mrd protocol

8/13/2019 MRD Protocol

1/27

Contents

AuthorizationofStaffMembersMakingEntryintoMedicalRecordsChart(File)....................................... 1

RetentionofMedicalRecord........................................................................................................................ 2

ConfidentialityofMedicalRecords............................................................................................................... 3

SecurityofMedicalRecords......................................................................................................................... 4

ICD10CodingandDataAbstracting............................................................................................................ 6

MedicalRecordsTrackingSystem................................................................................................................. 8

PatientMedicalRecordIdentification.......................................................................................................... 9

MedicalAlert................................................................................................................................................. 9

EnteringLaboratoryResultsintoPatientRecords...................................................................................... 10

MedicalRecordAnalysisandCompletion.................................................................................................. 11

StorageofOldInactiveRecords.................................................................................................................. 13

ApprovedandProhibitedAbbreviations.................................................................................................... 14

Abbreviations&Meaning........................................................................................................................... 15

FoetalpositionandPresentation................................................................................................................ 20

Abbreviationforuseontheabstracts(MedicalRecords).......................................................................... 21

DentalAbbreviations.................................................................................................................................. 23

AbbreviationNOTtobeused..................................................................................................................... 25

INDEX.......................................................................................................................................................... 26


2/27

1

IPPNO:MR002

AuthorizationofStaffMembersMakingEntryintoMedicalRecordsChart(File)PURPOSE:Itprovidethehospitalwithauthorizedstafftomakeentriesinthemedicalrecord

POLICY:OnlyauthorizedstaffmembersshallbeallowedtomakeentriesinMedicalRecord.Suchstaff

membersincludephysiciansnursesandotherparamedicalstaffinvolvedinthepatientsmedicalcare.

PROCEDURES:Thefollowingcriteriashallbeobserved:

1. Thereisauniqueidentifier(NameandEmployeeNumber)foreachstaffmember.2. Physiciansshallbeexpectedtohaveastampbearingboth(NameandEmployeeNumber)3. Nursingandotherstaffmembersshallbeexpectedtohaveastampormayusetheirnameandemployeenumber(handwritten)insigningentriesintomedicalrecords.

4. AllentriesintotheMedicalRecordsbyStaffMembershavetobesignedandauthenticatedwithastamp

whenever

applicable,

dated

and

timed.

5. AlltheentriesinthefileshouldbeinEnglishLanguage.6. AllresultsfromRadiologyandLaboratoryhavetobesignedbyamemberofthemedicalteambeforebeinginsertedintothemedicalrecords.

7. EachentrymustbedatedaccordingtoGregoriancalendarindaymonthyearsequence.8. Timeentriesaremadeusing12hoursclocksystem.

AuthorizedStaffMemberstomakeEntries:ThefollowingMedicalandHealthCareProfessionals

areauthorizedtomakeentriesintheMedicalRecordsofMGMC&RIwiththecoordinationof

MedicalRecordsStaffMembers:

Allphysicians. Nurse. Physiotherapists. Dietitian. MedicalRecordsTechnicians. OtherHealthCareProviderssharinginpatientscare.

ProceduresinMakingEntries:

ResponsibleMedicalorHealthCareProvidersarerequiredtocompletethespacesprovidedforthedate,patientsname,ageandsex. Detailedclinicalassessmentsshallbeenteredinalegiblemanner. Aftertheentryofeachclinicalassessmenttheresponsiblemedicalorhealthcareprovidersmustplacetheirnameornumber,signature,dateandtime.


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2

IPPNO:MR003

RetentionofMedicalRecord

PURPOSE:To

retain

and

preserve

the

Medical

Records

for

atime

period

as

specified

by

NABH

standards

formedical,legal,administrative,educationalandotherpurposes.

POLICY:ItisthepolicyoftheMedicalRecordsDepartmenttocomplywithNABHMedicalRecords

RetentionscheduleasmentionedintheNABHpoliciesandmanual.

PROCEDURES:

MedicalRecordsare retainedasper the followingmedical retentionschedulestated inNABHpolicies/proceduresmanual.

ApprovalfromDean,MGMC&RIwouldbetakenbeforedestroyinganymedicalrecord.Preservation

of

Records:

1. Allmedicalrecords includingpatientsfiles,registerbooks,etc.,relatingdirectlytopatientcarehavetobemaintainedbythemedicalRecordsDepartment.

2. Theoldfiles,registerbooks,aretobepreservedinasecureplaceforaprescribedperiod.Laterthe records have to be disposed off as per the Record Retention Schedule procedures

mentionedintheNABHmanual.

3. Specialcarehastobetakentoreservethesafetyofrecords.Recordshavetobeprotectedfrominsects, termites and prevent them from being exposed to heat, fire, dampness and dust.

Adequatefireextinguishersshouldbeavailableinthefillingarea.


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3

IPPNO:MR004

ConfidentialityofMedicalRecords

PURPOSE:Tomaintainconfidentialityofalltypesofinformation.Thisincludesmedicalrecordsdiseases,

operationindex.

