A Study of MEDICAL RECORD DEPARTMENT

At
Mission of Mercy Hospital & Research Centre

by:

Sk Azharuddin Ahmed

BBA in Hospital Management

Roll: 31303318005, Reg. no.: 183131310026 of 2018-2019

GURUNANAK INSTITUTE OF PHARMACEUTICAL SCIENCE AND

TECHNOLOGY

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CERTIFICATE

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APPROVAL FORM

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NAME: Sk Azharuddin Ahmed

Roll no.: 31303318005

Registration no.: 183131310026 of 2018-2019

Project Name: A study report on MEDICAL RECORD DEPARTMENT

Project guide: Mr. Tanmoy Majumder (Asst. Prof. of BBHM)

Duration of training: 30 days

Place of training: Mission of Mercy Hospital & Research Centre

College: Gurunanak Institute of Pharmaceutical Science & Technology

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

Guide signature Candidate signature

Self Declaration

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I Sk Azharuddin Ahmed, 3rd year 5th semester, roll – 31303318005
declared that I had conducted my one month training work in Mission
of Mercy Hospital & Research Center and the project report on
medical record department submitted by me is the result of my original
and independent research work.
All the information of this project is to the best of my knowledge and
interest. The data and information provided in this project is also truly
original and valid and was not influenced by any other work. It is
prepared by discussion with staffs and executive of concerned
department. The fact and findings are collected directly from the hospital
in my good faith and this training work conducted as per MAKAUT
BBA in HOSPITAL MANAGEMENT course curriculum.

------------------- ----------------------
Date Signature

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 ACKNOWLEDGEMENT
This project consumed huge amount of work, research, dedication. Still
implementation would not have been possible if I did not have support of many
individuals. Therefore I would like to extend my sincere gratitude to all of them.

First of all I am thankful to my friends and colleagues for their kind co-operation
and encouragement which help me in completion of this project.

I am also thankful to my respected principal Dr. Lopamudra Datta and HOD of our
department Dr. Swati Nandi Chakraborty for their concern.

I am also thankful to my respected teacher of our hospital management department

Mr. TANMOY MAJUMDER(Asst. Professor) for his constant support and
valuable guidance.

I am also grateful to respected Medical record department officer Mr. RUBOL

BHUIYA for his educative and logistical support and providing necessary
guidance concerning training implementation.

Apart from these I want to thank each and every staff of Mercy Hospital as they
had guided and helped me and solves my problem and making me feel as I am one
of among them.

Sk Azharuddin Ahmed
Date:
Place: KOLKATA

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 Executive summary
The minor project has been successfully completed at Mission of Mercy Hospital
and Research Center, Kolkata.

The project is done as the part of 5th semester Maulana Abul Kalam Azad
University of Technology Hospital Management Syllabus.

Hospital sets the stage for an uninterrupted programmed of patient care. A hospital
is an integral part of social and medical organization. The function of which is both
curative and preventive.

The main objective of this project was to interpret the overall work of the medical
record department and satisfactory level of patient and patient party and also to
understand the role and responsibilities of the staff in the hospital.

The methodology of this studies included personal observation, patient surveys

through structured questionnaires and direct data used has been collected through
structured questionnaires administered to a sample of 100 people who had been
randomly selected as per research convenience.

Then I have discussed about the patient satisfaction on different services in

hospital and their recommendation or suggestion. Then I wrote the conclusion of
my project. At last I have discussed about the references which help me for
completing my project.

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CONTENT

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 Medical Record Department
Sl. No. Topic Pg. no.
1 Introduction of 9-10
MRD
2 MRD of Mercy 11-13
Hospitral
3 MRD Checklist 14
4 About MRD 15-18
Checklist
5 Working 19
procedure of
MRD
6 Functions 20-25
7 Objectives 27
8 Review of 28-30
literature
9 Hos[ital profile 31-33
10 Mission-Vision 34
11 Methodology 35
12 Data collection & 36-39
analysis
13 Problem 40
identification
14 Recommendation 41
of problem
15 Conclusion 42
16 Bibliography 43
17 Abbreviation 44

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 INTRODUCTION:

