Aa

aA

AN ANALYTICAL STUDY ON MEDICAL RECORDS

DEPARTMENT carrying out

at SAMBHUNATH PANDIT HOSPITAL

for partial fulfilment of BBA(H)

MAULANA ABUL KALAM AZAD UNIVERSITY OF

TECHNOLOGY

FROM

DINABHANDU ANDREWS INSTITUTE OF MANAGEMENT

& TECHNOLOGY

NAME- SAHELI GHOSH CLASS- BHM 6TH SEMESTER

Roll No-15403315025

Registration No- 151541310025

SESSION-2015-2018

SHAMBHUNATH PANDIT HOSPITAL

Address: 11, Elgin Road, Lala Lajpat Rai Sarani,

Kolkata - 700020, Near NetajiBhawan

Hours Open: 24 hours

Company certificate

AKNOWLADGEMENT

Success is sweet but the secret is ‘sweat of the brow’ –

this I realize while I was in training! Even though it required a

lot of physical and mental effort during the process, it bore a

real sweet fruit. Every moment of my training period was full

of lesson-learning and acquiring experience.

I would like to thank Dr. Sankta Nandy (Principal, DAITM), Mr.

Surajit Das (HOD of BHM, DAITM) for giving me opportunity

to complete my internship from SAMBHUNATH PANDIT

HOSPITAL, KOLKATA.

This project has been done in the IRIS HOSPITAL, Kolkata and

the work would not have been possible without the help and

guidance of Mr. Soumya Ranjan Das (In charge of MRD) &

Mrs. Paramita Ghosh (Faculty of BHM) as my project guides.

They provided me continuous support and valuable

suggestions during the entire period of my training. I am really

indebted to them!

DECLARATION

This is to certify that the dissertation entitled “Training

Report on MRDICAL RECORDS DEPARTMENT” at

SAMBHUNATH PANDIT HOSPITAL, KOLKATA has been

prepared by Saheli Ghosh herself in partial fulfilment of the

requirement of BHM degree in Maulana Abdul Kalam Azad

University of Technology, West Bengal.

I, Saheli Ghosh, hereby declare that all the information and

facts provided here are based on my own findings and studies

at SAMBHUNATH PANDIT HOSPITAL. The contents of report

are a true experience of my efforts.

Signature of the student

Place: Kolkata

Date:

Executive Summary As a part of a specialized internship programme, I was

assigned as a medical record intern in SAMBHUNATH PANDIT

HOSPITAL. I got some knowledge about medical records

department and I have gained experience of working in MRD.

During my training period in MRD of Shambhunath Pandit

hospital, I have learnt about after discharging a patient the file

treatment, discharge record maintain, treatment of MLC file,

procedures of birth file, birth register, treatment of death file

and death register, leave against medical record(LAMA) file

treatment, medical record keeping system, diagnostic report

keeping, file assembling, numbering and keeping them

according to discharge date, treatment of outpatient

department’s file.

During 1 months of my internship in MRD I was given

few tasks like file assembling, number, binding & storing them

properly. I was assigned for a survey of MRD staff’s

satisfaction. as per result of the survey I can there many things

need to be developed immediately. Those factors can be

improved with help of the employee of MRD as well as other

department of hospital.

Overall, I can say that I got through a very fruitful

internship it allows me to gain a good experience in hospital

industry.

Content

Serial No. Topic

1 Hospital profile

2 Introduction of MRD

3 Review of literature

4 Objective

5 Broad overview

6 Methodology

7 Data collection &

Interpretation

8 Problems & findings

9 Conclusion

10 Bibliography

11 Annexure

Hospital Profile

Sambhunath Pandit was the first Indian to become judge of Calcutta High Court in 1863. He served in that position from 1863-1867. One of the leading personalities of Kolkata in his age, he had contributed in many ways to the development of legal systems and enrichment of social life.

He published a book entitled On the Being of God. A government hospital and an important road in Bhowanipur are named after him.

In Kolkata, Sambhunath Pandit Hospital is a recognized name in patient care. They are one of the well-known Hospitals in Lala Lajpat Rai Sarani. Backed with a vision to offer the best in patient care and equipped with technologically advanced healthcare facilities, they are one of the upcoming names in the healthcare industry. Located in, this hospital is easily accessible by various means of transport.

