1. University Of Tabuk
Medical record
department
Medical Record
Science
Corse semester (1434/1433)
Presented By: Murad younis RN,MS

2. Out line
At the end of this presentation, the student
should able to:
• Brief history of medical record.
• Introduction to medical record science.
• Medical record department structure.
• List unit that contain to medical record
department.
• The main complication in the medical
record department.

3. Out line
• The rout of organization and content of
medical record.
• Designing and general rule of medical record.
*AL DEPERGH Design.
*LORANS WED Design(P.O.M.R).
Jopdescrption to manger of medical record.

4. Brief history
• The medical Record was started with beginning in
old medicine.
• The U.K the first called as medical record since
1912, then development step by step by time, the
actually development in 1969 by lorans.
• He make the basic modern to medical record, thin
started the classification system of record and
stored the file record, after that the
computerization system establish this is the
actually steps in developing history.

5. Brief history
• Thin starting using the microfilm and
microfation.
• Finally the medical record now a day
electronic record and generally to don’t
used the paper and pencil so we depend on
electronic method rather than not paper
method.

6. DEFINITION
Medical Record
• “ Medical record as a clinical, scientific
,administrative , and legal document
relating to patient care in which are
recorded sufficient data written in the
sequence of events to justify diagnosis and
warrant treatment and end results” Mc
Gibony

7.  It has various uses to
 Patients
 Doctors
 Hospital
 Teachers
 Students
 For research work
 National & International agencies
ORIGIN :-
The inpatient Medical Record in originated at the
admission office based on the admission order
made by the clinician or at ER Dept. and various
OPDs of the Hospital.

8. • At present the Medical Record Dept. has
 Medical Record Officer
 Medical Record Technicians
 Medical Record Clerks
 Medical Record Attendants.
• The Reception, Enquiry and Admission office functions
round the clock under the charge of Medical Record
Officer.
• Presently only inpatients records are maintained in the
Medical Record Department.
• Registration work of OPDs are also managed by the
Medical Record Officer.
• Statistical information about the functioning of OPDs is
regularly submitted by the Medical Record Officials in the
Medical Record Deptt.

9. The unit of administration of
medical rescored
• 1- Save unit .
• 2-Statical unit.
• 3-Secretary and reporting unit.
• 4-Admation patient officer.
• 5-Reciption in out department clinical.
• 6-Reciption in emergency room department.
• 7-Central of computer system.

10. The main complication with
employment in medical record
• Careless the manager officer to give the
worker good continuous education and
training program.
• Put the worker in bad envermental and UN
appraperat setting.

11. The main complication with
employment in medical record
• Unappriparat the equipment and technology
beside the level of technical worker.
• Careless in Put the good person in good
place.
• Careless in motivations worker.

12. The rout of organization and
content of medical record
• First rout
Prepare medical record according to sours and
time frequently .
Scand rout
Prepare medical record according to used
comprehensive to development the health
status patient and treatment ,and diagnosis
and medical note ..

13. The rout of organization and
content of medical record
• There'd rout
Prepare the contain record according to health
complain.
This depended on loranse it make the medical
record to four part.
1-Basic medical data.
2-list of health complain.

14. According to loranse
3-pramiry planning for complain .
4-Dector note to development health status.

15. Medical record department
structure
• The medical record administration
`organized as :-
1- Centralization System.
2- Decentralization System Under Supervisor
The Centralization System.
3-Compined System.

16. Centralization System
Organized
• Easy to organized and can be retain back as
need.
• Have supervisor technical and
administration on the worker.
• Work group as one tem.

17. Centralization System
Organized
• To make sure to open the one file for
patient.
• Low in space area work, lower in human
worker(personal), lower economical costly.
• Easy to add the modern technology in this
system.

18. Decentralization System
• Store the record in clinical department it
helped the speed work in health care system
• To make sure the confidential privacy to
information.
• To be oriented about miss take inside the
clinic and disadvantage.

19. Decentralization System
• Over to need the human personal
qualification .
• High costly.
• Frequent open the file

20. Combined System
• Decreeing in mistake during work.
• Good method used in clinical department to
cover the gap.
• Make more than medical record to same
patent.
• High in equipment and resource including
in personal.
• Using high space in work use.
• make a Combination in role and worker.

21. The factor to be selecting the
appropriate system
1- Hospital mainfstrction.
2-The size of hospital.
3- The costly.
4-Reped to work complitionment.
5-Number of worker.

22. AL DEPERGH DESIN
According to AL Depergh design it used six type
of card ready:
1-sumarize medical it is first paper then record
vacation in lower paper.
2-famly history and personal ,enogram to 3 rd
generation.
3-card to record the follow up visit (D.M,HTN)

23. AL DEPERGH DESIN
5- Card to descriptive health condition.
6- data base to filling according questioner for
patient.
Can be added any paper to this system as
need.

24. LORANS WED
(P.O.M.R)
According to lorans wed the file must be
counting on :
*personal data.
*progress note.
*health problem list.
*medication list.
*flow chart.

25. LORANS WED
(P.O.M.R)
• This is system called problem oriented
medical record(P.O.M.R).
• And used in international clinic in world
wide because it is :
*easy to use.
*flexible.
*can be monitor and assess to contain.

26. The flow chart of inpatient Medical
Record for example
Central Admission Wards
Office
Medical Record
Department
1. Assembling After completion of
Records
2. ADMN. & Hospital statistics prepared
Discharge Monthly/Yearly
analysis
Medical Record is filled for perusal of
3. Storage Area Patients/claims/research purposes.

27. The Jop Description To Manger OF Medical
Record Department
1- To monitor the record follow up and open
new files.
2- To monitor on employment the medical
record department.
3-development the work performance to all
department.
4-make good envermental to employment to
increasing performance and achieve target
goal.
5-To make sure that patient recording
according to policy.

28. The Jop Description To
Manger OF Medical Record
Department
6-To make sure that have no mixing file.
7-corrdination and follow-up the next visit in
accuracy work,proble solver.
8-improve the quality inside the clinic .

29. General rule of organizing the medical
record
1- you must the cover of medical record
including on thickness of paper.
2-you must prefer to fix by plastic to save the
cared patent.
3-It is very important to put main list including
on paper used.
4-put the color to indicated to type record file.
5-used special paper to investigation.
6-you must to be in same size.

30. THANK YOU