1. 2. MEDICAL RECORDS department
Dr Kithsiri Edirisinghe
MBBS, MSc, MD ( Medical Administration)
Cert. IV in TAE
Master Trainer ( Australia)

2. Insight to Medical Record Department in Hospitals
Session outcomes
Insight to Medical Record Department in Hospitals

7. 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

8. 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.

9. DEFINITION OF 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.

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

11. 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

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

13. 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

14. 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.

15. 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

16. 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

17. 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.

18. 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)

19. 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.

20. Clinical Coding

21. DATA EXTRACTION FOR CLINICAL CODING
Objective
To build on the participant’s experience in extraction of data from medical records, focussing on identifying data items of particular importance for morbidity & mortality coding, and coding quality

22. Lesson Plan 1. Sources of data for coding 2. Responsibilities
3. Data abstraction
4. Main diagnosis
5. Accurate coding
6. Quality assurance in morbidity data collections
Coding quality
Source documentation quality
7. Auditing of source documents

23. Introduction
For clinical coding to be as valuable as possible it is critical the coder has:
access to a comprehensive and accurate medical record,
the skills to extract all pertinent data for coding,
access to clinicians to ask questions and seek clarification

24. Sources of clinical data for coding
Morbidity coding is usually performed after the patient has left the hospital
Information to be coded is abstracted from the whole medical record
The coding process has two parts:
analysis of the medical record
allocation of correct codes

25. Responsibilities Coders reviewing the entire record
verifying the record contains appropriate documentation
coding specifically and accurately the conditions or diagnoses treated or affecting a patient’s care
referring the record to clinicians for clarification
Clinicians
recording accurate and complete clinical documentation in the medical record
recording all diagnoses on the front summary sheet
identifying the main condition

26. 7 Steps for Abstraction of Relevant Data from the Medical Record
Read the front sheet of the relevant admission
Read the discharge summary or other correspondence
Compare any diagnosis in the discharge summary/letter with that recorded as admission or provisional diagnosis and with that recorded on the front sheet
Read the history and physical examination
Identify relevant procedures
Review the entire record
Clarify information with the clinician if necessary

27. When to consult with the Medical Officer
If conflicting, incomplete or ambiguous information is found or if documentation is unclear
Check with the attending medical officer, the medical officer who filled in the front sheet or the radiologist or pathologist
Coding should be a cooperative and collaborative effort between the clinician and the coder

28. What to code? Main condition or principal diagnosis
+/- other or secondary conditions
+/- procedures, operations and interventions

29. Selecting the Main Condition or Main Diagnosis
Consider those conditions which:
caused the patient to be admitted
were treated and/or investigated during the acute admission
affected the treatment given and/or the length of stay
developed during the admission
The main diagnosis can then be selected from these conditions

30. WHO definition of main diagnosis or main condition
…the diagnosis established at the end of the episode of care to be the condition primarily responsible for the patient receiving treatment or being investigated…that condition that is determined to have been mainly responsible for the episode of health care...
(ICD-10, volume 2, 4.4)

31. Secondary diagnosis / Other condition
a diagnosis that either co-exists with the main diagnosis at the time of admission, or which appears during the episode of care
complications and comorbidities

32. What is a comorbidity?
A disease that accompanies the main diagnosis and requires treatment and additional care, in addition to the treatment provided for the condition for which the patient was admitted

33. What is a complication?
A disease that appears during the episode of care, due to a pre-existing condition or arising as a result of the care received by the patient

34. Problems with determining the main diagnosis
absence of a clear-cut main diagnosis
minor condition recorded as main diagnosis
diagnosis recorded in general or ill-defined terms
uncertainty of diagnosis
symptoms or signs listed as the main diagnosis
no diagnosis recorded

35. What is accurate coding?
each diagnosis must be assigned its correct code (or codes)
Codes should be as complete as possible
all diagnoses affecting the care of the patient and procedures performed during the episode of care should be assigned codes
codes must be sequenced correctly with the main diagnosis listed first
morbidity coding rules in volume 2 of ICD-10 should be followed

36. To ensure accurate coding:
Coders should be familiar:
with anatomy and physiology of the human body
with medical terminology so that disease descriptions can be interpreted into ICD language
with disease processes and medical practice to be able to understand etiology, pathology, symptoms, signs, diagnostic procedures, etc.

