Medical record & Health information Technician

Medical record &health information management

1. [MEDICAL RECORD &
HEALTH INFORMATION
TECHNICIAN]

2023

STUDENT NAME :
SURESH MANDRIYA
SUBJECT : MEDICAL
RECORD & HEALTH
INFORMATION
TECHNICIAN

2. INTRODUCTION
This chapter describes various medical record operations which includes, Filing systems—
Decentralization and Centralization of medical records, Filing methods — Alphabetical, Straight
numerical & Terminal / middle digit filing method; Numbering of medical records — Unit, Serial
& serial Unit numbering system; Tracking of medical records; electronic medical record(EMR);
Organisation and management of IPD,OPD & Unit numberings, Filing system medical records —
Work flow; Origin of medical records, Central Admitting Office, Principle of interviewing the
patient; Medical Record and Audit Committee.
FILING SYSTEMS
There are two types of medical record systems for filing of medical records: -
• Decentralized Medical Record System
• Centralized Medical Record System
DECENTRALIZED MEDICAL RECORD SYSTEM
In Decentralized Medical Record System, inpatient and outpatient departments have their own
individual medical records and should file them independently. Inpatient medical records are
filed in the Medical Record Department and Outpatient Medical Records are filed in the
Outpatient Department.
CENTRALIZED MEDICAL RECORD SYSTEM
In Centralized Medical Record System, all medical records of a patient, whether inpatient or
outpatient, are filed together in one folder and kept in the Medical Record Department.
Medical Record Departments in most countries today use a Centralized Medical Record System.
METHODS OF FILING OF MEDICAL RECORDS
Whether using a centralized or decentralized medical record system, there are four types of
filing methods used in hospitals: -
Alphabetical Filing
• Straight numeric Filing
• Terminal Digit Filing
• Middle Digit Filing System
ALPHABETICAL FILING
In this system the record is filed alphabetically according to the names of the patient. For the
same name, it is filed according to father's name, alphabetically.

3. STRAIGHT NUMERIC FILING
In this method, medical records are filed in strict number order according to the MRN starting
with the lowest number and ending with the highest number.

TERMINAL DIGIT FILING
In this method usually six digit number same divided with hyphen into three parts, the last two digits are the
primary digit (PD) and in middle two digits are secondary digits (SD) and the two left of secondary digits are
tertiary digits (TD). Keeping primary and secondary digits constant, the record is filed according to the tertiary
digit in a chronological order. For example:
TD-SD-PD
• 32-56-78
• 33-56-78
• 34-56-78
• 35-56-78
Adaption can be made to five, seven or in nine digits also such as: (TD-SD-PD).
• 0-24-46
• 024-24-46
Some hospitals also use a color code on the folder to assist in identifying the medical record quickly and
improve the efficiency of the filing clerk.
MIDDLE DIGIT FILING SYSTEM
Middle digit filing is an alternative to terminal digit filing. In this system, middle two digits are termed as
primary digits and left to the primary digit are secondary digits and right to primary digit is tertiary digits.
Record is filed according to the said tertiary digit. The sample sequence of middle digit filing system is as under:
-
SD-PD-TD
• 35-56-78
• 35-56-79
• 35-56-80
• 35-56-81

4. NUMBERING OF MEDICAL RECORDS
A unique number to every patient and filing his record according to that number is the best way to maintain
records. There are three methods for Numbering of Medical Records.
• Serial Numbering System
• Unit Numbering System
• Serial- Unit Numbering System
SERIAL NUMBERING SYSTEM
In serial numbering system, a new number is given on each admission and the medical record (i.e. case sheet) is
filed according to this number.

