Medical Records Unit
Introduction
The patient’s medical record is the most important document in the hospital, it is a legal documents.
The information contained in the medical record allows health care provider to provide continuity of care to individual patients.
The medical record serves as a basis for planning patient care, documenting communication between the health care provider and any other health professional contributing to the patient′s care
In addition, the medical record may serve as a document to:
- educate medical students/ resident physicians
- provide data for internal hospital auditing and quality assurance
- provide data for medical research
Aims
- Maintains all hospital records in a safe, secure, confidential environment
- Provides in a timely manner patient medical records to all hospital and outpatient department units
- Supervises all medical files and ensures its accuracy, completeness, and timeliness of work as per established policies and procedures
- Plans, develops, and supervises the implementation and maintenance of medical records systems and participates in developing policies and procedures on confidentiality, patient registration, medical record content, documentation issues, and others related to accreditation standards and ISO requirements
Responsibilities
- Concurrent and retrospective analysis and monitoring of medical records according to established rules and regulations
- Reporting of errors or deficiencies encountered, and notifying the responsible parties
- Ensuring that the signature of physicians are available on the medical files- as per rules and regulations
- Ensuring that all patients medical files are assembled, completed, stored under appropriate conditions, in secure and timely manners
- Efficient retrieval of records and providing access to patient records only to those who are authorized
- Making sure that each patient has a unique medical record despite the number of his visits to the hospital
- Unification of ER records and OPD files with the inpatient medical files to provide a continuity of care
- Preparing the quality indicators and the data collection
Services offered
- Providing medical record to inpatient, OPD and ER departments when requested
- Providing patient, or any authorized person, copy of his medical file (laboratory results and X-ray reports) upon the approval of the concerned attending physician
The Medical Records Unit at Ain Wazein Hospital has been created since the hospital was established. All medical records are kept in hard copies.
A record scanning project is in process of being implemented for the old OPD files, and will be developed later to cover all old inpatients medical files and ER records.
Paperless strategy
The medical files have began to be computerized (part of data) since 1999, and become fully computerized (all medical and nursing notes, consultations, orders, progress notes, laboratory, pathology and radiology reports, discharge summary, physiotherapy notes, dietitian notes, medications requests … ).
The electronic medical file provides the ability to rapidly find, retrieve, and share documents in our database
The "Quality Assurance Committee for Medical File" is responsible for:
- Improving the documentation in the medical record through regular data collection and analysis
- Making sure that all forms are filled properly in the medical records
- Approving all forms to be used in the medical records
- Reviewing the quality indicator(s) related to medical records and suggesting improvement plan (corrective and preventive actions)
How to Request Your Medical Records
According to Lebanese law, patient has the right to obtain copy of his medical records (lab and radiology reports and the discharge summary) based on his request and the approval of concerned attending physician.
The attending physician is requested to fill in the form "MC-FO-07 إطلاع المريض على ملفه الطبـي" available in all nursing units, and send it back to medical records for preparing the required documents
Operation hours
- The Medical Records Unit operates 8 hours a day (from 8 am till 4:00 pm) six days a week (from Monday till Saturday)
- After working hours- and for emergency cases- the requested medical records can be retrieved by the on call nursing supervisor, or through the hospital information system (SINA) since the medical file is computerized
Head Unit
Location
- Basement floor (-2)
Extension
2970- 2971
