Presentation on theme: "ROLE & IMPORTANCE OF MEDICAL RECORDS"— Presentation transcript:
1ROLE & IMPORTANCE OF MEDICAL RECORDS C.GovindarajanChief Medical Records Officer&President, Health Records Association of INDIA
2Location & Days and Hours of Operation The Medical Records Department should be located adjacent to the Front OfficeThe Medical Record department have to function 24 hours on all the days to cater the Medical Records immediately.
3About MRD Bridges the gap between medical and non-medical departments. Enables continuity of care to the patients without difficulty at appropriate timeHeaded by MS has skilled persons termed as Medical Record Technicians and othersGoverned by the Medical Records CommitteeFor 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
4Guiding 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 dataSource: Medical Records Manual, WHO
5CODE OF ETHICS MEDICAL STAFF Bound by Professional Secrecy and Oath PARAMEDICAL STAFFMEDICAL 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.
6What 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
7What 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 purposeThe 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.
8HOSPITAL STATISTICS PROOF OF WORK DONE FOR CURRENT AND FUTURE PLANNING DISEASE /PROCEDURE INCIDENCESOUT PATIENT TURN OUTBED OCCUPANCY RATEAVERAGE LENGTH OF STAYDEATH RATEDEATHS UNDER 48 hrs.DEATHS MORE THAN 48 hrs.
9FLOW OF MEDICAL RECORDS Registration counterConsultantsO.PI.PAdmissionWardsMedical recordsIndexingDeficiency check and codingAssemblingComputer entryPermanent filingScanning
10In-patient records: Assembling format: The arrangement of medical records takes place in thefollowing order:SUMMARY SHEET& ADMISSION RECORD,DISCHARGE SUMMARYHISTORY OF FINDINGSCONSULTATION REQUESTLAB & ECG REPORTSANESTHESIA CHARTSOPERATION NOTESPROGRESS SHEETSDOCTORS ORDERSICCU CHARTSCONSENT FORMSNURSES CHARTSCLINICAL CHARTSDRUG CHARTSIV FLUID CHARTSOTHER AUTOPSYBIOPSY REPORTS AND OTHER HOSPITAL REPORTS.
11Medical Records Committee Members Medical Superintendent (Convener)Three Sr.Consultants (various specialties)AdministratorHOD – Medical Records DepartmentHOD - Quality SystemsNursing Superintendent / RepresentativeHOD – OP/IP Services.
12INTERNATIONAL CLASSIFICATION OF DISEASES INTRODUCTIONClassification 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 The conference was attended by delegates from 43 member states
13ICD 10TH REVISION BY WORLD HEALTH ORGANIZATION Volume 1IntroductionWHO Collaborating Centers for Classification of DiseasesReport of the International Conference for the Tenth RevisionList of three-character categoriesTabular list of inclusions and four-charactersubcategoriesMorphology of neoplasm'sSpecial tabulation lists for mortality and morbidityDefinitionsRegulationsVolume 2 Instruction manualVolume 3 Alphabetical index
14CHAPTERS OF ICD – 10TH REVISION I Certain infectious and parasitic diseasesII Neoplasm'sIII Diseases of the blood and blood-forming organs and certain disorders involving theimmune mechanismIV Endocrine, nutritional and metabolic diseasesV Mental and behavioural disordersVI Diseases of the nervous systemVII Diseases of the eye and adnexaVIII Diseases of the ear and mastoid processIX Diseases of the circulatory systemX Diseases of the respiratory systemXI Diseases of the digestive systemXII Diseases of the skin and subcutaneous tissueXIII Diseases of the musculoskeletal system and connective tissueXIV Diseases of the genitourinary systemXV Pregnancy, childbirth and the puerperiumXVI Certain conditions originating in the prenatal periodXVII Congenital malformations, deformations and chromosomal abnormalitiesXVIII Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classifiedXIX Injury, poisoning and certain other consequences of external causesXX External causes of morbidity and mortalityXXI Factors influencing health status and contact with health services
15Indexing 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.
