medical records wing commander (dr) suresh tahiliani nabh assessor aima-accredited management...
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MEDICAL RECORDS
Wing Commander (Dr) Suresh TahilianiNABH AssessorAIMA-Accredited Management [email protected]
Definition
Clear concise & accurate history of patient’s life & illness, written from medical point of view.
-Mac Eachern (1957) A clinical, scientific, administrative & legal
document relating to patient care in which recorded sufficient data written in sequence of events to justify the diagnosis & warrant the treatment & the result. Chronicle of the pageantry of medical & scientific progress.
-Mc Gibony (1969)
Medical Records
It is a repository of all information pertaining to a patient’s health and health history, thus it contains information on diseases diagnosis, tests and examinations, therapies, prognosis and discharge status.
In simple terms it reveals theWhomWhatWhy Of patient careWhereWhen
Contents of Medical Records
Personal & demographic profile Clinical notes Case history Diagnosis Treatment Investigations undertaken Discharge status
In different forms:-
•Paper
•Microfilm
•Optical disc
•Tape
•Computer drives
Modern History (in India) 1667 St Bartholomew’s Hospital –First Medical
Record Unit established JACH (Joint Commission on Accreditation of
Hospitals) Assumed responsibility of standardisation, leading to improvement of medical care
1946 Bhore Committee – Stressed on it’s importance 1962 Mudaliar Committee – Reiterated
recommendation of Bhore 1965 Medical Review Committee
Min basic requirement of forms Standardised size & paper for forms Evolution & est of 5 regional trg centres
CMC, Vellore first to organise MRD & hold training courses for technicians
Medical Record Department (MRD)
Earlier-
Depository of medical Information
Now-
Vital source of statistics Reimbursement Utilisation Peer review Clinical research Legal issues
Need for Medical Records
Three primary reasons:- Ensures continuity of treatment & care Can be retrieved at later date on re-admission, for
medico legal requirements For medical audit, research & training
1979- Seminar organised by DGHS observed:- Gross inadequacies of health information Cumbersome retrieval process Hosp statistics collected by paramedics eg nurses Medical certification of cause of death not maintained Few hospitals report data to state health authorities No proper maintenance of health statistics at state &
national level
Types of Medical Records
Directly related to patient care activities Admission Forms- Medical history
sheets, medical treatment record forms Nurses bed side records- TPR charts,
consultations, investigations OT notes, discharge summaries
Indirectly related to patient care activities Budget, accounts/financial transactions
during patient stay
Characteristics of Medical Records
Complete – Should have sufficient data to identify pt, justify treatment , inv, etc
Adequate – All necessary forms & all relevant clinical information
Accurate – Capable of quantitative analysis
Scope & Importance: For Patients
Assist continuity of care Avoid omission/ repetition/
duplication of investigations Evidence to support/refute medico
legal questions Documents story of patient Ready info for life & health insurance Disability entitlements
Scope & Importance: For Physician
Assurance of adequacy, quality & continuity of care
Helps evaluation of medical care Protects from legal suits An aid in research
Scope & Importance: For Hospital
Documentation as evidence for evaluation of medical & nursing care
Helps the management in planning & allocation of resources
Protects in case of legal suits
Scope & Importance: For Medical Education & Research
Assists in deriving conclusions or investigating them
Aids informal education Forms basis of clinical research Reliable for advancement of
medicine
Scope & Importance: For Public Health Authorities
Reliable info regarding mortality, morbidity profile of population
Assists in planning preventive & social measures
Provide early warning of incidence of communicable diseases
Physical Facilities for MRD
UnitArea
(sq ft)Location
Admission Office
125 - 175 As near OPD & Casualty as possible
Medical Record Office
50 beds – 175100 beds – 240200 beds – 500
>500 beds - 1200
Where possible In-patient & OPD records must be kept together
Storage 125 – 500 For vertical storage. In one shelf = 36 – 125 indoor patient’s or 300 OPD records
Staffing of MRD
PersonnelBeds in Hospital
200 300 400 500750
Med Rec Officer - - - - 1
Asst MRO - - - - 1
Tech Asst - - - - 1
Med Rec Tech/Clk 2 4 6 8 12
Med Rec Attendants
4 4 5 6 10
Functional Organisation of MRD
Chief of MRD
Relief clkMed corres & abstract
Asst Chief for admitting & OPD
Asst Chief for Central
Transcription
Asst Chief for pers trg & med correspondence
Consultancy service & Research
Secretary
Reports & statisticsCentral discharge
File clkAppt & admission
Index files•Diagnostic•Operation•Physician
Responsibilities of MRD
Designing hospital forms Admission/Registration Census Checking/verification/correctness of every
record for inaccuracy, incompleteness, coding, indexing
