QUALITY ASSURANCE IN MEDICAL
RECORDS DEPARTMENT OF A HOSPITAL
SUBMITTED BY:
Dr.Richa Rattan
MBA Hospital Admn
Roll no.-14
Guided by: Dr.Puneet kapoor
QUALITY ASSURANCE IN MEDICAL
RECORDS DEPARTMENT
SUBMITTED BY:
Dr.Richa Rattan
MBA –Hospital Admn
Roll no-14
Guided by:
Dr,Puneet Kapoor
DEFINITION OF A MEDICAL RECORD-
A clinical, scientific, administrative and legal
document related to patient care in which is
recorded sufficient data in the sequence of
events to justify the diagnosis and warrant
the treatment and the end results.
(Mc Gibony)
HISTORICAL DEVELOPMENT OF MEDICAL
RECORDS
First medical record dates back to 1667 of 1st Bartholomew’s Hospital
England
Maintenance of patient’s registration in Pennysylvania-USA-1752
Indexing of diseases in New York in 1862
Record maintenance was emphasized by American College of surgeons & American College of
physicians in the first quarter of 20th century
CONT..
Association of medical records of librarstat was formed in 1928
Bhore committee recommended maintenance of medical records in India
in 1946
It was reiterated by Mudaliar committee 1962 in India
Computerized medical records keeping in present era
ROLE AND IMPORTANCE OF MEDICAL RECORDS
To the patients
To the clinicians
To the hospital and hospital administration
To the public health authorities
To medical education and research
Medico-legal cases
MEDICAL RECORDS
DEPARTMENT
FUNCTIONS OF MEDICAL RECORD DEPARTMENT
Functions of MRD
Assembling of the medical records
Quantitative
analysis of the
records
CODING
INDEXING
Deficiency check
Numbering and Filing
Storage and
retention of
records
Completion of
incomplete
records
Retreival of
records
OTHER FUNCTIONS-
• Analysis of records and generation of statistics
• Submitting the periodic reports(births/deaths notifications,
notification of communicable diseases, morbidity
statistics)as required by the health statistics
• Daily ward census and monthly bed utilization statistics
• Production in the courts of law, when summoned
QUALITY ASSURANCE OF MEDICAL RECORDS
Quality of services is defined as “the totality of features
and characteristics of service that bear on its ability to
satisfy the stated and implied needs of the client.”
-Client users (internal and external) who have to be satisfied
are-
1.The patient
2.The clinicians
3.The management
4.The health authorities
5.The legal authorities
6.The insurance authorities
WHAT ALL IS REQUIRED TO SATISFY ALL
THE CLIENTS?
1.Quality of structure 2.Quality of
Process
1.QUALITY OF STRUCTURE-
A. Location and Layout
Should be located close to the admitting area, outpatient
department, emergency room and the business office.
Or
Close to or on the corridor leading to the doctor’s lounge.
LOCATON OF A MEDICAL RECORDS
DEPARTMENT
B. Space Requirement-
(i)Admission & Enquiry office: Space of 125-175sq feet is recommended.
(ii)Central Record Office: Space of 2-3sq feet per bed is sufficient
(iii)OPD record section: Average of 2-3 sq feet per bed space is required
(iv) Offices for the medical records officer and assistant medical officer
(v) Space for sectional supervisors
(vi) Work area for record processing, assembling, numbering, indexing, utilization
review, discharge analysis, work processing etc.
(vii) Record storage for active and inactive files
(vii) Space for copier
CONT..
(viii) A room for medical staff to complete records, study cases with tables, chairs, dictating equipments
(ix) An area with bookcases or shelves to house the medical records
(x) Transcription area with space for the central recording equipment, tables, computers etc for medical secretaries to transcribe information
(xi) Space for master patient index depending on the kind of system used, for immediate identification of current and past patients
(xii)Storage area for medical record carts
(xiii) Supplies storage space for unused medical record file folders, forms.etc
(xiv) Staff facilities
(xv) An electrically operated dumbwaiter, if the MRD is on two floors
B.STAFFING-
- A hospital with 300 beds and above should have an Asst Medical records
officer and that with 500 beds a Medical records officer(MRO) as in charge of
the department.