37. To ensure accurate coding:
Coders should also have:
an understanding of the content of the medical record
experience with the actual medical records so specific details can be located
detailed knowledge of the coding system being used
an understanding of data reporting requirements

38. Quality Assurance in Morbidity Data Collection
Increasing use of morbidity data leads to an increasing concern for the reliability of data
Sources of error in MR information systems:
documentation of the patient’s care and condition during the episode in hospital
coding the information in the medical record
processing the coded information

39. Coding accuracy Three dimensions of coding accuracy:
accuracy and completeness of individual codes
accuracy of the totality of codes to ensure they reflect all diagnoses treated; and
accuracy in the sequence in which the codes are recorded, particularly in selection of the main condition

40. Common sources of coding errors:
Clerical
careless mistakes, transposing numbers
Judgmental
wrong subjective decisions taken
Knowledge
mistakes due to lack of coder knowledge
Systematic
errors in the process of coding or problems with the environment in which coders work
Documentation
incomplete, inaccurate, ambiguous, conflicting
illegible

41. What affects coding quality?
Errors in the choice of code
Lack of feedback
Casemix – number and type of cases to be coded
Use of coding conventions and coding rules
Lack of clarity in coding books
Changes in coding practice

42. What affects coding quality?
Documentation
Incomplete medical records
Availability of records
Coder/clinician communication
Data entry
System edits
Forms design
Documentation
May be late, misleading, incomplete or inadequate.
Clinicians responsible for completion of the clinical record may not understand the definition of the term ‘principal diagnosis’ (main diagnosis), and the clinical coder has to interpret the record to decide which diagnosis corresponds with the definition of principal diagnosis (main diagnosis).
The clinical coder may have to make a decision based on conflicting information within the record. For example, an operation report may state that a unilateral salpingo-oophorectomy was performed, but the histopathology report state that both tubes and ovaries were submitted for analysis.
Data in the record may be illegible and the clinical coder may be forced to seek clarification from a colleague or a clinician about the entry written.
Incomplete medical records
Often the clinical record is incomplete at the time of coding and, if pressured to code quickly due to deadlines, the clinical coder may be forced to make clinical judgments in relation to the patient’s diagnosis and procedures. Essential reports required for accurate coding such as radiology and pathology reports may also be absent at the time of coding.
Availability of records
Records may be unavailable at the time of coding.
Coder/clinician communication
There may be inadequate coder/clinician communication resulting in inappropriate code assignment.
Data entry
There may be poor data entry e.g. dates of birth may have been recorded incorrectly for cases that have inappropriate combinations of age and code or codes may have been transcribed incorrectly.
System edits
There may be inadequate editing at point of input.
Forms design could be improved to ensure all the information required for coding is captured.

43. What affects coding quality?
Workload
Education
Human resources
Environment
The individual
Reference material
The clinical coding process is extremely complex and there are several things that affect the quality of coding:
Workload
Coders are often required to perform other duties, which means less time to spend on coding.
Education
There may be gaps in coder education.
Human resources
There may not be enough clinical coders to complete the task in the time available, not enough adequately trained clinical coders or new coders.
Environment
There may be inadequate physical resources or a noisy environment.
The individual
Knowledge uptake, coding aptitude, desire to code - job satisfaction.
Reference material
There may be inadequate reference resources for coders.

44. Coder/Clinician Communication is important for:
Team approach to achieve complete and accurate documentation
Clinician’s responsibility to record accurate diagnoses and procedures and document fully the episode of care
Coder’s responsibility to review and use documentation; use standard definitions, use their skill and knowledge of the current coding system

45. Why has communication traditionally been lacking?
lack of understanding of coding as a process and of the importance of coded data
clinicians do not feel a sense of ownership of the classification system or the fact that the coded data reflect their work
coders feel intimidated about asking questions, seeking advice or asking about clinical issues

46. Ways of improving communication
encourage clinicians to attend coding meetings in the clinical coding/medical record department
request coders attend clinician meetings conducted by each clinical specialty
organise coding service to allow coders to specialise
clinician involvement in the development of coding guidelines
education for clinicians and coders

47. Five steps for quality control of coding:
establishment of objective criteria for coding quality
measurement of performance
analysis of problems identified
action taken to correct identified problems
review of performance after corrective action

