What are Hospital Records?
Hospital records are the information about a patient stored by the hospital administration for the time the patient has been hospitalized. Hospitals hold important information which helps in serving as a basis for arrangement of patient care, documenting communication between healthcare providers and patients. Such records also serve as a teaching basis for educating medical students and residents. They mostly include the following information:
- Patients’ personal information such as name, age and address.
- The date and time of admission and time of discharge of the patient.
- The disease for which the patient was admitted or the symptoms he was experiencing when admitted.
- The consultant who was attending the patient in the hospital.
- The medicines prescribed and taken by the patient while in the hospital.
- The amount that was charged for staying in the hospital and using hospital services.
- Medical history of the patient
- Orders and prescriptions for the patients
- Progress notes of the patient
- Investigation results.
- Other information such as readings of blood pressure, temperature, intake of food, water, fluids and medication, capability of four limbs of the body.
- Administrative issues.
- Demographics of patient’s information.
- A separate record of the patient’s who were kept in emergency rooms or Intensive Care Units.
Hospital records are of two types:
- Computerized Hospital records.
Like all offices and institutions everyone prefers to keep records in computerized databases. These database softwares hold all the information needed to update existing and making new records. They are interactive and easy to use as they already are programmed in such a way that they hold all the information needed to make records such as information about consultants, tests and medicines. Backups are usually kept by hospitals so that if the system crashes the hospital has all its records safe. Usually computerized hospital records are used by private hospitals but not necessarily as in many countries government hospitals also use computerized systems. These simplify patient tracking and allow medical research. They allow a large number of records to be kept compactly, so thousands and thousands of records can be kept and maintained.
2. Hand written Hospital Records
Traditionally paper is the medium used for handwritten hospital records and are kept in folders. These folders are divided into different sections in order to update them. Many hospitals especially small ones use handwritten hospital records. Rural areas in many countries are usually not well organized and even if they are they do not have the budget to keep computerized systems. Such hospital records are usually not very detailed and even if so they are difficult to manage. Such records do not have any backup and if once they are lost they cannot be retrieved. They also require a lot of space to be stored.
Computerized medical records are a huge help for both government as well as private hospitals. Computerized data is a neat idea to keep things organized as well as easily accessible in the time of need.