Medical Records Department

Helpful for those looking for information on Medical Records Department.

1. MEDICAL RECORDS DEPARTMENT By- COL VARUGHESE DANIEL MBA (HA) 1 st Yr (2 nd Sem.)

2. PREVIEW OBJECTIVE INTRODUCTION, DEFINITION, PURPOSE PLANNING, ORGANIZATION AND STAFFING PHYSICAL FACILITIES PROCESSING OF RECORDS AND THEIR RETRIEVAL CODING AND INDEXING STORAGE AND RETRIEVAL REPORTS AND RETURN MEDICO LEGAL ASPECTS OF MEDICAL RECORDS

3. OBJECTIVES DEFINE THE MEDICAL RECORD. ENLIST THE PURPOSES OF MEDICAL RECORDS IN RELATION TO PATIENT, DOCTOR, HOSPITAL AND MEDICAL EDUCATION AND RESEARCH. ENUMERATE THE STEPS IN PLANNING AND ORGANIZATION OF MEDICAL RECORDS DEPARTMENT IN A HOSPITAL.

4. INTRODUCTION FIRST MEDICAL RECORD UNIT WAS ESTABLISHED IN 1667 AT ST. BARTHOLOMEW’S HOSPITAL, ENGLAND. FOLLOWED BY PRACTICE OF MAINTAINING PATIENT REGISTER IN PENNSYLVANIA HOSPITAL, USA IN 1792. IDEA OF PROPER MEDICAL RECORDS IN FORM OF STANDARDIZED INPATIENTS RECORDS CAME IN USA FROM THE AMERICAN COLLEGE OF PHYSICIANS AND AMERICAN COLLEGE OF SURGEONS IN THE LAST QUARTER OF THE 20 TH CENTURY. IN INDIA BHORE COMMITTEE (1946) FIRST STRESSED THE IMPORTANCE OF KEEPING MEDICAL RECORDS.

5. REITERATED BY MUDALIAR COMMITTEE IN 1962. SUBSEQUENTLY, HEALTH AND HOSPITAL REVIEW COMMITTEE (JAIN COMMITTEE AND RAO COMMITTEE) HIGHLIGHTED POOR STATE OF MEDICAL RECORDS AND RECOMMENDED THE ESTABLISHMENT OF A PROPER MEDICAL RECORDS SECTION IN EACH HOSPITAL. WITH TECHNICAL ADVANCEMENT, COMPUTERS ARE EXTENSIVELY USED FOR RECORD GENERATION, ANALYSIS AND RETRIEVAL. MICROFILMING HAS ALSO BEEN INTRODUCED FOR EASY STORAGE AND RETRIEVAL.

6. DEFINITION “A CLINICAL, SCIENTIFIC, ADMINISTRATIVE AND LEGAL DOCUMENT RELATING TO PATIENT CARE IN WHICH ARE RECORDED SUFFICIENT DATA WRITTEN IN THE SEQUENCE OF EVENTS TO JUSTIFY THE DIAGNOSIS, WARRANT THE TREATMENT AND RESULTS”. A MEDICAL RECORD IS- A DOCUMENT OF FACTS, WHICH CONTAINS STATEMENTS BY TRAINED OBSERVERS OF CONDITION FOUND AND THE APPLICATION AND THE RESULT OF THE EXAMINATION AND THERAPY. IT ALSO INDICATES WHETHER OR NOT THE EFFORTS OF THE DOCTORS , SUPPLEMENTED BY THE HOSPITAL AND RELATED FACILITIES ARE IN ACCORDANCE WITH THE REASONABLE EXPECTATIONS OF THE PRESENT DAY’S SCIENTIFIC MEDICINE.

