Contents

AuthorizationofStaffMembersMakingEntryintoMedicalRecordsChart(File).......................................1 RetentionofMedicalRecord........................................................................................................................ 2 ConfidentialityofMedicalRecords............................................................................................................... 3 SecurityofMedicalRecords......................................................................................................................... 4 ICD10CodingandDataAbstracting............................................................................................................ 6 MedicalRecordsTrackingSystem ................................................................................................................. 8 PatientMedicalRecordIdentification.......................................................................................................... 9 MedicalAlert.................................................................................................................................................9 EnteringLaboratoryResultsintoPatientRecords...................................................................................... 10 MedicalRecordAnalysisandCompletion.................................................................................................. 11 StorageofOldInactiveRecords.................................................................................................................. 13 ApprovedandProhibitedAbbreviations.................................................................................................... 14 Abbreviations&Meaning........................................................................................................................... 15 FoetalpositionandPresentation................................................................................................................ 20 Abbreviationforuseontheabstracts(MedicalRecords).......................................................................... 21 DentalAbbreviations..................................................................................................................................23 AbbreviationNOTtobeused..................................................................................................................... 25 INDEX..........................................................................................................................................................26

IPPNO:MR002

AuthorizationofStaffMembersMakingEntryintoMedicalRecordsChart(File)
PURPOSE:Itprovidethehospitalwithauthorizedstafftomakeentriesinthemedicalrecord POLICY:OnlyauthorizedstaffmembersshallbeallowedtomakeentriesinMedicalRecord.Suchstaff membersincludephysiciansnursesandotherparamedicalstaffinvolvedinthepatientsmedicalcare. PROCEDURES:Thefollowingcriteriashallbeobserved: 1. Thereisauniqueidentifier(NameandEmployeeNumber)foreachstaffmember. 2. Physiciansshallbeexpectedtohaveastampbearingboth(NameandEmployeeNumber) 3. Nursingandotherstaffmembersshallbeexpectedtohaveastampormayusetheirnameand employeenumber(handwritten)insigningentriesintomedicalrecords. 4. AllentriesintotheMedicalRecordsbyStaffMembershavetobesignedandauthenticatedwitha stampwheneverapplicable,datedandtimed. 5. AlltheentriesinthefileshouldbeinEnglishLanguage. 6. AllresultsfromRadiologyandLaboratoryhavetobesignedbyamemberofthemedicalteam beforebeinginsertedintothemedicalrecords. 7. EachentrymustbedatedaccordingtoGregoriancalendarindaymonthyearsequence. 8. Timeentriesaremadeusing12hoursclocksystem. AuthorizedStaffMemberstomakeEntries:ThefollowingMedicalandHealthCareProfessionals areauthorizedtomakeentriesintheMedicalRecordsofMGMC&RIwiththecoordinationof MedicalRecordsStaffMembers: Allphysicians. Nurse. Physiotherapists. Dietitian. MedicalRecordsTechnicians. OtherHealthCareProviderssharinginpatientscare.

ProceduresinMakingEntries: ResponsibleMedicalorHealthCareProvidersarerequiredtocompletethespaces providedforthedate,patientsname,ageandsex. Detailedclinicalassessmentsshallbeenteredinalegiblemanner. Aftertheentryofeachclinicalassessmenttheresponsiblemedicalorhealthcareproviders mustplacetheirnameornumber,signature,dateandtime.

 IPPNO:MR003

RetentionofMedicalRecord
PURPOSE:ToretainandpreservetheMedicalRecordsforatimeperiodasspecifiedbyNABHstandards formedical,legal,administrative,educationalandotherpurposes. POLICY:ItisthepolicyoftheMedicalRecordsDepartmenttocomplywithNABHMedicalRecords RetentionscheduleasmentionedintheNABHpoliciesandmanual. PROCEDURES: Medical Records are retained as per the following medical retention schedule stated in NABH policies/proceduresmanual. ApprovalfromDean,MGMC&RIwouldbetakenbeforedestroyinganymedicalrecord.

