Medical Records Department

Introduction :

The first medical records unit was established in 1667 at St.Barthlomew’s Hospital in England followed by the practice of maintaining the Patient’s register in Pennsylvania Hospital in USA in 1752. The impetus to the idea of proper medical records in the form of standardized inpatients records came in the USA from American College of Physicians and American College of Surgeons in the first part 20th century. In 1928, the Association of Medical Record Librarians was formed. Bhore Committee (1946) first stressed the importance of keeping adequate medical records, which was reiterated by the Mudaliar Committee in 1963. Subsequently, Health and Hospital Review Committees (Dr. KNRao committee 1968 and Jain committee 1968) recommended the establishment of a proper medical section in each hospital.

Definition:

The medical record is defined as a clinical, scientific, administrative, and legal document Medical Record Department relating to patient care in which are recorded sufficient data written in the sequence of events to justify the diagnosis, warrant the treatment and results.

The medical record therefore is :

A document of facts, which contains statements by trained observers of the condition found and the application and the result of the examination and therapy.

It also indicates whether or not the efforts of the doctors, supplemented by the hospital and related facilities are in accordance with the reasonable expectations of the present day's scientific medicine.

Classically the medical record of a patient contains the documents arranged in the following sequence :

Admission form
Case sheet comprising of
Medical history
Clinical findings
Investigation ordered
Treatment instituted
Progress reports
Consent form for surgery or specialized procedures
Anesthesia check record, if applicable
Lab reports in chronological sequence of their ordering
Films along with their reports
At the time of discharge a narrative summary is prepared and the discharge form is generally placed in the first position when the record is finally stored.

Medical records both for inpatients and outpatients should be prepared. Each individual attending an OPD is given a registration number and all medical records are kept in a folder bearing the same number. The patient is issued a ticket/token bearing the registration number. The folder is sent to the appropriate dept on the presentation of a token. The folder is deposited back after the visit.

The medical record dept is an integral part of hosp to achieve the unique task of maintaining and storing medical records in good order. In small hosp or in PHC it may be in the form of a medical record section.

Purpose

The medical record is indispensable for patients, doctors, and the hospital and for medical education and research.

Patient’s needs:

The written report is evidence that the patient’s care is being handled in a scientific manner.

It serves to document the clinical story of the patient’s illness and course of the disease.
It serves to avoid omission or unnecessary repetition of diagnostic and treatment measures.
It assists in the continuity of care in the event of future illness.
It serves as evidence in a court of law.
Provides necessary information for insurance, contributory health scheme, or employment purposes.

Physicians needs :

From the point of view of the doctor, the medical record serves as:

Assurance of quality, quantity, and adequacy of diagnostic and therapeutic measures undertaken.
An assurance of orderly continuity of medical care.
Evaluation of medical practice.
Aid in research and the continuing education of health professionals.
Protection against litigation.

Institution / Hospital needs :

From a hospital point of view the medical records are necessary for the following purpose :

Document the type and quantity of work undertaken and accomplished.
Furnish proof of the type and quantity of care rendered to the patient.
Evaluate the proficiency of the individual doctor, for administration and clinical purposes.
Evaluate the services of the hospital in terms of accepted norms and standards.
Protect the hospital in the event of legal matters.
Serve as the administrative record of personnel performance and staffing needs, budget preparation, statistical data for administrative use and evaluation, for estimating equipment and supply utilization and needs.

Health Authorities needs :

The records are important to the public health authority as they contain reliable information regarding morbidity and mortality patterns of dependent populations. Reports like births and deaths, infectious diseases, notifiable diseases, statistics regarding the incidence of diseases, and types and number of family planning procedures are constantly required by the Govt.

Medical education and research :

Medical records can also be used for medical education and research in the following ways :

Recorded observations are the basis for all clinical research.
Group studies of records by the medical staff serve to further the education of doctors and other health personnel.
Medical records supply pertinent data for use by public health authorities in control of the diseases.

