Medical Record Management

Ravinder Singh
B.A. (Delhi University), ADMRTT & DMRT
Medical Records Supervisor
Medanta-Gurgaon Haryana
proprietary & confidential- any use of this material
without specific permission is prohibited

BRIEF HIOSTORY OF MEDICAL RECORDS IN INDIA
 Mr. Daniel Gajraj is first Indian who is graduated in USA as a registered
Medical Records Librarian.
 Mr. Daniel Gajraj also known as Father of Medical records in India.
 CMC Vellore is first Institution in India to start Medical Records course in
year 1962.
 Safdurjaung Hospital Delhi started six month Medical records Technician
course in 1973.
 CMAI & JIPMER started courses in between 1970-80.
 Computerized Medical Records EMR/EHR in present era – Game Changer.
 Today many university in India offers B.sc / Bachelor in Medical Records
and two years Diploma courses also popular by CMAI/ IMA certified etc. in
India.

Career prospects In the field of Medical Records
Medical Records Administration:-
 Medical Record Assistant /Clerk
 Medical Records Technician
 Medical Records Coder
 Medical Records Officer
 Medical Records Supervisor
 Medical Records Manager
 Director Medical Records /HIM
Informatics /Compliance/Data
analytics:-
 Medical Records Coder
 Clinical Informatics Manager
 Data Quality Manager
 Compliance Auditor
 Quality Improvement Analyst
 Medical Coding
 Director of clinical Informatics

MEDICAL RECORDS DEPARTMENT (MRD)
A Medical Records
Department (MRD)
is a place where the
records of the
patient are usually
stored, maintained
and retrieved .

MEDICAL RECORD DEPARTMENT ( MRD)
Major function of MRD:-
 Design Patient Information
 Administer Medical Records Services ( Planning, Directing, Controlling )
 Develop Statistical and other informative reports
 ICD -10 coding of diseases & operation
 Develop,analyse and technically evaluate health records and information
 Inform and report government agencies about Birth & Death, notifiable and
communicable diseases etc. according to law of land
 Compile ,process, and maintain medical records in a manner consistent with
medical, administrative, ethical,lagal and regulatory requirements of hospital
 Responding of request for patient medical records received from the patient, legal
attendant, insurance company, social agency, other healthcare facilities, subpoenas
and legal authority etc. according to policies and procedures for the release of
medical information
 Retain & Destruction of the medical records as per the record retention/discarding
policy

What is Medical Records ?
Medical Records is a collection of recorded facts
concerning a particular patient and is the documentary
evidence of the care given to a patient.
Medical records is clear precise and accurate history of patient
life and illness ,including past and present illness and
treatment, written from the medical point of view and to be
complete the medical records must contain the sufficient data
& information written in sequence of events to justify the
diagnosis and warrant the treatment and end result.

Identification
Medical
Nursing Others
CONTENTS OF
A MEDICAL
RECORDS

Identification
 Every Medical Records (Manual /electronic) shall have
unique identifier.
Every Pages of Medical
Records Must have label
with UHID,Patient Name
, Age and Sex.
UHID NO. & Patient Full Name
Every pages of Medical Records must have label having UHID
no. , Patient Name , Age, Sex ,Bed no, Ward name etc.
Face Sheet ( All demographic Details of patient

CONTENTS OF A MEDICAL RECORDS CONTD………
Nursing
Admission Checklist
Initial Nursing Assessment- Emergency Department
Pediatric Nursing Assessment on Admission
IP initial Assessment Nursing
Nursing Care Plan
Fall Risk Assessment
Nurses Progress notes
Daily Nurses Flow sheet
NEWS form ( National Early Warning score)
Nursing risk Assessment form
ICU/CCU flow sheet
Any others nursing related documents

Medical
Initial Doctor Assessment- Emergency Department
Inpatient History , Physical Record & Assessment Sheet
Dr. Progress Sheet
Cross Consultation Forms
Medication Records
Discharge summary
Preoperative Anesthesia form (PAC)
Surgical safety check list
OT Notes (procedure notes )
Any others Records