- Todd Wheeler’s Staffing scale-
- Manpower requirement for medical records Department:
BEDS 100 200 300 400
500
STAFF 4 6 8 10
12
FOR EXAMPLE.-
STAFF REQUIREMENT RECOMMENDED FOR A 500
BEDDED HOSPITAL AT A SCALE OF:
1.Medical record officer 01
2.Medical record technician 04
3.Clerks 03
4.Peon 01
5.Statistician 01(part time)
Additional staff -
1.Admission and enquiry office-
•Assistant medical record officer 01
•Medical record technician 05
•Medical record attendant 04
•Receptionist 05
CONT..
2.Central record office- • Assistant medical record officer 01
• Medical record technician 08
• Medical record attendant 08
• Statistical assistant 01
C.EQUIPMENT AVAILABILTY
a. Computerization/Microfilming/Manual Storage of hard copies
b. The storage racks/almirahs- type size,quantity depending upon the volume of records being generated
c. Type writers
d. Data storage devices
e. Printers
f. Camera
g. File cabinets
h. Photo copiers, Fax machines, Phone, etc
i. Instruments and stationary items like poker,staplers,spiral binding machine,laminating machines etc
D.ENVIRONMENT CONTROL- Control of dust, humidity, pests and availability of adequate
light/ventilation
2.QUALITY OF PROCESS
1.Availability of Quality manual- Should contain in a documented form, the policies and procedures essential to meet the information needs of the various
organisations
2 .Standard Operating Procedures-(SOP)-
Procedures governing every activity of the department and should be reviewed once a year/earlier .
3.DATA MANAGEMENT
4.MEDICAL RECORDS COMMITTEE(MRC)-
To frame and review various policies and procedures about efficient functioning of the department and
periodic monitoring of the quality of records generated.
5.PATIENT’S RECORDS-
Complete-sufficient data to identify the patient, justify diagnosis, treatment, follow up and outcome
Adequate- with all necessary forms, all clinical information, and
Accurate- capable of quantitative analysis
6.STANDARDIZED CONTENTS OF RECORDS- • Order ,accuracy and brevity should result from the use of these forms
• Filing of records in appropriate sequence and manner:-
Summary sheet Operation record
History Tissue report
Physical examination Death certificate
Laboratory reports Authority for autopsy
Physician’s order Hospital infection report
Progress notes X-ray reports
Nurses records and charts ECG reports
Labour record Urology reports
Birth certificate Other graphic records and
charts
Authority to operate
7.STANDARDIZED FORMAT- • Collection of data/generation of records should be as per standardised formats
in the form of printed forms made available in the hospital.
• Good quality paper should be used to withstand frequent handling
•Most common size of an inpatient medical record is 8-1/2”x 11”
8.PROCESS FLOW CHART FOR MOVEMENT OF MEDICAL RECORDS
9.NUMBERING SYSTEM(Serial numbering/unit numbering/serial unit numbering)-
Single permanent number is assigned for each patient which can be used for
future
subsequent admissions
10.FILING SYSTEM- Facilitates sorting, filing and retreival
METHODS OF FILING SYSTEM
Alphabetical method
Numerical method
Chronological
method
Mid-digit systems
Terminal digit
systems
11.INDEXING SYSTEM- Facilitates quick retrieval for research and education
INDEXING
Operation Index
Disease Index
Unit Index Physician’s
Index
Alphabetical Index
12. CODING-
•Classifyng the record of inpatient by diseases using ICD coding system.
•Coding to provisional diagnosis(at the time of admission)
•Coding to death certificate.
13.DICTATING AND TRANSCRIPTION SYSTEM-
Doctors dictate their notes or discharge summaries from various locations in
the
hospital and the medical secretaries then transcribe the recorded dictation.
