1035 Defining Indicators For The Medical Record

Author(s): 
D Tayar
Text: 
Aim of the workshop
To define a list of indicators, which can help GP's and family physicians to evaluate and improve the use of the patient's medical record (MR) in various recording systems and in different health care systems., for the benefit of both patients and physicians. Each indicator can than be evaluated by different criteria and attributed by a different score and standard, suitable to the local situation To experience the complexity of the process that aims to reach a consensus about what is a 'good enough medical record', within a group of GP's from different countries
THE MEDICAL RECORD
*Is a cumulative reservoir of information, organised in a way that enables the health care providers to insert and retrieve information easily.
*Reflects the biopsychosocial state of the patient - present, past (history) and working plan for the future.
*Management and health policy planning
*Legal aspects
*Statistics, epidemiology, research
*For the evaluation of health needs of the population and for Functions of the Medical Record
The MR is essentially an aide-memoir for several purposes. It is a tool (source of data) for:
*Communication
Within the practice, with various care providers
With the patient or his/her representatives
Outside the practice
*Quality Improvement (QI)
Audit
Evaluation of processes and outcomes
Clinical activity analysis
Clinical decision analysis
Peer review
Characteristics needed for the MR
1. Legible
2. Explicit
3. Standardized to a certain level
4. Continuously updated
5. Easily retrievable and updated
6. Confidential and secure
7. Selection / triage
8. Organised:
Chronologically
Problem oriented
Structured for defined aims
9. Continuous prioritizing process
10. Built for a coding system
Literature: 
1035
Defining indicators for the Medical Record