints can be filed under the Consumer court and the precedent has been established that it is a service. CPA of 2019 provides detailed regulations for performing scrutiny of cases, fines that can be levied, the directives for seeking compensation, etc., Every anaesthesiologist must have some knowledge of law and ethics in order to protect himself/herself from avoidable litigation or disciplinary action.

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Management of Medical Records: Facts and Figures for Surgeons

Cited by 56 publications

References 2 publications

Motivators and barriers to research among doctors in the Indian medical scenario: A cross-sectional study from Karnataka, India

Motivators and barriers to research among doctors in the Indian medical scenario: A cross-sectional study from Karnataka, India

Clinical Audit and Record Keeping Guide for Improving Patient Care

Medico-legal and ethical issues in anaesthesiology profession

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