ADVANTAGES:
• Simple to Operate
DISADVANTAGE:
• One patient's record is available at different places.
• More time required for retrieval of records.
UNIT NUMBERING
In this system only one number is given at the time of first admission, and the same number will be used for
readmission and the record will be filed in one folder.
ADVANTAGES:
• Ideal system for a small hospital
• Time/Labour saving for retrieval Of records
• Records are available at one place
DISADVANTAGES:
• Patients Index must be adequate i.e. the admission records must be adequate to maintain unit
numbering not appropriate for Migratory population.
• Difficulty in Destruction of records
• More- Messengers required
• Racks will be overcrowded (70% space used)
SERIAL-UNIT NUMBERING SYSTEM:
In this system a new number is given on each admission but the record is filed at one place Of the last number,
the Tracer Card is filed at previous place of record, with the help of Index Card,
At the time Of filing of patient index card you will find that there is already one index card containing
theinformation regarding the previous admissions of the patient then makes entry on the last index card of
present index card.

5. So there will be only one index card for various admissions of one patient. In such cases the information Of
current admission with previous record number should be sent to the filing area in order to remove the
previous record from that place. The same should be filed with the latest record at the medical record number
of latest admission. The tracer card should be filed at the place of previous record from where the record is
shifted. The tracer card should keep the information that the record is being filed at the record number of
latest admission.
ADVANTAGES:
• Unit Record - means one patient one record.
• Easy in destruction of records
• Drawers are not over crowded (30% space should be kept for earlier admissions.)
DISADVANTAGES:
•
Earlier Drawers loosens i.e. there are chances of merging of new records with earlier records
TRACKING OF MEDICAL RECORD
Tracking system refers to retrieval and proper follow up of medical records. For proper filing of medical records
and 100 % control of medical records the following system should be followed:-
• Proper sorter or pre file system
• Check out system (tracer system)
• Requisition and charge out system should be followed
A SORTER PRE FILE SYSTEM
Each file room should have a set of shelves for records waiting to be filed. This is usually called a
Sorter.
Medical records that are returned from outpatient clinics (if the medical records are combined i.e., a
centralized system is used) or completed after discharge of an inpatient and ready to be filed, should
be "sorted" in a manner which will enable them to be found, if required, while waiting to be filed.
The shelves should be numbered, perhaps in sections of IOS or 20s and the records placed on
thecorrect numbered shelf. This makes it easier to find a record which is waiting to befiled.
TRACER CARD
To ensure proper record control, whenever a medical record is removed from a file for any purpose, it should
be replaced by a Tracer, which indicates where the medical record has been sent. A tracer is also called an Out
guide in many countries. Tracers or Out guides enable medical records to be traced when not in place.
One of the important rules which all the staff in the medical record department should follow is that no file
should be removed from its place without being replaced by an out-guide or a tracer card, as it is called in some
hospitals. This indicates the new, "temporary address" of the file and tells you where the record has gone to.
Records should never be removed from the facility except under subpoena or a valid court order.
Many record departments lend records to authorized staff, clinics or other departments only on the basis Of a
written requisition form. The minimum information on the form should include the patient's name and hospital
number, the name of the requisitioning dept. /area or person, purpose and the date. The requisition form

6. often comes in duplicate or triplicate. When the record is pulled out, one copy is attached to the out guide who
replaces the record in its place. The out guide and the sign-out slip are removed when the record is returned.
REQUISITION AND CHARGE OUT SYSTEM
Table-I: Following is the requisition and charge out system of medical records: -
1. Tracer Card* File at Once
2. Remove tracer card* Immediately on receipt back of record
3. Periodical Check up Either once a week or a month or a year



