Medical Record Department

2. PREVIEW
 OBJECTIVE
 INTRODUCTION, DEFINITION, PURPOSE
 PLANNING, ORGANIZATION AND STAFFING
 PHYSICAL FACILITIES
 PROCESSING OF RECORDS AND THEIR RETRIEVAL
 CODING AND INDEXING
 STORAGE AND RETRIEVAL
 REPORTS AND RETURN
 MEDICO LEGAL ASPECTS OF MEDICAL RECORDS

3. OBJECTIVES
DEFINE THE MEDICAL RECORD.
ENLIST THE PURPOSES OF MEDICAL RECORDS IN
RELATION TO PATIENT, DOCTOR, HOSPITAL AND
MEDICAL EDUCATION AND RESEARCH.
ENUMERATE THE STEPS IN PLANNING AND
ORGANIZATION OF MEDICAL RECORDS
DEPARTMENT IN A HOSPITAL.

4. INTRODUCTION
FIRST MEDICAL RECORD UNIT WAS ESTABLISHED IN
1667 AT ST. BARTHOLOMEW’S HOSPITAL, ENGLAND.
FOLLOWED BY PRACTICE OF MAINTAINING PATIENT
REGISTER IN PENNSYLVANIA HOSPITAL, USA IN 1792.
IDEA OF PROPER MEDICAL RECORDS IN FORM OF
STANDARDIZED INPATIENTS RECORDS CAME IN USA
FROM THE AMERICAN COLLEGE OF PHYSICIANS AND
AMERICAN COLLEGE OF SURGEONS IN THE LAST
QUARTER OF THE 20TH CENTURY.
IN INDIA BHORE COMMITTEE (1946) FIRST
STRESSED THE IMPORTANCE OF KEEPING MEDICAL
RECORDS.

5. REITERATED BY MUDALIAR COMMITTEE IN 1962.
SUBSEQUENTLY, HEALTH AND HOSPITAL REVIEW
COMMITTEE (JAIN COMMITTEE AND RAO
COMMITTEE) HIGHLIGHTED POOR STATE OF
MEDICAL RECORDS AND RECOMMENDED THE
ESTABLISHMENT OF A PROPER MEDICAL RECORDS
SECTION IN EACH HOSPITAL.
WITH TECHNICAL ADVANCEMENT, COMPUTERS ARE
EXTENSIVELY USED FOR RECORD GENERATION,
ANALYSIS AND RETRIEVAL.
MICROFILMING HAS ALSO BEEN INTRODUCED FOR
EASY STORAGE AND RETRIEVAL.

6. DEFINITION
🟔“A CLINICAL, SCIENTIFIC, ADMINISTRATIVE AND LEGAL
DOCUMENT RELATING TO PATIENT CARE IN WHICH ARE
RECORDED SUFFICIENT DATA WRITTEN IN THE SEQUENCE
OF EVENTS TO JUSTIFY THE DIAGNOSIS, WARRANT THE
TREATMENT AND RESULTS”.
🟔A MEDICAL RECORD IS-
 A DOCUMENT OF FACTS, WHICH CONTAINS
STATEMENTS BYTRAINED OBSERVERS OF CONDITION
FOUND AND THE APPLICATION AND THE RESULT OF
THE EXAMINATION AND THERAPY.
 IT ALSO INDICATES WHETHER OR NOT THE EFFORTS OF
THE DOCTORS, SUPPLEMENTED BYTHE HOSPITAL AND
RELATED FACILITIES ARE IN ACCORDANCE WITH THE
REASONABLE EXPECTATIONS OF THE PRESENT DAY’S
SCIENTIFIC MEDICINE.

