The document discusses the planning and organization of a medical records department in a hospital. It begins by defining medical records and outlining their purposes for patients, doctors, hospitals, and research. It then describes how to plan and organize the department, including establishing sections for admissions, central records, and outpatient records. Staffing requirements are provided for a 500-bed hospital. Physical facility needs are also outlined. The document concludes by explaining the process of medical record flow upon patient admission.
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.
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 is a foremost important in the healthcare accreditation bodies like JCI,NABH are very adherent about its documentation,retention and confidentiality.
OPD is the mirror of the hospital, which reflects the functioning of the hospital being the first point of contact between the patient and the hospital staff.
Patients visit the OPD for various purposes, like consultation, day care treatment, investigation, referral, admission and post discharge follow up. Not only for treatment but also for preventing and promotive services like, health check up, Immunisation, Physio-therapy and so on.
Medical Records: Intro, importance, characteristics & issuesSrishti Bhardwaj
Unit 1 of MHA SEM- III's syllabus of Medical records Management
(Bharati Vidyapeeth- Center for Health Management Studies & Research, Pune)
Self made- study purpose- reference presentation
avoid hyperlinks on certain slides- inactive
sources shared on last slide as REFERENCES
Hope it helps :)
SIM Unit 4
Store management :
Materials handling,
Flow of goods/FIFO,
Computerization of inventory transactions
Security of stores,
Stocking and technical impacts-
shelf life,
wastage,
pilferage
Medical Records is a foremost important in the healthcare accreditation bodies like JCI,NABH are very adherent about its documentation,retention and confidentiality.
OPD is the mirror of the hospital, which reflects the functioning of the hospital being the first point of contact between the patient and the hospital staff.
Patients visit the OPD for various purposes, like consultation, day care treatment, investigation, referral, admission and post discharge follow up. Not only for treatment but also for preventing and promotive services like, health check up, Immunisation, Physio-therapy and so on.
Medical Records: Intro, importance, characteristics & issuesSrishti Bhardwaj
Unit 1 of MHA SEM- III's syllabus of Medical records Management
(Bharati Vidyapeeth- Center for Health Management Studies & Research, Pune)
Self made- study purpose- reference presentation
avoid hyperlinks on certain slides- inactive
sources shared on last slide as REFERENCES
Hope it helps :)
SIM Unit 4
Store management :
Materials handling,
Flow of goods/FIFO,
Computerization of inventory transactions
Security of stores,
Stocking and technical impacts-
shelf life,
wastage,
pilferage
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
2. PREVIEW
OBJECTIVE
INTRODUCTION, DEFINITION, PURPOSE
PLANNING, ORGANIZATION AND STAFFING
PHYSICAL FACILITIES
PROCESSING OF RECORDS AND THEIR RETRIEVAL
CODING AND INDEXING
STORAGE AND RETRIEVAL
REPORTS AND RETURN
MEDICO LEGAL ASPECTS OF MEDICAL RECORDS
3. OBJECTIVES
DEFINE THE MEDICAL RECORD.
ENLIST THE PURPOSES OF MEDICAL RECORDS IN
RELATION TO PATIENT, DOCTOR, HOSPITAL AND
MEDICAL EDUCATION AND RESEARCH.
ENUMERATE THE STEPS IN PLANNING AND
ORGANIZATION OF MEDICAL RECORDS
DEPARTMENT IN A HOSPITAL.
4. INTRODUCTION
FIRST MEDICAL RECORD UNIT WAS ESTABLISHED IN
1667 AT ST. BARTHOLOMEW’S HOSPITAL, ENGLAND.
FOLLOWED BY PRACTICE OF MAINTAINING PATIENT
REGISTER IN PENNSYLVANIA HOSPITAL, USA IN 1792.
IDEA OF PROPER MEDICAL RECORDS IN FORM OF
STANDARDIZED INPATIENTS RECORDS CAME IN USA
FROM THE AMERICAN COLLEGE OF PHYSICIANS AND
AMERICAN COLLEGE OF SURGEONS IN THE LAST
QUARTER OF THE 20TH CENTURY.
