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ROLE & IMPORTANCE OF
MEDICAL RECORDS
C.Govindarajan
Chief Medical Records Officer
&
President, Health Records Association of INDIA
Location & Days and Hours of Operation
• The Medical Records Department should be located
adjacent to the Front Office
• The Medical Record department have to function 24 hours
on all the days to cater the Medical Records immediately.
About MRD
– Bridges the gap between medical and non-medical departments.
– Enables continuity of care to the patients without difficulty at
appropriate time
– Headed by MS has skilled persons termed as Medical Record
Technicians and others
– Governed by the Medical Records Committee
– For the department to function efficiently the medical record must
be Accurate, Complete, and Timely. Of course, the caregivers
shall Legibly write it.
– Primary role is safe guarding the records and to issue them on
demand
Guiding Principles of the Department
• The hospital shall maintain an adequate medical record for every
individual who is evaluated or treated as an inpatient, outpatient, or
emergency patient, which shall be documented accurately with all
significant clinical and other information in a timely manner.
• The medical record shall be readily accessible for providing
continuing patient care by medical and other staff, and permit
retrieval of information for medical education, research, quality
assurance activities, and statistical data
Source: Medical Records Manual, WHO
CODE OF ETHICS
MEDICAL STAFF
• Bound by Professional Secrecy and Oath
PARAMEDICAL STAFF
• MEDICAL RECORD PROFESSIONALS, NURSES,
OTHER PARA MEDICAL STAFF TO MAINTAIN.
• Confidentiality about patients, disease, treatment & end results.
• Not to divulge any type of information about patients.
• Abides by Ethical principles.
What is a medical record ?
• It is a document containing sufficient data written in sequences of
events to justify the diagnosis, and warrant the treatment given and
the end results.
Importance of medical record:
• Contributes professional care rendered to the patient.
• Reflect the quality care rendered by the institution.
Differentiation of the medical record:
• In-patient record.
• Out-patient record.
• Emergency record
What are the uses of Medical Records?
– The Medical Record is useful to the Patient for his/her further
treatment.
follow-up and
– The Medical Record safeguard the Physicians and Surgeons from the
integrity.
– The Medical Record is useful for Teaching for Postgraduates and
undergraduates.
– The Medical Record is useful for Research purpose
– The Medical Record is useful for the Health Programme for controlling the
epidemic diseases.
– The Medical Record is useful to the Administrator to manage the Hospital and
use this as yardstick for controlling the Hospital.
HOSPITAL STATISTICS
•
•
•
•
•
•
PROOF OF WORK DONE
FOR CURRENT AND FUTURE PLANNING
DISEASE /PROCEDURE INCIDENCES
OUT PATIENT TURN OUT
BED OCCUPANCY RATE
AVERAGE LENGTH OF STAY
• DEATH RATE
– DEATHS UNDER 48 hrs.
– DEATHS MORE THAN 48 hrs.
Registration counter
Consultants
O.P
I.P
Admission
Indexing
Computer entry
Wards
Deficiency check
and coding
Scanning
Medical records
Assembling
Permanent filing
In-patient records:
Assembling format:
The arrangement of medical records takes place in the
following order:
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
SUMMARY SHEET& ADMISSION RECORD,
DISCHARGE SUMMARY
HISTORY OF FINDINGS
CONSULTATION REQUEST
LAB & ECG REPORTS
ANESTHESIA CHARTS
OPERATION NOTES
PROGRESS SHEETS
DOCTORS ORDERS
ICCU CHARTS
CONSENT FORMS
NURSES CHARTS
CLINICAL CHARTS
DRUG CHARTS
IV FLUID CHARTS
OTHER AUTOPSY
BIOPSY REPORTS AND OTHER HOSPITAL REPORTS.
Medical Records Committee Members
• Medical Superintendent (Convener)
• Three Sr.Consultants (various specialties)
• Administrator
• HOD – Medical Records Department
• HOD - Quality Systems
• Nursing Superintendent / Representative
• HOD – OP/IP Services.
