MEDICAL RECORD DEPARTMENT
PRESENTED BY
EEPIKA SHARMA Roll no-D-1522 MBA(H0M) 09-11
? INTRODUCTION ? DEFINITION ? FUNCTION ? PHYSICAL ? IMPORTANCE ? LOCATION
LAYOUT ? KEY PLANNING & DESIGNING ? FILING & STORAGE SYSTEM ? SPACE REQUIREMENT ? CONCLUSION ? REFERENCES
? Medical
records through which hospital statistics is generated and medical records are important to hospital for evaluation of its services for better patient care.
? Mc
scientific, administrative and legal document relating to patient care in which are recorded sufficient data written in the sequence of events to justify diagnosis and warrant treatment and end results.
Gibony considered medical record as a clinical,
?
Medical records is defined simply as a systematic documentation of a patient·s personal and social data , history of his or her ailment clinical findings, investigations, diagnosis, treatment given and an account of follow-up and final outcome.
1. 2. 3. 4. 5. 6. 7. 8.
Progressive patient care and are an important aid in continuity of care in case of future illness. Evaluation of quality of patient care through their retrospective review. Evaluation of performance of medical and nursing staff. Medical education and clinical research. Provision of Health information ( morbidity & mortality) for use by the public health authorities. Issue of birth, death and sickness certificate. Provision of information for Medical Insurance Agencies. Medico- legal cases.
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Collection of information and maintenance of records of patient·s movement from registration to discharge. Collection of case documents after discharge(IPD cases)/OPD consultation. Checking the records as per the checklist for completion , and getting the incomplete records completed without any delay. Coding as per the International classification of diseases(ICD)and indexing the records as per the patient·s name , disease/diagnosis , physician and the surgical procedure carried out. Analysis of records and generation of statistics for clinical research and administrative use. Daily ward census and monthly bed utilization statistics for the information of management. Filing and safe storage of records. Maintenance and safe/secure preservation of records for the period mandated by law.
? The
medical record department should be within the hospital building, near the administration office, and not very far from the entrance. The general tendency to locate the MRD in the basement is fraught with risk of fire/water logging/seepage and should be avoided. The storage wing of the office used for inactive records can be located relatively distantly from the hospital building.
The medical record department should have provision for the following areas/rooms:
Office of medical record officer. Office of asst. medical record officer. Waiting space/lounge. Modular workstations for different functions with scope for expansion. A conference/seminar room for doctors- incomplete record control. Issue desk/counter with photocopying equipment. Storage room/area for active records. Storage area/room for inactive records in a contiguous area or remote area with proper communication.
Medical record office should be spacious, well ventilated, & have adequate protection from pest & rodents. It may be prudent to have air- conditioning so as to control humidity & improve comfort levels. The walls, floors & ceilings should be leak & seepage proof, especially in storage portion. Adequate light (200-300 lux) should be provided for office work. Compactor system for storage areas effectively increase the storage space as compared to conventional racks. Access control to storage area is essential , hence entry gate should be strategically located.
? ? ? ?
? ? ?
?
Filing system of records plays a crucial role in smooth functioning of the department . To file the case sheet according to serial inpatient CR( Central Registration) number. To paste the slip on filing racks indicating the records, i.e. 1 to 300, 301 to 600 & so on. Always remove the case sheet by keeping a tracer card for knowing the movement , & care should be taken to withdraw the tracer card, while the case sheet is filed back. An efficient system involves the following: Properly organising the documents of each & every patient. Identifying each record. This can be indexed. Alphabetical Numerical Serial unit Terminal digit Placing the record file in cabinets / shelf
? ?
Keeping track when withdrawn from cabinet/ shelf. Numbering:- various system of numbering of the records are followed in different hospitals, the most common is the serial numbering.
Medico ² legal records:- There should be separate cabinets for such records , & separate indexing. They should remain in personal custody of the record officers , & should be available all times. ? Retention of records:- The length of time a medical record is to be retained should be determined by the existing law. However there is no law in India which specifies such a period. In absence of such regulatory requirement the hospital administration will have to establish its own policy governing retention. ? Some of the senior medical record officers consider it desireable to retain them as under:a. Need of patient : Upto 7 yrs b. Medicolegal : Inpatient ² 7yrs : Outpatient ² 5yrs c. Teaching / research : Upto ² 7yrs
?
?
? ?
The medical record department should be @ 1.0 sq.m / bed, but would also depend upon the status of computerization of the hospital. Storage should be 15 ² 50 sq. m with compactors to store more number of files in same space. Filing space should be provided adequately & can be calculated.
?
?
An effective & efficient medical record department is an important variable for a hospital as a quality parameter especially in light of Consumer Protection Act 1986 & the recent Right To Information Act 2005. It is also a mandatory requirement for accreditation of hospitals & computerization can go a long way in ensuring optimal functioning.
