This document discusses the importance and organization of medical records in major hospitals. Key points include: - Medical records contain a patient's medical history and details of treatments to help coordinate their care over time. - Good record keeping is important for patient care, legal protection, evaluating staff performance, and defending against malpractice suits. - A qualified medical records officer should oversee proper organization, classification, indexing, and statistical analysis of records. - Records include outpatient and inpatient files as well as forms, registers, and other documentation of treatments, procedures, and patient information.

1. Medical Record Maintenance in
Major Hospitals
PATIENT MAY FORGET BUT RECORD REMEMBER
Mr Keshava Rao T.,
ASST., MEDICAL ROCORD
OFFICER, Belgaum Institute of
Medical Sciences, Dist Hospital,
Belgaum

2. Medical records
• Compilation of facts, patient’s life history
• History of past & present illness, treatment
contributing to patient’s care
• Records must have sufficient data, justify
treatment and accurately document to end
results

3. Purpose of records
Planning
Organization
 Coordination
 Control of health services

4. Use of good medical records to
the patients
• Details of patient’s illness
• May save time, examination, avoid
discomfort
• Protect legal interest, compensation, injury
etc

5. Use of good medical records to
the hospital
• Evaluation of competency of staff, results
of tretament
• Performance of health care professonals
• Uses of facility resources
• Defense in malpractice suits

6. Use of good medical records to
the doctor
• Ascertain patient’s and treatment records
• Assess methods for treatment
• Help in publication
• Protect legal interests

7. Organizing the Medical Record
Dept
• Qualified medical record officer
• Physician – prepare accurate & adequately
• Classification of diseases as per ICD-10 edition
• Maintenance of Indexing
• Available, accessible and retrievable
• Comply and publication of hospital statistics
• MR committee, medical audit committee to
review

8. Types of MR files
• OP
• IP

9. OPD records
• Name, age, sex, religion, occupation,
income, place, service
• Serial nos. 000001 - 999999

10. OP statistics
• Male – Female
• Male – Female children
• Age
• Geography
• Occupation
• Income
• Service

11. IPD records
• Admission order form – signed
• Other examination – name, age etc
• Sign, consent of attainder
• IP register no

12. Maintenance of MR in wards
• Ward admission book
• Staff nurse – vital signs records, notes
• Discharge, death, etc records
• Census

13. MR forms
• Basic forms
• Specialized forms

14. Arrangements of MR forms
• Admission card
•Short stay records
• History
•Labour room
• Doctor’s orders •Prenatal records
• Nurses notes •Blood transfusion
• Graphic sheets •X-ray
• Lab •Other EEG, etc
• Discharge •Operations

15. Registers in MRD
• OPD
• Admission
• Birth – Death
• Operation
• Anesthesia
• MLC/Accident
• Accession
• All statistical registers
• Post mortem registers

16. MLC records
• Keep separately
• Should not send outside
• Avoid problems

17. MRD work in brief
• Discharge sheets receive with recorder’s sign 
Assemble  check deficiency  correction
• Sheets coded as per ICD-10 and WHO
• Diagnose, operation, doctors indexing
• Daily census
• Compilation of statistics
• Daily accession register
• Birth – death register
• Send data to state and central govts

18. Disposal of records
• OPD – 5 yrs
• 10 yrs – 10 yrs
• MLC – 10 yrs / till result of the case