POLICY:Itisthepolicyofthedepartmenttosetforthprocedurestomaintainalltypesofinformationin

utmostconfidentialityincompliancewithMGMC&RIHospitalpolicyandethicalrightsofpatientsand

hospitalstaff

PROCEDURES:

1. PersonsworkingintheMedicalRecords,personsdirectlyinvolvedinpatientcareandotherauthorizedpersonswhohaveaccesstopatientmedicalrecordsmustnotunderany

circumstancesdiscloseanytypeofpatientinformationtounauthorizedpersons.Disclosuresof

anyinformationcontainedinthemedicalrecordsareabreachofconfidentiality.Anyonefound

tohavedisclosedanyinformationtounauthorizedpersonswouldbesubjecttodisciplinary

actionand

possible

termination.

2. Authorizedpersons,whoneedtoobtainanykindofpatientinformation,shouldadheretoguidelinesinpolicyandproceduresfortheReleaseofInformation.

3. MedicalRecordsinthedepartmentarekeptsecuredandinstrictconfidentiality.Nounauthorizedpersonsareallowedtohaveaccesstopatientmedicalrecordsoranytypeof

patientdatainformation.


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4

IPPNO:MR005

SecurityofMedicalRecords

PURPOSE: To ensure that allMedical Records (Data Information) are kept safe and secured in the

MedicalRecords

Department

and

protection

of

Medical

Records

from

loss,

theft

or

deliberate

alteration

/tampering

POLICY: To establish responsibilities and procedures for safeguarding Medical Records (data and

information).

PROCEDURES:

1. MedicalRecordsoriginated in thehospital are thepropertyofMGMC&RIHospital and aremaintainedforthebenefitofpatientsandhospitalstaff.

2. InaccordancewithMGMC&RIHospitalspolicies,medicalrecordsshallnotberemovedfromthehospitalexceptbycourtofMinistryofHealth.(Onlycopy)

3. MedicalRecordscanbetakenoutofMedicalRecordsDepartmentonlybyauthorizedpersons4. Ifthefile/sarerequiredforapurpose,otherthanpatientappointment,thepersonsrequestingthe file/s should fillup a file request formwithin theorganization, available fromMedical

RecordsDepartment.

5. ForemergencypatientthemedicalrecordsstaffwillpromptlydeliverthefiletoERnurseortheERstaffcancollectthefilefromMedicalRecordsDepartmentwithproperidentification.

6. To ensure maximum security against loss, defacement, tampering and from use by anyunauthorizedindividual:

NounauthorizedpersonsareallowedtoenterMedicalRecordsDepartmentortohaveaccesstopatientMedicalrecordsoutofthedepartment.

Allmedicalrecordstaken fromtheMedicalRecordsdepartmentduringworkinghoursby any outpatient department /ER or by any authorized persons/unites should be

returnedonthesameday.Norecordsaretobekeptovernight inanyunitotherthan

inpatients.

Patientsortheirrelativeswillnotbeallowedtocarrythepatientfilesortokeepthemintheirpossessions.

7. authorizedallowed8. ThemaindooroftheMedicalRecordsDepartmentshouldbekeptlockedafterworkinghours.9. All persons who need to enterMedical Records Department after 4:30 pm should contactMedical

Record

staff

on

duty

through

reception

counter

or

by

phone

Ext.

10.Norecords/filesshouldbeleftunattended.11.Medicalrecordstaffshouldalwaysbeavailable.Nostaffshould leavethedepartmentwithouthandingover.

12.Anymisconductmade by any of the authorized and responsible staffmembers against thispolicy requires immediatenotice from theheadofmedical recordswith the approvalof the


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chief medical director for prompt initiation of penalty depending on the signification of

offense/sandelaboratedasfollows:

First offense requires a warning letter signed by the medical director stating theconsequenceifthesamemisconductisrepeatedandheistrainedfurthernottorepeat

hismistakeagain.

Second offense necessitates a three not to sevendays salary deduction dependingupon the type of fault alongwith awrittenmemorandum duly signed by the chief

medicaldirectorandtheadministrativemanager.

Thirdoffenseissubjecttoterminationofcontract.


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6

IPPNO:MR006

ICD10CodingandDataAbstracting

PURPOSE:TocorrectlyandaccuratelyassignStandardsDisease,Operationand/orProcedureCodesto

alldischarged

Inpatients

Medical

Records

and

to

enter

the

data

in

the

computer

for

future

reference.

POLICY:ItisthepolicyoftheMedicalRecordsDepartmenttocodeallinpatientdischarges.

PROCEDURES:

1. Receivemedical recodes from theMedicalRecordTechnicianwhohave analyzed the file forcompleteness.

2. Dischargedinpatientmedicalrecordswillbecodeddailyagainstthedischargecensusandattheendofeachmonth,themedicalrecordtechnicianwillrefertotheirlistofdischargesforallfiles

thatarenotyetcoded.

