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Organization of Medical Record

The document summarizes the organization and importance of medical records in a hospital setting. It discusses the components and flow of medical records, as well as the roles and responsibilities of the medical records department. Key points include that the medical record documents patient care for clinical, legal, and administrative purposes. It outlines the various sections that make up a medical record and how the records move from registration to the central filing unit.

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ORGANIZATION OF MEDICAL RECORD DR.N.C.DAS
RECORD AND MEDICAL RECORD RECORD is a inscripted information (regardless of physical format) that can be retrieved at any time. It includes all original documents, letters, photographs, books, blueprints, sound & video recordings and electronic data. MEDICAL RECOED : The medical record is a clinical, scientific, administrative, & legal document relating to patient care It records sufficient data written in the sequence of events to identify and locate the patient and justify the diagnosis, the treatment given and the final outcome. MRD is also known as Central admission office.
ORGANIZATION OF MEDICAL RECORD The medical record is a scientifically clinical, administrative and legal document relating to patient care services. The record contains statements of trained observes regarding the patient history, physical condition, investigations, line of treatment, daily progress and discharge/ death summary. It provides the adequacy, quality and quantity of care provided to a indoor patients. The hospital is the sale owner of the medical record, which is confidential and can only be given to the patient/ spouse or in court of law by order.
HISTORY 1 ST MRD was est. in 1667 at St.Barthlomew’s hospital in England. 2 nd MRD in 1752 at Pennsylvania hospital in USA In 1925 scientific vision of MRD started by American college of surgeons & physicians. In India: 1946- Bhore’s committee 1962- Mudaliar committee Health & Hospital review committee (jain & Rao committee)
IMPORTANCE OF MEDICAL RECORD MEDICAL RECORD FOR THE PATIENT FOR THE DOCTOR MEDICOLEGAL RESEARCH & TRAINING HOSPITAL Documentation of clinical history Continuity of treatment Claiming Insurances Issue of Med. Certificate Legal Evidence Medical review of treatment Research & publication Assist in legal proceedings For claiming insurance and tax benefit Malpractices and negligence Evidence in Court of Law Certification of Birth & Death Certification of Mental Status Certification of Invalid Pension -CPA -RTI - Education & Training -Clinical, Epidemiological Research -Health System Research Quality, quantity and adequacy of treatment Medical Audit Future Planning & decision making Administration & Management Medico legal Protection Disease Surveillance Epidemiological Studies
MEDICO LEGAL RECORD To meet the legal requirements & avoid complications, medical record must fulfil the following criteria:
MEDICO LEGAL EVIDENCE Hospital medical records is a documentary evidence as per the Indian Evidence Act, 1872 , as amended up to August 1, 1952 & 1961 and medical records are generally summon to the court of law in the following types of cases in our country. Insurance Cases Death or Injury caused due to compromise of safety.. Workmen’s Compensation Cases Personal Injury Suits in case of doctors negligence. Malpractice Suits againt hospital The Income Tax Act: for claiming rebate. Criminal Cases. Medico legal case sheet. Evidence in the Court of Law. RTI Claims under CPA Age verification as order by court.. Regd. Of Birth and Death.
