Documente Academic
Documente Profesional
Documente Cultură
MEDICAL RECORDS
Mahboob ali khan MHA,CPHQ
Consultant Healthcare
Location & Days and Hours of Operation
MEDICAL STAFF
• Bound by Professional Secrecy and Oath
PARAMEDICAL STAFF
• 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 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
• DEATH RATE
I.P O.P
Assembling format:
The arrangement of medical records takes place in the
following order:
• Administrator
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
– the next two are secondary & the last two are primary.
Quality Objectives
• 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.
• 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.
Tracer card
• The tracer card plays a very vital role in the filing area.
• 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
• 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.
Month
Year Financial Same Day MTD YTD Financial
Descriptions Today To Date
To Date Year Last year Last year Last year Last Year
Registrations
Admissions
Emg Admission
Discharges
Birth
Deaths
Census
Occupancy
Thursday
Friday
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.
• 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:
• 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.
• 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.
• 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.
• 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
ELECTRONIC MEDICAL RECORDS
• The file types such as Volumes No, IP, OP, MLC, EXPIRED
are also to be included in the entries.
Total No of Repeat
MHC - New
MHC - Repeat
MHC - Total
Total IP Admissions
Total IP Discharges
Total Births
Total Deaths
IP deaths
OP deaths
TOTAL
National Accreditation Board for Hospitals &
Health Care Providers (NABH)
PATIENTS HOSPITAL
Evaluation of patient
satisfaction.
BENEFITS OF NABH ACCREDITATION
3. HOSPITAL STAFF
Care of patients.
Patient Rights and Education (PRE)
Consent Forms.
Information on Treatment.
• Emergency Services.
• Administration of anesthesia.
• 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)
• Surveillance activities.
• Department documentation.
• Equipment Management.
• Disaster management.
• Safety Committee.
Human Resource Management (HRM)
• Disciplinary procedures.
• Grievance handling.
• Medical Records.
• Accurate • Legible
• Complete • Readable
• Timely • Acceptable
• Contents • Timely
• Chronology • Consent recorded
• Continuity • Error free
• Promptness • Reproducible
• Authentication
Medical Records in OT (Anesthesia / Surgery)
• Blood Group
• Date of surgery
• Sight marking
• Complete Surgical Notes
• Starting time
• Incision time
• Ending time
• Pre-operative diagnosis
• Signature of the operating surgeon
Consultation request
• 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