Medical Records Management

By Abdulla Israr & Simran Rani

Medical Records Management

Introduction

  • Medical Record Management involves the systematic control of the creation, distribution, use, maintenance, and disposition of patient medical records.
  • These records serve as a legal document, source of patient care, tool for hospital planning, education, research, and statistics.

Essentials of Medical Records

  • Completeness – All necessary patient data should be recorded.
  • Accuracy – Information must be factual and verified.
  • Timeliness – Entries must be recorded as soon as events occur.
  • Confidentiality – Data must be kept secure and shared only on a need-to-know basis.
  • Accessibility – Records must be retrievable when needed for treatment, audit, or legal use.

Contents of Medical Records

  • Patient Identification Data
  • Medical History & Examination Findings
  • Diagnosis (Provisional & Final)
  • Investigations (Lab/Radiology)
  • Treatment Plans & Progress Notes
  • Operation/Procedure Notes
  • Nursing Records
  • Consent Forms
  • Discharge Summary
  • Follow-up Instructions

Mechanism of Record Management

  • Creation: Done at registration/admission.
  • Filing: Numerical, Alphabetical, Terminal Digit systems.
  • Storage: Physical records in MRD; digital on servers/cloud.
  • Retrieval: Manual or automated retrieval systems.
  • Preservation & Retention: Based on institutional & legal policy.
  • Disposal: Shredding/incineration after the retention period.

Hospital Statistics from Medical Records

  • Admission, discharge, transfer data
  • Average Length of Stay (ALOS)
  • Bed Occupancy Rate (BOR)
  • Mortality & morbidity rates
  • Readmission rates
  • Infection control data
  • Diagnosis-based statistics for policy-making

Medical Record Department (MRD)

  • The backbone of hospital information management.
  • Functions:
    • Maintain patient records.
    • Ensure confidentiality and compliance.
    • Support legal and audit processes.
    • Compile hospital statistics.
    • Assist in insurance, medico-legal cases, and research.

Roles in Medical Record Management

Medical Record Officer (MRO)

  • Supervises MRD staff and operations.
  • Ensures accuracy and completeness of records.
  • Implements hospital policies regarding documentation.
  • Coordinates with clinical departments and admin.
  • Maintains confidentiality and legal compliance.
  • Trains staff and conducts record audits.

Hospital Manager

  • Integrates record-keeping with hospital management.
  • Ensures HIS/ERP systems are effectively used.
  • Uses MR data for decision-making, planning, and accreditation.
  • Manages human and technological resources in MRD.

MRD Personnel

  • Record Clerks: Filing, retrieval, indexing of records.
  • Coders: Apply ICD-10/11 codes for diseases/procedures.
  • Data Entry Operators: Digitize paper records.
  • Technicians: Maintain equipment/software.
  • Reception Staff: Handle patient inquiries and MLC documentation.

Forms and Documentation

Case Sheet Requirements

  • A case sheet is a comprehensive medical document that includes:
    • Patient biodata
    • Admission details
    • History and physical examination
    • Diagnostic test reports
    • Progress notes and physician orders
    • Surgery/Anesthesia records
    • Medication and nursing notes
    • Discharge summary and instructions
    • Consent forms
    • Referral and transfer notes
  • Must be legible, signed, dated, and timed.

ERP Modules in MRD (Electronic Record Keeping)

  • Registration Module: Patient demographic data entry, UHID generation.
  • Admission/Discharge Module: Real-time tracking of inpatient movement.
  • Clinical Documentation: Digital case sheets, doctors' notes, nursing notes.
  • Lab & Radiology Integration: Test results linked with patient file.
  • Coding & Billing Module: ICD/CPT coding and integration with billing.
  • Medical Statistics: Auto-generated hospital statistics and reports.
  • Record Tracking: Locating physical or scanned records.
  • Data Security: User access controls, audit trails, data encryption.
  • Legal Compliance: Digital signature, time stamps, and retention settings.

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