Medical record system in health care institutions

Medical Record

1. 4/23/2024 1 Medical Record Operations

2. Learning Objectives After the completion of this session, students will be able to: Explain Basics of MR operations Describe purpose of a MR operations Identify Medical record unit standards and procedures 2 4/23/2024

3. A medical record is a systematic documentation of a single patient or client’s long term individual medical history and care . It should always be kept confidential in a safe place in a health institution. Introduction 4/23/2024 3

4. Medical records are kept in the Medical Record Unit ( MRU ) or card room of every health facility. It has been our daily experience to listen to the problems faced by MRUs. Introduction 4/23/2024 4

5. Some of the difficulties that have been documented are inappropriate recording and unsafe record keeping, lack of confidentiality , lack of integration and duplicate recording , long waiting hours and missing health records. These issues have contributed to client dissatisfaction and mistrust in health service provision. Introduction 4/23/2024 5

6. The reformed HMIS has a focus on the following important issues related to medical record and record keeping : Integration of medical records Proper recording and record keeping organization of MRU client satisfaction Introduction 4/23/2024 6

7. If medical records are integrated , it can be accessible at any time and place, whenever required by the service provider or patient . It improves communication between services and health workers , and saves time and money Introduction 4/23/2024 7

8. Intro….. Medical records form an essential part of a patient’s present and future health care . They are used in the management and planning of health care facilities and services, for medical research and the production of health care statistics. Medical Records should be generated with sufficient data, properly stored and retrieved when needed for patient care. 4/23/2024 8

9. The medical record today is a compilation of the pertinent facts, a patient’s health history , including past and present illness or illnesses, and treatments prescribed by health professionals. The medical record should be compiled chronologically and should contain sufficient data to Identify the patient, Support the diagnosis Justify the treatment and Accurately document the result. Intro….. 4/23/2024 9

10. The medical record is assembled after the discharge of the patient , so as to facilitate the logical flow of information regarding the patient’s past and present illnesses, diagnosis, treatment and the outcome. The information must be available readily as and when required for several purposes; for example- patient care, legal affairs, research, education, quality review, correspondence and so on. Intro….. 4/23/2024 10

11. Intro….. 4/23/2024 11 Hence, the MR Is a multi-disciplinary document Includes information gathered during a patient’s visit to a health care facility Is used both during the visit and in the event that the patient returns Directs patient care

12. Overview of Medical Records Management Purposes of a Medical Record To record the facts about a patient's health with emphasis on events affecting the during the current admission or attendance at the health care facility, and For the continuing care of the patient when they require health care in the future. 12 4/23/2024

13. 4/23/2024 13 Therefore a good health record should contain all the information about a patient's health, ill health and treatment over a period of time and be readily accessible. Health records are kept for: Communication purposes Continuity of patient care Evaluation of patient care Medico-legal purposes Statistical purposes Research and education

14. Medical Record Unit (MRU) Standards 1. MRU physical specifications: Adequate room with height 3m and 2 windows for fast track At least 60 square meter space for a hospital At least 24 square meter space for a health center Options where the MRU of facilities is not as per the standard Expansion, merging with adjacent rooms, shifting to another rooms or construction of a new room. 14 4/23/2024

15. Medical Record Unit (MRU) Standards 2. MRU Furnishing (Shelves and MPI Box) Shelves Open shelf filing is the most common filing method for medical records in various practice settings in healthcare. It allows for easy access to files. The file folders used with open shelf filing must have side tabs/visible spines for viewing the medical record number for identification. 15 4/23/2024

16. Medical Record Unit (MRU) Standards Specification of shelves For a standard room with a height of 3 meters , the required shelf standard is a 2.75m height and 2m length (see the figure below for illustration) the shelf specification in rooms with smaller height is similar. While the height of the shelves may vary, there should always be a 25cm space between the top of the shelf and the ceiling. 16 4/23/2024

17. Medical Record Unit (MRU) Standards The dimensions of the standard shelf are basically determined by the size of the Integrated Medical Folder which is 23 cm by 32 cm in size. Each cell (compartment) of a shelf should comfortably accommodate the Integrated Medical Folder when shelved on its spine. Hence, a cell will have 25 cm height and 35 cm depth when measured internally. 17 4/23/2024

18. Medical Record Unit (MRU) Standards The total height and length of the shelf can be modified based on the dimensions of the card room with out compromising the height and depth of the cells (compartments) and the total capacity of the shelves required for a facility. 18 4/23/2024

