MRD/ Clinical Information Unit

Purpose

The purpose of the Clinical Information Unit is toprovide for the secure maintenance, storage andretrieval of confidential clinical records.

Provision should be made for 24 hour availability ofclinical records either by a computerized or manualsystem.

All patient related administrative, historical andmedical records must be stored in a fire ratedconstruction as indicated in local bylaws.

What is a medical record ?

It is a document containing sufficient data written in sequences of events to justify the diagnosis, andwarrant the treatment given and the end results.

must contain sufficient data to identify the patient, support the diagnosis or reason for attendance at thehealth care facility, justify the treatment and accurately document the results of that treatment(Huffman, 1990).

The main purpose of the medical record is:

To record the facts about a patient's health with emphasis on events affecting the patient during the current admission or attendance at the health care facility, and

For the continuing care of the patient when they require health care in the future.A patients medical record should provide accurate information on:

who the patient is and who provided health care;

what, when, why and how services were provided; and

the outcome of care and treatment.

Importance of medical record:

Contributes professional care rendered to the patient. Reflect the quality care rendered by the institution.

Differentiation of the medical record:

In-patient record. Out-patient record. Emergency record

The hospital shall maintain an adequate medical record for every individual who is evaluated or treated as an inpatient, outpatient, or emergency patient, which shall be documented accurately with all significant clinical and other information in a timely manner.

The medical record shall be readily accessible for providing continuing patient care by medical and other staff, and permit retrieval of information for medical education, research, quality assurance activities, and statistical data

Source: Medical Records Manual, WHO

The medical record has four majorsections:

Administrative, which includesdemographic and socioeconomic datasuch as the name of the patient(identification), sex, date of birth,place of birth, patients permanentaddress, and medical record number;

Legal data including a signed consentfor treatment by appointed doctorsand authorization for the release ofinformation;

Financial data relating to the paymentof fees for medical services andhospital accommodation; and

Clinical data on the patient whetheradmitted to the hospital or treated asan outpatient or an emergencypatient.

Functions

The function of the Clinical Information Unit is the development andmaintenance of health information systems involving the following:

Retrieval, assembly, sorting and distribution of records for and to thewards and other patient units.

Transcription / typing service for outpatient letters, discharge summariesand operation reports

Classification (clinical coding) of diseases and procedures for inpatientadmissions using an International Classification of Diseases

Provision of information to management and other authorized staff forpurposes such as planning, utilization review, quality Assurance, case mixstudies and research

Quality assurance of the medical record to ensure standards are met

Primary role is safe guarding the records and to issue them on demand

Bridges the gap between medical and non-medical departments.

Enables continuity of care to the patients without difficulty at appropriate time

Headed by MEDICAL SUPRITENDANT has skilled persons termed as Medical Record Technicians and others

Governed by the Medical Records Committee

For the department to function efficiently the medical record must be Accurate, Complete, and Timely. Of course, the caregivers shall

Legibly write it.

What are the uses of Medical Records?

What are the uses of Medical Records?

The Medical Record is useful to the Patient for his/her further follow-up and treatment.

The Medical Record safeguard the Physicians and Surgeons from the integrity.

The Medical Record is useful for Teaching for Postgraduates and undergraduates.

The Medical Record is useful for Research purpose

The Medical Record is useful for the Health Programme for controlling the epidemic diseases.

The Medical Record is useful to the Administrator to manage the Hospital and use this as yardstick for controlling the Hospital.

HOSPITAL STATS

PROOF OF WORK DONE

FOR CURRENT AND FUTURE PLANNING

DISEASE /PROCEDURE INCIDENCES

OUT PATIENT TURN OUT

BED OCCUPANCY RATE

AVERAGE LENGTH OF STAY

DEATH RATE

DEATHS UNDER 48 hrs.

DEATHS MORE THAN 48 hrs.

FLOW

Registration counter

Admission Medical records

AssemblingDeficiency check and coding

Scanning Computer entry Permanent filing

Consultants

I.P O.P

Wards

Indexing

OPERATIONAL POLICIESOperational Policies that may have an impact on the planning of the Clinical Information Unit and may require decisions by policy makers include the following:

How records are to be managed and identified; essential elements include:

Provision of a centralized record system for all inpatient, emergency and outpatient/day patient attendances or decentralized systems; where decentralize systems are in operation, the existence of sub-files will require a registration, allowing retrieval of the sub-file for patient care or medico-legal purposes

Provision of a unit numbering system providing a single identifying number for every patient who presents to the Hospital i.e. the Medical Record Number (MRN); the MRN issued at the time of first admission or attendance is then used for all subsequent admissions and treatment

The use of terminal digit filing systems in both active storage and secondary storage

Maintenance of record confidentiality, including authorized access to the record and release of information to other parties

Preparation of Medico-legal reports in accordance with the local statutory requirements

Retrieval of medical records from secondary storage within a set time if deemed clinically necessary; the location of secondary storage to be considered

Provision of a centralised dictating system utilising the telephone system for clinical staff to compile discharge reports and summaries

Transcription of discharge summaries, operation reports and outpatient letters to be completed in the Unit.