7. 🟔MEDICAL RECORD AS SUCH IS A PACKAGE OF FORMS,
CASE SHEETS PLACED IN CHRONOLOGICAL ORDER
OF OCCURRENCE OF EVENTS AND INVESTIGATION
REPORTS. THE NATURE OF FORMS, LAB REPORTS
AND EVEN CASE SHEET RECORDINGS MAYVARY
FROM HOSPITAL TO HOSPITAL.
🟔CLASSICALLY THE MEDICAL RECORD OF A PATIENT
CONTAINS THE DOCUMENTS ARRANGED IN THE
FOLLOWING SEQUENCE:
ADMISSION FORM
CASE SHEET COMPRISING OF:
MEDICAL HISTORY CLINICAL FINDINGS
INVESTIGATION ORDERED TREATMENT ISSUED
PROGRESS REPORTS CONSENT FORM FOR SURGERY OR
SPECIALIZED PROCEDURES
ANESTHESIA CHECK RECORD, IF APPLICABLE NOTES ON SURGICAL/SPECIAL PROCEDURES
LAB REPORTS IN CHRONOLOGICAL
SEQUENCE OF THEIR ORDERING
FILMS ALONG WITH THEIR REPORTS

8. ⚫MEDICAL RECORDS FOR THE OUTPATIENTS SHOULD
ALSO BE PREPARED, PROCESSED AND STORED IN THE
SAME MANNER AS THE INPATIENT’S RECORDS.
⚫EACH INDIVIDUAL ATTENDING AN OPD IS GIVEN A
REGISTRATION NUMBER AND ALL THE MEDICAL
RECORDS ARE KEPT IN A FOLDER BEARING THE SAME
NUMBER.
⚫THE PATIENT IS ISSUED A TICKET/TOKEN BEARING
THE REGISTRATION NUMBER.
⚫THE INDIVIDUAL AT THE OPD RECORD ROOM SENDS
THE FOLDER TO THE APPROPRIATE DEPARTMENT ON
THE PRESENTATION OF TOKEN. THE FOLDER IS
DEPOSITED BACK AFTER THE VISIT.

9. PURPOSE
⚫THE MEDICAL RECORD IS INDISPENSABLE FROM THE
POINT OF VIEW OF THE PATIENT, THE DOCTOR, AND
THE HOSPITAL AND FOR MEDICAL EDUCATION AND
RESEARCH.
🞴THE PATIENT:
 IT SERVES TO DOCUMENT THE CLINICAL HISTORY OF THE
PATIENT’S ILLNESS AND COURSE OF THE DISEASE.
 IT SERVES TO AVOID OMISSION OR UNNECESSARY REPETITION OF
DIAGNOSTIC AND TREATMENT MEASURES.
 IT ASSISTS IN CONTINUITY OF CARE IN THE EVENT OF FUTURE
ILLNESS.
 PROVIDES NECESSARY INFORMATION FOR INSURANCE,
CONTRIBUTORY HEALTH SCHEMES OR FOR THE EMPLOYMENT
PURPOSES.

10. 🞴THE DOCTOR:
 ASSURANCE OF QUALITY, QUANTITY, AND
ADEQUACY OF DIAGNOSTIC AND THERAPEUTIC
MEASURES UNDERTAKEN.
 AN ASSURANCE OF ORDERLY CONTINUITY OF
MEDICAL CARE.
 EVALUATION OF MEDICAL PRACTICE.
 AN AID IN RESEARCH AND THE CONTINUING
EDUCATION OF HEALTH PROFESSIONALS.
 A PROTECTION IN THE EVENT OF LEGAL
QUESTION.

