MEDICAL RECORDS

Wing Commander (Dr) Suresh TahilianiNABH AssessorAIMA-Accredited Management Teacherskstahil@yahoo.co.in

Definition

Clear concise & accurate history of patient’s life & illness, written from medical point of view.

-Mac Eachern (1957) A clinical, scientific, administrative & legal

document relating to patient care in which recorded sufficient data written in sequence of events to justify the diagnosis & warrant the treatment & the result. Chronicle of the pageantry of medical & scientific progress.

-Mc Gibony (1969)

Medical Records

It is a repository of all information pertaining to a patient’s health and health history, thus it contains information on diseases diagnosis, tests and examinations, therapies, prognosis and discharge status.

In simple terms it reveals theWhomWhatWhy Of patient careWhereWhen

Contents of Medical Records

Personal & demographic profile Clinical notes Case history Diagnosis Treatment Investigations undertaken Discharge status

In different forms:-

•Paper

•Microfilm

•Optical disc

•Tape

•Computer drives

Modern History (in India) 1667 St Bartholomew’s Hospital –First Medical

Record Unit established JACH (Joint Commission on Accreditation of

Hospitals) Assumed responsibility of standardisation, leading to improvement of medical care

1946 Bhore Committee – Stressed on it’s importance 1962 Mudaliar Committee – Reiterated

recommendation of Bhore 1965 Medical Review Committee

Min basic requirement of forms Standardised size & paper for forms Evolution & est of 5 regional trg centres

CMC, Vellore first to organise MRD & hold training courses for technicians

Medical Record Department (MRD)

Earlier-

Depository of medical Information

Now-

Vital source of statistics Reimbursement Utilisation Peer review Clinical research Legal issues

Need for Medical Records

Three primary reasons:- Ensures continuity of treatment & care Can be retrieved at later date on re-admission, for

medico legal requirements For medical audit, research & training

1979- Seminar organised by DGHS observed:- Gross inadequacies of health information Cumbersome retrieval process Hosp statistics collected by paramedics eg nurses Medical certification of cause of death not maintained Few hospitals report data to state health authorities No proper maintenance of health statistics at state &

national level

Elements of Medical Records

Input Analysis Processing Output Storage Retrieval Flow

Types of Medical Records

Directly related to patient care activities Admission Forms- Medical history

sheets, medical treatment record forms Nurses bed side records- TPR charts,

consultations, investigations OT notes, discharge summaries

Indirectly related to patient care activities Budget, accounts/financial transactions

during patient stay

Characteristics of Medical Records

Complete – Should have sufficient data to identify pt, justify treatment , inv, etc

Adequate – All necessary forms & all relevant clinical information

Accurate – Capable of quantitative analysis

Scope & Importance: For Patients

Assist continuity of care Avoid omission/ repetition/

duplication of investigations Evidence to support/refute medico

legal questions Documents story of patient Ready info for life & health insurance Disability entitlements

Scope & Importance: For Physician

Assurance of adequacy, quality & continuity of care

Helps evaluation of medical care Protects from legal suits An aid in research

Scope & Importance: For Hospital

Documentation as evidence for evaluation of medical & nursing care

Helps the management in planning & allocation of resources

Protects in case of legal suits

Scope & Importance: For Medical Education & Research

Assists in deriving conclusions or investigating them

Aids informal education Forms basis of clinical research Reliable for advancement of

medicine

Scope & Importance: For Public Health Authorities

Reliable info regarding mortality, morbidity profile of population

Assists in planning preventive & social measures

Provide early warning of incidence of communicable diseases

Physical Facilities for MRD

UnitArea

(sq ft)Location

Admission Office

125 - 175 As near OPD & Casualty as possible

Medical Record Office

50 beds – 175100 beds – 240200 beds – 500

>500 beds - 1200

Where possible In-patient & OPD records must be kept together

Storage 125 – 500 For vertical storage. In one shelf = 36 – 125 indoor patient’s or 300 OPD records

Staffing of MRD

PersonnelBeds in Hospital

200 300 400 500750

Med Rec Officer - - - - 1

Asst MRO - - - - 1

Tech Asst - - - - 1

Med Rec Tech/Clk 2 4 6 8 12

Med Rec Attendants

4 4 5 6 10

Functional Organisation of MRD

Chief of MRD

Relief clkMed corres & abstract

Asst Chief for admitting & OPD

Asst Chief for Central

Transcription

Asst Chief for pers trg & med correspondence

Consultancy service & Research

Secretary

Reports & statisticsCentral discharge

File clkAppt & admission

Index files•Diagnostic•Operation•Physician

Responsibilities of MRD

Designing hospital forms Admission/Registration Census Checking/verification/correctness of every

record for inaccuracy, incompleteness, coding, indexing

Filing according to pre-determined system Compiling hospital/diagnostic statistics Generating reports for administrators,

management, audit committees, Govt health dept

Processing of Medical Records

Admitting Office Census desk Assembling & deficiency check desk Incomplete records control desk Admission & discharge analysis Coding & indexing desk Filing

