Medical records department

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This is an overview on the organization andd function of the medical records department in a hospital. It would be of help to administrators and planners, as well as for teachers.

Medical records department

  1. 1. MRS DEPARTMENTDr (Gp Capt) Suchitra Mankar MD MMS Assoc Fe AvMed
  2. 2. Functions of MR Services Outpatient A&E service Inpatient MR Library
  3. 3. Outpatient Services Central Registration and Appointments  24X 7, 3 shifts  Functions Outpatient Clinics  OPD timings  Functions
  4. 4. A & E Service 24 X 7, 3 shifts May take on the 3rd shift of admission office (small hospitals) Functions  Casualty Nos, folders,regist’n  Appointments, admissions  Medico legal  Statistics and A&E records
  5. 5. Inpatient Services Admission Office  24 X 7, 3 shifts  Functions: waiting list, Regist’n of A&D, bed occu chart, pt property Ward  Ward nurse/clerk/CWM  Functions
  6. 6. MR Library 24 X 7, 3 shifts Functions  Processing outpatient records  Processing inpatient records  Generating and analysing stats  Filing and retrieval of records  General MR functions
  7. 7. Filing and Retrieval Straight numeric filing Terminal digit filing Middle digit filing Colour coding
  8. 8. MRs Department Main factors that govern the organisation of work: MRs should always he available when required and in the form they are required Adequate liaison should exist between different staff using MRs to enable proper design and contents, methods , storage availability, Procedures should cause patients the minimum inconvenience
  9. 9. Personnel Section Personnel requirement Job description for – MRO, MRT, Asst MRT HR functions
  10. 10. For 500 bedded hosp MR Officer 1 MR Technician 4 Clerks 3 Peon 1 Statistician 1 (on part lime basis) Computer literate
  11. 11. Norms for Personnel Working days X No of shifts Man days 2 persons for any hospital + 1 person for every 100 beds (up to 500) + 1 person for every 10 beds Calculate for 800 beds
  12. 12. Categories of Personnel MRO MRT Asst MRT Transcription/ Medical Secretary QA Specialist
  13. 13. Job Description MRO Qualifications  Graduate with 01 year diploma in MR, 03 years experience  University degree in MR with exp Line of reporting/ promotion Duties & responsibilities
  14. 14. Operational Policy To guide the functions of MR dept Includes  Working hours and shift  Duty rosters  Orga’nal chart  Training schedules  Fire safety  Disaster plans, etc
  15. 15. Interdepartmental Relationship Medical Staff Nursing Staff Diagnostic departments Computer section Stats section Administration
  16. 16. Physical Facilities Areas required: primary records, sec records, conference room, MRd staff, teaching, research, admin reqmts, legal reqmts Upto 99 beds: 50 sqm + 1 sqm for each bed More than 100 beds: 100 sqm + 1 sqm for each bed
  17. 17. Equipment Requirement Shelves, Pigeon hole rack Cupboards, Bookshelves Filing cabinets, Index cabinets Table, chairs, stools, steps Typewriters, computers Label dispenser, numbering machine Photocopier, duplicator Microfilming etc
  18. 18. Location of various sections Admission and Inquiry Office: A space of 125-175 sq ft is considered adequate. facilitate easy communication between General office equipment will mainly be required for the staff Separate counters for admitting clerk, receptionist and billing clerk Adequate waiting space Telephone with facility local calls1STD must be made available
  19. 19. Central Record Office A rough guide 2 to 3 sq ft per bed may be sufficient. The details are as under: 50 bed hospital-1 50-175 sq ft 100 bed hospital- 225-250 sq ft 200 bed hospital--450-500 sq ft 500 bed hospital-1000-1200 sq ft
  20. 20. Calculation of space 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 10years.
  21. 21. Security There should be procedures to protect MRs from fire, water damage ,pest damage, and unauthorized access. Lock on all doors. Access should be restricted . There should be one open entrance to the MR file room and a fire exit. No smoking policy in the file room. Fire equipment and written procedures on in case of fire There should be regular pest control in the file room.
  22. 22. Coding and Indexing International Code Number based on "International Classification of Disease" issued by the World Health Organisation Accuracy and uniformity in reporting
  23. 23. Indexing Alphabetic or Master Index: Indexing based on patients name sequenced in alphabetic order. The primary purpose of a name index is to provide entry into the filing system and finding out MR for a patient. The patient index card is usually 3"x5" card giving identification data, registration number etc Disease index: Disease index is a catalogue of cards of 3"x5" or S"xX", maintained to find out groups of clinical records of patients having the same diagnosis.
  24. 24.  Operation index: It is a catalogue containing the details of patients who have undergone operations. Physicians index: Catalogue containing details of all patients treated by particular physicians. Unit index: Details of all the patients treated in a particular unit are indexed.
  25. 25. Storage and Retrieval Effective filing system Compactness to reduce physical effort and cost of storage Accessibility for speedy location and identification. Simplicity for understanding of all concerned. Economical both in the cost of installation and operation. Elasticity to expand according to future requirement. Tracer system for document in circulation
  26. 26. System of Filing Decentralised system: Under this system inpatient and outpatient department have their own individual records and file them independently If a patient is transferred from one department to another the file may be loaned to other department. This system is labour intensive and the operating cost are higher. Centralised system: In the centralised system, MRs are filed centrally The centralised system is more efficient, provides better control and followed in most hospitals.
  27. 27.  Numerical method: This method is most suitable for retrieval of files. disadvantage of –new files (most active) are added to one end of the system, which usually is the furthest from the working area
  28. 28. Alphabetical method andChronological order filing is done in alphabetical sequence of names and sequence based on their date of admission respectively. Requires maintenance of indexes to allow access to the documents maintained in the libraries.
  29. 29. Terminal digit System 6 digits . First two primary, second two secondary and last two numbers, are the sequence number of the file Storage spaces is divide into 100 equal parts from 00 to 99 The primary section. Each primary section is further sub divided in 100 equal parts again running from 00 to 99. File number 123456; is located section 56 and secondary section 34. File number 12 is the required file
  30. 30.  12 34 56 Tertiary secondary Primary Sorter shelf for records waiting to be filed
  31. 31. Middle digit system Middle two digits are the primary number, the first two digits the secondary number last two is the file number
  32. 32. Misfiling Look for the transposition of digits in a number. For example, 131234 may be filed as 131243 or 121334. Look for missing files under similar looking numbers such as "3" under "5" or "8" or vice versa Check for a certain number such as 584 under 583 or 585 or under a similar combination. Check the transpositions of first and last numbers. Check the MR just before and just after the one needed. Check the shelf immediately above and below
  33. 33. Culling/Purging Based on last date of admission Based on retention policy Done every year usually in the same month Records kept Make a committee in charge, Med record member may be present, but MRO should not be part of the committee
  34. 34. Filing Procedure Different color for different years Types of filing Vertical Suspended Horizontal
  35. 35. Microfilming Answer for inactive MR storage. Advantages of microfilming are: Saving of space: 90% of the space can be saved if records are microfilmed. Easy accessibility: Due to easy storage in a smaller area Protection: Elimination of incorrect filing Saves manhours
  36. 36. Computerisation of MRs Automation is not the same as electronic MRs EMRS improve access and sharing of information. A well run and organized manual system is a must. before EMRs EMRs will not remove the problems of a Medicl records dept
  37. 37. Retrieval of MRs Depends on system of storage Record removed and tracer inserte’. Keep a copy if records are moving out of the hospital Treat the records with as much care as the original. Destroy the copy after original is received
  38. 38. Thank

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