Hospital Record Keeping, important feature in hospital management studies

1. ORGANIZATION OF MEDICAL RECORD DR.N.C.DAS

6. MEDICO LEGAL RECORD To meet the legal requirements & avoid complications, medical record must fulfil the following criteria:

11. FLOW OF MEDICAL RECORDS The Medical Record Department has two units and flow of record is from peripheral to Central Unit. MR DEPARTMENT PERIPHERAL UNIT OPD REGISTRATION EMERGENCY REGISTRATION INQUIRY & CENTRAL ADMITTING OFFICE ADMISSION CHECK DESK WARD WARD CENSUS DESK CENTRAL UNIT MRD ASSEMBLY & DEFFICIENCY CHECK INCOMPLETE RECORD DESK ADMISSION DISCHARGE ANALYSIS CODEING & INDEXING FILLING M.R LIBRARY

12. ORGANIZATION OF MEDICAL RECORD DEPARTMENT MRD ORGANOGRAM SIZE FUNCTIONS STAFFING LOCATION

13. ORGANOGRAM MEDICAL SUPERINTENDENT MEDICAL RECORD COMMITTEE OFFICER- IN CHARGE-MRD MEDICAL RECORD OFFICER PERIPHERAL UNIT REGISTRATION COUNTER CLERK INQUIRY & CENTRAL ADMISSION OFFICE CLERK ADMISSION CHECK DESK CLERK CENSUS DESK CLERK CENTRAL UNIT MRD ASSEMBLY & DEFFICIENCY CHECK TECHNICIAN INCOMPLETE RECORD DESK ASSISTANT ADMISSION & DISHARGE ANALYSIS TECHNICIAN CODEING & INDEXING TECH. M.R LIBRARY ASSISTANT

16. STAFFING The average staffing for 250 beds and 500 beds hospital should be as under. 25% for leave reserve extra. S.NO. MANPOWER 250 BEDS 500 BEDS 1000 BEDS 1. MRO ONE ONE ONE 2. M.R Technician 4 6 8 3. M.R Assistant 4 6 8 4. Census Staff 3 6 10 5. Admission Clerk 2 4 10 6. Helping Staff 2 3 5

17. MEDICAL RECORD COMMITTEE (AUDIT) Additional Medical Superintendent - Chairman Officer- In- charge - Member Nursing Superintendent - Member HOD Surgery/ Medicine - Member Medical Record Officer - Member Secretary Term : The term of the committee is two years. Meeting : The committee to meet once a month and minutes circulated to different departments. Function : Training policies & procedures for medical record Examine adequacy, quality and quantity of patient care.

19. FUNCTIONS OF MRD FUNCTIONS CUSTODY OF MED. RECORDS MEDICO LEGAL SUPPORT PREPARATION OF MONTHLY & YEARLY BULLETINS NOTIFICATION OF BIRTH & DEATH ASSISTANCE IN RESEARCH NOTIFICATION OF INFECTIOUS DISEASES DISEASE SURVEILLANCE ATTENDING COURT SUMMONS

24. MICROFILMING OF MEDICAL RECORDS Space saving Easy accessibility Safe preservation Elimination of misfiring Saves time & manpower Clean & easy handling

25. COMPUTERIZED MEDICAL RECORDS Retrieve demographic information and consultants report, as well as laboratory, radiology and other tests. Improve productivity & quality. Reduce cost. Allow an interactive computer assisted diagnosis & treatment. Generate reminders for follow-up testing Aid in standardizing treatment protocols

26. OWNERSHIP OF RECORDS The medical record is the property of the hospital & not of the patient, the clinical department or the attending doctor. The medical record must be considered from two points of view: As a personal document As a impersonal document: For education, research & information.

27. CONFIDENTIALITY/RELEASE OF PATIENT INFORMATION 1.There is vital need to maintain patient information in a confidential manner. Patient information shall not be released without legal authorization. 2.Hospital employees, physicians, and students are expected to control the informal transmission of confidential nature. 3.Sensitive information concerning personnel and management issues shall be maintained in the strictest of confidence and shall be utilized only by those individuals legally authorized to review and act on such information.

28. CONFIDENTIALITY OF MEDICAL RECORD System employees pledge to keep medical record information confidential and to respect privacy. A medical record or information contained in a medical record should be released only if: i)A valid written consent for the release of this information is obtained from the patient or legally authorized representative. ii)Reporting is required or permitted by law.

29. WHO CAN SEEK ACCESS TO HEALTH INFORMATION? i)Patient himself ii)Family Physician iii)A person can seek access to information on behalf of someone else: *authorized person by the Patient. iv)In case of death *Authorized representative of family/ **Legal representative of the deceased. ***Court of Law.

30. ROLE OF STAFF MAINTAINING CONFIDENTIALITY Medical record department personal are advised to: i)Acknowledge request for health information promptly ii)Maintain integrity of records iii)Take reasonable steps to confirm the identity of the person seeking the information iv)Assess the information to determine whether access to it must or may be denied .

31. Hospital Administration Made Easy http//hospiad.blogspot.com An effort solely to help students and aspirants in their attempt to become a successful Hospital Administrator. hospi ad DR. N. C. DAS