3. ReviewthemedicalrecordInpatientAdmissionSheet,DischargeSummary,HistoryandPhysical,Physician

Progress

Notes,

Consultation

Notes,

Operation

and

Procedure

Notes

and

all

Investigations(ifpresent).

4. Compare the final diagnosis of the Inpatient Admission sheet to the one recorded on theDischargeSummary,HistoryandPhysicalandprogressreport,plustheOperativeandPathology

Reports toascertain that therearenodiscrepancies in information. If thereare,ask first the

physicianforclarificationofthediagnosisbeforeputtingthecode.

5. Determinethattheprimary (final)diagnosishasbeen listed firstandanysecondarycodesarelistedincorrectcodingsequence.

6. CodetheidentifiedDiagnosis,OperationsandProcedures,listedtheminpencilontheInpatientAdmissionsheetincorrectsequence,inthecolumnmarkedICD10

7. Placeyour initialnexttothoseoftheanalyst intheblankboxnexttothecolumnmarked ICDCodeNumbersontheInpatientAdmissionsheet.

CODINGGUIDELINES:

Thefollowingbasicstepsincodingshouldbefollowed:

LocatethemaintermintheAlphabeticIndex. Refertoanynotesunderthemainterm. Refertoanymodifiersofthemainterm. Refertoanysubtermsindentedunderthemainterm. Followanycrossreferenceinstructions. Readandbeguidedbyanyinstruction,terms,symbols,etcwhichmayfurtherqualifythecode. AssigntheCodeNumberthusobtained.

a. Code all operative procedure, all invasive procedures and all diagnostic procedures,whichareinvasive.


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2. It is imperativethatboththealphabetic indicesandthetabular indicesbeusedwhen locatingand assigning a code.Do not try to code directly from the alphabetical indices because the

tabular indicesmayprovideadditional information.Suchasexclusion terms,5thdigitcodes(in

thecaseofdiagnosticcoeds)orinstructionstousemorethanonecodeforanygivendiagnosis

orprocedure.

3. Each individualdiagnosisorproceduremustbeassigneda correct and complete coed. If thephysicianhadnotgivenspecific information,searchthehistoryandphysical,doctorsprogress

notes,operativereportsandpathologyreports formore information. Ifnotclearlydefined,as

theconcernedphysicianforclarification.

4. Theprinciplediagnosisandtheprincipleproceduremustbecodedfirst,becausethecategoriesinwhichpatients are grouped for thepurposeof evaluating theutilization ofHealthRecord

facilities are basedonprinciplediagnosis andprincipleprocedure. Secondary codesmustbe

sequencedintheorderofimportanceandtheireffectintheprinciplediagnosis.

NOTE: CODING IS AN IMPARTENT ASPECT OF RESEARCH IN THE MEDICAL RECORDS

DEPARTMENTANDITMUSTBEDONEACCURATELY.

5. AftereachcodingprocedurehasbeencompletedforadischargedInpatientMedicalRecord,putahighlight ineachappropriatemedicalrecordnumberfromthecorrectdischargecensus list .The filemay then be put in the prefiling area or give to the Transcriptionist for typing of

DischargeSummaryifnecessary.


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8

IPPNO:MR007

MedicalRecordsTrackingSystem

PURPOSE:Toprovideasystemtofacilitateandensureeasilytrackingofmedicalrecord.

POLICY:PatientrecordsareonlyreleasedoutofMedicalRecordsaccordingtoapolicyapprovedbythehospital.

PROCEDURES:

1. Recordscanbereleasedtothenursesintheoutpatientclinics.2. RecordscanbereleasedtotheEmergencyRoomnursesforapatientinEmergencyRoom.3. Recordsarereleasedtomedicalcommitteeandhesignsforit.4. Approvalbythemedicaldirectorforallotherrequestsforreleaseofthemedicalrecord.5. ReleasesandReturnofFiles(MedicalRecordsTrackingSystem):

AnyMedicalRecord files sent from the filing areawillhave theRecords Transfer Cardwrittenandthekeptinitsplace.

Aretrievalregistershouldbemaintained inMedicalRecordsDepartmentforallrequestsfor files. Date,Medical RecordNumber, Dr.Name, Time Department, name and time

requestedshouldbeenteredinthelogbookwiththesignatureofthemedicalrecordstaff.

A logbook should also be maintained for all outgoing patient medical record, clinic,receivingthefilesshouldbeenteredinthePINwithdate,time,andsignature.

AllMedicalRecordssentoutmustbereturnedtothefilingareaonthesameday FilingforOPDappointmentsarepreparedaccordingtotheappointmentlistthepreviousday.

AllthefilesfromtheOPDclinicarecollectedat12.00to01.00pmand8.00to9.00pmasroutine.

Ifany filesarenotreturnedtotheMedicalRecordsDepartmentsonthesameday fromtheclinicthefilesaresentforadmissionortoanotherclinic incasethepatienthadtwo

differentappointmentsonthesameday.