Functions of Medical Records

The functions of the medical record dept are:

To develop a good medical record system
To generate hospital statistics
Develop new record system in newer departments
Reporting to state and health agencies
Training
Quality assurance
Assembling of the medical record
Retrieval of records
Storage & retention
Numbering & filing
Reporting
Analysis of statistics
Completion of incomplete records
Deficiency check

Following should be ensured in MRD

Prompt record service at all hours of any information
Convenient and adequate accommodation and easy accessibility.
Easy availability and retrievability
Simple procedure

Characteristic of good medical record

Complete in all respects
Provide adequate information
Provide accurate information
Legible & documents to be signed by the clinician

Completion of a Medical Record

The consent form for treatment has been signed by the patient/relatives.
Patients identification details should be entered in correct forms
Doctors have recorded all essential documents
Doctors have signed all dated and clinical entries an especially the front sheet of record.
Nurses have recorded with sign and date of all daily notes regarding patients condition and care of the patients
All the orders for treatment have been recorded in the medication form and signed.
The main condition and principles of the disease should be mentioned on the front sheet of the record.
The anesthetic/operation form if any has been completed and signed.
Operations and procedures have been recorded on the front sheet.
All diagnostic reports have been attached
The discharge/referral summary is fully filled and signed.

Planning, Organization & Staffing

The main factors that govern the organization of work in a medical records dept are

Medical records should always be available where required in the form they are required.

Adequate liaison should exist between different groups of staff using medical records to enable to give due consideration to matters such as design and contents, method and storage availability, use and movement of records.

Procedures should be in a convincing way, cause patients the minimum of waiting and inconvenience.

The overall responsibility for the efficient functioning of MRD is that of the administrator/MS. However, the department should function under the direct supervision of a medical record officer who should be given authority commensurate to the responsibility.

Necessary assistance to the functioning of MRD is given by ‘Medical Records Committee’ which is a policy-making body and meets periodically to review the forms, records, existing policies, and procedures. The committee is composed of Representative of clinical discipline, Nursing staff, Rep of lab service, and Administrator

Organization: the MRD is organized as under

Admission and Enquiry office :

This office initiates documentation of inpatients, maintains records of all admissions, discharges, and deaths, collects the documents after discharge, and forwards the same to the central record office for further processing. It keeps up-to-date information on the bed state of each ward. This office operates round the clock and provides all necessary information. This office has

Admitting office,
Admission check desk,
Census desk and
Enquiry office.

Central Record Office :

The central record office is organized to perform the following functions :

Receipt, checking, assembly, and storage of medical records of all discharged patients.
Discharge analysis and statistics
Coding of all as per international classification of diseases.
Indexing of all discharged patients by disease, doctor
Making records available for the medico-legal purpose
Issue of medical certificates of various types
Send notification of all communicable diseases
Issue of medical records to physicians when required
Preparation of monthly abstracts and annual statistical details
Dealing with enquiries from LIC
Training
Storage of all types forms of used in hospital
Keeping this in view this dept should have Office for Medical Record Officer and Asst MRO, Document processing area comprising assembly and deficiency check desk, incomplete record control desk, coding and indexing desk, discharge analysis and vital statistics desk, Record storage area of both active storage and inactive record storage areas.

Out-Patient Record Section: These records are as important as that of inpatients.

Staffing :

The staffing of MRD depends upon the size, type, and services being provided by the hospital. Dr. JR McGibony has suggested a staffing pattern for a 500 bedded hospital as under :

Medical Record Officer 1

Medical Record Technician 4

Clerks 3

Peon 1

Statistician 1 ( on part time basis)

Admission and Enquiry office

Asst Medical Record Officer 1

Medical record technician 5

Medical record attendant 4

Receptionist 5

Central record office

Asst medical record officer 1

Medical record technician/clerk 8

Medical record attendants 8

Statistical asst 1

Each category of personnel should be computer literate.

Physical Facilities

While planning physical facilities for MRD the following should be taken into consideration:

Location :

Admission and enquiry office should be located near the main entrance, in close proximity of OPD and A & E-service. The outpatient record section should also be located near the main entrance. The Central medical record office may form a part of the administrative wing. Since this office deals with IP records, it should be near to the inpatient areas.

Space and General facilities requirement

Admission and enquiry office :

A space of 125 – 175 sqft. is adequate. The counter should be aesthetically made to facilitate easy communication between staff and clientele. General office equipment will be required for staff working. Separate counters for admitting clerks, receptionists, and billing clerks should be provided. It should have adequate space with facilities for waiting, toilet for staff, patients and their attendants. PCO may be provided.

Central Record Office :

As a rough guide, a space of 2to 3 sqft. per bed may be sufficient. The details are under :

50 bed hosp 150 -175 sqft.

100 bed hosp 225 – 250 sqft.

