Health record practices in hospital & importance of various indices

3/18/2018 Dr CB Narayan, CMO(SG) 1
Hospital Statistics Made Easy
By, Dr. Narayan, CMO(SG)/Comdt(Med)

2
Record Practices in Hospital
IMPORTANCEOF
VARIOUSINDICES
3/18/2018 Dr CB Narayan, CMO(SG)

OPD-Sections
Disp
Lab
X-Ray, ECG,
USG
Physio
Dental
Refer
Death
Admit-IPD
LAMA
Review
EMR-Sections
EMR-KUO
EMR-Admit
EMR-Ref
Death
E-F/Aid-
Dressing
E-Rx-RTU
E-Rx-Review
DailyInflow

OPD-Sections Disp
Lab
X-Ray, ECG,
USG
Physio
Dental
Refer
Admit-IPD
LAMA
Death
Review
EMR-Sections
EMR-KUO
EMR-Admit
EMR-Ref
Death
E-F/Aid-
Dressing
E-Rx-RTU
E-Rx-Review
Daily Inflow
COUNTED IN
DAILY
EMERGENCY
MERGED
WITH DAILY
OPD
KEPT IN CH/FTR/LOCAL
UNIT FOR REVIEW IN
CH / MED COLLEGE

1 QM-Store Register 9 Physiotherapy Medical Eqpt
Register
2 Bio Medical Waste
Disposal Register
10 X-Ray/ECG/USG Med Eqpt
Register
3 VCCT Register 11 Electrical Eqpt register
4 Lab Register 12 Firefighting Register
5 Emergency Medical Eqpt
Register
13 OT Sterilization Register
6 Surgical Eqpt Register 14 Washer man items issue
Register
7 Gynecological Eqpt
Register
15 Safai-Karamchari item issue
Register
8 OPD Med Eqpt Register

1 Surprise Monthly
Checking of Cash Book
7 Monthly Sainik Sammelan
Register
2 Checking of Staff Mess
Cash Book
8 Maintenance of Office Secret
3 Checking of Patient Mess
Cash Book
9 Monthly Family Welfare
Meet
4 GD / Parade Register 10 I/Card Checking Register
5 Grievance Register 11 Interview Register
6 Monthly Monitoring on
Sexual Harassment
Register
12 Disciplinary Case Register

1 OPD Registration
Register
10 Blood Grouping Register
2 Admission-Discharge
Register
11 AMR Register
3 Referral Register 12 LMC Register
4 Main Stock Register 13 Monthly Expenditure
Register
5 Sub Stock Register 14 Med / Prov Demand Register
6 Main Stock Register 15 Training Register
7 Injury Register 16 Emergency Register
8 Immunization
Register
17 Emergency FA/Dressing
Register
9 ANC Register 18 Surgery / Serious Case

8
Medical Records Mantra
GOOD MEDICAL CARE
GENERALLY MEANS A
GOOD MEDICAL RECORD,
WHILE AN INADEQUATE
MEDICAL RECORD
GENERALLY REFLECTS
POOR MEDICAL CARE.

Importance of Various Indices

IMPORTANCE
OF MEDICAL
RECORD
FOR THE PATIENT FOR THE DOCTOR
For Hospital
Training & Research
MEDICOLEGAL
 Documentation of Clinical
History
 Continuity & Follow up of
Treatment
 Claiming Insurance
 Issue of Medical Certificate
 Legal Evidence
 Evidence in Court of Law
 For claiming Insurance & tax benefit
 Malpractice & Negligence
 Certification of Birth & Death
 Certification of Invalided person
 Certification of Mental Status
 CPA
 RTI
 Clinical & Epidemiological
Research
 Health Status Research
 Education & Training
 Yardstick for Administrator in management of
Hospital Manpower & Resources
 Quality, Quantity & Adequacy of treatment
 Medical Audit
 Future Planning & Decision Making
 Medico Legal Protection
 Disease Surveillance
 Epidemiological Studies
 Safeguards Doctors from Integrity
 Medical Review of Treatment
 Research & Publication
 Assists in Legal Proceedings
Medical Records Mantra
GOOD MEDICAL CARE GENERALLY MEANS A GOOD MEDICAL RECORD,
WHILE AN INADEQUATE MEDICAL RECORD GENERALLY REFLECTS
POOR MEDICAL CARE

Total No of
OPD Patients
signifies
Work Load
Higher
number
shows better
Reputation
Trend line of
OPD can help
in Planning
Trend of
Reporting
Time of OPD
or OPD-Rx
vs EMR-Rx
can hint
about Time-
Constraint of
Patients
Trend of
Reporting
Day of OPD
or OPD-Rx
vs EMR-Rx
can hint
about Day-
Constraint of
Patients
Doctor Wise
OPD can give
clue about
utility of
different
doctors
Disease Wise
OPD can give
clue about
Epidemiologi
cal Pattern
of Diseases
CAPFs Wise
OPD can help
in knowing
Patients
Health
Status
Month wise OPD

