MEDICAL RECORD DEPARTMENT

RAVI BAGALI JAYENDRA TRIPATI AMRITHAYAN DAS SHIVARAM GAURAV RAVI

MANIPAL INSTITUTEOF MANAGEMENT

ORGANISATIONAL STRUCTURE

MEDICAL RECORD OFFICER

Job title: Medical Record Officer Department: Medical Record Education: Post Graduate in Medical Record Graduate in Medical Record Experience: 5+ year of experience in medical record department

MAIN JOB TASKS:

1. Directs the activities of subordinates engaged in analyzing, compiling, coding, indexing, and filing the medical records of patients 2. Carries out training programs for subordinate technical and clerical employees. 3. Assists in the selection of subordinates. 4. Reviews records for completeness, accuracy, and conformance to requirements for hospital accreditation and requirements for the preparation and maintenance of medical

5. Recommends standards and methods of operation to achieve greater efficiency and compliance with requirements for hospital accreditation and requirements for the preparation and maintenance of medical records. 6. Informs medical staff of atypical materials related to medical records. 7. Selects and tabulates data from patients' charts as requested by the medical staff. 8. Transcribes notes and reports for the medical staff. 9. Compiles statistical reports (such as analyses of types of surgery performed, types of diseases treated, and types of cases receiving special

10. Prepares reports relating to the admission, birth, transfer, discharge, or death of patients; utilization of hospital beds; or outpatient services. 11. Answers inquire from authorized persons relating to the medical records of patients. 12. Performs other related duties as assigned. 13. Reviews and evaluates technical work involved in the preparation and maintenance of medical records. 14. Establishes work priorities and controls, based on work flow requirements.

15. Assists superior in the selection, training, and evaluation of the medical record staff. 16. Implements necessary changes in methods of operation. 17. Recommends need for additional corrective action. 18. Prepares technical reports requiring a thorough knowledge of institutional policies, standards, and procedures.

Job title: Medical Record Clerk Department: Medical Record Qualifications & Experience Graduate in Medical Record Diploma in Medical Record Experience: 2+ year of experience in health care

MAIN JOB TASKS

1. Maintains patient files and statistics. 2. Responds to requests for medical records. 3. Performs clerical duties.

4. Answers telephone calls regarding medical record questions in a friendly and knowledgeable manner. 5. Files charts gathered from doctors office, pods, and counters and files in front and back chart filing rooms in alphabetical order. 6. Communicates with the front desk to ensure quality of customer service with patient requests.

7. Prepare and maintain accurate medical records for appointments, patient phone calls, prescription refills and triage requests. 8. Interact with patients, healthcare providers and other medical personnel regarding update of medical records. 9. Update patient records and availability for continuity of care. ensure its

10. Maintain patients' information in computer relating to identification number, medical record number, appointment data and chart location.

12. Ensure chart availability for patients seen at multiple locations. 13. Create new patient established guidelines. records on

14. Create logistics in troubleshooting problems relating to maintenance and updating of medical records. 15. Initiate quality service to ensure accuracy of filing and chart availability.

PLANNING MEDICAL RECORD DEPARTMENT

Location Adjacent to the Admission Office, the Emergency Department (ED), the Outpatient Department (OPD) Close to medical staff office, entrance, or lounge Close to the administrative and business offices Close to other service departments, e.g. xray, pathology, etc.

SPACE
Population of the district served by the hospital Hospital services proposed Number and type of beds Current and projected number of discharges/deaths and outpatient and emergency registrations and visits Major functions to be performed in the department Number of personnel required to perform proposed functions Equipment most suitable for the work to be done Extent of computerization anticipated

Type of filing system to be used The numbering system Whether the record services are to be centralized or decentralized Whether emergency/casualty records are to be included in the main record Number of years of active storage Length of time original records are to be retained and whether inactive records will be selectively purged or microfilmed, Type of secondary storage required Special services to be offered by the department.

LAYOUT

To eliminate the hazard of electrical cords. Temperature control and circulation of air, i.e. adequate ventilation, fans, windows. Adequate lighting Use of colour Employees handling enquiries should be placed near the main entrance. Equipment should be near users and the doors wide enough for record carts.