A team of well-trained medical staff, non-medical staff and

experienced clinical technicians work round-the-clock to offer

various services. Their professional services make them a

sought after Hospitals in Kolkata. A team of doctors on board,

including specialists are equipped with the knowledge and

expertise for handling various types of medical cases.

SAMBHUNATH PANDIT HOSPIATAL is a 570 bedded general hospital under Municipal Corporation of Kolkata.

For management and systematic maintenance of hospital medical record department has been established. In Kolkata, SAMBHUNATH PANDIT Hospital is a recognized name in patient care. They are one of the well-known Hospitals in LALA LAJPAT RAI SARANI. Backed with a vision to offer the best in patient care and equipped with technologically advanced healthcare facilities, they are one of the upcoming names in the healthcare industry. A team of well-trained medical staff, non-medical staff and experienced clinical technicians work round-the-clock to offer various services. Their professional services make them a sought after Hospitals in Kolkata. A team of doctors on board ,including specialists are equipped with the knowledge and expertise for handling various types of medical cases. At SAMBHUNATH PANDIT Hospital in LALA LAJPAT RAI SARANI, the various modes of payment are accepted.

Introduction of

Medical Records Department

Medical records is the systematic documentation of the patient’s personal and social data, history of his or her ailment, clinical findings, investigations, diagnosis, treatment given, account of following up and outcome. Medical records through which hospital statistics are generated serve as a eyes and ears to the hospital administrator. Medical records are of importance to the hospital for the evaluation of its services for better patient care. They also serve as a resource for education and training of physicians and others, also being a basis for clinical research. Research to be effective requires scientifically recorded observations as reflected in the medical record. And, the importance of medical records for legal purpose is well established. Over the years Medical Records Department has arises as a vital part of any health care organization or a hospital. The dictum is “People forget, but Records remember”. Medical Records has become a specialty in its own right, and the Medical Record Officers and Medical Record Technicians have earned the right to be considered as specialist in their own field. This is so because patient care requires a chronological record of patient care and treatment, and this enables the clinical team, as well as the hospital administrator, to evaluate the quality of medical care, and the effectiveness of the hospital services. This study is based on some objectives, to evaluate the existing medical record

keeping system and evaluate the effectiveness of the current medical record system. Each MRD in the hospitals includes the following four units,

each of which undertakes special functions:

• Admission: Registration of inpatients and outpatients who are admitted to Hospital wards and the Accident and Emergency Department

• Archive: Checking to ensure that a complete discharge summary and all other necessary notes and reports are present in the MRs; assembling and internally organizing the MR and filing them in an orderly and timely manner; retrieving these records for various users, for treatment and the provision of other services

• Statistics: Preparing statistics for administration, hospital wards, and external agencies such as the Ministry of Health; providing health information for physicians, nurses and students for medical research purposes

• Coding: Analysing the MRs of all inpatient’ following discharge and assigning a set of numeric codes to the diagnostic data based on the International Classification of Diseases-10 and the International Classification of Procedures in Medicine.

Review of literature

(2013) [1] Isfahani SS, Bahrami S, Torki S. in a research paper “Job characteristic perception and intrinsic motivation in medical record department staff.” determined the relationship between job characteristics and intrinsic motivation in medical record staff in hospitals. This study also described that human resources are key factors in service organizations like hospitals. Therefore, motivating human recourses to achieve the objectives of an organization is important. (2013) [2] Al-Jafar E. in the study titled “Exploring patient satisfaction before and after electronic health record (EHR) implementation: the Kuwait experience.” investigated patient satisfaction with the quality of services provided before and after the implementation of electronic health records (EHRs) at Primary Health Care Centers (PHCCs) in Kuwait. In this study it was find out that Before EHR implementation, respondents' disagreement regarding the doctor's carefulness in conducting the examination, uses of medical terminology, explanations for medication given, and time given for a patient was more than 30 percent. Disagreement regarding the rest of the questions related to the patient/physician relationship after EHR implementation was also higher (25 percent to 39 percent).