11. 🞴THE HOSPITAL:
 DOCUMENTTHE TYPE AND QUANTITY OF WORK UNDERTAKEN
AND ACCOMPLISHED.
 FURNISH PROOF OF THE TYPE AND QUANTITY OF CARE
RENDERED TO THE PATIENT.
 EVALUATE THE PROFICIENCY OF THE INDIVIDUAL DOCTOR, FOR
ADMINISTRATION AND CLINICAL PURPOSES.
 EVALUATE THE SERVICES OF THE HOSPITAL IN TERMS OF
ACCEPTED NORMS AND STANDARDS.
 PROTECTTHE HOSPITAL IN THE EVENT OF LEGAL MATTERS.
 SERVE AS AN ADMINISTRATIVE RECORD OF PERSONNEL
PERFORMANCE AND STAFFING NEEDS, FOR BUDGET
PREPARATION, JUSTIFICATION FOR PHYSICAL FACILITY
ALLOCATION AND UTILIZATION, FOR STATISTICAL DATA FOR
ADMINISTRATIVE USE AND EVALUATION, FOR ESTIMATING
EQUIPMENTAND SUPPLY UTILIZATION AND NEEDS.
 ASSIST IN FUTURE PROGRAM PLANNING.

12. 🞴MEDICAL EDUCATION AND RESEARCH:
 RECORDED OBSERVATIONS ARE THE BASIS
FOR ALL CLINICAL RESEARCH.
 FURTHER THE EDUCATION OF DOCTORS
AND OTHER HEALTH PERSONNEL.
 MEDICAL RECORDS SUPPLY PERTINENT
DATA FOR THE USE BY PUBLIC HEALTH
AUTHORITIES FOR CONTROL OF DISEASES.

13. PLANNING, ORGANISATION AND STAFFING
⚫ THE MAIN FACTORS THAT GOVERN THE ORGANISATION
OF WORK IN A MEDICAL RECORDS DEPARTMENT ARE:
 MEDICAL RECORDS SHOULD ALWAYS BE AVAILABLE
WHEN REQUIRED AND IN THE FORM THEY ARE
REQUIRED.
 ADEQUATE LIAISON SHOULD EXIST BETWEEN DIFFERENT
GROUPS OF STAFF USING MEDICAL RECORDS TO ENABLE
TO GIVE DUE CONSIDERATION TO MATTERS SUCH AS
DESIGN AND CONTENTS, METHOD AND STORAGE
AVAILABILITY, USE AND MOVEMENT OF RECORDS.
PROCEDURES SHOULD CAUSE PATIENTS THE MINIMUM
OF WAITING AND INCONVENIENCE.
 THE MEDICAL RECORDS COMMITTEE IS COMPOSED OF:
REPRESENTATIVE OF THE
CLINICAL DISCIPLINE
REPRESENTATIVE OF THE
NURSING STAFF
MEMBER FROM THE PATHOLOGY
SERVICES
ADMINISTRATOR

14. ORGANISATION
⚫ADMISSION AND INQUIRY OFFICE :
🖊ADMITTING OFFICE
🖊ADMISSION CHECK DESK
🖊CENSUS DESK
🖊INQUIRY OFFICE
⚫CENTRAL RECORD OFFICE:
🖊RECEIPT, CHECKING, ASSEMBLY AND STORAGE OF ALL
MEDICAL RECORDS OF DISCHARGED PATIENTS.
🖊DISCHARGE ANALYSIS AND STATISTICS.
🖊CODING OF ALL DIAGNOSIS AS PER INTERNATIONAL
CLASSIFICATION OF DISEASE.
🖊INDEXING OF ALL DISCHARGED PATIENTS BY DISEASE,
DOCTOR, ETC.

15. 🖊MAKING RECORDS AVAILABLE FOR MEDICO LEGAL
PURPOSE.
🖊ISSUE OF MEDICAL CERTIFICATES OF VARIOUS TYPES.
🖊SEND NOTIFICATION OF ALL COMMUNICABLE DISEASES
TO THE PUBLIC HEALTH AUTHORITIES.
🖊PREPARATION OF MONTHLY ABSTRACTS AND ANNUAL
STATISTICAL DETAILS.
🖊DEALING WITH INQUIRIES FROM LIFE INSURANCE
CORPORATION REGARDING DISEASE AND CAUSE OF DEATH
OF THE INSUREE.
🖊TRAINING OF ALL CATEGORIES OF PERSONNEL.
🖊STORAGE OF ALL TYPES OF FORMS USED IN THE
HOSPITAL.
⚫OUT PATIENT RECORD SECTION

