Statutory & Standard Procedures in Medical Records

Statutory & Standard Procedures in Medical Records

Introduction

·       Statutory requirements are legal obligations imposed by regulatory authorities and government laws to ensure patient data is properly maintained, accurate, and accessible when needed.

Maintenance of Medical Records

• Medical records must be maintained in a systematic, legible, and complete manner.
• Minimum retention period (as per Medical Council of India / National Medical Commission):
• Indoor records: 3 to 10 years (depending on the hospital policy/state laws)
• Medico-legal cases (MLC): Must be kept indefinitely
• OPD records: 3 years
• Records should be protected from physical damage, theft, and unauthorized access.

Coding and Indexing

• ICD-10 / ICD-11 (International Classification of Diseases) is used for diagnosis coding.
• Procedure coding uses systems like ICD-9-CM / ICD-10-PCS / CPT.
• Coding is essential for:
• Statistical analysis
• Epidemiological research
• Insurance & reimbursement (e.g., DRGs)
• Indexing involves creating a Patient Master Index (PMI), Disease Index, Procedure Index for easy retrieval and analysis.

Filing of Records

• Records are filed using systems like:
• Alphabetical filing
• Numerical (straight, terminal digit, unit number)
• Filing must ensure quick retrieval, minimal duplication, and confidentiality.
• Use of color coding and barcoding improves accuracy and efficiency.

Use of ICD (International Classification of Diseases)

• ICD is a WHO-mandated system to classify diseases and related health problems.
• Used for:
• Diagnoses recording
• Health statistics
• International disease comparisons
• Insurance claims and audits
• Hospitals must regularly update to the latest ICD version (currently ICD-11 in many countries).

Reports & Returns by MR Department

a. Routine Reports

• Daily Admission & Discharge Report
• Bed Occupancy and Bed Turnover Rate
• Death and Birth Report
• OPD and IPD Statistics

b. Monthly & Annual Returns

• Morbidity and Mortality Statistics
• Disease-wise Reports (e.g., TB, HIV, COVID-19)
• Infection Control Reports
• Departmental Performance Indicators
• Annual Statistical Report for health department/state registry

c. Legal Returns

• Notification of births and deaths to Municipal Authorities
• Medico-legal Reports (with police intimation)
• Reports to Statutory Bodies (e.g., MCI/NMC, NABH)

Standards in Medical Records Services

a. MR Services

• Availability of 24/7 access for emergency retrieval
• Confidentiality and integrity maintained at all times
• All entries must be:
• Signed
• Dated
• Legible
• Use of standard abbreviations, forms, and nomenclature

b. Form Assembly

• Uniform chart order:
• Admission notes
• Progress notes
• Investigation reports
• Treatment plans
• Discharge summary
• Use of printed, serial-numbered forms
• Patient Identification on each page

c. Patient Property Records

• Proper documentation of:
• Valuables at admission
• Handover on discharge
• Records signed by patient, nursing staff, and guardian (if applicable)
• Stored in a secure location until returned

d. Medical Records of Staff

• Separate and confidential MR files for employees
• Records of occupational illnesses, vaccinations, health checkups
• Handled only by authorized personnel (HR/Medical Admin)

e. Microfilming and Digital Archiving

• Used for long-term preservation of records
• Ensures space saving, data security, and quick access
• Can be done through:
• Microfiche
• Scanning & Electronic Medical Records (EMR)
• Must comply with IT Act, 2000 and NMC guidelines

f. Preservation of Records

• Timeframes as per statutory laws (varies by record type)
• Secure storage conditions: pest-free, fireproof, moisture-controlled
• Records of deceased patients and medico-legal cases preserved indefinitely or as per law

g. Patient Rights & Responsibilities (in MR context)

Patient Rights:

·        Right to access own medical records

·        Right to confidentiality

·        Right to correction in case of errors

·        Right to informed consent for sharing MR

Patient Responsibilities:

·        Provide accurate personal and health information

·        Cooperate in record keeping

·        Understand hospital policies on MR access and retention

Basic Medical Records Proformas (Formats)

• Patient Admission Form
• Consent Form (surgery, anesthesia, blood transfusion)
• History and Clinical Examination Sheet
• Progress Notes
• Investigation Report Sheet
• Operation Theater Notes
• Nursing Assessment Chart
• Discharge Summary
• MLC Form
• Referral & Transfer Forms
• Patient Valuables List
• Feedback/Grievance Form

Video Description

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