ROLE & IMPORTANCE OF MEDICAL RECORDS C.Govindarajan Chief Medical Records Officer &

1. ROLE & IMPORTANCE OF MEDICAL RECORDS C.Govindarajan Chief Medical Records Officer & President, Health Records Association of INDIA

2. Location & Days and Hours of Operation • The Medical Records Department should be located adjacent to the Front Office • The Medical Record department have to function 24 hours on all the days to cater the Medical Records immediately.

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

4. Guiding Principles of the Department • 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

5. CODE OF ETHICS MEDICAL STAFF • Bound by Professional Secrecy and Oath • PARAMEDICAL STAFF • MEDICAL RECORD PROFESSIONALS, NURSES, • OTHER PARA MEDICAL STAFF TO MAINTAIN. • Confidentiality about patients, disease, treatment & end results. • Not to divulge any type of information about patients. • Abides by Ethical principles.

6. 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. 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

7. 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.

8. HOSPITAL STATISTICS • 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.

9. FLOW OF MEDICAL RECORDS Registration counter Consultants O.P I.P Admission Wards Medical records Indexing Deficiency check and coding Assembling Computer entry Permanent filing Scanning

10. In-patient records: Assembling format: The arrangement of medical records takes place in the following order: • SUMMARY SHEET& ADMISSION RECORD, • DISCHARGE SUMMARY • HISTORY OF FINDINGS • CONSULTATION REQUEST • LAB & ECG REPORTS • ANESTHESIA CHARTS • OPERATION NOTES • PROGRESS SHEETS • DOCTORS ORDERS • ICCU CHARTS • CONSENT FORMS • NURSES CHARTS • CLINICAL CHARTS • DRUG CHARTS • IV FLUID CHARTS • OTHER AUTOPSY • BIOPSY REPORTS AND OTHER HOSPITAL REPORTS.

11. Medical Records Committee Members • Medical Superintendent (Convener) • Three Sr.Consultants (various specialties) • Administrator • HOD – Medical Records Department • HOD - Quality Systems • Nursing Superintendent / Representative • HOD – OP/IP Services.

12. INTERNATIONAL CLASSIFICATION OF DISEASES INTRODUCTION Classification of diseases and operations is one of the most important functions of the medical record department. A well-organized medical record department selects one of the best suited International Classification Systems to code and index diseases and operations for the collection of morbidity and mortality information. The International Conference for the Tenth revision of the International Classification of Diseases was convened by the World Health Organization at WHO headquarters in Geneva from 26 September to 2 October 1989. The conference was attended by delegates from 43 member states

13. ICD 10TH REVISION BY WORLD HEALTH ORGANIZATION Volume 1 Introduction WHO Collaborating Centers for Classification of Diseases Report of the International Conference for the Tenth Revision List of three-character categories Tabular list of inclusions and four-character subcategories Morphology of neoplasm's Special tabulation lists for mortality and morbidity Definitions Regulations Volume 2 Instruction manual Volume 3 Alphabetical index

14. CHAPTERS OF ICD – 10TH REVISION (21 Chapters) I Certain infectious and parasitic diseases II Neoplasm's III Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism IV Endocrine, nutritional and metabolic diseases V Mental and behavioural disorders VI Diseases of the nervous system VII Diseases of the eye and adnexa VIII Diseases of the ear and mastoid process IX Diseases of the circulatory system X Diseases of the respiratory system XI Diseases of the digestive system XII Diseases of the skin and subcutaneous tissue XIII Diseases of the musculoskeletal system and connective tissue XIV Diseases of the genitourinary system XV Pregnancy, childbirth and the puerperium XVI Certain conditions originating in the prenatal period XVII Congenital malformations, deformations and chromosomal abnormalities XVIII Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified XIX Injury, poisoning and certain other consequences of external causes XX External causes of morbidity and mortality XXI Factors influencing health status and contact with health services

15. Indexing of patients data • Disease & operation indexes are maintained separately. A physician or a medical staff can use these index for the following purposes. • Review cases of disease to provide the management a scenario of current health problems. • Compose data on diseases in order to prepare scientific papers. • Procure data on the utilization of hospital facilities and increase the needs such as equipments and beds. • Evaluate the quality of care in the hospital. • Providing patient care data for committees. • Data on the medical practice in the hospital. • Data on the Drug Trail for research.