Doctor wise IPD

Disease wise IPD

 Total No of OPD Patients signifies Work Load
 Trend line of OPD
 Average No of Daily OPD
 Trend of Reporting Time of OPD
 Trend of Reporting Day of OPD
E-Rx in OPD-Hrs Vs Non-OPD Hrs

 Total Number of Investigation carried out Month Wise
 Abnormal Routine Investigation Month Wise
Abnormal Investigation Results

 Bed Occupancy Rate signifies utility of hospital
 Bed Turn Over Rate signifies promptness of Healthcare
 Unit/Sector Wise IPD
 Work Load assessment
 Future Administrative Planning
Administrative Values @ OPD/IPD

BOR is a ratio which exhibits the actual consumption of an
inpatient health ability of a hospital for a given time period.
Average Daily Census
Bed Occupancy Rate = ------------------------------- x 100
Available beds
 It is an index of utilization of hospital beds.
 Ideally the bed occupancy should be 85 % to 90 %.
 Less than 85% questions on reputation of the hospital.
 Exhibits actual consumption of an inpatient health ability of a hospital.
 Reflects Quality & Working Culture of hospital
Bed Occupancy Rate & Average Stay

It is the average days of service rendered to each
patient during a fixed period i.e.:-
ALS = Total days of stay of all discharged patients
Total No. of discharge during the period
 Average Stay of Communicable Diseases
 Average stay of Psychiatric Diseases
 Average Post-Operative Stay
 Average Stay of Orthopedic Cases
 Average Stay of Chronic Diseases
 Average Stay of FU Cases at other Ref-Hospital
Average Length of Stay (ALS)-IPD (Normal 7-10 Days)
It helps to identify
essential and unnecessary
length of stay. Normally
ALS should be 7-10 days.
If it’s more than this ;
reflects inadequate
functioning of hospital and
quality care. ALS varies
with
1. characteristic of
patient,
2. Disease character,
3. Hospital infection,
4. Habit of doctor & staff,
5. Hospital functioning.
These last 3 increases
unnecessary length of stay
& appropriate remedial
measures should be
taken.

Average Length of Stay (ALS)-IPD (Normal 7-10 Days)
ALS varies with
1. Characteristics of patient,
2. Disease character,
3. Habit of doctor & staff,
4. Hospital functioning.
5. Hospital infection,
These last 3 unnecessarily increases length of stay & appropriate remedial measures
should be taken if it goes high.
Habits of Doctor & Staff:-
 Delay in case examination
 Delay in investigation
 Delay in scheduling operation
 Delay in starting treatment or wrong treatment
 Unnecessary admission to increase the Bed Occupancy.
 Poor Nursing Care.
Hospital Functioning:-
 Delay in special investigation.
 Inadequate Sanitation.
 Improper disposal of BMW
 Hospital Acquired Infection.
 By controlling above factors, length of stay can be reduced, thereby reducing cost
of bed which shoots up hospital productivity.

It is Average number of patients per bed during a given period
Number of Discharge during period
Bed Turn Over Rate = -------------------------------------------------- x 100
No. of available beds
 It is an index of Hospital Efficiency.
 Quick turnover indicates better care, quick recovery & discharge.
 Delayed turnover indicates complications in recovery & delay in discharge.
Bed Turn Over Rate

It is Average number of days a bed remains vacant between Discharge & Admission to a
bed during a given period
Bed Turn Over Interval = All Vacant Days of Beds (No of beds – average Daily Census)
No. of Discharges
 It indicates the productivity of the hospital.
 More vacant beds reflects bad reputation of the hospital.
 Shows the extent of non-utilization of beds.
Bed Turn Over Interval

Lack of Immediate Retrieval.
Lack of Immediate Information Storage.
Lack of Para wise Modification & Prompt Updating.
Error prone Manual Calculation.
Less Accuracy & No Promptness in Report Extraction.
Lack of System Security, Data Security & Reliability.
Time consuming.
Consumes Large Volume of Paper Work.
No Direct Role for the Higher Official.
To avoid all these limitations & to make the system working more
accurately, The whole data needs to be computerized.
Problem/Limitations with Conventional System

Accuracy and validity of the original source data;
Reliability – data is consistent and information generated is understandable;
Completeness – all required data is present;
Legibility – data is readable;
Currency and timeliness – data is recorded at the point of care; &
Accessibility – data is available to authorized persons when and where needed.
 All these characteristics are important in both manual and electronic record
systems and when changing to an electronic system they must be kept in mind
and addressed.
 Whatever the system, the quality of healthcare data is crucial, not only for
patient care but also for monitoring the healthcare services and the performance
of the institution.
Quality of EHI (Electronic Health information) depends on

Patients will be uniquely identified at all times
All healthcare information generated within the institution will be documented at the
point of care
 Standard terminology will be used to ensure information is universally understood
 All health records will be accurate, reliable, and completed promptly
 Data will be processed to support better decision-making by healthcare
practitioners
 Information about an individual patient will be immediately available at
all times for present and future care
 Quality of healthcare will be enhanced by the provision of better
information for clinicians to make decisions about treatment and
healthcare planning
 Patient confidentiality and privacy will be maintained
 With improved clinical documentation at the point of care, problems
associated with coding of diseases and procedures will be eliminated