PreservationofRecords: 1. All medical records including patients files, register books, etc., relating directly to patient care havetobemaintainedbythemedicalRecordsDepartment. 2. The old files, register books, are to be preserved in a secure place for a prescribed period. Later the records have to be disposed off as per the Record Retention Schedule procedures mentionedintheNABHmanual. 3. Specialcarehastobetakentoreservethesafetyofrecords.Recordshavetobeprotectedfrom insects, termites and prevent them from being exposed to heat, fire, dampness and dust. Adequatefireextinguishersshouldbeavailableinthefillingarea.

IPPNO:MR004

ConfidentialityofMedicalRecords
PURPOSE:Tomaintainconfidentialityofalltypesofinformation.Thisincludesmedicalrecordsdiseases, operationindex. POLICY:Itis thepolicyofthedepartment tosetforthprocedurestomaintain alltypesofinformationin utmost confidentiality in compliance with MGMC & RI Hospital policy and ethical rights of patients and hospitalstaff PROCEDURES: 1. PersonsworkingintheMedicalRecords,personsdirectlyinvolvedinpatientcareandother authorizedpersonswhohaveaccesstopatientmedicalrecordsmustnotunderany circumstancesdiscloseanytypeofpatientinformationtounauthorizedpersons.Disclosuresof anyinformationcontainedinthemedicalrecordsareabreachofconfidentiality.Anyonefound tohavedisclosedanyinformationtounauthorizedpersonswouldbesubjecttodisciplinary actionandpossibletermination. 2. Authorizedpersons,whoneedtoobtainanykindofpatientinformation,shouldadhereto guidelinesinpolicyandproceduresfortheReleaseofInformation. 3. MedicalRecordsinthedepartmentarekeptsecuredandinstrictconfidentiality.No unauthorizedpersonsareallowedtohaveaccesstopatientmedicalrecordsoranytypeof patientdatainformation.

IPPNO:MR005

SecurityofMedicalRecords
PURPOSE: To ensure that all Medical Records (Data Information) are kept safe and secured in the MedicalRecordsDepartmentandprotectionofMedicalRecordsfromloss,theftordeliberatealteration /tampering POLICY: To establish responsibilities and procedures for safeguarding Medical Records (data and information). PROCEDURES: 1. Medical Records originated in the hospital are the property of MGMC & RI Hospital and are maintainedforthebenefitofpatientsandhospitalstaff. 2. In accordance with MGMC & RI Hospitals policies, medical records shall not be removed from thehospitalexceptbycourtofMinistryofHealth.(Onlycopy) 3. MedicalRecordscanbetakenoutofMedicalRecordsDepartmentonlybyauthorizedpersons 4. If the file/s are required for a purpose, other than patient appointment, the persons requesting the file/s should fill up a file request form within the organization, available from Medical RecordsDepartment. 5. For emergency patient the medical records staff will promptly deliver the file to ER nurse or the ERstaffcancollectthefilefromMedicalRecordsDepartmentwithproperidentification. 6. To ensure maximum security against loss, defacement, tampering and from use by any unauthorizedindividual: No unauthorized persons are allowed to enter Medical Records Department or to have accesstopatientMedicalrecordsoutofthedepartment. All medical records taken from the Medical Records department during working hours by any outpatient department /ER or by any authorized persons/unites should be returned on the same day. No records are to be kept overnight in any unit other than inpatients. Patientsortheirrelativeswillnotbeallowedtocarrythepatientfilesortokeepthemin theirpossessions.

7. authorizedallowed 8. ThemaindooroftheMedicalRecordsDepartmentshouldbekeptlockedafterworkinghours. 9. All persons who need to enter Medical Records Department after 4:30 pm should contact MedicalRecordstaffondutythroughreceptioncounterorbyphoneExt. 10. Norecords/filesshouldbeleftunattended. 11. Medical record staff should always be available. No staff should leave the department without handingover. 12. Any misconduct made by any of the authorized and responsible staff members against this policy requires immediate notice from the head of medical records with the approval of the

chief medical director for prompt initiation of penalty depending on the signification of offense/sandelaboratedasfollows: First offense requires a warning letter signed by the medical director stating the consequence if the same misconduct is repeated and he is trained further not to repeat hismistakeagain. Second offense necessitates a three not to sevendays salary deduction depending upon the type of fault along with a written memorandum duly signed by the chief medicaldirectorandtheadministrativemanager. Thirdoffenseissubjecttoterminationofcontract.