4. Attend at once/ within 24 hrs. The requisition received in MRD
5. Three Requisitions
i)
Ward To be retained in ward / requesting facility
Tracer Card To file with tracer card
iii) MRD file To be filed in MRd file
6. Loan Cards Physician's Index
7. Reminders To doctors to return the record
8. Clearance to doctors Clearance only after checking loan card
Tracer Card: When the inpatient medical record (case sheet) is removed from the filing rack then thetracer card
is filled in its place. The tracer card contains the medical record department No., Name of patient, date of
admission & discharge and the name of the Doctor to whom it is being issued.
In case the record is filled in folder system the tracer card may be printed on the folder of the case sheet and
when the case sheet is retrieved the folder will remain in the rack .0nly the case sheet Will be retrieved from
the folder and the case sheet will be sent in another new folder after writing the Serial number or record / case
sheet i.e. C.R. No. MRD No., IPD No. etc. It will be very useful to keep the track of record as to how many times
it has moved out and for what purpose etc.
Remove Tracer Card: When the case sheet is received back it should be filed immediately at its place andthe
tracer card should be removed.
case of tracer card on the folder when the case record comes back, it should be kept in the concerned folder
with marking on the tracer card of the folder with the date of return. The cover prepared at the time of
retrieval of the file should be removed.
Periodical Check-up: The inpatient medical record filing racks should be checked periodically that there isno
misfiling in future. It should be checked either once a week or a month or a year whichever is possible.
Attend at once/within 24 hrs: The requisition for issue of medical record should be attended at once
orminimum within 24 hours.
Three Requisitions for (i) Ward (ii) Tracer Card (iii) MRD File: The requisition for issue of medical recordshould
be prepared in triplicate: (i) one copy may be retained in the ward, (ii) Second copy should be filed with the
tracer card and (iii) the third copy should be filed in the file of medical record department.

7. Loan Cards -Physicians Index: The index card by the name of the Doctors, to whom the case sheet or therecord
is issued, should be prepared and filed alphabetically in the filing area. This index may be called as physician's
index also.
Reminders: If the record is not received back within reasonable time then reminders should be sent to
theDoctors to return the record.
Clearance to Doctors: At the time of giving clearance to the doctors,the physicians' indexand the loanslips kept
in medical record department file, should be checked thoroughly and seen that no record is pending with the
concerned doctor. There should be one Doctor's clearance register in the filing area and at the time of giving
clearance the name and residential address and place of various posting with the specimen signature of the
doctors should be noted in this register.
Table-2: Sample Requisition For Medical Record
Requisition For Medical Record
DATE Time a.m. /p.m.
Location of Clinic / Dept.

Name of the Patient

Serial Number /Unit Number

Purpose of record use

Duration for which record is needed:
Signature of executive / client Signature of Consultant

IMPORTANT POINTS ON FILING OF MEDICAL RECORDS:-
All medical records should be filed as soon as possible when returned to the Medical
RecordDepartment or completed following the discharge of the patient.
The best way to locate a medical record when not in use is in its correct place on the shelf in the
medical records department.
At the end of every day, there should be no medical records waiting for filing. That is, at the end
Ofevery day, all completed and returned medical records should be filed.
Medical records that are too big should be separated into two or more volumes and clearly marked
asVOL. I or VOL. 2 etc. and filed together in the correct placewhen filing medical records, torn or
damaged folders should be replaced and any loose forms should be secured.
PREVENTING ERRORS IN FILING (MISFILES):
To prevent the misfiling of the record, the following points should be followed: One
person responsible for filing of records
File at once
Check No. in / out folder