TheMedicalRecordsstaffwhoisoperatingthefileMovementwillcheckeachmorningtoensure thatallthe filessentout thepreviousdayarereturnedto the filingareaon the

sameday.

Ifthereareunreturnedfiles,theMedicalRecordsstaffthepersonresponsibleastowhoborrowed

these

files,

make

enquiries

and

take

action

to

collect

them

at

the

earliest.

TheMedical Records tracer card should be updated in cases of unreturned files afterensuringthelocation.

IfaMedicalRecordcannotbelocatedbytheborrowerortheMedicalRecordsstaffafter3days,itwillbeinformedtomedicaldirectorMedicalRecordfileismissing.

AlistofthemissingfilesshouldbepresentedtotheMedicalRecordsMCIcommittee.


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9

IPPNO:MR008

PatientMedicalRecordIdentification

PURPOSE:Itprovideaprocessforidentificationofpatientdatainthemedicalfile.

POLICY:Everypatientshallhaveamedicalrecordcreatedinhis/hername

PROCEDURES:

1. Allforminthepatientsfileshallhavetheadhesivelabelincluding(PINNumber,name,DateofBirth)orfilledupdailybythenurse

2. Informationconcerningnextofkinincludingaddress,telephonenumber.

MedicalAlert

PURPOSE:Itprovidemedicalrecordstaffbyasystemtocompletethepatientseriousdata.

POLICY:Essentialinformationaboutthepatientsshallbelegibleandlocatedinthefacesheet,andshall

include.

PROCEDURES:

1. Allergies.2. CodeStatus.


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10

IPPNO:.MR 019

EnteringLaboratoryResultsintoPatientRecords

PURPOSE:Itprovidesamechanismforenteringlaboratoryresultinmedicalfile.

POLICY:All Laboratory results shallbe signed&authenticatedbyaphysicianprior toplacement intoMedicalRecords.

PROCEDURES:

1. As soon as a Laboratory result is receivedon theward thenurse shall inform theAttendingPhysician.

2. Ifshouldjuniorstaffmembersnotbeabletoattend,theConsultantsshouldbeinformedofthePresenceoflaboratoryresult.


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11

IPPNO:.MR 021

MedicalRecordAnalysisandCompletion

PURPOSE: To Complete all Medical Records of inpatient discharges in compliance with the

hospitalsstandards.

POLICY: It isthepolicyoftheMedicalRecordsDepartmenttoensurethatallMedicalRecordsarecompleted according to established criteria and contains complete documentation relating to

treatmentand progressduringhospitalization.

PROCEDURES:

Allnewlydischargedandexpiredrecordswillbeanalyzedwithintwo(2)workingdaysofdischarge.

Verifythatalldischargedrecordsforthedayarecollectedorpresent. Use aPhysician IncompleteChecklist from foreachphysicianhavingmedical recordsdeficienciesinanyrecord.

UseNursingDeficiencyChecklistformforeachNursingUnithavingdeficiencies. NursingDeficiencyChecklistformusedwillthenbedistributedasfollows:

Top copywill be given to each nursing unit in thewardwith backed copysignedbyanyofthenursingstafffromtheward.

BackedcopywillthenbegiventotheDoctorsCompletionInchargeforherlistofNursingDeficiency.

PhysiciansChecklistwillbeattached to the right sideof themedical recordwith theMostrecentchecklistontop.

Alldeficienciesrequiringsignatureswillbetaggedwithcoloredlocatortags. Theappropriatecoloredtagswillbeplacedoneachdeficiencychecklist. The following information will be recorded on the Physician Deficiencychecklist:

PatientName. PatientMedicalRecordNumber. Unit. DateofDeficiency. TypeofDeficiency.

OneMedicalRecordControlCardwillbepreparedforeachmedicalRecordhavingphysiciansdeficiency.

ForeachMedicalRecordhavingdischargesummaryand/oroperationreportthat needs to be typed,Medical Record Control Card with copy will be

preparedandthendividedanddistributedasfollows:

TopcopygiventotheDoctorscompletionIn charge.


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12

BackupcopygiventotheTranscriptionist. MortalityRecords:

If the patient has expired, record all the information in Death Registry(patientname,dateofdeath,medical recordnumber,ward/unit, sexand

treatingphysician).

Ensuremortalityrecordsarecompletedsuchasdeathsummary,diagnosisorcauseofdeath.

Write to each top face side of folder EXPIRED with date and time ofdeath.

Keeptheexpiredfilesinseparatefilingshelvesfiledinnumericorder. An outguidewill be preparedwith the following information written inBlockformtobeplacedinthemainfilingarea:

MedicalRecordNumber. EXPIRED. Dateandtimeofexpiration.

CompletethedownpartcorneroftheInpatientAdmissionsheetbywritingthedateofdischarge or date of expired, time and write the initials and the date the file was

analyzed.

Analyzedfileswillbepassedontotheperson(s)responsibleforCoding.