The terms medical records are used somewhat interchangeably to describe the

systematic documentation of a single patient's medical history and care across time
within one particular health care provider's jurisdiction. A medical record includes
a variety of types of "notes" entered over time by healthcare professionals,
recording observations and administration of drugs and therapies, orders for the
administration of drugs and therapies, test results, x-rays, reports, etc. The
maintenance of complete and accurate medical records is a requirement of health
care providers and is generally enforced as a licensing or certification prerequisite.
The terms are used for the written (paper notes), physical (image films) and digital
records that exist for each individual patient and for the body of information found
therein.
Medical records have traditionally been compiled and maintained by health care
providers, but advances in online data storage have led to the development
of personal health records (PHR) that are maintained by patients themselves, often
on third-party websites. This concept is supported by US national health
administration entities and by AHIMA, the American Health Information
Management Association.
Uses:
1. The information contained in the medical record allows health care providers to
determine the patient's medical history and provide informed care
2. The medical record serves as the central repository for planning patient care and
documenting communication among patient and health care provider and professionals
contributing to the patient's care.
3. An increasing purpose of the medical record is to ensure documentation of
compliance with institutional, professional or governmental regulation.
4. To serve as an informational document to assist in the quality review of patient
care.
5. To supply patient care information to authorized organization and third party
payers.
6. To furnish documentary evidence of care provided in health care facility.

7. To provide a means of communication among physician, nurses, and other allied

health care organizations.

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8. To protect the patient, physician, and health care organization in the event of any
litigation.

The traditional medical record for inpatient care can include admission notes, on-service
notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative
notes, procedure notes, delivery notes, postpartum notes, and discharge notes.
Personal health records combine many of the above features with portability, thus
allowing a patient to share medical records across providers and health care systems.

File storage compartment of Medical Record Department

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MEDICAL RECORD DEPARTMENT OF MERCY HOSPITAL
Medical record department (MRD) of Mercy Hospital situated on the 6th floor
of the main building. There is one staff Mr.Rubol Bhuiya who is the Medical
record officer and one computer system is available.

Working Procedure:

When the patient is admit in the ward it is duty of the respective officer to visit
the ward and check the patient files, if any mistake is visible then he/she should
inform the nurses to verify the file closely, which is called open audit.

If any hospital do open audit willfully then there is no place for closed audit.

After discharging of patients files comes from billing department, in some

hospital files comes from ward but here files comes from billing department.

When the files comes from billing department its is the duty of respective staff
to collect the files date wise and write a note on how much files are come into
the MRD.

After that the every individual files must be check through MRD check list, if
any mistake is present then the file must be go back to the respective ward for
close audit.

After close audit system entry is started, where we input patient’s serial
number, registration number, IPD number date of admission, date of discharge,
consultant name, diagnosis, ICD coding.

After that the file should be bundled with a quantity of 1-25 and put a tracker
card on it which is helpful when you need to fine some specific file.

Bundle should be based on various categories of files like general file, medico
legal case (MLC), leave against medical advice (LAMA), death file, delivery
file with IPD number.

Sometimes files should be demanded by other department; on that time the duty
of respective staff is to write a note on lending book that the file is given to this
specific department with the name of receiver and date. And take a note on

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tracker card that the specific file is given to the specific department on
requirement.

Every time the tracker card is changed when the file is back in to the MRD
from the specific department and it is necessary to check the file on that time.

No person is allowed to take patient file without any proper requisition from
MRD, it is unlawful incident.

o General files are preserved for 10 years generally

o MLC files are preserved for 25 years generally, if court cases are running
then the file is preserved for some more years.

One master register is maintained yearly to preserve the patients information,

and also birth and death register also maintained in MRD.

For insurance, corporate patient or if court has sending a letter for some
documents of patients record, the MRD should be provided the required
documents after the approval of medical superintendent.

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Files bundling with IPD number

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MRD CHECKLIST

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 ABOUT MRD CHECKLIST
Medical Records of patient is the most important record that a hospital maintains.
Contents in medical records serve as an important evidence of compliance to many
NABH standards and objective elements. For a hospital that is preparing for
NABH accreditation, concentrating on medical records is very important. Here is
the list of things that must be ensured to comply with accreditation requirements.

(Please note that this checklist is meant for documentation and organizing of
medical records and not meant for treatment audit or medical audit)

1.   Medical record of each patient should have a unique identification number. 

2. Unique identification number of the medical record should be printed/written on

every sheet inside the medical record to prevent misplacement of sheets

3. If applicable, MLC identification and number and details should be mentioned

on medical record

4. Medical record should contain general consent of the patient in all admissions

5. Medical records of currently admitted patients must contain documented

initial assessment within the time-frame defined by hospital (maximum 24
hours). The documented initial assessment should include following;

a. Assessment of presenting complaints, vital signs (temperature, pulse, BP and

respiration) and salient examination findings

b.       Specialty specific assessment findings

c.   Nursing assessment of patient and care plan(identification of nursing needs,

special requirements of patients, identification of vulnerable patient etc.)

d.       Nutritional screening to identify nutritional needs of patient, if any.

e.       Diagnosis (Final or Provisional)

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f.    Plan of care, which includes treatment plan, preventive aspects of care and desired
result of care)