INTERNATIONAL CLASSIFICATION OF
DISEASES
INTRODUCTION
Classification of diseases and operations is one of the most
important functions of the medical record department. A wellorganized medical record department selects one of the best suited
International Classification Systems to code and index diseases and
operations for the collection of morbidity and mortality information.
The International Conference for the Tenth revision of the
International Classification of Diseases was convened by the World
Health Organization at WHO headquarters in Geneva from 26
September to 2 October 1989. The conference was attended by
delegates from 43 member states
ICD 10TH REVISION BY WORLD HEALTH
ORGANIZATION
Volume 1
Introduction
WHO Collaborating Centers for Classification of Diseases
Report of the International Conference for the Tenth Revision
List of three-character categories
Tabular list of inclusions and four-character
subcategories
Morphology of neoplasm's
Special tabulation lists for mortality and morbidity
Definitions
Regulations
Volume 2
Instruction manual
Volume 3
Alphabetical index
CHAPTERS OF ICD – 10TH REVISION
(21 Chapters)
I
II
III
IV
V
VI
VII
VIII
IX
X
XI
XII
XIII
XIV
XV
XVI
XVII
XVIII
XIX
XX
XXI
Certain infectious and parasitic diseases
Neoplasm's
Diseases of the blood and blood-forming organs and certain disorders involving the
immune mechanism
Endocrine, nutritional and metabolic diseases
Mental and behavioural disorders
Diseases of the nervous system
Diseases of the eye and adnexa
Diseases of the ear and mastoid process
Diseases of the circulatory system
Diseases of the respiratory system
Diseases of the digestive system
Diseases of the skin and subcutaneous tissue
Diseases of the musculoskeletal system and connective tissue
Diseases of the genitourinary system
Pregnancy, childbirth and the puerperium
Certain conditions originating in the prenatal period
Congenital malformations, deformations and chromosomal abnormalities
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
Injury, poisoning and certain other consequences of external causes
External causes of morbidity and mortality
Factors influencing health status and contact with health services
Indexing of patients data
• Disease & operation indexes are maintained separately. A physician
or a medical staff can use these index for the following purposes.
• Review cases of disease to provide the management a scenario of
current health problems.
• Compose data on diseases in order to prepare scientific papers.
• Procure data on the utilization of hospital facilities and increase the
needs such as equipments and beds.
• Evaluate the quality of care in the hospital.
• Providing patient care data for committees.
• Data on the medical practice in the hospital.
• Data on the Drug Trail for research.
FEW EXAMPLES
DIAGNOSIS
1.DIABETES MELLITUS
2.ACUTE MYOCARDIAL INFARCTION
3.ABORTION (Attempted Failed)
4.AMOEBIC ABSCESS
5.IRON DEFICIENCY ANAEMIA
6.CALCULUS KIDNEY
7.CANCER BREAST
8.CANCER LIVER
9.CANCER LUNG
10.SPRAIN (JOINT)
11.ULCER STOMACH
CODE NO.
-
E14
I 21.9
O07.9
A06.4
D50.9
N20.0
C50.9
C22.9
C34.9
T14.3
K25.9
Numbering System - MRD
 The unit numbering system may be followed .
 It provides a unit record which is a composite of all IP& OP
data on a given patient.
 When first registered in the hospital the patient is assigned
a number which remains same for all his subsequent
visits.
 His entire medical record is in one folder under one
hospital number i.e. the number first registered in the
hospital.
Filing system
The terminal filing system may be followed
– The first two digits are tertiary,
– the next two are secondary & the last two are primary.
– The primary digit remains constant. Eg 127,227,327,427.
– Each staff may be assigned responsibility for certain section of
files.
– This eliminates confusion and one person cannot blame the
other.
– Also, misfiling can be reduced in this case.