Filing according to pre-determined system Compiling hospital/diagnostic statistics Generating reports for administrators,
management, audit committees, Govt health dept
Processing of Medical Records
Admitting Office Census desk Assembling & deficiency check desk Incomplete records control desk Admission & discharge analysis Coding & indexing desk Filing
Functional Activities in MRD
Admission Office Reception & registration Assignment to OPD/wards Initiates documentation Collects documents after discharge &
sends to Central Records Officer Keeps upto date info of bed state Notification, if needed
Functional Activities in MRD
OPD Registration Every patient is given a regn No
All records of the patient stored in this file
Functional Activities in MRD
Wards/Nursing Units History & examination Diagnosis Investigation & consultations & progress notes Education Evaluation Discharge
Functional Activities in MRD
Central Record Office Assembling. Order of arranging medical records Checking for incomplete records Analysing (physician or medical audit committee) Reporting (Hospital Statistical Abstracts) of
communicable diseases Filing – De/centralised, horizontal/vertical Storage & retention depends on hospital & Govt
policy Retention of Medical Records:-
OPD - 5 years Indoor - 5 years Medico legal - Life Long
Functional Activities in MRD
Reporting, analysis & preparation of monthly hosp abstracts & annual statistics
NumberingSerial Numbering. New No on each admission
regardless of No of new admissionsUnit Numbering. Same admission No in all re-
admissionsSerial Unit Numbering. Same as serial No but
records are subsequently filed under latest No
Functional Activities in MRD
Filing SystemDecentralised. OPD & In patient have
separate records. Increases work, operating cost & likelihood of duplication
Centralised. Records filed centrally Qualitative Analysis. Responsibility of
MRO to check component parts & analyse for accuracy, completeness & adequacy
Coding. As per ICD X
Functional Activities in MRD
Deficiency Checks. Deficient records placed in incomplete file rack till completed till completed by concerned physician, nurse, dept
Indexing. Different types:-Patient Index (Alpha Index)Disease IndexUnit IndexOperation index
Functional Activities in MRD
Filing.HorizontalVertical - Economy of space, scope for
expansion, safety & adaptability
Forms. Coloured files for different years of records for easy retrieval. Uniform file size 8in x 11in for easy filing
Manual Recording in MRD
Most widely used Advantages
Portable Subjective data easy to recordScanning is easierCan be organised in any way
DisadvantagesOnly one copyCost of missing records Incomplete/illegible recordsDifficult to track down dataPapers may not be in chronological order
MRD: Situation in India
Too many patients
Facilities/resources over stretched
Voluminous paper works
Less time spent on actual patient care
Innovations in MRD
Comprehensive Summary
Only salient & essential data stored
Can be done for records > 10 yrs old
Name, age, sex, father’s name, address, DOA, DOD/death
Innovations in MRD
Microfilming – Filming of records in miniature size
AdvantagesSpace saving (75 – 80%)Accessibility – Can be stored in dept Protection – Cannot be easily tampered No misfilming – Once filmedSaves time
DisadvantageInconvenient for studying
Innovations in MRDComputerisation (can also be shared by many
hospitals, Professional Activity Study- PAS) Advantages
Single database shared by all departments Easy accessibility/retrieval Instant access to many users Real time information available Comprehensive/legible information Productivity of practitioners Reduced time of clerical functions
Disadvantage Not portable Needs down time Computer literate staff required Affected by disruption in power supply
Legal Aspects
PROPERTY OF HOSPITAL
Not of patient or doctor
Personal Document
Confidential & privileged communication- Must not be released without patient consent
Legal Aspects: Personal Document Can divulge to:-
Patient – Brief summaryRelatives/Friends – No written infoPress – None other than administratorLIC – Even without consent of patient to
dispose claims arising from insurance policies
Police – In case of MLC, Injury Report given. Not allowed to record patients statement without prior certification by MO .
Court of Law – According to Indian Evidence Act hospital document incl medical records admissible as evidence. Court can summon any document or medical record. Can summon doctor for evidence under law of torts
Legal Aspects: Impersonal Document
Can be used for education, research, public health
In communication. Diseases/notifiable diseases. Some personal information at times has to be divulged in public interest
Mainly it is impersonal data
Medical Records & Hospital Information System
Wide ranging reports & returns can be generated in the medical records department. The basic purpose of these reports are:
a) Evaluating the quality of care being renderedb) Locating the deficiencies in : I) Means: Staff, physical facilities, equipment including plants & machine.