16. FEW EXAMPLES • DIAGNOSISCODE NO. • DIABETES MELLITUS - E14 • ACUTE MYOCARDIAL INFARCTION - I 21.9 • ABORTION (Attempted Failed) - O07.9 • AMOEBIC ABSCESS - A06.4 • IRON DEFICIENCY ANAEMIA - D50.9 • CALCULUS KIDNEY - N20.0 • CANCER BREAST - C50.9 • CANCER LIVER - C22.9 • CANCER LUNG - C34.9 • SPRAIN (JOINT) - T14.3 • ULCER STOMACH - K25.9

17. Numbering System - MRD • The unit numbering system may be followed . • It provides a unit record which is a composite of all IP& OP data on a given patient. • When first registered in the hospital the patient is assigned a number which remains same for all his subsequent visits. • His entire medical record is in one folder under one hospital number i.e. the number first registered in the hospital.

18. Filing system The terminal filing system may be followed • The first two digits are tertiary, • the next two are secondary & the last two are primary. • The primary digit remains constant. Eg 127,227,327,427. • Each staff may be assigned responsibility for certain section of files. • This eliminates confusion and one person cannot blame the other. • Also, misfiling can be reduced in this case.

19. Quality Policy • Medical record documents shall be treated as confidential, secure, current, authenticated, legible, and complete • Medical Records Department shall be provided with adequate direction, staffing, and facilities to perform all recognized functions Quality Objectives • To provide medical records within -- minutes of request for the patient care. • To provide timely intimation of birth & death to the statutory board. • To provide timely intimation of Infectious and Notifiable diseases. • To minimize the deficiency in the Medical Records

23. IP DEFICIENCY

24. Birth and death certificates: • Birth to be reported to the corporation within 21 days. • Death to be reported to the corporation within 21 days. After the stipulated time: • Up to 1 month: Rs 5/- as penalty. • 1 month- 1 yr: Rs 10/- as penalty +letter to the Assistant Revenue Officer with notary public(affidavit) + hospital covering letter signed by medical superintendent. • After 1 yr: Rs 15/- as penalty +magistrate order +covering letter signed by the Medical Superintendent.

25. Out-patient records Retrieval area • According to the appointments the Record no. is sent on line in the system and also informed for walking patients by the respective concerned secretaries over the intercom. • They are entered in the retrieval register along with the consultant name. • The records are then pulled out from the filing areas and to be sent for dispatch within 15 minutes.(International benchmark –45Min). • The records that are to be dispatched through confidential Bag and given to the secretaries and an acknowledgement is taken with employee number from them in the dispatch register. • This plays a vital role in finding the missing record from the consultation areas. • Care should be taken while filing so that misfiling is avoided and also for prompt delivery of the records the next time patient visits the hospital.

26. Tracer card • The tracer card plays a very vital role in the filing area. • It contains the RECORD NO, CONSULTANTS NAME ANDTHE DATE OF RETREIVAL. • The cardial rule in the filing area is that no record can be removed from rack without being replaced by a tracer card or a tracer card with the requisition(IP). • This rule applies not only to extra departmental staff but to the employees of MRD.

27. Census • In patient census: The number of In-patients at any time. • Daily In-patient census: The number of In-patient days of the patients who are both admitted & discharged after the census taking time of the previous day. This census is sent to the top management. • Average daily census: The average number of IP present each day for a given period of time. Medical Record usually compile the census and send it to top management. This census is usually taken at midnight. This census should always comparing with the previous year.

29. Medico legal cases • Suicide, accident, quarrel, fights, cuts, tablet poisoning, over dosage of drugs, suspected case of EMO (patient dies on the way)). • In these cases the medical officer creates an Accident Report (AR) copy & the police is intimated. MLC ordinary Cases • AR Report. (Accident Register Report) • Police intimation.(informed by the security) to the Police station. MLC death cases: • Original death certificate, death summary( if required photocopy of history, progress sheet and operation notes.) • The above documents are handed over to the Security Officer which in turn sent to the police along with body for post mortem

30. Wound certificate: • This occurs in MLC cases. • The case is first attended by the casualty medical officer (CMO) and then reported. • If required, the police with an authorization from a higher official along with valid station seal will handover the letter • The Staff of the MRD has to insist on the Photocopy of the Police. • The type of injury to the patient (simple/grievous) is explained in the certificate. • A copy of this wound certificate is kept in the medical record folder for future reference.

31. Insurance cases – Post Claim • These cases arise when the patient has a medical insurance coverage . • The patient is given two forms from the insurance company- B & B1. • Both the forms cover about the treatment undergone in the hospital and about the expired details of the patient, if any. • A nominal fees may be collected by the cashier. as per the policy • The forms are sent to the concerned Consultant and filled up by the consultant with the authorization at the bottom along with the hospital seal. • The original copy is sent to the insurance company, one photocopy is sent to the patient/ relative address and another photocopy is filled in the Medical Record.