IPPNO:MR006

ICD10CodingandDataAbstracting
PURPOSE: To correctly and accurately assign Standards Disease, Operation and /or Procedure Codes to alldischargedInpatientsMedicalRecordsandtoenterthedatainthecomputerforfuturereference. POLICY:ItisthepolicyoftheMedicalRecordsDepartmenttocodeallinpatientdischarges. PROCEDURES: 1. Receive medical recodes from the Medical Record Technician who have analyzed the file for completeness. 2. Dischargedinpatientmedicalrecordswillbecodeddailyagainstthedischargecensusandatthe end of each month, the medical record technician will refer to their list of discharges for all files thatarenotyetcoded. 3. ReviewthemedicalrecordInpatientAdmissionSheet,DischargeSummary,HistoryandPhysical, Physician Progress Notes, Consultation Notes, Operation and Procedure Notes and all Investigations(ifpresent). 4. Compare the final diagnosis of the Inpatient Admission sheet to the one recorded on the DischargeSummary,HistoryandPhysicalandprogressreport,plustheOperativeandPathology Reports to ascertain that there are no discrepancies in information. If there are, ask first the physicianforclarificationofthediagnosisbeforeputtingthecode. 5. Determine that the primary (final) diagnosis has been listed first and any secondary codes are listedincorrectcodingsequence. 6. CodetheidentifiedDiagnosis,OperationsandProcedures,listedtheminpencilonthe Inpatient Admissionsheetincorrectsequence,inthecolumnmarkedICD10 7. Place your initial next to those of the analyst in the blank box next to the column marked ICD CodeNumbersontheInpatientAdmissionsheet. CODINGGUIDELINES: Thefollowingbasicstepsincodingshouldbefollowed: LocatethemaintermintheAlphabeticIndex. Refertoanynotesunderthemainterm. Refertoanymodifiersofthemainterm. Refertoanysubtermsindentedunderthemainterm. Followanycrossreferenceinstructions. Readandbeguidedbyanyinstruction,terms,symbols,etcwhichmayfurtherqualifythecode. AssigntheCodeNumberthusobtained. a. Code all operative procedure, all invasive procedures and all diagnostic procedures, whichareinvasive.

2. It is imperative that both the alphabetic indices and the tabular indices be used when locating and assigning a code. Do not try to code directly from the alphabetical indices because the tabular indices may provide additional information. Such as exclusion terms, 5th digit codes(in the case of diagnostic coeds) or instructions to use more than one code for any given diagnosis orprocedure. 3. Each individual diagnosis or procedure must be assigned a correct and complete coed. If the physician had not given specific information, search the history and physical, doctors progress notes, operative reports and pathology reports for more information. If not clearly defined, as theconcernedphysicianforclarification. 4. The principle diagnosis and the principle procedure must be coded first, because the categories in which patients are grouped for the purpose of evaluating the utilization of Health Record facilities are based on principle diagnosis and principle procedure. Secondary codes must be sequencedintheorderofimportanceandtheireffectintheprinciplediagnosis. NOTE: CODING IS AN IMPARTENT ASPECT OF RESEARCH IN THE MEDICAL RECORDS DEPARTMENTANDITMUSTBEDONEACCURATELY. 5. AftereachcodingprocedurehasbeencompletedforadischargedInpatientMedicalRecord,put a highlight in each appropriate medical record number from the correct discharge census list . The file may then be put in the prefiling area or give to the Transcriptionist for typing of DischargeSummaryifnecessary.

