ORGANIZATION & MANAGEMENT MEDICAL RECORDS DEPARTMENTKESHAVARAO.TASST., MEDICAL RECORD OFFICER,BELGAUM INSTITUTE OF MEDICAL SCIECES,BELGAUM-590001. T.Keshavarao Mob.9880569550
T.Keshavarao Mob.9880569550 IP REGISTRATION OR SERVICESThe IP Medical records classified into 2 section1.Admission office2. WardFunctions of Admission officeAdmitting office functioning 24 hours. In this section staff posted 3 shifts.Prepare the case sheetsCollection of Identification data through the Patients At tenders.Allot the MRD Number.Record the hospital number with sociological data with date of admission,Time, Department, Unit etc in the admission register.Take the consent from the patients or his relatives for treatment andoperation purpose.Prepare daily admission list and hand over to the census clerk Maintainance of Patient Master IndexMaintainance of Bed Occupancy board
T.Keshavarao Mob.9880569550 WARDThe ward medical record will be performed by the ward nurse.Functions of the Medical records in the wardRegistration of admitting patients on the ward admission book.Maintainance of vacant bed position.Kept the all investigation in the appropriate case folder.Preparation and submission of ward daily census report.
T.Keshavarao Mob.9880569550 Numbering RECORD DEPARTMENT MEDICALNumbering system is facilitate easy to identification of the patient presentand future visits. Easy to retrieve the case folders for continuity care. Filingpurpose.Confidentiality purpose.Mainly there are 2 types of MR Numbering systems recognized.1.Unit numbering system-This numbering system has been preferred largeno. Of MRDs. The method involves the use of a number, which isthereafter applied permanently to the same patient. This patients has onlyone medical record. All data about the patients are collected together onefolder.2. Serial Numbering system- It consists of assigning the patients a newnumberEach time the patients visits the hospital. One patients will have manyrecords, as times he has been seen and each records will file under thedifferent numbers.
T.Keshavarao Mob.9880569550CONTAINS AND COMPONENTS OF MEDICAL RECORDSContains of Medical records: As a minimum information should contain in each Medical Record. I.e.,. Sufficient information to identify the patient. Date of contact, reasonfor contact, findings, treatment and recommendations etc.Components of Medical records When a patient has been admitted to the hospital they become an IPand front sheet is beginning the IP Medical record. IP usually occupies a bed in a health care facility for at least 4 hours orovernight.The Physical Medical Record will eventually consist of the following.1. MR Form2. Divider between each admission IP and OP3. Clip or fastener to hold the papers together4. Folder
T.Keshavarao Mob.9880569550It should be all in sameFORMS MEDICAL RECORD size Usually A4 size.The patient Medical record number and the name of the form should be inthe same place on every form.Medical record forms approved by administration or Medical recordcommitteeShould be included in MRO.Medical Record divider. It is good practice to separate each admissions by a divider, the dividerwill be slightly wider than the forms in the Medical records and have a tab inwhich to write 1st admission 2nd admission.etc. In addition combined with the IP notes all OP Notes can be storedbehind an OP divider.Clip or fastenerStaples should not be used as they tend to rest and additional forms. If uselargeFastener which is secured in the top left hand corner of MR.Plastic rather metal clip also best for use of MR.
T.Keshavarao Mob.9880569550 FOLDER All medical record forms should be kept in Medical Record Folder. This should be a thick folder(Manilla)of if possible stronger card boardshould be purchased. Medical record folder should be filled on their spine so that medical recordnumber is clearly visible for filing purposes. Every medical record Folder should contain MRD No. Hospital Name &Process check ie. Assembling ,Deficiency check, Accession Register,Discharge Analysis, Patients Index, Diagnostic Index, Operation Index,Surgeon IndexCheked by, Filing clerk, Date of filing etc.,
T.Keshavarao Mob.9880569550 CENSUSEach and every Hospital should maintain Mid night census.The hospital inpatient Census is the number of inpatients occupying beds inthe hospital at a given time.Procedure.a) Collect daily admissions from the admitting office.b) Collect from the sister-in charge of the ward the following Daily census report form. Discharged case sheets whether complete or incomplete. Including Investigation reports.c) Check the No of admissions & Discharges with actual No of admission list and and discharge Records.d) Check the Transfer in and Transfer out case records.e) Hand over to the Census report at Census or statistics deskf) Hand over all discharged case records to Assembling and Deficiency check desk.
T.Keshavarao Mob.9880569550 ASSEMBLING AND DEFICIENCY CHECKAssembling and deficiency check section collects the discharge records ofthe previous day and make discharge details on the computer or register.All the deficiencies are pointed out of the deficiency are marked at thedeficiency check list. It is helpful to the doctors for complete the recordsweekly visit.