Hospital medical records is a documentary evidence as per the Indian Evidence Act, 1872 , as amended up to August 1, 1952 & 1961 and medical records are generally summon to the court of law in the following types of cases in our country.
Death or Injury caused due to compromise of safety..
Workmen’s Compensation Cases
Personal Injury Suits in case of doctors negligence.
Malpractice Suits againt hospital
The Income Tax Act: for claiming rebate.
Criminal Cases. Medico legal case sheet.
Evidence in the Court of Law.
Claims under CPA
Age verification as order by court..
Regd. Of Birth and Death.
COMPONENTS OF MEDICAL RECORD COMPONENTS IDENTIFICATION SHEET OBSTETRIC RECORD BABY NOTES INVESTIGATION RECORDS DEATH/ DISCHARGE SUMMARY CLINICAL RECORDS DOCTOR’S ADVISE & TREATMENT SHEET NURSING RECORDS Name, Address, Age, Sex, Religion, Admission No. & date, Prov. diagnosis
History, Physical Examination,
Operation Note, Progress &
- Temperature, B.P, Pulse - Fluid in take/ loss
DATA OBTAINED FROM MEDICAL RECORD DATA DISCHARGE ANALYSIS EPIDEMIOLOGICAL INFORMATION
Daily Census, Discharge, Death
Length of stay, Bed occupancy/ turn over
Operations, Morbidity Rate, Complication
Age, Sex, Geographic Distribution
Investigations and Autopsies
Targets and Achievements
Medico legal Cases
Incidence and Prevalence
Disease Specific Deaths
Hospital Case/ work load
ORGANIZATION OF MEDICAL RECORD DEPARTMENT MRD PERIPHERAL UNIT CENTRAL UNIT
Medical record Office
FLOW OF MEDICAL RECORDS The Medical Record Department has two units and flow of record is from peripheral to Central Unit. MR DEPARTMENT PERIPHERAL UNIT OPD REGISTRATION EMERGENCY REGISTRATION INQUIRY & CENTRAL ADMITTING OFFICE ADMISSION CHECK DESK WARD WARD CENSUS DESK CENTRAL UNIT MRD ASSEMBLY & DEFFICIENCY CHECK INCOMPLETE RECORD DESK ADMISSION DISCHARGE ANALYSIS CODEING & INDEXING FILLING M.R LIBRARY
ORGANIZATION OF MEDICAL RECORD DEPARTMENT MRD ORGANOGRAM SIZE FUNCTIONS STAFFING LOCATION
ORGANOGRAM MEDICAL SUPERINTENDENT MEDICAL RECORD COMMITTEE OFFICER- IN CHARGE-MRD MEDICAL RECORD OFFICER PERIPHERAL UNIT REGISTRATION COUNTER CLERK INQUIRY & CENTRAL ADMISSION OFFICE CLERK ADMISSION CHECK DESK CLERK CENSUS DESK CLERK CENTRAL UNIT MRD ASSEMBLY & DEFFICIENCY CHECK TECHNICIAN INCOMPLETE RECORD DESK ASSISTANT ADMISSION & DISHARGE ANALYSIS TECHNICIAN CODEING & INDEXING TECH. M.R LIBRARY ASSISTANT
Location - near main entrance in close proximity with OPD & Emergency
Admission & enquiry space- 125 -175 sq.ft
medical record office for 50beddedHospital175sq.ft
, medical record office for 100, bedded Hospital 240sq.ft
medical record office for 200 & > bedded Hospital 500sq.ft
medical record office for 500 bedded hospital 1200sq.ft
Storage - 120-500sq.ft with shelving.