Quality Policy
• Medical record documents shall be treated as confidential, secure,
current, authenticated, legible, and complete
• Medical Records Department shall be provided with adequate
direction, staffing, and facilities to perform all recognized functions
Quality Objectives
•To provide medical records within -- minutes of request for the
patient care.
• To provide timely intimation of birth & death to the statutory board.
•To provide timely intimation of Infectious and Notifiable diseases.
•To minimize the deficiency in the Medical Records
Response Time for Record
Retrivel & Despatch
30
25
25
25
25
25
25
25
25
20
20
25
25
25
25
20
17
15
25
17
17
17
17
13
17
17
17
13
10
5
0
Jan
Feb
Mar
Apr
May
Jun
July
Bench Mark Value (25Min)
Aug
Sep
Oct
Mean Time
Nov
Dec
AVERAGE BIRTH REPORTING TIME
25
20
AVERAGE
DAYS
15
21
21 21
21 21
21
21 21
21 21 21 21
10
5
2
2
2
2
2
2
2
2
2
2
2
2
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
MONTH
Standard Days
Average Reporting Days
AVERAGE DEATH REPORTING TIME
25
20
AVERAGE
DAYS 15
21
21
21
7
7
7
21 21
21
21
21
21 21
21
21
5
5
10
5
5
5
5
5
5
5
5
0
Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec
MONTH
Standard Days
Average Reporting Days
IP DEFICIENCY
MONTH
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
NO. OF PATIENTS DISCHARGED
TOTAL NO IP DEF
PERCENTAGE
3011
3029
3258
3263
3493
3173
3727
3556
3441
3574
3351
3300
811
765
884
900
959
874
712
691
319
295
480
335
26.93
25.25
27.13
27.58
27.45
27.54
19.10
19.43
9.27
8.25
14.32
10.15
3727
4000
3258
3500
3011
3029
811
765
3263
3556
3493
3441
3574
3351
3173
3300
3000
2500
2000
1500
1000
884
900
959
874
712
691
319
500
26.93
25.25
27.13
27.58
27.45
27.54
19.10
0
JAN
FEB
MAR
APR
MAY
JUN
JUL
19.43
AUG
9.27
SEP
295
8.25
OCT
480
14.32
NOV
335
10.15
DEC
Birth and death certificates:
• Birth to be reported to the corporation within 21 days.
•
Death to be reported to the corporation within 21 days.
After the stipulated time:
•
Up to 1 month: Rs 5/- as penalty.
•
1 month- 1 yr: Rs 10/- as penalty +letter to the Assistant Revenue Officer with
notary public(affidavit) + hospital covering letter signed by medical
superintendent.
•
After 1 yr: Rs 15/- as penalty +magistrate order +covering letter signed by the
Medical Superintendent
.
Out-patient records
Retrieval area
•
According to the appointments the Record no. is sent on line in the system and
also informed for walking patients by the respective concerned secretaries over
the intercom.
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They are entered in the retrieval register along with the consultant name.
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The records are then pulled out from the filing areas and to be sent for dispatch
within 15 minutes.(International benchmark –45Min).
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The records that are to be dispatched through confidential Bag and given to the
secretaries and an acknowledgement is taken with employee number from them
in the dispatch register.
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This plays a vital role in finding the missing record from the consultation areas.
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Care should be taken while filing so that misfiling is avoided and also for prompt
delivery of the records the next time patient visits the hospital.
Tracer card
• The tracer card plays a very vital role in the filing area.
• It contains the RECORD NO, CONSULTANTS NAME
AND THE DATE OF RETREIVAL.
• The cardial rule in the filing area is that no record can be removed from
rack without being replaced by a tracer card or a tracer card with the
requisition(IP).
• This rule applies not only to extra departmental staff but to the
employees of MRD.
Census
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In patient census:
The number of In-patients at any time.
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Daily In-patient census:
The number of In-patient days of the patients who are both admitted
& discharged after the census taking time of the previous day.
This census is sent to the top management.