7. MEDICAL RECORD AS SUCH IS A PACKAGE OF FORMS, CASE SHEETS PLACED IN CHRONOLOGICAL ORDER OF OCCURRENCE OF EVENTS AND INVESTIGATION REPORTS. THE NATURE OF FORMS, LAB REPORTS AND EVEN CASE SHEET RECORDINGS MAY VARY FROM HOSPITAL TO HOSPITAL. CLASSICALLY THE MEDICAL RECORD OF A PATIENT CONTAINS THE DOCUMENTS ARRANGED IN THE FOLLOWING SEQUENCE: ADMISSION FORM CASE SHEET COMPRISING OF: MEDICAL HISTORY CLINICAL FINDINGS INVESTIGATION ORDERED TREATMENT ISSUED PROGRESS REPORTS CONSENT FORM FOR SURGERY OR SPECIALIZED PROCEDURES ANESTHESIA CHECK RECORD, IF APPLICABLE NOTES ON SURGICAL/SPECIAL PROCEDURES LAB REPORTS IN CHRONOLOGICAL SEQUENCE OF THEIR ORDERING FILMS ALONG WITH THEIR REPORTS

8. MEDICAL RECORDS FOR THE OUTPATIENTS SHOULD ALSO BE PREPARED, PROCESSED AND STORED IN THE SAME MANNER AS THE INPATIENT’S RECORDS. EACH INDIVIDUAL ATTENDING AN OPD IS GIVEN A REGISTRATION NUMBER AND ALL THE MEDICAL RECORDS ARE KEPT IN A FOLDER BEARING THE SAME NUMBER. THE PATIENT IS ISSUED A TICKET/TOKEN BEARING THE REGISTRATION NUMBER. THE INDIVIDUAL AT THE OPD RECORD ROOM SENDS THE FOLDER TO THE APPROPRIATE DEPARTMENT ON THE PRESENTATION OF TOKEN. THE FOLDER IS DEPOSITED BACK AFTER THE VISIT.

9. PURPOSE THE MEDICAL RECORD IS INDISPENSABLE FROM THE POINT OF VIEW OF THE PATIENT, THE DOCTOR, AND THE HOSPITAL AND FOR MEDICAL EDUCATION AND RESEARCH. THE PATIENT: IT SERVES TO DOCUMENT THE CLINICAL HISTORY OF THE PATIENT’S ILLNESS AND COURSE OF THE DISEASE. IT SERVES TO AVOID OMISSION OR UNNECESSARY REPETITION OF DIAGNOSTIC AND TREATMENT MEASURES. IT ASSISTS IN CONTINUITY OF CARE IN THE EVENT OF FUTURE ILLNESS. PROVIDES NECESSARY INFORMATION FOR INSURANCE, CONTRIBUTORY HEALTH SCHEMES OR FOR THE EMPLOYMENT PURPOSES.

10. THE DOCTOR : ASSURANCE OF QUALITY, QUANTITY, AND ADEQUACY OF DIAGNOSTIC AND THERAPEUTIC MEASURES UNDERTAKEN. AN ASSURANCE OF ORDERLY CONTINUITY OF MEDICAL CARE. EVALUATION OF MEDICAL PRACTICE . AN AID IN RESEARCH AND THE CONTINUING EDUCATION OF HEALTH PROFESSIONALS. A PROTECTION IN THE EVENT OF LEGAL QUESTION.

11. THE HOSPITAL: DOCUMENT THE TYPE AND QUANTITY OF WORK UNDERTAKEN AND ACCOMPLISHED. FURNISH PROOF OF THE TYPE AND QUANTITY OF CARE RENDERED TO THE PATIENT. EVALUATE THE PROFICIENCY OF THE INDIVIDUAL DOCTOR, FOR ADMINISTRATION AND CLINICAL PURPOSES. EVALUATE THE SERVICES OF THE HOSPITAL IN TERMS OF ACCEPTED NORMS AND STANDARDS. PROTECT THE HOSPITAL IN THE EVENT OF LEGAL MATTERS. SERVE AS AN ADMINISTRATIVE RECORD OF PERSONNEL PERFORMANCE AND STAFFING NEEDS, FOR BUDGET PREPARATION, JUSTIFICATION FOR PHYSICAL FACILITY ALLOCATION AND UTILIZATION, FOR STATISTICAL DATA FOR ADMINISTRATIVE USE AND EVALUATION, FOR ESTIMATING EQUIPMENT AND SUPPLY UTILIZATION AND NEEDS. ASSIST IN FUTURE PROGRAM PLANNING.