IN INDIA BHORE COMMITTEE (1946) FIRST STRESSED
THE IMPORTANCE OF KEEPING MEDICAL RECORDS.
5. REITERATED BY MUDALIAR COMMITTEE IN 1962.
SUBSEQUENTLY, HEALTH AND HOSPITAL REVIEW
COMMITTEE (JAIN COMMITTEE AND RAO
COMMITTEE) HIGHLIGHTED POOR STATE OF
MEDICAL RECORDS AND RECOMMENDED THE
ESTABLISHMENT OF A PROPER MEDICAL RECORDS
SECTION IN EACH HOSPITAL.
WITH TECHNICAL ADVANCEMENT, COMPUTERS ARE
EXTENSIVELY USED FOR RECORD GENERATION,
ANALYSIS AND RETRIEVAL.
MICROFILMING HAS ALSO BEEN INTRODUCED FOR
EASY STORAGE AND RETRIEVAL.
6. DEFINITION
“A CLINICAL, SCIENTIFIC, ADMINISTRATIVE AND LEGAL
DOCUMENT RELATING TO PATIENT CARE IN WHICH ARE
RECORDED SUFFICIENT DATA WRITTEN IN THE SEQUENCE
OF EVENTS TO JUSTIFY THE DIAGNOSIS, WARRANT THE
TREATMENT AND RESULTS”.
A MEDICAL RECORD IS-
A DOCUMENT OF FACTS, WHICH CONTAINS
STATEMENTS BY TRAINED OBSERVERS OF CONDITION
FOUND AND THE APPLICATION AND THE RESULT OF
THE EXAMINATION AND THERAPY.
IT ALSO INDICATES WHETHER OR NOT THE EFFORTS OF
THE DOCTORS, SUPPLEMENTED BY THE HOSPITAL AND
RELATED FACILITIES ARE IN ACCORDANCE WITH THE
REASONABLE EXPECTATIONS OF THE PRESENT DAY’S
SCIENTIFIC MEDICINE.
7. MEDICAL RECORD AS SUCH IS A PACKAGE OF FORMS,
CASE SHEETS PLACED IN CHRONOLOGICAL ORDER
OF OCCURRENCE OF EVENTS AND INVESTIGATION
REPORTS. THE NATURE OF FORMS, LAB REPORTS
AND EVEN CASE SHEET RECORDINGS MAY VARY
FROM HOSPITAL TO HOSPITAL.
CLASSICALLY THE MEDICAL RECORD OF A PATIENT
CONTAINS THE DOCUMENTS ARRANGED IN THE
FOLLOWING SEQUENCE:
ADMISSION FORM
CASE SHEET COMPRISING OF:
MEDICAL HISTORY CLINICAL FINDINGS
INVESTIGATION ORDERED TREATMENT ISSUED
PROGRESS REPORTS CONSENT FORM FOR SURGERY OR
SPECIALIZED PROCEDURES
ANESTHESIA CHECK RECORD, IF APPLICABLE NOTES ON SURGICAL/SPECIAL PROCEDURES
LAB REPORTS IN CHRONOLOGICAL
SEQUENCE OF THEIR ORDERING
FILMS ALONG WITH THEIR REPORTS
8. MEDICAL RECORDS FOR THE OUTPATIENTS SHOULD
ALSO BE PREPARED, PROCESSED AND STORED IN THE
SAME MANNER AS THE INPATIENT’S RECORDS.
EACH INDIVIDUAL ATTENDING AN OPD IS GIVEN A
REGISTRATION NUMBER AND ALL THE MEDICAL
RECORDS ARE KEPT IN A FOLDER BEARING THE SAME
NUMBER.
THE PATIENT IS ISSUED A TICKET/TOKEN BEARING
THE REGISTRATION NUMBER.
THE INDIVIDUAL AT THE OPD RECORD ROOM SENDS
THE FOLDER TO THE APPROPRIATE DEPARTMENT ON
THE PRESENTATION OF TOKEN. THE FOLDER IS
DEPOSITED BACK AFTER THE VISIT.
