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Dear Readers,
Medical Records management has become an integral activity of the hospital management. The department provides multiple benefits not only to the patients but also to running a hospital efficiently. The introductory set of articles provide an overview to the reader about the purpose of the Medical Records department. There are many aspects to be considered while setting up a Medical Records department. This is captured in the planning of the Medical Records department. A variety of forms make the activity of information collection a systematic and easy process. There are different filing systems which can be considered to allow for easy storage as well as facilitate easy retrieval. Coding and indexing system also has to be understood as there are standard and internationally accepted practices. Following which will make it easier for comparisons and research. With increasing consumer cases due to medical negligence the Medical Records plays a very important role in terms of providing evidence. The legal aspects however vary geographically and is determined by the policies of that region. To run a Medical Records department well the staff of that department need to be well trained and their job descriptions clear.

Happy Reading!

Regards,

Vision 2020 e-resource team
The Issue Features...
Medical Records in Hospitals
Vol. 3 No. 8 August 2006
•   Introduction
•   Planning MRD
•   Job Description
•   Medical Record Forms
•   Filing Systems
•   Coding & Indexing System
•   Health Information Database
•   Legal Aspects of Medical Records
•   Electronic Medical Records
•   Training
•   Websites
•   Collaborating Partner

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Medical Records are a clinical, scientific, administrative and legal document relating to patient care in which sufficient data is recorded by trained observers as per sequence of events to justify the diagnosis and therapy, giving the results thereof are in accordance with reasonable expectation of present day scientific medical care. It is in other words a performance barometer of the hospital.

A medical record system must be organized to render service to the patient, the medical staff, the hospital administration, and society. In the interests of economy, accuracy of information, and good communication, all information should be concentrated in the original Medical Records, which should be indexed and filed in the main medical record department.
  • INTRODUCTION TO MEDICAL RECORDS

  • Abstract:
    This article provides a brief introduction about the Medical Records. It also tells in details the objectives and the use of Medical Records. It describes how the Medical Records play a vital role in treating the Patients. It also describes the policies and the procedures that have to be followed in maintaining the Medical Records.

  • NEED FOR MEDICAL RECORD

  • Abstract:
    This article tells in detail the needs and necessities of maintaining the Medical Records. It also provides in detail how the Medical Records provides with the hands-on information to the Patients as well as the Doctors while treating the Patients. It also describes in detail how the Medical Records help in the statistical analysis of the Patients data in the field of Medical Research.

  • MEDICAL RECORD MANUAL

  • Abstract:
    This article describes in detail about the Medical Records and its components. It also describes different forms used in Medical Records in the Health sector. It also tells the data requirements that each form have to fulfill for the healthcare needs. It also describes hoe the forms have to be effectively stored.

  • QUALITY ASSURANCE IN MEDICAL RECORDS

  • Abstract:
    This article describes how to ensure the quality of Medical Records by conducting proper Quality Audit. It also tells in detail the importance of organizing a Medical record committee in the hospital.

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Planning is a fundamental function of Medical Records Department. It consists of selecting the Proper Employees, Office Space and location, Office furniture and equipment, and spatial conditioning factors such as lighting, color, sound and air. Planning here is, in effect, deciding in advance what to do, how to do it, when to do it and who is to do it. Planning assumes that rational processes can be used to nominate resources and define appropriate future action which will produce desired outcomes.
  • MEDICAL RECORDS DEPARTMENT PLANNING

  • Abstract:
    This article provides in details how to set up a Medical Records Department in hospitals. It also includes the infrastructure planning, Recruitment of personals. It also provides how the staffs have to engage in the departments, and how they have to maintain the Medical Records.

  • MEDICAL RECORDS DEPARTMENT - PLANNING AND ADMINISTRATION

  • Abstract:
    This discus in detail the Planning and Setting up of an Medical Records Department. It also tells in detail how the policies and procedures have to be developed in effectively planning and administering the Medical Records Department. It also tells in brief the planning of Departmental Infrastructure.

  • OVERVIEW OF FRONT OFFICE (REGISTRATION & ENQUIRY)

  • Abstract:
    This article describes in detail how the Patients have to be effectively handled in the Front office. It also describes in detail the capabilities and responsibilities of the Receptionists while handling the Patients.