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13

IPPNO:.MR023

StorageofOldInactiveRecords

PURPOSE: To store oldmedical records (which are inactive and less likely to be needed) in such a

mannerthattheycouldberetrievedifrequired.

POLICY:ItisthepolicyoftheMedicalRecordsDepartmenttomakeavailablesufficientspaceinthefilingareafornewlyopenedfiles.

PROCEDURES:

Patientrecords(InpatientandOutpatient):Allpatient files inwhich thepatientshasnot attendedOPDClinicorwerenot treated, as

inpatientforthelast2yearsshallberemovedfromthemainfilingarea.

ThesefilesshallbestoresinaplaceincloseproximitytotheMedicalRecordsDepartmentsothattheycouldberetrievedquickly.

Theserecordswillbearrangedproperlyinshelvesinnumericordertofacilitateeasyretrievalwhenrequired.

ERRecords: ER Records for the current year shall be kept inside the Medical RecordsDepartment.

All the ER records of previous yearswill be removed from the filing area andstoredintheoldrecordsstoreroom.

Accordingtotheavailabilityofshelvesandspaceinthestoreroom,oldERRecordsshallbearrangedproperlyinshelvesinchronologicalorderto

Facilitieseasyretrievalwhenrequired. OldER recordswillbearranged inchronologicalorderbybundleof100recordseachandfiledinaspecialfilingshelfchronologically.

MortalityFiles:

Mortalityfilesbelongingtothecurrentyearshallbekeptinspecialshelves.AllpreviousMortalityfiles

shall be transferred to the old records storeroom and arranged in shelves in chronological order to

enableeasyretrieval.

GeneralInstructionforStoringOldRecords:

Oldrecordsshouldbestoredinasafeandsecuredplace. AnoldRecordsRegisterwillbemaintainedandalltheoldrecordsremovedFromthefilingareamustbeenteredinthisregister. Alltheoldandinactiverecordshavetoberetaineduntiltheyaredisposedoff,aspertheruleslaiddownbyMOHforRecordRetention,(PleaseseepolicyandproceduresonRetentionof

MedicalRecords).


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IPPNO:.MR 024

ApprovedandProhibitedAbbreviations

PURPOSE:Toestablishasystem inthehospitaltoutilizeonlytheapprovedandcomprehensive listof

abbreviationsapprovedbythemedicalrecordscommittee.

POLICY: It is thepolicyof theHospital touseapprovedand standard abbreviations listwhich givens

guidancefordocumentationinpatientrecordsinaccordancewiththeMRQPstandards.

PROCEDURE:

1. The Pharmacy will not accept orders and prescriptions from InPatient which includes nonapprovedabbreviationsandsymbols.

2. Orderscontainingnonapprovedabbreviationsandsymbolsareclarifiedwiththephysician.3. Medication orders containing Abbreviations of Medications, will not be filled unless theAbbreviation is universally accepted, i.e P.P.D (purified Protein Derivative) and listed in the

currenteditionofMedicalRecordsAbbreviationsBooklet.

4. Nonuniversally accepted abbreviations ofMedications, in the approved hospital listings areintendedforuseinmedicalrecordsetc,andwillnotbeacceptedforuseinmedicationorders.

5. AlistingofselectedAbbreviationsofMedications,orderscanbefoundinthecurrenteditionoftheFormulary.

6. The abbreviations shall be reviewed yearly or whenever new additions and deletions arerequired.

7. TheuniformityofabbreviationsamongtheHospitalstaffwouldbemaintained.8. Anysuggestedadditions/deletionsshallbesubmittedtotheMedicalDirectorforreviewandapproval.

9. The abbreviation list is reviewed by the Medical Records Committee and the approvedabbreviationlistiscirculatedtoallthedepartmentsoftheHospitaltobefollowed.

10.The prohibited abbreviation list is also forwarded to the departments to confirm the use ofappropriateabbreviationlistisfollowedandnottheprohibitedlist.

11.The listed out prohibited abbreviations should never be used by the departmental staff andwhichwasapprovedbythemedicalrecordscommittee.