9. PURPOSE
THE MEDICAL RECORD IS INDISPENSABLE FROM THE
POINT OF VIEW OF THE PATIENT, THE DOCTOR, AND
THE HOSPITAL AND FOR MEDICAL EDUCATION AND
RESEARCH.
THE PATIENT:
IT SERVES TO DOCUMENT THE CLINICAL HISTORY OF THE
PATIENT’S ILLNESS AND COURSE OF THE DISEASE.
IT SERVES TO AVOID OMISSION OR UNNECESSARY REPETITION OF
DIAGNOSTIC AND TREATMENT MEASURES.
IT ASSISTS IN CONTINUITY OF CARE IN THE EVENT OF FUTURE
ILLNESS.
PROVIDES NECESSARY INFORMATION FOR INSURANCE,
CONTRIBUTORY HEALTH SCHEMES OR FOR THE EMPLOYMENT
PURPOSES.
10. THE DOCTOR:
ASSURANCE OF QUALITY, QUANTITY, AND
ADEQUACY OF DIAGNOSTIC AND THERAPEUTIC
MEASURES UNDERTAKEN.
AN ASSURANCE OF ORDERLY CONTINUITY OF
MEDICAL CARE.
EVALUATION OF MEDICAL PRACTICE.
AN AID IN RESEARCH AND THE CONTINUING
EDUCATION OF HEALTH PROFESSIONALS.
A PROTECTION IN THE EVENT OF LEGAL
QUESTION.
11. THE HOSPITAL:
DOCUMENT THE TYPE AND QUANTITY OF WORK UNDERTAKEN
AND ACCOMPLISHED.
FURNISH PROOF OF THE TYPE AND QUANTITY OF CARE
RENDERED TO THE PATIENT.
EVALUATE THE PROFICIENCY OF THE INDIVIDUAL DOCTOR, FOR
ADMINISTRATION AND CLINICAL PURPOSES.
EVALUATE THE SERVICES OF THE HOSPITAL IN TERMS OF
ACCEPTED NORMS AND STANDARDS.
PROTECT THE HOSPITAL IN THE EVENT OF LEGAL MATTERS.
SERVE AS AN ADMINISTRATIVE RECORD OF PERSONNEL
PERFORMANCE AND STAFFING NEEDS, FOR BUDGET
PREPARATION, JUSTIFICATION FOR PHYSICAL FACILITY
ALLOCATION AND UTILIZATION, FOR STATISTICAL DATA FOR
ADMINISTRATIVE USE AND EVALUATION, FOR ESTIMATING
EQUIPMENT AND SUPPLY UTILIZATION AND NEEDS.
ASSIST IN FUTURE PROGRAM PLANNING.
12. MEDICAL EDUCATION AND RESEARCH:
RECORDED OBSERVATIONS ARE THE BASIS
FOR ALL CLINICAL RESEARCH.
FURTHER THE EDUCATION OF DOCTORS
AND OTHER HEALTH PERSONNEL.
MEDICAL RECORDS SUPPLY PERTINENT
DATA FOR THE USE BY PUBLIC HEALTH
AUTHORITIES FOR CONTROL OF DISEASES.
13. PLANNING, ORGANISATION AND STAFFING
THE MAIN FACTORS THAT GOVERN THE ORGANISATION
OF WORK IN A MEDICAL RECORDS DEPARTMENT ARE:
MEDICAL RECORDS SHOULD ALWAYS BE AVAILABLE
WHEN REQUIRED AND IN THE FORM THEY ARE
REQUIRED.
ADEQUATE LIAISON SHOULD EXIST BETWEEN DIFFERENT
GROUPS OF STAFF USING MEDICAL RECORDS TO ENABLE
TO GIVE DUE CONSIDERATION TO MATTERS SUCH AS
DESIGN AND CONTENTS, METHOD AND STORAGE
AVAILABILITY, USE AND MOVEMENT OF RECORDS.
PROCEDURES SHOULD CAUSE PATIENTS THE MINIMUM
OF WAITING AND INCONVENIENCE.
