Medical Records Procedures & Operations

Medical Record Procedures & Operations

Central Registration System

·       A centralized mechanism for recording all patients (new and returning) to avoid duplication, improve patient identification, and streamline services.

Functions:

• Issue Unique Hospital Identification Number (UHID) to each patient.
• Record demographic details: name, age, gender, address, contact.
• Maintain a Master Patient Index (MPI).
• Coordinate with departments for department-specific registration.

Process:

• New Patient: Fill registration form → UHID generation → Record entered into system.
• Old Patient: Use UHID or name search → Retrieve record → Update details if needed.

Benefits:

• Reduces duplication and errors.
• Faster service delivery.
• Ensures integrated care by linking all visits to a single UHID.

Appointment System

• Types of Appointments:
• Walk-in
• Pre-scheduled (manual or digital)
• Referral-based
• Methods:
• Manual (registers/appointment books)
• Telephone
• Online portals / hospital apps
• Key Features:
• Scheduling as per doctor’s availability.
• Rescheduling/cancellation options.
• SMS/Email reminders.
• Integration with central registration.
• Advantages:
• Reduced waiting time.
• Streamlined patient flow.
• Efficient resource use.

Services Covered by MR Department

A. Outpatient Department (OPD):

• Registration & identification of new/returning patients.
• Maintenance of OPD case files.
• Coding and indexing of diagnosis.
• Summary statistics (daily/monthly/yearly).

B. Emergency & Accident Cases:

• Immediate registration with emergency code.
• Creation of preliminary record on arrival.
• Handover to MRD after stabilization/discharge for proper record completion.

C. Inpatient (IPD) Admissions:

• Receive admission slip from ward.
• Initiate inpatient file with:
• Admission form
• Consent forms
• Initial clinical notes
• Assign a file number and send file to ward.

D. Wards:

• Regular file updates from wards.
• Monitor documentation completeness (progress notes, vitals, investigations, etc.).
• Collect files after discharge for final processing.

Processing of OPD & IPD Records

A. OPD Records:

• Collected daily after clinics close.
• Check for completeness of:
• Clinical notes
• Diagnosis
• Investigations
• Enter data into system.
• Code and index based on ICD.
• File in OPD record section.

B. IPD Records:

• Collected after patient discharge.
• Ensure inclusion of:
• Admission sheet
• Treatment chart
• Progress notes
• Lab/radiology reports
• Discharge summary
• Code and index diagnoses and procedures.
• Review for completeness and accuracy.
• Enter into Hospital Information System (HIS).

Medical Statistics Compilation

• Types:
• Daily, monthly, and annual reports.
• Department-wise statistics: OPD visits, IPD admissions, surgeries, deaths, etc.
• Disease frequency reports.
• Hospital performance indicators.
• Uses:
• Quality control
• Research & audits
• Government reporting
• Resource planning

File Retrieval System

• Objective: Provide quick access to records when needed for:
• Follow-up visits
• Clinical care
• Legal/investigative purposes
• Research and audits
• Retrieval Methods:
• Manual (number-based storage)
• Barcode/RFID tagging
• Electronic indexing (using HIS)
• File Tracking:
• Issue register (manual) or
• Digital log of file movement (to wards, doctors, legal dept.)
• Best Practices:
• FIFO (First In, First Out) for shelving.
• Immediate re-filing after use.
• Use of color-coded files for easy identification.

X-ray & Imaging Records Management

• Traditional X-rays:
• Stored physically in MR Library or Radiology archive.
• Indexed by UHID or film number.
• Digital Imaging (PACS):
• Linked to patient ID.
• Viewed/accessed through HIS.
• Integration:
• X-ray reports attached to medical record file.
• Films (if needed physically) retrieved along with MR file.

Medical Record Library (MRL)

• Central storage area for all patient medical records after completion.

Operations:

• Receive completed files from all departments.
• Arrange files in a numerical or terminal digit order.
• Ensure proper coding, indexing, and filing.
• Maintain file issue and return registers.
• Manage file retention and disposal as per policy.

Storage Systems:

• Open shelves or compactors.
• Fireproof, pest-free, and temperature-controlled environment.
• Digital archiving (scanned documents or EHR).

Retention Schedule:

• Based on hospital policy or statutory norms (e.g., 3–10 years or longer for MLC cases).

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