6.  Initial assessment record should have name, signature, date and time

7. Plan of care should be signed / counter-signed by consultant in-charge of the

patient

8. Medical records should contain results of tests carried out, the care provided and
re-assessment findings

9. If patient is transferred to other hospital, medical records should contain date

of transfer, reason of transfer and name of receiving hospital

10. Each entry in medical records should be signed, named, dated and timed

11. Entries in medical records should be legible

12. Medication orders and charts should not have any non-standard abbreviations.
Or should have only those abbreviations that are defined by the hospital

13. Entries in medical records should be up-to-date 

14. Medical records of Patients who have undergone surgery should contain
following documentation

a.       Pre-operative assessment

b.   Type of anesthesia and anesthetic medications used

c.       Safety checklist to prevent surgical errors (like WHO surgical safety checklist)

d.       Informed consent (refer point no. 11 also)

e.       Operative note by the surgeon or his/her team member

f.       Post-operative plan of care

15.   Informed consent in medical records should contain following

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a.       Information on the surgical procedure, risks, benefits, alternatives, name of the
doctor who will perform surgery

b.   Informed consent should be in language that patient understand (having a bi-

lingual consent form can be of help)

c.       Consent form signed by patient (or guardian if applicable)

d.       Consent form signed by the doctor taking consent

e.       Consent form signed by an independent witness

16.   Medical records of discharge patients should contain following

documents

a.       Discharge summary (refer point no. 14 also)

b.       Death summary in case of deaths (should mention cause of death)

c.       Final diagnosis of the patient

d.       ICD coding on the file within a defined timeframe

e.       In case of autopsy, a copy of autopsy report

17.   Discharge summary of patient should contain following documentation

a.       Patient’s name, demographic details and unique identification number

b.       Date of admission and date of discharge

c.      Reason of admission, significant findings, diagnosis and patient’s condition as

the time of discharge

d. Information regarding investigation results, any procedure performed, medication

administered and other treatment given

e.       Follow up advice, medication and other instructions

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f.        Instruction on when to obtain urgent care

g.       Instruction on how to obtain urgent care

18.   Safety, security and confidentiality of medical records. Medical records

department should additionally take care of following points,

a.       Sufficient and safe storage for medical records

b.       Regular pest control in medical record storage area

c.       Availability of fire extinguisher near-by and knowledge on how to use the same

d.       Policy of who can access medical records

e.       How to respond to different request for accessing medical records

f.        Mechanism to quickly retrieve the medical records

g.       ICD codification

h.       Screening of medical records

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Working procedure of MRD

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The department also provides numerous functions and
services
 Training of new staff

Every new staff must be clearly informed in writing of hospital and departmental
policies, rules and procedures. A supervisor cannot hold a staff accountable for
his / her actions unless the staff has a clear understanding of his responsibilities.

 Provide on Job Orientation and Training

All staff are entitled to thorough training for the job to which they are assigned.
An intensive training of three to four weeks should be given to all new
departmental staff before they are independently put to work.

The new staff member should first be introduced to all the personnel of the
department and later to the hospital’s important units, which maintain a close
relationship with the medical record department.

In the initial training stage, staff members should be placed under an

experienced medical records supervisor who in turn must impart “on job
training” and instruct the new staff in observing the correct policies and
procedures.

 Evaluate performance

Every staff wants to know where he stands with his/her supervisor.

Evaluations of performance should take place on a regular basis. Point out to the
staff his/her strengths and weakness.

The medical records technician should assist the staff in correcting poor
performance. The medical records technician and the supervisor should share in a
process of goal setting. This provides a staff with direction for development and
creates job satisfaction and improves his/her self-confidence. Verbally scolding a
staff in presence of others is not acceptable.

Supervisors should strive to maintain two way communications with staff, and
staffs should be encouraged to make suggestions. Supervisors in turn should be
sympathetic when listening to staff’s problems. Finally, a supervisor will at times
have to give priority to get a job done by the staff or to untie a problem.

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 Main Functions
Out-patient service
 Registration of new and revisit patients
 Guiding patient to units and specialties
 Coding of out-patient and in-patient medical records
 Collecting, processing, sorting and arranging of medical records
In-patient service
 Admitting patients
 Discharging patients
Out-patient service

The purpose of the out-patient service area is to register new and revisit patients
and direct them to the concerned units or specialties for consultation and treatment.