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Job Description is a written document which tells the job holder what he/she has to do, how the work should be done and also the purpose of work. Job Description should clearly define the job responsibilities, duties and tasks to be done and should have Job Identification, Job Summary, Duties to be performed, Relation to other jobs/departments, Supervision to be given/taken, Type of tools/equipments used, Condition of Work etc. Some of the reasons to have Job Description are
  • Role clarity for the job holder
  • Keeps the employees focus on the job.
  • Training Need Assessment could be done by referring the Job Description
  • Evaluation of the employees performance could be easily done.
  • Increase in pay and bonus could be given with reference to Job Description.

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Forms should be designed to facilitate data collection as well as to provide complete and accurate data. Because of the costs of storage space and microfilming, as well as the difficulty of finding desired information in many records, it is imperative that good organization, conservation of paper, and effective methods of record indexing be carefully considered when selecting forms. A collection of Medical Records forms developed and used by Aravind has been provided as a supplement. These forms are not to be considered as standard but can be used as model forms.
  • DEVELOPMENT OF MEDICAL RECORDS FORM

  • Abstract:
    This article describes in detail about the various Medical Records form. It also provides in the steps that have to be followed in providing necessary data in the requisite form. It also describes in detail the various legal and confidential aspects have to be concentrated in designing and providing Medical information inn each form.

  • INPATIENT RECORD

  • Abstract:
    This is an In-Patient form. This form comprises the identification details of the patient, his health conditions before and after the surgery and also the details about the surgery.

  • IOL INPATIENT RECORD

  • Abstract:
    This is an IOL INPATIENT record form. It comprises the details regarding the patients admitted for IOL Surgery only. It also provides surgical details like the eye conditions before and after the surgery. It provides the details like the type of cataract, the eye which has to be operated, health conditions of the patients like sugar level before and after the surgery. It also comprises the signature of the patient consenting for surgery.

  • DISCHARGE SUMMARY REPORT

  • Abstract:
    This form is provided while discharging the patients after surgery. It lists in detail the health strategies patients have to follow after the surgery. It lists the surgical details, follow up details, their dosage and instructions.

  • CAMP RECORD

  • Abstract:
    This form is particularly used for the camp patients. It comprises details like the patients personal information along with the patients identification number. It also provides the eye conditions of the patients. It provides the cataract details if the patients have to be admitted for the surgery or the refraction details for patients having refraction.

  • CATARACT SURGERY RECORD - FREE SECTION

  • Abstract:
    This form is a surgical record for the patients admitted in the free hospital for the surgery. It comprises the details like personal information of the patients. It also gives the surgical details like which eye have to be operated for the surgery, the name of the surgeon performing the surgery, the type of surgery and the health directions the patient has to follow after the surgery.

  • REGISTRATION INFORMATION CARD

  • Abstract:
    This Card is an information card listed alongside the patients Identity. This card will be provided to the patients while registering for the health checkup.

  • POST-OPERATIVE CARD

  • Abstract:
    This card is provided after the surgery. It provides the date of the patients admission, the follow up date, their eye conditions before and after the surgery.

  • REFRACTION FORM

  • Abstract:
    This form is maintained for the patients who have refractive error. It tells in detail about the refraction in the eyes.

  • IOL DISCHARGE SUMMARY

  • Abstract:
    This discharge summary is maintained only for the patients admitted for IOL surgery. It comprises the patients personal details, their eye condition before and after surgery. It also provides the instructions that have to be followed by the patients before and after the surgery.

  • IOL SURGERY RECORD FREE SECTION

  • Abstract:
    This form is maintained for the free hospital patients admitted only for the IOL surgery. It also comprises details like patient information, eye condition before and after the surgery, the date of surgery, the surgeons performing surgery. It also gives the surgical details and other health condition before and after the surgery.

  • OUTPATIENT RECORD

  • Abstract:
    This record is maintained for the outpatients after the surgery. It comprises patient identification details, their eye conditions before and after the surgery, the surgery details, and other health conditions before and after the surgery. It also gives the refraction details for the patients having refraction.

  • RECEIPT

  • Abstract:
    This form is given to the patients on receipt of their payment.

  • OP RECORD CONTINUATION CARD

  • Abstract:
    This card is just used as an attachment to the Outpatient Record. It comprises the Patient name with the Medical Record number.

  • INSTRUCTIONS FOR PATIENTS AFTER DISCHARGE - (IOL)

  • Abstract:
    This article provides in detail about the health strategies that have to be followed by patients admitted for IOL surgeries.

  • BILL

  • Abstract:
    This form is given to the inpatients on payment. It comprises the patients Identification details and other payment particulars.