COMPONENTS OF MEDICAL RECORD COMPONENTS IDENTIFICATION SHEET OBSTETRIC RECORD BABY NOTES INVESTIGATION RECORDS DEATH/ DISCHARGE SUMMARY CLINICAL RECORDS DOCTOR’S ADVISE & TREATMENT SHEET NURSING RECORDS Name, Address, Age, Sex, Religion, Admission No. & date, Prov. diagnosis History, Physical Examination, Observation Operation Note, Progress & Referral - Temperature, B.P, Pulse - Fluid in take/ loss
DATA OBTAINED FROM MEDICAL RECORD DATA DISCHARGE ANALYSIS EPIDEMIOLOGICAL INFORMATION Daily Census, Discharge, Death Length of stay, Bed occupancy/ turn over Operations, Morbidity Rate, Complication Age, Sex, Geographic Distribution Investigations and Autopsies Targets and Achievements Medico legal Cases Incidence and Prevalence Disease Specific Deaths Hospital Case/ work load Communicable Disease Vital Statistics Disease Surveillance Modifiable Disease
ORGANIZATION OF MEDICAL RECORD DEPARTMENT MRD PERIPHERAL UNIT CENTRAL UNIT Admission office Inquiry Medical census Medical record Office
FLOW OF MEDICAL RECORDS The Medical Record Department has two units and flow of record is from peripheral to Central Unit. MR DEPARTMENT PERIPHERAL UNIT OPD REGISTRATION EMERGENCY REGISTRATION INQUIRY & CENTRAL ADMITTING OFFICE ADMISSION CHECK DESK WARD WARD CENSUS DESK CENTRAL UNIT MRD ASSEMBLY & DEFFICIENCY CHECK INCOMPLETE RECORD DESK ADMISSION DISCHARGE ANALYSIS CODEING & INDEXING FILLING M.R LIBRARY
ORGANIZATION OF MEDICAL RECORD DEPARTMENT MRD ORGANOGRAM SIZE FUNCTIONS STAFFING LOCATION
ORGANOGRAM MEDICAL SUPERINTENDENT MEDICAL RECORD COMMITTEE OFFICER- IN CHARGE-MRD MEDICAL RECORD OFFICER PERIPHERAL UNIT REGISTRATION COUNTER CLERK INQUIRY & CENTRAL ADMISSION OFFICE CLERK ADMISSION CHECK DESK CLERK CENSUS DESK CLERK CENTRAL UNIT MRD ASSEMBLY & DEFFICIENCY CHECK TECHNICIAN INCOMPLETE RECORD DESK ASSISTANT ADMISSION & DISHARGE ANALYSIS TECHNICIAN CODEING & INDEXING TECH. M.R LIBRARY ASSISTANT
SIZE AND LOCATION Peripheral Unit is situated in OPD/ Emergency and functions round the clock. Central Unit should be close to indoor but with adequate space. OPD Registration Counter must have several cubicles 40” x 20” along with work table, file drawer, chair, file cabinets. Central admitting office round the clock functioning, some furniture's, index card and index board 200 to 250 sq ft area. Medical Record Department 250 beds - 600-700 sq ft 500 beds - 1200 sq ft
PHYSICAL FACILITIES Location - near main entrance in close proximity with OPD & Emergency Admission & enquiry space- 125 -175 sq.ft Space - medical record office for 50beddedHospital175sq.ft , medical record office for 100, bedded Hospital 240sq.ft medical record office for 200 & > bedded Hospital 500sq.ft medical record office for 500 bedded hospital 1200sq.ft Storage - 120-500sq.ft with shelving. Retaintion Schedule OPD -5yrs IPD -10yrs MLC -lifelong
STAFFING The average staffing for 250 beds and 500 beds hospital should be as under. 25% for leave reserve extra. S.NO. MANPOWER 250 BEDS 500 BEDS 1000 BEDS 1. MRO ONE ONE ONE 2. M.R Technician 4 6 8 3. M.R Assistant 4 6 8 4. Census Staff 3 6 10 5. Admission Clerk 2 4 10 6. Helping Staff 2 3 5
MEDICAL RECORD COMMITTEE (AUDIT) Additional Medical Superintendent - Chairman Officer- In- charge - Member Nursing Superintendent - Member HOD Surgery/ Medicine - Member Medical Record Officer - Member Secretary Term : The term of the committee is two years. Meeting : The committee to meet once a month and minutes circulated to different departments. Function : Training policies & procedures for medical record Examine adequacy, quality and quantity of patient care.
MEDICAL RECORD OFFICER Members Secretary of Medical Audit Committee. Safe Custody of Medical Record. Preparation and of various components of medical records and distribute to all departments. Ensures coding and indexing according ICD-10. Training of sub-ordinate staff. Annual Statistical Report/ Bulletin. Supplying various information on demand. Assists in researches and projects.
