This document summarizes the medical records system at Hindu Rao Hospital in Delhi, India. It describes how the medical records department was established in 1970 with one record keeper and has since expanded. The department now maintains inpatient and outpatient records, compiles statistics, and files records for 10 years. Medical records originate at admission and are assembled, analyzed, and stored by the department. The department also issues birth and death certificates and handles medico-legal tasks like attending courts. It is responsible for collecting utilization data from various departments and compiling monthly reports on topics like communicable diseases and immunizations.

1. SYSTEM OF MEDICAL
RECORDS HOSPITAL, IN
DELHI
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2. INTRODUCTION
• Hindu Rao Hospital 980 beded general Hospital.
• Under Municipal Corporation of Delhi.
• For the management and systematic maintenance
of Medical Records in the Hospital a Medical
Record Department was established in the year,
1970
• To begin with MRS was started with one Medical
Record Keeper and 3 class IV employees.
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3. • At present the Medical Record Deptt. has
 Medical Record Officer
 Medical Record Technicians
 Medical Record Clerks
 Medical Record Attendants.
• The Reception, Enquiry and Admission office functions round the
clock under the charge of Medical Record Officer.
• Presently only inpatients records are maintained in the Medical Record
Department.
• Registration work of OPDs are also managed by the Medical Record
Officer.
• Statistical information about the functioning of OPDs is regularly
submitted by the Medical Record Officials in the Medical Record
Deptt.
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4. SYSTEM OF MEDICAL RECORD
• DEFINITION
Medical Record of the patient stores the
knowledge concerning the patient and his care. It
contains sufficient data written in sequence of
occurrence of events to justify the diagnosis,
treatment and outcome.
In the modern age, Medical Record has its utility
and usefulness and is a very broad based indicator
of patients care.
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5.  It has various uses to
 Patients
 Doctors
 Hospital
 Teachers
 Students
 For research work
 National & International agencies
ORIGIN :-
The inpatient Medical Record in originated at the
admission office based on the admission order made
by the clinician or at Casualty Deptt. and various
OPDs of the Hospital.
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6. Flow of Medical Record :-
The flow chart of inpatient Medical Record is as under :-
Central Admission Office
Wards
Medical Record Department
1. Assembling
2. ADMN. &
Discharge analysis
3. Storage Area
Afetr completion of Reccords
Hospital statistics prepared
Monthly/Yearly
Medical Record is filled for
perusal of
Patients/claims/research
purposes.
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7. FILING OF MEDICAL RECORDS
• The inpatients Medical Record is filed by the serial numbers
assigned at central Admitting Office.
• The Record is bound in bundles 100 each and are kept year wise
according to the serial number.
RETENTION OF MEDICAL RECORD
• The policy is to keep indoor patient Records for 10 years
• The OPD registers for 5 years
• The record which is register for legal purposes in Maintained for
10 years or till final decision at the court of Law.
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8. OUTPATIENT DEPARTMENT
• There is a decentralized system for
registration of OPD patients.
• Patients are registered at different
registration counter specialty wise.
• Clerks posted for registration have been
made responsible for the preparation and
submission of statistical data of their
respective OPD
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9. FUNCTIONS OF MEDICAL RECORD
DEPARTMENT
1. Daily receipt of case sheets pertaining to discharge, 2 A.M. an expired patients
from various wards, there checking and assembly.
2. Daily compilation of Hospital census report.
3. Maintains & retrieval of records for patient care and research study.
4. Completion and Procession of Hospital statistics and preparation on different
periodical reports on morbidity and mortality.
5. Online registration of vital events of Birth & Death
6. Issuing Birth & Death certificated upto one year.
7. Dealing with Medico Legal records and attending the courts on summary.
8. Arrangement & Supervision of enquiry and admission office.
9. Arrangement & Supervision of OPD registration
10. Management of disability boards.
11. Management of Medical Examination
12. Management of Mortality Review Committee Meetings (Twice month)
13. Assistance to Hospital Administration in various matters.
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10. SYSTEM OF COLLECTION, COMPILATION
AND FORWARDING STATISTICAL REPORTS
• Medical Record officials posted for registration of OPD patients have been
made responsible for the preparation and submission of statistical data on
their OPDs.
• One Medical Record Officer visits to the wards daily and collects the
disease wise reports of the discharged patients and submits the same in the
medical record section. One official of the Medical Record Section
classifies the data according to the different performa. Following reports
are compiled forwarded to various departments.
1. National list for Tabulation of Morbidity and Mortality
2. Monthly Health Bulletin
3. Monthly report of Polio Cases
4. Monthly report of GWEP
5. Report of cataract operations
6. Monthly report of communicable diseases
7. Monthly report of Measles cases
8. Monthly report of Japanese Encephalitis
9. Monthly report of MNT (Paed & Gynae)
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11. 10. Monthly report of AIDS cases
11. Monthly report of Anti Rabic cases
12. Monthly report of STD
13. Monthly report of cases & Death due to snakebite.
14. Monthly report of Sex Ratio (Birth Death)
15. Monthly report of Malaria cases.
16. Monthly report of Deliveries
17. Monthly report of Family Planning
18. Monthly report of Medicine, DRT, Polio, TT
19. Monthly report of Leprosy cases
20. Weekly report of Polio
21. Weekly report – Statement showing the no. of cases treated (OIVS)
22. Weekly report of National Programme for surveillance of communicable
disease (DHO)
23. Weekly report of Dengue fever cases
24. Weekly report of Pyogenic Meningitis
25. Weekly report of Gastro-enteritis, Cholera
26. Daily report of Noticeable Disease under surveillance.
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