Developing recording system in the hospital: Maintaining adequate records on the patient file, Training programs for staff, *Retention and storing of medical Records*: Outpatient, Inpatient, Medico legal cases retention policies, process of medical record storing

1. UNIT-II
• Developing recording system
in the hospital:
• Maintaining adequate records
on the patient file,
• Training programs for staff,
• Retention and storing of
medical Records:
• Outpatient,
• Inpatient,
• Medico legal cases retention
policies,
• process of medical record
storing
-SRISHTI BHARDWAJ

2. ADEQUATE RECORDS ON PATIENT FILE
MR comprises three general sections.
(that comprise : ADEQUACY)

3. SECTION ONE:
• A general section covering administrative
and personal data. The socio-economic
data of the patient include:
• The name of the patient
• The name of next-of-kin
• Patient’s age,
• Patient’s sex
• Patient’s religion
• Patient’s income
• Patient’s address
• Address of next-of-kin.
• Other administrative information included
is:
• DOA
• IP number
• Name of nursing unit
• Bed number
• This sheet is prepared in the central
admitting office.

4. SECTION TWO
• A nurses section wherein are noted the
observations of trained nurses and the
details of treatment administered.
• This part of the MR consists of graphic
charts related to
• Temperature
• Pulse
• Respiration
• BP
• Intake-Output
• Medication administered
• Any other observations maintained

5. SECTION THREE:
• A medical section
containing statement on
the studies, observations,
conclusions and activities
of the treating/ attending
doctors or of the Intern or
the Resident working
under him.
• The medical section of the
record consists of the
entire medical history of
the patient. It contains:
• History Sheet
• Physical examination
sheet
• Provisional diagnosis
• All investigation reports
• Physician’s order sheet
• Treatment
(medical/surgical)
• Anaesthesia records
• Operation records
• Obstetric records
• Consultancy report
• Progress report
• Final diagnosis
• Discharge summary
• If dead, cause of death.
• Autopsy report

6. CLASSIFICATION:
• The classification of records would depend upon the nature of organization.
However, it would be useful to classify records into the following four fold
classifications:
• Vital records: Protected and preserved for a long time.
• Important records: Not currently in use, but are of high value in retain.
• Useful records: Currently used correspondence.
• Transit records: Useful for only a short period till the subject is alive or active.

7. TRAINING PROGRAMS FOR STAFF
• Below is an explanation of the training and awareness required for:
● All staff
● The practitioner (the person with operational responsibility)
● The senior management lead

8. ALL STAFF
• inclusion of records management in the organization's employee induction programme
● formal technical training for employees new to particular system responsibilities or at times of
system change
● formal or informal in-service training and coaching
● training courses provided by external training providers either as part of their general syllabus or
customized to meet the organization's requirements.
 Decide what should happen to records held by the body losing the function or being abolished.
Document any transfer of records.
Agree how to manage future Freedom of Information (FOI) requests relating to those records

9. THE PRACTITIONER (THE PERSON WITH
OPERATIONAL RESPONSIBILITY)
• The records manager needs a full understanding of records management principles and
practices.
• He or she also needs to be aware of the organization's obligations under the relevant legislation
so that the records management policies and procedures will support compliance with those
obligations.
• Follow up initial training – offer refresher training and surgeries
• Keep records management visible within your organisation by publishing news items in
newsletters and on internal websites.
• Quality Strategy:
• Strategic planning for knowledge and information management (business focus)
● Using and exploiting knowledge and information (user focus)
● Managing and organising information (process focus)
● Information governance (compliance focus).

10. THE SENIOR MANAGEMENT LEAD
• The person with lead responsibility needs a general understanding of what the
records manager is trying to achieve but does not need to be a records specialist
themselves.
• For training purposes this person will count as a general staff member.

11. RETENTION AND STORING
OF MEDICAL RECORDS
• MEDICAL RECORDS FORM AN IMPORTANT PART OF A PATIENT MANAGEMENT.
• IT IS IMPORTANT FOR THE DOCTOR AND MEDICAL ESTABLISHMENT TO PROPERLY
MAINTAIN THE RECORDS OF THE PATIENT FOR 2 IMPORTANT REASONS.
• First one is that it helps in proper evaluation of the patient and to plan treatment protocol.
• Second is that the legal system relies mainly on documentary evidence in cases of medical
negligence.
• THEREFORE, MEDICAL RECORDS SHOULD BE PROPERLY WRITTEN AND PRESERVED TO
SERVE THE INTEREST OF DOCTOR AS WELL AS HIS PATIENT.

12. • 1. Where there is chance of litigation arising for medical purpose of negligence,
record should be preserved for at least 25 years, specially because there are rules
where the minors have the rights to sue the doctor within three years from the
date of majority, for the injuries sustained due to negligence of the doctor during
the period of his minority.
2. Other medico legally important records should be preserved upto 10 years after
which they can be destroyed after making index and recording summary of the
case.
3. Routine cases records may be preserved upto 6 years after completion of
treatment and upto 3 years after death of the patient.
4. There are certain records in hospital, which are of public interest and are
transferred to public records library after 50 years for release to public and those
involve confidentiality of the individuals are released only after 100 years.