•
Average daily census:
The average number of IP present each day for a given period
of time. Medical Record usually compile the census and send it to
top management. This census is usually taken at midnight.
This census should always comparing with the previous year.
Medical Records Department
Daily Statistical Report of Patients
DATE
Descriptions
31.12.2009
Today
Month
To Date
31.12.2008
Year
To Date
Financial
Year
Same Day
Last year
MTD
Last year
YTD
Last year
Registrations
Admissions
Emg Admission
Discharges
Birth
Deaths
Census
Occupancy
Friday
Thursday
Financial
Last Year
Medico legal cases
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Suicide, accident, quarrel, fights, cuts, tablet poisoning, over dosage of drugs,
suspected case of EMO (patient dies on the way)).
•
In these cases the medical officer creates an Accident Report (AR) copy & the police
is intimated.
MLC ordinary Cases
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AR Report. (Accident Register Report)
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Police intimation.(informed by the security) to the Police station.
MLC death cases:
•
Original death certificate, death summary( if required photocopy of history, progress
sheet and operation notes.)
•
The above documents are handed over to the Security Officer which in turn sent to the
police along with body for post mortem
Wound certificate:
•
This occurs in MLC cases.
•
The case is first attended by the casualty medical officer (CMO) and then
reported.
•
If required, the police with an authorization from a higher official along with
valid station seal will handover the letter
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The Staff of the MRD has to insist on the Photocopy of the Police.
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The type of injury to the patient (simple/grievous) is explained in the
certificate.
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A copy of this wound certificate is kept in the medical record folder for future
reference.
Insurance cases – Post Claim
•
These cases arise when the patient has a medical insurance coverage .
•
The patient is given two forms from the insurance company- B & B1.
•
Both the forms cover about the treatment undergone in the hospital
and about the expired details of the patient, if any.
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A nominal fees may be collected by the cashier. as per the policy
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The forms are sent to the concerned Consultant and filled up by the
consultant with the authorization at the bottom along with the hospital seal.
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The original copy is sent to the insurance company, one photocopy
is sent to the patient/ relative address and another photocopy is filled in the
Medical Record.
Destruction of records
•
As per the Gazette of India, April ,6,2002, under clause
•
1.3 Every Physician shall maintain the Medical Records pertaining to his/her
INDOOR patients for a period of 3 years from the date of commencement of the
treatment in a standard proforma laid down By the Medical Council of India.
•
If any request if made for medical records either by the patient/ authorized
attendant or legal authorities involved, the same may be duly acknowledged and
documents shall be issued within the period of 72 hours.
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The expired and MLC records are kept permanently for legal purposes.
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Efforts shall be made to computerize the medical records for quick retrieval
ELECTRONIC MEDICAL RECORDS
• The Medical Record has been a collection or package of handwritten
or typed notes, forms & reports.
• Automation has made possible to capture, store, retrieve present
clinical data.
• “On line Systems” – The hospital staff can directly access the
databases through communication terminals connected by Local Area
Network (LAN).
• Backup system – Backup can be taken in Floppies, CDs or in Double
Hard disk system.
• Scanners – Records are scanned and stored in Hard disks or CDs. A
software helps to retrieve and analyses the cases.
Computer entries
• The entries such as issues, receipts, updates, indexing
( diseases and procedures) are done on a daily basis.
• This plays vital to view the location of the various files.
• The file types such as Volumes No, IP, OP, MLC, EXPIRED
are also to be included in the entries.
• The monthly and yearly statistics are to be prepared.