19. Medical Record Unit (MRU) Standards Fig: standard shelf 4/23/2024 Fig: standard shelf

20. Medical Record Unit (MRU) Standards MPI boxes: A standard MPI box should be able to accommodate MPI cards so that MRU clerks can easily put and withdraw when required. The size of MPI card is 11 cm (height) by 15 cm (length) . MPI box has 32-35 pockets (drawers) for Health centers / 64-70 pockets for Hospitals . Each drawer (pocket) will have 17 cm length , 13 cm height and 50 cm depth when measured internally (excluding the thickness of the blocks) 20 4/23/2024

21. Medical Record Unit (MRU) Standards so that MPI cards can be comfortably filed in the drawers. The base of the big box is 15 cm high . The total height and length of the MPI box will be determined by the required number of pockets (drawers) the box is made to have. Note: Pay attention that these measurements are internal measurements. It is recommended to use MPI samples during the construction process. 21 4/23/2024

22. Medical Record Unit (MRU) Standards 22 4/23/2024 Fig. Standard MPI box

23. Medical Record Unit (MRU) Standards 3. Human Resource requirement for MRU Medical Record Unit Clerks are required to facilitate the registration of patients, and proper documentation and shelving of Medical records. In a health center , at least three MRU clerks are required. Additional clerks are required based on the patient load of each facility (one clerk per 100 patient/client load per day). For Hospitals , at least 5 clerks are required with additional requirement based on patient load (one clerk per 100 patient/client load per day). 23 4/23/2024

24. The development of a medical record 4/23/2024 24 Four requirements should be considered essential for success: 1. Integration - individual clinical and service records should be assembled systematically into one IMR (integrated medical record) 2. Fulfilling - satisfies the basic needs of the health system 3. Adaptable - works with the existing healthcare system, workflows and parallel projects support the existing system 4. Flexible - implementation should guarantee flexibility to allow future dynamicity, in anticipation of further system reforms, and to fulfill unanticipated needs.

25. The development of a medical record 4/23/2024 25 Four requirements should be considered essential for success: 1. Integration - individual clinical and service records should be assembled systematically into one IMR (integrated medical record) 2. Fulfilling - satisfies the basic needs of the health system 3. Adaptable - works with the existing healthcare system, workflows and parallel projects support the existing system 4. Flexible - implementation should guarantee flexibility to allow future dynamicity, in anticipation of further system reforms, and to fulfill unanticipated needs.

26. Tools of the MRU 4/23/2024 26 The following are the major types of cards and forms that are used in MRUs: 1.Integrated Individual medical folder 2.Patient card (form) 3.Integrated ANC, Delivery, postnatal and neonatal card 4.Woman’s card 5.Master Patient Index (MPI) 6.Service identification card 7.Appointment card

27. 4/23/2024 27 8.Tracer card 9. Admission/Discharge card 10. HIV exposed infant follow-up card 11. ART intake and follow up forms 12. Progress note forms 13. Inpatient Clinical Forms i. Consultation Request ii. Discharge Summary iii. Death Summary iv. Order Sheet v. Vital Sign Sheet

28. I. Generation of a Medical Record When a patient arrives at a hospital seeking care and treatment, the hospital’s first interaction with the patient is to identify his/her status – does the patient require emergency care or routine care? is he/she a new or returning patient? Once status is determined, the hospital must obtain returning patients’ MRNs and associated MRs, or the hospital must assign a unique MRN to new patients. 28 4/23/2024

29. A) Patient registration – Medical Record Number generation A unique MRN shall be assigned to each patient's MR upon first registration at the hospital. This MRN is used to identify the patient's MR and all materials filed therein. All MRNs shall be issued in straight numeric sequence, taking great care to avoid skipping any numbers. Each MRN should be assigned to one and only one patient!!! 29 Generation of…. 4/23/2024

30. To avoid duplicating MRNs, the following steps must be taken: Manual Paper-Based System: A permanent log or pre-numbered folders should detail each and every MRN issued at a facility. Computer-Based System: A properly developed software program used for MRM systems will automatically generate a unique MRN. It will also enable the user to easily obtain information on previously generated MRNs, while being certain to prohibit the generation of duplicate MRNs. 30 Generation of…. 4/23/2024