IPPNO:MR007

MedicalRecordsTrackingSystem
PURPOSE:Toprovideasystemtofacilitateandensureeasilytrackingofmedicalrecord. POLICY: Patient records are only released out of Medical Records according to a policy approved by the hospital. PROCEDURES: 1. Recordscanbereleasedtothenursesintheoutpatientclinics. 2. RecordscanbereleasedtotheEmergencyRoomnursesforapatientinEmergencyRoom. 3. Recordsarereleasedtomedicalcommitteeandhesignsforit. 4. Approvalbythemedicaldirectorforallotherrequestsforreleaseofthemedicalrecord. 5. ReleasesandReturnofFiles(MedicalRecordsTrackingSystem): Any Medical Record files sent from the filing area will have the Records Transfer Card writtenandthekeptinitsplace. A retrieval register should be maintained in Medical Records Department for all requests for files. Date, Medical Record Number, Dr. Name, Time Department, name and time requestedshouldbeenteredinthelogbookwiththesignatureofthemedicalrecordstaff. A logbook should also be maintained for all outgoing patient medical record, clinic, receivingthefilesshouldbeenteredinthePINwithdate,time,andsignature. AllMedicalRecordssentoutmustbereturnedtothefilingareaonthesameday Filing for OPD appointments are prepared according to the appointment list the previous day. All the files from the OPD clinic are collected at 12.00 to 01.00 pm and 8.00 to 9.00 pm as routine. If any files are not returned to the Medical Records Departments on the same day from the clinic the files are sent for admission or to another clinic in case the patient had two differentappointmentsonthesameday. The Medical Records staff who is operating the file Movement will check each morning to ensure that all the files sent out the previous day are returned to the filing area on the sameday. If there are unreturned files, the Medical Records staff the person responsible as to who borrowedthesefiles,makeenquiriesandtakeactiontocollectthemattheearliest. The Medical Records tracer card should be updated in cases of unreturned files after ensuringthelocation. IfaMedicalRecordcannotbelocatedbytheborrowerortheMedicalRecordsstaffafter3 days,itwillbeinformedtomedicaldirectorMedicalRecordfileismissing. AlistofthemissingfilesshouldbepresentedtotheMedicalRecordsMCIcommittee.

 IPPNO:MR008

PatientMedicalRecordIdentification
PURPOSE:Itprovideaprocessforidentificationofpatientdatainthemedicalfile. POLICY:Everypatientshallhaveamedicalrecordcreatedinhis/hername PROCEDURES: 1. 2. All form in the patients file shall have the adhesive label including(PIN Number, name,Date of Birth)orfilledupdailybythenurse Informationconcerningnextofkinincludingaddress,telephonenumber.

MedicalAlert
PURPOSE:Itprovidemedicalrecordstaffbyasystemtocompletethepatientseriousdata. POLICY:Essentialinformationaboutthepatientsshallbelegible andlocatedinthefacesheet,andshall include. PROCEDURES: 1. Allergies. 2. CodeStatus.

IPPNO:.MR019

EnteringLaboratoryResultsintoPatientRecords
PURPOSE:Itprovidesamechanismforenteringlaboratoryresultinmedicalfile. POLICY: All Laboratory results shall be signed & authenticated by a physician prior to placement into MedicalRecords. PROCEDURES: 1. As soon as a Laboratory result is received on the ward the nurse shall inform the Attending Physician. 2. If should junior staff members not be able to attend, the Consultants should be informed of the Presenceoflaboratoryresult.

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IPPNO:.MR021

MedicalRecordAnalysisandCompletion
PURPOSE: To Complete all Medical Records of inpatient discharges in compliance with the hospitalsstandards. POLICY: It is the policy of the Medical Records Department to ensure that all Medical Records are completed according to established criteria and contains complete documentation relating to treatmentandprogressduringhospitalization. PROCEDURES: Allnewlydischargedandexpiredrecordswillbeanalyzedwithintwo(2)workingdaysof discharge. Verifythatalldischargedrecordsforthedayarecollectedorpresent. Use a Physician Incomplete Checklist from for each physician having medical records deficienciesinanyrecord. UseNursingDeficiencyChecklistformforeachNursingUnithavingdeficiencies. NursingDeficiencyChecklistformusedwillthenbedistributedasfollows: Top copy will be given to each nursing unit in the ward with backed copy signedbyanyofthenursingstafffromtheward. BackedcopywillthenbegiventotheDoctorsCompletionInchargeforherlist ofNursingDeficiency.