(2012) [3] Nahid Tavakoli, Sakineh Saghaiannejad, Mohammad Reza Habibi “ A comparative study of laws and procedures pertaining to the medical records retention in selected countries” concluded that the lack of a complete, transparent and update medical record retention schedule in Iran, lead to confusion for hospitals. (2011) [4] Bali Amit, Bali Deepika, Iyer Nageshwar and Iyer Meenakshi in the study titled “Management of Medical Records: Facts and Figures for Surgeons”explained the various aspect of record maintenance. Medical records are the one of the most important aspect on which practically almost every medico-legal battle is won or lost. If written correctly, notes will support the doctor about the correctness of treatment. In spite of knowing the importance of proper record keeping in India, it is still in the initial stages. (2009) [5] Thomas Joseph in his research publication on “Medical records and issues in negligence stated about various methods” stated various methods of record keeping. The traditional method of keeping records that is followed in most of the hospitals across India is the manual method involving papers and books. There are serious limitations of manual record keeping including the need for large storage areas and difficulties in the retrieval of records. However, it is legally more acceptable as documentary evidence as it is difficult to tamper with the records without detection.

(2009) [6] Gurudatta. S. Pawar, Jayashree .G. Pawar in a research paper “Facts of Medical Record Keeping - The Integral Part of Medical and Medico Legal Practice.” stated that Medical records are the integral part of medical practice/ medical profession. In the present days of consumer awareness and litigation suites, they help the treating physician to prove that he /she has used proper care and skill while treating the patient. Maintaining and preserving them in a proper and methodical way is the responsibility of the concerned doctor. (2009) [7] Mestri Shashidhar C in his study “Legal and ethical aspects of medical records – An Indian Perspective” stated that Medical records are an index of a Health Institution and Medical Records department is the back bone of Health information system. Medical records speak volumes on and about, inception and progress of Hospital, retrospective and prospective statistical analysis, trends of cases admitted to the hospital etc. Medical Records act as growing data base of medical and scientific knowledge; and help the Government while planning and allocation of budget for health care system of the country. The need of hour is uniformity in storing Medical Records by various Acts.

Objectives

When I was in my previous internship I was influenced to go to MRD. Over the years Medical Records Department has arises as a vital part of any health care organization or a hospital. The dictum is “People forget, but Records remember”. Medical Records has become a specialty in its own right, and the Medical Record Officers and Medical Record Technicians have earned the right to be considered as specialist in their own field. This is so because patient care requires a chronological record of patient care and treatment, and this enables the clinical team, as well as the hospital administrator, to evaluate the quality of medical care, and the effectiveness of the hospital services. This study is based on some objectives, to evaluate the existing medical record keeping system and evaluate the effectiveness of the current medical record system.

Broad Overview

This study was aimed to analyse the existing working procedure of Medical Record department to find out the areas that could be further improved. It was observed that the personnel in the Medical Record Department were sincere and conscious and the department was computerized, ICD coding system is implemented though there is scope for implementation of Electronic Health Record. Medical records is the systematic documentation of the patient’s personal and social data, history of his or her ailment, clinical findings, investigations, diagnosis, treatment given, account of following up and outcome. Medical records through which hospital statistics are generated serve as a eyes and ears to the hospital administrator. Medical records are of importance to the hospital for the evaluation of its services for better patient care. This study is based on some objectives, which are as under:

1. To evaluate the existing medical records keeping system 2. To assess and evaluate the effectiveness of the current

medical record system 3. To assess the logical and legal aspects of the current

medical records keeping system 4. To identify the shortcoming if any & provide suitable

recommendation to improve the existing medical recording system.