Electronic Medical Records

The Electronic Medical Record (EMR) is a computerised online record, which tracks and details a patients care during the time spent in hospital.

The EMR enables staff to enter patient data at the point of care and allows authorised clinicians and access a patients records from any online location, at any time, to make rapid assessments and coordinate care. In the future, as electronic systems are implemented, the EMR will begin to replace paper-based records by integrating patient information in a central system. As a result, the provisions for paper based systems may not be required if EMR is provided.

Location

Location may depend on whether or not a pneumatic or mechanicalautomated records transport system is to be installed and thedepartments to which it is linked.

The decision to include such a system will strongly influence the externalfunctional relationships of the Unit with the Outpatients Clinic area, inparticular and may reduce the importance of direct access to theEmergency Unit

Planners must consider possible future uses of the unit envelope for such time as an electronic record system has evolved with consequent reduction in staff and diminishing storage needs.

The Unit should be considered as soft space into which an adjoining unit could expand or a new unit established.

Functional Areas

The Clinical Information Unit will consist of the following functional areas:

Entry/ Reception/ Administration area with waiting

Record Processing Area Assembly/ Sorting area

Transcription area

Clinical Coding area

Photocopy/ Printing area

Record Microfilming area, if applicable

Record Scanning area, if applicable

Record Storage area for active and archived records

Offices for Manager, Quality Assurance, Medico-legal personnel.

Entry / Reception / Administration

A single controlled point of entry to the Clinical Information Unit for thereception of visitors and staff is recommended.

A temporary storage area will be required for returned files or filesawaiting delivery to departments. A small amount of waiting will berequired for visitors to the Unit.

Access will be required within this area to Dictating / Research Cubicles sothat visiting staff do not have to traverse the Unit.

Dictation Cubicles

The dictating area will be used by medical staff and others to view andresearch medical records as well as dictating and completing the dischargesummaries.

The cubicles should be located on the perimeter of the unit adjacent tobut inside the reception area.

The number of cubicles will depend on usage and the cubicles may be self-contained or in an open plan office in which case cubicle partitions will berequired.

Record Processing Area

Assembly & Sorting

Record assembly and sorting will generally be undertaken in an open planarea used for the processing activities associated with the filing andpreparation of the medical records for clinics, admissions and discharges.

This area may have zones for assembled files ready for issue and recordswaiting to be refiled.

The record assembly area should have direct access to the filing storageareas The area will include workstations and sorting tables. Each recordsofficer will need a records storage bay and a trolley at or in close proximityto their workstation.

Storage will be required for: records awaiting sorting and assembly

records awaiting filing

Note that records awaiting medico-legal attention will be stored in the Medico-Legal Office.

Clinical Coding

Clinical Coding of medical records requires a quiet area.

Photocopying / Printing

Dedicated, acoustically-treated and ventilated space is required. Thisspace may also be used for generating bar code labels etc. This may alsoinclude stationery storage.

Locate with ready access to the medico-legal offices that generate a largeamount of photocopying.

Scanning and Microfilming

Records may be scanned to create a digital record and filed on an optical disc.

Alternatively records may be microfilmed and stored as film. If records are to be microfilmed a dedicated room should be provided.

Record Storage The most common and suitable method to file active medical records is on

fixed metal shelving units (bays).

Archived files may be stored in a compactus shelving unit but acompactus is not recommended for active

The number of shelves in each bay (up to seven) - usually six levels ofshelving is recommended. Maximum height should be 2175 mm.

A minimum width of 750 mm per aisle between facing bays must beprovided; however for efficient retrieval of records, 900 mm isrecommended as it allows space for trolleys, library stools and for staff topass each other in the aisles.

Fire water sprinklers should NOT be installed. Records storage areas mustbe temperature and humidity controlled for preservation of records.

In a traditional, hard copy environment, the critical relationship is with the Emergency Department for immediate record retrieval. Less critical is the relationship with Outpatient Unit/s as files are usually retrieved and delivered to the Units prior to clinic sessions. However, distances for transport of heavy records need to be considered.

Archive File Store

All the records requiring storage should meet the statutory requirements beyond the 5 year active storage period

Room Space Quantity Area ( sq.m)

Reception 1 10-20

Waiting 1 4-6

Meeting/interview 1 9

Record processing 1 25-50

Bay- mobile equipments 2 6

Review cubicles 1 9-20

Records store-active 1 80-200

Office single person 1 9

Office single person 1 12

Office-medicolegal 1 9-12

Workstation(typing) 2-4 5.5

Worksatation-coding 1-2 5.5

Store general 1 9

Scanning area 1 20

Photcopy-stationary 1 8

Circulation 15%