THE MEDICAL RECORDS COMMITTEE IS COMPOSED OF:
REPRESENTATIVE OF THE
CLINICAL DISCIPLINE
REPRESENTATIVE OF THE
NURSING STAFF
MEMBER FROM THE PATHOLOGY
SERVICES
ADMINISTRATOR
14. ORGANISATION
ADMISSION AND INQUIRY OFFICE :
ADMITTING OFFICE
ADMISSION CHECK DESK
CENSUS DESK
INQUIRY OFFICE
CENTRAL RECORD OFFICE:
RECEIPT, CHECKING, ASSEMBLY AND STORAGE OF ALL
MEDICAL RECORDS OF DISCHARGED PATIENTS.
DISCHARGE ANALYSIS AND STATISTICS.
CODING OF ALL DIAGNOSIS AS PER INTERNATIONAL
CLASSIFICATION OF DISEASE.
INDEXING OF ALL DISCHARGED PATIENTS BY DISEASE,
DOCTOR, ETC.
15. MAKING RECORDS AVAILABLE FOR MEDICO LEGAL
PURPOSE.
ISSUE OF MEDICAL CERTIFICATES OF VARIOUS TYPES.
SEND NOTIFICATION OF ALL COMMUNICABLE DISEASES
TO THE PUBLIC HEALTH AUTHORITIES.
ISSUE OF MEDICAL CERTIFICATES OF VARIOUS TYPES.
PREPARATION OF MONTHLY ABSTRACTS AND ANNUAL
STATISTICAL DETAILS.
DEALING WITH INQUIRIES FROM LIFE INSURANCE
CORPORATION REGARDING DISEASE AND CAUSE OF DEATH
OF THE INSUREE.
TRAINING OF ALL CATEGORIES OF PERSONNEL.
STORAGE OF ALL TYPES OF FORMS USED IN THE
HOSPITAL.
OUT PATIENT RECORD SECTION
16. KEEPING ALL THIS IN VIEW THE MEDICAL
RECORDS DEPARTMENT IS ORGANISED AS UNDER
OFFICE FOR MEDICAL RECORD
OFFICER (MRO) AND ASST. MRO.
ASSEMBLY AND
DEFICIENCY
CHECK DESK
INCOMPLETE
RECORD CONTROL
DESK
CODING AND
INDEXING
DESK
DISCHARGE
ANALYSIS AND
VITAL STATISTICS
DESK
DOCUMENT PROCESSING AREA COMPRISING OF:
RECORD STORAGE :
*ACTIVE RECORD STORAGE *INACTIVE RECORD STORAGE
17. STAFFING (FOR 500 BEDDED HOSPITAL)
• MEDICAL RECORD
OFFICER 1
• MEDICAL RECORD
TECHNICIAN 4
• CLERKS 3
• PEON 1
• STATISTICIAN 1
ADMISSION AND INQUIRY
OFFICE
• ASST. MEDICAL
RECORD OFFICER 1
• MEDICAL RECORD
TECHNICIAN 5
• MEDICAL RECORD
ATTENDANT 4
• RECEPTIONIST 5
18. CENTRAL RECORD OFFICE
• ASST. MEDICAL
RECORD OFFICER 1
• MEDICAL RECORD
TECHNICIAN/ ASST.
MEDICAL RECORD
TECHNICIAN
8
• MEDICAL RECORD
ATTENDANTS
8
• STATISTICAL ASST. 5
19. PHYSICAL FACILITIES
SPACE AND GENERAL FACILITIES REQUIREMENT:
a) ADMISSION AND INQUIRY OFFICE:
SPACE- 125-175 SQ. FT.
REQUIREMENTS-
GENERAL OFFICE EQUIPMENT FOR THE STAFF.
SEPARATE COUNTERS FOR ADMITTING CLERK, RECEPTIONIST
HANDLING INFORMATION AND BILLING CLERK SHOULD BE
PROVIDED.
ADEQUATE WAITING SPACE, TOILET FOR STAFF, PATIENT AND
ATTENDANTS.
