Medical Records; Present Status and Ways Forward in Nepal

This study is a qualitative analysis of medical records, present record keeping practices and ways forward in Nepal. In this study, the history of medical records has been illustrated along with its basic contents, objectives, present legal provisions etc. in Nepal. Present medical recording system in Nepal is mostly paper based but there is also the practice of digitization of old records and starting over the digitalization. Electronic medical recording system is adopting in different hospitals. National and provincial governments have been contributing to implement the EMR system in order to make full digitalization. At present, different softwares have been used for EMR to enhance the quality of medical records and trying to make interoperable among them. Even though the National and subnational governments of Nepal have put efforts to develop the digital medical record management system through the digitalization of system but there are some challenges in the transition like physical infrastructures, finance, resistance to change, digital literacy, medico-legal management, data security, cyber threats etc. For making an efficient healthcare delivery system, there is no alternative for the development of digital medical recording system throughout the country. Similarly for the timely diagnosis, quality treatment and cure, as well as well as to reduce the out of pocket expenditure in health efficiently and effectively EMR should be implemented and overall medical recording system should be strengthened. There should be the strong commitment to implement full EMR system throughout the country by using the appropriate software making them interoperable so that the quality of health services can be provided efficiently and effectively. Transition of paper based system into paper less medical recording system should be the goal of the country, to achieve common goal, all the national and provincial governments should put equal efforts.