MEDICAL RECORD DEPARTMENT OF

GaneshDas Govt M&CH Hospital

Pressented by: Bonneyson Shangdiar

&
Wealthyland Sohkhlet
Intern of Hospital Administration
USTM
content
DEFINATION
PURPOSE
ORGANIZING, STAFFING
PHYSICAL FACILITIES
PROCESSING OF RECORD AND THEIR FLOW
CODING & INDEXING
STORAGE AND RERIVAL
REPORTS AND RETURNS
MEDICO-ASPECT OF RECORD
INTRODUCTION
First medical record unit was establish in 1617 at saint bartholomews
Hospital, England
Followed by practice of maintaining patient register in pennsylvania
hospital, USA in 1972
Followed by american college of physician and American college of
surgeon in the last quarter of 20th century
In india Bhore committee in 1946 first stressed the importance of
keeping medical records
Followed by mudaliar committee in 1962
Subsequently, health and hospital review committee highlighted
poor state of MRD and recommended of establishment of proper
MRD section in each hospital
Computer are extensively used for record analysis and retrieval
Microfilming has also been introduce for easy storage and retrieval
DEFINITION
Dr. J.R. Mc Gibony has defined Medical Record as “a
clinical, scientific, administrative and legal document
relating to patient care in which is recorded sufficient data
written in sequence of events to justify the diagnosis and
warrant the treatment and end results”.
Dr. Malcom T. Mac Eachern in his book " Hospital
Organisation & Management" has defined "Medical
Record as a clear concise and accurate history of patient's
life and illness written from medical point of view ".
The health provider that created the patient’s records,
owns the information. Therefore you may need to contact
the hospital or the private health service provider such as
the GP that was treating you.
CONTENT OF MEDICAL RECORD COMPRISING OF :
1-Admission ticket/Registration form

Personal and demographic profile

2-Case sheet
Medical history Clinical findings
Investigation ordered Treatment issue
Progress reports Consent form for surgery or procedure
Anaesthesia check record if applicable Notes on surgical/special procedure
Lab reports in chronological sequence Films along with their reports
of their ordering
PURPOSE
Patient Care
Communication.
Legal documentation.
Billing and reimbursement.
Research and quality management
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.
THE GOOD MEDICAL RECORD PROVIDES ITS
UTILITY TO :

1. Patient
2. Doctor
3. Hospital
4. Teachers ,Students & Researcher
5. National & International agencies.
VALUES OF MEDICAL RECORD TO THE PATIENT
1. Continuity
2. Follow up
3. Re-admission - ( for same / new disease )
4. Communication
5. Maltreatment - claim
6. Medico-Legal safe guard
7. Medical Certificate
VALUES OF MEDICAL RECORD TO THE
DOCTOR
1. Scientific Medicine
2. Continuity
3. Trial on new equipment / medicine
4. Publication
5. Medico- Legal safeguard
VALUES OF MEDICAL RECORD TO THE HOSPITAL.

1. Hospital Statistics
2. Administrative Control
3. Cost Analysis
4. Planning
5. Improving quality
6. Medical legal safeguard
VALUES OF MEDICAL RECORD TO CLINICAL
TEACHERS AND STUDENTS.
Practical Book of Medicine: For learning art of
writing.
Teachers : The clinical teachers can use the
medical record for teaching objective and subjective
symptoms of diseases. The teacher teaches the
practical record of medicines with the help of
medical record.
Students : The student also uses medical record for
learning the art of writing of medical records. They
use medical record as a practical book of medicine.
VALUES OF GOOD MEDICAL RECORD TO NATIONAL AND INTERNATIONAL AGENCIES.

The Medical Record is very useful for National and

International agencies because it generates the
diagnostic data which is very useful for planning of
prevention of diseases and promotion of health.
Following are the National & International agencies :-
1. PHC
2. TALUK(CHC)
3. DIST H.Q
4. STATE H.Q (DHS)
5. NATIONAL H.Q (CBHI)
6. INTERNATIONAL H.Q (WHO)
Function
Development of good Medical Record
Accessibility of Medical Record
Development of Hospital Statistics
Development of Medical Record Forms
Reporting to Health Authorities
Assistance to Medical Staff
Advisory service
Educational Training
Assistance to Medical Audit
Correspondence pertaining to patients
Any other work assigned by the Hospital Administrator
STRUCTURE
ORGANIZING
Organizing of health records means having all
important documents and information in one place,
such as a binder or a “folder” on your computer. Ideally,
we should arrange them in a way that’s easy to sort
through and read. When we sort the health information
like this, there are numerous benefits, including:
Easy access to important medical info
Better understanding of health needs
Emergency preparedness
Consistency from doctor to doctor
STEPS IN ORGANIZING OF RECORDS
Step 1: Locate and keep copies of medical records.

