The document provides information on medical records including what they are, their components, functions of the medical record department, and processes for receiving, retrieving, completing, and releasing medical records. Some key points:
- Medical records chronicle a patient's medical history and care, including notes, test results, reports, and other documentation entered by healthcare professionals over time.
- Records are used for documenting treatment, communication between providers, collecting health statistics, and legal/insurance matters.
- The medical record department is responsible for filing, retrieving, completing, coding, and evaluating medical records as well as compiling statistics.
- Strict processes are followed for receiving records at discharge or death, retrieving records for care or authorized
Medical Records is a foremost important in the healthcare accreditation bodies like JCI,NABH are very adherent about its documentation,retention and confidentiality.
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 :)
Medical Records is a foremost important in the healthcare accreditation bodies like JCI,NABH are very adherent about its documentation,retention and confidentiality.
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 :)
A brief presentation on the Medicolegal aspects of healthcare initially intended for the students - Post Graduate Diploma in Hosp. Management (Medvarsity)
The objective of this presentation is to make you aware of issues which are generally confronted during medical practice.
SOURCES OF LAWS:
PRIMARY SOURCES
Laws passed by the Parliament or the State Legislative
Ordinances passed by the President and the Governor
Subordinate legislation: Rules and regulations made by the executive through the power delegated to them by the Acts.
SECONDARY SOURCES:
Judgments of the Supreme Court, High Court and Tribunals (The ratio decedendi is a binding precedent)
Judicial legislation
Judgment of Foreign Courts
International Treaty
detail knowledge of medico-legal cases, introduction,types, reports, consent,death certificate, patient right. it will help you to understand the concept of medico-legal cases
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.
In the presentation efforts have been made to guide the medical professionals how to deal with a MLC case in a step by step manner and certain issues relating to medical case records.
Medical college of wasit
Department of medicine
Case sheet history
Thing to remember :-
1) Stand on the right side of the patient with good confidence .
2) Introduce yourself as a medical student not as a doctor . ( you may face difficult question ).
3) Talk the patient gently with clear comprehensible words .
4) Remember don’t hurt the patient in your speak & touch .
A brief presentation on the Medicolegal aspects of healthcare initially intended for the students - Post Graduate Diploma in Hosp. Management (Medvarsity)
The objective of this presentation is to make you aware of issues which are generally confronted during medical practice.
SOURCES OF LAWS:
PRIMARY SOURCES
Laws passed by the Parliament or the State Legislative
Ordinances passed by the President and the Governor
Subordinate legislation: Rules and regulations made by the executive through the power delegated to them by the Acts.
SECONDARY SOURCES:
Judgments of the Supreme Court, High Court and Tribunals (The ratio decedendi is a binding precedent)
Judicial legislation
Judgment of Foreign Courts
International Treaty
detail knowledge of medico-legal cases, introduction,types, reports, consent,death certificate, patient right. it will help you to understand the concept of medico-legal cases
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.
In the presentation efforts have been made to guide the medical professionals how to deal with a MLC case in a step by step manner and certain issues relating to medical case records.
Medical college of wasit
Department of medicine
Case sheet history
Thing to remember :-
1) Stand on the right side of the patient with good confidence .
2) Introduce yourself as a medical student not as a doctor . ( you may face difficult question ).
3) Talk the patient gently with clear comprehensible words .
4) Remember don’t hurt the patient in your speak & touch .
The Happy Marriage of Hospital Finance and Frontline OperationsHealth Catalyst
The hospital finance department typically acts as administrator and controller over hospital operations, at least in the eyes of frontline clinicians. Additionally, finance is burdened with the day-today tasks of balancing the books. And all too often, finance thinks they know what their customers want, but customers think that finance is isolated, secretive, and bureaucratic. The hospital finance department needs a makeover. To transition into the role of valued business partner and financial expert, finance needs to reinvent itself by:
Simplifying the flow of, and expand access to, information
Repositioning financial analysts as experts
Understanding what customers value
Learn how these straightforward business practices can support operations in their outcomes improvement efforts, and ultimately benefit the entire healthcare organization.