Functional Activities in MRD

Admission Office Reception & registration Assignment to OPD/wards Initiates documentation Collects documents after discharge &

sends to Central Records Officer Keeps upto date info of bed state Notification, if needed

Functional Activities in MRD

OPD Registration Every patient is given a regn No

All records of the patient stored in this file

Functional Activities in MRD

Wards/Nursing Units History & examination Diagnosis Investigation & consultations & progress notes Education Evaluation Discharge

Functional Activities in MRD

Central Record Office Assembling. Order of arranging medical records Checking for incomplete records Analysing (physician or medical audit committee) Reporting (Hospital Statistical Abstracts) of

communicable diseases Filing – De/centralised, horizontal/vertical Storage & retention depends on hospital & Govt

policy Retention of Medical Records:-

OPD - 5 years Indoor - 5 years Medico legal - Life Long

Functional Activities in MRD

Reporting, analysis & preparation of monthly hosp abstracts & annual statistics

NumberingSerial Numbering. New No on each admission

regardless of No of new admissionsUnit Numbering. Same admission No in all re-

admissionsSerial Unit Numbering. Same as serial No but

records are subsequently filed under latest No

Functional Activities in MRD

Filing SystemDecentralised. OPD & In patient have

separate records. Increases work, operating cost & likelihood of duplication

Centralised. Records filed centrally Qualitative Analysis. Responsibility of

MRO to check component parts & analyse for accuracy, completeness & adequacy

Coding. As per ICD X

Functional Activities in MRD

Deficiency Checks. Deficient records placed in incomplete file rack till completed till completed by concerned physician, nurse, dept

Indexing. Different types:-Patient Index (Alpha Index)Disease IndexUnit IndexOperation index

Functional Activities in MRD

Filing.HorizontalVertical - Economy of space, scope for

expansion, safety & adaptability

Forms. Coloured files for different years of records for easy retrieval. Uniform file size 8in x 11in for easy filing

Manual Recording in MRD

Most widely used Advantages

Portable Subjective data easy to recordScanning is easierCan be organised in any way

DisadvantagesOnly one copyCost of missing records Incomplete/illegible recordsDifficult to track down dataPapers may not be in chronological order

MRD: Situation in India

Too many patients

Facilities/resources over stretched

Voluminous paper works

Less time spent on actual patient care

Innovations in MRD

Comprehensive Summary

Only salient & essential data stored

Can be done for records > 10 yrs old

Name, age, sex, father’s name, address, DOA, DOD/death

Innovations in MRD

Microfilming – Filming of records in miniature size

AdvantagesSpace saving (75 – 80%)Accessibility – Can be stored in dept Protection – Cannot be easily tampered No misfilming – Once filmedSaves time

DisadvantageInconvenient for studying

Innovations in MRDComputerisation (can also be shared by many

hospitals, Professional Activity Study- PAS) Advantages

Single database shared by all departments Easy accessibility/retrieval Instant access to many users Real time information available Comprehensive/legible information Productivity of practitioners Reduced time of clerical functions

Disadvantage Not portable Needs down time Computer literate staff required Affected by disruption in power supply

Legal Aspects

PROPERTY OF HOSPITAL

Not of patient or doctor

Personal Document

Confidential & privileged communication- Must not be released without patient consent

Legal Aspects: Personal Document Can divulge to:-

Patient – Brief summaryRelatives/Friends – No written infoPress – None other than administratorLIC – Even without consent of patient to

dispose claims arising from insurance policies

Police – In case of MLC, Injury Report given. Not allowed to record patients statement without prior certification by MO .

Court of Law – According to Indian Evidence Act hospital document incl medical records admissible as evidence. Court can summon any document or medical record. Can summon doctor for evidence under law of torts

Legal Aspects: Impersonal Document

Can be used for education, research, public health

In communication. Diseases/notifiable diseases. Some personal information at times has to be divulged in public interest

Mainly it is impersonal data

Medical Records & Hospital Information System

Wide ranging reports & returns can be generated in the medical records department. The basic purpose of these reports are:

a) Evaluating the quality of care being renderedb) Locating the deficiencies in : I) Means: Staff, physical facilities, equipment including plants & machine.