Desks should face the same direction with 1 to 1 meters between desks. Supervisors should be at the back of the people she/he is supervising should be able to see all employees without leaving desk. Two desks placed side by side in the same direction is a compact arrangement. It is best to place the file space to the back of the department it should not be placed near the main entrance (for safe keeping). Sufficient space for workers to stretch and move around.

POLICY ON HOSPITAL INFORMATION SYSTEM DEVELOPMENT (MEDICAL RECORDS)

OBJECTIVES:

To formulate effective policies and to guide the operation and management of the medical records.

To strictly implement approved policies for the good of the service.

To make available to the concerned staff the approved policies for their information and guidance.

To use the approved policies in monitoring staff performed and the operation of the department.

To ensure systematic approach in filling the records. To maintain the accuracy, completeness & confidentially of

STANDARDS: All applicable policies and procedures in an effective medical records management form record creation for disposal.

All departments must be aware of the existence of medical records section (MRS) policies and procedures. Presence of copy of the policy of the manual in strategic location of the medical records section (MRS). Policy manual must be updated every 5 years. Availability of needed resources. At least the services which will be affected shall be consulted.

THE LIST OF ADMISSION AND CHECK THE PATIENTS ASSIGNED NUMBER. REARRANGES THE RECORD ACCORDING TO THE STANDARD FORMAT
Identification Data Chief Complaint History of Present Illness Physical Examination Diagnosis/ Admitting Diagnosis Admitting/ Attending Physician Doctors Order Sheet Progress Notes Clinical Laboratory

X-ray Reports Consultation/ Referral Notes Medication/ Treatment Final Diagnosis Nursing Record Discharge Summary Obstetrical Record (If applicable) Consent

RECORD COMPLETION:

The medical records should be completed within 48 hours after the discharge of the patient. History & PE should be completed within 24 hours after admission. An incomplete chart, not completed within 15 days after patients discharge, shall be considered a delinquent chart. The attending physician has the final and major responsibility for completeness and accuracy of the data entry in the record. The medical record in-charge is also encouraged to raise the level of quality of the individual health record and high level of recording.

Residents and interns may be delegated the duty of recording medical information as history, PE and discharge summaries, their entries have to viewed, corrected, and countersigned by the attending physician.

Maintain the completeness of the medical record records by checking with the set omissions policies and and discrepancies and helps ensure that medical comply standards.

RELEASE OF INFORMATIONS:
Release of health information is a very sensitive issue in several respects. The CONFIDENTIALITY of the medical records should always be the concern of people involved in the release of health information. Information of no clinical value can be disclosed by the staff of the hospital with utmost care Name Address Attending physician Name of relative with patient during admission Admission and discharge dates

POLICIES FOR DOCTORS RELEASE OF INFORMATION

Authorization signed by the patient before they are given access to the record. Insurance company doctors shall need proper written authorization from the patient. Consultants shall have access to records of patients referred to them.

POLICIES FOR NURSES ON RELEASE OF INFORMATION

Nurses may borrow/ sign-out medical records per doctors instruction for ward use. In the ward, student nurses shall have access to the records of patients assigned to them. Private Nurse shall only be allowed to review records of patients assigned to them. Ward nurses should always see to it that charts are in a secured place away from the patients or the patients relative.

OTHER PEOPLE CONCERNED

Lawyer Insurance Researchers

POLICY ON MEDICAL RECORDS OBJECTIVES:

To ensure systematic approach in filling the records. To maintain the accuracy, completeness & confidentiality of data. Confidentiality of patient information is maintained at all times.

PATIENTS RECORD FILE:

Patients chart from ER & nurse station upon discharged, must be forwarded to the medical record section for recording. Check all charts received against the list of discharges as reflected in the Daily Census Report. Records all chart received to the logbook. Prepares the patients index based on the list of admission and check the patients assigned number. Rearranges the record according to the

 Analyze
If

data on patients chart.

the data are incomplete (from ER & ward), fill up the deficiency sheet, attach it to the chart and return it to the ward or unit concerned. Upon receipt of incomplete chart and deficiency sheet, fill up the required data and sign it. Return completed chart and deficiency sheet to the Medical Record Section. Once the data are already completed the medical record in-charge will sort our according to filling system and prepare folder with corresponding terminal digits.
File

the patients record (folder) in terminal digit filing.