12. MEDICAL EDUCATION AND RESEARCH: RECORDED OBSERVATIONS ARE THE BASIS FOR ALL CLINICAL RESEARCH. FURTHER THE EDUCATION OF DOCTORS AND OTHER HEALTH PERSONNEL. MEDICAL RECORDS SUPPLY PERTINENT DATA FOR THE USE BY PUBLIC HEALTH AUTHORITIES FOR CONTROL OF DISEASES.

13. PLANNING, ORGANISATION AND STAFFING THE MAIN FACTORS THAT GOVERN THE ORGANISATION OF WORK IN A MEDICAL RECORDS DEPARTMENT ARE: MEDICAL RECORDS SHOULD ALWAYS BE AVAILABLE WHEN REQUIRED AND IN THE FORM THEY ARE REQUIRED. ADEQUATE LIAISON SHOULD EXIST BETWEEN DIFFERENT GROUPS OF STAFF USING MEDICAL RECORDS TO ENABLE TO GIVE DUE CONSIDERATION TO MATTERS SUCH AS DESIGN AND CONTENTS, METHOD AND STORAGE AVAILABILITY, USE AND MOVEMENT OF RECORDS. PROCEDURES SHOULD CAUSE PATIENTS THE MINIMUM OF WAITING AND INCONVENIENCE. THE MEDICAL RECORDS COMMITTEE IS COMPOSED OF: REPRESENTATIVE OF THE CLINICAL DISCIPLINE REPRESENTATIVE OF THE NURSING STAFF MEMBER FROM THE PATHOLOGY SERVICES ADMINISTRATOR

14. ORGANISATION ADMISSION AND INQUIRY OFFICE : ADMITTING OFFICE ADMISSION CHECK DESK CENSUS DESK INQUIRY OFFICE CENTRAL RECORD OFFICE:  RECEIPT, CHECKING, ASSEMBLY AND STORAGE OF ALL MEDICAL RECORDS OF DISCHARGED PATIENTS.  DISCHARGE ANALYSIS AND STATISTICS.  CODING OF ALL DIAGNOSIS AS PER INTERNATIONAL CLASSIFICATION OF DISEASE.  INDEXING OF ALL DISCHARGED PATIENTS BY DISEASE, DOCTOR, ETC.

15.  MAKING RECORDS AVAILABLE FOR MEDICO LEGAL PURPOSE.  ISSUE OF MEDICAL CERTIFICATES OF VARIOUS TYPES.  SEND NOTIFICATION OF ALL COMMUNICABLE DISEASES TO THE PUBLIC HEALTH AUTHORITIES.  ISSUE OF MEDICAL CERTIFICATES OF VARIOUS TYPES.  PREPARATION OF MONTHLY ABSTRACTS AND ANNUAL STATISTICAL DETAILS.  DEALING WITH INQUIRIES FROM LIFE INSURANCE CORPORATION REGARDING DISEASE AND CAUSE OF DEATH OF THE INSUREE.  TRAINING OF ALL CATEGORIES OF PERSONNEL.  STORAGE OF ALL TYPES OF FORMS USED IN THE HOSPITAL. OUT PATIENT RECORD SECTION

16. KEEPING ALL THIS IN VIEW THE MEDICAL RECORDS DEPARTMENT IS ORGANISED AS UNDER CODING AND INDEXING DESK DISCHARGE ANALYSIS AND VITAL STATISTICS DESK RECORD STORAGE : * ACTIVE RECORD STORAGE * INACTIVE RECORD STORAGE   