Perceived Benefits of EHI system

OPD
SLIP
IPD
SHEET
DISCHARGE
Till Now
WE WRITE OUR HOSPITAL PAPERS & REGISTERS AS: -
 IN VERY ILLEGIBLE MANNER
 Involving Minimal use of Computer

Dr CB Narayan, CMO(SG) 27
 Brand-Names of most of the new preparations hardly correlates with the salt
of drug.
 Resulting in state of confusion for other doctors.
 Different doctors adopt variable patterns of writing OPD/IPD-Case
Sheet/Discharge & Referral papers which always creates problem for MRD
section to compile it.
 Data of patients are required to be computerized in suitable formats to extract
any queries for various purposes in future.
a) Knowing Demographic, Financial & Social Status of unit personnel.
b) Knowing Health Status of unit personnel on various clinical parameters.
c) Concluding the inference based on various parameters.
d) Easy entering the data in databank through specially designed forms.
e) Preparing report based on any type of query as per demand within seconds.
f) These reports can be sent/e-mailed within seconds on internet/intranet.
g) These specific information can be used for various statistical inferences.
3/18/2018

Administrative Values @ Stores/Mess
Sorting of Stores/Inventories – Page wise Controlling Food Quality/Quantity in Mess- Month wise

Scientific Values @ OPD/IPD
Based on OPD or IPD Data, we can get
 Disease profile in various Age-Group
 Incidence of Major Diseases
 Prevalence of Major Diseases
 Incidence of Communicable Diseases
 Incidence of Modifiable Diseases
 Incidence of Malaria Frontier-wise
 Seasonal Variation of Malaria incidence
 Future Planning & Decision Making
 Disease Surveillance

Based on OPD/IPD data, we can show evidence @
Medico Legal Protection
Malpractices
Negligence
Quality of Treatment
Adequacy of Treatment
 To meet the legal requirement & avoid future
complicacies Complete, Adequate, Accurate, Legible
Medico Legal Values @ OPD/IPD

HOSPITAL STATISTICS
• PROOF OF WORK DONE
• FOR CURRENT AND FUTURE PLANNING
• DISEASE /PROCEDURE INCIDENCES
• OUT PATIENT TURN OUT
• BED OCCUPANCY RATE
• AVERAGE LENGTH OF STAY
• DEATH RATE
– DEATHS UNDER 48 hrs.
– DEATHS MORE THAN 48 hrs.

Registration counter
Admission Medical Records
Assembling
Deficiency check
& coding
ScanningComputer entry
Permanent
filing
Consultants
IPD OPD
Wards
Indexing
3/18/2018 34

In-patient records
Assembling format: -
The arrangement of medical records takes place in the
following order:
• SUMMARY SHEET& ADMISSION RECORD,
• DISCHARGE SUMMARY
• HISTORY OF FINDINGS
• CONSULTATION REQUEST
• LAB & ECG REPORTS
• ANESTHESIA CHARTS
• OPERATION NOTES
• PROGRESS SHEETS
• DOCTORS ORDERS
• ICCU CHARTS
• CONSENT FORMS
• NURSES CHARTS
• CLINICAL CHARTS
• DRUG CHARTS
• IV FLUID CHARTS
• OTHER AUTOPSY
• BIOPSY REPORTS AND OTHER HOSPITAL REPORTS.

Retrieval area
• According to the appointments the Record no. is sent on line in the system and
also informed for walking patients by the respective concerned secretaries over
the intercom.
• They are entered in the retrieval register along with the consultant name.
• The records are then pulled out from the filing areas and to be sent for dispatch
within 15 minutes.(International benchmark –45Min).
• The records that are to be dispatched through confidential Bag and given to the
secretaries and an acknowledgement is taken with employee number from them
in the dispatch register.
• This plays a vital role in finding the missing record from the consultation areas.
• Care should be taken while filing so that misfiling is avoided and also for prompt
delivery of the records the next time patient visits the hospital.
Out-Patient Records

Dr CB Narayan, CMO(SG) 38
Establishment can work on Access for maintaining
following administrative issues: -
• Bio Data
• Inventories
• Health & Fitness Record
• Tax Planning, Calculating Income Tax & Balance Sheet
• Low Medical Category personnel supervision
• Leave Planning & keeping Leave Record
• Educational qualification, Telephone, Business Card &
Contact Detail
• Training & Duty Planning
• Annual Transfer Posting with Past Posting Detail
• Firing, FPET record
3/18/2018

Following Clinical & Scientific issues can well be
managed using Access Data
Disease Pattern
1) Age-wise,
2) Height-wise,
3) Weight-wise,
4) State-wise
These data can easily be
reflected in chart form
instantly by updating the
data in table which can be
printed or mailed within
minutes.

UPDATING AME REPORT
ON HEALTH CARDS
Annual Medical
Report can be printed
every year in
individual health card
by inserting it in
special printers as
done on passbooks in
banks.