. The reports maybe generated daily, weekly, monthly, quarterly and annually depending upon the requirement. The reports generally pertains to :
a) Vital Statistics b) ADT analysis (Admission, Discharge
& Transfer Analysis ) c) General Health Statistics
Comprehensive list of such reports and returns cannot be laid out since there will be so much variation from hospital to hospital. Some of the reports that can be commonly generated by the hospital are :
Maximum patients on any one day Minimum patients on any one day Daily average Bed occupancy rate Total patient days care Bed turn over interval
b) AdmissionDaily admissionDaily admission unit/specialty wise Total admission over a periodpatients distribution by age, sex, religion
& regionc) DischargesDaily dischargesTotal patients discharged over a periodDays of care to the patients discharged
Average length of stayd) DeathsDaily number of deathsTotal deaths over a periodNet death rateGross death rate
Foetal death rateMaternal death rateInfant death ratePost operative death rateAnaesthetic death ratee) Work load statistics Total number of outpatients :New cases
Repeat cases Total number of operations Total number of X-ray & other
related investigations Total number of lab
investigations/lab wise investigations.
Department wise workload statistics
f) Hospital Care Evaluation Statistics Post operative infection rate Post operative complication rate Caesarian section rate Autopsy rate Consultation rate Rate of normal tissue removed Percentage of disagreement between final
& pathological diagnosis
Gross result of treatment, I.e., patients recovered, improved or not relieved.
Admission Admission is the acceptance of a
patient by the hospital for inpatient service, which may be for investigation and / or treatment.
Discharge Discharge is the release of an inpatient.
Death of an admitted patient is also considered as discharge.
Hospital Deaths Death of an admitted patient is
considered as a hospital death. Death of a patient in the casualty, OPD or in an ambulance, before the actual admission of the patient
Total deaths of hospitalized patients is known as Gross Deaths. Total deaths after 48 hours of admission is considered net deaths.
Patient Day A patient day is the period of service
rendered to an inpatient between the census taking hours of two successive days.
While counting, the day of discharge of an inpatient is not counted, irrespective of the time of discharge. Similarly the day of the admission is counted always regardless of the time of admission.
Patient day is a valuable unit used for expressing the various activities of a hospital such as patient days of service rendered during the given period, cost of food per patient per day etc.
Bed Complement Bed complement is the number of
hospital beds normally available for use by the in patient. It includes the following types of beds:
a) Adult beds b) Crids
c) Bassinets for use of infants other than new born
d) Incubators for prematures Casualty ward beds Postoperative ward beds Intensive care unit beds Isolation beds Staff sickness beds
The following types of beds are not included in the bed complement of a hospital :
a) Recovery room beds b) Observation beds of casualty c) Examination beds The methods of calculation of some of
the commonly used statistics are given below:
Average Daily Census Average daily census is the average
number of patients in the hospital at a given time per day& is expressed as :
Sum of daily census for a given period --------------------------------------------------- Number of calendar days in the period
Death Rates a) Gross death rate:Total number of hospital deaths during given period ------------------------------------------------------------------
X100Total discharge (including deaths) during the same
periodb)Net death rate:Total deaths of in patients after 48 hrs of admission
during the given period -----------------------------------------------------------------X100Total discharges (including deaths) during the
same period
C) Specific death rate: Number of net deaths in a ward or department
during a given period ----------------------------------------------------------X100 Total discharges (including deaths) in that
department during the same period.
Average Length of Stay Average length of stays is the average
number of days of service rendered to each discharged patient during the given period of time. Patient days are complied from the discharge summary of discharged patient. The formula is :
total patient days during the given period
----------------------------------------------------------------------
Total discharge (including deaths) during the same period.
Turnover Interval or “T” Interval“T” interval is the average period in days
a bed remains vacant between one discharge & another admission & is expressed as:
(Bed complement x period)- Pt. days for that period---------------------------------------------------------------No. of discharges(including deaths) during that period.
The value of “T” may be negative or positive:- A negative “T” indicative of scarcity of
beds and over utilisation. A long positive”T” is indicative of
underutilisation because of either defective admission procedures or poor quality medical care.
A short “T” is indicative of optimum utilisation.
Safety of records Responsibility lies with the administration.
Proper records of their movement must be kept during its transit from indoor to medical records department or whenever a document is taken out for education/research.
A single person should control all medico legal records of the hospital, preferably medical record officer
Medico legal record
Kept in safe custody Separate medico legal record movement
register should be maintained at the medical records department.
Any movement of the medico legal record along with its purpose should be recorded
A responsible person from the medical records department should be detailed to present the medico legal records in the court of law whenever the need arises.