17. STAFFING (FOR 500 BEDDED HOSPITAL) PEON 1 STATISTICIAN 1 MEDICAL RECORD ATTENDANT 4 RECEPTIONIST 5

18. MEDICAL RECORD ATTENDANTS 8 STATISTICAL ASST. 5

19. PHYSICAL FACILITIES SPACE AND GENERAL FACILITIES REQUIREMENT: ADMISSION AND INQUIRY OFFICE: SPACE- 125-175 SQ. FT. REQUIREMENTS- GENERAL OFFICE EQUIPMENT FOR THE STAFF. SEPARATE COUNTERS FOR ADMITTING CLERK, RECEPTIONIST HANDLING INFORMATION AND BILLING CLERK SHOULD BE PROVIDED. ADEQUATE WAITING SPACE, TOILET FOR STAFF, PATIENT AND ATTENDANTS. TELEPHONE FACILITY FOR LOCAL CALLS AND STD MUST BE MADE.

20. B) CENTRAL RECORD OFFICE SPACE REQUIREMENT DEPENDS UPON THE SIZE OF THE HOSPITAL- 50 BED- 150-175 SQ. FT. 100 BED- 225-250 SQ. FT. 200 BED- 450-500 SQ. FT. 500 BED- 1000-1200 SQ. FT. THIS AREA MAY BE ADEQUATE TO STORE INACTIVE MEDICAL RECORDS ALSO. SPACE 120 SQ. FT. – 500 SQ. FT REQUIRED. FULLY FUNCTIONAL COMPUTERS, AND PROPER OFFICE EQUIPMENT FOR STAFF REQUIRED. C) OUT PATIENT RECORD SECTION SPACE- 2-3 SQ. FT. PER BED. SEPARATE COUNTERS FOR THE REGISTRATION OF OLD AND NEW, MALE AND FEMALE PATIENTS. COUNTER SPACE- 24” WIDE, 40” HIGH. WAITING AREA FURNISHED WITH CHAIRS AND ANNOUNCEMENT BOARDS.

21. LAYOUT OF MEDICAL RECORD OFFICE

22. PROCESSING OF RECORDS AND THEIR FLOW UPON ADMISSION OF A PATIENT ADMITTING OFFICE ADMISSION LIST ADMISSION RECORDS COPY OF ADMISSION LIST CENSUS DESK INFORMATION DESK NURSING UNIT CHECK DESK ADMISSION INCOMPLETE PATIENT INDEX CARD INCOMPLETE RECORDS CONTROL DESK

23. IMPORTANT ACTIONS PERFORMED BY THE ADMITTING OFFICE ARE SUMMARIZED BELOW ADMITTING OFFICE: INITIATES PATIENT’S HOSPITALIZATION RECORDS. ASSIGNS ADMISSION NUMBER. PREPARES ADMISSION RECORD: ADMISSION NUMBER IDENTIFYING DATA SIGNATURE OF AUTHORIZATION SENDS PATIENT TO NURSING UNIT. SENDS ADMISSION RECORD TO NURSING UNIT. SENDS COPY OF ADMISSION RECORD TO ADMISSION CHECK DESK.

24. B) ADMISSION CHECK DESK: RECEIVES ADMISSION ADVICE FROM ADMITTING OFFICE. CHECKS PATIENT INDEX FOR PREVIOUS ADMISSIONS. ENTERS THIS ADMISSION ON PATIENT INDEX CARD OF PREVIOUS ADMISSION. IF NO PREVIOUS ADMISSION, MAKE NEW PATIENT INDEX CARD. SENDS INDEX CARD TO INCOMPLETE RECORD CONTROL DESK. SENDS RECORDS OF PREVIOUS ADMISSION TO NURSING UNIT. PREPARES RECORD FOLDER WITH ADMISSION RECORD AND NAME AND SENDS IT TO COMPLETE RECORDS CONTROL DESK. MAKES ENTRIES TO ACCESSION REGISTER. C) CENSUS DESK: PREPARES ADMISSION LIST FROM ADMITTING OFFICE. COLLECTS DISCHARGE PATIENT RECORDS FROM NURSING UNITS DAILY. PREPARES DISCHARGE LIST. PREPARES CENSUS REPORTS.