8. Use Guides
Do not allow access to outsiders.
Do not overcrowd.
Check continuously. viii. Use colour codes.
COMPUTERIZED RECORD LOCATION/TRACKING SYSTEM
Many types of computerized file location/tracking systems are available. With such a system, the location of a
medical record can be readily found. In addition, a list of previous places where the
medical record was sent can be printed, e.g.; clinics including the date when the record was sent to that
location. Some hospitals use a bar code system as seen in the super markets while other enters details via a
computer terminal in the Medical Record Department.
LOCATING MISFILES:
In case the medical record is misfiled then the following steps should be followed: -
Transposition hundred/ thousand sees 257400 in 254700
Look for 3 in 5 & 8
Change first and last number. See 5001 in 1005.
Check before and after folder.
CULLING MEDICAL RECORDS (REMOVAL OF INACTIVE RECORDS AFTER A SPECIFIEDPERIOD)
Culling medical records is the removal Of medical records from the active file room that have not been used for
a specified number of years.Each New Year a patient attends, the year shall be written on the top of the folder.
The date on the outside enables the medical record staff to see when the patient was last at the hospital. This
means that they do not have to search through the medical record to find the date of the last attendance. The
aim of culling is to remove inactive medical records from a file to make more filing space. There should be a
hospital policy stating how long medical records should be kept in the active filing area. This is referred to as
the Retention Policy. Culling should be done every year. Either culling is carried out in the same month each
year or a regular program of culling is carried out throughout the year as part of normal duties.
ELECTRONIC MEDICAL RECORDS (EMR)
Meaning of Electronic Medical Record (EMR): The Electronic Medical Record (EMR) is the maintenance of
medical records in computers and its accessory output devices such as CDs, DVD, Hard Disk Drives, online
internet, cloud etc. Electronic medical records contain the same information as paper record but in an
electronic form. This information is accessible to the health care providers through computers located
throughout the Medical Centre/Hospital/healthcare setting.
The password-protected internet access of the ASP allows for increased file security, with employees only
having access to the patient records they manage. COMPUTERIZED RECORD LOCATION/TRACKING
SYSTEM
Many types of computerized file location/tracking systems are available. With such a system, the location of a
medical record can be readily found. In addition, a list of previous places where the medical record was sent
can be printed, e.g.; clinics including the date when the record was sent to that location. Some hospitals use a
bar code system as seen in the super markets while other enters details via a computer terminal in the Medical
Record Department.
LOCATING MISFILES:
In case the medical record is misfiled then the following steps should be followed: -

9. • Transposition hundred/ thousand sees 257400 in 254700 Look for 3 in 5 & 8
• Change first and last number. See 5001 in 1005.
• Check before and after folder.
CULLING MEDICAL RECORDS (REMOVAL OF INACTIVE RECORDS AFTER A SPECIFIEDPERIOD)
Culling medical records is the removal Of medical records from the active file room that have not been used for
a specified number of years.Each New Year a patient attends, the year shall be written on the top of the folder.
The date on the outside enables the medical record staff to see when the patient was last at the hospital. This
means that they do not have to search through the medical record to find the date of the last attendance. The
aim of culling is to remove inactive medical records from a file to make more filing space. There should be a
hospital policy stating how long medical records should be kept in the active filing area. This is referred to as
the Retention Policy. Culling should be done every year. Either culling is carried out in the same month each
year or a regular program of culling is carried out throughout the year as part of normal duties.
ELECTRONIC MEDICAL RECORDS (EMR)
Meaning of Electronic Medical Record (EMR): The Electronic Medical Record (EMR) is the maintenance of
medical records in computers and its accessory output devices such as CDs, DVD, Hard Disk Drives, online
internet, cloud etc. Electronic medical records contain the same information as paper record but in an
electronic form. This information is accessible to the health care providers through computers located
throughout the Medical Centre/Hospital/healthcare setting.
The password-protected internet access of the ASP allows for increased file security, with employees only
having access to the patient records they manage.
Table-3: Advantages& Disadvantages Of Electronic Medical Records
S.No. Advantages S.No. Disadvantages
1
Time Saving
1
Difficulty in sharing data due to
incom atibili
2 Up-to-date 2 Hacking of computers — Privacy and
Security can be compromised
3 Legible accurate and complete 3 Crashing of computers
4 Secure 4 Implementation cost can be
expensive



5 Provisions for backups and recovery of
data
5 Resistance from older generation
doctors
6 Quick Access
7 Easy Storage
8 Cost Effective
9 Remove viewing (e.g. CT, MRI)
10 Dynamics records (e.g. procuring videos)
ORGANIZATION AND MANAGEMENT OF EFFICIENT IPD & OPD MEDICAL