16. KEEPING ALL THIS IN VIEW THE MEDICAL
RECORDS DEPARTMENT IS ORGANISED AS UNDER
OFFICE FOR MEDICAL RECORD
OFFICER (MRO) AND ASST. MRO.
ASSEMBLY AND
DEFICIENCY
CHECK DESK
INCOMPLETE
RECORD CONTROL
DESK
CODING AND
INDEXING
DESK
DISCHARGE
ANALYSIS AND
VITAL STATISTICS
DESK
DOCUMENT PROCESSING AREA COMPRISING OF:
RECORD STORAGE :
*ACTIVE RECORD STORAGE *INACTIVE RECORD STORAGE
❶
❷
❸

17. STAFFING (FOR 500 BEDDED HOSPITAL)
• MEDICAL RECORD
OFFICER
• MEDICAL RECORD
TECHNICIAN
• CLERKS
• PEON
• STATISTICIAN
1
4
3
1
1
ADMISSION AND INQUIRY
OFFICE
• ASST. MEDICAL
RECORD OFFICER
• MEDICAL RECORD
TECHNICIAN
• MEDICAL RECORD
ATTENDANT
• RECEPTIONIST
1
5
4
5

18. CENTRAL RECORD OFFICE
• ASST. MEDICAL
RECORD OFFICER 1
• MEDICAL RECORD
TECHNICIAN/ ASST.
MEDICAL RECORD
TECHNICIAN
• MEDICAL RECORD
ATTENDANTS
• STATISTICAL ASST.
8
8
5

19. PHYSICAL FACILITIES
⚫SPACE AND GENERAL FACILITIES REQUIREMENT:
a) ADMISSION AND INQUIRY OFFICE:
SPACE- 125-175 SQ. FT.
REQUIREMENTS-
 GENERAL OFFICE EQUIPMENT FOR THE STAFF.
 SEPARATE COUNTERS FOR ADMITTING CLERK, RECEPTIONIST
HANDLING INFORMATION AND BILLING CLERK SHOULD BE
PROVIDED.
 ADEQUATE WAITING SPACE, TOILET FOR STAFF, PATIENT AND
ATTENDANTS.
 TELEPHONE FACILITY FOR LOCAL CALLS AND STD MUST BE
MADE.

20. B) CENTRAL RECORD OFFICE
•
•
•
•
1) SPACE REQUIREMENT DEPENDS UPON THE SIZE OF THE HOSPITAL-
50 BED- 150-175 SQ. FT.
100 BED- 225-250 SQ. FT.
200 BED- 450-500 SQ. FT.
500 BED- 1000-1200 SQ. FT.
2) THIS AREA MAY BE ADEQUATE TO STORE INACTIVE MEDICAL
RECORDS ALSO. SPACE 120 SQ. FT. – 500 SQ. FT REQUIRED.
3) FULLY FUNCTIONAL COMPUTERS, AND PROPER OFFICE EQUIPMENT
FOR STAFF REQUIRED.
C) OUT PATIENT RECORD SECTION
⚫ SPACE- 2-3 SQ. FT. PER BED.
⚫ SEPARATE COUNTERS FOR THE REGISTRATION OF OLD AND
NEW, MALE AND FEMALE PATIENTS.
⚫ COUNTER SPACE- 24” WIDE, 40” HIGH.
⚫ WAITING AREA FURNISHED WITH CHAIRS AND
ANNOUNCEMENT BOARDS.