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IPPNO:.MR 025

Abbreviations&Meaning

ABBREVIATION MEANING

a.m BeforeMidday,Morning

AB Apexbeat

ABG Arterialbloodgas

AGA AppropriateforgestationalAge

AIDS AcquiredImmunodeficiencySyndrome

AP&Lat Anteroposterior&lateral

APChest Antero Posterior

APH Antepartumhaemorrhage

ARM Artificialruptureofmembranes

ASAP Assoonaspossible

ASD Atrialseptaldefect

AXR Abdominalxray

b.i.d TwoTimesaDay

BCG BacillusCalmett Guerin

BE Baseexcess

BIL bilateral

BILI bilirubin

BILIC Conjucatedbilirubin

BILID Directbilirubin

BMR BasalMetabolicRate

BP Bloodpressure

BPD Bronchopulmonarydysplasia

BUN BloodUreaNitrogen

BW BirthWeight

C&S CultureandSensitivity

C.S.S.D CentralSterilization&SuppliesDepartment

C.S.T ContinueSameTreatment

C.T.Scan ComputerizedTomographyScan

Ca++ Calcium

CBC CompleteBloodCount

IDDM Insulindependentdiabetesmellitus

IDM InfantofDiabeticMother

IERation Inspiratory/expiratory

IM

Intramuscular

IMV Intermittentmandatoryventilation

Inc Incubator

IPPV Intermittentpositivepressureventilation

IT Inspiratorytime

IUD IntrauterineContraceptiveDevice

IUFD Intrauterinefetaldeath

IUGR Intrauterinegrowthrestriction


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IV IntraVenous


IVH Intraventricularhaemorrhage

IVP IntraVenousPyelogram

IVU IntraVenousUrogram

IWL

Insensiblewater

loss

K++ Potassium

KCL Potassiumchloride

Kg(Kgms) Kilogram(s)

KUB Kidney,Ureter,bladder

L&D LabourandDelivery

Lab Laboratory

Ib Pound

LBW LowBirthWeight

LDH LacticAcidDehydrogenase

LGA Largeforgestationalage

LMP

Lastmenstrual

period

LP LumbarPuncture

LSCS Lowersegmentcaesareansection

LT Left

M Minimum

MAP MeanArterialPressure

CCN ClinicalchargeNurse

CDH Congenitaldiaphragmatichernia

CHD Congenitalheartdisease

CLD Chroniclungdisease

Cm Centimeter

CMV

Cytomegalovirus

CNS CentralNervousSystem

CO Carbonmonoxide

Co2 CarbonDioxide

COPD ChronicObstructivePulmonaryDisease

CPAP Continuouspositiveairwaypressure

CVA CerebroVascularAccident

CVL Centralvenousline

CVP Centralvenouspressure

CXR ChestX ray

D&C DilationandCurettage

D10w

Dextrose

10%

in

water

D5w Dextrose5%inwater

DDH Developmentaldysplasiaofthehips

DIC Disseminatedintravascularcoagulation

DOA DeadonArrival

DPT DiphtheriaToxoid,pertussisVaccineTetanusToxoid

DR Deliveryroom

EBM ExpressedBreastMilk


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ECG/EKG Electrocardiogram


EDD Estimateddateofdelivery

EEG Electroencephalogram

ELBW Extremelylowbirthweight

ENT

Ear,Nose,

Thorat

ER EmergencyRoom

ESR ErythrocyteSedimentationRate

ET Expiratorytime

ETA Estimatedtimeofarrival

ETT Endotrachealtube

FBS FastingBloodSugar

FEBM Fortifiedexpressedbreastmilk

FFP Freshfrozenplasma

FH Fetalheart

FiO2 Fractionofinspiredoxygen

FUO

Feverof

unknown

Origin

G.U. Genito Urinary

Gm Gram

GrI,IIG Gravida,pregnantindicatingawomanofmanypregancies

GTT GlucoseToleranceTest

Gtt Drops

GYN Gynecology

H&P HistoryandPhysicalExam

H.I.E HypoxicIschemiaEncephalopathy

H.M.D HyalineMembraneDisease

Het Hematocrit

Hgb

Hemoglobin

HIE Hypoxicischaemicencephalopathy

HMD Hyalinemembrancedisase

HPU Haspassedurine

HR Hearrate

Hrs Hours

I&D IncisionandDrainage

I&O IntakeandOutput

IA Intraarterial

ICP Intracranialpressure

ICU IntensiveCareUnit

MAS

MeconiumAspiration

Syndrome

MAS Meconium

mEq Milliequivalent

Mg Milligram

MI MyocardialInfarction

Mm Millimeter

Mv Minutevolume

N10 Newbornintravenousnutrition10%dextrose


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N.PR Nasalprongs


Na+ Sodium

NAD Noabnormalitydetected

NaHCo3 Sodiumbicarbonate

NBM

Nilby

mouth

NEC Necrotisingenterocolitis

NG Nasogastric

NGT NasogastricTube

NICU Newbornintensivecareunit

NND Neonatal

NP Nasophargyneal

NPO Nothingperorally

NS NormalSaline

NVD Normalvaginaldelivery

O2 Oxygen

OA

Onadmission

OB Obstetric

OG Orogastric

OR OperatingRoom

OTT Orotrachealtube

Oz Ounce

P Pulse

P.I.E PulmonaryInterstitialEmphysema

p.m AfterMidday

p.o(perorally) PerMouth

P.V PerVaginum

PA

Postero

Anterior

PAChest Posteranteriorchestx Ray

PaCO2 Partialpressurearterialcarbondioxide

PaO2 Partialpressurearterialoxygen

PapSmear PapanicolaousmearTest

ParaI,IIIndicatesthenumberoftimesawomenhasproducedaviable

Infant(over500gramsand20weeksgestation)