10. RECORDDEPARTMENT/ UNIT IN THE HOSPITAL
ORGANIZATION:Organization is group of people working together using the resources to meet a common
objective.
ORGANOGRAM
Organogram of Medical Record Department of a Hospital is as follows: Chief /
Senior / Medical Record Officer
• Assistant Medical Record Officer
• Senior MRT MRT
• Asst. M.R.T.
• Record Attendants
• Sweepers / cleaners
MANAGEMENT OF IN-PATIENT MEDICAL RECORDS OF A HOSPITAL
The management of medical records refers to its maintenance and analysis of medical records in order to
generate a data which is very useful for not only planning of hospital services but also planning of health
services of a country. The management and movement of medical records of


any hospital can be explained in the following two type of flowchart for inpatient and outpatient medical
records. It contains the whole process of managing and analysis of medical records of a hospital.

11. OPD / CASUALTY:
The patient will either report to the OPD or to the Casualty. During OPD time if he is not serious, he will be
reporting to OPD i.e. usually between 8.30AM to 11.30 AM. After OPD hours, he will report to the casualty
Deptt. The OPD ticket will be made at both places. The Medical Record up to this stage is called Out Patient
Record. Hence OPD and casualty is the originating place of OPD record.
CENTRAL ADMITTING OFFICE (C.A.O.)
In case the patient requires the admission, the Doctor will write "admit in ward - 11, Medical Unit — l¯on the
OPD ticket. This is called "Admission Order" of the patient. The patient will take this admission order to the
Central Admitting Office. Here the front sheet of the case sheet will be prepared i.e. Admission Record along
with other medical record documents.
WARDS
From the Central Admitting office (CAO) the patient will take the admission record to the ward. After discharge
of the patient, the in-patient medical record will come back to Central Admitting Office, now called the

12. Discharge in-patient medical record. The discharge record will come to C.A.O. by the census clerk. He will
collect the discharge case sheet from the ward along with daily mid night census report of the nurse.
HOSPITAL CENSUS
With the help of hospital census the discharged case sheets are received in the medical record department of a
hospital. There are various methods of census used in a hospital i.e. hospital census done by the MRD staff or
the hospital census with the discharged cases sheet sent by ward nurses to the MRD. In the organisation having
billing section the Census is routed through the billing section of a hospital, because the patients are discharged
after final billing and its payment made by the patients or their
The meaning of word census is counting, the hospital census means counting of inpatients of a hospital. It is
done every midnight. This shows number of patients admitted in a ward / hospital at the beginning of the day +
number Of patients admitted during the day + number of patients transferred in ward during the day) —
(number of patients discharged / died / transfer out from the ward during the day) number of patients
remained admitted at the end of the day.
USES OF CENSUS REPORT:
The census report is very useful for calculating the bed occupancy rate of a hospital. For 100 % bed occupancy
of any month, the total census (Inpatient days) are equal to the beds available multiplied by the days of the
month. For example if there are 1500 beds in a hospital and there are 1500 patients admitted till midnight it
means there is 100 % occupancy on that day. On the basis of the bed occupancy rate, the re-allocation of beds
may be done for optimal usage of beds. This will help the patients get the beds for admissions easily. Without a
proper allocation of beds, some beds may remain vacant in some wards while in other words, patients may
face a problem to get the beds.

CENSUS REPORT:
The census report contains the following columns: -
Table-8: Census Report
MEDICAL RECORD DEPARTMENT-MRD
When the discharged case sheet with census record comes to the Central Admitting Office, then the census
clerk, first of all, takes out the alpha index card of the discharged patient. He will write the date of discharge on
this card. This card will be filled in medical record department for 3 years or till the inpatient record is
maintained. It helps in retrieval of records in medical record department. Then the census clerk will prepare the
census report of the whole hospital. After this the discharge case sheet, daily census report and alpha index
card comes to the medical record department.
ASSEMBLING
In the medical record department, the record is assembled in a particular order as mandated adopted by the
Medical Record Department.
ALPHA INDEX CARDS
On this desk, all the alpha index cards are filled alphabetically year wise. The alpha index cards also called
Master Index of patients. This is prepared in the manual system of the medical records, in the CAO, at the time
of admission. They are sent to the medical record department (MRD) after discharge of the patients for filing

