A presentation on Medical Records Department of a hypothetical 50 bedded hospital in INDIA

1. 50 – BEDDED PRIVATE HOSPITAL
MRD DEPARTMENT
Roll no Name
0998 Shreeparna Das
0999 Shreosee Mukherjee
1000 Shruti Aggarwal
1001 Shweta Bisht
1002 Shweta Shastri
1003 Sonal Jain
1004 Sonali Taggar
1006 Sriram Suresh

2. 2
ANANGYA hospital is a 50 bedded private hospital located at Rajpur
Road, Dehradun, established in the year 2011 and has gone leaps and bounds to
deliver its mission of bringing quality healthcare services for all.
Estd. 2011
ANANGYA HOSPITAL
"To be the most trusted healthcare partner for People, through
our unsurpassed quality & care and by striving to provide
ACCESIBLE, AFFORDABLE and BEST HEALTHCARE
services in India"
VISION
"To provide comprehensive patient care by working as a team
and offering highest standards of medical service in
an ethical manner for delivering extraordinary
customer satisfaction"
MISSION
"Humaara Prayaas, Aapka Swaasthya"MOTTO

3. HISTORY OF MEDICAL RECORDS
3
 1st Medical Record Unit was established in 1667 at ST. BARTHOLOMEW HOSPITAL,
England
 Followed by practice of maintaining patient register in Pennsylvania Hospital, USA in 1792
 Idea of proper medical records in the form of standardized inpatient 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
 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

4. 4
Medical record can be defined as an orderly written document encompassing the patient identification data, health history, physical examination, findings,
laboratory reports, diagnosis, treatment, surgical procedures and hospital course. When complete, the records should contain sufficient data to justify the
investigation, diagnosis, treatment, length of hospital stay, results of care and the future course of action.
Means of communication
among
physicians, nurses and
other allied
health professionals
INTRODUCTION
PURPOSE
Informational
document to assist in
quality review in
patient care
Supply pertinent
patient care information
to
authorized organizations
& third-party payers
Furnish documentary
evidence of care
provider in healthcare
facility
Easy reference for
providing continuity
in patient care
Protection of patients,
physicians, healthcare
institution
& employees in case
of litigation
Clinical & Administrative
data for budget
management,
service development,
planning, review, medical
education & research

5. IMPORTANCE OF MEDICAL RECORDS
5
Medical records are important- “people forget, and records remember”. The record is
valuable to many individuals and groups: patients, physicians, health care institutions,
research teams, teachers and students, national health agencies and international health
organizations. The following lists summarize important aspects of medical records to each
of these users:-
PATIENT
PHYSICIAN
HEALTH CARE INSTITUTION
RESEARCH TEAM
NATIONAL HEALTH
AGENCIES
INTERNATIONAL HEALTH
ORGANIZATIONS

6. INFRASTRUCTURE
6
 Our hospital has it's Medical Record Department located on the ground floor
 It is located in close proximity to the OPD and Emergency ward
 We have a centralised Medical Record System wherein the medical record number is
allocated at first admission of the patient to our hospital and is used for all the subsequent
services thereafter
 Our hospital has a mixed Medical Record System where we have not just the paper-
based records but also make use of the computer systems for carrying out our admission
and enquiry related procedures

7. INFRASTRUCTURE
7
ADMISSION &
INQUIRY
OFFICE
125- 175 sq ft
CENTRAL
RECORD
OFFICE
150- 175 sq ft
Storage of Inactive Medical
Record
120-500 sq ft
OUTPATIENT
RECORD
SECTION
• Separate Registration
Counters
• Waiting Area
• Counter Space
25" wide | 40" high
• Separate Counters
• Waiting Space
• Toilet
• Telephone Facility
100-150 sq ft

8. EQUIPMENT
8
PIGEON-
HOLE RACK
SHELVES
INDEX
CABINET
FILING
CABINET
BOOKSHELF
LABEL
DISPENSER
CUPBOARD
NUMBERING
MACHINE
DESKTOP
PHOTOCOPY
MACHINE
TYPEWRITER
TABLE
CHAIR

9. STAFFING FOR 50- BEDDED HOSPITAL
9
MEDICAL RECORD OFFICER Not Needed
MEDICAL RECORD TECHNICIAN 1
ASSISTANT MEDICAL RECORD
TECHNICIAN
7
QUALITY ASSURANCE SPECIALIST
PEON
Not Needed
1
Note: The number recommended is optimum, but varies according to workload, record retention policy and other related activities.
Formula for calculation of personnel required
for MRD
A min of 2 persons for any size of the
hospital+ 1 person for every 100 beds{50-
100}+ person for every beds

10. 10
FLOW OF MEDICAL RECORD
MR
DEPARTMENT
PERIPHERIAL UNIT CENTRAL UNIT
MRD
ASSEMBLY &
DEFICIENCY CHECK
INCOMPLETE
RECORD DESK
ADMISSION
DISCHARGE
ANALYSIS
CODING &
INDEXING
FILING
M.R LIBRARY
EMERGENCY
REGISTRATION
OPD
REGISTRATION
INQUIRY &
CENTRAL
ADMITTING OFFICE
ADMISSION CHECK
WARDWARD
CENSUS DESK

11. COMPONENTS OF MEDICAL RECORD
11
• Front sheet or identification summary sheet
• Consent for treatment
• Legal documents like referral letter, request for information etc.
• Discharge summery, referral slip
• Admission note, clinical progress notes, nurses progress notes
• Operation report if operation has been performed
• Investigation reports like the X-ray, pathology etc.
• Orders for treatment and medication forms listing daily medications
ordered and given with signature of the doctor prescribing the treatment
and the nurse administering it