Others
Investigation reports (Cath)-CAG/PTCA/EPS/RFA
Investigation reports (Radiology)-X-ray/TC/MRI/USG
Investigation reports (Heart station)-Echo/TMT/Holter/Nuclear
Medicine
Investigation reports (Labs)-Hem/Bio/Micro/Blood
Bank/Histopathology
Activity of Billing records
Final Bill
RFA ( request for Admission form )
Nutritional Assessment Screening Form
Nutrition planning form
Any others Administrative Records

Why do we keep medical records ?
• For communication purposes while caring for the
patient.
 For continuity of patient care over the course of the
patient’s life.
 For evaluating patient care.
 For medico- legal purpose .
 For use as a source of health Statistics .
 For research , education and planning purposes.

Why do we keep medical records ? CONTD……
 For accreditation ( NABH/JCI/ ISO) purpose.
 For Insurance /TPA / reimbursement etc.
 For professional advancement of physician.
 Licensure ( DNB/MCI etc).
 Correspondence etc.

Uses of the medical records
PERSONAL IMPERSONAL
 An Authorization for release of
information must be obtained
from the patient/legal guardian
unless there is a legal obligation to
provide information .
 Request for a part of medical
records by an insurance company
or LIC is an example of the
personal use of medical records
 Name of the patient or
identity is not revealed .
 for example for a research 200
records of similar diagnosis or
surgery are used , the identity
of each patient is not relevant.

Scope and importance of Medical Records Management
Patients
• Re –admitted in same Hospital or any other Hospital.
• Workman’s Compensation or Medical Insurance.
• Legal Interest of patient .
• Disability entitlements.
Doctor / Physician & other Healthcare professionals
• Communication.
• Continuity of care.
• Professional Advancement.
• Legal Interest or Litigation.

Scope and importance of Medical Records Management……Cont……..
Hospital
• Evidence of care given.
• Legal Interest of Hospital.
• Assist in future Planning .
• Utilization of Facility & Staff.
• Medical Audit ,Mortality Review .
• Vital Source of Statistics.
• Education & Research etc.

Scope and importance of Medical Records Management……Cont……..
Public Health Authorities/ Govt. Agencies/WHO etc.
 Birth & Death
 Communicable Diseases
 Non- communicable Diseases
 MTP
 PNDT
 Fetal Echo
 IDSP/ UDSP
 Cataract
 Snake Bite
 Insurance / TPA
 Notifiable diseases as per local or national law
 Any others data & reports as per local or national law etc.

Numbering and filing of Medical Records
• Patient assigned a number or UHID on
the first visit either OPD/ER/IPD and
retain the particular number
throughout his subsequent visit.
Unit
Numbering
• A new number or UHID is assigned
each time he is treated in hospital
either OPD/IPD/ ER.
Serial
Numbering
• New number or UHID is assigned to patient
as in serial numbering system but on every
visit or admission previous records are
brought forward to patient new or the
most recent number to create a unit
record.
Serial-Unit
Numbering

Filing of Medical Records
The Straight Numerical Filing-filing in
the strict numerical sequence , Its very easy and
needs no special training.
 The Terminal Digit Filing-
Records are filed according to the last digit, Its not easy
required special Training of MRD Staff and not popoular filing
system.

Medical Record Audits
Review of the process of documentation rather than
the process of clinical care ( distinct from clinical
audit)
Focusses on –Timeliness, Legibility, Completeness
 Open and closed file audit ( i.e. active and passive
file audit) and Sampling based on statistical principles
To be done by identified care providers- Doctor ,
Nurses & allied Health professional
Adequate Corrective Action, Preventive Action (CAPA)

Medico Legal Aspects of Medical Records Management
 MLC’s are Increasing.
 Proper Handling of MLC, and
accurate documentation is
Key.
 Marking of MLC in
HIS/Manual & Tagging .
 Know the Law of the Land.
 Definition of MLC &
Incidents .
Step In MLC:-
 MLC Identification & Tagging
 Police intimation
 MLC evidence Should be
Identified, labeled, sealed .
 Safe Custody of evidence and
handover the documents
/evidence as per protocol.
 MLC registers,MLR, and case files
should be stored under lock and
key.
 Production of original
records/evidence in Court.