BIRTH CERTIFICATE POLICY:

1.

The medical record in-charge will provide a birth certificate draft form to the parent. The parent fills-up the draft form. The medical record on duty will interview the parent and verifies data. The medical record in charge advises the parent to sign a preliminary blank official certificate form. The medical record will advise the parent to submit the following documents that requires in the submission of the birth certificate to the Local Civil Registrar (LCR).

2.

3.

4.

5.

FOR MARRIED Marriage contract (Xerox copy) Two (2) valid ID namely: Passport, company ID, Voters ID & etc. (Xerox copy). Latest Residence Certificate (Xerox copy) UNMARRIED Affidavit of paternity signed & notarized by lawyer Two (2) valid ID namely: Passport, company ID, Voters ID & etc. (Xerox copy). Birth Certificate of the parents (Xerox copy) Latest Residence Certificate (Xerox copy)

MEDICO LEGAL POLICY:

MLR comprises of three parts: a) Pre-ambleincludes the date, time and place of examination, name of the patient, his Residential address, occupation; name of the person(s)/police official accompanying, DDR/FIR No., informed consent of the person being examined, two marks of identification. b) Body (Findings/Observations)includes a complete description of the injuries/any other findings present; any investigations/referrals. c) Post-amble (Opinion) - Nature of the injurywhether simple or grievous. - Weapon/Force usedwhether blunt or sharp or firearms or burns, etc.

DEATH OF A PERSON ADMITTED AS A MEDICO-LEGAL CASE:

Inform the police immediately. Send the body to the hospital mortuary for preservation, till the legal formalities are completed and the police releases the body to the lawful heirs. Request a medico-legal post mortem examination. Do not issue a death certificate even if the patient was admitted. The dead body should never be released to the relatives; it should only be handed over to the police.

DEATH POLICY:
This is carried out by a registered medical practitioner. Death will be verified using the following criteria: Absence of carotid pulses over one minute

Absence of heart sounds over one minute Absence of respiratory movements and breath sounds over one minute Fixed dilated pupils No response to painful stimuli

Inform relatives cause of death by doctor.

The verifying doctor and nurse will record the following details in the patients medical notes: The date and time of death That they are verifying that death has occurred That the next of kin have been informed/ have not been informed (and what arrangements are being made to inform them) The names, designations and signatures of both nurse and doctor

Inform patient relatives detail death of cause by doctor. The doctor has to write death summary include date and time of death, cause of death, and emergency treatment. The staff nurse has to prepare file and inform higher authority of patient name, cause of death and further plans. The nurse has to send file to billing and billing procedure has to be complete within 2hrs.

Pack the body and label name, age, sex, and IP number and date. Discuss relatives further plans like to take the body or shift body to mortuary. Inform bill and ask to bring bill receipt. Take bill receipt number and note in death log book. Handover body to relatives.

DEATH CERTIFICATE:

If the patient dies the medical record in-charge will prepare four (4) copies of death certificate and let the attending physician signed the certificate. The attending physician will check, completes and signs death certificate and return it to the medical record section. The medical record in-charge will check the accuracy and completeness of data and forwards it to the releasing/ information clerk.

The information clerk will record the death certificate in the official logbook and releases four (4) copies of the death certificate to the patients relative. The patients relative acknowledges acceptance of the death certificate and sign the logbook. Medical record in-charge files the annotated Death Certificate copy from the Local Civil Registrar.

NIGHT CASE POLICY:

Shift patient from vehicle to stretcher. Shift to casualty or Emergency department. Call duty doctor and necessary staff. Administer emergency care. Ask patient relatives to open file. Collect history of patient. Assess condition of patient.

Check doctor order for shift to ward/ ICU Inform to patient relatives. Inform to respective ward/ ICU staff. Shift patient respective ward/ ICU and handover to respective staff.

Inform patient name, condition, and treatment to night supervisor.