14.TRACKING/TRACING OF RECORDS- To ensure confidentiality and safety
15.ISSUE OF RECORDS-
To ensure the issuance of records to the authorized personnel and their return
in
time without any damage or loss, strict policy and procedures for the issue
and
return of medical records must be followed:
a) Medico-legal records
b) Panel cases(non-medico legal)
c) At the time of discharge - Discharge summary(duly checked and signed by
physician)
Copies of investigation reports
Copies of case records(on payment)
16.ANALYSIS OF RECORDS AND GENERATION OF STATISTICS
17.PROVISION OF INFORMATION TO THE EXTERNAL AGENCIES-
A checklist for the information to be forwarded to the regulatory body in the
form of periodic reports should be prepared
18.POLICY AND PROCEDURE FOR SAFETY AND SECURITY OF RECORDS-
a) No ad-hoc or temporary staff
b) Medico legal case records to be kept in steel cabinets under lock and key
c) Storage area should be free from seepage/dampness and termite nuisance
19.POLICY FOR PRESERVING THE INTEGRITY OF MEDICAL RECORDS
GENERATED-
a) Entries must be made only by doctors/nurses/technicians involved directly with
the treatment of the patient.
b) Entries should be at relevant places
c) Entries should be updated real time
d) No alterations of any kind should be allowed after completion of records.
The medical record should contain-
Information regarding reasons for admission, diagnosis and plan of
care.
Operative and other procedures performed should be incorporated
In case of transfer of patient to other hospital
In case of death
Clinical autopsy
Access to current and past medical records
20.POLICY AND PROCEDURE REGARDING THE CONTINUITY
OF CARE- According to NABH guidelines-
C.Medical records and information must be protected from public access and any
information released must comply with Health Insurance Portability and
Accountability Act (HIPAA) guidelines.
22.PRESERVATION OF RECORDS- •The policies and procedures are in consonance with the local and national laws
and regulations(NABH)
•HIPAA requires that Protected Health Information (PHI) must be kept secure for at
least six years, or two years after a patient's death.
i. OPD cases :depending upon the policy of the hospital
ii. Indoor records : 5years
iii. Medico-legal cases:10 years or permanently/until the case is finally settled
21.POLICY AND PROCEDURE FOR MAINTAINING
CONFIDENTIALITY/PRIVACY OF MEDICAL RECORDS- A. As an impersonal document- for training and research
A. As personal document- When required by LIC or income tax authorities
For proving the validity of patients will
For settling the queries about birth and deaths
.
24.DESTRUCTION OF OLD RECORDS- The destruction of medical records, data and information is in accordance with
the laid down policy (NABH)
Documented procedure should be followed and a public notice must be issued
before destroying the old records.
25.HANDLING OF MEDICO-LEGAL CASES- Documented procedure for receipt, registry
and timely response to the summons should be followed.
26.POLICY AND PROCEDURE FOR REGULAR AUDIT OF PATIENT
CARE SERVICES- The organisation should regularly carry out medical audits carried out by
identified care providers(NABH)
23.OWNERSHIP OF MEDICAL RECORDS- Medical records are the property of the hospital which is responsible for
their
safe custody and the confidentiality of the information contained in them.
A qualitiy assurance committee (QAC) can be formed for the same and may
consist of following-
•Medical Administrator
•Two Clinicians
•Pathologist
•Radiologist
•Nurse Administrator(Matron)
•Medical records officer-secretary
Objective elements of QAC-(NABH): The medical records are reviewed periodically
The review is conducted by identified care providers.
The review focuses on the timeliness, legibility and completeness of the medical records
The review process includes records of both active and discharged patients
The review points out and documents any deficiencies in records
Appropriate corrective and preventive measures undertaken are documented
QUALITY INDICATORS FOR EVALUATION
OF SERVICES:
1. Number of records found incomplete during random checks
2. Number of records found damaged
3. Percentage of records found missing/untraceable
4. Complaints from front desk staff/consultants about delays in retrieval
5. Complaints from patients/relatives/health authorities about delay or
non availability of records
6. Observations by courts/insurance agencies
7. Instances of breach of confidentiality of information
8. Poor physical condition of records as seen during periodic
inspections.
References:
Principles of Hospital Administration and Planning-BM
Sakharkar
Quality Management in Hospitals-SK Joshi
Hospital Facility planning and Management-GD Kunders
Hospital Administration-DC Joshi
NABH standards and guidelines for hospitals
http://in.wikipidia.org/wiki/recordsmanagement
http://laico.org/v2020.resource/files/numberingandfilingsys
tem.html
Thank you!