Visoka zdravstveno-sanitarna škola strukovnih studija
“Visan“, Beograd
Predmet: Engleskijezik
Medical record/record keeping
Seminarski rad
Mentor:
Student:
Aleksandra Malivuk
MarjanStojanović
Beograd, mart 2017.
Medical record/record keeping
2
The medical record
Before looking at specific medical record procedures, we need to discuss the medical
record, what it is, how it develops and why it is so important. As mentioned in the
introduction, the medical record is an important compilation of facts about a patient’s life and
health. It includes documented data on past and present illnesses and treatment written by
health care professionals caring for the patient. The medical record “must contain sufficient
data to identify the patient, support the diagnosis or reason for attendance at the health care
facility, justify the treatment and accurately document the results of that treatment”
(Huffman, 1990).
The medical record has four major sections:
administrative, which includes demographic and socioeconomic data such as the
name of the patient (identification), sex, date of birth, place of birth, patient’s
permanent address, and medical record number;
legal data including a signed consent for treatment by appointed doctors and
authorization for the release of information;
financial data relating to the payment of fees for medical services and hospital
accommodation; and
clinical data on the patient whether admitted to the hospital or treated as an outpatient
or an emergency patient.
It is important to note at this time that accurate, timely and accessible health care data
plays a vital role in the planning, development and maintenance of health care services. The
quality of data in the medical record and its availability is essential if health care authorities
wish to maintain health care at optimal level.
The purpose of medical record