One of the most common problem of every MRD is find out a file and provide proper information to the concerning department. Time taken in retrieving a file reflects the efficiency of Medical Record Department. The personnel working in the Medical Record Department answered that files in the Medical Record Department are easily accessible. Time was assessed for retrieving a particular file on request according to Out-Patient & In-Patient records. The personnel working in the Medical Record Department answered that time taken for retrieval of outpatient records is 3 minutes and for inpatient records is 5 minutes. There should be adequacy of infrastructure & facilities in Medical Record Department for effective work flow. Infrastructure & facilities in Medical Record Department include ample number of rooms, file storing racks; computers & scanners. The personnel working in the Medical Record Department responded that infrastructure and facilities in medical record department are adequate. Extent of workload on staff working in working in Medical Record Department affects the efficiency. Excessive workload decreases efficiency of staff working in Medical Record Department. The personnel working in the Medical Record Department responded that working load is affecting them to great extent. IPD and medico legal files have to be kept for years. There should be no difficulty in storing files. Filing system should be in a proper way. The personnel working in the Medical Record Department answered there is no problem in storing of files & In-Patient case files are stored for 5 years and Medico Legal case files are stored for 10 years.

ICD 10 is the coding system used now in most of the medical record department. It provides uniformity while comparing data. The personnel working in the Medical Record Department answered that In-Patient cases are classified according to ICD10 Coding System & they are filing Medical records in the numerical manner. Scanning of files is helpful as it eliminates paper based files which require more space and are more prone to wear and tear.The personnel working in the Medical Record Department answered that the scanning & elimination of paper based file system is advantageous, feasible & it will improve accessibility to old medical records. As Medical Record Department is the most suitable department for computerization. Most of developed countries have adopted Health Record. The personnel working in the Medical Record Department answered that the computerization of essential and useful in Medical Record department & preparation of daily statistics with the help of computers decreases workload. As computerization is becoming an essential component of health information system. It is easy to retrieve the information if there is computerization. The personnel working in the Medical Record Department answered that the computerization of medical records reduced their workload.

Procedure of receiving, checking & storing of medical

records files:

Receiving the INPATIENT DEPARTMENT(IPD) files:

1. Every inpatient medical record has two unique identifies which

are the inpatient number for that admission and the registration

number which is unique to the patient. Every patient medical

record can be identified with the inpatient & registration

number.

2. Representative floor manager of ward prepares a list of IPD

Medical Records and then brings to the Medical Records

Department(MRD) within 2:00 PM to 4:00pm. MRD personnel

receives the medical records after verifying their register. Floor

manager are requested to sign the receiving register at MRD. All

file should be brought to MRD within 48 hours after

discharging/death of the patient.

3. OPD (outpatient department) prescription are sent from OPD

month wise after completion of the respective months.

Checking IPD files:

While receiving the discharged or death patients files, medical

records assistants check whether the file is complete or not, the

complete file means Discharge/Death/LAMA summery, Dearth/

Birth certificate, Treatment sheets, Operation/Procedure (if

any), Consent forms, Medicine card, Nursing records,

Investigation reports, and all the other records pertaining to the

treatment of the patient.

Policy for medical Records of OPD:

OPD staffs collects carbon copy of every OPD prescription form

of MRD

Treatment for receiving of MLC files:

MLC forms are stored in Emergency department for 3 months.

They are sent to MRD after that. File containing MLC form are

will be stored for 15 years in MRD, hereafter that would be

destroyed.

Storing the files:

1. Medical records assistant separate the discharged, expired,

LAMA & MLC patient files and does the numbering. Then the MR

files are filed according to serial number & date of

discharge/LAMA/death.

2. Death patient files are marked by black marker pen on the MR

check list.

3. Medico legal(MLC) files are kept under lock and key.

4. IPD medical records as well as carbon copies of OPD

prescriptions are stored in Medical Records Department for 3

months.

5. After In House Retention period is over, the original files are

listed, indexed, packed and sent to the IRC limited; they store

the Medical Record files of the patient of our hospital till the

retention period.

Procedures for access of Information by

patient/authorized attendant/Mediclaim/insurance

companies/legal authorities from the medical records

department:

• The medical records can be accessed by the patients, their

authorities, research department of our hospital or employees

of our hospital.

• For Mediclaim/insurance company to access medical records,

prior authorization from the patient/their next of kin must be

obtained; an authorization from the company is also obtained

with an identity proof of the medicine/insurance company

representative.

• When a medical record or information is to be given to

1. Patient (his or her identification)

2. N.O.K (Authorization is required from the patient with an

identification of patient & N.O.K)

3. Any other person (Authorization is required from the

patient/next of kin in case of patient is

minor/deceased/unable to write), an authorization letter

from the Insurance company and an identification of either

patient or NOK as the case may be & authorized person.

