Medical Record and Date-Driven Healthcare

Thursday, November 09, 2017

The medical record and data-driven healthcare:  A new animation from the Commission and IHPA

Patient medical records are an essential tool for clinical communication and handover. In addition to this primary purpose, the information derived from the medical record is used for range of other purposes including forming the basis for health service funding, informing safety and quality initiatives and contributing to research to improve care.

Once the patient leaves the hospital the clinical coders convert the information in the medical recode into codes. They have to follow strict guidelines and cannot make assumptions about the information in the medical record. Clear, accurate and complete documentation in patient medical records is critical to ensuring that the coding is accurate.
 
The Commission and IHPA have developed an animation called the Medical Record and Date-Driven Healthcare. It aims to raise awareness of the importance of the medical record to the accuracy of this data and encourage improvements in clinical documentation.
 
Watch the animation on the medical record and data-driven healthcare here