Chapter: 4.1 Uses of records

Uses of records

Records have multiple uses for the modern Health Professional.

1.    It helps to document the patient's past & present history of illness.
2.    It helps in following up patients' progress & response to treatment.
3.    It sometimes helps in predicting future risks to the patient's health.
4.    It helps the community to maintain epidemiological data, which in turn helps in identifying & alleviating risks to the community at large.
5.    It may also help in improving the health prospects of future generation. Medical records also serve the purpose of medical audit as well as hospital statistics.
6.    Documentation also contributes to clinical research data.
7.    Proper records form a mirror in the court of law, of Health Professional actions.

In other words the courts are able to judge the correctness of the treatment only by the available documentary evidence. Properly maintained case notes are, thus vitally important in proving a case.

The list of the records that a hospital is supposed to maintain is very large Use of EMR Electronic Medical Records has made record keeping an easy job.