New and revisit registration

This section functions throughout the week from Monday to Saturday. The medical
records assistant employed in the new registration area performs the following
function:

I. Procedure for New Registration

 Before registering the new patients the medical records assistant checks for
the sociological data form, outpatient records, and plastic pouch to keep ID card,
staplers and bell pin in the new registration counter.
 The medical records assistant checks the system and other tools to assure
they are working properly.
 The New Registration counter starts functioning in the morning.
 The sociological form filled up by the patient contains the patient’s name,
age, sex and relatives name, address of the patient with city, Patient’s telephone
number, mobile number and fax number.
 The filled up sociological data form is collected at the new registration
counter and checked for any correction, omissions and additions.
 The medical records assistant then enters the data in the system.
 The amount that may be due for the new registration is collected from the
patient.

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 The currency notes are then checked in the fake note identifier machine to
confirm good notes.
 The medical record assistant checks with the patient for any referral letters
from outside doctors.
 The data is then printed in the outpatient main card.
 The identification card along with the receipt is given to the patient bearing
his medical records number.
 The patient is well informed about the likely duration of his consultation and
treatment with the doctor.
 The patient is then taken to the doctor along with his outpatient record for
consultation.
II. Procedure for Revisit Registration
 Patients visiting the hospital from the next day of their new registration are
subsequently called as revisit patients.
 The medical records assistant checks the system and other tools at the
counter to assure they are working properly.
 The revisit registration counter starts functioning in the morning.
 The revisit patient produces the identification card to the revisit registration
counter
 The medical records assistant then enters the medical record number in the
system to register the patient
 The money that is due for the revisit registration is collected from the patient
 Tracer card is prepared for record retrieval by entering the date of
registration and medical records number
 The purpose of the tracer card is to help the retriever to trace the medical
records when it is not found in its place
 The tracer card is then taken by the medical records assistant to retrieve the
medical record
 After retrieving the medical record by M.R.Number, the tracer card is kept
in place of the record
 In case if the medical record is missing, the tracer card will help to find out
the location of the medical record
2. Procedure for patient guides
 During the course of training in medical records, the medical record trainees
are assigned the role of the patient guides
 The role of the patient guides is to guide the patients to the concerned units
from the new and revisit registration area

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 After registration, the new and revisit patients waiting in the lounge are
called through the public address system
 After confirming the name and city of the patients called, the patient guides
will guide them to the concerned units and specialties
Processing and filing of out-patient and in-patient medical records

The main functions of this area are:

 Collection of medical records from the out-patient clinics, specialty clinics

and discharge counter
 Checking for deficiencies in outpatient and inpatient records
 Coding of completed records in the system
 Sorting and serially arranging medical records
Collection and sorting out of disposed of records for filing
 The patient medical records are collected from the dispose box of each out-
patient clinics, speciality clinics and discharge counter by the patient guides.
 The collected medical records are checked for deficiency in outpatient and
inpatient records. The medical records are checked for any incompleteness, final
diagnosis and, doctor’s signature.
 The collected medical records are sorted out according to units and specialty
for coding.
 Each medical record is coded according to the diagnosis and treatment
given. (The importance of coding is explained elaborately in chapter – 6 of this
manual).
 The coding is done in computer software designed for this purpose.
 After coding is done, all the medical records are arranged serially in
ascending order according to the medical records number The medical records thus
sorted out and arranged in ascending order are placed in different medical record
boxes for filing.
 Each medical record box is assigned with serial numbers in a continuous
sequence from 1 to 10000 and from 10001 to 20000 and so on.
 Each medical record box is allotted to a medical records assistant for filing
in relevant racks.
In- patient service

The in-patient medical record services are classified into two sections. They are
Admission and Discharge counter and Accident and Emergency (casualty) service.

Admission counter
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 This admission counter functions 24 hours a day throughout the year. Staff are
posted in two shifts (morning and night) to perform the following functions.

 The patients are guided by the counselors to the admission counter after
counseling is done for the type of lens and room they prefer.
 The admission counter staff collects the money for the surgery and an
advance receipt is generated in the system.
 The receipt is signed by the staff and handed over to the patient.
 The inpatient record is prepared with patient name, age, sex and a rubber
stamp is stamped to write the type of lens and the amount paid by the patient.
 Signature of the patient or his attendant is obtained in the operation consent
form.
 A color folder is attached to hold all the relevant medical record forms of the
patient. This folder denotes the specialty to which the patient is admitted.
 Patient is then taken to the ward or theatre by the nursing staff along with the
case sheet for surgery.
In-patient coding assistant
 After surgery is performed in the theatre, the medical records are sent to the
inpatient coding assistant.
 Each medical record is coded for the surgery performed in the theatre, which
automatically updates the charges for the surgery in the system.
 If patient is supported by monitor or any other additional procedure is done
during the course of the surgery, they are also charged and updated in the system.
Discharge counter
 The case sheet is received from the ward through the nursing staff to the
discharge counter
 The final receipt is generated according to the number of days stay and for
the surgery performed
 The final receipt along with the discharge summary is handed over to the
patient
 The follow-up date of patient’s revisit is explained to the patient by the
discharge counter staff
Monthly duty rosters (schedules)

For effective utilization of personnel, a monthly duty roster must be prepared.

