Medical Records: Organization and Management – Clinical Guide

This is a cookbook for medical and health care professionals including medical, nursing, paramedical, particularly medical records, administra¬tive, insurance, billing, legal and software development personnel. This book would be of immense use to medical educational institutions for medi¬cal, dental, nursing, paramedical, administrative, patient relation services, medical legal and consumer courts, insurance, accounts, etc. The health care software companies engaged in developing hospital information system and electronic health records will find a great boon in designing and developing appropriate product that will meet the clients to the fullest satisfaction. The health record manager as a domain specialist has a vital role in the transfor-mation of manual records into hybrid and involve actively in each stage of design and development of health care software for effective implementation of electronic health record in health institutions. Also, it is of significant value to hospital organizers, research workers and national health care providers., The important features of the book are mainly classified into three parts:, €¢ Part 1: It deals with traditional medical records organization and management procedureshistory of medical records administration, role of medical records in health care delivery, general medical records standards and policies, legal aspects of medical records and electronic health records (EHRs), medical audit, International Classification of Diseases 10th revision together with the information on ICD-10 CM and ICD-10 PCS revision, hospital information system, how to economize, health service expenditure, organization and management of the medical record department, medical record procedures, €¢ Part 2: It contains design and development of hospital information system (HIS) for software productioncomputerization of the medical records, challenges of the health care delivery in 21st century, domain for designing the hospital information system (HIS) software, designing the hospital ward nursing administrative activities, blood transfusion service, pediatric center, diabetic center, dialysis center, dental clinic, IVF (in vitro fertilization) clinic, occupational health and safety, biomedical equipment maintenance, €¢ Part 3: It includes development and implementation of electronic health record (EHR)perspective of information technology (IT) in hospital information system, challenges in hospital IT and networking design, tips for evaluation of electronic health record software, roadmap for successful implementation of EHR, amalgamation of manual record (MR) with electronic health record (EHR), health record manager (HRM) revolves around patient as a good leader, modern trends and issues of developing countries in maintaining medical records, health information management (HIM) professionals endurance in 21st century, implementation of personal health records (PHR).