This document outlines the purposes and policies around records and reports maintained in hospitals. It discusses: 1) The definition of medical records as clinical, scientific, administrative, and legal documents that justify a patient's diagnosis and treatment. 2) The purposes of medical records which include studying patients, avoiding omissions, ensuring continuity of care, serving as legal evidence, and providing insurance information. 3) Hospital policies for medical records including documenting employee work, evaluating medical staff performance, and aiding future planning.

1. Records and reports
maintained in the hospital

3. DEFINITION:-
It is the clinical ,scientific, administrative and legal document related to
the patient care, which is recorded with sufficient data, written in a
sequence to justify the diagnosis and treatment.

4. PURPOSES:-
1. Study about the patient and his or her activities.
2. Helps to avoid omission and repetition.
3. Continuity of care.
4. Serves as legal evidence.
5. Provide necessary information about insurance and health schemes.

5. IN HOSPITAL:-
1. To document the type of work which is assigned to the employs.
2. To have the proof of the type and quality of care rendered to the patient.
3. To evaluate the proficiency of medical staffs.
4. To evaluate the norms and standards(rules and regulations).
5. To keep the document of staffing pattern, performance, needs, budget preparation and
justification.
6. to assist in future programme planning.
RESEARCH:-
1. Recorded observation are the basis for all clinical research.
2. Group study of records by the medical staff serve to ferther the education of health
personnel.
3. Medical records supply pertinent data for use by public health authorities in control of
diseases.

6. RIGHTS:-
1. Referred patient.
2. To evaluate whether complete care and treatment is given or not.
3. Financial settlement.
4. Medical record contain vital information that protect the legal issues of the
patient, physician and the hospital.
5. Education for medical faculty, case study.
6. It helps in research.
7. To understand epidemiology, communicable and non communicable diseases.
8. For improving present service and planning future services.

7. POLICIES
• Made by medical record committee – the medical staff , nursing services, medical record
department and administration.
• It should be written in a book and each and every person should be aware of their responsibility.
• No policy shall be changed or discontinued.
• Quarterly meeting of committee members .
• Confidentiality – don’t reveal without written consent except following circumstances-
1. Attending doctors may be given information regarding former treatment by another doctor.
2. Other hospital in which patient is undergoing the treatment.
3. Bedside clinic.
4. When court demand for the records.

8. • Availability:-
1. No medical record should be removed without the permission of medical director.
2. If patient want information he or she can consult HOD of that particular department.
3. Should not reviewed to employee of other department.
 History collection and physical examination should be done and recorded after patient
admission.
 Doctors order should be written and signed.
 No surgery should begin until and unless HC and PE is not done.
 OT forms should be completed on the day of surgery by the surgeon.
 When the patient is about to discharge the doctors should record the final notes and
discharge summary within 1 week.
 If it is delayed beyond 30 days it becomes a legal issue.

9.  Admitting officer should be located near the OPD to refer the patient to his
department.
 Officer should have current knowledge about the beds in his ward.
 He has to follow the written policy before the patient is shifted to the ward.
 Allot patient to respected unit.
 Alphabetically arrange all the record in the file.
 Officers should have blank clinical records/stock.

10.  5 × 8 inch card.
 When old patient come back they directly go to clinical
department so the records should be maintained in
alphabetically order along with OPD cards in the
department.
 All these are beneficial for the patients only.
 Causality records should be given special attention in
relation to the legal aspects.

11. EXAMPLES
1. Patient has no history of suicide.
2. Patient refused an autopsy.
3. Patient had anorexia for lunch.
4. Patient is numb for her toes down.
HOW LONG THE RECORDS ARE TO BE PRESERVED:-
• Active case – 5 years
• Old cases – 10 years
• Medicolegal cases – 10 years
As per the rule of the state/ central government.