Translation and Transcription Process | Medical Transcription Service Company amar519
Translation and Transcription Process System information. Medical Transcription Service Company. Affordable transcription and accurate translation services
The Impact of Duplicate Medical Records and Overlays on the Healthcare Industry RightPatient®
Duplicate medical records and overlays continue to be two pressing issues for the healthcare industry as we usher in the age of electronic medical records, health information exchanges, and integrated delivery networks. Although these two issues can seriously jeopardize patient safety, increase the likelihood of unnecessary treatments and a misdiagnosis, raise the cost of care, and have a detrimental effect on the revenue cycle for medical facilities, they are different in size and scope and until only recently, have not been getting the attention they deserve from C-level executives.
Healthcare and similar industries have stringent regulations and requirements when managing patient records and documents. Learn how you should handle these files and the proper ways to destroy them when their retention periods are up. For additional information, check out www.shrednations.com.
Voice & Speech Recognition Technology in HealthcareCaroline Macleod
Can Hands-Free Voice/Speech Recognition in Home Care, Care Homes and Community settings bridge the gap between increased clinical efficiency and enhanced patient-led care? Learn more about voice technology solutions that enable clinical data to become potentially accessible through integrated computer networks for the purposes of improving health outcomes for patients and creating efficiencies for health professionals. Language (Voice Recognition) technologies hold the potential for making information easier to understand and access.
Medical Transcription is a process of converting physician dictated audio into text format. Physician dictation would include any type of medical treatment, procedure, diagnosis etc.
These documents should be recorded into patient’s permanent medical record.
Lecture 17 ethical issues in medical reports, sick-leaves & medical rec...Dr Ghaiath Hussein
A talk delivered by Dr Ghaiath Hussein for 3rd-year medical students at Alfarabi Medical College about the ethical issues in filling of documents related to the clinical condition of the patient.
A complete medical record will have a patient information form, medical history, physical examination, consent form, nursing records, doctor’s orders and progress reports, and more.
Navigating the Health Insurance Market_ Understanding Trends and Options.pdfEnterprise Wired
From navigating policy options to staying informed about industry trends, this comprehensive guide explores everything you need to know about the health insurance market.
Welcome to Secret Tantric, London’s finest VIP Massage agency. Since we first opened our doors, we have provided the ultimate erotic massage experience to innumerable clients, each one searching for the very best sensual massage in London. We come by this reputation honestly with a dynamic team of the city’s most beautiful masseuses.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
2. WHAT IS MEDICAL RECORD ?
The medical record is a legal document providing a chronicle of a
patient's medical history and care. Physicians, nurse practitioners,
nurses and other members of the health care team may make
entries in the medical record.
The medical record includes a variety of types of "notes" entered
over time by health care professionals, recording observations and
administration of drugs and therapies, orders for the administration
of drugs and therapies, test results, x-rays, reports, etc.
3. USE OF MEDICAL RECORDS
• To document the course of patient’s illness
& treatment.
• Communicate between attending doctors
and other health Care professional
providing care to the patient
• Collection of health Statistics.
• Legal Matters & Court Cases
• Insurances Cases
4. COMPONENTS OF MEDICAL RECORD
Front Sheet or identification Summary Sheet
Consent for Treatment
Legal Documents like referral letter, request for Information etc
Discharge Summary, referral slip
Admission notes, clinical progress notes, Nurses progress note
Operation report if operation has been performed
Investigation reports like, X-ray, pathology etc
Orders for treatment and medication forms listing daily medications ordered and given
with signatures of the doctor prescribing the treatment and the nurse administering
it
5. LABELING OF MEDICAL RECORD FOLDER
The following should be written on the medical
record folder:
Patient’s name;
Patient's medical record number
Year of last attendance
6. ISSUE OF MEDICAL RECORD NUMBER / UID
NUMBER
Medical Record Numbering Systems are
HOW WE GIVE A NUMBER to Medical
Records.