? Modern
trends in planning & designing of hospitals; By S Gupta & S Kant«««««« ? Principles of hospital administration & planning; By BM Sakharkar«««« ? Images from www.googleimages.com
doc_932548618.pptx
PRESENTED BY
EEPIKA SHARMA Roll no-D-1522 MBA(H0M) 09-11? INTRODUCTION ? DEFINITION ? FUNCTION ? PHYSICAL ? IMPORTANCE ? LOCATION
LAYOUT ? KEY PLANNING & DESIGNING ? FILING & STORAGE SYSTEM ? SPACE REQUIREMENT ? CONCLUSION ? REFERENCES
? Medical
records through which hospital statistics is generated and medical records are important to hospital for evaluation of its services for better patient care.
? Mc
scientific, administrative and legal document relating to patient care in which are recorded sufficient data written in the sequence of events to justify diagnosis and warrant treatment and end results.
Gibony considered medical record as a clinical,
?
Medical records is defined simply as a systematic documentation of a patient·s personal and social data , history of his or her ailment clinical findings, investigations, diagnosis, treatment given and an account of follow-up and final outcome.
1. 2. 3. 4. 5. 6. 7. 8.
Progressive patient care and are an important aid in continuity of care in case of future illness. Evaluation of quality of patient care through their retrospective review. Evaluation of performance of medical and nursing staff. Medical education and clinical research. Provision of Health information ( morbidity & mortality) for use by the public health authorities. Issue of birth, death and sickness certificate. Provision of information for Medical Insurance Agencies. Medico- legal cases.
?
? ?
?
?
?
? ?
Collection of information and maintenance of records of patient·s movement from registration to discharge. Collection of case documents after discharge(IPD cases)/OPD consultation. Checking the records as per the checklist for completion , and getting the incomplete records completed without any delay. Coding as per the International classification of diseases(ICD)and indexing the records as per the patient·s name , disease/diagnosis , physician and the surgical procedure carried out. Analysis of records and generation of statistics for clinical research and administrative use. Daily ward census and monthly bed utilization statistics for the information of management. Filing and safe storage of records. Maintenance and safe/secure preservation of records for the period mandated by law.
? The
medical record department should be within the hospital building, near the administration office, and not very far from the entrance. The general tendency to locate the MRD in the basement is fraught with risk of fire/water logging/seepage and should be avoided. The storage wing of the office used for inactive records can be located relatively distantly from the hospital building.
The medical record department should have provision for the following areas/rooms:
Office of medical record officer. Office of asst. medical record officer. Waiting space/lounge. Modular workstations for different functions with scope for expansion. A conference/seminar room for doctors- incomplete record control. Issue desk/counter with photocopying equipment. Storage room/area for active records. Storage area/room for inactive records in a contiguous area or remote area with proper communication.
Medical record office should be spacious, well ventilated, & have adequate protection from pest & rodents. It may be prudent to have air- conditioning so as to control humidity & improve comfort levels. The walls, floors & ceilings should be leak & seepage proof, especially in storage portion. Adequate light (200-300 lux) should be provided for office work. Compactor system for storage areas effectively increase the storage space as compared to conventional racks. Access control to storage area is essential , hence entry gate should be strategically located.
? ? ? ?
? ? ?
?
Filing system of records plays a crucial role in smooth functioning of the department . To file the case sheet according to serial inpatient CR( Central Registration) number. To paste the slip on filing racks indicating the records, i.e. 1 to 300, 301 to 600 & so on. Always remove the case sheet by keeping a tracer card for knowing the movement , & care should be taken to withdraw the tracer card, while the case sheet is filed back. An efficient system involves the following: Properly organising the documents of each & every patient. Identifying each record. This can be indexed. Alphabetical Numerical Serial unit Terminal digit Placing the record file in cabinets / shelf
? ?
Keeping track when withdrawn from cabinet/ shelf. Numbering:- various system of numbering of the records are followed in different hospitals, the most common is the serial numbering.
Medico ² legal records:- There should be separate cabinets for such records , & separate indexing. They should remain in personal custody of the record officers , & should be available all times. ? Retention of records:- The length of time a medical record is to be retained should be determined by the existing law. However there is no law in India which specifies such a period. In absence of such regulatory requirement the hospital administration will have to establish its own policy governing retention. ? Some of the senior medical record officers consider it desireable to retain them as under:a. Need of patient : Upto 7 yrs b. Medicolegal : Inpatient ² 7yrs : Outpatient ² 5yrs c. Teaching / research : Upto ² 7yrs
?
?
? ?
The medical record department should be @ 1.0 sq.m / bed, but would also depend upon the status of computerization of the hospital. Storage should be 15 ² 50 sq. m with compactors to store more number of files in same space. Filing space should be provided adequately & can be calculated.
?
?
An effective & efficient medical record department is an important variable for a hospital as a quality parameter especially in light of Consumer Protection Act 1986 & the recent Right To Information Act 2005. It is also a mandatory requirement for accreditation of hospitals & computerization can go a long way in ensuring optimal functioning.
? Modern
trends in planning & designing of hospitals; By S Gupta & S Kant«««««« ? Principles of hospital administration & planning; By BM Sakharkar«««« ? Images from www.googleimages.com
doc_932548618.pptx