200 bed hosp 450 – 500 sqft.

500 bed hosp 1000 – 1200 sqft.

This area may be sufficient to store inactive medical records also. The space for this may be in the general record storage area. Space ranging from 120 to 500 sqft. with adequate shelves will be required.

In addition to computers, general office equipment will be required. Adequate facility for holding the meeting, to pursue the record needs to be catered.

Outpatient record section :

Average 2 – 3 sqft. per bed of space is required. A space of 150 sqft. for 50 bed hospital to 1200 sq.ft. for a 500 bed hosp may be adequate for outpatient records.

Separate counter for registration of old and new, male and female patients are to be provided.

Counter 24” wide, 40” high with file drawers beneath it is required.

The waiting area adjacent to registration furnished with chairs, announcement boards, and health education visual aids need to be catered.

Equipment

Typewriters
Computers
Data storage devices
Printers
Microfilming devices
Photocopier

Processing of Records and their Flow

Whenever a patient admitted the following steps are involved :

Initiate inpatient records
Fill in a Patient Index Card: Patient identifying data
Inscribe in an admission register: The identification data with date of admission.
Identifying Number: Each patient is given a unique identifying number.
Medical records so initiated containing patient’s admission number and identification data sent to the ward with the patient.

Action taken by various functionaries at admitting office are:

Admitting office

Initiates patient’s hospitalization record
Assign admission number
Prepares admission records
Sends patient along with admission record to the nursing unit
Send a copy of the admission record to the admission check desk

Admission check desk

Receives admission advice from admitting office
Checks patient index for the previous admission
If no previous admission, make a new patient index card
Sends index card to the incomplete record control desk
Send records of the previous admission to the nursing unit
Prepares record folder with admission record and sends it to complete records control desk.

Census desk

Prepare admission list from admitting office
Collect discharge patient records from nursing units daily
Prepare discharge list
Prepare census reports

Medical Records at Inpatient unit :

The patient document is filled in by the attending doctors for history, physical examination, treatment, order for diet, operation procedures and progress notes, investigation/ procedure ordered and referral if any. Nurses fill in the charts for temperature, pulse, respiration.

Medical Records on Discharge :

The attending doctor completes all the entries in the clinical case documents including preparation of discharge summary and discharge slip.

Action taken by various functionaries in medical record office:

Assembling and deficiency check desk :

Receives discharge patients' records from the census desk.
Assembles records in standard order and staple bind.
Checks deficient entries on records.
Send records to the incomplete control desk.

Incomplete record control desk :

Receive discharge records from the assembling desk.
Receives index card from admission check desk.
Maintains “in hospital” file index cards of patients not discharged.
Maintains index cards of discharged patients whose records are incomplete.
Send reminders to doctors of incomplete records.
Complete index cards of discharged patients
Sends index card to admission check desk for filing.
Sends records to discharge analysis desk

Coding and Indexing

Coding :

In each medical record, the International Code Number is assigned to the diagnosis based on the “International Classification of Disease” issued by WHO. This is to bring about accuracy and uniformity in reporting of diseases by the various hospitals.

Indexing :

Alphabetic or Master index: Based on the patient's name in alphabetical order.
Disease index
Operation index
Physician index: For evaluating the performance of physician
Unit index: To evaluate the performance of a particular unit.
Completed records control desk: Places in a folder, stores, makes available records when required.

System of Filing :

Decentralized system: Under this system inpatient and outpatient dept have their own individual records and file them independently within the dept. this system is labor-intensive and the operating cost are higher.
Centralized system: In the centralized system, medical records are filed centrally in the medical records dept. it is more efficient, provides better control.

Methods of Filing :

The various methods are

Numerical method
Alphabetical method
Chronological order
Terminal digit system
Mid digit system

Filing Procedure :

Types of Files :

It is useful to use files of different colors for different years for easy retrieval and identification. Files should be of uniform standard size depending upon the size of forms in use in a hospital. For most forms a standard size depending upon the size of forms in use in a hospital. For most forms a standard size of 8 ½’’x 11” is preferable. The filing jacket should be ½” bigger than the length and width of the biggest form in use.