17Numbering 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.
18Filing 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.
19Quality Policy Quality Objectives Medical record documents shall be treated as confidential, secure, current, authenticated, legible, and completeMedical Records Department shall be provided with adequate direction, staffing, and facilities to perform all recognized functionsQuality ObjectivesTo 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
23NO. OF PATIENTS DISCHARGED IP DEFICIENCYMONTHNO. OF PATIENTS DISCHARGEDTOTAL NO IP DEFPERCENTAGEJAN301181126.93FEB302976525.25MAR325888427.13APR326390027.58MAY349395927.45JUN317387427.54JUL372771219.10AUG355669119.43SEP34413199.27OCT35742958.25NOV335148014.32DEC330033510.15
24Birth 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.
25Out-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.
26Tracer cardThe tracer card plays a very vital role in the filing area.It contains the RECORD NO, CONSULTANTS NAMEAND THE 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.
27Census 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 periodof time. Medical Record usually compile the census and send it totop management. This census is usually taken at midnight.This census should always comparing with the previous year.
28Medical Records Department Daily Statistical Report of Patients DATEDescriptionsTodayMonthTo DateYearFinancialSame DayLast yearMTDYTDLast YearRegistrationsAdmissionsEmg AdmissionDischargesBirthDeathsCensusOccupancyFridayThursday
29Medico legal casesSuicide, 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 CasesAR 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
30Wound 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 letterThe 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.
31Insurance 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 hospitaland about the expired details of the patient, if any.A nominal fees may be collected by the cashier. as per the policyThe forms are sent to the concerned Consultant and filled up by theconsultant with the authorization at the bottom along with the hospital seal.The original copy is sent to the insurance company, one photocopyis sent to the patient/ relative address and another photocopy is filled in theMedical Record.
32Destruction of records As per the Gazette of India, April ,6,2002, under clause1.3 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
33ELECTRONIC 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.
34Computer entriesThe 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.
35Medical Records Department Comparative Statistics December 2009 DescriptionDecemberFinancial Year- YTDCalender Year - YTDMonth20092008Change %Dec-09Nov-09Total New OP RegistrationsDaily average new OP registrationsTotal No of RepeatDaily average of RepeatMHC - NewMHC - RepeatMHC - TotalTotal IP AdmissionsDaily average IP admissionsTotal IP DischargesDaily average IP dischargesTotal BirthsTotal DeathsIP deathsOP deathsTotal IP Service days renderedAverage Length of StayAverage Daily CensusAverage daily Percentage Bed OccupancyGross Death RateNet Death Rate
36Medical Record Department Comparative Statistics March 2011 Service Breakup of New RegistrationsDescriptionMarchFinancial Year YTDCalender Year YTDMonth20112010Change %March-11Feb-11AllergyAnesthesiaAudiometryAurvedicBreathe Eazy ClinicCardiologyCardio Thoracic UnitCosmetologyCritical Care GroupDentistryDermatologyDiabetologyDiabetic surgeonDieticianENTEmergencyEndocrinologyEndocrinology/SurgeryGastroenterologyGastroenterology - SurgicalGen. MedicineGen. SurgeryGeriatricGynecologyGeneral physicianHematologyInfectious DiseasesMHCMedical GeneticNephrologyNeuro surgeryNeurologyNuclear MedicineOncologyOphthalmologyOrthopedicsPediatricsPediatric SurgeryPediatric gastroentrologyPlastic SurgeryPsychiatryPsychologyRadiologyRespiratory MedicineRheumatologySexual MedicineThoracic UnitUrologyUrogynocologyVascular SurgeryWell Woman Check UpTransplant SurgeonOther DepartmentsAroma TherapeuticsNeuro RehabilationTOTAL
37National 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 .
