ROLE

1

• ROLE IMPORTANCE OF
• MEDICAL RECORDS
• C.Govindarajan
• Chief Medical Records Officer
• President, Health Records Association of INDIA

2
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.

3
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

4
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

5
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.

6

• 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

7
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.

8
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.

9
FLOW OF MEDICAL RECORDS
Registration counter
Consultants
O.P
I.P
Admission
Medical records
Wards
Deficiency check and coding
Indexing
Assembling
Computer entry
Permanent filing
Scanning
10
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

11
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.

12
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
13
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 Mo
rphology of neoplasm's Special tabulation lists
for mortality and morbidity Definitions Regula
tions Volume 2 Instruction manual Volume
3 Alphabetical index
14
CHAPTERS OF ICD 10TH REVISION (21
Chapters) I Certain infectious and parasitic
diseases II Neoplasm's III Diseases of the blood
and blood-forming organs and certain disorders
involving the immune
mechanism IV Endocrine, nutritional and metabolic
diseases V Mental and behavioural
disorders VI Diseases of the nervous
system VII Diseases of the eye and
adnexa VIII Diseases of the ear and mastoid
process IX Diseases of the circulatory
system X Diseases of the respiratory
system XI Diseases of the digestive
system XII Diseases of the skin and subcutaneous
tissue XIII Diseases of the musculoskeletal
system and connective tissue XIV Diseases of the
genitourinary system XV Pregnancy, childbirth and
the puerperium XVI Certain conditions originating
in the prenatal period XVII Congenital
malformations, deformations and chromosomal
abnormalities XVIII Symptoms, signs and abnormal
clinical and laboratory findings, not elsewhere
classified XIX Injury, poisoning and certain
other consequences of external causes XX External
causes of morbidity and mortality XXI Factors
influencing health status and contact with health
services
15
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.

16

• FEW EXAMPLES
• DIAGNOSIS CODE NO.
• DIABETES MELLITUS - E14
• ACUTE MYOCARDIAL INFARCTION - I 21.9
• ABORTION (Attempted Failed) - O07.9
• AMOEBIC ABSCESS - A06.4
• IRON DEFICIENCY ANAEMIA - D50.9
• CALCULUS KIDNEY - N20.0
• CANCER BREAST - C50.9
• CANCER LIVER - C22.9
• CANCER LUNG - C34.9
• SPRAIN (JOINT) - T14.3
• ULCER STOMACH - K25.9

17
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.

18
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.

19
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

20
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23
IP DEFICIENCY
MONTH NO. OF PATIENTS DISCHARGED TOTAL NO IP DEF PERCENTAGE
JAN 3011 811 26.93
FEB 3029 765 25.25
MAR 3258 884 27.13
APR 3263 900 27.58
MAY 3493 959 27.45
JUN 3173 874 27.54
JUL 3727 712 19.10
AUG 3556 691 19.43
SEP 3441 319 9.27
OCT 3574 295 8.25
NOV 3351 480 14.32
DEC 3300 335 10.15
24

• 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.

25
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.
• 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.

26

• 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.

27
Census

• 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.

28

Medical Records Department Medical Records Department Medical Records Department Medical Records Department Medical Records Department Medical Records Department Medical Records Department Medical Records Department Medical Records Department
Daily Statistical Report of Patients Daily Statistical Report of Patients Daily Statistical Report of Patients Daily Statistical Report of Patients Daily Statistical Report of Patients Daily Statistical Report of Patients Daily Statistical Report of Patients Daily Statistical Report of Patients Daily Statistical Report of Patients
DATE 31.12.2009 31.12.2009 31.12.2009 31.12.2009 31.12.2008 31.12.2008 31.12.2008 31.12.2008
Descriptions Today Month To Date Year To Date Financial Year Same Day Last year MTD Last year YTD Last year Financial Last Year
Registrations
Admissions
Emg Admission
Discharges
Birth
Deaths
Census
Occupancy
Friday Friday Friday Friday Thursday Thursday Thursday Thursday
29
Medico legal cases

• 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

30

• 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.

