Rajakumar.M,
Manager-Medical Records,
Aravind Eye Care System.

Good Medical Care Means Good Medical Records

The organization of Medical Records department and its regulations regarding documentation of patient care are based on guidelines established by the Joint Commission on Accreditation of Health organizations (JCAHO) of USA

The Medical Records Department is primarily concerned with documentation of patient care. It does not deal directly with reviews of actual treatment given or set standards of care. By ensuring that all personnel comply with regulations regarding documentation of patient care, the Medical Records department supports various medical staff committees by providing data from medical records

Medical records play an important role in the functioning of any hospital in terms of giving vital information for conducting research, statistical data on utilization of hospital services, mortality and morbidity profiles, and to evaluate performance of clinical facilities. It is beyond doubt that a well-organized and managed Medical Records department will go a long way in providing quality services to the patient.

Objectives:

1. To maintain a central system of complete medical record of all patients.
2. To serve as effective managerial tool for future planning.
3. To provide data for quality check, medical research and education.
4. To fulfill the legal requirements.

Value and Uses:

1. The documentation information is always useful in defending the patient, physician and hospital against any malpractice suits.
2. It helps the patient to remember his/her problems and the treatment rendered during the time
3. To hasten the treatment to any patient during emergency admission.
4. It acts as a communication tool between all the health professionals.
5. It helps in the collection of statistical data related to diagnosis, procedure, infection rates and mortality rates, length of stay, occupancy ratio and in medical research and education.


6. To justify the quality of treatment rendered to patients by physicians, nurses and other health care professionals.

Policies:

A well organized medical record department should have clearly laid down written medical record policies in accordance with the institutional mission, goals, objectives and resources for the effective function of the hospital.

• Ideally a central registration system with 24 hours service should be maintained for all OPs and IPs.
• All medical records should be stored centrally in a secured place under the control and supervision of the department in charge.
• Access to the medical record department should be limited to only its personnel.
• All staff should be provided with uniform code to have a control over the records department.
• Patients should be registered with full sociological (identification) data.
• Only the authorized personnel of the hospital should handle medical records.
• Every patient undergoing any procedures should sign a Consent form.
• Every hospital should follow the assembling order to maintain a system on handling inpatient records.
• Doctors and paramedics must complete all deficient records prior to the discharge of the patient.


• All the patients records must be coded as per the international classification of diseases and procedures book prescribed by WHO.
• Medical Records should be retrieved only with a requisition from the medical or paramedical professionals, authorized only by the Medical Records-In-Charge.
• Patients who leave against medical advice of the doctor should give their written consent for leaving the hospital.
• Medical Record is the property of the hospital. But, the contents in it are the property of the patient.
• Photocopy of the Medical Record or the summary of the medical treatment can be given to the patient on his/her request.