2. MEDICAL RECORDSdepartment

Dr Kithsiri Edirisinghe MBBS, MSc, MD ( Medical Administration)

Cert. IV in TAEMaster Trainer ( Australia)

Session outcomes

Insight to Medical Record Department in Hospitals

INTRODUCTION

• 1000 bedded general Hospital.• For the management and systematic maintenance of

Medical Records in the Hospital a Medical Record Department is an essential component. m

• Staff Medical Record Officer Medical Record Technicians Medical Record Clerks Medical Record Attendants

• The Reception, Enquiry and Admission office functions round the clock under the charge of Medical Record Officer.

• Inpatients records and out patients records are maintained in the Medical Record Department.

• Registration work of OPDs are also managed by the Medical Record Officer.

• Statistical information about the functioning of OPDs is regularly submitted by the Medical Record Officials in the Medical Record Deptt.

Description

DEFINITIONOF MEDICAL RECORD

• Medical Record of the patient stores the knowledge concerning the patient and care given .

• It contains sufficient data written in sequence of occurrence of events to justify the diagnosis, treatment and outcome.

• In the modern age, Medical Record has its utility and usefulness and is a very broad based indicator of patients care.

PatientsDoctorsHospitalTeachersStudentsFor research workNational & International agencies

Benefits of the MRD

ORIGIN :-

• The inpatient Medical Record in originated at the admission office based on the admission order made by the clinician or at Casualty Deptt. and various OPDs of the Hospital.

• Outpatient medical records originates from the registration desk of the OPD and clinic services

Process flow of Medical Records

Central Admission Office Wards

Medical Record Department

1. Assembling

2. ADMN. &

Discharge analysis

3. Storage Area

Afetr completion of Reccords

Hospital statistics prepared Monthly/Yearly

Medical Record is filled for perusal of Patients/claims/research purposes.

OPD and Clinic registration department

FILING OF MEDICAL RECORDS

• The inpatients Medical Record is filed by the serial numbers assigned at central Admitting Office.

• The Record is bound in bundles 100 each and are kept year wise according to the serial number

• OPD and clinic services are also filed in seriol numbers

• Other services too are registered , preventive , investigative and curative care

RETENTION OF MEDICAL RECORD

• The policy is to keep indoor patient Records

for 10 years

• The OPD registers for 5 years

• The record which is register for legal purposes

in Maintained for 10 years or till final decision

at the court of Law.

OUTPATIENT DEPARTMENT

• There is a decentralized system for registration of OPD patients.

• Patients are registered at different registration counter specialty wise.

• Clerks posted for registration have been made responsible for the preparation and submission of statistical data of their respective OPD

FUNCTIONS OF MEDICAL RECORD DEPARTMENT

1. Daily receipt of case sheets pertaining to discharge, 2 A.M. an

expired patients from various wards, there checking and

assembly.

2. Daily compilation of Hospital census report.

3. Maintains & retrieval of records for patient care and research

study.

4. Completion and Procession of Hospital statistics and

preparation on different periodical reports on morbidity and

mortality.

5. Online registration of vital events of Birth & Death

FUNCTIONS OF MEDICAL RECORD DEPARTMENT

6. Issuing Birth & Death certificated upto one year.7. Dealing with Medico Legal records and attending

the courts on summary.8. Arrangement & Supervision of enquiry and

admission office.9. Arrangement & Supervision of OPD registration10. Management of disability boards.11. Management of Medical Examination12. Management of Mortality Review Committee

Meetings (Twice month)13. Assistance to Hospital Administration in various

matters.

SYSTEM OF COLLECTION, COMPILATION AND FORWARDING STATISTICAL REPORTS

• Medical Record officials posted for registration of OPD patients have been made responsible for the preparation and submission of statistical data on their OPDs.

• One Medical Record Officer visits to the wards daily and collects the disease wise reports of the discharged patients and submits the same in the medical record section. One official of the Medical Record Section classifies the data according to the different performa. Following reports are compiled forwarded to various departments.

1. National list for Tabulation of Morbidity and Mortality (IMMR)2. Monthly Health Bulletin3. Monthly report of Polio Cases4. Monthly report of GWEP5. Report of cataract operations6. Report on the notifiable disease 7. Monthly report of communicable diseases8. Monthly report of MNT (Paed & Gynae)

10. Monthly report of AIDS cases11. Monthly report of Anti Rabic cases12. Monthly report of STD13. Monthly report of cases & Death due to snakebite.14. Monthly report of Sex Ratio (Birth Death)15. Monthly report of Malaria cases.16. Monthly report of Deliveries17. Monthly report of Family Planning18. Monthly report of Medicine, DRT, Polio, TT19. Monthly report of Leprosy cases20. Weekly report of Polio21. Weekly report – Statement showing the no. of cases treated (OIVS)22. Weekly report of National Programme for surveillance of communicable

disease (DHO)23. Weekly report of Dengue fever cases24. Weekly report of Pyogenic Meningitis25. Weekly report of Gastro-enteritis, Cholera26. Daily report of Noticeable Disease under surveillance.