38BENEFITS OF NABH ACCREDITATION PATIENTSHOSPITALHigh Quality Care & Patient SafetyService of credential medical staffPatient RightsEvaluation of patient satisfaction.Continuous improvementCommitment to Quality Care.Benchmarking
39BENEFITS OF NABH ACCREDITATION 3. HOSPITAL STAFFProvides Continuous LearningGood working environmentProfessional development of clinicians & paramedical staffQuality improvement in medicine and nursing
40Accreditation Process StepsPreparationStep 1Application for accreditation (submitted by the Health care organization)Step 2Acknowledgement for accreditation (by NABH Secretariat)Step 3Pre assessment visit (by Assessor)Step 4Final assessment of hospital (by Assessment Team)Step 5Scrutiny of the assessment report (by NABH secretariat)Step 6Recommendation for accreditation (by accreditation Committee)Step 7Approval for accreditation (by Chairman NABH)Step 8Issue of accreditation certificate (by NABH secretariat)
41PATIENT 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
42ORGANIZATION CENTERED CHAPTERS Continuous Quality Improvement (CQI)Responsibility of Management (ROM)Facility Management and Safety (FMS)Human Resource Management (HRM)Information Management System (IMS)
43NABH 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
44Access, Assessment and Continuity of Care (AAC) Services Provided in the HospitalWell Defined Registration, Admission and Discharge Procedure.Initial Assessment and re assessment.Care of patients.
45Patient Rights and Education (PRE) Privacy during examination, procedure and treatment.Confidentiality of Patient Information.Consent Forms.Information on Lodging a compliantInformation on Treatment.Information on expected cost (estimation)
46Care 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.
47Management of Medication (MOM) Hospital FormularyStorage of medicinesPrescription of MedicationsAdministration of medicationsPolicy for dispensing medicine.Guide to use narcotic drugs.Chemotherapeutic agentRadioactive drugsGuide for usage of medical gases.
48Hospital Infection Control (HIC) Infection Control ManualSurveillance activities.Reduction on HAI (Hospital Associated Infection)Procedure for sterilization activities.Bio-Medical Waste Management.Regular training for staffs.
49Continuous Quality Improvement (CQI) Quality Assurance ProgramIdentification 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.
50Facility 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.
51Human Resource Management (HRM) Orientation of New StaffsTraining staffs on safety.Documentation of performance appraisal system.Disciplinary procedures.Grievance handling.Procedure for Collecting , Verifying and evaluating the credentials of all staffs.
52Information Management System (IMS) Process for effective management of data.Medical Records.Policies for maintenance of confidentiality , integrity and security of information.Policies and procedures for retention period for records.Regular Medical Audit.
53Accurate Complete Timely Contents Chronology Continuity Promptness Good Medical RecordDocumentation in Medical RecordsAccurateCompleteTimelyContentsChronologyContinuityPromptnessAuthenticationLegibleReadableAcceptableTimelyConsent recordedError freeReproducible
54Medical Records in OT (Anesthesia / Surgery) Blood GroupInformation about AllergiesPre assessment with date & timeStarting time/Recovery time/Shifting timeSignature with date & time
55Contents of Operation Notes Date of surgerySight markingComplete Surgical NotesStarting timeIncision timeEnding timePre-operative diagnosisSignature of the operating surgeon
56Consultation request Date and time of request with signature Reason for referralReferral consultant’s ordersSignature with date and time of the referral consultant
57Deficiencies in Medical Records Improper terminologyDifferent diagnosisProcedures not recordedWrong formsMissing Progress NotesName, Date, and Time to be recordedPoor medical follow upRepetition of investigationsMixing up of casesDelay in MR coding, statisticsTPA settlements
58GOOD MEDICAL CARE GENERALLY MEANS A GOOD MEDICAL RECORD, WHILE AN INADEQUATE MEDICAL RECORD GENERALLY REFLECTS POOR MEDICAL CARE
59Medical Records Mantra Patient forgets;record remembers