Every month the staff should be rotated from one section to another, with the
exception of the specially trained and supervisory staff. The supervisory and
specially trained should be rotated once every three to six months. The monthly
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duty schedule should include name of the staff, his or her designation, place of
work, main duties and responsibilities, and the person to whom he or she should
report.

Departmental meetings

There should be weekly general meeting with all departmental staff to review the
day-to-day work carried out by the medical records department. Any new
innovations brought for the better improvement of the department can be shared
with the staff members. The problems and issues related to the staff and the
department can be discussed among the staff with the medical records technician
and proper solution should be evolved for the smooth functioning of the
department.

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27
 Objectives
The Medical Records Department (MRD) prime objective is the provision of
patient Medical Records in a timely manner to different hospital units in order to
assist clinicians, allied health professionals and other hospital staff in the provision
of quality care to patients. 
In addition, MRDis responsible for maintaining medical records in a standardized
and professional manner in order to protect patient confidentiality while allowing
adequate access to providers in order to promote quality patient care. 
Therefore, MRD has become an essential department in every hospital, which
provides multiple services not only to the patients but also to running a hospital
efficiently and plays a key role in health promotion and patient care quality.
 

 Creation, storage and maintenance of patient’s medical record.

 Reporting of statistical data to the Department of Health and Hospital

Executives.

 Monitoring the quality of medical record content.

 Maintaining a patient’s right to confidentiality and privacy by adhering to

information release guidelines and ensuring records are kept in a secure
environment.

 Clinical coding.

 Forms design.

 Management of policies on health privacy, patient registration, records

management and archiving, and medical record documentation.

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 Review of Literature
The goal of this review was to identify an data analyze the published literature on
health policy training, specifically in the context of the identified need for health
policy training among health professionals and the increasing emphasis on broader
approaches to policy, including population health, health equity, and health in all
policies.
The context within which health care and public health systems operate is framed
by health policies. There is growing consents us about the need for increased
health policy leadership and a health professional work for prepared to assume
these leadership roles. At the same time, there is strong evidence supporting the
need for a broader policy lens and the need to intentionally target health disparities.
We reviewed the published literature between 1983 and 2013 regarding health
policy training.From5124 Articles identified 33 met inclusion criteria. Articles
varied across common themes including target audience, goal(s), health policy
definition and core curricular content. The majority of articles we redirected to
medical or nursing audiences. Most articles framed health policy as healthcare
policy and only a small number adopted a broader health in all policies definition.
Few articles specifically addressed vulnerable populations or health disparities.
The need for more rigorous research and evaluation to inform health policy
training is compelling. Providing health professionals with the knowledge and
skills to engage and take leadership roles in health policy will require training
programs to move beyond their limited healthcare-oriented health policy frame
work to adopt a broader health and health equity in all policies approach.
Patient care includes a systematic and chronological record of care and treatment which
necessitates the establishment of medical records department in hospitals. The medical record is
a storehouse of knowledge concerning the patient.
Today technology is transforming the4 way healthcare is delivered, managed, and assessed with
a continued shift from record management to data management so MRDs are moving from
surveillance and archival functions to prospective functions and process intervention.
THE MEDICAL RECORD Consider that this is an INITIAL evaluation of the problem. A
clinician will need to look at the progress the primary MD may providenotes for any changes in
status or treatment. the initial dictation but then may consult other specialists (pulmonologist,
endocrinologist, gastroenterologist, n nephrologists, psychologist, etc) to This is the MD’s or
consulting MD’s initialdictate their assessment assessment of the patient and his/her problem
when a patient is first admitted to facility or hospital. It may be several pages long and tends to
be DICTATION:very thorough. RDs and DTRs should go here FIRST to review!