TELEPHONE FACILITY FOR LOCAL CALLS AND STD MUST BE
MADE.
20. B) CENTRAL RECORD OFFICE
1) SPACE REQUIREMENT DEPENDS UPON THE SIZE OF THE HOSPITAL-
• 50 BED- 150-175 SQ. FT.
• 100 BED- 225-250 SQ. FT.
• 200 BED- 450-500 SQ. FT.
• 500 BED- 1000-1200 SQ. FT.
2) THIS AREA MAY BE ADEQUATE TO STORE INACTIVE MEDICAL
RECORDS ALSO. SPACE 120 SQ. FT. – 500 SQ. FT REQUIRED.
3) FULLY FUNCTIONAL COMPUTERS, AND PROPER OFFICE EQUIPMENT
FOR STAFF REQUIRED.
C) OUT PATIENT RECORD SECTION
SPACE- 2-3 SQ. FT. PER BED.
SEPARATE COUNTERS FOR THE REGISTRATION OF OLD AND
NEW, MALE AND FEMALE PATIENTS.
COUNTER SPACE- 24” WIDE, 40” HIGH.
WAITING AREA FURNISHED WITH CHAIRS AND
ANNOUNCEMENT BOARDS.
21.
22. PROCESSING OF RECORDS AND THEIR FLOW
UPON ADMISSION OF A PATIENT
ADMITTING
OFFICE
ADMISSION
LIST
ADMISSION
RECORDS
COPY OF
ADMISSION
LIST
CENSUS
DESK
INFORMATION
DESK
NURSING
UNIT
CHECK
DESK
ADMISSION
INCOMPLETE
PATIENT
INDEX CARD
INCOMPLETE
RECORDS
CONTROL DESK
23. IMPORTANT ACTIONS PERFORMED BY THE
ADMITTING OFFICE ARE SUMMARIZED BELOW
a) ADMITTING OFFICE:
INITIATES PATIENT’S HOSPITALIZATION RECORDS.
ASSIGNS ADMISSION NUMBER.
PREPARES ADMISSION RECORD:
i. ADMISSION NUMBER
ii.IDENTIFYING DATA
iii.SIGNATURE OF AUTHORIZATION
• SENDS PATIENT TO NURSING UNIT.
• SENDS ADMISSION RECORD TO NURSING UNIT.
• SENDS COPY OF ADMISSION RECORD TO
ADMISSION CHECK DESK.
24. B) ADMISSION CHECK DESK:
RECEIVES ADMISSION ADVICE FROM ADMITTING OFFICE.
CHECKS PATIENT INDEX FOR PREVIOUS ADMISSIONS.
ENTERS THIS ADMISSION ON PATIENT INDEX CARD OF
PREVIOUS ADMISSION.
IF NO PREVIOUS ADMISSION, MAKE NEW PATIENT INDEX CARD.
SENDS INDEX CARD TO INCOMPLETE RECORD CONTROL DESK.
SENDS RECORDS OF PREVIOUS ADMISSION TO NURSING UNIT.
PREPARES RECORD FOLDER WITH ADMISSION RECORD AND
NAME AND SENDS IT TO COMPLETE RECORDS CONTROL DESK.
MAKES ENTRIES TO ACCESSION REGISTER.
C) CENSUS DESK:
PREPARES ADMISSION LIST FROM ADMITTING OFFICE.
COLLECTS DISCHARGE PATIENT RECORDS FROM NURSING
UNITS DAILY.
PREPARES DISCHARGE LIST.
PREPARES CENSUS REPORTS.
25. MOVEMENT OF MEDICAL RECORDS
UPON DISCHARGE OF A PATIENT
NURSING UNIT
DISCHARGED
RECORDS
CENSUS
DESK
ASSEMBLING
AND DEFICIENCY
CHECK DESK
ASSEMBLED
DISCHARGED
RECORDS
COMPLETE
DISCHARGED
RECORDS
INCOMPLETE
DISCHARGED
RECORDS
CODING AND
INDEXING
DESK
DISCHARGE
ANALYSIS DESK AND
VITAL STATISTICS
COMPLETE
PATIENT INDEX
CARDS
COMPLETED
RECORDS
FILES
ADMISSION
CHECK DESK
26.
