Review on Medicare-Diagnosis and Medication

Medical histories include a variety of documentation of patient's past, clinical discoveries, diagnostic check results, preoperative care, operation notes, post-operative care, and daily notes of a patient's progress and medications. It is very important for the treating doctor to properly document the management of a patient under his care. Medical record keeping has evolved into a science of itself. This will be the only way for the doctor to prove that the conduct was carried out properly. It is important for the doctors and medical establishments to properly maintain the records of patients for two important reasons: the first one is that it will help them in the systematic evaluation of their patient profile, helping in analysing the treatment results, and to plan treatment protocols. It also helps in planning governmental strategies for future medical care. The legal system relies mainly on documentary evidence in a situation where medical negligence is alleged by the patient or the relatives. With the increasing use of medical cover for treatment, the insurance companies also require proper record for keeping proof of the patient's demand for medical expenses. Improper record keeping can result in declining medical claims. It is overwhelming to note that in spite of knowing the importance of appropriate record keeping it is still in an emerging stage in India. The traditional method of keeping records that is followed in most of the hospitals across India is the manual method involving papers and books. There are serious boundaries of physical record keeping including the need for large storage areas and difficulties in the recovery of records. Our aim is to create an online space for doctors as well as patients to maintain the medical records and to ensure a transparent and reliable medical treatment system.