25. MOVEMENT OF MEDICAL RECORDS UPON DISCHARGE OF A PATIENT NURSING UNIT DISCHARGED RECORDS CENSUS DESK ASSEMBLING AND DEFICIENCY CHECK DESK ASSEMBLED DISCHARGED RECORDS COMPLETE DISCHARGED RECORDS INCOMPLETE DISCHARGED RECORDS CODING AND INDEXING DESK DISCHARGE ANALYSIS DESK AND VITAL STATISTICS COMPLETE PATIENT INDEX CARDS COMPLETED RECORDS FILES ADMISSION CHECK DESK

26. INCOMPLETE RECORD CONTROL COMPACTOR SYSTEM FILING OF MEDICAL RECORDS FILING OF MEDICAL RECORDS

27. CODING AND INDEXING CODING : IN EACH MEDICAL RECORDS INTERNATIONAL CODE NUMBER IS ASSIGNED TO THE DIAGNOSIS BASED ON “ INTERNATIONAL CLASSIFICATION OF DISEASE” ISSUED BY THE WORLD HEALTH ORGANISATION. THIS IS TO BRING ABOUT ACCURACY AND UNIFORMITY IN THE REPORTING OF THE DISEASES BY THE VARIOUS HOSPITALS.

28. INDEXING : ALPHABETIC/ MASTER INDEX : INDEXING BASED ON PATIENT’S NAME SEQUENCED ALPHABETICALLY. THE PRIMARY PURPOSE OF A NAME INDEX IS TO PROVIDE ENTRY INTO THE FILING SYSTEM AND FINDING OUT MEDICAL RECORD FOR A PATIENT. DISEASE INDEX : DISEASE INDEX IS A CATALOGUE OF CARDS 3” X 5” OR 5” X 8”, MAINTAINED TO FIND OUT GROUPS OF CLINICAL RECORDS OF PATIENTS HAVING THE SAME DIAGNOSIS. BESIDES PATIENT’S IDENTIFICATION DATA, AGE, GENDER, RESULT OF TREATMENT AND COMPLICATION MAY ALSO BE MENTIONED. OPERATION INDEX : IT IS A CATALOGUE CONTAINING THE DETAILS OF PATIENTS WHO HAVE UNDERGONE THE OPERATIONS. PHYSICIAN’S INDEX : CATALOGUE CONTAINING THE DETAILS OF ALL PATIENTS TREATED BY PARTICULAR PHYSICIANS. ANALYSIS OF SUCH RECORDS MAY BE UTILIZED FOR EVALUATING THE PERFORMANCE OF A PHYSICIAN. UNIT INDEX : DETAILS OF ALL THE PATIENTS TREATED IN A PARTICULAR UNIT ARE INDEXED. THESE RECORDS MAY ULTIMATELY BE UTILIZED TO EVALUATE THE PERFORMANCE OF A PARTICULAR UNIT.

29. STORAGE AND RETRIEVAL STORAGE: THE FOLLOWING FACTORS ARE CONSIDERED FOR AN EFFECTIVE FILING SYSTEM: COMPACTNESS TO REDUCE PHYSICAL EFFORT AND COST OF STORAGE SPACE. ACCESSIBILITY FOR SPEEDY LOCATION AND IDENTIFICATION. SIMPLICITY FOR UNDERSTANDING OF ALL CONCERNED. ECONOMICAL BOTH IN THE COST OF INSTALLATION AND OPERATION. ELASTICITY TO EXPAND ACCORDING TO FUTURE REQUIREMENT. TRACER SYSTEM FOR DOCUMENT IN CIRCULATION.

30. SYSTEMS OF FILING- DECENTRALIZED SYSTEM UNDER THIS SYSTEM, INPATIENT AND OUTPATIENT DEPARTMENTS HAVE THEIR OWN INDIVIDUAL RECORDS AND FILE THEM INDEPENDENTLY WITHIN THEIR DEPARTMENTS. THIS SYSTEM IS LABOUR INTENSIVE AND THE OPERATING COST ARE HIGHER. CENTRALIZED SYSTEM IN THE CENTRALIZED SYSTEM, MEDICAL RECORDS ARE FILED CENTRALLY IN THE MEDICAL RECORD DEPARTMENT. THIS SYSTEM IS MORE EFFICIENT, PROVIDES BETTER CONTROL AND IS FOLLOWED IN MOST HOSPITALS.