27. CODING AND INDEXING
CODING:
IN EACH MEDICAL RECORDS INTERNATIONAL
CODE NUMBER IS ASSIGNED TO THE DIAGNOSIS
BASED ON “INTERNATIONAL CLASSIFICATION OF
DISEASE” ISSUED BY THE WORLD HEALTH
ORGANISATION.
THIS IS TO BRING ABOUT ACCURACY AND
UNIFORMITY IN THE REPORTING OF THE DISEASES
BY THE VARIOUS HOSPITALS.
28. INDEXING:
a) ALPHABETIC/ MASTER INDEX: INDEXING BASED ON PATIENT’S
NAME SEQUENCED ALPHABETICALLY. THE PRIMARY PURPOSE OF
A NAME INDEX IS TO PROVIDE ENTRY INTO THE FILING SYSTEM
AND FINDING OUT MEDICAL RECORD FOR A PATIENT.
b) DISEASE INDEX: DISEASE INDEX IS A CATALOGUE OF CARDS
3” X 5” OR 5” X 8”, MAINTAINED TO FIND OUT GROUPS OF
CLINICAL RECORDS OF PATIENTS HAVING THE SAME DIAGNOSIS.
BESIDES PATIENT’S IDENTIFICATION DATA, AGE, GENDER, RESULT
OF TREATMENT AND COMPLICATION MAY ALSO BE MENTIONED.
c) OPERATION INDEX: IT IS A CATALOGUE CONTAINING THE
DETAILS OF PATIENTS WHO HAVE UNDERGONE THE
OPERATIONS.
d) PHYSICIAN’S INDEX: CATALOGUE CONTAINING THE DETAILS OF
ALL PATIENTS TREATED BY PARTICULAR PHYSICIANS. ANALYSIS
OF SUCH RECORDS MAY BE UTILIZED FOR EVALUATING THE
PERFORMANCE OF A PHYSICIAN.
e) UNIT INDEX: DETAILS OF ALL THE PATIENTS TREATED IN A
PARTICULAR UNIT ARE INDEXED. THESE RECORDS MAY
ULTIMATELY BE UTILIZED TO EVALUATE THE PERFORMANCE OF A
PARTICULAR UNIT.
29. STORAGE AND RETRIEVAL
STORAGE: THE FOLLOWING FACTORS ARE
CONSIDERED FOR AN EFFECTIVE FILING SYSTEM:
a) COMPACTNESS TO REDUCE PHYSICAL EFFORT AND
COST OF STORAGE SPACE.
b) ACCESSIBILITY FOR SPEEDY LOCATION AND
IDENTIFICATION.
c) SIMPLICITY FOR UNDERSTANDING OF ALL
CONCERNED.
d) ECONOMICAL BOTH IN THE COST OF INSTALLATION
AND OPERATION.
e) ELASTICITY TO EXPAND ACCORDING TO FUTURE
REQUIREMENT.
f) TRACER SYSTEM FOR DOCUMENT IN CIRCULATION.
30. SYSTEMS OF FILING-
DECENTRALIZED
SYSTEM
UNDER THIS SYSTEM,
INPATIENT AND
OUTPATIENT
DEPARTMENTS HAVE THEIR
OWN INDIVIDUAL
RECORDS AND FILE THEM
INDEPENDENTLY WITHIN
THEIR DEPARTMENTS. THIS
SYSTEM IS LABOUR
INTENSIVE AND THE
OPERATING COST ARE
HIGHER.
CENTRALIZED
SYSTEM
IN THE CENTRALIZED
SYSTEM, MEDICAL
RECORDS ARE FILED
CENTRALLY IN THE
MEDICAL RECORD
DEPARTMENT. THIS
SYSTEM IS MORE
EFFICIENT, PROVIDES
BETTER CONTROL AND IS
FOLLOWED IN MOST
HOSPITALS.