Report of Health Status of an
Unit or Organization
Report of any
company / unit can be
instantly generated &
got printed as such. It
reflects any modification
in individual record
instantly in reports once
generated which further
got printed or e-mailed
or that specific
information can be used
for various statistical
inferences

Hospital Inventories
Hospital Inventories can
be sorted room wise /
Page wise to ease
1. Handing Taking over
2. Tracking AMC
3. Tracking
Condemnation
4. Planning
Procurement
can be found instantly &
its print can be printed or
e-mailed within minutes.

Medicine Stock Position
of a Hospital
Medicine stock can be
monitored as
a) Group of Med wise
b) Page No wise
c) DOExpiry wise
d) Issue to sub stock
e) Balance in stock
f) Planning for
Procurement
can be found instantly &
its print can be printed or
e-mailed within minutes.

Tax Planning &
Income Tax Calculation
I was facing problems
in memorizing my
income detail, my tax
liabilities & planning
my investments
accordingly for every
months & every year. I
formatted my income,
TDS, investments &
other financial
implications in this
table & with various
angles of sorting this
data could be modified
for yearly Balance
Sheet of my Income-
Investment.

Monitoring Dose of Insulin
in Diabetic Patient
There has always been a problem in
understanding insulin doses accurately. After
going through the method of calculation, I
formatted it based on pre-lunch blood sugar
level. This can easily be prescribed by CPMF
GDMOs now as seen here by just putting the
Weight of Patient in Kg & pre-lunch blood
sugar level in required space of this form. Rest
doses are counted & displayed immediately.
 Night/Bedtime Basal Dose = @ 50%
=25U
 Bolus AC (BBF+BL+BD) = @ 50% =25U
(Approx. 25/3= 8U each)
 Correction Factor (CF) = 1700/TDD or
3000/Wt. in Kg = 30 for 100 Kg Wt.
CF = 30 means 1 unit will lower 30 mg/dl of
glucose.
Ideal Pre-Lunch reading is = 120 mg/dl.
5U each required to cover each of 3 meals
So, if patients Pre-Lunch Glucose if 250
mg/dl, then
 Current BG = 250 mg/dl
 Target BG = 120 mg/dl
 Correction Factor = 30, So
 Correction Bolus = (250-120)/30 = 4U
 So, Bedtime = 30 U Lantus
BBF, BL & BD = 5(Meal)+4(CB) = 9U each

Prescription of Patients
in OPD
Now a days it is seen that there are
rush in most of the OPDs because
the doctors are busy in clinical
examination, BP checking & writing
the whole matters on OPD slip.
To reduce this burden & fasten it
I formatted the OPD slip so that
some of the parameters like date of
Birth, Name, Unit, Height, and
Weight get printed automatically
taking these data from organization
record. This can be done by
paramedic at Registration Window.
The doctor also can use drop
down look ups to select Complain
/Sign /Symptoms then Past History
then can prescribe the medicines
already given in drop down look ups

Handing-Taking Charge
I was finding difficulty in identifying
various equipment and other
inventory in my hospital at Congo.
Also their sorting by page number of
register, stock position, Room wise &
Date wise was difficult in word
tables.
So I decided to put the data in
access and it was then only that I
could be able to sort it on above
points and submit the reports to
higher HQs.
I put the list of every
inventory/equipment contained in
rooms. Also I made a complete list of
equipment/ inventories to ease the
method of Handing –Taking over of
charge room wise without disturbing
the register entries.

Managing Hospital Indices
Budget Flow can be seen on page or it can be displayed in charts

Medical Board Part-1 Preparation
Made Easy
Part-1 of MBP can be made only on 2 pages within few minutes

ICD 10 Search
Within seconds ICD-CODES can be found
*Here we can see result of search for Type-1 Diabetes Mellitus as “E-10”
Further number of person suffering different diseases can be
displayed easily in chart or report

OPD -Slip
OPD Slip:-
OPD Slip displaying all required data as
1. Doctor wise OPD patients
2. Disease wise OPD patients
3. Date/Age/Sex/Location/Unit/CPMF
wise
4. Rank/Entry route to Hospital wise
We can get/sort answers like;
1. Rx Medicine from Inside/Outside
CH
2. Purpose of coming to Hospital
 OPD
 IPD
 Investigation
 Review Board / AME
1. Referred to which Hospital
2. Reason of Referral
 Specialist Available / Not Available
 Facility Available / Not Available
1. Type of Case of Referral
2. Purpose of Referral: -
 Treatment
 Advice/Opinion
 Follow up3/18/2018 Dr CB Narayan, CMO(SG) 51
After completing the patient general & clinical profile at
Registration Point, doctors can write the
Complaints/Diagnosis & can prescribe medicine in the
Text Spaces.
Also one can write Approx. Cost of the Medicines
provided / Investigations carried out for estimating
BE/RE

Managing Hospital Indices -IPD
Indoor data can be extracted out and required papers can be generated easily like
a) Indoor Case Sheet b) Continuation Sheet
c) Referral Slip d) Discharge Slip

Training in CH
 1 Month
 3 Months
 6 Months
I have formatted syllabus of
these courses being run in
Composite Hospitals
incorporating all topics plus
some more topics which are
expected from paramedics in
routine practice. This Table can
be used for various training
requirements as
1. Making Weekly Programme
2. Sorting Date wise Classes
3. Sorting Type wise as
Theory/Practical
4. Sorting Instructor wise
Classes
5. Re-scheduling Missed
Classes
Training in CH

