MRD/ Clinical Information Unit

Purpose
The purpose of the Clinical Information Unit is to
provide for the secure maintenance, storage and
retrieval of confidential clinical records.
Provision should be made for 24 hour availability of
clinical records either by a computerized or manual
system.
All patient related administrative, historical and
medical records must be stored in a fire rated
construction as indicated in local bylaws.

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.

must contain sufficient data to identify the patient, support the diagnosis or reason for attendance at the
health care facility, justify the treatment and accurately document the results of that treatment
(Huffman, 1990).
The main purpose of the medical record is:

To record the facts about a patient's health with emphasis on events affecting the patient during the
current admission or attendance at the health care facility, and

For the continuing care of the patient when they require health care in the future.
A patients medical record should provide accurate information on:

who the patient is and who provided health care;

what, when, why and how services were provided; and

the outcome of care and treatment.

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

 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

The medical record has four major

sections:
Administrative,
which
includes
demographic and socioeconomic data
such as the name of the patient
(identification), sex, date of birth,
place of birth, patients permanent
address, and medical record number;
Legal data including a signed consent
for treatment by appointed doctors
and authorization for the release of
information;
Financial data relating to the payment
of fees for medical services and
hospital accommodation; and
Clinical data on the patient whether
admitted to the hospital or treated as
an outpatient or an emergency
patient.

Functions
The function of the Clinical Information Unit is the development and
maintenance of health information systems involving the following:
Retrieval, assembly, sorting and distribution of records for and to the
wards and other patient units.
Transcription / typing service for outpatient letters, discharge summaries
and operation reports
Classification (clinical coding) of diseases and procedures for inpatient
admissions using an International Classification of Diseases
Provision of information to management and other authorized staff for
purposes such as planning, utilization review, quality Assurance, case mix
studies and research
Quality assurance of the medical record to ensure standards are met

 Primary role is safe guarding the records and to issue them on demand
Bridges the gap between medical and non-medical departments.
Enables continuity of care to the patients without difficulty at
appropriate time
Headed by MEDICAL SUPRITENDANT 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.

What are the uses of Medical

Records?
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 STATS

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.

FLOW
Registration counter

Consultants

O.P

I.P
Admission

Indexing

Computer entry

Wards

Deficiency check
and coding

Scanning

Medical records

Assembling

Permanent filing

OPERATIONAL POLICIES
Operational Policies that may have an impact on the planning of the Clinical Information Unit and
may require decisions by policy makers include the following:
How records are to be managed and identified; essential elements include:

Provision of a centralized record system for all inpatient, emergency and outpatient/day patient
attendances or decentralized systems; where decentralize systems are in operation, the existence of
sub-files will require a registration, allowing retrieval of the sub-file for patient care or medico-legal
purposes
Provision of a unit numbering system providing a single identifying number for every patient who
presents to the Hospital i.e. the Medical Record Number (MRN); the MRN issued at the time of first
admission or attendance is then used for all subsequent admissions and treatment

The use of terminal digit filing systems in both active storage and secondary storage
Maintenance of record confidentiality, including authorized access to the record and release
of information to other parties
Preparation of Medico-legal reports in accordance with the local statutory requirements
Retrieval of medical records from secondary storage within a set time if deemed clinically
necessary; the location of secondary storage to be considered
Provision of a centralised dictating system utilising the telephone system for clinical staff to
compile discharge reports and summaries
Transcription of discharge summaries, operation reports and outpatient letters to be
completed in the Unit.

Electronic Medical Records

The Electronic Medical Record (EMR) is a computerised online record,

which tracks and details a patients care during the time spent in hospital.
The EMR enables staff to enter patient data at the point of care and allows
authorised clinicians and access a patients records from any online
location, at any time, to make rapid assessments and coordinate care. In
the future, as electronic systems are implemented, the EMR will begin to
replace paper-based records by integrating patient information in a central
system. As a result, the provisions for paper based systems may not be
required if EMR is provided.