12. CONSTRAINTS OF MANUAL MEDICAL
RECORDS
12
• Paper based medical records must be preserved for a long period of time
• A huge space is required for the storage
• Retrieval of the records is a difficult task
• Lack of backups & limited security
• Inconsistent layouts
• The safety and the security of medical records is a challenge to personnel in-
charge of the patient records
• No clear audit trails & version history
• Many records are illegible

13. REMEDIES
13
Some better methods of record keeping are as follows:-
 Microfilming
 Space saving
 Safe preservation
 Saves time and manpower
 Clean and easy handling
 Computerized medical records
 Retrieves demographic information and consultants report, as well as
laboratory, radiology and other tests
 Improved quality
 Unlike the manual system, a UID/MR number is auto generated and there is
OPD visit number & IPD visit number
 Retains accountability

14. OWNERSHIP OF THE MEDICAL RECORDS
14
 An important issue of dispute between the patient and the treating
hospital is about the ownership of the medical records
 Medical records are the property of the hospitals and it is the
responsibility of the hospitals to maintain it properly
 However, it is the primary duty of the treating doctor to see that all the
documents regarding management are written properly and signed
 The patient or their legal heirs can ask for copies of the treatment records
that have to be provided within 72 hours
 The hospitals can charge a reasonable amount for the administrative
purposes including photocopying the documents
 Failure to provide medical records to patients on proper demand will
amount to deficiency in service and negligence

15. QUALITY ASSURANCE
15
PURPOSE:
Create standards for documentation within medical records.
QUALITY POLICY:
Ensure uniform construction of all medical records in order to enhance the
effectiveness of the contribution to patient care made by complete, concise
medical records.
QUALITY OBJECTIVES:
• Provide medical records within minutes of request for the patient care
• Provide timely intimation of birth & death to the statutory board
• Provide timely intimation of infectious and notifiable diseases
• Minimize the deficiency of the medical records

16. QUALITY ASSURANCE (contd...)
16
MEDICAL RECORD COMMITTEE:
Established which is responsible for all matters relating to the content of
Medical records and the provision of medical record services in the
hospital.
MEMBERS OF THE COMMITTEE SHOULD CONSIST OF:
• Doctors from surgery & medicine
• Nursing Administration
• Management Staff
• Medical Record Staff
RESPONSIBILITIES:
• Review of medical records
• Ensure the completeness of the documents
• Determine standards and policy for the MRD
• Recommend actions when problems arise
• Determine the format of the medical record and approve and control the
introduction of new medical records
• Development, analysis and technical evaluation of clinical records
• Preservation of medical records
• Pest control measures at regular intervals

17. bm
QUALITY INDICATORS OF MRD
17
• Are medical records filed promptly?
• Is the file room clean room clean and tidy?
• Are master patient index filed promptly? An MRO checks the
information on records with a doctor
• Are all discharges returned to the MRD the day after discharge?
• Are medical records complete
• Are medical record forms filed in the correct order?
• Are all medical records completed within a specified time after
discharge?
• Are all medical records coded correctly?
• Are the monthly and yearly statistics collected within a specified time?

18. RETENTION OF MEDICAL RECORDS
18
Each state has its own norms when it comes to medical record retention. Usually records
are retained depending upon the space availability within the Hospital, but every
hospital maintain:-
• OPD records – 5 years
• IPD records- 10 years
• MLC cases – Permanently until the case is solved
• Birth and death registration - Permanently
 Other medico legally important records should be preserved up to 10 years after which
they can be destroyed after making index and recording summary of the case
 It is important to note that in pediatric cases, a medical negligence case can be filed
by the child after acquiring the age of majority.
 There are certain records in hospital, which are of public interest and are transferred to
public records library after 50 years for release to public and those involve
confidentiality of the individuals are released only after 100 years
 Medical records are acceptable as per Section 3 of the Indian Evidence Act, 1872
amended in 1961 in a court of law. These are considered useful evidence by the
courts as it is accepted that documentation of facts during the course of treatment of
a patient is genuine and unbiased.

19. DESTRUCTION OF MEDICAL RECORDS
19
• In order to retain the medical records for prolonged period, the hospitals
must pay for secure storage services as the records contain confidential
information
• In order to avoid high maintenance, hospitals opt to destroy medical
records after completion of the retention period
• Prior to destroying the records the hospital should publish an
advertisement in the regional and national newspaper, giving details about
the period of medical records to be destroyed
• A log is maintained to document the destroyed records
• Destruction method for paper-based records, microfilm, CD, DVD or
magnetic strip:
 Incineration
 Shredding
• Destruction of pen drives, SSD or HDD is done by purging

20. ECONOMIC IMPLICATIONS
20
PAPER BASED
1. Purchase & Maintenance Cost of system infrastructure- Software & Hardware
2. Development & Maintenance Cost of EMR viewer & Medical Device Interface System
3. Purchase & Maintenance Cost of PCs, Monitors, Scanners, Printers, etc.
4. Cost of scanning charts into EMR
5. Managing Costs of Medical Transcriptionists
6. Reduced Transport and Rental Cost from hospital to storage area
7. Reduced cost of paper supplies
8. Reduced costs on cabinets, bookshelves, etc.
9. Reduced costs on manpower
10. Incremental revenue from remodeled storage space to clinic rooms
11. Additional revenue from Medical Transcriptionist due to faster process
EMR BASED
COSTBENEFITS
v/s
1. Cost of office stationery
2. Rental Costs of outside
storage
3. Personnel Costs of
dispensing, recollecting
& delivering paper charts
to the clinic room
4. Costs of supplies of
medical devices- A4
sheet, photographic
paper, roll paper, etc.

21. MRD Information bhool jaaye,
yeh ho nahi sakta,
Aur hospital administration
information bhool jaye,
yeh MRD hone nahi
dega !!!
21
THANK YOU