22. PROCESSING OF RECORDS AND THEIR FLOW
UPON ADMISSION OF A PATIENT
ADMITTING
OFFICE
ADMISSION
LIST
ADMISSION
RECORDS
COPY OF
ADMISSION
LIST
CENSUS
DESK
INFORMATION
DESK
NURSING
UNIT
CHECK
DESK
ADMISSION
INCOMPLETE
PATIENT
INDEX CARD
INCOMPLETE
RECORDS
CONTROL DESK

23. IMPORTANT ACTIONS PERFORMED BY THE
ADMITTING OFFICE ARE SUMMARIZED BELOW
a) ADMITTING OFFICE:
⚫ INITIATES PATIENT’S HOSPITALIZATION RECORDS.
⚫ ASSIGNS ADMISSION NUMBER.
⚫ PREPARES ADMISSION RECORD:
i. ADMISSION NUMBER
ii.IDENTIFYING DATA
iii.SIGNATURE OF AUTHORIZATION
• SENDS PATIENTTO NURSING UNIT.
• SENDS ADMISSION RECORD TO NURSING UNIT.
• SENDS COPY OF ADMISSION RECORD TO
ADMISSION CHECK DESK.

24. B) ADMISSION CHECK DESK:
⚫ RECEIVES ADMISSION ADVICE FROM ADMITTING OFFICE.
⚫ CHECKS PATIENT INDEX FOR PREVIOUS ADMISSIONS.
⚫ ENTERS THIS ADMISSION ON PATIENT INDEX CARD OF
PREVIOUS ADMISSION.
⚫ IF NO PREVIOUS ADMISSION, MAKE NEW PATIENT INDEX CARD.
⚫ SENDS INDEX CARD TO INCOMPLETE RECORD CONTROL DESK.
⚫ SENDS RECORDS OF PREVIOUS ADMISSION TO NURSING UNIT.
⚫ PREPARES RECORD FOLDER WITH ADMISSION RECORD AND
NAME AND SENDS IT TO COMPLETE RECORDS CONTROL DESK.
⚫ MAKES ENTRIES TO ACCESSION REGISTER.
C) CENSUS DESK:
⚫ PREPARES ADMISSION LIST FROM ADMITTING OFFICE.
⚫ COLLECTS DISCHARGE PATIENT RECORDS FROM NURSING
UNITS DAILY.
⚫ PREPARES DISCHARGE LIST.
⚫ PREPARES CENSUS REPORTS.

25. MOVEMENT OF MEDICAL RECORDS
UPON DISCHARGE OF A PATIENT
NURSING UNIT
DISCHARGED
RECORDS
CENSUS
DESK
ASSEMBLING
AND DEFICIENCY
CHECK DESK
ASSEMBLED
DISCHARGED
RECORDS
COMPLETE
DISCHARGED
RECORDS
INCOMPLETE
DISCHARGED
RECORDS
CODING AND
INDEXING
DESK
DISCHARGE
ANALYSIS DESK AND
VITAL STATISTICS
COMPLETE
PATIENT INDEX
CARDS
COMPLETED
RECORDS
FILES
ADMISSION
CHECK DESK

26. CODING AND INDEXING
⚫CODING:
⚫IN EACH MEDICAL RECORDS INTERNATIONAL
CODE NUMBER IS ASSIGNED TO THE DIAGNOSIS
BASED ON “INTERNATIONAL CLASSIFICATION OF
DISEASE” ISSUED BY THE WORLD HEALTH
ORGANISATION.
⚫THIS IS TO BRING ABOUT ACCURACY AND
UNIFORMITY IN THE REPORTING OF THE DISEASES
BY THE VARIOUS HOSPITALS.