31. METHODS OF FILING- NUMERICAL METHOD ALPHABETICAL METHOD CHRONOLOGICAL ORDER TERMINAL DIGIT SYSTEM MID DIGIT SYSTEM FILING OF MEDICAL RECORDS FILING OF MEDICAL RECORDS

32. S. No DATE IP No FILE TYPE PATIENT NAME DATE OF DISCHARGE DIS- CHARGE TYPE RESIDENT SIGN MRD CLERK SIGN MLC LAMA/ ABSCONDED GENERAL DISCHARGED/ ETC. DEPARTMENT______________UNIT/CONSULTANT______________ PERFORMA OF FILING REGISTER

33. FILING PROCEDURES- TYPES OF FILES- USEFUL TO USE FILES OF DIFFERENT COLOURS FOR DIFFERENT YEARS FOR EASY RETRIEVAL AND IDENTIFICATION . FILING : THREE TYPES OF FILING PROCEDURE IN USE VERTICAL- SUSPENDED HORIZONTAL

34. MICROFILMING OF MEDICAL RECORDS IN LARGE TEACHING HOSPITALS DUE TO CONSTRAINTS OF SPACE MICROFILMING IS RESORTED TO. ADVANTAGES OF MICROFILMING :- SAVING OF SPACE BY 90%. EASY ACCESSIBILITY. PROTECTION. ELIMINATION OF MISFIRING. SAVING OF TIME & MANPOWER. SPECIAL EQUIPMENT REQUIRED INCLUDES MICROFILMING CAMERA,PROCESSORS, VIEWING MACHINES, DUPLICATING & XEROX MACHINES, MICROFILMING ROLLS, FIXER & DEVELOPER AND MICROFILMING TECHNICIANS.

35. COMPUTERISATION OF MED RECORDS TECH ADVANCEMENTS & DECREASING COST OF COMPUTERISATION HAVE REVOLUTIONISED THE MED RECORD SYSTEM. POSSIBLE TO STORE TEXT & ALL TYPES OF IMAGES VIZ X-RAYS, CAT SCAN, MRI. BY NETWORKING SYSTEM ACCESS CAN BE PROVIDED TO DRs, NURSES, TECHNICIANS & ADMINISTRATOR WHILE MAINTAINING CONFIDENTIALITY.

36. RETREIVAL OF MEDICAL RECORDS USUALLY REQD FOR FOLLOW UP OF PATIENTS. ADMISSION TO WARD/ CASUALTY FOR OBSERVATION. RESEARCH WORKERS FOR ACADEMIC PURPOSES. MEDICAL REIMBURSEMENT. PRODUCING IN COURT OF LAW.

37. REPORTS AND RETURNS BASIC PURPOSE OF REPORTS ARE: EVALUATING THE QUALITY OF CARE. LOCATING THE DEFI IN : MEANS – STAFF, PHYSICAL FACILITIES, EQPT INCL PLANTS & MACHINES. METHODS – OPERATING POLICIES & PROCEDURES. END RESULT- OUTCOME OF BENEFITS DERIVED BY THE COMMUNITY FROM THE HOSP. EFFECTIVENESSOF HOSP ADMINISTRATION. PREVENION OF DISEASES

38. TYPES OF REPORTS TYPES OF REPORTS & FREQUENCY WILL VARY WITH TYPE OF HOSPITAL & ADM REQMTS. REPORTS GENERATED DAILY, WEEKLY, FORTNIGHTLY, MONTHLY, QUARTERLY, SIX MONTHLY OR ANNUALLY DEPENDING ON REQMT . REPORTS GENERALLY PERTAIN TO : VITAL STATS. ADT(ADMISION, DISCHARGEAND TRANSFER ANALYSIS. GENERAL HEALTH STATS.