Clinical Coding

DATA EXTRACTION FOR CLINICAL CODING

• Objective

• To build on the participant’s experience in extraction of data from medical records, focussing on identifying data items of particular importance for morbidity & mortality coding, and coding quality

Lesson Plan• 1. Sources of data for coding• 2. Responsibilities• 3. Data abstraction• 4. Main diagnosis • 5. Accurate coding• 6. Quality assurance in morbidity data collections– Coding quality– Source documentation quality

• 7. Auditing of source documents

Introduction

• For clinical coding to be as valuable as possible it is critical the coder has:

• access to a comprehensive and accurate medical record,

• the skills to extract all pertinent data for coding,

• access to clinicians to ask questions and seek clarification

Sources of clinical data for coding

• Morbidity coding is usually performed after the patient has left the hospital

• Information to be coded is abstracted from the whole medical record

• The coding process has two parts:– analysis of the medical record– allocation of correct codes

Responsibilities• Coders

– reviewing the entire record – verifying the record contains appropriate documentation– coding specifically and accurately the conditions or diagnoses

treated or affecting a patient’s care– referring the record to clinicians for clarification

• Clinicians– recording accurate and complete clinical documentation in the

medical record– recording all diagnoses on the front summary sheet– identifying the main condition

7 Steps for Abstraction of Relevant Data from the Medical Record

1. Read the front sheet of the relevant admission2. Read the discharge summary or other correspondence3. Compare any diagnosis in the discharge summary/letter

with that recorded as admission or provisional diagnosis and with that recorded on the front sheet

4. Read the history and physical examination5. Identify relevant procedures6. Review the entire record7. Clarify information with the clinician if necessary

When to consult with the Medical Officer

• If conflicting, incomplete or ambiguous information is found or if documentation is unclear

• Check with the attending medical officer, the medical officer who filled in the front sheet

or the radiologist or pathologist

• Coding should be a cooperative and collaborative effort between the clinician and the coder

What to code?

• Main condition or principal diagnosis

• +/- other or secondary conditions

• +/- procedures, operations and interventions

Selecting the Main Condition or Main Diagnosis

• Consider those conditions which:– caused the patient to be admitted– were treated and/or investigated during the acute

admission– affected the treatment given and/or the length of

stay– developed during the admission

• The main diagnosis can then be selected from these conditions

WHO definition of main diagnosis or main condition

• …the diagnosis established at the end of the episode of care to be the condition primarily responsible for the patient receiving treatment or being investigated…that condition that is determined to have been mainly responsible for the episode of health care...

• (ICD-10, volume 2, 4.4)

Secondary diagnosis / Other condition

a diagnosis that either co-exists with the main diagnosis at the time of admission, or which appears during the episode of care

complications and comorbidities

What is a comorbidity?

• A disease that accompanies the main diagnosis and requires treatment and additional care, in addition to the treatment provided for the condition for which the patient was admitted

What is a complication?

• A disease that appears during the episode of care, due to a pre-existing condition or arising as a result of the care received by the patient

Problems with determining the main diagnosis

• absence of a clear-cut main diagnosis• minor condition recorded as main diagnosis• diagnosis recorded in general or ill-defined terms• uncertainty of diagnosis• symptoms or signs listed as the main diagnosis• no diagnosis recorded

What is accurate coding?• each diagnosis must be assigned its correct code

(or codes)• Codes should be as complete as possible• all diagnoses affecting the care of the patient

and procedures performed during the episode of care should be assigned codes

• codes must be sequenced correctly with the main diagnosis listed first

• morbidity coding rules in volume 2 of ICD-10 should be followed

To ensure accurate coding:

• Coders should be familiar:– with anatomy and physiology of the human

body– with medical terminology so that disease

descriptions can be interpreted into ICD language

– with disease processes and medical practice to be able to understand etiology, pathology, symptoms, signs, diagnostic procedures, etc.

To ensure accurate coding:

• Coders should also have:

– an understanding of the content of the medical record

– experience with the actual medical records so specific details can be located

– detailed knowledge of the coding system being used

– an understanding of data reporting requirements

Quality Assurance in Morbidity Data Collection

• Increasing use of morbidity data leads to an increasing concern for the reliability of data

• Sources of error in MR information systems:– documentation of the patient’s care and

condition during the episode in hospital– coding the information in the medical record– processing the coded information

Coding accuracy

• Three dimensions of coding accuracy:

– accuracy and completeness of individual codes– accuracy of the totality of codes to ensure they

reflect all diagnoses treated; and – accuracy in the sequence in which the codes are

recorded, particularly in selection of the main condition

Common sources of coding errors:• Clerical– careless mistakes, transposing numbers

• Judgmental– wrong subjective decisions taken

• Knowledge– mistakes due to lack of coder knowledge

• Systematic– errors in the process of coding or problems

with the environment in which coders work• Documentation– incomplete, inaccurate, ambiguous,

conflicting– illegible

•

•

What affects coding quality?– Errors in the choice of code– Lack of feedback– Casemix – number and type of cases to be

coded– Use of coding conventions and coding rules– Lack of clarity in coding books– Changes in coding practice

What affects coding quality?– Documentation – Incomplete medical records– Availability of records– Coder/clinician communication– Data entry– System edits– Forms design

What affects coding quality?