48. Auditing To inspect and verify
To determine the degree of accuracy in ICD coding based on coding rules and coding conventions

49. Audit principles Coder A (original coder) Coder B (auditor)
Coder C (independent adjudicator)

50. Sample selection Period of audit Audit sample Random sample
Target sample

51. Sample selection Random representative of morbidity database
suitable for benchmarking
only some records will have errors
5% sample size recommended
random number generator or table

52. Sample selection Target defined by coder-in-charge or auditor
cases selected because of known or suspected errors or difficult cases or because a new coder has started work
only some records will have errors

53. Retrieving and preparing clinical records
Retrieve original record
Temporarily remove or obscure coded data

54. Recoding process Coder B If there is a dispute, Coder C
Recodes each record
Assigns error categories if errors found – tries to determine what has caused the error
If there is a dispute, Coder C
Assigns error categories

55. Coder C recoding Recodes record ‘blind’
Discusses code differences with Coder A and Coder B
Make final decision about correct codes
Assign errors to error categories
Assign errors to the appropriate categories.
Coder C’s Data Collection form becomes the correct record of codes for that case.
Disputes are not very common. Where initial examination of results and discussion with Coder A does not reveal any disputed code assignments, the involvement of Coder C is not necessary.

56. Examine and analyse results
Need to develop a form for reporting of results
Scoring Tool form
Summary Data form
The summary data forms the basis for a report about coding quality and can be used to compare data at different time periods.

57. Questions to ask when reviewing coding:
Is the main diagnosis correctly identified?
Are all secondary diagnoses coded?
Are all diagnoses coded?
Are all diagnoses and procedures coded correctly?
Have the codes been transcribed or data entered correctly?

58. Coder competency is influenced by:
Knowledge
Skill
Attitude
Behaviour
Experience

59. Ways of improving coder competency:
Training (initial education and training)
Continuing education (ongoing education)
Reference materials
Coder peer support
Recognition of competence

60. Documentation Key elements - accurate, complete, timely, legible
Source document - quality of the clinical record
Documentation errors - Main condition, other diagnoses, operations

62. Documentation requirements – what clinical staff should write:
Do write:
Date and time of entries
Purpose of entry eg. admission note, planned review, asked to see patient, end of shift report
History and examination findings – be succinct!
Assessment of current situation
Plan for what needs to happen now and later
Print name and sign, include position, contact details for every entry
Use only approved abbreviations
Complete discharge summary and front sheet

63. Documentation requirements – what clinical staff should not write:
Don’t write:
A repeat of clinical details previously written – this wastes your’s and other’s time and wastes paper
Anything unpleasant, rude, or critical of either relatives, patients or staff
Anything that is not true or does not reflect reality
Backdated entries or changes to existing entries

64. Documentation policy
Need to ensure there is a documentation policy in place so clinical staff know the requirements for documentation and can be assessed against those requirements
See sample Guidelines for Medical Record and Clinical documentation
What are the requirements for clinical documentation in your country? Are these written in a policy? Do clinical staff know what they should be documenting?

65. Ways of improving documentation
1. record design - well structured, standard order, complete, cover the scope of the care
2. forms design - elicit information needed for patient care and coding, easy to use, legible, designed in conjunction with health professionals who will use them
3. education
clinicians - documentation is as much part of clinical care as direct patient contact
management - channel resources and enthusiasm into this area

66. Assessment of documentation quality
Conduct a regular audit of documentation quality
Use standard data collection form – can compare results over time to determine improvements
Consider the data items that must be presented in a documentation quality report and the format in which they should be recorded
See example of documentation audit sheet

67. Process for a documentation audit
Complete at least 1 audit per year
Select a random sample of 5% of discharges in a given month, or at least 10 records (whichever is the higher number) should be audited
Select records from a printout of the Medical Record or Bedhead Ticket numbers of all discharges in a month ordered by discharge date. Select every 20th medical record number on list for audit. If record selected is not available, the next record on the list should be selected
The audit relates to documentation within the selected admission only

68. Medical Record documentation Assessment
In country groups, using the sample medical records brought with you, complete a documentation audit for each record.
What are the major problems you have found?
What are some way that these might be addressed?