4. Mediclaim/ insurance companies (Authorization is

required from the patient/ next of kin in case of patient is

minor/deceased/ unable to write) an authorization letter

from the insurance company and an identification means

any of the following identity proof:

Voter’s identity card, Pan card, Driving license, Passport,

Ration card, Madhyamik admit card or certificate, Birth

certificate etc.

Procedures for maintaining the Confidentiality,

Integrity & Security of the Medical Records:

• This hospital maintains the integrity of the medical records and

guards against damage and tampering while in the wards, or in

the Medical Records Department or in its outsourced storage

facility.

• It maintains the security of medical records and guards against

theft and misplacement. In the wards the medical records are

under the custody of the nurse-in-charge on duty. In the MRD, it

is under the custody of the executive, Medical records.

• Always lock the room before leaving MRD.

• Ensure closing of the electric equipment’s like light, fan, AC etc

before leaving.

Procedure for retention policy:

The medical record retention policies are as follows:

IPD Records 10 years

OPD Records 5 years

MLC Records 15 years

Birth/death Records Not to be destroyed

MLC Registers Not to be destroyed

PNDT/Death files Not to be destroyed

All register 5 years

Procedure & protocol for integrity & security of

medical records:

1. The medical records are (Refer to MR checklist) good quality

paper and kept in secure place in the wards in Medical Record

File.

2. In the wards the medical records files are kept in a secure place

under the supervision of the nurses, dieticians, laboratory and

imaging personnel and any other employee authorized by the

hospital authority. The above mentioned persons are only

authorized to make entries in the medical records files except

the laboratory or imaging personnel unless authorized by the

hospital authority to do so.

3. After the discharge or death of patient, the medical records are

handed over to the custody of the respective floor manager.

Then the MR files are checked for sequence of arrangement &

pages are numbered by the floor manager. Floor manager of the

respective ward prepares the list of Medical Records files and

brings them to MRD along with Medical Record files from

2:00PM to 4:00PM except Sunday & hospital holidays.

4. In the MRD the medical records files are checked according to

MR checklist, numbered according to the date of

discharge/death and then the files are kept in good quality with

identification on the outside.

5. In the MRD the Zip plastic packets containing medical record files

are field in sequence in steel racks.

6. In the MRD the medical records are checked weekly to look for

signs of pest infestation & insecticide/pesticide spray are done

on weekly basis.

7. The Medical Records Department has adequate and proper fire

fighting system & fire extinguishers.

.

Methodology

Duration of training: 06/03/18 to 06/04/18

Timing: Monday to Saturday from 9:30- 2:30

Method of data collection:

Topic Sample sizes:

(1) Questions and responses of 30

users by working of Medical Record Department

(2) Opinion of Staff working in MRD about the existing Medical 4 Record Keeping System

Type of data:

Primary data:

The data used in project are primary data. The primary data has

been collected from stuff of medical records and the patients.

The data were mainly collected through observation, regular

interaction with hospital employees.

Secondary data:

Few secondary data have been used in this project.

DATA COLLECTION & INTERPRETATION

Questions and responses of users by working of Medical Record Department

YES (83%)

NO(17%)

Q. DO YOU GET THE NEEDED INFORMATION IN TIME?

Does the MRD provide precise information?

Series1 26 -86.60%

Series2 4 -13.30%

YES (86.6)

-86.60%

NO (13.3)

-13.30%-5

0

5

10

15

20

25

30

Q. Does the MRD provide precise information?

YES(83.3%)

NO(16.7%)

Q. Does the information content meet your needs?

YES (27)

-90%

NO (3)

-10%

-5 0 5 10 15 20 25 30

DO YOU THINK THAT YOU GOT CLEAR INFORMATION?

Do you think that you got clear information?

Series2 3 -10%

Series1 27 -90%

Q. Do you think that you got clear information?

27

-90%

3

-10%

-5 0 5 10 15 20 25 30

Do you think the output information youneeded is presented in a useful format?

Do you think the output information youneeded is presented in a useful format?

