ROLE & IMPORTANCE OF MEDICAL RECORDS

Mahboob ali khan MHA,CPHQConsultant Healthcare

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 follow-up and treatment.

– 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

Admission Medical records

AssemblingDeficiency check and coding

Scanning Computer entry

Permanent filing

Consultants

I.P O.P

Wards

Indexing

In-patient records:

Assembling format:The arrangement of medical records takes place in the following order:

• 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 well-organized 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 RevisionList of three-character categoriesTabular list of inclusions and four-character

subcategoriesMorphology of neoplasm'sSpecial tabulation lists for mortality and morbidityDefinitionsRegulations

Volume 2 Instruction manual

Volume 3 Alphabetical index

CHAPTERS OF ICD – 10TH REVISION (21 Chapters)

I Certain infectious and parasitic diseasesII Neoplasm'sIII Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanismIV Endocrine, nutritional and metabolic diseasesV Mental and behavioural disordersVI Diseases of the nervous systemVII Diseases of the eye and adnexaVIII Diseases of the ear and mastoid processIX Diseases of the circulatory systemX Diseases of the respiratory systemXI Diseases of the digestive systemXII Diseases of the skin and subcutaneous tissueXIII Diseases of the musculoskeletal system and connective tissueXIV Diseases of the genitourinary systemXV Pregnancy, childbirth and the puerperiumXVI Certain conditions originating in the prenatal periodXVII Congenital malformations, deformations and chromosomal abnormalitiesXVIII Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classifiedXIX Injury, poisoning and certain other consequences of external causesXX External causes of morbidity and mortalityXXI 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 CODE NO.

1.DIABETES MELLITUS - E142.ACUTE MYOCARDIAL INFARCTION - I 21.93.ABORTION (Attempted Failed) - O07.94.AMOEBIC ABSCESS - A06.45.IRON DEFICIENCY ANAEMIA - D50.96.CALCULUS KIDNEY - N20.07.CANCER BREAST - C50.98.CANCER LIVER - C22.99.CANCER LUNG - C34.9•SPRAIN (JOINT) - T14.3•ULCER STOMACH - 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.

• 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 Policy Quality Policy

Quality ObjectivesQuality 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

IP DEFICIENCYMONTH

NO. OF PATIENTS DISCHARGED TOTAL NO IP DEF PERCENTAGE

JAN 3011 811 26.93FEB 3029 765 25.25MAR 3258 884 27.13APR 3263 900 27.58MAY 3493 959 27.45JUN 3173 874 27.54JUL 3727 712 19.10AUG 3556 691 19.43SEP 3441 319 9.27OCT 3574 295 8.25NOV 3351 480 14.32DEC 3300 335 10.15

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.

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.

• They are entered in the retrieval register along with the consultant name.

• The records are then pulled out from the filing areas and to be sent for dispatch within 15 minutes.(International benchmark –45Min).

• 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.

• This plays a vital role in finding the missing record from the consultation areas.

• 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.

Out-patient records

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.

• In patient census: The number of In-patients at any time.

• 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.

Census

Medical Records Department

Daily Statistical Report of Patients

DATE 31.12.2009 31.12.2008

Descriptions TodayMonthTo Date

YearTo Date

FinancialYear

Same DayLast year

MTDLast year

YTDLast year

FinancialLast Year

Registrations

Admissions

Emg Admission

Discharges

Birth

Deaths

Census

Occupancy

Friday

Thursday

• 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

• AR Report. (Accident Register Report)

• 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

Medico legal cases

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

• The Staff of the MRD has to insist on the Photocopy of the Police.

• The type of injury to the patient (simple/grievous) is explained in the certificate.

• A copy of this wound certificate is kept in the medical record folder for future reference.

• 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.

• A nominal fees may be collected by the cashier. as per the policy

• 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.

• 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.

Insurance cases – Post Claim

• 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.

• The expired and MLC records are kept permanently for legal purposes.

• Efforts shall be made to computerize the medical records for quick retrieval

Destruction of records

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

Description

December Financial Year- YTD Calender Year - YTD Month

2009 2008 Change % 2010-2009 2008-07 Change % 2009 2008Change % Dec-09 Nov-09 Change %

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 CensusAverage daily Percentage Bed Occupancy

Gross Death Rate

Net Death Rate

Medical Record DepartmentComparative Statistics March 2011

Service Breakup of New Registrations 

DescriptionMarch Financial Year YTD Calender Year YTD Month

2011 2010 Change % 2010-11 2009-10Change % 2011 2010 Change % March-11 Feb-11 Change %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                        

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 .

National Accreditation Board for Hospitals & Health Care Providers (NABH)

BENEFITS OF NABH ACCREDITATION

High Quality Care & Patient Safety

Service of credential medical staff

Patient Rights

Evaluation of patient satisfaction.

HOSPITAL

Continuous improvement

Commitment to Quality Care.

Benchmarking

PAT I ENTS

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)

• 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

• Accurate• Complete• Timely• Contents• Chronology• Continuity• Promptness• Authentication

Documentation in Medical Records

• 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

• 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

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