– Workload– Education– Human resources– Environment– The individual– Reference material

Coder/Clinician Communication is important for:

• Team approach to achieve complete and accurate documentation

• Clinician’s responsibility to record accurate diagnoses and procedures and document fully the episode of care

• Coder’s responsibility to review and use documentation; use standard definitions, use their skill and knowledge of the current coding system

Why has communication traditionally been lacking?

• lack of understanding of coding as a process and of the importance of coded data

• clinicians do not feel a sense of ownership of the classification system or the fact that the coded data reflect their work

• coders feel intimidated about asking questions, seeking advice or asking about clinical issues

Ways of improving communication• encourage clinicians to attend coding meetings in

the clinical coding/medical record department• request coders attend clinician meetings

conducted by each clinical specialty• organise coding service to allow coders to

specialise• clinician involvement in the development of

coding guidelines• education for clinicians and coders

Five steps for quality control of coding:

• establishment of objective criteria for coding quality

• measurement of performance• analysis of problems identified• action taken to correct identified problems• review of performance after corrective

action

Auditing

• To inspect and verify

• To determine the degree of accuracy in ICD coding based on coding rules and coding conventions

Audit principles

• Coder A (original coder)

• Coder B (auditor)

• Coder C (independent adjudicator)

Sample selection

• Period of audit

• Audit sample – Random sample – Target sample

Sample selection

• Random– representative of morbidity database– suitable for benchmarking– only some records will have errors– 5% sample size recommended– random number generator or table

Sample selection

• Target– defined by coder-in-charge or auditor– cases selected because of known or suspected

errors or difficult cases or because a new coder has started work

– only some records will have errors

Retrieving and preparing clinical records

• Retrieve original record

• Temporarily remove or obscure coded data

Recoding process

• Coder B– Recodes each record– Assigns error categories if errors found – tries

to determine what has caused the error

• If there is a dispute, Coder C– Recodes each record– Assigns error categories

Coder C recoding

• Recodes record ‘blind’

• Discusses code differences with Coder A and Coder B

• Make final decision about correct codes

• Assign errors to error categories

Examine and analyse results

• Need to develop a form for reporting of results– Scoring Tool form– Summary Data form

• The summary data forms the basis for a report about coding quality and can be used to compare data at different time periods.

Questions to ask when reviewing coding:

• Is the main diagnosis correctly identified?• Are all secondary diagnoses coded?• Are all diagnoses coded?• Are all diagnoses and procedures coded

correctly?• Have the codes been transcribed or data

entered correctly?

Coder competency is influenced by:

– Knowledge– Skill– Attitude– Behaviour– Experience

Ways of improving coder competency:

– Training (initial education and training)– Continuing education (ongoing education)– Reference materials– Coder peer support– Recognition of competence

Documentation

• Key elements - accurate, complete, timely, legible

• Source document - quality of the clinical record

• Documentation errors - Main condition, other diagnoses, operations

Documentation requirements – what clinical staff should write:

• Do write:• Date and time of entries• Purpose of entry eg. admission note, planned review,

asked to see patient, end of shift report• History and examination findings – be succinct!• Assessment of current situation• Plan for what needs to happen now and later• Print name and sign, include position, contact details for

every entry• Use only approved abbreviations• Complete discharge summary and front sheet

Documentation requirements – what clinical staff should not write:

• Don’t write:• A repeat of clinical details previously written –

this wastes your’s and other’s time and wastes paper

• Anything unpleasant, rude, or critical of either relatives, patients or staff

• Anything that is not true or does not reflect reality

• Backdated entries or changes to existing entries

Documentation policy• Need to ensure there is a documentation policy in place so

clinical staff know the requirements for documentation and can be assessed against those requirements

• See sample Guidelines for Medical Record and Clinical documentation

• What are the requirements for clinical documentation in your country? Are these written in a policy? Do clinical staff know what they should be documenting?

Ways of improving documentation• 1. record design - well structured, standard order,

complete, cover the scope of the care

• 2. forms design - elicit information needed for patient care and coding, easy to use, legible, designed in conjunction with health professionals who will use them

• 3. education– clinicians - documentation is as much part of

clinical care as direct patient contact– management - channel resources and

enthusiasm into this area

Assessment of documentation quality

• Conduct a regular audit of documentation quality

• Use standard data collection form – can compare results over time to determine improvements

• Consider the data items that must be presented in a documentation quality report and the format in which they should be recorded

• See example of documentation audit sheet

Process for a documentation audit• Complete at least 1 audit per year

• Select a random sample of 5% of discharges in a given month, or at least 10 records (whichever is the higher number) should be audited

• Select records from a printout of the Medical Record or Bedhead Ticket numbers of all discharges in a month ordered by discharge date. Select every 20th medical record number on list for audit. If record selected is not available, the next record on the list should be selected

• The audit relates to documentation within the selected admission only

Medical Record documentation Assessment

• In country groups, using the sample medical records brought with you, complete a documentation audit for each record.

• What are the major problems you have found?

• What are some way that these might be addressed?