The MRN should be issued in straight numerical order
from the NUMBER REGISTER commencing with the
number 1. For example, if the last number given to a
patient were 342, the number issued to the next patient
would be 343 and the next 344 and so on.
Manual
System
In a Computerized System, UID / MR Number is
auto generated and there is OPD visit number &
IPD Visit Number
UID Number is permanent
but OPD Visit number/ IPD
number may change
7. FUNCTIONS OF MEDICAL RECORD
DEPARTMENT
• Filing of Medical records.
• Retrieval of medical records for patient care and other
authorized use.
• Completion of medical records after an inpatient has
been discharged or died.
• Coding diseases and operations of patients discharged
or having died
• Evaluation of the Medical Record Service.
• Completion of monthly and annual statistics.
• Medico-legal issues relating to the release of patient
information and other legal matters.
8. RECEIVE OF PATIENT RECORD IN MRD
A list of patient records is
prepared & given to MRD with
patient case Sheet
Checking
of
Records
Yes NO
MRO conveys to the
Nursing unit In-charge for
the same & returns the
record
After sorting of records,
details are written in the
Death register, patient
record register as per the
case sheets
MRD is filed in
cabinets/racks
after labeling
Nursing Unit keeps
the patient record
after the discharge
of the patient
9. RETRIEVE OF PATIENT RECORD
Retrieve form is
filled up by
concerned
person.
After approval from MS,
given to MRO.
MRO gives the person
the record in duplicate &
notes down the number
of pages in the form &
takes signature
After giving the record
back, the person signs on
that form.
• The treating consultants and the other
clinical doctors are authorized to have
access to the discharged inpatient
health record charts
• The non–clinical doctors and other
administrative staff can access the
charts with the written approval of the
Medical Superintendent
• In all MLC and death cases the
Medical Superintendent’s written
permission is a must to access them
• Concerned person from outside
should get written approval from
Patient in order to get the patient
record
• In Insurance cases, the release of
such information without the prior
consent of the patient is permissible
because the patient had waived his
claim of this privilege at the time of
taking out a policy with the
corporation.
10. SEQUENCE OF MEDICAL RECORD
• Information & identification sheet
• Clinical Notes
• Diagnostic reports
• Blood Transfusion notes
• Nurse Notes
• Informed Consent
X-ray Films are stored Separately
11. COMPLETION OF MEDICAL RECORDS
• The consent form for treatment has been signed by the patient;
• Patient identification details (name and medical record number) are correct and entered on all forms
• Doctors have recorded all essential information
• Doctors have signed and dated all clinical entries
• The front sheet has been completed and signed by the attending doctor
• Nurses have recorded and signed all daily notes regarding the condition and care of the patient;
• All the orders for treatment have been recorded in the medication form and signed;
• Medication administration has been recorded and signed
• The anesthetic form (if any) has been completed and signed
• The operation form (if any) has been completed and signed
• The main condition/principle diagnosis has been recorded on the front sheet
• Operations and/or procedures have been recorded on the front sheet
• Diagnostic reports have been attached
• Discharge/referral summary is duly filled and signed.
12. RELEASE OF INFORMATION IN MLC
CASE/COURT
• Requests from lawyers are usually registered and date of receipt of request
recorded by the hospital administration and forwarded to the MRO for
processing.
• The medical record is located and the patient's signature checked against the
signature on the consent form in the medical record.
• The information requested is identified and the attending doctor is asked to
write a report. A pre-designed form may be used (see example) or if a
discharge summary is already in the medical record, it is checked and if it
includes all the requested information, a copy is made. This will save the
doctor having to write a new report.
• The MRO may write a brief letter acknowledging the request and enclosing
the doctor's report. In some hospitals, a "With Compliments" slip is used
instead of a letter from the MRO.
