Medical records is the term used in collecting and storing data of a single patient’s medical examination, diagnostic tests, treatments suggested, medical history, chronic complications, adverse reactions and other services provided. These records are mainly electronically and a sample copy can be accessible to patients upon request. The professional coder who does this job is commonly known as a medical records coder.
Medical records have historically been prepared and stored by physicians or health care providers. During last decade whole healthcare industry has changed a lot. One thing caught everyone’s attention is that the introduction of IT facilities in medical institutions. This modern concept is highly encouraged and supported by US health administration, AHIMA, AAPC and other governing bodies. Medical coders do a tremendous job to put all the medical related information under one alpha numerical code which can be easily accessible in future if necessary. In reality, these records help physicians all over the country to make correct treatments aligned with patient’s medical history and present condition.
Now, the question comes what a medical records coder does regularly? Answer of this question varies a little according to medical settings they are presently working. But the basics remain the same. If they are in in-patient care facility they job involves recoding admission records, on-service records, health condition progress records (SOAP records), operative records, preoperative records, postoperative records, process records, delivery records, postpartum records, and discharge records. If the medical coder works in a physician’s office or out-patient facility, then his duty involves compilation and maintenance of health check-up report, diagnostic report, treatment and medication report. In surgery facilities, they prepare medical records consisting of assessment report, diagnostic report, medical history, Preoperative report, post operative report, premedication report, post medication report, hospital clearance report etc. If coders are coding in a maternity clinic or gynecologists chamber, he/ she have to prepare and maintain condition assessment report, test report, pre delivery report, post delivery report, clearance report etc. These records are forwarded to a patient upon request so that where ever he/ she go within the country the standard of medical practice remain the same.
It is also used as a good training material for medical and nursing students. Perhaps, recording and keeping of medical information is not a new issue. It is actually dated back to many centuries ago when our ancestors treat patients through herbs. They used to write it down to stone, leaves, wood etc. Recent advancement of IT facility and high speed computer network has made easy for us to code all the medical information under a single code. Medical records coder follows some rules and guidelines in medical records keeping. As these information’s are highly confidential and personal issues, they should not be disclosed for any forgery action and the corresponding laws should be strictly followed. Thus, these medical records also have become a yardstick of medical practice at present as these codes have given a common standard of medical practice all over the country.