31. METHODS OF FILING-
NUMERICAL METHOD
ALPHABETICAL METHOD
CHRONOLOGICAL ORDER
TERMINAL DIGIT SYSTEM
MID DIGIT SYSTEM
32. S.
No
DATE IP
No
FILE TYPE PATIENT
NAME
DATE OF
DISCHARGE
DIS-
CHARGE
TYPE
RESIDENT
SIGN
MRD
CLERK
SIGN
MLC LAMA/
ABSCONDED
GENERAL DISCHARGED/
ETC.
DEPARTMENT______________UNIT/CONSULTANT______________
33. FILING PROCEDURES-
TYPES OF FILES-
USEFUL TO USE FILES OF DIFFERENT COLOURS
FOR DIFFERENT YEARS FOR EASY RETRIEVAL AND
IDENTIFICATION.
FILING : THREE TYPES OF FILING PROCEDURE IN
USE
VERTICAL-
SUSPENDED
HORIZONTAL
34. MICROFILMING OF MEDICAL RECORDS
IN LARGE TEACHING HOSPITALS DUE TO CONSTRAINTS OF
SPACE MICROFILMING IS RESORTED TO.
ADVANTAGES OF MICROFILMING :-
SAVING OF SPACE BY 90%.
EASY ACCESSIBILITY.
PROTECTION.
ELIMINATION OF MISFIRING.
SAVING OF TIME & MANPOWER.
SPECIAL EQUIPMENT REQUIRED INCLUDES MICROFILMING
CAMERA,PROCESSORS, VIEWING MACHINES, DUPLICATING & XEROX
MACHINES, MICROFILMING ROLLS, FIXER & DEVELOPER AND
MICROFILMING TECHNICIANS.
35. COMPUTERISATION OF MED RECORDS
TECH ADVANCEMENTS & DECREASING COST OF
COMPUTERISATION HAVE REVOLUTIONISED THE
MED RECORD SYSTEM.
POSSIBLE TO STORE TEXT & ALL TYPES OF
IMAGES VIZ X-RAYS, CAT SCAN, MRI.
BY NETWORKING SYSTEM ACCESS CAN BE
PROVIDED TO DRs, NURSES, TECHNICIANS &
ADMINISTRATOR WHILE MAINTAINING
CONFIDENTIALITY.
36. RETREIVAL OF MEDICAL RECORDS
USUALLY REQD FOR
FOLLOW UP OF PATIENTS.
ADMISSION TO WARD/ CASUALTY FOR
OBSERVATION.
RESEARCH WORKERS FOR ACADEMIC PURPOSES.
MEDICAL REIMBURSEMENT.
PRODUCING IN COURT OF LAW.
37. REPORTS AND RETURNS
BASIC PURPOSE OF REPORTS ARE:
EVALUATING THE QUALITY OF CARE.
LOCATING THE DEFI IN :
MEANS – STAFF, PHYSICAL FACILITIES, EQPT INCL
PLANTS & MACHINES.
METHODS – OPERATING POLICIES & PROCEDURES.
END RESULT- OUTCOME OF BENEFITS DERIVED BY THE
COMMUNITY FROM THE HOSP.
EFFECTIVENESSOF HOSP ADMINISTRATION.
PREVENION OF DISEASES
38. TYPES OF REPORTS
TYPES OF REPORTS & FREQUENCY WILL VARY
WITH TYPE OF HOSPITAL & ADM REQMTS.
REPORTS GENERATED DAILY, WEEKLY,
FORTNIGHTLY, MONTHLY, QUARTERLY, SIX
MONTHLY OR ANNUALLY DEPENDING ON
REQMT .
REPORTS GENERALLY PERTAIN TO :
VITAL STATS.
ADT(ADMISION, DISCHARGEAND TRANSFER
ANALYSIS.
GENERAL HEALTH STATS.
39. REPORTS RELATED TO HOSP BEDS
DAILY CENSUS
MAX PATIENTS ON ANY ONE DAY.