STAFFING The average staffing for 250 beds and 500 beds hospital should be as under. 25% for leave reserve extra. S.NO. MANPOWER 250 BEDS 500 BEDS 1000 BEDS 1. MRO ONE ONE ONE 2. M.R Technician 4 6 8 3. M.R Assistant 4 6 8 4. Census Staff 3 6 10 5. Admission Clerk 2 4 10 6. Helping Staff 2 3 5
MEDICAL RECORD COMMITTEE (AUDIT) Additional Medical Superintendent - Chairman Officer- In- charge - Member Nursing Superintendent - Member HOD Surgery/ Medicine - Member Medical Record Officer - Member Secretary Term : The term of the committee is two years. Meeting : The committee to meet once a month and minutes circulated to different departments. Function : Training policies & procedures for medical record Examine adequacy, quality and quantity of patient care.
Preparation and of various components of medical records and
distribute to all departments.
Ensures coding and indexing according ICD-10.
Training of sub-ordinate staff.
Annual Statistical Report/ Bulletin.
Supplying various information on demand.
Assists in researches and projects.
FUNCTIONS OF MRD FUNCTIONS CUSTODY OF MED. RECORDS MEDICO LEGAL SUPPORT PREPARATION OF MONTHLY & YEARLY BULLETINS NOTIFICATION OF BIRTH & DEATH ASSISTANCE IN RESEARCH NOTIFICATION OF INFECTIOUS DISEASES DISEASE SURVEILLANCE ATTENDING COURT SUMMONS
RESPONSIBILITY OF VARIOUS UNITS OF MRD A. REGISTRATION UNIT - Maintenance of registration counters in OPD and Emergency .
CENTRAL ADMISSION DESK
Round the clock functioning as inquiry office.
All admission to the hospital indoor.
Preparation of case sheet and administration record.
ADMISSION CHECK DESK
Checks the completeness of identification.
Data of patient, admission unit/ ward and bed number.
Maintains admission index for facilitating relatives and visitors.
Issue of visitors pass and tally number of admissions.
- Collection of daily census and discharge/ death case sheets from various wards.
ASSEMBLY AND DEFFICIENCY CHECK
Receives all case records from census desk.
Assemble the sheets in order as per list, stapled and tagged.
Accessibility for speedy location & identification
MICROFILMING OF MEDICAL RECORDS Space saving Easy accessibility Safe preservation Elimination of misfiring Saves time & manpower Clean & easy handling
COMPUTERIZED MEDICAL RECORDS Retrieve demographic information and consultants report, as well as laboratory, radiology and other tests. Improve productivity & quality. Reduce cost. Allow an interactive computer assisted diagnosis & treatment. Generate reminders for follow-up testing Aid in standardizing treatment protocols
OWNERSHIP OF RECORDS The medical record is the property of the hospital & not of the patient, the clinical department or the attending doctor. The medical record must be considered from two points of view: As a personal document As a impersonal document: For education, research & information.
CONFIDENTIALITY/RELEASE OF PATIENT INFORMATION 1.There is vital need to maintain patient information in a confidential manner. Patient information shall not be released without legal authorization. 2.Hospital employees, physicians, and students are expected to control the informal transmission of confidential nature. 3.Sensitive information concerning personnel and management issues shall be maintained in the strictest of confidence and shall be utilized only by those individuals legally authorized to review and act on such information.
CONFIDENTIALITY OF MEDICAL RECORD System employees pledge to keep medical record information confidential and to respect privacy. A medical record or information contained in a medical record should be released only if: i)A valid written consent for the release of this information is obtained from the patient or legally authorized representative. ii)Reporting is required or permitted by law.
WHO CAN SEEK ACCESS TO HEALTH INFORMATION? i)Patient himself ii)Family Physician iii)A person can seek access to information on behalf of someone else: *authorized person by the Patient. iv)In case of death *Authorized representative of family/ **Legal representative of the deceased. ***Court of Law.
ROLE OF STAFF MAINTAINING CONFIDENTIALITY Medical record department personal are advised to: i)Acknowledge request for health information promptly ii)Maintain integrity of records iii)Take reasonable steps to confirm the identity of the person seeking the information iv)Assess the information to determine whether access to it must or may be denied .
Hospital Administration Made Easy http//hospiad.blogspot.com An effort solely to help students and aspirants in their attempt to become a successful Hospital Administrator. hospi ad DR. N. C. DAS