27. ⚫ INDEXING:
a) ALPHABETIC/ MASTER INDEX: INDEXING BASED ON PATIENT’S
NAME SEQUENCED ALPHABETICALLY. THE PRIMARY PURPOSE OF
A NAME INDEX IS TO PROVIDE ENTRY INTO THE FILING SYSTEM
AND FINDING OUT MEDICAL RECORD FOR A PATIENT.
b) DISEASE INDEX: DISEASE INDEX IS A CATALOGUE OF CARDS
3” X 5” OR 5” X 8”, MAINTAINED TO FIND OUT GROUPS OF
CLINICAL RECORDS OF PATIENTS HAVING THE SAME DIAGNOSIS.
BESIDES PATIENT’S IDENTIFICATION DATA, AGE, GENDER, RESULT
OF TREATMENT AND COMPLICATION MAYALSO BE MENTIONED.
c) OPERATION INDEX: IT IS A CATALOGUE CONTAINING THE
DETAILS OF PATIENTS WHO HAVE UNDERGONE THE
OPERATIONS.
d) PHYSICIAN’S INDEX: CATALOGUE CONTAINING THE DETAILS OF
ALL PATIENTS TREATED BY PARTICULAR PHYSICIANS. ANALYSIS
OF SUCH RECORDS MAY BE UTILIZED FOR EVALUATING THE
PERFORMANCE OF A PHYSICIAN.
e) UNIT INDEX: DETAILS OF ALL THE PATIENTS TREATED IN A
PARTICULAR UNIT ARE INDEXED. THESE RECORDS MAY
ULTIMATELY BE UTILIZED TO EVALUATE THE PERFORMANCE OF A
PARTICULAR UNIT.

28. STORAGE AND RETRIEVAL
⚫STORAGE: THE FOLLOWING FACTORS ARE
CONSIDERED FOR AN EFFECTIVE FILING SYSTEM:
a) COMPACTNESS TO REDUCE PHYSICAL EFFORT AND
COST OF STORAGE SPACE.
b) ACCESSIBILITY FOR SPEEDY LOCATION AND
IDENTIFICATION.
c) SIMPLICITY FOR UNDERSTANDING OF ALL
CONCERNED.
d) ECONOMICAL BOTH IN THE COST OF INSTALLATION
AND OPERATION.
e) ELASTICITY TO EXPAND ACCORDING TO FUTURE
REQUIREMENT.
f) TRACER SYSTEM FOR DOCUMENT IN CIRCULATION.

29. SYSTEMS OF FILING-
DECENTRALIZED
SYSTEM
UNDER THIS
INPATIENT
SYSTEM,
AND
OUTPATIENT
DEPARTMENTS HAVE THEIR
OWN INDIVIDUAL
RECORDS AND FILE THEM
INDEPENDENTLY WITHIN
THEIR DEPARTMENTS. THIS
SYSTEM IS LABOUR
AND THE
COST ARE
INTENSIVE
OPERATING
HIGHER.
CENTRALIZED
SYSTEM
IN THE CENTRALIZED
MEDICAL
ARE
IN
SYSTEM,
RECORDS
CENTRALLY
MEDICAL
DEPARTMENT.
FILED
THE
RECORD
THIS
MORE
SYSTEM IS
EFFICIENT, PROVIDES
BETTER CONTROL AND IS
FOLLOWED IN MOST
HOSPITALS.

30. METHODS OF FILING-
 NUMERICAL METHOD
 ALPHABETICAL METHOD
 CHRONOLOGICAL ORDER
 TERMINAL DIGIT SYSTEM
 MID DIGIT SYSTEM

31. S.
No
DATE IP FILE TYPE
No
PATIENT
NAME
DATE OF
DISCHARGE
DIS-
CHARGE
TYPE
RESIDENT
SIGN
MRD
CLERK
SIGN
MLC LAMA/
ABSCONDED
GENERAL DISCHARGED/
ETC.
DEPARTMENT UNIT/CONSULTANT

32. FILING PROCEDURES-
⚫TYPES OF FILES-
⚫USEFUL TO USE FILES OF DIFFERENT COLOURS
FOR DIFFERENT YEARS FOR EASY RETRIEVAL AND
IDENTIFICATION.
⚫FILING : THREE TYPES OF FILING PROCEDURE IN
USE
⚫ VERTICAL-
⚫ SUSPENDED
⚫ HORIZONTAL

