Patients: For Continuity, follow up, re- admission &

communication, Medico legal safe guard, Medical Certification

purposes, ….

Doctors - Continuity in scientific knowledge purposes,

publications, Medical Research and Patient Drug Trial purposes,

etc.

Hospital - Quality & quantity purposes, preparing hospital

Statistics like GDR,NDR, BOR, BTOR, ALOS, for future hospital

expansion planning, and various projections…

Hon’ble Court Compliances - MRD provides Written documentary

evidences to various Hon’ble Court/s in Country for proper &

speedy Justices and other compliances.

Research - Various researches are conducted in hospital, MRD

provides information and Data to the researcher.

Life/Medical Insurance Purposes - MRD provides information to

LIC, UIC,SBI life, PNB Life, ICICI Prudential Life, TATA AIG, STAR

Insurance,….

National level information to - CBHI-MOH&FW, GOI, State Health

Department, Govt. Institutions, RGI, FRRO, NDMC, NGO, National

Human

Rights Commission, Women Rights Commission, Child Rights

Protection Commission, Persons with Disability Commission, SC&

ST Commission,…

International level Information to – WHO, World Bank, IFHIMA,

WHA, IHTSDO, HL7, LOINC, Health Economics & Statistics Deptt.

UNICEF, UNDIO, RED Cross...

RAMESH KUMAR KAUL (Jr. Medical Record Officer)Medical Record Technician- TeamDr. Sanjeev K. Bhoi - F/I/C MRS-TC

Prof. M.C. Misra (Chief of JPN Apex Trauma Centre)

Introduction:MRD plays very important and pivotal role in patient healthcare

delivery system in any hospital. MRD keep all record of clinical

information of patients, who attend the hospital for their aliment.

Hospital keeps the record of all documents of patient/s for various

purposes like to examine the past and present medical history of

patient; legal purposes; drug trial and medical research purposes;

preparing hospital statistics/Hospital performances reports, etc.

Dr. G.R.Mac Giboney defines: ‘ Medical Record as a clinical,

scientific, administrative and medico-legal documents related to the

patients care, which contains sufficient data in sequence of events,

to justify the diagnosis, warrants the treatment and end results’.

The medical record must contain sufficient data to identify the

patient, support the diagnosis or reason for attendance at the health

care facility, justify the treatment accurately and documents should

contain the result of that treatment (Huffman 1990)

And many more Act……… The AIM of MRD at Trauma Centre:

To keep available and ready all clinical information related the

patient care during Hospitalization, and other various Data, related

the patient under Concern.

Value is to supply information at fasted to the applicant.

Mission is to build a State of Art Medical Record Documentation

Centre; as Model for SEARC countries.

Medical Record Department (MRD-TC Participates in various

committees:

Medical Record Policy & SOP Committee

Medical Record Medico-legal Policy Committee

Medical Record Hospital Research Committee

Medical Record Participated in requirement of Manpower in MRD

Medical Record participated in developing inclusions/exclusions

in ICD-10 and ICF (WHO) Compiled Versions

Medical Record Form Committee

Medical Record Committee- for developing, upgrade Hi-tech for

medical record dissemination.

Participated in SNOMED-CT high level meeting at AIIMS: for

Developing & Designing SNOMED-CT model suitable for India

The laws and Acts related to Medical record in India:

1. Medical Council of India Act.1956

2. Consumer Protection Act.1986

3. Indian Penal Code 1860

4. Birth & Death Registration Act.1969

5. Persons with Disability Act.1995.

6. ESI Act.1948

7. PC & PNDTC Act.

8. NOTTO Act- Organ & tissue transplant.

9. Nurses Act 1950

10. Dental act 1948

11. Drugs & Cosmetics Act 1940

12. Mental Health Act.1987

13. Indian Evidence Act 1872,1952,1961.

14. IRDA Act.1999

15. Pharmacy Act.

16. Income Tax Act

17. Notifiable & Communicable Diseases Act

18. MTP Act

19. Right to Information Act.2005

20. Cancer Registry

EMR can improve the efficiency and quality of medical care and

can minimize the repetition of work done.

EMR will help in reducing a bit in Carbon Emission into

atmosphere; consequently; will put affect on reducing Global

Warming.

Medical record is concerned with: NIC, HL7, LOINC, SNOMED-CT

computer design programs.

Values of Medical Record:

Characteristics of Medical Record document.: it should contain

Complete information - Sufficient data, to determine the diagnosis.

Accurate information - Progress notes, process and procedures of

treatment.

Adequate information – Deficiency check up.

EMR: Electronic Medical Record, it is a systematic, sequential and

chronological ordered patient’s health information in electronic

form, in a given time frame, in any healthcare centre.

EMR systems are designed to store, retrieve, transfer, share data

safely, efficiently and accurately at very low cost maintenances.

“Doctor & Patient forgets but Record

Remembers”

MRD keeps all Indoor/Outdoor Patients Clinical written record in its

Chronological order in safe & secure custody.

MRD issues Birth/Death Certificates to next to nearest patient’s

relative at JPNATC.

MRD issues Patient’s Record to Hon’ble Court for Documentary

evidence purposes.

MRD issues record to: Patient, Police, Public, Govt. Institution, NGO,

WHO, MOH&FW, Red Cross, Various Commissions,…

MRD issues record to Researchers for Evidence base Medical

Research and Development, Patient Drug trial purposes, various

periodical publications,….

MRD prepares Annual Hospital Performance Report: Statistics of

Patients.

MRD prepares and gives regularly feedback to Authorities, for

developing Complete EMR System /Computerization in Trauma Centre.

MRD conducted Various Workshop, Seminar, professional trainings, in

house lectures, Poster…..

MRD participated in International Health Record Congress-2015 at

Hyderabad under HIMA-India banner.

HIMA-India is recognized National Association of Health Record

Professionals in India, and is a Part of IFHIMA: International

Federation of Health Information Management Associations. (28

Nation Members)

MRD participated in Various National Health Record Conference

under HRAI - India banner. MEDRECON - 2012 to 2016, HIMA- India-

2016, IFHIMA-Tokyo-2106, WTC-New Delhi-2016, CEUTEH-AIIMS-2016,

AIIMS Annual Exhibition: 2016

For any information/Suggestion please visit our Web page under

AIIMS NEW DELHI>JPNATC>Medical Record Section.

Future Plan for creation: Centre for Health Record Science &

Informatics- Under AIIMS Authority New Delhi

R.K.KAUL (Jr. Medical Record Officer)

Medical Record Technician- Team

Dr. Sanjeev K. Bhoi - F/I/C MRS-TC

MRD Activity

“Doctor & Patient forgets

but

Record Remembers”