THE FLOW CHART OF OUTPATIENT MEDICAL RECORD

THE FLOW CHART OF INPATIENT MEDICAL RECORD

THE FLOW CHART OF DISCHARGE POLICY

REPORTS/STATISTICS: Daily Census Report

Monthly Hospital Statistical Report Quarterly Hospital Statistical Report. Annual Hospital Statistical Report

DAILY CENSUS REPORT

Admission Transfer LAMA (Leaving Against Medical Advice) Discharge Death

FORMATS:
1. ADMISSION RECORD/SLIP Hospital Number Name Age Gender Address Telephone No Department/ Ward

2. OUT-PATIENT RECORD: Name of Hospital Hospital No:

Hiatory, Examination, Treatment Investigations Signature of Doctor

Name:
Date

3. DOCTORS ORDERS Name of Hospital Name: Hospital No:

Patient Name Date Age: Sex: Medicines Dept: Ward: Treatment Hosp. No: IP. No: Investigations

4. CONSULTATION RECORD: Name of Hospital

Patient Name Age: Sex: Dept: Ward: Hosp. No: IP. No:

Referred By Dr..to Dr Findings: Diagnosis: Recommendations: Date:

Consultant Signature

5. HISTORY AND PHYSICAL EXAMINATION: Name of Hospital

Patient Name Age: Sex: Dept: Ward: Hosp. No: IP. No:

Date:

Signature of Doctor & Date

6. INTAKE AND OUTPUT CHART

Name of Hospital
Patient Name Age: Sex: INTAKE Time I.V Time Oral Time Dept: Ward: Hosp. No: IP. No: OUTPUT Urine

7. NURSES NOTES Name of Hospital

Patient Name Time Medicines Age: Sex: Time Dept: Ward: Treatment Hosp. No: IP. No: Signature

8. PHYSIOTHERAPY RECORD Name of Hospital

Patient Name Age: Sex: Dept: OP/Ward: Hosp. No: OP/IP. No:

Diagnosis. Treatment:
Date Treatment

9. PRE-OPERATIVE CHECKS LIST CHART: Name of Hospital

Patient Name Age: Sex: Dept: OP/Ward: Hosp. No: IP. No:

DateandTime: Operation: 1. TPR and BP and weight recorded 2. Nail polish removed 3. Hair clips removed 4. X-rays 5. Old Notes 6. Laboratory reports

Name/Signature of Nurse

10. OPERATION REPORT: Name of Hospital

Patient Name Age: Sex: Dept: OP/Ward: Hosp. No: IP. No:

DateandTime: Surgeon: Anesthetist: DescriptionofOperation:

Operation: Assistants:

DurationofSurgery:

Signature of Surgeon

11. DISCHARGE NOTE: Name of Hospital

Patient Name Age: Sex: Dept: OP/Ward: Hosp. No: IP. No:

Diagnosis: Treatment: Instructions: NextVisit:

Signature of Doctor

LABORATORY FORMATS:

BLOOD GROUPIG & TYPING FORM Name of the hospital Patients Name: Examination: A B AB A B B ABO blood group RHO BLOOD OTHER TESTS

URINE ANALYSIS REQUEST FORM

Clinical details: Patients name Dept/unit Age: Hno: Sex: OP/Ward IP No

Tests: Sugar Protein Sugar and ketones Complete urine analysis Hemosiderin Haemoglobin Others

COAGULATION AND HAEMOSTATIC PROFILE FORM Clinical details: Patients name Age: Dept/unit Hno: Sex: OP/Ward IP No Investigations Bleeding time Clotting time Prothrombin time Activated partial Thrombin time Clot retraction Factor xiii Fibrinogen assay

RADIO DIAGNOSIS & IMAGING CT REFERRAL FORM

CT NO: Patients name OP/Ward IP No REF. CONSULATANT Part to e scanned: Area of particular interest: Clinical summary & diagnosis: H/O Previous Surgery with dates: Contrast enhancement may be necessary May we do it -H/O Allergy, if any Signature of the Consultant Yes No Age: Hospital no: DATE: Sex:

THANK YOU!!