33. MICROFILMING OF MEDICAL RECORDS
⚫ IN LARGE TEACHING HOSPITALS DUE TO CONSTRAINTS OF
SPACE MICROFILMING IS RESORTED TO.
⚫ ADVANTAGES OF MICROFILMING :-
⚫ SAVING OF SPACE BY 90%.
⚫ EASY ACCESSIBILITY.
⚫ PROTECTION.
⚫ ELIMINATION OF MISFIRING.
⚫ SAVING OF TIME & MANPOWER.
⚫SPECIAL EQUIPMENT REQUIRED INCLUDES MICROFILMING
CAMERA,PROCESSORS, VIEWING MACHINES, DUPLICATING & XEROX
MACHINES, MICROFILMING ROLLS, FIXER & DEVELOPER AND
MICROFILMING TECHNICIANS.

34. COMPUTERISATION OF MED RECORDS
⚫TECH ADVANCEMENTS & DECREASING COST OF
COMPUTERISATION HAVE REVOLUTIONISED THE
MED RECORD SYSTEM.
⚫POSSIBLE TO STORE TEXT & ALL TYPES OF
IMAGES VIZ X-RAYS, CAT SCAN, MRI.
⚫BY NETWORKING SYSTEM ACCESS CAN BE
PROVIDED TO DRs, NURSES, TECHNICIANS &
ADMINISTRATOR WHILE MAINTAINING
CONFIDENTIALITY.

35. RETREIVAL OF MEDICAL RECORDS
⚫USUALLY REQD FOR
⚫FOLLOW UP OF PATIENTS.
⚫ADMISSION TO WARD/ CASUALTY FOR
OBSERVATION.
⚫RESEARCH WORKERS FOR ACADEMIC PURPOSES.
⚫MEDICAL REIMBURSEMENT.
⚫PRODUCING IN COURT OF LAW.

36. REPORTS AND RETURNS
⚫BASIC PURPOSE OF REPORTS ARE:
⚫EVALUATING THE QUALITY OF CARE.
⚫LOCATING THE DEFI IN :
⚫ MEANS – STAFF, PHYSICAL FACILITIES, EQPT INCL
PLANTS & MACHINES.
⚫ METHODS – OPERATING POLICIES & PROCEDURES.
⚫ END RESULT- OUTCOME OF BENEFITS DERIVED BY THE
COMMUNITY FROM THE HOSP.
⚫EFFECTIVENESSOF HOSP ADMINISTRATION.
⚫PREVENION OF DISEASES

37. TYPES OF REPORTS
⚫TYPES OF REPORTS & FREQUENCYWILL VARY
WITH TYPE OF HOSPITAL & ADM REQMTS.
⚫REPORTS GENERATED DAILY, WEEKLY,
FORTNIGHTLY, MONTHLY, QUARTERLY, SIX
MONTHLY OR ANNUALLY DEPENDING ON
REQMT .
⚫REPORTS GENERALLY PERTAIN TO :
⚫VITAL STATS.
⚫ADT(ADMISION, DISCHARGEAND TRANSFER
ANALYSIS.
⚫GENERAL HEALTH STATS.

38. ⚫REPORTS RELATED TO HOSP BEDS
⚫ DAILY CENSUS
⚫ MAX PATIENTS ON ANY ONE DAY.
⚫ MIN PATIENTS ON ANY ONE DAY.
⚫ DAILYAVG.
⚫ BED OCCUPANCY RATE.
⚫ TOTAL PATIENT DAYS CARE.
⚫ BED TURN OVER INTERVAL.
⚫ ADMISSION
⚫ DAILY ADMISSION.
⚫ DAILY ADMISSION UNIT/SPECIALITY WISE.
⚫ TOTAL ADMISION OVER A PERIOD.
⚫ PATIENTS DISTRIBUTION BY AGE, SEX, RELIGION
&REGION