39. REPORTS RELATED TO HOSP BEDS DAILY CENSUS MAX PATIENTS ON ANY ONE DAY. MIN PATIENTS ON ANY ONE DAY. DAILY AVG. BED OCCUPANCY RATE. TOTAL PATIENT DAYS CARE. BED TURN OVER INTERVAL. ADMISSION DAILY ADMISSION. DAILY ADMISSION UNIT/SPECIALITY WISE. TOTAL ADMISION OVER A PERIOD. PATIENTS DISTRIBUTION BY AGE, SEX, RELIGION &REGION

40. DISCHARGES DAILY DISCHARGES. TOTAL PATIENTS DISCHARGED OVER A PERIOD. DAYS OF CARE TO THE PATIENTS DISCHARGED. AVG LENGTH OF STAY. DEATHS DAILY NUMBER OF DEATHS . TOTAL DEATHS OVER A PERIOD. TOTAL DEATHS OVER 48 HRs. TOTAL DEATHS UNDER 48 HRs. NET DEATH RATE. GROSS DEATH RATE. FOETAL DEATH RATE. MATERNAL DEATH RATE. INFANT DEATH RATE. POST OPERATIVE DEATH RATE. ANAESTHETIC DEATH RATE.

41. WORK LOAD STATITICS . TOTAL NO OF OUTPATIENTS. NEW CASES. REPEAT CASES. TOTAL NO OF OPERATIONS. TOTAL NO OF X RAY & OTHER RELATED INV. DEPT WISE WORKLOAD STATS. HOSP CARE EVALUATION STATS POST OPERATIVE INFECTION RATE. POST OPERATIVE COMPLICATION RATE. CAESARIAN SECTION RATE. AUTOPSY RATE. CONSULTATION RATE. RATE OF NORMAL TISSUE REMOVED. % OF DISAGREEMENT BETWEEN FINAL & PATHOLOGICAL DIAGNOSIS. GROSS RESULTS OF TREATMENT, i.e PATIENTS RECOVERED, IMPROVEDOR NOT RELIEVED.

42. MEDICO LEGAL ASPECTS OF MRD MED REC PROPERTY OF THE HOSP, NEITHER PATIENT NOR DR. AS A PERS DOCU, CONFD & PRIVILEDGED DOCU, CANNOT BE DIVULGED W/O PATIENT CONSENT EXCEPT UNDER PROCESS OF LAW, AS AN IMPERSONAL DOCU, CAN BE USED FOR EDN & RESEARCH. A CLINICALAS ALSO LEGAL DOCU, HENCE IT SHOULD FULFILL THE FWG CRITERIA : COMPLETE : MUST CONTAIN SUFFICIENT DATA TO IDEN PATIENT, JUSTIFY DIAGNOSIS, WARRANT TREATMENT & OUTCOME & OTHER ROUTINE & SPL REC. ADEQUATE : NOT SKETCHY BUT DETAILED, MUST CONTAIN ALL NECY FORM & ALL RELEVANTCLINICAL INFO. ACCURATE : SUITABLE FOR QUANTITATIVE ANALYSIS. LEGIBLE : EASILY DECIPHERABLE WITH PRINTED NAMES & DESIGNATIONSOF ALL SIGNATORIES.

43. INDIAN EVIDENCE ACT 1872 AS AMENDED REQUIRES MED REC TO BE PRODUCED BEFORE COMPETENT AUTH IN FWG CONDITIONS: IN COURT OF LAW. LIC OF INDIA. INCOME TAX. PATIENTS WILL. QUERIES REGARDING BIRTH OR DEATH.

44. RETENTION OF MED REC FACTORS AFFECTING RETENTION PERIOD : NEED OF PATIENT. MEDICO LEGAL ASPECT. EDN & MED RESEARCH. GEN GUIDELINES: OPD REC 5 YRS IPD REC 10 yrs MLC PERMT NOTE: IN TEACHING MED COLLEGE & HOSP RECORDS KEPT PERMANENTLY.

45. Any Questions?

46. THANK YOU