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Filing is defined as the process of systematic placing of documents in acceptable containers according to some predetermined arrangement. The purpose of filing records is to facilitate complete and quick retrieval of pertinent information whenever the need arises. It is most important, to select the filing system that will most efficiently provide the type of service required by the individual hospital.
  • NUMBERING AND FILING SYSTEM

  • Abstract:
    This article describes in detail about the numbering system in Medical Records. It describes the different types and utilities of the number system followed in maintaining the Medical Records in the Healthcare facilities. It also discuss the various Filing system and their utilities in the Health care facilities.

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Filing is defined as the process of systematic placing of documents in acceptable containers according to some predetermined arrangement. The purpose of filing records is to facilitate complete and quick retrieval of pertinent information whenever the need arises. It is most important, to select the filing system that will most efficiently provide the type of service required by the individual hospital.
  • NUMBERING AND FILING SYSTEM

  • Abstract:
    This article describes in detail about the numbering system in Medical Records. It describes the different types and utilities of the number system followed in maintaining the Medical Records in the Healthcare facilities. It also discuss the various Filing system and their utilities in the Health care facilities.

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Statistical data are collected to help hospital administrators and physicians evaluate the hospitals program administratively and medically. The gathering and use of data should be purposeful, rather than indiscriminate of haphazard. The process involves devices for classifying, collecting, and recording data systematically; storing them efficiently; retrieving them quickly; and summarizing them in the most usable forms. All these functions are intrinsically important in a good medical record system.
  • COLLECTION OF HEALTH INFORMATION DATA

  • Abstract:
    This article lists out the Statistical data that can be calculated by proper maintenance of the Medical record. It also describes in detail how the statistics can be calculated.

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A medical record, health record, or medical chart is a systematic documentation of a patient's medical history and care. The term 'Medical record' is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient's health history. Medical Records are intensely personal documents and there are many ethical and legal issues surrounding them such as the degree of third-party access and appropriate storage and disposal. Although Medical Records are traditionally compiled and stored by health care providers, personal health records maintained by individual patients have become more popular in recent years.

Medical Records are legal documents and are subject to the laws of the country/state in which they are produced. As such, there is great variability in rule governing production, ownership, accessibility, and destruction. YOUR MEDICAL RECORD RIGHTS IN DIFFERENT STATES OF USA

MASSACHUSETTS ALABAMA ARKANSAS
ARIZONA CALIFORNIA COLORADO
CONNECTICUT DISTRICT OF COLUMBIA FLORIDA
GEORGIA ILLINOIS INDIANA
IOWA KANSAS MARYLAND
MICHIGAN MINNESOTA MISSISSIPPI
MISSOURI NEW JERSEY NEW YORK
NORTH CAROLINA OHIO OKLAHOMA
OREGON PENNSYLVANIA SOUTH CAROLINA
TENNESSEE TEXAS VIRGINIA
WASHINGTON WISCONSIN  


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Recent studies of Medical Records have showed tremendous waste of paper, with as much as one half the paper surfaces remaining unused. Cost of storage space and of microfilming processes, as well as the difficulty of finding desired information in many current records, makes it imperative that thought and effort be directed to Electronic Medical Records.

An electronic medical record (EMR) is a computer-based patient medical record. An EMR facilitates
  • access of patient data by clinical staff at any given location
  • accurate and complete claims processing by insurance companies
  • building automated checks for drug and allergy interactions
  • clinical notes
  • prescriptions
  • scheduling
  • sending to and viewing by labs
  • BENEFITS OF ELECTRONIC MEDICAL RECORD

  • Abstract:
    This article provides in detail how the Electronic Medic Records has been evaluated. It also gives in detail how the Electronic Medical Records Record management made tremendous improvement in technology in the Health Care society.

  • EMR HARDWARE AND SOFTWARE REQUIREMENTS

  • Abstract:
    This article describes in detail the Hardware and Software requirements needed while planning and Implementing Electronic medical record Systems. It also tells in detail the storage facilities and the utilities of the Electronic Medical Records systems.

  • EMR STANDARDS

  • Abstract:
    This article discusses in detail the various EMR standards that can be adopted in providing the efficient Electronic Record Management system. It also tells in detail how the patients medical data has been recorded and interchanged through a process cycle to provide efficient workflow in the hospitals.

  • CHALLENGES IN EMR

  • Abstract:
    This article discusses in detail the end users, Doctors expectation and challenges that have to be faced right from the Planning, Developing, Implementing and Initializing the Electronic Medical Records.

  • EMR, ITS RELEVANCE, ITS BENEFITS AND OPTIONS AVAILABLE

  • Abstract:
    This article discusses in detail the steps that have to be analyzed while planning an user-friendly Electronic Medical Records Systems. It also discussed the various facilities, time saving , cost effective and effectively manageable Electronic Medical Records System.