Paw Meanairwaypressure

Pc AfterMeals

PCO2 CarbonDioxidepressure

PDA Patentductusarteriosus

PEEP

Positiveand

expiratory

pressure

PH HydrogenionConcentration

PID PelvicInflammatoryDisease

PIE Pulmonaryinterstitialemphysema

PIP Peakinspiratorypressure

Postop AfterOperation

PP PostPartum

PPD Purifiedproteinderivative(TBtest)


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PPH Postpartumhaemorrhage


PPHN Persistentpulmonaryhypertensionofthenewborn

PPROM Prelabourprematureruptureofthemembrances

Preop BeforeOperation

PRN(prn)

As

indicated,

as

necessary

PROM Prolongedruptureofmembrances

PSV Pressuresupportventiliation

PTU Phototherapyunit

PVH Periventricularhaemorrhage

PVLorPVLM Periventricularleucomalacia

Q Every

Q2h Every2Hours

Q4h Every4Hours

Qd EveryDay

q.h EveryHour

q.i.d

Fourtimes

aday

RBS Randombloodsugar

RDS Respiratorydistresssyndrome

Resp Respiration

RHT Radianthearttable

ROP Retinopathyofprematurity

RSV Respiratorysynctivalvirus

Rt Right

RTA RoadTrafficAccident

SBR Serumbilirubin

SFD Smallfordates

Sg

SpecificGravity

SGA SmallforgestationalAge

SIMV SynchronisedIMV

SIPPV SynchronisedIPPV

SLE Systemiclupuserythematosis

Spec Specimen

SpO2 Oxygensaturation

SRM Spontaneousruptureofmembrances

SSG(S/C) SplitSkinGraft

STAT Atonce

SVD SpontaneousVaginalDelivery

T&

A

Tonsillectomy

&

Adenoidectomy

TorTemp Temperature

Tabs Tablets

TAPVD TotalanomalouspulmonaryVenous

TB Tuberculosis

TBW Totalbodywater

TE Expiratorytime

Tet TetralogyofFallot


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TGA Transpositionofthethegreatvessels


TI Inspiratorytime

TKVOorTKQ Tokeepveinopen

TOF Trachealoesophagealfistula

TPN

Totalparenteral

nutrition

TPR Temperature,Pulse,Respiration

TTN Transienttachypnoeaofthenewborn

TUR TransurethralResection

TV Tidalvolume

Type&Xmatch Typeandcrossmatch

UAC Umbilicalarterialcatheter

URTI UpperRespiratoryTractInfection

UTI UrinaryTrackInfection

UVC Umbilicalvenouscatheter

V/Q Ventilationperfusion

VDRL

VenerealDisease

Research

Laboratory

VG VolumeGuarantee

VLBW Verylowbirthweight

VSD Ventricularseptaldefect

Vx vertex

WBC Whitebloodcount

Wt Weight

ZIG Zosterimmuneglobulin

FoetalpositionandPresentation


LOA(ROA) LeftOcciputAnterior(right)

Lop(ROP) LeftOcciputPosterior(right)

LOT(ROT) LeftOcciputTransverse(right)

LSA(RSA) LeftScrumAnterior(right)

LSP(RSP) LeftScrumPosterior(right)

LST(RST) LeftScrumTransverse(right)


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21

Abbreviationforuseontheabstracts(MedicalRecords)


Aband Abandoned,Abandonment

ve Negative

+ve

Positive

ABD Abdomen

ADM Admission

AKA AbovekneeAmputation

AMA AgainstMedicaladvice

ANESTH Anesthesia,Anesthetist

ASSESS Assessment

BF BlueFiles,BurmperFiles

BKA BelowKneeamputation

C Centigrade,Celsius

CA Cancer

Cardio

Cardiology

CCU Coronarycareunit

CxR ChestX Ray

D.U DuodenalUlcer

Derma Dermatology

Disc Discharge

DOB DateofBirth

DOD DateofDischarge

EBL EstimatedBloodLoss

ER EmergencyRoom

FH FamilyHistory

FMW

FemaleMedical

Ward

FRH FemaleRehabilittion

FSI FemaleSurgicalI

FSII FemaleSurgicalII

G.A GeneralAnesthesia

G.S GeneralSurgery

Gyne Gynecology

HOSP Hospital

HR HeartRate

ICU IntensiveCareunit

IM(int.Med) InternalMedicine

Lab

Laboratory

LOS LengthofStay

MM MaleMedical

MOH Ministryofhealth

MR MedicalRecord

MRH MaleRehabilitation

MSI MaleSurgicalI


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MSII MaleSurgicalII


N.Sur Neurosurgery

NBN Newborn

Nephro Nephrology

NpN

Nursingprogress

note(s)

NSG Nursing

O.Surg OralSurgery

O.T OccupationTherapy

OB Obstetrics

OH ObstetricalHistory

Onco Oncology

OPDI OutpatientDepartmentI

OPDII OutpatientDepartmentII

Ophthal Ophthalmology

Ortho Orthopedic

P&

P

Policy&

Procedures

PAT Patient

Pedia Pediatrics

Phar Pharmacy

Pl.Surg PlasticSurgery

PMH PastMedicalHistory

PPN PhysicianprogressNote(s)