31
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.
• 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.

32
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.
• The expired and MLC records are kept permanently
  for legal purposes.
• Efforts shall be made to computerize the medical
  records for quick retrieval

33
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.

34
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.

35

Medical Records Department Medical Records Department Medical Records Department Medical Records Department Medical Records Department Medical Records Department Medical Records Department Medical Records Department Medical Records Department Medical Records Department Medical Records Department Medical Records Department Medical Records Department
Comparative Statistics December 2009 Comparative Statistics December 2009 Comparative Statistics December 2009 Comparative Statistics December 2009 Comparative Statistics December 2009 Comparative Statistics December 2009 Comparative Statistics December 2009 Comparative Statistics December 2009 Comparative Statistics December 2009 Comparative Statistics December 2009 Comparative Statistics December 2009 Comparative Statistics December 2009 Comparative Statistics December 2009

Description December December December Financial Year- YTD Financial Year- YTD Financial Year- YTD Calender Year - YTD Calender Year - YTD Calender Year - YTD Month Month Month
Description 2009 2008 Change 2010-2009 2008-07 Change 2009 2008 Change 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 Census
Average daily Percentage Bed Occupancy
Gross Death Rate
Net Death Rate
36
Medical Record Department Medical Record Department Medical Record Department Medical Record Department Medical Record Department Medical Record Department Medical Record Department Medical Record Department Medical Record Department Medical Record Department Medical Record Department Medical Record Department Medical Record Department
Comparative Statistics March 2011 Comparative Statistics March 2011 Comparative Statistics March 2011 Comparative Statistics March 2011 Comparative Statistics March 2011 Comparative Statistics March 2011 Comparative Statistics March 2011 Comparative Statistics March 2011 Comparative Statistics March 2011 Comparative Statistics March 2011 Comparative Statistics March 2011 Comparative Statistics March 2011 Comparative Statistics March 2011
Service Breakup of New Registrations Service Breakup of New Registrations Service Breakup of New Registrations Service Breakup of New Registrations Service Breakup of New Registrations Service Breakup of New Registrations Service Breakup of New Registrations Service Breakup of New Registrations Service Breakup of New Registrations Service Breakup of New Registrations Service Breakup of New Registrations Service Breakup of New Registrations Service Breakup of New Registrations
                         
Description March March March Financial Year YTD Financial Year YTD Financial Year YTD Calender Year YTD Calender Year YTD Calender Year YTD Month Month Month
Description 2011 2010 Change 2010-11 2009-10 Change 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                        
37

• 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 .

38
BENEFITS OF NABH ACCREDITATION

• HOSPITAL

• High Quality Care Patient Safety
• Service of credential medical staff
• Patient Rights
• Evaluation of patient satisfaction.

• Continuous improvement
• Commitment to Quality Care.
• Benchmarking

39
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

40
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)
41
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

42
ORGANIZATION CENTERED CHAPTERS

• Continuous Quality Improvement (CQI)
• Responsibility of Management (ROM)
• Facility Management and Safety (FMS)
• Human Resource Management (HRM)
• Information Management System (IMS)

43

• 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

44
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.

45
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)

46
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.

47
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.

48
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.

49
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.

50
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.

51
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.

52
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.

53

• Good Medical Record

• Documentation in Medical Records

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

• Legible
• Readable
• Acceptable
• Timely
• Consent recorded
• Error free
• Reproducible

54
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

55
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

56
Consultation request

• Date and time of request with signature
• Reason for referral
• Referral consultants orders
• Signature with date and time of the referral
  consultant

57
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

58

• GOOD MEDICAL CARE GENERALLY MEANS A GOOD MEDICAL
  RECORD, WHILE AN INADEQUATE MEDICAL RECORD
  GENERALLY REFLECTS POOR MEDICAL CARE

59
Medical Records Mantra

• Patient forgets
• record remembers

60

• THANK YOU