Abstract:

Medical records, which are created by different health professionals in different departments, at different times, and contain the patient's medical history, must be preserved in terms of judicial, administrative and legal aspects. In addition to treatment services, the complete and accurate creation of medical records, which contain basic data for different fields of study such as education, research, health management, forensic medicine, financial management, and public health, brings many advantages in terms of patients, doctors and health institutions. The patient file archive management creates a structure for the timely and complete creation of medical records by the responsible persons, the simultaneous tracking of the changes made, their safe keeping, and authorization-based access. The establishment of this structure is the responsibility of health institutions. With this study based on literature review, it is suggested that the records that do not have any obstacles in electronic production in accordance with the current legislation and standards should be included in the electronic patient file, and the paper patient file should be arranged in a simple and functional structure, including only the forms that are required to be produced and preserved physically. It is emphasized that the transition to the electronic patient file, which provides significant advantages in terms of medical record quality, is also effective in the restructuring of the patient file archive units, which creates a large space, material and personnel requirement for healthcare institutions, and allows for more effective use of business resources of the healthcare institution.

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