About MRD
 Bridges the gap between medical and non-medical departments.
 Enables continuity of care to the patients without difficulty at
appropriate time
 Headed by MS has skilled persons termed as Medical Record
Technicians and others
 Governed by the Medical Records Committee
 For the department to function efficiently the medical record must
be Accurate, Complete, and Timely. Of course, the caregivers
shall Legibly write it.
 Primary role is safe guarding the records and to issue them on
demand

Guiding Principles of the Department
• The hospital shall maintain an adequate medical record for every
individual who is evaluated or treated as an inpatient, outpatient, or
emergency patient, which shall be documented accurately with all
significant clinical and other information in a timely manner.
• The medical record shall be readily accessible for providing
continuing patient care by medical and other staff, and permit
retrieval of information for medical education, research, quality
assurance activities, and statistical data
Source: Medical Records Manual, WHO

CODE OF ETHICS
MEDICAL STAFF
• Bound by Professional Secrecy and Oath
PARAMEDICAL STAFF
• MEDICAL RECORD PROFESSIONALS, NURSES,
OTHER PARA MEDICAL STAFF TO MAINTAIN.
• Confidentiality about patients, disease, treatment & end results.
• Not to divulge any type of information about patients.
• Abides by Ethical principles.

INTERNATIONAL CLASSIFICATION OF
DISEASES
INTRODUCTION
Classification of diseases and operations is one of the most
important functions of the medical record department. A well-
organized medical record department selects one of the best suited
International Classification Systems to code and index diseases
and operations for the collection of morbidity and mortality
information.
The International Conference for the Tenth revision of the
International Classification of Diseases was convened by the
World Health Organization at WHO headquarters in Geneva from
26 September to 2 October 1989. The conference was attended by
delegates from 43 member states3/18/2018 Dr CB Narayan, CMO(SG) 62

ICD 10TH REVISION BY WORLD HEALTH
ORGANIZATION
Volume 1
Introduction
WHO Collaborating Centers for Classification of Diseases
Report of the International Conference for the Tenth Revision
List of three-character categories
Tabular list of inclusions and four-character
subcategories
Morphology of neoplasm's
Special tabulation lists for mortality and morbidity
Definitions
Regulations
Volume 2 Instruction manual
Volume 3 Alphabetical index

CHAPTERS OF ICD – 10TH REVISION
(21 Chapters)
I Certain infectious and parasitic diseases
II Neoplasm's
III Diseases of the blood and blood-forming organs and certain disorders involving the
immune mechanism
IV Endocrine, nutritional and metabolic diseases
V Mental and behavioural disorders
VI Diseases of the nervous system
VII Diseases of the eye and adnexa
VIII Diseases of the ear and mastoid process
IX Diseases of the circulatory system
X Diseases of the respiratory system
XI Diseases of the digestive system
XII Diseases of the skin and subcutaneous tissue
XIII Diseases of the musculoskeletal system and connective tissue
XIV Diseases of the genitourinary system
XV Pregnancy, childbirth and the puerperium
XVI Certain conditions originating in the prenatal period
XVII Congenital malformations, deformations and chromosomal abnormalities
XVIII Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
XIX Injury, poisoning and certain other consequences of external causes
XX External causes of morbidity and mortality
XXI Factors influencing health status and contact with health services

Indexing of patients data
• Disease & operation indexes are maintained separately. A physician
or a medical staff can use these index for the following purposes.
• Review cases of disease to provide the management a scenario of
current health problems.
• Compose data on diseases in order to prepare scientific papers.
• Procure data on the utilization of hospital facilities and increase the
needs such as equipments and beds.
• Evaluate the quality of care in the hospital.
• Providing patient care data for committees.
• Data on the medical practice in the hospital.
• Data on the Drug Trail for research.3/18/2018 Dr CB Narayan, CMO(SG) 65

Numbering System - MRD
 The unit numbering system may be followed .
 It provides a unit record which is a composite of all IP& OP
data on a given patient.
 When first registered in the hospital the patient is assigned
a number which remains same for all his subsequent
visits.
 His entire medical record is in one folder under one
hospital number i.e. the number first registered in the
hospital.

Filing system
The terminal filing system may be followed
– The first two digits are tertiary,
– the next two are secondary & the last two are primary.
– The primary digit remains constant. Eg 127,227,327,427.
– Each staff may be assigned responsibility for certain section of
files.
– This eliminates confusion and one person cannot blame the
other.
– Also, misfiling can be reduced in this case.

• Medical record documents shall be treated as confidential, secure,
current, authenticated, legible, and complete
• Medical Records Department shall be provided with adequate
direction, staffing, and facilities to perform all recognized functions
Quality Policy
Quality Objectives
•To provide medical records within -- minutes of request for the
patient care.
• To provide timely intimation of birth & death to the statutory board.
•To provide timely intimation of Infectious and Notifiable diseases.
•To minimize the deficiency in the Medical Records3/18/2018 Dr CB Narayan, CMO(SG) 68

Tracer card
• The tracer card plays a very vital role in the filing area.
• It contains the RECORD NO, CONSULTANTS NAME
AND THE DATE OF RETREIVAL.
• The cardial rule in the filing area is that no record can be
removed from rack without being replaced by a tracer card or a
tracer card with the requisition(IP).
• This rule applies not only to extra departmental staff but to the
employees of MRD.