Medico Legal Aspects of Medical Records Management. Contd…
Summon/Subpoena: A summon is a document issued from the court of
justice, calling upon the person to whom it is directed to attend before a
judge or officer of the court/legal authorities for a certain purpose.
 Never ignore a subpoena/summon
 Judge/Lawyer/Special officers can issue a Summon.
 Hand delivered /Registered Post / E-mailed with receipt.
 Read and comply accordingly, adequately prepare documents asked by
court & make note of date time and place & Consult legally if needed.
 Penalties – Civil or criminal contempt of court if not attended.
 In case, one cannot attend the court because of unavoidable
circumstances, an official communication should be sent to the Court well
in time.

Retention Period of Medical records
Different countries and different states have their own sets of rule and regulation for retention
of medical records-
India-
Some example-
 MCI- 03 years from the date of commencement of the treatment.
 Issued records within 72 hours of request to patient or authorized
representative.
 As per DGHS Vide letter no 10-3/68-MH dated 31-08-68 Medical Records Should
be maintained as follows
IPD-------------------------------10 Years
MLC Registers__________10 Years
OPD___________________05 years
 Punjab Medical Manual( 1934) MLC__________12 years
 Medico-legal records to be kept for at least period of 15 years or up till the cases
are decided in the court of law whichever is earlier ,even though it is so difficult to
keep them for such along period.

Hospital Statistics
In Many hospitals, which do not have a separate
department of statistics & IT the medical record
department prepares all statistical reports. These
involve statistics relating to census, bed occupancy,
admissions, discharges, outpatient visits by service etc.
The medical record staff in most hospitals computes
rates and ratios relating to clinical data also. The
administration use this valuable information available
from the statistical reports for all management
functions like planning, organizing, controlling and
actuating.

Hospital Statistics….contd..
Common Statistical data collected and calculated by MRD are:-
 Number of admissions - total hospital and by service / Unit wise .
 OPD Attendance/Visit – Total hospital , Service wise , Unit wise , New & Old ,Average etc.
 Number of discharges- (live and expired) - total hospital and by service .
 Number of deaths – total hospital and by service .
 Number of surgical procedures –Major/ Minor, Specialty wise etc.
 Number of deliveries (obstetric patients) –Normal , Caesarian etc.
 Emergency – Visit/ Admitted.
 Number of LAMA- Reason for LAMA
 Number of MLC / Outside MLC
 Daycare Admission-SPECIALITY WISE
 Diagnosis and Operations ( ICD-10)
 ALOS- Specialty ,Unit , Bed category wise
 Number of Live & Still Birth etc.
 Death Rate:- NDR, GDR etc.
 Bed turnover rate
 Number of Investigations- Laboratory ,Radiology & others- OPD & IPD/speciality wise
 Statistics of notifiable diseases .
 compilation and presentation of other kind of statistics as required by the MCI or Accreditation (quality
indicators) etc.

Coding & Indexing of Diseases and operations ( ICD-10)
Why we need to code ? Purpose of coding ( ICD-10)
 To Allow Easy Storage ,Retrieval And
Analysis Of Data.
 To Allow Systematic Recording,
analysis, interpretation And
Comparisons Of Mortality And
Morbidity Data.
 Forecast Health Needs Of
Communities, Region And Nations .
 Standardize Reporting Systems For
Easy Assimilation.
 Provide Teaching Material For Medical
Education.
Counting of diseases
External cause of death
Reason for encounter
Prevention
Education & Research
Managing health care
ICD makes people count

Medical Record Management

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