Step 2: Organize medical history and current health

information categorically and chronologically

Step 3: List all current and past medications and

prescriptions.

Step 4: Keep track of billing and insurance

documents.

Step 5: Create a list of important contacts

STAFFING of MRD in Ganesh das
Government MCH hospital(400
Bedded)
SL.NO Manpower Number of staff
1 MRO 1
2 MR technician 0
3 MR assistant 0
4 LDA 4
5 Admission clerk 4
6 Helping staff 6
7 Census staff 1
Total Staff 16
 Norms for developing the number of personnel in MRD
Formula for developing the number of personnel to furnish
around the clock service:
no. of person to be posted

Example; no. of person to be posted

=5
General Categories of staff for MRD
according to bed strength:
CATEGORY BED
50 100 250 500 750

MRO - 1 1 1 1
MRT 1 2 6 12 14
ASST. MRT 7 10 23 44 70
MED.TRANCRIPTI 1 2 4 7 8
ONIST
QUALITY - 1 1 1 1
ASSURANCE
SPECIALIST
TOTAL 9 16 35 65 94
Space and general facilities requirement: Space of MRD at Ganesh Das Govt. MCH
hospital:

• General office requirement for staff • General office for staff

• Separate counters for admitting clerk , • Separate counters for admitting clerk ,
receptionist receptionist

• Adequate waiting space, • Adequate waiting space,

• Toilet for staff, patient and attendant • Toilet for staff,

• Telephone facility for local calls and STD • Telephone facility

must be made

• Storage-120-500 sq ft with shelving • Storage-700 sq ft with shelving

• Retention schedule • Retention schedule

OPD-5 years OPD-5 years
IPD- 10 years IPD- 10 years
MLC- life long MLC- life long
Location requirement: Location of MRD at Ganesh Das Hospital

Near main entrance in close proximity with Near main entrance adjacent to front office
emergency and OPD and adjacent to front
office

Admission and inquiry office Admission and inquiry office

Separate counters of old and new Separate counters of old and new
registration registration
Fully functional computers Fully functional computers

Waiting area Waiting area

Space- Space-
Medical record office for 50 bedded Medical record office of this 400 bedded
hospital-74 sqft hospital -300 sqft
MRD for 100 bedded hospital- 104 sqft
MRD for 250 bedded hospital -177 sqft
MRD for 500 bedded hospital-354 sqft
MRD for 750 bedded hospital-474 sqft
PROCESSING OF RECORD & THEIR
FLOW
Processing of birth certificate
Arrival of
birth Received in Register in the system for
reports MRD issuing of birth certificate
from before 21 days
wardsm

Receiving of form filled

up/supporting
Issuing of Birth documents from
certificate parents for birth
certificate after 21 days

Deliver of
Printing Birth
certificate
Processing of death certificate
Arrival of
death Received in Register in the system for
reports MRD issuing of death certificate
from
wardsm

Receiving of form filled

up/supporting
Issuing of death documents from
certificate parents for death
certificate

Deliver of
Printing death
certificate
In-patient record process:
Organised case
Arrival of sheet by date and
Received in ward name
tickets/
MRD
patient’s
data from
wardsm

Filing in MR-
library

Disposing
ordinary
case sheet
after 10
years
General Flow of MRD
 CODING AND INDEXING
 Medical coding is the process of taking a patient’s health care
information like medical procedures, diagnosis, necessary medical
equipment, and medical services information from the physician's
notes. A medical coder transforms this information into universal
medical alphanumeric codes.

 Medical coding's primary use is to ensure medical billing and insurance

carriers pay and process claims correctly, but the system is also valuable
for research purposes and basic medical record-keeping for patients.

 Each code tells insurance companies, researchers, and health care

providers the exact diagnosis, procedure, and/or medical service
provided. In short, these codes act as a universal way to quantify health
care visits and make physician’s notes less abstract for insurance carriers
and future health providers
CODING AND INDEXING
 There are three types of universally known medical alphanumeric codes:
1. International Classification of Diseases (ICD): The World Health
Organization (WHO) created this internationally used code. The
classification system is largely used for the purpose of health
recording and data collection, among other uses. These codes can
classify symptoms, diseases, illnesses, and causes of death.
2. Current Procedural Terminology (CPT): CPT codes identify
medical, surgical, and diagnostic procedures and services within the
US. The American Medical Association (AMA) developed this
system, which includes three categories: procedures and
contemporary medical practices, clinical labs, and emerging
technologies.
3. Healthcare Common Procedure Coding (HCPCS): The Centers
for Medicare and Medicaid Services (CMS) developed this coding
system to help with processing insurance claims for Medicare or
other providers. Coders use them to note medical procedures,
products, supplies, and services.
 Paper-based system:

A code number(s) is/are assigned to the diagnoses and procedures documented in the
health record. The coder looks the code number up in a coding book or by entering
key words into the computer using software called an encoder.