• In patient census:
The number of In-patients at any time.
• Daily In-patient census:
The number of In-patient days of the patients who are both admitted
& discharged after the census taking time of the previous day.
This census is sent to the top management.
• Average daily census:
The average number of IP present each day for a given period
of time. Medical Record usually compile the census and send it to
top management. This census is usually taken at midnight.
This census should always comparing with the previous year.
Census

CAPFS’ CH BSF AGARTALA
Medical Records Department
Daily Statistical Report of Patients
DATE 31.10.2017 31.10.2016
Descriptions Today
Month
To Date
Year
To Date
Financial
Year
Same Day
Last year
MTD
Last year
YTD
Last year
Financial
Last Year
Registrations
Admissions
Emg Admission
Discharges
Birth
Deaths
Census
Occupancy
Remark Tuesday Monday

• Suicide, accident, quarrel, fights, cuts, tablet poisoning, over dosage of drugs,
suspected case of EMO (patient dies on the way)).
• In these cases the medical officer creates an Accident Report (AR) copy & the police
is intimated.
MLC ordinary Cases
• AR Report. (Accident Register Report)
• Police intimation.(informed by the security) to the Police station.
MLC death cases:
• Original death certificate, death summary( if required photocopy of history, progress
sheet and operation notes.)
• The above documents are handed over to the Security Officer which in turn sent to the
police along with body for post mortem
Medico legal cases

Wound certificate:
• This occurs in MLC cases.
• The case is first attended by the casualty medical officer (CMO) and
then reported.
• If required, the police with an authorization from a higher official along
with valid station seal will handover the letter
• The Staff of the MRD has to insist on the Photocopy of the Police.
• The type of injury to the patient (simple/grievous) is explained in the
certificate.
• A copy of this wound certificate is kept in the medical record folder for
future reference.

• These cases arise when the patient has a medical insurance coverage .
• The patient is given two forms from the insurance company- B & B1.
• Both the forms cover about the treatment undergone in the hospital
and about the expired details of the patient, if any.
• A nominal fees may be collected by the cashier. as per the policy
• The forms are sent to the concerned Consultant and filled up by the
consultant with the authorization at the bottom along with the hospital seal.
• The original copy is sent to the insurance company, one photocopy
is sent to the patient/ relative address and another photocopy is filled in the
Medical Record.
Insurance cases – Post Claim

• As per the Gazette of India, April ,6,2002, under clause
• 1.3 Every Physician shall maintain the Medical Records pertaining to
his/her INDOOR patients for a period of 3 years from the date of
commencement of the treatment in a standard proforma laid down By
the Medical Council of India.
• If any request if made for medical records either by the patient/
authorized attendant or legal authorities involved, the same may be duly
acknowledged and documents shall be issued within the period of 72
hours.
• The expired and MLC records are kept permanently for legal purposes.
• Efforts shall be made to computerize the medical records for quick
retrieval
Destruction of Records Ref –GOI-6 Apr 2002 (1.3)
3/18/2018
S/N Register/Record Period of
Preservation
1 Case record other than Medico legal 5 yrs.
2 Case Record with Medico legal
importance
15 yrs.
3 OPD New-Registration / Old-
Registration / Disease Registers
2 Yrs.
4 Casualty Register 3 Yrs.
5 Casualty Register maintained by
DMO
2 Yrs.
6 IPD Registration Register 10 Yrs.
7 Ward IP Register 5 Yrs.
8 Operation / Anaesthesia Register 10 Yrs.
9 Obstetric / Birth / Labour / Death
Register
Permanent
10 Mortuary/Postmortem Register 15 Yrs.
11 Discharge register 2 Yrs.
12 Medical Board Examination Register 5 Yrs.
13 Police Information Register / Injury /
Postmortem Certificate Register
15 Yrs.
SN Register / Record Period of
Preservation
14 Drunkenness / Intoxication 10 Yrs.
15 Common Forms / Periodicals /
Proforma
5 Yrs.
16 Application Received from Police /
Govt. official for Certificates etc.
3 Yrs.
17 Other documents of Medico legal
importance (Potency test,
Examination for suspected rape)
15 Yrs.
18 Diet sheet 5 Yrs.
19
20

ELECTRONIC MEDICAL RECORDS
• The Medical Record has been a collection or package of handwritten or
typed notes, forms & reports.
• Automation has made possible to capture, store, retrieve present
clinical data.
• “On line Systems” – The hospital staff can directly access the
databases through communication terminals connected by Local Area
Network (LAN).
• Backup system – Backup can be taken in Floppies, CDs or in Double
Hard disk system.
• Scanners – Records are scanned and stored in Hard disks or CDs. A
software helps to retrieve and analyses the cases.