PT Physiotheraphy

Pulmo pulmonary

Rehab Rehabilitation

RX,TX,TRT Treatment

SICU

SurgicalIntensive

Care

Unit

Sur Surgery

T0 Temp


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23

DentalAbbreviations


GC ThreequarterGoldCrown

Abg Autogenousbonegraft

Adh

Adhesive

AG Attachedgingival

AgPt Silverpoint

AL Attachment

Alg Alginate

Amg Amalgam

ApRep Apicallyrepositioned

B Buccal

BAWON Brokenappointmentwithout

Beh Behavior

BL Bonelevel/loss

BOP

Bleedingon

probing

BLUP Buildup

BW Bitewingradiograph

CA Citricacid

CA(OH)2 Calciumhydroxide

Carbo Carbocaine

Cav Cavitron

CR&BR Crownandbridge

CUDET Completemaxillarydenture

CLDET Completemandibulardenture

Cem Cementation

ChX

Chlorhexidine

CL CrownLength

CPTIN Communitybasedperiodontalindexoftreatmentneeded

CR Crown

CTG Connectivetissuegraft

Cutt curretage

Cx Cancelled

D Distal

DB Disto incise

DFDBA Demineralizedfreezedrilledboneallogant

DI Dsito lingual

DO

Ditsoligual

DPC Directpulpcap

DSK Drysocket

E/IOE Extraoral/infroaralexamination

Epi Epinephrine

ETB Electrictoothbrush

ETTB Endtufttoothbrush


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EXT Extract/extraction


F Facial

FB Fissureblock

FBImp Fullbonyimpaction

FGCR

Full

gold

crown

FGG Freegingivalgraft

FI Flossinstruction

Fin&pol Finishandpolish

FL Floride

FMX Fullmouthxrays

FPCR Fullprocelan

FPDET FixedpatialDenture

GCR Goldcrown

GI Glasslonomer

GP Guttapercha

GTR

GuidedTissue

Regulation

I Incisal

IUCDET ImmediateUppercompletedenture

ILUDET Lowerimmediatecompletedenture

IE Initialexamination

Imp Impression

IP Initialpreparation

IPE Initialperodntal

IPX Interproximal

IRM Intermediatedrestrorative

KF Kelac f

Ks

Ketlacsilver

L L:ingual

L(cricted) Left

LA Localanesthesia

LHA Lingualholdingarch

Lido Liocaine


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AbbreviationNOTtobeused


BT BedTime

D/C

Usedinmorethanonesenseoftheword

Discontinue.

Discharge.

C.S.T ContinueSameTreatment

IJ Injection

Mg Microgram

SC,SQ,SUBQ Subcutaneous

TIW Twiceorthricetimesaweek

U Unit

IU Internationalunit

Q.D.,Q.O.D Everyotherday

X.Omg Trailingzero

Ms,MSo4,

MGSO4

Magnesium

sulfate,

Morphine

Sulfate

H.S HalfstrengthorLatinabbreviationforbedtime

T.I.W Threetimesaweek

S.C.orS.Q. Subcutaneous

D/C Discharge

c.c. Cubiccentimeter

A.S.,A.D.,A.U. Latinabbreviationforleft,right,orbothears


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IPPNO:.MR 026

INDEX

Sl.No. TITLE PolicyNo.

01 RegistrationofNewpatients 001

02AuthorizationofStaffMembersMakingEntryIntoMedicalRecordsCharts

(File)002

03 RetentionofMedicalRecords 003

04 ConfidentialityofMedicalRecords 004

05 SecurityofMedicalRecords 005

06 ICD10AMCodingandDataAbstracting 006

07 MedicalRecordsTrackingSystem 007

08 PatientMedicalRecordIdentification 008

09 RecordingByVariousHealthCareProvidersInpatientsMedicalCharts/File 009

10 ContentsofMedicalRecords 010

11 CompletionofMedicalRecords 011

12 ReviewofMedicalRecordsForQuality 012

13 PhysicianOrderTelephone&VerbalOrders 013

14 QuantitativeAnalysis 014

15 StaffingofMedicalRecordsDepartment 015

16 FilingAndRetrievalofMedicalRecords 016

17 TranscriptionofDischarge/DeathSummariesandOperativeReports 017

18 ReleaseofMedicalRecordsorInformation 018

19 ExecutiveInformationaboutThepatientsShallBeLocatedIntheFaceSheet 019

20 GuidelinesofCorrectionofEntriesIntheMedicalRecords 020

21 EnteringLaboratoryResultsIntoPatientsRecords 021

22

ParticipationofMedicalDirectorIntheRecordsQualityManagement

Program 022

23 MedicalRecordAnalysisandCompletion 023

24 StorageRecordAnalysisAndCompletion 024

25 Abbreviations 025

mrd protocol

Documents