Dr.

Padma Bhatia
Assistant Professor,
Dept Of Community
Medicine,
GMC, Bhopal.
 Traditional surveillance
 Improving program delivery – monitoring and
evaluation
 ◦ Improve health care quality.
◦ Prevent medical errors.
◦ Reduce health care costs.
◦ Increase administrative efficiency.
◦ Decrease paperwork.
◦ Expand access to affordable care.

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 Legislation and Regulations
 Hospital Management
 Human Resources
 Quality Management
 Hospital Financing
 Hospital Information
Technology
 Hospital Planning
 Marketing & Business
Development
 Emerging Technologies &
Discoveries
 Best Practices
 Patient Safety
 Training and Education
 health Correlates
 Conditions
 Care and
 Consequences.

Planning for the Use of Health Resources and Services
Statistics about health services are used to analyze
alternatives for service utilization. Health planners rely on
them as they allocate resources for costly equipment
 Hospital administrators use them to decide on
investments to meet emerging needs for care.

Surveillance of Emerging Threats

Health trends help care givers spot new developments,
track emerging threats—such as epidemics or endemic
conditions and identify new diseases—such as AIDS. They
can be important weapons in the response to biological
attacks. For example, these indicators are a critical part of
the plan to mitigate the impact of pandemic influenza.
 “ Medical record as a clinical, scientific,
administrative , and legal document relating to
patient care in which are recorded sufficient data
written in the sequence of events to justify
diagnosis and warrant treatment and end results”
 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
 Has economic benefits
 Useful to produce health statistics
 Provides epidemiological data
 Assists practice management
 Electronic Medical Records (EMR)
◦ Importance of access and accuracy of medical
history of patients
◦ Privacy issues regarding storage and access to
information
◦ Diagnosis, treatment and potentially detrimental
other information being accessed by patient or
others (e.g., sexually transmitted disease, genetic
disease or DNA disease susceptibility analysis
information)
 Increasing use of morbidity data leads to an
increasing concern for the reliability of data

 Sources of error in MR information systems:

◦ documentation of the patient’s care and
condition during the episode in hospital
◦ coding the information in the medical
record
◦ processing the coded information
 Clerical
◦ careless mistakes, transposing numbers
 Judgmental
◦ wrong subjective decisions taken
 Knowledge
◦ mistakes due to lack of coder knowledge
 Systematic
◦ errors in the process of coding or problems with the
environment in which coders work
 Documentation
◦ incomplete, inaccurate, ambiguous, conflicting
◦ illegible


1. Read the front sheet of the relevant admission
2. Read the discharge summary or other
correspondence
3. Compare any diagnosis in the discharge
summary/letter with that recorded as admission
or provisional diagnosis and with that recorded on
the front sheet
4. Read the history and physical examination
5. Identify relevant procedures
6. Review the entire record
7. Clarify information with the clinician if necessary
◦ Documentation
◦ Incomplete medical records
◦ Availability of records
◦ Coder/clinician communication
◦ Data entry
◦ System edits
◦ Forms design
◦ Workload
◦ Education
◦ Human resources
◦ Environment
◦ The individual
 Confidentiality
◦ Assuring that medical information will be used only for
appropriate care and treatment of individuals and
populations.
 Security
◦ The protections (policy, physical, and where appropriate,
electronic) which assure that no breaches in the
confidentiality of medical information will occur.
 Local health facilities
◦ Staff responsible for medical care may lack sufficient
training in or understanding of the importance of
maintaining confidentiality or security of medical
records;
◦ Physical protections around records systems may be
inadequate or unaffordable
 Log books are often readily accessible by unauthorized staff
 Multiple copies of potentially sensitive information exist
throughout larger facilities
 There are two exceptions
◦ Public health needs
◦ Law enforcement/national security
Information Must be Information Must be
Accessible to Provide Protected to Prevent
Appropriate Care Harm to the Patient
 Maximize accuracy of data collection
 Standardize methodology for data collection &
analysis
 Minimize costs to hospitals & government
agencies
 Produce data that are valid, fair to hospitals, &
useful to consumers

Edmond MB. In: Hospital Infections, 5th ed., 2007.

 Required by licensing authorities.
 Provide documentation and continuity of care.
 Provide a foundation for managing the patient’s
health care.
 Serve as a legal document/record.
 May provide clinical data for education and
research.

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 Entries in the medical record must be
◦ Concise.
◦ Complete and objective.
◦ Clear and legibly written.
◦ Correct.
◦ Chronologically ordered.
 Entries should never include inappropriate
statements or attempts at humor.

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 Clinical  Administrative
◦ Medical history ◦ Full name and
◦ Symptoms demographics
◦ Examination, assessment ◦ Informed consent if
and diagnosis appropriate
◦ Treatment ◦ Documentation of phone
◦ Documentation of calls
instructions ◦ Other medical records
◦ Test results
◦ Prescriptions and refills

McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved

 Records should be kept until applicable statute of
limitations has expired.
 Statutes vary from state to state.
◦ Two to seven years.
 Records are also kept for tax and liability reasons.

McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved

 Data that is considered to be part of the medical
record:
◦ Personal
◦ Financial
◦ Medical
 : 1. Daily receipt of case sheets pertaining to discharge,
 . 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 & Death
 6. Issuing Birth & Death certificated up to one year.
 Dealing with Medico Legal records and attending the courts on
summary.
 Arrangement & Supervision of enquiry and admission office.
Arrangement & Supervision of OPD registration
 Management of disability boards.
 Management of Medical Examination
 Management of Mortality Review Committee Meetings (Twice month)
Assistance to Hospital Administration in various matters.
 “Equity and excellence:
the government has shown a strong commitment
to ensuring that information is collected and used
to secure good quality outcomes and to inform
patient choice