Computer entries
• The entries such as issues, receipts, updates,
indexing
( diseases and procedures) are done on a daily basis.
• This plays vital to view the location of the various files.
• The file types such as Volumes No, IP, OP, MLC,
EXPIRED are also to be included in the entries.
• The monthly and yearly statistics are to be prepared.

CAPFS’s CH BSF Agartala
Medical Records Department
Comparative Statistics December 2017
Description
December Financial Year- YTD Calender Year - YTD Month
2016 2017 Change % 2016-2017 2016-17 Change % 2016 2017
Change
% Dec-17 Nov-17 Change %
Total New OP Registrations
Daily average new OP registrations
Total No of Repeat
Daily average of Repeat
MHC - New
MHC - Repeat
MHC - Total
Total IP Admissions
Daily average IP admissions
Total IP Discharges
Daily average IP discharges
Total Births
Total Deaths
IP deaths
OP deaths
Total IP Service days rendered
Average Length of Stay
Average Daily Census
Average daily Percentage Bed
Occupancy
Gross Death Rate
Net Death Rate

Medical Record Department
Comparative Statistics March 2011
Service Breakup of New Registrations
Description
March Financial Year YTD Calender Year YTD Month
2011 2010 Change % 2010-11 2009-10Change % 2011 2010 Change % March-11 Feb-11 Change %
Allergy
Anesthesia
Audiometry
Aurvedic
Breathe Eazy Clinic
Cardiology
Cardio Thoracic Unit
Cosmetology
Critical Care Group
Dentistry
Dermatology
Diabetology
Diabetic surgeon
Dietician
ENT
Emergency
Endocrinology
Endocrinology/Surgery
Gastroenterology
Gastroenterology - Surgical
Gen. Medicine
Gen. Surgery
Geriatric
Gynecology
General physician
Hematology
Infectious Diseases
MHC
Medical Genetic
Nephrology
Neuro surgery
Neurology
Nuclear Medicine
Oncology
Ophthalmology
Orthopedics
Pediatrics
Pediatric Surgery
Pediatric gastroentrology
Plastic Surgery
Psychiatry
Psychology
Radiology
Respiratory Medicine
Rheumatology
Sexual Medicine
Thoracic Unit
Urology
Urogynocology
Vascular Surgery
Well Woman Check Up
Transplant Surgeon
Other Departments
Aroma Therapeutics
Neuro Rehabilation
TOTAL

BENEFITS OF NABH ACCREDITATION
 High Quality Care &
Patient Safety
 Service of credential
medical staff
 Patient Rights
 Evaluation of patient
satisfaction.
HOSPITAL
 Continuous improvement
 Commitment to Quality
Care.
 Benchmarking
PATIENTS

BENEFITS OF NABH ACCREDITATION
3. HOSPITAL STAFF
 Provides Continuous Learning
 Good working environment
 Professional development of clinicians & paramedical
staff
 Quality improvement in medicine and nursing

Accreditation Process
Steps Preparation
Step 1 Application for accreditation (submitted by the Health care organization)
Step 2 Acknowledgement for accreditation (by NABH Secretariat)
Step 3 Pre assessment visit (by Assessor)
Step 4 Final assessment of hospital (by Assessment Team)
Step 5 Scrutiny of the assessment report (by NABH secretariat)
Step 6 Recommendation for accreditation (by accreditation Committee)
Step 7 Approval for accreditation (by Chairman NABH)
Step 8 Issue of accreditation certificate (by NABH secretariat)

PATIENT CENTERED CHAPTERS
APPLICABLE TO THE MEDICAL RECORDS.
 Access, Assessment and Continuity of Care (AAC)
 Patient Rights and Education (PRE)
 Care of Patient (COP)
 Management of Medication (MOM)
 Hospital Infection Control (HIC)
 Information Management System (IMS)

ORGANIZATION CENTERED CHAPTERS
 Continuous Quality Improvement (CQI)
 Responsibility of Management (ROM)
 Facility Management and Safety (FMS)
 Human Resource Management (HRM)
 Information Management System (IMS)

• NABH Application has to be submitted to the Quality
Council of India
• Pre assessment dates will be announced by the
NABH Secretariat.
• Pre assessment likely to be fixed after two months.
The audit may be likely for 2 or 3 days.
• Self Assessment tool kit has to be completed and
submitted within a week

Access, Assessment and Continuity of Care
(AAC)
 Services Provided in the Hospital
 Well Defined Registration, Admission and Discharge
Procedure.
 Initial Assessment and re assessment.
 Care of patients.

Patient Rights and Education
(PRE)
 Privacy during examination, procedure and treatment.
 Confidentiality of Patient Information.
 Consent Forms.
 Information on Lodging a compliant
 Information on Treatment.
 Information on expected cost (estimation)

Care of Patient (COP)
• Emergency Services.
• Usage for blood products.
• ICU & HDU.
• Guidelines for Sedation.
• Administration of anesthesia.
• Care of vulnerable patients.
• Guidelines for surgical procedures.
• Pain management.
• Research Activities.

Management of Medication
(MOM)
• Hospital Formulary
• Storage of medicines
• Prescription of Medications
• Administration of medications
• Policy for dispensing medicine.
• Guide to use narcotic drugs.
• Chemotherapeutic agent
• Radioactive drugs
• Guide for usage of medical gases.