FUNCTIONS OF MRD FUNCTIONS CUSTODY OF MED. RECORDS MEDICO LEGAL SUPPORT PREPARATION OF MONTHLY & YEARLY BULLETINS NOTIFICATION OF BIRTH & DEATH ASSISTANCE IN RESEARCH NOTIFICATION OF INFECTIOUS DISEASES DISEASE SURVEILLANCE ATTENDING COURT SUMMONS
RESPONSIBILITY OF VARIOUS UNITS OF MRD A. REGISTRATION UNIT - Maintenance of registration counters in OPD and Emergency . CENTRAL ADMISSION DESK Round the clock functioning as inquiry office. All admission to the hospital indoor. Preparation of case sheet and administration record. ADMISSION CHECK DESK Checks the completeness of identification. Data of patient, admission unit/ ward and bed number. Maintains admission index for facilitating relatives and visitors. Issue of visitors pass and tally number of admissions. CENSUS DESK - Collection of daily census and discharge/ death case sheets from various wards. ASSEMBLY AND DEFFICIENCY CHECK Receives all case records from census desk. Assemble the sheets in order as per list, stapled and tagged. Marks deficiency in check list. Sends complete records to analysis desk. Incomplete records to incomplete record desk.
INCOMPLETE RECORD CONTROL DESK Sends reminder to doctors to complete case record. Prepare index card of discharged patients. Sends index card to admission check desk. Completed records to analysis desk. G. ADMISSION DISCHARGE ANALYSIS Admission and discharge analysis, disease and unit wise, age, sex wise. Prepare daily, weekly, monthly, quarterly and annual statistical report . H. CODING AND INDEXING Coding is done for disease and operation as per ICD-10 coding. Indexing is done on specially designed index card. I. FILING Final check for completing process. Place records on folders and stored in file cabinets. Maintenance of record of withdrawal and reminder for return. STORAGE - All records are kept in cabinet month wise and disease wise for easy retrieval .
FILE RETRIEVAL When patient attends follow-up For research & academic purposes For medical reimbursement For producing in court of law for medico-legal purposes.
CONSTRAINTS AND REMADIES Medical records has to be kept for 10 years. Huge space is required. Retrieval of record is a difficult task. Better methods for record keeping are a) Microfilming b) Magnetic Disk Storage c) Digitalization of Medical Records d) Computerization and Networking Factors considered for effective filing system: Accessibility for speedy location & identification Compactness Economical Elasticity Tracer system
MICROFILMING OF MEDICAL RECORDS Space saving Easy accessibility Safe preservation Elimination of misfiring Saves time & manpower Clean & easy handling
COMPUTERIZED MEDICAL RECORDS Retrieve demographic information and consultants report, as well as laboratory, radiology and other tests. Improve productivity & quality. Reduce cost. Allow an interactive computer assisted diagnosis & treatment. Generate reminders for follow-up testing Aid in standardizing treatment protocols
OWNERSHIP OF RECORDS The medical record is the property of the hospital & not of the patient, the clinical department or the attending doctor. The medical record must be considered from two points of view: As a personal document As a impersonal document: For education, research & information.
CONFIDENTIALITY/RELEASE OF PATIENT INFORMATION 1.There is vital need to maintain patient information in a confidential manner. Patient information shall not be released without legal authorization. 2.Hospital employees, physicians, and students are expected to control the informal transmission of confidential nature. 3.Sensitive information concerning personnel and management issues shall be maintained in the strictest of confidence and shall be utilized only by those individuals legally authorized to review and act on such information.
CONFIDENTIALITY OF MEDICAL RECORD System employees pledge to keep medical record information confidential and to respect privacy. A medical record or information contained in a medical record should be released only if: i)A valid written consent for the release of this information is obtained from the patient or legally authorized representative. ii)Reporting is required or permitted by law.
WHO CAN SEEK ACCESS TO HEALTH INFORMATION? i)Patient himself ii)Family Physician iii)A person can seek access to information on behalf of someone else: *authorized person by the Patient. iv)In case of death *Authorized representative of family/ **Legal representative of the deceased. ***Court of Law.
ROLE OF STAFF MAINTAINING CONFIDENTIALITY Medical record department personal are advised to: i)Acknowledge request for health information promptly ii)Maintain integrity of records iii)Take reasonable steps to confirm the identity of the person seeking the information iv)Assess the information to determine whether access to it must or may be denied .
Hospital Administration Made Easy http//hospiad.blogspot.com An effort solely to help students and aspirants in their attempt to become a successful Hospital Administrator. hospi ad DR. N. C. DAS