Filing :

Three types of filing procedure are generally used :

Vertical Suspended: Specially made filing cabinets and records are suspended from frames in drawers in the cabinet. It is costly.
Horizontal: Files are kept one upon another in chronological order. Retrieval of records is difficult.The reports may be generated daily, weekly, monthly, quarterly, and annually depending on the requirement. The report generally pertains to :
Vital statistics: Admission, Discharge, and Transfer analysis, General Health Statistics

Some of the reports that can be commonly generated are :

Reports related to a hospital bed

Daily census
Minimum and Maximum patients on any day
Bed occupancy rate
Bed turn over an interval

Admission

Daily admission, unit wise and specialty wise
Patient distribution by age, sex, and region

Discharges

Daily discharges
The average length of stay
Total patients discharged over a period

Deaths

Daily number of deaths
Total deaths over a period
Total deaths over 48 hours
Net death rate and gross death rate
Fetal death rate
Maternal and infant death rate
Postoperative death rate and anesthetic death rate

Workload statistics

Total number of outpatients both new and repeat cases
Total number of operation
Total number of investigation both lab and imaging
Department wise workload statistics

Retrieval of medical records :

The retrieval of medical records is usually required for any of the following purposes:

When a patient attends for follow up
Patient is admitted
When the files are issued to research workers for academic purposes
For medical reimbursement
For producing in the court of law for the medico-legal purpose

The medico-legal aspect of medical records :

It is an important legal document and can help the patient, aid and protect the doctor and act as a shield to any institution. To meet the legal requirement, the medical records must fulfill the following criteria :

Complete
Adequate
Accurate
Legible

Storage

Completed medical documents are stored in the main medical records by following a filing system.

The following factors are considered for an effective filing system :

Compactness to reduce physical effort and cost of storage space.
Accessibility for speedy location and identification.
Simplicity for understanding of all concerned.
Economical both in the cost of installation and operation.
Elasticity to expand according to future requirements.
Tracer system for documents in circulation.

In a conventional system where medical records have been stored in shelves, the file is traced by number allotted. The file folder is taken out and a tracer card is placed in its place as marker. The tracer card contains basic information regarding the recipient of the document, purpose for which documents are required, date of issue, signature of individual receiving and issuing the documents. The tracer remains in its place until the file is returned.

Retention of medical records:

Need of patient
Medico-legal requirement
Education and research requirement
As a general guide the documents be retained for the following periods :
OPD records 5years
Indoor records 10 years
Medico-legal records till finalization of case permanently

Safety of records :

Responsibility for the safety of records lies with the administration. Medical record officers should control all medico-legal records in safe custody.

Confidentiality of Medical records

There is a vital need to maintain patient information in a confidential manner. Patient information shall not be released without legal authorization.

A medical record information contained in a medical record should be released only if
A valid written consent for the release of this information is obtained from the patient or legally authorized representative.
Reporting is required or permitted by law.

Who can access to the Health information?

Patient himself
Treating Physician
Authorized person by the patient
Other clinicians and administrative staffs can access after Medical superintendent approval. s
In case of death: Authorized representative of family/court of law.
In insurance cases ,the release of information without prior consent of the patient is permissible coz the patient had already claimed at the time of taking out a policy with the corporation.

Role of staff maintain confidentiality

Acknowledge request for health information promptly.
Maintain integrity of records
Take reasonable steps to confirm identity of the person seeking the information.
Access the information to determine weather access to it must or may be denied.

Audit of Medical records

Medical record committee

Is established which responsible for all matters relating to the content of medical records and the provision of medical records in the hospital. The committee is consists of

Doctors from Surgery & Medicine
Nursing Administration
Management staff
Medical Record Officer

Responsibilities

Review of medical records to ensure that they are accurate, clinically pertinent, completely & readily available for continuing patient care, medico legal requirements & medical research.
Ensure that medical staff completes all the medical records of patients under their care by recording a discharge diagnosis and writing discharge summary for each discharged patient within a specific period of time.
Determine the standards and policies for the medical records and the medical record services of the health care and facility.
Recommend action when problem arises in relation to medical records and the medical record service.
Determine the format of medical record and approve and maintain the introduction of new medical record forms used in the medical facility.
Assist and support the MRO in liaising with other staff/departments in the healthcare facility.

Audit

Are medical records filed promptly?
Is the file room clean and tidy?
Are patient index cards filed promptly?
Are all discharge records return to the medical record department after the day of discharge ?
Are the medical records complete?
Are medical record forms filled in correct order?
Are all medical records completed within a specified time after discharge.
Are medical records coded correctly?
Are the monthly and yearly statistics collected within a specified time?

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The Medical Records Department