Medical Records Department
Comparative Statistics December 2009
December
Description
Total New OP Registrations
Daily average new OP registrations
Total No of Repeat
Daily average of Repeat
MHC - New
MHC - Repeat
MHC - Total
Total IP Admissions
Daily average IP admissions
Total IP Discharges
Daily average IP discharges
Total Births
Total Deaths
IP deaths
OP deaths
Total IP Service days rendered
Average Length of Stay
Average Daily Census
Average daily Percentage Bed
Occupancy
Gross Death Rate
Net Death Rate
2009
Financial Year- YTD
2008 Change % 2010-2009 2008-07 Change %
Calender Year - YTD
2009
Change
2008 %
Month
Dec-09 Nov-09 Change %
Medical Record Department
Comparative Statistics March 2011
Service Breakup of New Registrations
Description
Allergy
Anesthesia
Audiometry
Aurvedic
Breathe Eazy Clinic
Cardiology
Cardio Thoracic Unit
Cosmetology
Critical Care Group
Dentistry
Dermatology
Diabetology
Diabetic surgeon
Dietician
ENT
Emergency
Endocrinology
Endocrinology/Surgery
Gastroenterology
Gastroenterology - Surgical
Gen. Medicine
Gen. Surgery
Geriatric
Gynecology
General physician
Hematology
Infectious Diseases
MHC
Medical Genetic
Nephrology
Neuro surgery
Neurology
Nuclear Medicine
Oncology
Ophthalmology
Orthopedics
Pediatrics
Pediatric Surgery
Pediatric gastroentrology
Plastic Surgery
Psychiatry
Psychology
Radiology
Respiratory Medicine
Rheumatology
Sexual Medicine
Thoracic Unit
Urology
Urogynocology
Vascular Surgery
Well Woman Check Up
Transplant Surgeon
Other Departments
Aroma Therapeutics
Neuro Rehabilation
TOTAL
2011
March
2010
Change %
2010-11
Financial Year YTD
2009-10 Change %
2011
Calender Year YTD
2010
Change %
March-11
Month
Feb-11
Change %
National Accreditation Board for Hospitals & Health
Care Providers (NABH)
 Constituent Board of Quality Council of India.
 Set up with the co-operation of Ministry Of Health & Family welfare
(Govt. Of India ) and Indian Health Industry.
 Standards are set for the progress of Health Industry.
 Standards have been drafted by the Technical Committee of NABH for
evaluation of hospitals & grant of Accreditation.
 Focus is on Patient Safety and Quality Patient Care.
 Standards are provided for Quality Assurance & Quality Improvement of
Hospital .
BENEFITS OF NABH ACCREDITATION
PATIENTS

High Quality Care &
Patient Safety

Service of credential
medical staff

Patient Rights

Evaluation of patient
satisfaction.
HOSPITAL
 Continuous improvement
 Commitment to Quality
Care.
 Benchmarking
BENEFITS OF NABH ACCREDITATION
3. HOSPITAL STAFF
 Provides Continuous Learning
 Good working environment
 Professional development of clinicians & paramedical
staff
 Quality improvement in medicine and nursing
Accreditation Process
Steps
Preparation
Step 1
Application for accreditation (submitted by the Health care organization)
Step 2
Acknowledgement for accreditation (by NABH Secretariat)
Step 3
Pre assessment visit (by Assessor)
Step 4
Final assessment of hospital (by Assessment Team)
Step 5
Scrutiny of the assessment report (by NABH secretariat)
Step 6
Recommendation for accreditation (by accreditation Committee)
Step 7
Approval for accreditation (by Chairman NABH)
Step 8
Issue of accreditation certificate (by NABH secretariat)
PATIENT CENTERED CHAPTERS APPLICABLE
TO THE MEDICAL RECORDS.
 Access, Assessment and Continuity of Care
(AAC)
 Patient Rights and Education (PRE)
 Care of Patient (COP)
 Management of Medication (MOM)
 Hospital Infection Control (HIC)
 Information Management System (IMS
ORGANIZATION CENTERED CHAPTERS
 Continuous Quality Improvement (CQI)
 Responsibility of Management (ROM)
 Facility Management and Safety (FMS)
 Human Resource Management (HRM)
 Information Management System (IMS)
• NABH Application has to be submitted to the Quality
Council of India
• Pre assessment dates will be announced by the NABH
Secretariat.