39. ⚫ DISCHARGES
⚫ DAILY DISCHARGES.
⚫ TOTAL PATIENTS DISCHARGED OVER A PERIOD.
⚫ DAYS OF CARE TO THE PATIENTS DISCHARGED.
⚫ AVG LENGTH OF STAY.
⚫ DEATHS
⚫ DAILY NUMBER OF DEATHS.
⚫ TOTAL DEATHS OVER A PERIOD.
⚫ TOTAL DEATHS OVER 48 HRs.
⚫ TOTAL DEATHS UNDER 48 HRs.
⚫ NET DEATH RATE.
⚫ GROSS DEATH RATE.
⚫ FOETAL DEATH RATE.
⚫ MATERNAL DEATH RATE.
⚫ INFANT DEATH RATE.
⚫ POST OPERATIVE DEATH RATE.
⚫ ANAESTHETIC DEATH RATE.

40. ⚫ WORK LOAD STATITICS.
⚫ TOTAL NO OF OUTPATIENTS.
⚫ NEW CASES.
⚫ REPEAT CASES.
⚫ TOTAL NO OF OPERATIONS.
⚫ TOTAL NO OF X RAY & OTHER RELATED INV.
⚫ DEPT WISE WORKLOAD STATS.
⚫ HOSP CARE EVALUATION STATS
⚫ POST OPERATIVE INFECTION RATE.
⚫ POST OPERATIVE COMPLICATION RATE.
⚫ CAESARIAN SECTION RATE.
⚫ AUTOPSY RATE.
⚫ CONSULTATION RATE.
⚫ RATE OF NORMAL TISSUE REMOVED.
⚫ % OF DISAGREEMENT BETWEEN FINAL & PATHOLOGICAL DIAGNOSIS.
⚫ GROSS RESULTS OF TREATMENT, i.e PATIENTS RECOVERED, IMPROVEDOR NOT
RELIEVED.

41. MEDICO LEGAL ASPECTS OF MRD
⚫ MED REC PROPERTY OF THE HOSP, NEITHER PATIENT NOR DR.
⚫ AS A PERS DOCU, CONFD & PRIVILEDGED DOCU, CANNOT BE DIVULGED W/O
PATIENT CONSENT EXCEPT UNDER PROCESS OF LAW, AS AN IMPERSONAL DOCU,
CAN BE USED FOR EDN & RESEARCH.
⚫ A CLINICALAS ALSO LEGAL DOCU, HENCE IT SHOULD FULFILL THE FWG
CRITERIA :
⚫ COMPLETE :MUST CONTAIN SUFFICIENT DATATO IDEN PATIENT, JUSTIFY
DIAGNOSIS, WARRANT TREATMENT & OUTCOME & OTHER ROUTINE & SPL REC.
⚫ ADEQUATE : NOT SKETCHY BUT DETAILED, MUST CONTAIN ALL NECY FORM &
ALL RELEVANTCLINICAL INFO.
⚫ ACCURATE: SUITABLE FOR QUANTITATIVE ANALYSIS.
⚫ LEGIBLE : EASILY DECIPHERABLE WITH PRINTED NAMES & DESIGNATIONSOF
ALL SIGNATORIES.

42. INDIAN EVIDENCE ACT 1872 AS AMENDED
⚫REQUIRES MED REC TO BE PRODUCED BEFORE
COMPETENT AUTH IN FWG CONDITIONS:
⚫IN COURT OF LAW.
⚫LIC OF INDIA.
⚫INCOME TAX.
⚫PATIENTS WILL.
⚫QUERIES REGARDING BIRTH OR DEATH.

43. RETENTION OF MED REC
⚫FACTORS AFFECTING RETENTION PERIOD :
⚫NEED OF PATIENT.
⚫MEDICO LEGAL ASPECT.
⚫EDN & MED RESEARCH.
⚫GEN GUIDELINES:
⚫OPD REC
⚫IPD REC
⚫MLC
5 YRS
10 yrs
PERMT
⚫NOTE: IN TEACHING MED COLLEGE & HOSP
RECORDS KEPT PERMANENTLY.

44. Any
Questions?