MEDICAL RECORDS department

1. MEDICAL RECORDSdepartment

6. INTRODUCTION • 1000 bedded general Hospital. • For the management and systematic maintenance of Medical Records in the Hospital a Medical Record Department is an essential component. m • Staff • Medical Record Officer • Medical Record Technicians • Medical Record Clerks • Medical Record Attendants

7. Description • The Reception, Enquiry and Admission office functions round the clock under the charge of Medical Record Officer. • Inpatients records and out patients records are maintained in the Medical Record Department. • Registration work of OPDs are also managed by the Medical Record Officer. • Statistical information about the functioning of OPDs is regularly submitted by the Medical Record Officials in the Medical Record Deptt.

8. DEFINITIONOF MEDICAL RECORD • Medical Record of the patient stores the knowledge concerning the patient and care given . • It contains sufficient data written in sequence of occurrence of events to justify the diagnosis, treatment and outcome. • In the modern age, Medical Record has its utility and usefulness and is a very broad based indicator of patients care.

9. Benefits of the MRD • Patients • Doctors • Hospital • Teachers • Students • For research work • National & International agencies

10. ORIGIN :- • The inpatient Medical Record in originated at the admission office based on the admission order made by the clinician or at Casualty Deptt. and various OPDs of the Hospital. • Outpatient medical records originates from the registration desk of the OPD and clinic services

11. Process flow of Medical Records OPD and Clinic registration department Wards Central Admission Office Medical Record Department Afetr completion of Reccords 1. Assembling 2. ADMN. & Discharge analysis Hospital statistics prepared Monthly/Yearly Medical Record is filled for perusal of Patients/claims/research purposes. 3. Storage Area

12. FILING OF MEDICAL RECORDS • The inpatients Medical Record is filed by the serial numbers assigned at central Admitting Office. • The Record is bound in bundles 100 each and are kept year wise according to the serial number • OPD and clinic services are also filed in seriol numbers • Other services too are registered , preventive , investigative and curative care

13. RETENTION OF MEDICAL RECORD • The policy is to keep indoor patient Records for 10 years • The OPD registers for 5 years • The record which is register for legal purposes in Maintained for 10 years or till final decision at the court of Law.

14. OUTPATIENT DEPARTMENT • There is a decentralized system for registration of OPD patients. • Patients are registered at different registration counter specialty wise. • Clerks posted for registration have been made responsible for the preparation and submission of statistical data of their respective OPD

15. FUNCTIONS OF MEDICAL RECORD DEPARTMENT 1. Daily receipt of case sheets pertaining to discharge, 2 A.M. an expired patients from various wards, there checking and assembly. 2. Daily compilation of Hospital census report. 3. Maintains & retrieval of records for patient care and research study. 4. Completion and Procession of Hospital statistics and preparation on different periodical reports on morbidity and mortality. 5. Online registration of vital events of Birth & Death

16. FUNCTIONS OF MEDICAL RECORD DEPARTMENT 6. Issuing Birth & Death certificated upto one year. • Dealing with Medico Legal records and attending the courts on summary. • Arrangement & Supervision of enquiry and admission office. • Arrangement & Supervision of OPD registration • Management of disability boards. • Management of Medical Examination • Management of Mortality Review Committee Meetings (Twice month) • Assistance to Hospital Administration in various matters.

17. SYSTEM OF COLLECTION, COMPILATION AND FORWARDING STATISTICAL REPORTS • Medical Record officials posted for registration of OPD patients have been made responsible for the preparation and submission of statistical data on their OPDs. • One Medical Record Officer visits to the wards daily and collects the disease wise reports of the discharged patients and submits the same in the medical record section. One official of the Medical Record Section classifies the data according to the different performa. Following reports are compiled forwarded to various departments. • National list for Tabulation of Morbidity and Mortality (IMMR) • Monthly Health Bulletin • Monthly report of Polio Cases • Monthly report of GWEP • Report of cataract operations • Report on the notifiable disease • Monthly report of communicable diseases • Monthly report of MNT (Paed & Gynae)

18. 10.Monthly report of AIDS cases 11. Monthly report of Anti Rabic cases 12. Monthly report of STD 13. Monthly report of cases & Death due to snakebite. 14. Monthly report of Sex Ratio (Birth Death) 15. Monthly report of Malaria cases. 16. Monthly report of Deliveries 17. Monthly report of Family Planning 18. Monthly report of Medicine, DRT, Polio, TT 19. Monthly report of Leprosy cases 20. Weekly report of Polio 21. Weekly report – Statement showing the no. of cases treated (OIVS) 22. Weekly report of National Programme for surveillance of communicable disease (DHO) 23. Weekly report of Dengue fever cases 24. Weekly report of Pyogenic Meningitis 25. Weekly report of Gastro-enteritis, Cholera 26. Daily report of Noticeable Disease under surveillance.

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