29
1. This is where you will find quick pertinent info (vital signs) like daily weights, temperature,
blood pressure, fluid intake, basic idea of pot intake GRAPHICS:(%), etc. Graphics are usually
completed or logged by the nurse.
2. This is where you find the daily orders for tests, procedures, labs, diets, medications,
consultant its, etc. *RDs/DTRs should go to the MD orders to PHYSICIANS ORverify and
confirm the DIET ORDER as well as supplements! MD ORDERS:
3. MD or other specialists follow up with patients daily (more or less frequently) and reassess
the patient’s progress usually AFTER the initial consultation or dictation. *The RD or DTR will
read this section to receive the most up to date review of the patient’s status. A patient’s status or
PROGRESS NOTES:diagnosis can change
4. This section includes the RN/LDNs review of physical symptoms, patient’s functional status,
patient’s or families’ complaints or concerns, etc. *RDs/DTRs may go to this section to find
more specific information about the patient’s dietary intake, appetite, functional ability,
orientation, affect, NURSING NOTES:etc.
5. This includes all lab tests of serum, urine, sputum, and stool. *RD/DTR would look here for
the most current information (i.e., Alb, Hgb, LABORATORY:etc).
6. This will include updated lists of medications the patient is receiving orally and via IV fluids
during the hospital stay. You will likely see a list of meds the patient takes at home and perhaps a
discharge medication listing. This will also include nursing documentation of date/time the
medication is MEDICATIONS OR MAR (MEDICATIONADMINISTRATIONadministered.
RECORD):
7. Allied health professionals (RDs, pharmacists, speech pathologists, social workers, etc) often
include their full assessments and documentation in this MULTIDISCIPLINARY:section of the
chart. RADIOLOGY:
8. This includes reports from radiology, MRIs, scans, EKGs, etc.
9. Documentation in the healthcare/medical records is crucial and necessary to ensure excellence
in healthcare. The saying “if you didn’t document it, it didn’t happen” is common in the
healthcare setting. Documentation is a legal record that must hold up in defense and justification
of care. It is MEDICAL RECORD DOCUMENTATIONrequired!
10. 1. Documentation must be in black pen---no pencils or erasing should ever be used, 2. If
mistakes occur the practitioner must mark through the error with one line, add the word “error”,
initial beside the error, and add the correction.3. Abbreviations must be approved by the
facility---you are not allowed to make up your own!4. All documentation must be dated5. There
should be no large gaps (blank space) between entries in a medical record6. Do not express your
personal opinions or make criticisms of the patient or other caregivers. Remember that others are
reading your notes!7. Date all entries---Sign all entries with your title8. Be BRIEF, be
THOROUGH, be ACCURATE!9. Do not make a suggestion of medical diagnosis—that is not in
your scope
11. There are various forms of medical record documentation. Regardless of the format the
information included or reviewed is consistent in all TYPES OF MEDICAL
RECORDDOCUMENTATIONforms.

30
12. A system of collection data that focuses on the primary client problems. A problem list is
generated, updated, and continually reviewed. The plan PROBLEM ORIENTED MEDICAL
RECORD (POMR)addresses this problem list.
13. Often a brief notation as a followup to an original assessment. This note will review the
problem, evaluate the effectiveness of plan, and indicate change. Progress notes are documented
at pre-established intervals (daily, PROGRESS NOTE:twice a week, monthly, etc).
14. Many physicians and health care providers document in this format and it is easy to follow.
Some facility use pre-printed forms and practitioners fill out the blanks. Others simply provide
lined sheets that the provider will Acronym forsimply write out S: then info, O: then info, on so
on. Subjective, Objective, Assessment, Plan (see handout on Basics of Soap
SOAP:Documentation).
15. The provider writes out information about the patient in an organized way (similar data
clustered together). Often this is in long phrases or sentences NARRATIVE
FORMAT:reviewing the patient’s problems.
16. Similar to SOAP but without the subjective component (all data, whether DAP (DATA,
ASSESSMENT,subjective or objective is clustered together) PLAN):
17. Intervention: the “actions” to address problem (food delivery, Diagnosis: Includes a
PESeducation/counseling, coordination of care) statement that is “pulled” from 3 domains
(intake, clinical, behavioral ADIME: Assessment: ABCD and pertinent client
history/environmental) this type of charting follows the Nutrition Care Process steps. Facilities
may decide to order notes in this format OR address the initial problem of the patient (in acute
care). 18. Evaluation: Have desired outcomes been achieved? How will this be Monitoring: what
will be “tracked” ortracked? On what time farm followed— loop back to the Assessment data
terms (but not all are selected).

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 HOSPITAL PROFILE

Mission Of Mercy Hospital & Research Centre, Kolkata is well known

hospital for valuable treatment ,it’s located at
125/1,ParkStreet,MullickBazar,Park Street area,
Kolkata700017,NearSouthParkStreetCemetery.

Foundedinasmallclinicinthebackofabuildingin1977 by Rev .Drs. Mark and

Huldah Buntain, Mercy Hospital has
since173bedhospitalwith30specialityunits&19 community clinics, all
serving more than 100,000 patients each year.

Continuinga40yearoldyearmissionto provide healthcare in Kolkata and

surrounding region. The hospital has aligned itself in the process to spread
healthcare to the remotest areas of the state.

