Medical Documentation is a combination of business, science, and information technology. These professionals are managers, experts in processing – analyzing – reporting information vital to the healthcare industry. A Medical Documentation professional is one of the key positions in a health care organization responsible for various health related information of patient, generated within the health care system.
Medical Documentation is Health information management, covers a broad spectrum of information pertaining to health of the people generated within or outside a health care system. The HIM professionals are essential for all health care setting to generate reports and records about patient care, design and manage health information system, maintain security and legal aspects of patients’ records and establishing appropriate procedures to protect patient data.
Mahatma Gandhi University has started two years postgraduate professional course M. Sc. (Medical Documentation) in 1995. Medical Documentation is the science dealing with the Health Information Management. The tremendous growth of technologies in the field of medicine and its specialization has changed the concept of ‘patient’ to that of ‘consumer’. The Consumer Protection Act, Indian Evidence Act, Workmen compensation Act etc. demands a well organized health information system. The involvement of health insurance agencies, stringent Quality control measures in accreditation process of the health care institutions and legal implications have made it imperative for the maintenance of medical records in each and every hospital.
Qualified Medical Documentation Professionals have lots of opportunities in India and Abroad. Kerala Public Service Commission has recognized this degree as the basic qualification for the post of Medical Record Librarian Grade II. In ESI hospitals they are posted as Senior and Junior Medical Record Technicians.
In the private sector these candidates are posted as Medical Record Officer, Medical Record Executive, Programme coordinator in Clinical Trial, Health information Manager, Coding Specialists etc.
The curriculum is developed in such a way to train the students to acquaint themselves with the changing trends in the field of health information system management. Hospital posting and seminars conducted by subject experts will enrich their knowledge.
Relevance of the Course
Whatever it is, the science of medical documentation has developed rapidly over the past few years, particularly, in the developed countries and the personnel associated with medical documentation are considered very important. The quality and effectiveness of medical care and medical education is directly dependant on the quality of medical documentation practices followed in the hospitals or medical education institutions. In the absence of enough number of medical documentation professionals, who are trained in medical records management as well as medical information management and retrieval, those who passed a course in Medical Records Management has been appointed as Medical Information Managers.
In countries like India, medical documentation has not been recognized as a very essential area in many hospitals. Only major hospitals have adopted a system of medical documentation. Even in such hospitals, documentation has not been comprehensive and not based on any approved policy or standards. Every hospital has been following a system of its own, resulting in inconsistencies in medical information management. This is because of the dearth in the personnel trained in Medical Documentation.
Therefore, the School of Medical Education started a Masters degree program in Medical Documentation with the main objective of moulding graduates with the necessary skill for total information management for the medical profession. There are candidates trained in the field of library and information science, who are not conversant with documentation of data pertaining to patients. There are also persons who are trained in medical record science, who are not familiar with medical information storage and retrieval systems. Those who complete the M. Sc. (Medical Documentation) course are given training on both these aspects and they will be capable of dealing with total information management in hospitals and medical documentation institutions. Kerala Public Service Commission recognized this qualification for the post of Medical Record Librarian Grade 2 (Order No: G.O(MS)No.99/2004/H& FWD dated Thiruvananthapuram, 28-4-2004).