• The letter (or "With Compliments" slip), report and account (if required) are
sent to the lawyer and a copy of each document is filed in the
correspondence section of the medical record.
• The MRO notifies the hospital administration that the report has been sent.
13. PREPARING A MEDICAL RECORD FOR COURT
• On receipt of a subpoena, the MRO records the date and time the subpoena was
received and records in a diary the date and time the medical record is due in court.
• The MRO should notify the attending doctor and hospital administration that a subpoena
has been received for the release of the medical record to court
• The MRO should locate the medical record. If the medical record is not on file, the MRO
should find it and keep it in a safe place awaiting preparation for court. A tracer is made
out showing that the medical record is with the MRO for medico-legal purposes
• The MRO should check that all necessary information, as specified in the subpoena, is in
the medical record and that it is complete.
• Medical record is given in Duplicate and page numbers are written on the case sheets.
• When the original medical record is returned to file, the copy is removed from file and
destroyed. To protect the privacy of the patient, it is important that if a medical record is
copied, the copy MUST be treated with the same respect as the original and MUST be
destroyed on return from court. These steps apply to original and photocopied medical
records
14. RETENTION OF MEDICAL RECORDS
• Usually records are retention policy of the records depending upon the space
availability within the Hospital, but every hospital more or less maintain
OPD records – 5 years
IPD records- 10 years
MLC cases – 30 years
• As per Forensic Department of India
– Where there is chance of litigation arising for medical purpose of negligence, record should be
preserved for at least 25 years, especially because there are rules where the minors have the
rights to sue the doctor within three years from the date of majority, for the injuries sustained due to
negligence of the doctor during the period of his minority.
– Other medico legally important records should be preserved upto 10 years after which they can be
destroyed after making index and recording summary of the case.
– Routine cases records may be preserved upto 6years after completion of treatment and upto 3
years after death of the patient.
– 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
15. Monitoring & Audit of Medical Records
• Medical Record Committee is 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 officer
• Responsibilities
– Review of medical records to ensure that they are accurate, clinically pertinent, Complete and readily
available for continuing patient care, medico-legal requirements, and medical research;
– Ensure that medical staff complete all the medical records of patients under their care by recording a
discharge diagnosis and writing a discharge summary (where required) for each discharged patient
within a specified period of time;
– Determine the standards and policies for the medical record and the medical record services of the
health care facility;
– Recommend action when problems arise in relation to medical records and the medical record
service;
– Determine the format of the medical record and approve and control the introduction of new medical
record forms used in the health care facility (all forms should be cleared by the Medical Record
Committee before being put into use)
– Assist and support the MRO in liaising with other staff/departments in the health care facility.
16. RESPONSIBILITY OF MEDICAL RECORD
OFFICER
• Management of Medical Record Department (including Central
Admitting and Enquiry Office)
• Development, analysis and technical evaluation of clinical
records
• Development of secondary records (ie indexes of various types)
• Preservation of medical records
• Development of statistics
• Assistance to the Medical Staff
• Co-operation with all other departments in the matter of records
• Pest Control measures at equal Intervals
17. QUALITY INDICATORS OF MEDICAL
RECORD DEPARTMENT
• Are medical records filed promptly?
• Is the file room clean and tidy?
• Are Master Patient Index cards filed promptly? An MRO checks the
information on records with a doctor.
• Are all discharges returned to the Medical Record Department the day
after discharge?
• Are the Medical Records Complete
• Are medical record forms filed in the correct order?
• Are all medical records completed within a specified time after discharge?
• Are medical records coded correctly?
• Are all discharges for last month coded by the middle of the next month?
• Are the monthly and yearly statistics collected within a specified time?
18. INFRASTRUCTURE REQUIREMENT FOR MRD
• Usually the space allocated for MRD is 1m2/ bed but depends on level
of computerization