• Pre assessment likely to be fixed after two months. The
audit may be likely for 2 or 3 days.
• Self Assessment tool kit has to be completed and
submitted within a week
Access, Assessment and Continuity of Care
(AAC)
 Services Provided in the Hospital
 Well Defined Registration, Admission and Discharge
Procedure.
 Initial Assessment and re assessment.
 Care of patients.
Patient Rights and Education (PRE)
 Privacy during examination, procedure and treatment.
 Confidentiality of Patient Information.
 Consent Forms.
 Information on Lodging a compliant
 Information on Treatment.
 Information on expected cost (estimation)
Care of Patient (COP)
• Emergency Services.
• Usage for blood products.
• ICU & HDU.
• Guidelines for Sedation.
• Administration of anesthesia.
• Care of vulnerable patients.
• Guidelines for surgical procedures.
• Pain management.
• Research Activities.
Management of Medication (MOM)
•
•
•
•
•
•
•
•
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Hospital Formulary
Storage of medicines
Prescription of Medications
Administration of medications
Policy for dispensing medicine.
Guide to use narcotic drugs.
Chemotherapeutic agent
Radioactive drugs
Guide for usage of medical gases.
Hospital Infection Control (HIC)
• Infection Control Manual
• Surveillance activities.
• Reduction on HAI (Hospital Associated Infection)
• Procedure for sterilization activities.
• Bio-Medical Waste Management.
• Regular training for staffs.
Continuous Quality Improvement (CQI)
• Quality Assurance Program
• Identification of key indicators for monitoring. Clinical
and Managerial.
• Auditing of patient care service.
• Analysis of Sentinel Event.
Responsibility of Management (ROM)
• Responsibility of management is defined.
• Department documentation.
• Patient safety and risk management issues.
Facility Management & Safety (FMS)
• Complies with relevant rules and regulations, laws and
byelaws.
• Operational and Maintenance plan.
• Equipment Management.
• Plans for fire and non- fire emergencies.
• Disaster management.
• Managing of Hazardous Material.
• Safety Committee.
Human Resource Management (HRM)
• Orientation of New Staffs
• Training staffs on safety.
• Documentation of performance appraisal system.
• Disciplinary procedures.
• Grievance handling.
• Procedure for Collecting , Verifying and evaluating the
credentials of all staffs.
Information Management System (IMS)
• Process for effective management of data.
• Medical Records.
• Policies for maintenance of confidentiality , integrity and
security of information.
• Policies and procedures for retention period for records.
• Regular Medical Audit.
Good Medical Record
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Accurate
Complete
Timely
Contents
Chronology
Continuity
Promptness
Authentication
Documentation in Medical
Records
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•
•
•
•
•
•
Legible
Readable
Acceptable
Timely
Consent recorded
Error free
Reproducible
Medical Records in OT (Anesthesia / Surgery)
• Blood Group
• Information about Allergies
• Pre assessment with date & time
• Starting time/Recovery time/Shifting time
• Signature with date & time
Contents of Operation Notes
• Date of surgery
• Sight marking
• Complete Surgical Notes
• Starting time
• Incision time
• Ending time
• Pre-operative diagnosis
• Signature of the operating surgeon
Consultation request
• Date and time of request with signature
• Reason for referral
• Referral consultant’s orders
•
Signature with date and time of the referral consultant
Deficiencies in Medical Records
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•
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•
•
•
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Improper terminology
Different diagnosis
Procedures not recorded
Wrong forms
Missing Progress Notes
Name, Date, and Time to be recorded
Poor medical follow up
Repetition of investigations
Mixing up of cases
Delay in MR coding, statistics
TPA settlements
• GOOD MEDICAL CARE
GENERALLY MEANS A GOOD
MEDICAL RECORD, WHILE AN
INADEQUATE MEDICAL RECORD
GENERALLY REFLECTS POOR
MEDICAL CARE
Medical Records Mantra
Patient forgets;
record remembers
THANK YOU