Series2 3 -10%

Series1 27 -90%

Q.DO YOU THINK THE OUTPUT INFORMATION YOU NEEDED IS PRESENTED IN A USEFUL

FORMAT?

YES93%

NO7%

Q. DOES THE STAFF WORKING IN MRD LISTEN TO YOUR REQUEST AT TENTATIVELY?

27

-90%

3

-10%

-5 0 5 10 15 20 25 30

Do the MRD officially provide sufficientinformation?

Do the MRD officially provide sufficientinformation?

Series2 3 -10%

Series1 27 -90%

Q. Do the MRD officially provide sufficient information?

YES (87%)

NO (13%)

Q. Are you satisfied with the working of MRD?

Graphical representation of opinion of Staff working in MRD about the existing Medical Record Keeping System:

As per opinion of MRD staff we can see that maximum employees of MRD are agree with the above factors. There are two factors, most employee disagreed. Those are adequate working place and problem in sorting file. Inadequate working place really make a very uncomfortable and obnoxious situation for employees. Lack of space do not allow them to work smoothly. Sorting of file is a critical work and it needs a lot of patience. But employees have no issue with it.

9%9%

0%9%

9%0%

8%8%8%

8%

8%

8%

8%8%

ACCESSIBILITY OF FILES IN MEDICAL RECORD DEPARTMENT

CENTRALIZATION OF FILING SYSTEM

ADEQUACY OF WORKING SPACE

ADEQUACY OF INFRASTRUCTURE &FACILITY

MENSE EXTENT OF WORKLOAD

PROBLEM IN STORING FILES

IMPLEMENTATION OF ICD10 CODING SYSTEM

FEASIBILITY OF SCANNING & ELIMINATIONOF PAPER BASED FILESYSTEM

IMPROVED ACCESSIBILITY TO THE OLD MEDICAL RECORD DUE TOSCANNING

ESSENTIALITY OF COMPUTERIZATION OF RECORD

COMPUTERIZATION OF RECORDS HELPFUL IN PREPARING DAILYSTATISTICS

REDUCTION OF WORKLOAD DUE TO COMPUTERIZATION OFRECORDS

ESTABLISHMENT OF E.H.R. LEADS TO IMPROVEMENT IN PATIENTCARE

E.H.R. DOCUMENTATION PROVIDING IMMEDIATE INFORMATIONDURING AN EMERGENCE

Graphical representation of time taken to get information in MRD:

% OF TOTAL NUMBER OF RESPONDANTS Time is important in every service. Taken time works as one of the parameter of patient satisfaction. lesser time indicates more patient satisfaction. here I did an observation on time taken of patient visiting MRD. Mostly it took 5 to 10 minutes or less then 5 minutes, a few cases took 10 to 30 minutes and a very few cases took more than 30 minutes.

0

5

10

15

20

25

30

<5 MINUTE 5-10 MINUTE 10-30 MINUTE >30 MINUTE TOTA

NO. OF RESPONDANTS % OF TOTAL NUMBER OF RESPONDANTS

Problems & findings

Current Problems in MRD:

1. Lack of space

2. Less number of trained personnel

3. Careless attitude of floor manager

4. Record keeping method – arrange file horizontally thus it

is very difficult to find out a particular file.

5. Absence of Medical Record number

6. Absence of patient identification sticker

7. Absence of ICD coding method

ICD coding have certain benefits:

• Improving the accuracy of claims processing

• More accurate and detailed clinical reporting

• Better tracking of patient outcomes

• Fine tuning quality programs

• Less confusion to recognize the disease

• Absence of ICD coding make physician confused and that

create a barrier towards a better patient care.

On the basis of problem and analysis of the study, it is recommended that some changes be considered in order to improve the quality of service rendered by Medical Record Department.

• The success of a good Medical Record depends upon the trained and adequate number of staff posted in Medical Record Department. In its absence it is not possible to develop a good medical record of medico legal importance, patient care and reliable health information (data) which is a key tool for planning. Hence the hospital must have trained and adequate number of staff in the Medical Record Department as the the number of staff working in Medical Record Department is inadequate.

• There is possibility for implementation of Electronic Health Record Documentation.

• Forms in the case sheets should be in A4 size which will be more feasible to scan.