13. till the inpatients records are maintained in MRD for retrieval of records. In EMR system it is maintained in the
computers.
ADMISSION & DISCHARGE ANALYSIS
After assembling the discharge records, admission and discharge analysis is done on this desk. Admission
analysis is done on the basis of pre-admission slip in the manual system of medical records. The data regarding
admissions is prepared sex wise and unit wise. Similarly the data regarding discharges is prepared on the basis
of discharged case sheet in the manual system. In EMR system of medical records, the admission and discharge
analysis is done by the computer with its software.
MONTHLY / YEARLY HOSPITAL STATISTIC BULLETIN
On the basis of admission and discharge analysis, the hospital statistical bulletin is prepared. The following data
is captured on the first page of the bulletin:-
• Total number of admissions, discharges, deaths of the hospital
• Total number of days of stay, census (in-patient days)
• Rates and ratios i.e. average length of stay, gross death rate, net death rate and bed occupancy rate.


At last, data regarding other supportive services i.e. total number of X-Rays, Laboratory Investigations,
Operations, Deliveries, OPD/Casualty attendance and Post-mortem etc. are given.
The second page of the bulletin captures specialty / unit wise data. The third page highlights the total number
of admissions and discharges sex wise and the fourth page provides bed occupancy rate speciality wise while
the fifth page gives the specialty wise OPD Data.
INCOMPLETE AREA
After Statistical analysis of the medical record, the record comes to incomplete area. In this area, the medical
record is sorted out and the case sheet bearing deficiency checks slip, are incomplete, and are kept in different
trays. Specialty wise, the doctors are sent reminders to come in medical record department and complete the
medical records. There is a medical record officer's room in this area. The doctors come to this room and
complete the medical record. They write the final diagnosis or discharge summary, whichever is not available
with their signature, name & designation. The completion of medical record is a part of quantitative analysis.
CODING ICD-IO (WHO)
After completion Of the medical record, the record is ready for generating the morbidity and mortality data.
For this purpose, coding and indexing of diseases is done. The coding of disease is the process of assigning code
numbers according to the coding books i.e. ICD-10th revision published by W.H.O. The code numbers are
written on the front sheet of the case sheet by MRT or any trained MRD staff.
DIAGNOSTIC INDEXING:
After coding of diseases, the code numbers are recorded on the diagnostic index cards. On the top of this post
card size Of index card, the disease code number is written. The format Of the diagnostic card is as follows: -
DIAGNOSTIC INDEX CARD
On the basis of this diagnostic index, the diagnostic data can be prepared and disease wise retrieval of record
can be done: -

14. Table-4: Diagnostic Index Card
MRD Name
of the
Patient
Age —
Male/
Female
Result —
Discharge /
Expired
Month of
Discharge
Days of
Stay
Final
Disease
Speciality /
Unit
Secondary
codes



