Medical Records – Evolution & Hybrid System

By Abdulla Israr & Simran Rani

Medical Records – Evolution & Hybrid System

Introduction

·       A Medical Record is a systematic documentation of a patient’s medical history, diagnosis, treatment, progress, and care during a healthcare interaction.

Historical Background

  • Originated from physician casebooks.
  • Institutionalized during early 20th century with standardization.
  • Major boost after American College of Surgeons (ACS) 1918 initiatives.

Evolution of Medical Records

Period

Key Developments

Ancient

Informal handwritten notes

Medieval–19th Century

Physician journals & casebooks

Early 20th Century

Standardization of hospital records

Late 20th Century

Computerization introduced

21st Century

EHR, cloud, interoperability, analytics

Types of Medical Records

  • Paper-based
  • Electronic Medical Records (EMR)
  • Electronic Health Records (EHR)
  • Personal Health Records (PHR)
  • Hybrid Medical Records (mix of paper & digital)

Transition: Manual to Electronic Records

  • Manual: Prone to loss/damage, time-consuming.
  • Electronic: Faster, accurate, integrated, analytical.
  • Hybrid: Interim model during the transition period.
  • Challenges: Staff resistance, cost, training, migration.

Importance of Medical Records

  • Clinical: Continuity of care.
  • Legal: Medico-legal proof.
  • Administrative: Billing, audits.
  • Research: Epidemiological studies.
  • Education: Case teaching.
  • Quality Control: Monitoring patient outcomes.

Development of Medical Record System

  • Planning → Designing Forms → Policy Making → Digitization.
  • Integration with HIS and national health portals.

Medical Record Procedures

  • Registration → Filing (serial/unit) → Coding & Indexing (ICD)
    → Record Retrieval → Completion & Authentication
    → Retention & Destruction (as per policy)

Quality Assurance (QA) Standards

  • Accuracy, Timeliness, Confidentiality, Legibility, Retention
  • Regular audits and compliance to standards.

POMR – Problem-Oriented Medical Record

  • Introduced by Dr. Lawrence Weed.
  • Based on patient problems (not diagnosis).
  • SOAP Format:
    • Subjective (symptoms)
    • Objective (findings)
    • Assessment (diagnosis)
    • Plan (treatment)

Patient Care Plan

  • A personalized plan to guide patient treatment.
  • Includes: Diagnosis, Goals, Interventions, Evaluation.
  • Promotes patient-centered and coordinated care.

Progress Notes

  • Daily updates by doctors/nurses.
  • Contains: Patient status, interventions, treatment response.
  • Useful for continuity, planning, and documentation.

Role of Nursing Services in MR

  • Contribute to:
    • Initial assessment
    • Vital signs monitoring
    • Medication records
    • Shift handovers
    • Nursing care plans and notes
  • Essential for accurate and continuous patient care.

CMRATRD (Central Medical Record Archive and Training cum Research Division)

  • Central unit for:
    • Archiving inactive records
    • Training MR staff
    • Supporting research
  • Enhances medico-legal support, planning, and data use.

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