medical record section in hospital

8/7/2019 medical record section in hospital

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MEDICAL RECORD

DEPARTMENT

PRESENTED BY:-

MHA VICTORIOUS

(MEGHA ,SONU)


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CONTENTS

INTRODUCTION

DEFINITION

FUNCTION OF MRD

WHY TO KEEP RECORDS?

NEEDS

FLOW CHART OF IN PATIENT RECORD

NEW FILE DOCUMENTS TYPES OF FILE

FINDING

RECOMMENDATION


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INTRODUCTION

Medical records through which hospitalstatistics are generated and medical recordsare important to the hospital for evaluation ofits services for better patient care


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DEFINITION

Medical record as a clinical, scientific

,administrative , and legal document

relating to patient care in which arerecorded sufficient data written in the

sequence of events to justify diagnosis

and warrant treatment and end results

Mc Gibony


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FUNCTIONS OF MEDICAL RECORD

DEPARTMENT1. Daily receipt of case sheets pertaining to discharge, 2 P.M. an

expired patients from various wards, there checking andassembly.2. Daily compilation of Hospital census report.3. Maintains & retrieval of records for patient care and research

study.4. Completion and Procession of Hospital statistics and preparation

on different periodical reports on morbidity and mortality.

5. Online registration of vital events of Birth & Death6. Issuing Birth & Death certificated up to one year.7. Dealing with Medico Legal records and attending the courts on

summary.8. Arrangement & Supervision of enquiry and admission office.9. Arrangement & Supervision of OPD registration

10. Management of disability boards.11. Management of Medical Examination12. Management of Mortality Review Committee Meetings (Twice

month)13. Assistance to Hospital Administration in various matters.


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WHICH data to record?

Personal info: age, sex, occupation, training,

family...

Risk factors: tobacco, alcohol, life styles...

Allergies and drug reactions

Problem list

Disease history: diseases, operations. . .

The disease process: main problem, history, exam,lab.

Management plan: advice, education, medication. .

.

Progress notes: in the P S O A P format/ 296


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PSOAP

Problem Everything the patient reports and doctorsfindings which are regarded as problems

Subjective History of the problem; what the patient feels or

thinks about the problem

Objective Doctors findings related with the problem

Assessment

Evaluation of the problem; the diff. diagnosis Plan

Prescription, consultation, advice, control visit...

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DIVISION

MRD has following functional unit:-

1. Receiving area

2. Checking area3. IT room

4. Record storage area (monthly wise)


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WHY TO KEEP RECORDS?

Helps in medical decisions(is the size of a lymph node or nodule

increasing with time?) Helps to share responsibility with the

patient

Legal obligation. Protects the patient as well as doctor

in front of the court

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CONTDt..

Has economic benefits

Useful to produce health statistics Provides epidemiological data

Assists practice management

/ 2910


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NEEDS

Patient needs

Physician needs

Institution needs Health authorities needs


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Flow chart of inpatient record

analysis ,,,

Assembling checking-incomplete- coding-indexing--- ----- filling

reporting

retrieval

Central

admission

Office

census

Nursing

unit


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Medical Record Officer Medical Record Technicians

Medical Record Clerks

Medical Record Attendants.

Ward Boy The Reception, Enquiry and Admission office functions roundthe clock under the charge of Medical Record Officer.

Presently only inpatients records are maintained in the MedicalRecord Department.

Registration work of OPDs are also managed by the Medical

Record Officer. Statistical information about the functioning of OPDs is regularly

submitted by the Medical Record Officials in the Medical RecordDept.

Staffing


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NEW FILE DOCUMENTS

File folder

General case sheet

Investigation

Progress record Treatment sheet

Vital chart

Nursing notes

Intake/output chart Temperature chart

Hospital charges chart


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TYPE OF FILE

General file

M.L.C. file

Ward register

All register of dept.


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FILING OF MEDICAL RECORDS

The inpatients Medical Record is filed by theserial numbers assigned at central AdmittingOffice.

The Record is bound in bundles 100 each

and are kept year wise according to the serialnumber.RETENTION OF MEDICAL RECORD

The policy is to keep indoor patient Recordsfor 10 years

The OPD registers for 5 years

The record which is register for legalpurposes in Maintained for 10 years or tillfinal decision at the court of Law.


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THANK YOU

medical record section in hospital

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