13. HOW LONG TO MAINTAIN THE RECORDS
• Ideally records of adult patient are maintained for 3 year.
• 21 year for neonatal patient (3 + 18 year).
• For children 18 year of age + 3 year.
• For mentally retarded patient forever till hospital/institution is working.
• From income tax point of view for 7 years.

14. PROCESS OF MEDICAL RECORD STORING
• When the medical record has been assembled after discharge, completed by the
medical officer, coded, and the relevant statistics collected the final procedure is
filed. Before looking at the filing procedure, we should take time to consider
where the medical records will be filed. It is important that careful planning be
given to the filing area for medical records

15. CONTINUED…
• Medical Record File Area: Plenty of space must be available for filing medical records and that the
file area is clean, tidy and has good light.
The file area should have desks for the medical record clerks to sort medical records and make out
tracers; and space for records awaiting filing or completion.
• How much space is needed?
• It is easy to calculate the amount of space required for medical record files
• Measure one full shelf.
• Count the number of files on the shelf.
• Calculate the number of files per linear metre.
• Count the number of new files created last year.
• Calculate the number of linear metres required per year.
• You can then calculate the number of linear metres required for one, five or 10 years.

16. FILING SHELVES/CABINETS
• Filing shelves should be used, NOT filing cabinets.
• Wood filing shelves are very good, and can be built by the hospital carpenter. Metal
filing shelves are also very good, EXCEPT in coastal/damp areas because of rust
problems. Metal filing shelves have to be purchased and can be expensive.
• If possible, compactus filing shelves should NOT be used to file active medical records,
but can be used in the secondary (inactive) file room. An ACTIVE medical record is one
that is still being actively used for patient care. An INACTIVE medical record is one
where the patient has not attended the hospital for a specific number of years.
• Enough space should be left between the filing shelves - the general standard is 900
mm, to allow space for a trolley and a person to walk between the shelves to file and
retrieve records.

17. CONTINUED:
• Filing shelves should be no higher than the average person can reach and steps
should be made available for access to the top shelf. Records should NOT be filed on
the bottom shelf. The bottom shelf tends to attract more dust. Also, some people find
it hard to file and retrieve records accurately from the bottom shelf.
• A 'bay' is a bank of filing shelves and filing bays should be no longer than 60 cm. If
filing bays are longer than 60 cm, upright file supports should be available to keep the
medical records standing upright.
• Medical record folders and the filing shelves should be designed to enable the
records to be filed lying on their spines so that the MRN is clearly visible for ease of
retrieval and filing. • Each filing bay should be labelled with the MRNs of the medical
records filed in that filing bay. • Each filing shelf should be labelled with the range of
numbers of medical records filed on that particular shelf. Number guides should be
placed at regular intervals

18. HOW TO DESTROY THE RECORDS
• Public notice of destroying the records in English news paper and in one vernacular
paper mentioning the specific date up to which destruction will be sought
• Give a time limit of 1 month for taking away records for those who want the records
with written consent
• After 1 month destroy the records up to date specified except for following
• where litigation is going on.
• Where future trouble is expected.
• Mentally ill or retarded patient.
• Pre-litigation process of notice exchange is going on

19. HARD COPY ONLY
• Computers are now widely used in institution/hospitals for electronic patient
records but still hard copy is required for following documents
• Consent need to be on hard copy.
• Referral to doctor need hard copy.
• Police case need hard copy.
• Certificate of fitness should be on hard copy.

20. MECHANISM OF RECORD MANAGEMENT:
• Filling:
• It is a process of classifying arranging
and storing records systematically so
that they can be easily retrieved.
• It can be defined as: the systematic
arrangement for keeping of business
correspondence and records so that
these may be found and delivered
quickly when needed for reference in
future.
• It can be also defined as: filling is the
placing of documents and papers in
acceptable containers according to
some
predetermined arrangement so that any
of these required, may be located
quickly and conveniently.
• File arrangement:
• Alphabetical order
• Numerical order
• Geographic order
• Chronological order
• Subject wise
• Colour wise

21. CONTINUED..
• File indexing:
It is key to locate the files.
Index is a reference list used
for locating a particular
document and filing
equipment.
• Vertical card indexing
• Visible card indexing
• Visible book indexing
• Loose leaf book
indexing
• Centralized filling system:
• It is the one where all
the filling equipment
and personnel are
located in the single
area of the office,
accessible to all
departments by
messengers, controlled
by a centralized plan or
index of the filing.
• Advantages: It ensures
uniformity
• Decentralised filling system:
• Also called as
departmentalised filing
system
• It is the one, where each
organisation makes its
own arrangement for
filing.

22. REFERENCES
• https://www.nrscotland.gov.uk/files/record-keeping/public-records-
act/element12-TNA.pdf
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3238553/
• http://www.wpro.who.int/publications/docs/MedicalRecordsManual.pdf