1. ORGANIZATION AND MANAGEMET OF
MEDICAL RECORDS
KESHAVARAO.T
ASST., MEDICAL RECORD OFFICER,
BELGAUM INSTITUTE OF MEDICAL SCIECES,
BELGAUM-590001. T.Keshavarao Mob.9880569550

2. ORGANIZATION OF MEDICAL RECORDS
INTRODUCTION
What is record ?
Record is a written document or something setting down
in writing.
But
What is medical record ?
The information set down in writing pertaining in the
patients illness, history ,treatment and end result known as
medical record.
T.Keshavarao Mob.9880569550

3. Functions of Medical Record
Act as a communication between Patients and Physician
Immediate clinical care of the patient.
Future care of the patient.
Utilization for clinical or epidemiological purposes.
Act as Documentary evidence in Legal purposes.
Source of nomination for management & Planning.
Principles & Policies of Medical Records.
Orient Patient care.
Establish a basis for the evaluation of Medical Record Programme.
To help estimate current & future staff , equipment and other requirements.
Improve decision making by reducing the number of arbitrary or conflicting
decisions.
Certain Policies should be standardized.
T.Keshavarao Mob.9880569550

4. Purpose of Medical Record
Patient Care.
1. Medical record are an aid to the treatment.
Communication within the facility (Inside the hospital)
Communication within the facility (one hospital to another Hospital)
2. Medical record act as a mediator physician and other health care
professionals individual patient care.
Education.
Medical records use to made retrospective review.
Research.
Providing data to Clinical, health services administrative point of view.
Retrospective and Prospective information for future.
Statistics.
Morbidity statistics for prophylactic action purpose.
Utilization statistics
T.Keshavarao Mob.9880569550

5. Evaluation
Easily evaluate the Medical care.
Programme Surveillance (Monitoring)
Individual Planning
Administrative Management (Planning. Budged. Organizing. Controlling)
Legal Aspects.
Furnishing documentary evidence of the course of the patient illness and
treatment during each and every treatment visit or hospitalization.
T.Keshavarao Mob.9880569550

6. BRIEF HISTORY OF MEDICAL RECORDS
MEDICAL RECORD KEEPING of sick and injury is not a new procedure of the
country. The history of medical records runs parallel with the history of the
medicine.
STONE AGE
> In the stone age as in Spain the peoples were recorded the surgical notes
of amputation of fingers in walls have been explained graphically about 2500
bc.
> Caves and temples of Ajanta , Ellora and Buddhist stupas of Amaravathy &
Nagarjuna konda also ample evidence of medical records.
> Indian medical practice documentation found in “Athervaveda”
> First Indian medicine text book is “Atreyasamhita”
> “Agnivesasamhita & “Agnivesasamhita” also documented art of healing.
> First Indian surgery text book is “Susrutasamhita”
T.Keshavarao Mob.9880569550

7. Egyptian period
In Egypt author “Thoth “ created 6 medical subject books. They discussed human
body diseases & diseases of opthal & gynaecology instruments, drugs.
Another Egypt physician “Imhotop”He has authourship of “Papyrus which is
ancient Medical documents dealing with surgical subjects. It is roll over 15 feet
and long 13 inches wide made up 12 sheets usual size. It is written both sides
and consists 48 cases of clinical surgeries.
Greek Period
In Greek scientist “Hippocrates” known as Father of medicine. He written several
volumes of medicine books like patient history, symptoms & physical science of
diseases. His books translated many languages.
Greco-Roman
In Rome physician “Galen” has first realized the function of arteries and contain
blood. He was maintained bedside records.
Mohammedian Period
“Rhases” treats smallpox and measles and were kept few medical records.
T.Keshavarao Mob.9880569550

8. 19th CENTURY
The famous Massachusetts general Hospital at Boston (USA) was opened and
maintained Medical record Library and appointed first Qualified Medcial Record
Librarian Mrs. Grace Whiting Myers (1859-1957)
The first record written in ink in folio volumes of 18 length and 12 wide 2 ½
thick bound in boards covered with dark red leather. The records show the days
prior to the discovery of Ether, 164 patients undergone surgery and following its
introduction 487 patients were operated upon. This fact alone proves the value of
keeping for medical records for research and statistical purposes.
20th CENTURY
In 1902 The American Hospital Association discussed Medical Records for the first
time at a convention. The problem brought out and discussed elaborately that
there was no uniformity in methods.
As a result American Medical Record Association convention developed the
medical record standardization.
1930 AMRA published medical record news bulletin.
1935 Medical records education programmed starts at Boston,Newyark,Chicago.
1952 Ist International Medical Record conference held in London.
T.Keshavarao Mob.9880569550

9. Medical Records in India
In 1950s importance was given for medical records development in India.
In 1957 Dr.J.R.McGibbony (Rock feller Foundation.USA) visited India and he
recommended to establish well developed MRDs in India.
1961 the Govt of India DGHS appointed Mudaliar committee for establishment of
MRDs.
1962 CMC Hospital Vellore was Started MRT & MRO courses.
1966 Govt of India DGHS Starts well organized MRD in JIPMER Puducherry.
28 th February 1973 (DGHS CBHI) MRT Training and 1978 MRO Training
programme started at Safdarjung hospital.New Delhi.
1977 MRO Course & 1979 MRT course (DGHS CBHI) started at JIPMER Puducherry.
T.Keshavarao Mob.9880569550