32. Destruction of records • As per the Gazette of India, April ,6,2002, under clause • 1.3 Every Physician shall maintain the Medical Records pertaining to his/her INDOOR patients for a period of 3 years from the date of commencement of the treatment in a standard proforma laid down By the Medical Council of India. • If any request if made for medical records either by the patient/ authorized attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within the period of 72 hours. • The expired and MLC records are kept permanently for legal purposes. • Efforts shall be made to computerize the medical records for quick retrieval

33. ELECTRONIC MEDICAL RECORDS • The Medical Record has been a collection or package of handwritten or typed notes, forms & reports. • Automation has made possible to capture, store, retrieve present clinical data. • “On line Systems” – The hospital staff can directly access the databases through communication terminals connected by Local Area Network (LAN). • Backup system – Backup can be taken in Floppies, CDs or in Double Hard disk system. • Scanners – Records are scanned and stored in Hard disks or CDs. A software helps to retrieve and analyses the cases.

34. Computer entries • The entries such as issues, receipts, updates, indexing ( diseases and procedures) are done on a daily basis. • This plays vital to view the location of the various files. • The file types such as Volumes No, IP, OP, MLC, EXPIRED are also to be included in the entries. • The monthly and yearly statistics are to be prepared.

37. National Accreditation Board for Hospitals & Health Care Providers (NABH) • Constituent Board of Quality Council of India. • Set up with the co-operation of Ministry Of Health & Family welfare (Govt. Of India ) and Indian Health Industry. • Standards are set for the progress of Health Industry. • Standards have been drafted by the Technical Committee of NABH for evaluation of hospitals & grant of Accreditation. • Focus is on Patient Safety and Quality Patient Care. • Standards are provided for Quality Assurance & Quality Improvement of Hospital .

38. BENEFITS OF NABH ACCREDITATION PATIENTS HOSPITAL Continuous improvement Commitment to Quality Care. Benchmarking • High Quality Care & Patient Safety • Service of credential medical staff • Patient Rights • Evaluation of patient satisfaction.

39. BENEFITS OF NABH ACCREDITATION 3. HOSPITAL STAFF • Provides Continuous Learning • Good working environment • Professional development of clinicians & paramedical staff • Quality improvement in medicine and nursing

40. Accreditation Process

41. PATIENT CENTERED CHAPTERS APPLICABLE TO THE MEDICAL RECORDS. • Access, Assessment and Continuity of Care (AAC) • Patient Rights and Education (PRE) • Care of Patient (COP) • Management of Medication (MOM) • Hospital Infection Control (HIC) • Information Management System (IMS

42. ORGANIZATION CENTERED CHAPTERS • Continuous Quality Improvement (CQI) • Responsibility of Management (ROM) • Facility Management and Safety (FMS) • Human Resource Management (HRM) • Information Management System (IMS)

43. NABH Application has to be submitted to the Quality Council of India • Pre assessment dates will be announced by the NABH Secretariat. • Pre assessment likely to be fixed after two months. The audit may be likely for 2 or 3 days. • Self Assessment tool kit has to be completed and submitted within a week

44. Access, Assessment and Continuity of Care (AAC) • Services Provided in the Hospital • Well Defined Registration, Admission and Discharge Procedure. • Initial Assessment and re assessment. • Care of patients.

45. Patient Rights and Education (PRE) • Privacy during examination, procedure and treatment. • Confidentiality of Patient Information. • Consent Forms. • Information on Lodging a compliant • Information on Treatment. • Information on expected cost (estimation)

46. Care of Patient (COP) • Emergency Services. • Usage for blood products. • ICU & HDU. • Guidelines for Sedation. • Administration of anesthesia. • Care of vulnerable patients. • Guidelines for surgical procedures. • Pain management. • Research Activities.

47. Management of Medication (MOM) • Hospital Formulary • Storage of medicines • Prescription of Medications • Administration of medications • Policy for dispensing medicine. • Guide to use narcotic drugs. • Chemotherapeutic agent • Radioactive drugs • Guide for usage of medical gases.

48. Hospital Infection Control (HIC) • Infection Control Manual • Surveillance activities. • Reduction on HAI (Hospital Associated Infection) • Procedure for sterilization activities. • Bio-Medical Waste Management. • Regular training for staffs.

49. Continuous Quality Improvement (CQI) • Quality Assurance Program • Identification of key indicators for monitoring. Clinical and Managerial. • Auditing of patient care service. • Analysis of Sentinel Event. Responsibility of Management (ROM) • Responsibility of management is defined. • Department documentation. • Patient safety and risk management issues.

50. Facility Management & Safety (FMS) • Complies with relevant rules and regulations, laws and byelaws. • Operational and Maintenance plan. • Equipment Management. • Plans for fire and non- fire emergencies. • Disaster management. • Managing of Hazardous Material. • Safety Committee.