• Working space and space for storage is insufficient which should be increased.

• Establishing ICD coding system properly

Conclusion The system was analyzed by observing working procedure, maintenance of records and registers in the department and personnel interview of Medical Record Department staffs through pre-tested standardized questionnaires. From the response obtained through the questionnaires, it was observed that the personnel in the Medical Record Department were sincere and conscious and the department was computerized, ICD coding system is implemented though scanning of records can be done which will be helpful. Analysis of result also showed that though the department is functioning reasonably well, there were areas which could be considerably improved. It was felt that the number of personnel working in Medical Record Department could be increased. The result of the present study also indicates that the present system of the Medical Records is useful, accessible and affordable.

As Medical Record Department is the most suitable department for computerization. Most of developed countries have adopted Health Record. The personnel working in the Medical Record Department answered that the computerization of essential and useful in Medical Record department & preparation of daily statistics with the help of computers decreases workload. As computerization is becoming an essential component of health information system. It is easy to retrieve the information if there is computerization.

The personnel working in the Medical Record Department answered that the computerization of medical records reduced their workload. A lot of Hospitals are going to implement E-health record documentation. But it is important to evaluate the existing system for feasibility in Establishment of Electronic health record documentation. E-health record will improve patient care and save time as it will be easy to get information about past disease and it will improve access to patient history. The personnel working in the Medical Record Department answered that establishment of Electronic health record documentation will improve patient care and save time. Moreover Electronic health record documentation will provide immediate information during an emergency

Bibliography

1. Al-Jafar E. “Exploring patient satisfaction before and after electronic health record (EHR) implementation: the Kuwait experience.” Perspective Health Inf Manag. 2013 Apr 1; 10:1c. Print 2013

2. Isfahani SS, Bahrami S, Torki S. “Job characteristic perception and intrinsic motivation in medical record department staff.” Med Arh. 2013;67(1):51-5

3. Nahid Tavakoli, Sakineh Saghaiannejad, Mohammad Reza Habibi “ A comparative study of laws and procedures pertaining to the medical records retention in selected countries

4. Bali Amit, Bali Deepika, Iyer Nageshwar and Iyer Meenakshi study titled “Management of Medical Records: Facts and Figures for Surgeons” J Maxillofac Oral Surg. 2011 September; 10(3): 199–202. Published online 2011 April 20

5. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3238553/

6. URL:http://rfppl.com/subscription/upload_pdf/Art%201_a28.pdf

7. http:// www.indianjournals.com/ijor.aspx?target=ijor:mlu&volume=9&issue=2&article=006

Annexure

Table No. 1: Opinion of Staff working in MRD about the

existing Medical Record Keeping System: SL

No. Factors Agree Disagree

1 ACCESSIBILITY OF FILES IN MEDICAL RECORD DEPARTMENT

4 0

2 CENTRALIZATION OF FILING SYSTEM 4 0

3 ADEQUACY OF WORKING SPACE 0 4

4 ADEQUACY OF INFRASTRUCTURE &FACILITY

4 0

5 MENSE EXTENT OF WORKLOAD 4 0

6 PROBLEM IN STORING FILES 0 4

7 IMPLEMENTATION OF ICD10 CODING SYSTEM

4 0

8 FEASIBILITY OF SCANNING & ELIMINATIONOF PAPER BASED FILE SYSTEM

4 0

9 IMPROVED ACCESSIBILITY TO THE OLD MEDICAL RECORD DUE TO SCANNING

4 0

10 ESSENTIALITY OF COMPUTERIZATION OF RECORD

4 0

11 COMPUTERIZATION OF RECORDS HELPFUL IN PREPARING DAILY STATISTICS

4 0

12 REDUCTION OF WORKLOAD DUE TO COMPUTERIZATION OF RECORDS

4 0

Table No. 2: No. of patients towards time taken in getting the information

TIME TAKEN TO

GET INFORMATION

NO. OF PATIENT OR PATIENT

PARTIES

% OF TOTAL PATIENT OR

PATIENT PARTIES <5 MINUTE 9 30%

5-10 MINUTE 16 53.3% 10-30 MINUTE 5 16.7% >30 MINUTE 0 0%

TOTA 30 100%