This is an overview on the organization andd function of the medical records department in a hospital. It would be of help to administrators and planners, as well as for teachers.
4. A & E Service
24 X 7, 3 shifts
May take on the 3rd shift of admission office (small
hospitals)
Functions
Casualty Nos, folders,regist’n
Appointments, admissions
Medico legal
Statistics and A&E records
6. MR Library
24 X 7, 3 shifts
Functions
Processing outpatient records
Processing inpatient records
Generating and analysing stats
Filing and retrieval of records
General MR functions
8. MRs Department
Main factors that govern the organisation of work:
MRs should always he available when required
and in the form they are required
Adequate liaison should exist between
different staff using MRs to enable proper
design and
contents, methods , storage availability,
Procedures should cause patients the
minimum inconvenience
10. For 500 bedded hosp
MR Officer 1
MR Technician 4
Clerks 3
Peon 1
Statistician 1 (on part lime basis)
Computer literate
11. Norms for Personnel
Working days X No of shifts
Man days
2 persons for any hospital + 1 person for every
100 beds (up to 500) + 1 person for every 10 beds
Calculate for 800 beds
13. Job Description MRO
Qualifications
Graduate with 01 year diploma in MR, 03 years
experience
University degree in MR with exp
Line of reporting/ promotion
Duties & responsibilities
14. Operational Policy
To guide the functions of MR dept
Includes
Working hours and shift
Duty rosters
Orga’nal chart
Training schedules
Fire safety
Disaster plans, etc
16. Physical Facilities
Areas required: primary records, sec
records, conference room, MRd
staff, teaching, research, admin reqmts, legal
reqmts
Upto 99 beds: 50 sqm + 1 sqm for each bed
More than 100 beds: 100 sqm + 1 sqm for
each bed
18. Location of various sections
Admission and Inquiry Office:
A space of 125-175 sq ft is considered adequate.
facilitate easy communication between
General office equipment will mainly be required for the staff
Separate counters for admitting clerk, receptionist and billing
clerk
Adequate waiting space Telephone with facility local
calls1STD must be made available
19. Central Record Office
A rough guide
2 to 3 sq ft per bed may be sufficient. The details
are as under:
50 bed hospital-1 50-175 sq ft
100 bed hospital- 225-250 sq ft
200 bed hospital--450-500 sq ft
500 bed hospital-1000-1200 sq ft
20. Calculation of space
Measure one full shelf.
Count the number of files on the shelf.
Calculate the number of files per linear metre.
Count the number of new files created last year.
Calculate the number of linear metres required
per year.
You can then calculate the number of linear
metres required for one, five or 10years.
21. Security
There should be procedures to protect MRs from
fire, water damage ,pest damage, and unauthorized
access.
Lock on all doors. Access should be restricted . There
should be one open entrance to the MR file room and
a fire exit.
No smoking policy in the file room.
Fire equipment and written procedures on in case of
fire
There should be regular pest control in the file room.
22. Coding and Indexing
International Code Number based on
"International Classification of Disease" issued
by the World Health Organisation
Accuracy and uniformity in reporting
23. Indexing
Alphabetic or Master Index: Indexing based on patient's name
sequenced in
alphabetic order. The primary purpose of a name index is to provide entry
into
the filing system and finding out MR for a patient. The patient index
card is usually 3"x5" card giving identification data, registration
number etc
Disease index: Disease index is a catalogue of cards of 3"x5" or
S"xX",
maintained to find out groups of clinical records of patients having the same
diagnosis.
24. Operation index: It is a catalogue containing
the details of patients who have undergone
operations.
Physician's index: Catalogue containing
details of all patients treated by particular
physicians.
Unit index: Details of all the patients treated in
a particular unit are indexed.
25. Storage and Retrieval
Effective filing system
Compactness to reduce physical effort and cost of
storage
Accessibility for speedy location and identification.
Simplicity for understanding of all concerned.
Economical both in the cost of installation and
operation.
Elasticity to expand according to future requirement.
Tracer system for document in circulation
26. System of Filing
Decentralised system: Under this system inpatient and
outpatient department
have their own individual records and file them independently
If a patient is transferred from one department to another the file
may
be loaned to other department. This system is labour intensive and
the operating
cost are higher.
Centralised system: In the centralised system, MRs are filed
centrally
The centralised system is more efficient, provides better control and
followed in most hospitals.
27. Numerical method: This method is most
suitable
for retrieval of files. disadvantage of –new files
(most active) are added to one
end of the system, which usually is the furthest
from the working area
28. Alphabetical method and
Chronological order
filing is done in alphabetical sequence of
names and sequence based on their date of
admission respectively. Requires maintenance
of indexes to allow access to the documents
maintained in the libraries.
29. Terminal digit System
6 digits . First two primary, second two secondary and
last two numbers, are the sequence number of the file
Storage spaces is divide into 100 equal parts from
00 to 99 The primary section.
Each primary section is further sub divided in 100
equal parts again running from 00 to 99.
File number 123456; is located section 56 and
secondary section 34. File number 12 is the required
file
30. 12 34 56
Tertiary secondary Primary
Sorter shelf for records waiting to be filed
31. Middle digit system
Middle two digits are the primary
number, the first two digits the secondary
number last two is the file number
32. Misfiling
Look for the transposition of digits in a number. For
example, 131234 may be filed as 131243 or 121334.
Look for missing files under similar looking numbers
such as "3" under "5" or "8" or vice versa
Check for a certain number such as 584 under 583 or
585 or under a similar combination.
Check the transpositions of first and last numbers.
Check the MR just before and just after the one
needed.
Check the shelf immediately above and below
33. Culling/Purging
Based on last date of admission
Based on retention policy
Done every year usually in the same month
Records kept
Make a committee in charge, Med record
member may be present, but MRO should not
be part of the committee
34. Filing Procedure
Different color for different years
Types of filing
Vertical
Suspended
Horizontal
35. Microfilming
Answer for inactive MR storage. Advantages of
microfilming are:
Saving of space: 90% of the space can be saved if
records are microfilmed.
Easy accessibility: Due to easy storage in a
smaller area
Protection:
Elimination of incorrect filing
Saves manhours
36. Computerisation of MRs
Automation is not the same as electronic MRs
EMRS improve access and sharing of
information.
A well run and organized manual system is a
must. before EMRs
EMRs will not remove the problems of a
Medicl records dept
37. Retrieval of MRs
Depends on system of storage
Record removed and tracer inserte’. Keep a
copy if records are moving out of the hospital
Treat the records with as much care as the
original.
Destroy the copy after original is received