  • HOW THE PUBLIC SEES HEALTH RECORDS AND AN EMR PROGRAM

  • Abstract:
    This article is a report on the survey of the need and the utilization of Medical Records System survey by telephone within the United States between February 8 and 13, 2005 among a nationwide cross section of 1,012 adults (ages 18 and over). Figures for age, sex, race, education, number of adults, number of voice/telephone lines in the household, region and size of place were weighted where necessary to align them with their actual proportions in the population.

  • ELECTRONIC MEDICAL RECORD

  • Abstract:
    This article discusses about the Electronic Medical Records. It also tells the purpose of the Medical Records. It also describes in detail the applications and the departments and how the Medical Records Systems are interfaced into a Network.

  • ELECTRONIC MEDICAL RECORDS DATA SAFETY AND SECURITY

  • Abstract:
    This article discusses in detail about the medico legal Issues that have to be analyzed before developing an EMR system. It also describes how the multiple data inputs from different counters can be integrated to form an effective EMR Systems. It also tells in detail the Medical Reports and the medico legal aspects that have to be followed by EMR system while issuing the Medical reports.

  • HOW THE PUBLIC SEES HEALTH RECORDS AND AN EMR PROGRAM MEICAL RECORDS AND HEALTH INFORMATION TECHNICIANS

  • Abstract:
    This article provides in detail about the job responsibilities of the Health Information Technicians. It also briefs about qualification and their training as per the current trends and needs.

  • ELECTRONIC MEDICAL RECORDS LESSONS FROM SMALL PHYSICIANS PRACTICES

  • Abstract:
    This article is a practical guide for physicians in a small group setting for planning and implementing the Medical Records System. It also tells in detail various processes involved in the maintenance and utilization of Medical Records. It also describes in detail about the capabilities that the EMR should have in effectively managing the data.

  • ELECTRONIC MEDICAL RECORDS A BUYERS GUIDE FOR SMALL PHYSICIANS PRACTICES

  • Abstract:
    This article provides guidelines to be followed for evaluating the purchase of an EMR for implementation in an enterprise. It also highlights the physicians perspectives while purchasing and implementing the EMR for practice. It also tells in detail the management perspective of deciding, designing and buying the EMR after analyzing the data needs for the practice and implementation of the Electronic Medical Records.

  • ELECTRONIC MEDICAL RECORDS MULTIPLE DATA INPUT OPTIONS

  • Abstract:
    This article describes in detail about the user-friendly Electronic Medical Records System for designing and monitoring data.

  • ELECTRONIC MEDICAL RECORDS AND CONTINUITY OF CARE RECORDS THE UTILITY THEORY

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The Medical Records Department forms the integral part of the patient care which comprises the Reception Counter, Outpatient registration service, Billing (Investigations) service and, Administration & Discharge Services. This department is headed by a qualified professional and managed by technicians and experienced and trained staffs. This department is organized and managed upon the concept that it exists for the benefit of the patients. Thus this department benefits the patient by being responsible for the completeness, accuracy, and availability of the medical records at all times.

Recognizing the needs, a medical records training course is conducted in Aravind Eye Care System. The trainees are given on the job training to meet the standards required for the management medical records department. Statistical reports based on the no. of patients treated and surgeries performed are generated every month. This report is sent to the governing board for future planning and control of activities.

For Further details contact

M. Rajakumar
Manager-Medical Records
Aravind Eye Hospital,
No1, Anna Nagar,
Madurai-625 020
raj@aravind.org


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MEDICAL RECORDS INSTITUTE :

The Medical Records Institute's (MRI) Mission is to promote and enhance the journey towards electronic health records, e-health, mobile health, and related applications of information technologies (IT).

MRI does this by :
  • Serving as an international forum for sharing knowledge, experience, and solutions
    • with the healthcare community at large, but especially with healthcare practitioners, as well as professionals in information system (IS) and health information management (HIM),
    • with vendors and vendor executives in regard to market strategies and technologies, and
    • with patients, patient advocates and agents, and the general public, regarding the management of personal health information.
  • Conducting international conferences, seminars, and other events, including Towards the Electronic Patient Record (TEPR), the annual conference on e-health and clinical IT issues.
  • Publishing the Institutes publication (Health IT Advisory Report) and Web sites
  • Supporting, coordinating, and leading the process of creating healthcare information standards.
  • Acting as a voice of conscience on aspects of confidentiality, security, and social impact.