Physicians Checklist will be attached to the right side of the medical record with the Mostrecentchecklistontop. Alldeficienciesrequiringsignatureswillbetaggedwithcoloredlocatortags. Theappropriatecoloredtagswillbeplacedoneachdeficiencychecklist. The following information will be recorded on the Physician Deficiency checklist: PatientName. PatientMedicalRecordNumber. Unit. DateofDeficiency. TypeofDeficiency.

OneMedicalRecordControlCardwillbepreparedforeachmedical Recordhavingphysiciansdeficiency. ForeachMedicalRecordhavingdischargesummaryand/oroperationreport that needs to be typed, Medical Record Control Card with copy will be preparedandthendividedanddistributedasfollows: TopcopygiventotheDoctorscompletionIncharge.

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BackupcopygiventotheTranscriptionist.

MortalityRecords: If the patient has expired, record all the information in Death Registry (patient name, date of death, medical record number, ward/unit, sex and treatingphysician). Ensure mortality records are completed such as death summary, diagnosis orcauseofdeath. Write to each top face side of folder EXPIRED with date and time of death. Keeptheexpiredfilesinseparatefilingshelvesfiledinnumericorder. An outguide will be prepared with the following information written in Blockformtobeplacedinthemainfilingarea: MedicalRecordNumber. EXPIRED. Dateandtimeofexpiration.

Completethedownpart corneroftheInpatientAdmissionsheetbywritingthedateof discharge or date of expired, time and write the initials and the date the file was analyzed. Analyzedfileswillbepassedontotheperson(s)responsibleforCoding.

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IPPNO:.MR023

StorageofOldInactiveRecords
PURPOSE: To store old medical records (which are inactive and less likely to be needed) in such a mannerthattheycouldberetrievedifrequired. POLICY:ItisthepolicyoftheMedicalRecordsDepartmenttomakeavailablesufficientspaceinthefiling areafornewlyopenedfiles. PROCEDURES: Patientrecords(InpatientandOutpatient): All patient files in which the patients has not attended OPD Clinic or were not treated, as inpatientforthelast2yearsshallberemovedfromthemainfilingarea. These files shall be stores in a place in close proximity to the Medical Records Department so thattheycouldberetrievedquickly. These records will be arranged properly in shelves in numeric order to facilitate easy retrieval whenrequired. ERRecords: MortalityFiles: Mortality files belonging to the current year shall be kept in special shelves. All previous Mortality files shall be transferred to the old records storeroom and arranged in shelves in chronological order to enableeasyretrieval. GeneralInstructionforStoringOldRecords: Oldrecordsshouldbestoredinasafeandsecuredplace. An old Records Register will be maintained and all the old records removed From the filing areamustbeenteredinthisregister. Alltheoldandinactiverecordshavetoberetaineduntiltheyaredisposedoff,aspertherules laid down by MOH for Record Retention, (Please see policy and procedures on Retention of MedicalRecords). ER Records for the current year shall be kept inside the Medical Records Department. All the ER records of previous years will be removed from the filing area and storedintheoldrecordsstoreroom. Accordingtotheavailabilityofshelvesandspaceinthestoreroom,oldERRecords shallbearrangedproperlyinshelvesinchronologicalorderto Facilitieseasyretrievalwhenrequired. Old ER records will be arranged in chronological order by bundle of 100 records eachandfiledinaspecialfilingshelfchronologically.