The NABH Accredited and NABH Nursing Excellence Certified,

organization has a dedicated team of doctors, nurses, partners with long
standing well wishers and education based institutions from across the
globe.

The hospital offers variety of services including a complete surgical facility

(General surgery, Orthopedic, Obstetrics, Gynecology and Neuro
-surgery), three critical care units (ICCU, ITU, NICU), a mother & child
centre, an emergency centre followed by a medical and general centres.
Since 1979 it operates a School of Nursing, which is affiliated to West
Bengal Nursing Council and recognized by The Indian Nursing Council.

Over 60 years ago, the late Rev. Dr. Mark Buntain and Rev. Dr. Huldah Buntain,
along with their one year old daughter Bonnie, arrived in Calcutta, now
rechristened as Kolkata. They saw the needs of the city and started an education
and feeding program. When a frail girl fainted at a school that Mark had founded,
he rushed her to a city hospital in search of emergency help. Startled by the
hospitals congestion and inability to meet the medical needs of the city’s poor and

32
sick, Mark vowed that day to medically treat the underserved of Kolkata. His
vision began with a small clinic. After several years of strenuous work and
multiple miracles, the plans to build a larger medical facility began to take shape.
In 1977, Mark opened the doors of Mercy Hospital (formerly AG Hospital &
Research Centre), a sevenstory general hospital devoted to serving the medical
needs of Kolkata.

The Mercy Group has a dedicated team of Doctors and Nurses and partners with
long standing well wishers, donors and education based institutions from across the
globe. What started as a small clinic in the back of a building has now expanded to
a 173-bedded multi specialty hospital, a school of nursing, diagnostic centre and a
footprint of outreach Mercy Clinics serving the outlying areas of Kolkata in the
states of West Bengal and Orissa. Over 40,000 needy people receive free
healthcare treatment every year through our medical network. As we move into the
future, we plan to expand our services to include a College of Nursing and 40
Mercy Clinics to carry on our founders original dream of serving the underserved.

The specific operational areas of Mercy Hospital: Mercy Hospital, a

multispecialty, tertiary care hospital currently is rationalized to around 170
operational beds. Through the network of Hospital, OPDs and Outreach Clinics,
approximately 100,000 patients are being served every year. The hospital offers a
variety of services, including a complete surgical facility (general surgery,
orthopedic, obstetrics, gynecology and neurosurgery), a critical care suite including
ICCU, ITU, Level II NICU, SICU & HDU, a mother and child centre, an
emergency center, and general medical and surgical centers. It offers the entire
suite of services offering round-the-clock emergency, trauma care supported by
more than 100 consulting doctors, an efficient laboratory and diagnostic facilities,
and a 24-hour pharmacy. The West Bengal Government has empanelled Mercy
Hospital as a Class-I Medical Service Provider. It is also among the very few
private hospitals in Kolkata affiliated to the West Bengal Health University for
research activities.

33
In the area of education, Mercy Hospital has collaborated with Christian Medical
College, Vellore and is successfully running the Masters in Family Medicine
(MFM) program for doctors since 2008. The ongoing efforts have also resulted in
Mercy Hospital becoming the only host centre for Certificate Course on
Gestational Diabetes Mellitus (CCGDM) in collaboration with Public Health
Foundation of India (PHFI) and Dr. Mohans Diabetes Education Academy. Mercy
Hospital operates a school of nursing that was started in 1979 under the West
Bengal Nursing Council and recognized by the Indian Nursing Council. At present,
work is underway to develop a College of Nursing. Also, work is in progress to
start a Masters in Hospital Administration program from this academic year.

Email: mercyhealthcare.org.in

Emergency number: +91-332-229-6666

Total bed: 173 

 Intensive care beds: 37

Ambulance service: 24*7 days

34
 MISSON, VISION & VALUES

Serving Together in the Spirit of the Gospel

At Mercy Hospital, everything we do is rooted in our heritage as a faith-based
organization and our strong commitment to improving health in the communities
we serve.

Mission
We serve together in the spirit of the Gospel as a compassionate and transforming
healing presence within our communities.

o Create and maintained a committed work environment

o Provide health care in a responsible manner
o Participate and create healthier community

Core Values
o Reverence – We honor the sacredness and dignity of every person
o Commitment to Those Who Are Poor – We stand with and serve those
who are poor, especially those most vulnerable
o Justice – We foster right relationships to promote the common good,
including sustainability of earth
o Stewardship – We honor our heritage and hold ourselves accountable for
the human, financial and natural resources entrusted to our care
o Integrity – We are faithful to who we say we are
o Safety – We embrace a culture that prevents harm and nurtures a healing,
safe environment for all
o Customer satisfaction and responsiveness
o Professionalism
o Integrity and ethics
o Work as a team to achieve goal
METHODOLOGY
35
  DATA CONVENTION : In this process I have two types of data,
i) PRIMARY DATA
ii) SECONDORY DATA

PRIMARY DATA : Primary data is a type of data that is collected by researchers

directly from main sources through interviews, surveys, experiments, etc. Primary
data are usually collected from the source—where the data originally originates
from and are regarded as the best kind of data in research.