Hospital Infection Control
(HIC)
• Infection Control Manual
• Surveillance activities.
• Reduction on HAI (Hospital Associated Infection)
• Procedure for sterilization activities.
• Bio-Medical Waste Management.
• Regular training for staffs.

Continuous Quality Improvement
(CQI)
• Quality Assurance Program
• Identification of key indicators for monitoring. Clinical
and Managerial.
• Auditing of patient care service.
• Analysis of Sentinel Event.
Responsibility of Management (ROM)
• Responsibility of management is defined.
• Department documentation.
• Patient safety and risk management issues.3/18/2018 Dr CB Narayan, CMO(SG) 91

Facility Management & Safety
(FMS)
• Complies with relevant rules and regulations, laws
and bye laws.
• Operational and Maintenance plan.
• Equipment Management.
• Plans for fire and non- fire emergencies.
• Disaster management.
• Managing of Hazardous Material.
• Safety Committee.

Human Resource Management
(HRM)
• Orientation of New Staffs
• Training staffs on safety.
• Documentation of performance appraisal system.
• Disciplinary procedures.
• Grievance handling.
• Procedure for Collecting , Verifying and evaluating the
credentials of all staffs.

Information Management
System (IMS)
• Process for effective management of data.
• Medical Records.
• Policies for maintenance of confidentiality , integrity and
security of information.
• Policies and procedures for retention period for records.
• Regular Medical Audit.

Good Medical Record
• Accurate
• Complete
• Timely
• Contents
• Chronology
• Continuity
• Promptness
• Authentication
Documentation in Medical
Records
• Legible
• Readable
• Acceptable
• Timely
• Consent recorded
• Error free
• Reproducible

Medical Records in OT (Anesthesia / Surgery)
• Blood Group
• Information about Allergies
• Pre assessment with date & time
• Starting time/Recovery time/Shifting time
• Signature with date & time

Contents of Operation Notes
• Date of surgery
• Sight marking
• Complete Surgical Notes
• Starting time
• Incision time
• Ending time
• Pre-operative diagnosis
• Signature of the operating surgeon

Consultation request
• Date and time of request with signature
• Reason for referral
• Referral consultant’s orders
• Signature with date and time of the referral consultant

Deficiencies in Medical Records
 Improper terminology
 Different diagnosis
 Procedures not recorded
 Wrong forms
 Missing Progress Notes
 Name, Date, and Time to be recorded
 Poor medical follow up
 Repetition of investigations
 Mixing up of cases
 Delay in MR coding, statistics
 TPA settlements

100
Record Practices in Hospital
IMPORTANCEOF
VARIOUSINDICES
• Clinical,
• Scientific,
• Administrative,
• Legal

101
Clinical values of Indices
Clinical Values @ OPD/IPD
 Monthly OPD
 Doctor-wise OPD
 Disease -wise OPD
 CAPFs-wise OPD
 Monthly Discharge
 Abnormal-Investigation-Result
 Quantity of Treatment
Administrative Values @ OPD/IPD
 Bed Occupancy Rate (BOR)
 Bed Turnover Rate (BTR)
 Average Length of Stay (ALS)
 Average Cost per Discharge (ACD)
 Unit/Sector wise IPD
 Work Load Assessment
 Future Administrative Planning
Administrative Values @ Stores/Mess
 Sorting of Stores/Inventories
 Controlling Food Quality/Quantity in Mess
Medico Legal Values @ OPD/IPD
 Medico Legal Protection
 Malpractices
 Negligence
 Quality of Treatment
 Adequacy of Treatment
Scientific Values @ OPD/IPD
 Disease profile in various Age-Group
 Incidence of Major Diseases
 Prevalence of Major Diseases
 Incidence of Communicable Diseases
 Incidence of Modifiable Diseases
 Incidence of Malaria Frontier-wise
 Seasonal Variation of Malaria incidence
 Future Planning & Decision Making
 Disease Surveillance

OPD-Sections-Doctors
Dr D P Patnaik DIG(Med)/MS
Dr A N Rai Comdt (Med)
Dr Leena Gupta CMO(SG)
Dr C B Narayan CMO(SG)
Dr Millie Murmu CMO(SG)
Dr AK Bhattacharya Cont/Gen-Surgeon
Dr AK Saha Cont/Pathologist
Dr AK Datta Cont/GDMO/Psychologist
Dr A K Pal Cont/GDMO/Pediatrics
Dr Priyank Gupta AC/Dental Surgeon

IPD-Wards-Doctors
Med / Ortho / Gynae - Dr C B Narayan, CMO(SG)/GDMO
Surgery - Dr AK Bhattacharya, Gen-Surgeon
Psychiatry - Dr S K Datta GDMO/Psychologist

Health record practices in hospital & importance of various indices

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Health record practices in hospital & importance of various indices

Similar to Health record practices in hospital & importance of various indices (20)

More from Dr CB Narayan

More from Dr CB Narayan (17)

Recently uploaded

Recently uploaded (20)

Health record practices in hospital & importance of various indices