ICD-9- and CPT are the two primary coding systems used in a hospital setting. The
purpose of the coding system is to provide uniform language that accurately
describes medical, surgical, and diagnostic services.

Coding ICD-10 : After completion of medical record now the record is ready for
generating Morbidity and Mortality data. For this purpose coding and indexing of
diseases is done. The coding of disease is the process of assigning code numbers
according to the coding books i.e. ICD-10th revision published by WHO. The code
numbers are written on the front sheet of case sheet by MRT.

Hybrid and EHR system:

The process is the same as the paper-based system, except that in the EHR
environment, the record that is reviewed is the electronic health records. Coding may
be remote to hospital; home-based coding is possible.
CODING & INDEXING
The Index of a hospital means listing of the patient's in a systematic manner. There are
various types of indexes used for the medical record of a hospital.

TYPES OF INDEXES USES

1. Alphabetical Index - Public Enquiry

(Patient's or Master - Retrieval of MR.
Index)
2. Diagnostic Index - To generate Diagnostic
statistics
- Primary Card and
- Secondary Card for Diseases
- Operations Card
- External Causes of Injury Card
- Cross Index.

3. Physician Index - Record Control

- Doctors Clearance
- Qualitative Data.
STORAGE & RETRIVAL
Paper-based system
Patient care information documented on paper and housed in file
folders .Records retrieved for patient care purposes, quality
improvement studies, audits, and other authorized uses. Records are
delivered to the nursing units, outpatient surgery, and the
emergency room as the patient is admitted or being treated.

Hybrid system
Patient care information documented both on paper and in the
computer. Record is accessible to patient care areas via the computer
by use of an electronic document management system (EDMS).

EHR
Patient care information captured at point of service and/or
electronically transmitted to the EHR. Record resides entirely in
electronic format with work processes performed via the computer
CONT…

File retrieval;
When patient attend follow up
For research and academic purposes
For medical reimbursement
For producing in court of law for medico-legal cases
 Retrieve form is filled
up by concern patient

After approval from MS

given to MRO

MRO giver the person record in

duplicate & note down the
number of page in the form and
takes signature

After giving the record back the

person sign on that form
REPORTS & RETURNS
Report can be compile daily, weekly, monthly, quarterly and
annually
Report summarise the service of nurses / agency
Report may be in the form of an analysis of some aspect of
services
Report are base on records on registers so it is relevant for the
nurse to maintain the record regarding their daily case load
service load and activities
The data can be obtained continuously and for a long period
Records and report reveal the essential aspect of service in such
logical order so that new staff may be able to maintain continuity
of service to individual families and communities
MEDICO-LEGAL ASPECT OF RECORD
 LEGAL ASPECTS OF MEDICAL RECORD.
  Legal aspect of Medical Record means uses of medical record
from the medico legal point of view in the court of law.
Following points are studied in the legal aspect of medical record
1. Property Right
2. Types of Medico Legal Cases
3. Terms used for summons
-subpoena
-subpoena duces tecum
4. Conduct as a witness
5. Release of information
6. Correction of Data
7. Authorization - Surgery / Autopsy
8. Coroner's or Medical Examiners cases
( for deaths )
MEDICAL RECORD COMMITTEE
Definition: Medical Record Committee is organized to
develop MR Forms, M.R. Policies, Ensure M.R. filing, M.R.
Legal Policies, and to assist in M.R. working of a hospital.
Mainly important for monitoring and audit of medical records

FUNCTIONS :
- M.R. Forms.
- M.R. Policies
- M.R. Filing -Ensure
- M.R. Legal Policies
- M.R. Working - Assist.
REMARKS
Lack of h0spital information system(HIS)
Lack of staff in storage room
Lack of trained man power in MRD
Less space for storing of new files
Improper storage/disposal of old and expired records
Difficulties of retrieval due to manual medical records
Pending of documentation and filing
RECOMMENDATION
Requirement of HIS in MRD for in patient record
keeping
Trained Manpower for storage and maintenance of
medical records
Installation of fully functional EDMS
THANK YOU