Location

Location may depend on whether or not a pneumatic or mechanical

automated records transport system is to be installed and the
departments to which it is linked.
The decision to include such a system will strongly influence the external
functional relationships of the Unit with the Outpatients Clinic area, in
particular and may reduce the importance of direct access to the
Emergency Unit
Planners must consider possible future uses of the unit envelope for such
time as an electronic record system has evolved with consequent
reduction in staff and diminishing storage needs.
The Unit should be considered as soft space into which an adjoining unit
could expand or a new unit established.

Functional Areas
The Clinical Information Unit will consist of the following functional areas:
Entry/ Reception/ Administration area with waiting
Record Processing Area

Assembly/ Sorting area

Transcription area
Clinical Coding area
Photocopy/ Printing area
Record Microfilming area, if applicable
Record Scanning area, if applicable

Record Storage area for active and archived records

Offices for Manager, Quality Assurance, Medico-legal personnel.

Entry / Reception / Administration

A single controlled point of entry to the Clinical Information Unit for the
reception of visitors and staff is recommended.
A temporary storage area will be required for returned files or files
awaiting delivery to departments. A small amount of waiting will be
required for visitors to the Unit.
Access will be required within this area to Dictating / Research Cubicles so
that visiting staff do not have to traverse the Unit.
Dictation Cubicles
The dictating area will be used by medical staff and others to view and
research medical records as well as dictating and completing the discharge
summaries.
The cubicles should be located on the perimeter of the unit adjacent to
but inside the reception area.
The number of cubicles will depend on usage and the cubicles may be selfcontained or in an open plan office in which case cubicle partitions will be
required.

Record Processing Area

Assembly & Sorting
Record assembly and sorting will generally be undertaken in an open plan
area used for the processing activities associated with the filing and
preparation of the medical records for clinics, admissions and discharges.
This area may have zones for assembled files ready for issue and records
waiting to be refiled.
The record assembly area should have direct access to the filing storage
areas The area will include workstations and sorting tables. Each records
officer will need a records storage bay and a trolley at or in close proximity
to their workstation.
Storage will be required for:
records awaiting sorting and assembly
records awaiting filing
Note that records awaiting medico-legal attention will be stored in the Medico-Legal Office.

Clinical Coding
Clinical Coding of medical records requires a quiet area.
Photocopying / Printing
Dedicated, acoustically-treated and ventilated space is required. This
space may also be used for generating bar code labels etc. This may also
include stationery storage.
Locate with ready access to the medico-legal offices that generate a large
amount of photocopying.
Scanning and Microfilming
Records may be scanned to create a digital record and filed on an optical
disc.
Alternatively records may be microfilmed and stored as film. If records are
to be microfilmed a dedicated room should be provided.

Record Storage

The most common and suitable method to file active medical records is on
fixed metal shelving units (bays).
Archived files may be stored in a compactus shelving unit but a
compactus is not recommended for active
The number of shelves in each bay (up to seven) - usually six levels of
shelving is recommended. Maximum height should be 2175 mm.
A minimum width of 750 mm per aisle between facing bays must be
provided; however for efficient retrieval of records, 900 mm is
recommended as it allows space for trolleys, library stools and for staff to
pass each other in the aisles.
Fire water sprinklers should NOT be installed. Records storage areas must
be temperature and humidity controlled for preservation of records.

In a traditional, hard copy environment, the critical relationship is with

the Emergency Department for immediate record retrieval. Less critical is
the relationship with Outpatient Unit/s as files are usually retrieved and
delivered to the Units prior to clinic sessions. However, distances for
transport of heavy records need to be considered.
Archive File Store
All the records requiring storage should meet the statutory requirements
beyond the 5 year active storage period

Room Space

Quantity

Area ( sq.m)

Reception

10-20

Waiting

4-6

Meeting/interview

Record processing

25-50

Bay- mobile equipments

Review cubicles

9-20

Records store-active

80-200

Office single person

Office single person

12

Office-medicolegal

9-12

Workstation(typing)

2-4

5.5

Worksatation-coding

1-2

5.5

Store general

Scanning area

20

Photcopy-stationary

Circulation

15%