The sources of primary data are usually chosen and tailored specifically to meet the
demands or requirements of a particular research. Also, before choosing a data
collection source, things like the aim of the research and target population need to
be identified.

SECONDORY DATA: Secondary data is the data that has already been collected
through primary sources and made readily available for researchers to use for their
own research. It is a type of data that has already been collected in the past.

A researcher may have collected the data for a particular project, then made it
available to be used by another researcher. The data may also have been collected
for general use with no specific research purpose like in the case of the national
census.

 Primary data: a) From observing the MRD

b) Staff and MRD officer
c) From physician,nurses
d) From patient and patient party
 Secondory data: From hospital records,articles,journals.


36
 Data Collection And Analysis

Performance of MRD of Mercy Hospital:

VERY GOOD: 8.2 FAIR: 1.4

GOOD: 3.2 POOR: 1.2

Performance of MrD

1.4
1.2

VERY GOOD
GOOD
FAIR
POOR
8.2
3.2

37
Management of MRD in this hospital

Excellent : 55 Good : 15
Very Good : 20 Poor : 10

Management of MRD
10

15 Excellent
Very Good
Good
Poor
55

20

38
 Quarterly discharge data :

March: 30 June: 35
September: 45 December: 38

Discharge Data
38 30

MARCH
JUNE
September
December

35

45

39
 Annual Death, Delivery, MLC, LAMA data :

Delivery: 80 Death: 20

MLC: 25 LAMA: 40

90

80

70

60

50 DEATH
40 DELIVERY
MLC
30 LAMA
20

10

0
Category 1 Category 2

40
 PROBLEM IDENTIFICATION
 No proper storage area for documents.

 Have no fire extinguisher

 No separate compartment for DEATH files.

 Shortage of computer.

 Lack of man power.

 Need to change old wiring of ceiling.

 Missing MRD checklist in many files, some file has no proper signature
of consultant.

 Lack of space.

 Quality of files is low.

 No proper ventilation.

41
 Recommendation of Problem
 There should be handsome number of compartment for file storage.

 There should be present all the fire safety measurements.

 It is important to arrange individual locker for MLC, DEATH, DELIVERY

files.

 There should be at least two computer system for data entry, and one extra
computer system for sending information to KMC, WBHS about death,
delivery report and disease like MALARIA, DENGUE, HIV, COVID report.

 It is important to appoint two more person as staff of MRD, as it is quite

 impossible for one person to manage whole MRD.

 It is important to look at the wiring system, as it is dangerous for MRD.

 Open audit must be done precisely and efficiently to handle the missing
paper or signatures in patient file.

 One more room must be allocated for MRD to combat against lack of space.

 Infirm the inventory department about the bad quality of file, and requisite
good quality file because these files are store for decade.

 Proper ventilator must be structured in MRD.

42
 CONCLUSION

Medical records play a vital role in patient care in any health care sector. A
qualified medical record practitioner should be available to plan, organize, and
develop policies and procedures which provide continuous direction for the
efficient functioning of well organized and effective medical care.

The process take care of all the requirements of an average hospital and is capable
to provide easy and effective storage of information related to patients that come
up to the hospital.

The training under MISSION OF MERCY HOSPITAL & RESEARCH CENTER

was really necessary as it not only helped me to see how hospital operates but it
also helped to learned about more precisely about how a Medical Record
Department run.

As trainee it was good experience in this hospital. The entire project serve as a
valuable reference guide for us. The hospital provides a vital role in providing
quality based healthcare to the patient and their family members.

43
 BIBLIOGRAPHY
1. https://www.aurosiksha.org/lica/ebook/medical_chapter3
2. https://en.wikipedia.org/wiki/Medical_record
3. https://en.wikipedia.org/wiki/Hospital
4.https://www.google.com/search?
q=medical+record&source=lnms&tbm=isch&sa=X&ved=2ahU
KEwjB5pfZmY_vAhVc8HMBHV3GB_gQ_AUoAXoECBQQ
Aw&biw=1366&bih=600

44
 ABBREVIATION
MRD – Medical Record Department
RD – Registered Dietitian
DTR – Dietetic Technician Registered
MLC- Medico Legal Case
LAMA- Leave Against Medical Advise

45