31. B) Patient Medical Records After the MRN is generated, an individual hospital-approved folder will be assigned to each patient. Any patient information generated by hospital staff during the period of care will be kept in this folder. A paper fastener or the equivalent shall be used to keep all pre-approved clinical documents/ forms in the folder. Only the MRN and the patient’s name shall be labeled on the folder as a form of identification. 31 Generation of…. 4/23/2024

32. C) Master Patient Index (MPI) Master patient index (MPI) is an A5 sized card meant to index client record in alphabetic order. The card is used to trace a client record when he/she appears lost service ID/MRN in order to not deny right of sought service All new patients should have a master patient index (MPI) card filled out with their identifying information and a medical record number on arrival to the MRU. 32 Generation of…. 4/23/2024

33. C) Master Patient Index (MPI) Is a permanent list that includes all previously registered patients and is updated regularly to include newly registered. Essential to identify the location of every MR. Each MPI card should include the following information: Patient’s full name Date of Birth (DOB) / Age Sex, Address, Phone number, MRN Location of MR within hospital 33 Generation of…. 4/23/2024

34. Generation of…. 4/23/2024 34 The index cards should be filed alphabetically by first name. When the hospital learns that a patient has changed his name, a cross-index file shall be made with the previous MRN to identify the initial record with the previous name.

35. 1. Manual Paper-Based System : Vertical file cabinets for filing index cards may be purchased for hospitals that use a paper-based MPI. The paper-based MPI shall be monitored by the MR Department quarterly to ensure that the MPI is filed correctly. Each facility must establish a procedure for this activity. Sub-headings may be added for common names (“Me” for Meskerems , “Mo” for Mohammeds , etc ). 35 Generation of…. 4/23/2024

36. Generation of…. 4/23/2024 36 2. Computer-Based System : The use of an in-built MPI permits faster retrieval of patients’ MRNs. However, a hard copy control index must also be maintained in case of computer technical failure/downtime. Therefore, hospitals must maintain a back-up system in order to ensure no interruption in MRN retrieval.

37. D) Creating a paper-based Master Patient Index The steps necessary for creating a paper-based MPI Prepare a stack of index card dividers with labels from A- Z. (Sub-headings with dividers may be used for common names: Ab , Ah, Am, etc.) When a patient is admitted to the hospital, a MR is created. An index card will be created with the same patient information written on it. The index card will be filed alphabetically in the MPI. 37 Generation of…. 4/23/2024

38. E) How to retrieve a Medical Record Number using the MPI When a patient is re-admitted to the hospital – ask if he/she knows his/her MRN? If not,  Employee will locate patient’s index card in the MPI according to patient’s first name. Patient’s MRN is on the index card. 38 Generation of…. 4/23/2024

39. MR 39 1 1 1 1 1 1 1 1 1 A B C D MPI 4/23/2024

40. 40 1 1 1 1 1 1 1 1 1 A B C D 235 Abera 4/23/2024

41. 41 1 1 1 1 1 1 1 1 1 Abera 235 A B C D 235 Abera 4/23/2024

42. 42 1 1 1 1 1 1 1 1 1 234 Betu Betu 234 Abera 235 A B C D 235 Abera 4/23/2024

43. 43 1 1 1 1 1 1 1 1 1 Betu 234 Abera 235 A B C D Abera 4/23/2024

44. 44 1 1 1 1 1 1 1 1 1 Betu 234 Abera 235 A B C D Abera MRN? 4/23/2024

45. 45 1 1 1 1 1 1 1 1 1 Betu 234 Abera 235 A B C D Abera 4/23/2024

46. 46 1 1 1 1 1 1 1 1 1 Betu 234 Abera 235 A B C D Abera 4/23/2024

47. F) Filing of Medical Records All active MRs should be filed in a centralized file room. All MRs must be filed numerically according to MRN. Hospitals should audit the files periodically (quarterly or as per hospital policy) to ensure correct filing and prevent loss. Generation of…. 4/23/2024 47

48. Key attributes of A Medical Record Number 4/23/2024 48 1. Unique - A valid MRN should identify only one individual and a person should have only one unique patient identifier . 2. Focused - The MRN should be created and maintained solely for the purpose of supporting health care delivery in the facility. 3. Longevity - should be designed to function for the foreseeable future. It should not contain known limitations. 4. Permanent - A MRN should never be reassigned to another person even after the original individual dies.

