T.Keshavarao Mob.9880569550

KESHAVARAO.TASST., MEDICAL RECORD OFFICER,BELGAUM INSTITUTE OF MEDICAL SCIECES,BELGAUM-590001.

ORGANIZATION & MANAGEMENT MEDICAL RECORDS DEPARTMENT

T.Keshavarao Mob.9880569550

IP REGISTRATION OR SERVICES

The IP Medical records classified into 2 section 1.Admission office2. WardFunctions of Admission officeAdmitting office functioning 24 hours. In this section staff posted 3 shifts.Prepare the case sheetsCollection of Identification data through the Patients At tenders.Allot the MRD Number.Record the hospital number with sociological data with date of admission, Time, Department, Unit etc in the admission register.Take the consent from the patients or his relatives for treatment and operation purpose.Prepare daily admission list and hand over to the census clerk Maintainance of Patient Master Index Maintainance of Bed Occupancy board

T.Keshavarao Mob.9880569550

WARD

The ward medical record will be performed by the ward nurse.Functions of the Medical records in the wardRegistration of admitting patients on the ward admission book.Maintainance of vacant bed position.Kept the all investigation in the appropriate case folder.Preparation and submission of ward daily census report.

T.Keshavarao Mob.9880569550

MEDICAL RECORD DEPARTMENT

NumberingNumbering system is facilitate easy to identification of the patient present and future visits. Easy to retrieve the case folders for continuity care. Filing purpose.Confidentiality purpose.Mainly there are 2 types of MR Numbering systems recognized.1.Unit numbering system-This numbering system has been preferred large no. Of MRDs. The method involves the use of a number, which is thereafter applied permanently to the same patient. This patients has only one medical record. All data about the patients are collected together one folder.

2. Serial Numbering system- It consists of assigning the patients a new numberEach time the patients visits the hospital. One patients will have many records, as times he has been seen and each records will file under the different numbers.

T.Keshavarao Mob.9880569550

CONTAINS AND COMPONENTS OF MEDICAL RECORDS

Contains of Medical records: As a minimum information should contain in each Medical Record. I.e.,. Sufficient information to identify the patient. Date of contact, reason for contact, findings, treatment and recommendations etc.

Components of Medical records When a patient has been admitted to the hospital they become an IP and front sheet is beginning the IP Medical record. IP usually occupies a bed in a health care facility for at least 4 hours or overnight.The Physical Medical Record will eventually consist of the following.1. MR Form2. Divider between each admission IP and OP3. Clip or fastener to hold the papers together4. Folder

T.Keshavarao Mob.9880569550

MEDICAL RECORD FORMSIt should be all in same size Usually A4 size.The patient Medical record number and the name of the form should be in the same place on every form.Medical record forms approved by administration or Medical record committeeShould be included in MRO.Medical Record divider. It is good practice to separate each admissions by a divider, the divider will be slightly wider than the forms in the Medical records and have a tab in which to write 1st admission 2nd admission.etc. In addition combined with the IP notes all OP Notes can be stored behind an OP divider.Clip or fastenerStaples should not be used as they tend to rest and additional forms. If use largeFastener which is secured in the top left hand corner of MR.Plastic rather metal clip also best for use of MR.

T.Keshavarao Mob.9880569550

FOLDER

All medical record forms should be kept in Medical Record Folder. This should be a thick folder(Manilla)of if possible stronger card board should be purchased. Medical record folder should be filled on their spine so that medical record number is clearly visible for filing purposes. Every medical record Folder should contain MRD No. Hospital Name & Process check ie. Assembling ,Deficiency check, Accession Register, Discharge Analysis, Patients Index, Diagnostic Index, Operation Index, Surgeon IndexCheked by, Filing clerk, Date of filing etc.,

T.Keshavarao Mob.9880569550

CENSUS

Each and every Hospital should maintain Mid night census.The hospital inpatient Census is the number of inpatients occupying beds in the hospital at a given time.Procedure.a) Collect daily admissions from the admitting office.b) Collect from the sister-in charge of the ward the following Daily census report form. Discharged case sheets whether complete or incomplete. Including Investigation reports.c) Check the No of admissions & Discharges with actual No of

admission list and and discharge Records.d) Check the Transfer in and Transfer out case records.e) Hand over to the Census report at Census or statistics deskf) Hand over all discharged case records to Assembling and Deficiency

check desk.

T.Keshavarao Mob.9880569550ASSEMBLING AND DEFICIENCY CHECKAssembling and deficiency check section collects the discharge

records of the previous day and make discharge details on the computer or register.All the deficiencies are pointed out of the deficiency are marked at the deficiency check list. It is helpful to the doctors for complete the records weekly visit.

T.Keshavarao Mob.9880569550

THANK YOU