. The reports maybe generated daily, weekly, monthly, quarterly and annually depending upon the requirement. The reports generally pertains to :

a) Vital Statistics b) ADT analysis (Admission, Discharge

& Transfer Analysis ) c) General Health Statistics

Comprehensive list of such reports and returns cannot be laid out since there will be so much variation from hospital to hospital. Some of the reports that can be commonly generated by the hospital are :

Maximum patients on any one day Minimum patients on any one day Daily average Bed occupancy rate Total patient days care Bed turn over interval

b) AdmissionDaily admissionDaily admission unit/specialty wise Total admission over a periodpatients distribution by age, sex, religion

& regionc) DischargesDaily dischargesTotal patients discharged over a periodDays of care to the patients discharged

Average length of stayd) DeathsDaily number of deathsTotal deaths over a periodNet death rateGross death rate

Foetal death rateMaternal death rateInfant death ratePost operative death rateAnaesthetic death ratee) Work load statistics Total number of outpatients :New cases

Repeat cases Total number of operations Total number of X-ray & other

related investigations Total number of lab

investigations/lab wise investigations.

Department wise workload statistics

f) Hospital Care Evaluation Statistics Post operative infection rate Post operative complication rate Caesarian section rate Autopsy rate Consultation rate Rate of normal tissue removed Percentage of disagreement between final

& pathological diagnosis

Gross result of treatment, I.e., patients recovered, improved or not relieved.

Admission Admission is the acceptance of a

patient by the hospital for inpatient service, which may be for investigation and / or treatment.

Discharge Discharge is the release of an inpatient.

Death of an admitted patient is also considered as discharge.

Hospital Deaths Death of an admitted patient is

considered as a hospital death. Death of a patient in the casualty, OPD or in an ambulance, before the actual admission of the patient

Total deaths of hospitalized patients is known as Gross Deaths. Total deaths after 48 hours of admission is considered net deaths.

Patient Day A patient day is the period of service

rendered to an inpatient between the census taking hours of two successive days.

While counting, the day of discharge of an inpatient is not counted, irrespective of the time of discharge. Similarly the day of the admission is counted always regardless of the time of admission.

Patient day is a valuable unit used for expressing the various activities of a hospital such as patient days of service rendered during the given period, cost of food per patient per day etc.

Bed Complement Bed complement is the number of

hospital beds normally available for use by the in patient. It includes the following types of beds:

a) Adult beds b) Crids

c) Bassinets for use of infants other than new born

d) Incubators for prematures Casualty ward beds Postoperative ward beds Intensive care unit beds Isolation beds Staff sickness beds

The following types of beds are not included in the bed complement of a hospital :

a) Recovery room beds b) Observation beds of casualty c) Examination beds The methods of calculation of some of

the commonly used statistics are given below:

Average Daily Census Average daily census is the average

number of patients in the hospital at a given time per day& is expressed as :

Sum of daily census for a given period --------------------------------------------------- Number of calendar days in the period

Death Rates a) Gross death rate:Total number of hospital deaths during given period ------------------------------------------------------------------

X100Total discharge (including deaths) during the same

periodb)Net death rate:Total deaths of in patients after 48 hrs of admission

during the given period -----------------------------------------------------------------X100Total discharges (including deaths) during the

same period

C) Specific death rate: Number of net deaths in a ward or department

during a given period ----------------------------------------------------------X100 Total discharges (including deaths) in that

department during the same period.

Average Length of Stay Average length of stays is the average

number of days of service rendered to each discharged patient during the given period of time. Patient days are complied from the discharge summary of discharged patient. The formula is :

total patient days during the given period

----------------------------------------------------------------------

Total discharge (including deaths) during the same period.

Turnover Interval or “T” Interval“T” interval is the average period in days

a bed remains vacant between one discharge & another admission & is expressed as:

(Bed complement x period)- Pt. days for that period---------------------------------------------------------------No. of discharges(including deaths) during that period.

The value of “T” may be negative or positive:- A negative “T” indicative of scarcity of

beds and over utilisation. A long positive”T” is indicative of

underutilisation because of either defective admission procedures or poor quality medical care.

A short “T” is indicative of optimum utilisation.

Safety of records Responsibility lies with the administration.

Proper records of their movement must be kept during its transit from indoor to medical records department or whenever a document is taken out for education/research.

A single person should control all medico legal records of the hospital, preferably medical record officer

Medico legal record

Kept in safe custody Separate medico legal record movement

register should be maintained at the medical records department.

Any movement of the medico legal record along with its purpose should be recorded

A responsible person from the medical records department should be detailed to present the medico legal records in the court of law whenever the need arises.

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