medical record section in hospital
Transcript of medical record section in hospital
-
8/7/2019 medical record section in hospital
1/17
Page 1
MEDICAL RECORD
DEPARTMENT
PRESENTED BY:-
MHA VICTORIOUS
(MEGHA ,SONU)
-
8/7/2019 medical record section in hospital
2/17
Page 2
CONTENTS
INTRODUCTION
DEFINITION
FUNCTION OF MRD
WHY TO KEEP RECORDS?
NEEDS
FLOW CHART OF IN PATIENT RECORD
NEW FILE DOCUMENTS TYPES OF FILE
FINDING
RECOMMENDATION
-
8/7/2019 medical record section in hospital
3/17
Page 3
INTRODUCTION
Medical records through which hospitalstatistics are generated and medical recordsare important to the hospital for evaluation ofits services for better patient care
-
8/7/2019 medical record section in hospital
4/17
Page 4
DEFINITION
Medical record as a clinical, scientific
,administrative , and legal document
relating to patient care in which arerecorded sufficient data written in the
sequence of events to justify diagnosis
and warrant treatment and end results
Mc Gibony
-
8/7/2019 medical record section in hospital
5/17
Page 5
FUNCTIONS OF MEDICAL RECORD
DEPARTMENT1. Daily receipt of case sheets pertaining to discharge, 2 P.M. an
expired patients from various wards, there checking andassembly.2. Daily compilation of Hospital census report.3. Maintains & retrieval of records for patient care and research
study.4. Completion and Procession of Hospital statistics and preparation
on different periodical reports on morbidity and mortality.
5. Online registration of vital events of Birth & Death6. Issuing Birth & Death certificated up to one year.7. Dealing with Medico Legal records and attending the courts on
summary.8. Arrangement & Supervision of enquiry and admission office.9. Arrangement & Supervision of OPD registration
10. Management of disability boards.11. Management of Medical Examination12. Management of Mortality Review Committee Meetings (Twice
month)13. Assistance to Hospital Administration in various matters.
-
8/7/2019 medical record section in hospital
6/17
Page 6
WHICH data to record?
Personal info: age, sex, occupation, training,
family...
Risk factors: tobacco, alcohol, life styles...
Allergies and drug reactions
Problem list
Disease history: diseases, operations. . .
The disease process: main problem, history, exam,lab.
Management plan: advice, education, medication. .
.
Progress notes: in the P S O A P format/ 296
-
8/7/2019 medical record section in hospital
7/17
Page 7
PSOAP
Problem Everything the patient reports and doctorsfindings which are regarded as problems
Subjective History of the problem; what the patient feels or
thinks about the problem
Objective Doctors findings related with the problem
Assessment
Evaluation of the problem; the diff. diagnosis Plan
Prescription, consultation, advice, control visit...
/ 297
-
8/7/2019 medical record section in hospital
8/17
Page 8
DIVISION
MRD has following functional unit:-
1. Receiving area
2. Checking area3. IT room
4. Record storage area (monthly wise)
-
8/7/2019 medical record section in hospital
9/17
Page 9
WHY TO KEEP RECORDS?
Helps in medical decisions(is the size of a lymph node or nodule
increasing with time?) Helps to share responsibility with the
patient
Legal obligation. Protects the patient as well as doctor
in front of the court
/ 299
-
8/7/2019 medical record section in hospital
10/17
Page 10
CONTDt..
Has economic benefits
Useful to produce health statistics Provides epidemiological data
Assists practice management
/ 2910
-
8/7/2019 medical record section in hospital
11/17
Page 11
NEEDS
Patient needs
Physician needs
Institution needs Health authorities needs
-
8/7/2019 medical record section in hospital
12/17
Page 12
Flow chart of inpatient record
analysis ,,,
Assembling checking-incomplete- coding-indexing--- ----- filling
reporting
retrieval
Central
admission
Office
census
Nursing
unit
-
8/7/2019 medical record section in hospital
13/17
Page 13
Medical Record Officer Medical Record Technicians
Medical Record Clerks
Medical Record Attendants.
Ward Boy The Reception, Enquiry and Admission office functions roundthe clock under the charge of Medical Record Officer.
Presently only inpatients records are maintained in the MedicalRecord Department.
Registration work of OPDs are also managed by the Medical
Record Officer. Statistical information about the functioning of OPDs is regularly
submitted by the Medical Record Officials in the Medical RecordDept.
Staffing
-
8/7/2019 medical record section in hospital
14/17
Page 14
NEW FILE DOCUMENTS
File folder
General case sheet
Investigation
Progress record Treatment sheet
Vital chart
Nursing notes
Intake/output chart Temperature chart
Hospital charges chart
-
8/7/2019 medical record section in hospital
15/17
Page 15
TYPE OF FILE
General file
M.L.C. file
Ward register
All register of dept.
-
8/7/2019 medical record section in hospital
16/17
Page 16
FILING OF MEDICAL RECORDS
The inpatients Medical Record is filed by theserial numbers assigned at central AdmittingOffice.
The Record is bound in bundles 100 each
and are kept year wise according to the serialnumber.RETENTION OF MEDICAL RECORD
The policy is to keep indoor patient Recordsfor 10 years
The OPD registers for 5 years
The record which is register for legalpurposes in Maintained for 10 years or tillfinal decision at the court of Law.
-
8/7/2019 medical record section in hospital
17/17
Page 17
THANK YOU