Year: ..Card No.
COMPLETE AREA

After completion and analysis of medical records, the medical record is the filed in complete area for the period
of 10 years or 3 year as per hospital policy. The case sheets are filed in the bundles of 100 each in the racks year
wise. The case sheets can also be filed vertically in the racks year wise. Colour codes may be used for
preventing misfiles.
The patient will report to the OPD either as a new case or as a repeat case. There may be two counters for both
the cases if the numbers of patients are more.
APPOINTMENT LIST
In case an appointment list is prepared in advance in any hospital then in new cases the new OPD record and
duplicate OPD record may be prepared at the time of giving appointments. In case of repeat cases the
duplicate OPD record is taken out before OPD hours, either in night or in evening shift one day before the OPD
appointment. In both the cases, the appointment list is provided to the OPD record room and the record is
placed on the table of the doctor. When the patients come to the repeat counter, his OPD ticket is entered in
the register and the patient goes to the respective consultation rooms.
DEVELOPMENT OF MEDICAL RECORD INCLUDING ORGANIZATION OF CENTRAL
ADMITTINGOFFICE (CAO)
ORIGIN OF MEDICAL RECORDS
Outpatient Medical Record in
OPD
In-patient Medical Record in
CAO
DEFINITION
The Central Admitting Office of a hospital is an office where the inpatient medical record is prepared and the
patients are admitted.
The Central Admitting Office not only provides the services of inpatient admission but also provides the
reception services i.e. public enquiries regarding inpatient of the hospital.
MEDICAL RECORD COMMITTEE

15. Medical Record Committee is organized to develop, M.R. Policies, M.R. Forms., ensure M.R. Filing, M.R. Legal
policies and assist in M.R. working.
MEMBERS:The Medical Record Committee is constituted of members from various specialties of the hospital
MRO is the member secretary of this committee.
FUNCTIONS: -
Develop M.R. Forms.
Develop M.R. Policies
Ensure M.R. Filing
Frame M.R. Legal Policies
Assist in M.R. working - Assist.

M.R. Forms: The medical record committee develops the Medical Record forms of inpatient
andoutpatients of the hospital. They recommend the said forms for the approval of
medicalstaff.
M.R. Policies: The medical record committee recommends the policies for the maintenance
ofmedical records and ensures that it contains sufficient data to evaluate the care of
apatient.
Ensure M.R. filing: Medical record committee ensures that proper filing and coding of
diseases is done according to ICD books of W.H.O.
M.R. Legal Policies: The medical record committee develops the legal policies for the release
of information from the medical records.
Assist M.R. working: The medical record committee assists the MRO / MRTs in discharging
their duties and advise them on their day to day working.
MEDICAL AUDIT COMMITTEE
Medical Audit Committee is formulated for measuring the quality of professional performance and
medical care given to the patients. In the medical audit committee the medical record of the
discharged (including death) patients is analyzed with: availability of sufficient data to justify the
diagnosis, warrant the treatment and end results. It should meet at least once a month.
MEMBERS
The Medical Audit Committee is constituted by, members from various specialties in the hospitals.
TheMRO is the member secretary of this committee.
FUNCTIONS OF MEDICAL AUDIT COMMITTEE: -
To Study infection
To Study Consultation
To Study Complications - preventable or not
To Study the Organs - removed / justified
To Study Autopsy - Required was done or not

16. To Study Result - Justifiable
To Study Diagnosis - Justified
Errors corrected
To Study Result / Suggest to avoid repentance of shortcoming Educative Committee and
not penetrative
5 Provisions for backups and recovery of
data
5 Resistance from older generation
doctors
6 Quick Access
7 Easy Storage
8 Cost Effective
9 Remove viewing (e.g. CT, MRI)
10 Dynamics records (e.g. procuring videos)
ORGANIZATION AND MANAGEMENT OF EFFICIENT IPD & OPD MEDICAL
RECORDDEPARTMENT/ UNIT IN THE HOSPITAL
ORGANIZATION:Organization is group of people working together using the resources to meet a common
objective.
ORGANOGRAM
Organogram of Medical Record Department of a Hospital is as follows: Chief /
Senior / Medical Record Officer
• Assistant Medical Record Officer
• Senior MRT MRT

17. • Asst. M.R.T.
• Record Attendants
• Sweepers / cleaners
MANAGEMENT OF IN-PATIENT MEDICAL RECORDS OF A HOSPITAL
The management of medical records refers to its maintenance and analysis of medical records in order to
generate a data which is very useful for not only planning of hospital services but also planning of health
services of a country. The management and movement of medical records of

18. Project By SURESH MANDRIYA
Medical record & Health Information
Technician