49. One patient→ One medical record number = One medical record Integrated individual folder : Generation of…. 4/23/2024 49

50. A) How and when to document Each clinical event, intervention, instruction or observation shall be documented after the occurrence and within standards set by the hospital. Discharged- all documentation completed within 24 hours of discharge (or as specified in hospital policy). All entries shall be dated and authenticated with full signatures. 50 Documenting patient information 4/23/2024

51. Documenting…. 4/23/2024 51 Initials with professional designation rather than a signature are acceptable, provided the initials are readily understood. One MR shall be maintained for all reports of health care. The information should be filed in one folder divided in sections, in chronological order and with most recent encounters on top.

52. B) General rules in clinical documentation The patient's name and MRN shall appear on each page. All handwriting shall be in permanent ink that is legible when photocopied. Pencil entries in any part of the record should not be permitted! All entries shall be dated and authenticated, including signature and title of the author. 52 Documenting…. 4/23/2024

53. Documenting…. 4/23/2024 53 Each clinician shall sign those portions of the MR containing documentation of care for which he/she is responsible, including secondary signatures where appropriate. Transcription of dictated information shall be accurate and complete.

54. C) Key components of clinical documentations In general, MR documentation shall contain: Identification of the patient. Diagnoses and treatment justification. Results of care or treatment. Condition of patient upon discharge. Documented instructions to the patient regarding follow up care, including possible self/home care, activity levels, and necessary medications. Environmental, family, and socioeconomic factors affecting patient's health. 54 Documenting…. 4/23/2024

55. In general, the following forms should be included in each MR: Front sheet Observation sheet (Vital sign record) Physicians’ orders Medication administration report (MAR) In-patient admission form Progress note Discharge summary 55 Documenting…. 4/23/2024

56. Other forms should be included: Laboratory testing/results Diagnostic imaging Consultation summaries Emergency record, if patient visited ER Immunization record Patient consent forms Anesthesia and operation report 56 Documenting…. 4/23/2024

57. D) Correction of Medical Record data No erasure or other elimination shall be made. Incorrect data shall be lined out with a single line. The date of correction, the initials of the person making the correction, the correct information, and the reason for the correction shall be added. E) Standardized documentations/forms Only approved and standard clinical forms shall be used in the MR. A standardized format shall be used throughout the hospital’s forms to facilitate the entry, review, and retrieval of information. Proposed new or revised forms must be submitted to a Medical Records Committee for approval in order to become an authorized part of the MR. 57 Documenting…. 4/23/2024

58. Required Characteristics of Entries in MR a) Appropriate documentation The medical record must at all times contain enough information, which will enable the attending physician to give effective continuity of care and determine the condition of the patient at any given time . 58 4/23/2024

59. Required Characteristics… b) Authentication Medical professionals who are authorized and responsible for providing care to patients are also responsible for verifying and documenting the care given , in the medical record, and authenticating the entry with the date of entry and signature . 59 4/23/2024

60. Required Characteristics… c) Abbreviations Only standard abbreviations and symbols, which are approved by medical professionals and the ones for which explanatory legend is available should be used. Abbreviations must never be used in the final diagnosis , and must also be avoided in all entries in the progress sheets . 60 4/23/2024

61. Required Characteristics… d) Timeliness Human memory tends to fail. Hence, it is imperative that all documentation regarding patient care must be done as soon as the treatment or care is given . 61 4/23/2024

62. Required Characteristics… e) Completeness All forms that need to be in the medical record for that particular admission must be completed and present in the record. f) Legibility The legibility of the documentation in the medical record determines the usefulness of the record. It is advisable that some of the forms in the record may be typed, if the costs are feasible. 62 4/23/2024

63. Required Characteristics… g) Correction errors and omissions drawing a line through the erroneous entry with the citation. The correct information must be documented immediately after striking out the wrong documentation, and it must be authenticated with the signature and date , by the doctor who identified and corrected the error. 63 4/23/2024

64. Legal Aspects of Medical Records The record is compiled, preserved and protected from unauthorized inspection for the benefit of the patient, the facility and the physician , as required by law in some countries, and by administrative practice in others. 64 4/23/2024

65. Legal Aspects… A properly completed and signed authorization should be required for release of all health information, the exceptions being: When it is required by law. When it is released to another health care provider, currently involved in the care of the patient. For medical care evaluation. For research and education. 65 4/23/2024

66. Reading Assignment About Electronic Medical Record Management The futurity of Medical Records Management The Medical Records Management in Ethiopia 4/23/2024 66