MIN PATIENTS ON ANY ONE DAY.
DAILY AVG.
BED OCCUPANCY RATE.
TOTAL PATIENT DAYS CARE.
BED TURN OVER INTERVAL.
ADMISSION
DAILY ADMISSION.
DAILY ADMISSION UNIT/SPECIALITY WISE.
TOTAL ADMISION OVER A PERIOD.
PATIENTS DISTRIBUTION BY AGE, SEX, RELIGION
®ION
40. DISCHARGES
DAILY DISCHARGES.
TOTAL PATIENTS DISCHARGED OVER A PERIOD.
DAYS OF CARE TO THE PATIENTS DISCHARGED.
AVG LENGTH OF STAY.
DEATHS
DAILY NUMBER OF DEATHS.
TOTAL DEATHS OVER A PERIOD.
TOTAL DEATHS OVER 48 HRs.
TOTAL DEATHS UNDER 48 HRs.
NET DEATH RATE.
GROSS DEATH RATE.
FOETAL DEATH RATE.
MATERNAL DEATH RATE.
INFANT DEATH RATE.
POST OPERATIVE DEATH RATE.
ANAESTHETIC DEATH RATE.
41. WORK LOAD STATITICS.
TOTAL NO OF OUTPATIENTS.
NEW CASES.
REPEAT CASES.
TOTAL NO OF OPERATIONS.
TOTAL NO OF X RAY & OTHER RELATED INV.
DEPT WISE WORKLOAD STATS.
HOSP CARE EVALUATION STATS
POST OPERATIVE INFECTION RATE.
POST OPERATIVE COMPLICATION RATE.
CAESARIAN SECTION RATE.
AUTOPSY RATE.
CONSULTATION RATE.
RATE OF NORMAL TISSUE REMOVED.
% OF DISAGREEMENT BETWEEN FINAL & PATHOLOGICAL DIAGNOSIS.
GROSS RESULTS OF TREATMENT, i.e PATIENTS RECOVERED, IMPROVEDOR NOT
RELIEVED.
42. MEDICO LEGAL ASPECTS OF MRD
MED REC PROPERTY OF THE HOSP, NEITHER PATIENT NOR DR.
AS A PERS DOCU, CONFD & PRIVILEDGED DOCU, CANNOT BE DIVULGED W/O
PATIENT CONSENT EXCEPT UNDER PROCESS OF LAW, AS AN IMPERSONAL DOCU,
CAN BE USED FOR EDN & RESEARCH.
A CLINICALAS ALSO LEGAL DOCU, HENCE IT SHOULD FULFILL THE FWG
CRITERIA :
COMPLETE :MUST CONTAIN SUFFICIENT DATA TO IDEN PATIENT, JUSTIFY
DIAGNOSIS, WARRANT TREATMENT & OUTCOME & OTHER ROUTINE & SPL REC.
ADEQUATE : NOT SKETCHY BUT DETAILED, MUST CONTAIN ALL NECY FORM &
ALL RELEVANTCLINICAL INFO.
ACCURATE: SUITABLE FOR QUANTITATIVE ANALYSIS.
LEGIBLE : EASILY DECIPHERABLE WITH PRINTED NAMES & DESIGNATIONSOF
ALL SIGNATORIES.
43. INDIAN EVIDENCE ACT 1872 AS AMENDED
REQUIRES MED REC TO BE PRODUCED BEFORE
COMPETENT AUTH IN FWG CONDITIONS:
IN COURT OF LAW.
LIC OF INDIA.
INCOME TAX.
PATIENTS WILL.
QUERIES REGARDING BIRTH OR DEATH.
44. RETENTION OF MED REC
FACTORS AFFECTING RETENTION PERIOD :
NEED OF PATIENT.
MEDICO LEGAL ASPECT.
EDN & MED RESEARCH.
GEN GUIDELINES:
OPD REC 5 YRS
IPD REC 10 yrs
MLC PERMT
NOTE: IN TEACHING MED COLLEGE & HOSP
RECORDS KEPT PERMANENTLY.