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!