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IPPNO:.MR024

ApprovedandProhibitedAbbreviations
PURPOSE: To establish a system in the hospital to utilize only the approved and comprehensive list of abbreviationsapprovedbythemedicalrecordscommittee. POLICY: It is the policy of the Hospital to use approved and standard abbreviations list which givens guidancefordocumentationinpatientrecordsinaccordancewiththeMRQPstandards. PROCEDURE: 1. The Pharmacy will not accept orders and prescriptions from InPatient which includes non approvedabbreviationsandsymbols. 2. Orderscontainingnonapprovedabbreviationsandsymbolsareclarifiedwiththephysician. 3. Medication orders containing Abbreviations of Medications, will not be filled unless the Abbreviation is universally accepted, i.e P.P.D (purified Protein Derivative) and listed in the currenteditionofMedicalRecordsAbbreviationsBooklet. 4. Nonuniversally accepted abbreviations of Medications, in the approved hospital listings are intendedforuseinmedicalrecordsetc,andwillnotbeacceptedforuseinmedicationorders. 5. A listing of selected Abbreviations of Medications, orders can be found in the current edition of theFormulary. 6. The abbreviations shall be reviewed yearly or whenever new additions and deletions are required. 7. TheuniformityofabbreviationsamongtheHospitalstaffwouldbemaintained. 8. Any suggested additions / deletions shall be submitted to the Medical Director for review and approval. 9. The abbreviation list is reviewed by the Medical Records Committee and the approved abbreviationlistiscirculatedtoallthedepartmentsoftheHospitaltobefollowed. 10. The prohibited abbreviation list is also forwarded to the departments to confirm the use of appropriateabbreviationlistisfollowedandnottheprohibitedlist. 11. The listed out prohibited abbreviations should never be used by the departmental staff and whichwasapprovedbythemedicalrecordscommittee.

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IPPNO:.MR025

Abbreviations&Meaning
ABBREVIATION a.m AB ABG AGA AIDS AP&Lat APChest APH ARM ASAP ASD AXR b.i.d BCG BE BIL BILI BILIC BILID BMR BP BPD BUN BW C&S C.S.S.D C.S.T C.T.Scan Ca++ CBC IDDM IDM IERation IM IMV Inc IPPV IT IUD IUFD IUGR MEANING BeforeMidday,Morning Apexbeat Arterialbloodgas AppropriateforgestationalAge AcquiredImmunodeficiencySyndrome Anteroposterior&lateral AnteroPosterior Antepartumhaemorrhage Artificialruptureofmembranes Assoonaspossible Atrialseptaldefect Abdominalxray TwoTimesaDay BacillusCalmettGuerin Baseexcess bilateral bilirubin Conjucatedbilirubin Directbilirubin BasalMetabolicRate Bloodpressure Bronchopulmonarydysplasia BloodUreaNitrogen BirthWeight CultureandSensitivity CentralSterilization&SuppliesDepartment ContinueSameTreatment ComputerizedTomographyScan Calcium CompleteBloodCount Insulindependentdiabetesmellitus InfantofDiabeticMother Inspiratory/expiratory Intramuscular Intermittentmandatoryventilation Incubator Intermittentpositivepressureventilation Inspiratorytime IntrauterineContraceptiveDevice Intrauterinefetaldeath Intrauterinegrowthrestriction

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IV ABBREVIATION IVH IVP IVU IWL K++ KCL Kg(Kgms) KUB L&D Lab Ib LBW LDH LGA LMP LP LSCS LT M MAP CCN CDH CHD CLD Cm CMV CNS CO Co2 COPD CPAP CVA CVL CVP CXR D&C D10w D5w DDH DIC DOA DPT DR EBM

IntraVenous MEANING Intraventricularhaemorrhage IntraVenousPyelogram IntraVenousUrogram Insensiblewaterloss Potassium Potassiumchloride Kilogram(s) Kidney,Ureter,bladder LabourandDelivery Laboratory Pound LowBirthWeight LacticAcidDehydrogenase Largeforgestationalage Lastmenstrualperiod LumbarPuncture Lowersegmentcaesareansection Left Minimum MeanArterialPressure ClinicalchargeNurse Congenitaldiaphragmatichernia Congenitalheartdisease Chroniclungdisease Centimeter Cytomegalovirus CentralNervousSystem Carbonmonoxide CarbonDioxide ChronicObstructivePulmonaryDisease Continuouspositiveairwaypressure CerebroVascularAccident Centralvenousline Centralvenouspressure ChestXray DilationandCurettage Dextrose10%inwater Dextrose5%inwater Developmentaldysplasiaofthehips Disseminatedintravascularcoagulation DeadonArrival DiphtheriaToxoid,pertussisVaccineTetanusToxoid Deliveryroom ExpressedBreastMilk

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ECG/EKG ABBREVIATION EDD EEG ELBW ENT ER ESR ET ETA ETT FBS FEBM FFP FH FiO2 FUO G.U. Gm GrI,IIG GTT Gtt GYN H&P H.I.E H.M.D Het Hgb HIE HMD HPU HR Hrs I&D I&O IA ICP ICU MAS MAS mEq Mg MI Mm Mv N10

Electrocardiogram MEANING Estimateddateofdelivery Electroencephalogram Extremelylowbirthweight Ear,Nose,Thorat EmergencyRoom ErythrocyteSedimentationRate Expiratorytime Estimatedtimeofarrival Endotrachealtube FastingBloodSugar Fortifiedexpressedbreastmilk Freshfrozenplasma Fetalheart Fractionofinspiredoxygen FeverofunknownOrigin GenitoUrinary Gram Gravida,pregnantindicatingawomanofmanypregancies GlucoseToleranceTest Drops Gynecology HistoryandPhysicalExam HypoxicIschemiaEncephalopathy HyalineMembraneDisease Hematocrit Hemoglobin Hypoxicischaemicencephalopathy Hyalinemembrancedisase Haspassedurine Hearrate Hours IncisionandDrainage IntakeandOutput Intraarterial Intracranialpressure IntensiveCareUnit MeconiumAspirationSyndrome Meconium Milliequivalent Milligram MyocardialInfarction Millimeter Minutevolume Newbornintravenousnutrition10%dextrose

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N.PR ABBREVIATION Na+ NAD NaHCo3 NBM NEC NG NGT NICU NND NP NPO NS NVD O2 OA OB OG OR OTT Oz P P.I.E p.m p.o(perorally) P.V PA PAChest PaCO2 PaO2 PapSmear ParaI,II Paw Pc PCO2 PDA PEEP PH PID PIE PIP Postop PP PPD

Nasalprongs MEANING Sodium Noabnormalitydetected Sodiumbicarbonate Nilbymouth Necrotisingenterocolitis Nasogastric NasogastricTube Newbornintensivecareunit Neonatal Nasophargyneal Nothingperorally NormalSaline Normalvaginaldelivery Oxygen Onadmission Obstetric Orogastric OperatingRoom Orotrachealtube Ounce Pulse PulmonaryInterstitialEmphysema AfterMidday PerMouth PerVaginum PosteroAnterior PosteranteriorchestxRay Partialpressurearterialcarbondioxide Partialpressurearterialoxygen PapanicolaousmearTest Indicatesthenumberoftimesawomenhasproducedaviable Infant(over500gramsand20weeksgestation) Meanairwaypressure AfterMeals CarbonDioxidepressure Patentductusarteriosus Positiveandexpiratorypressure HydrogenionConcentration PelvicInflammatoryDisease Pulmonaryinterstitialemphysema Peakinspiratorypressure AfterOperation PostPartum Purifiedproteinderivative(TBtest)

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PPH ABBREVIATION PPHN PPROM Preop PRN(prn) PROM PSV PTU PVH PVLorPVLM Q Q2h Q4h Qd q.h q.i.d RBS RDS Resp RHT ROP RSV Rt RTA SBR SFD Sg SGA SIMV SIPPV SLE Spec SpO2 SRM SSG(S/C) STAT SVD T&A TorTemp Tabs TAPVD TB TBW TE Tet

Postpartumhaemorrhage MEANING Persistentpulmonaryhypertensionofthenewborn Prelabourprematureruptureofthemembrances BeforeOperation Asindicated,asnecessary Prolongedruptureofmembrances Pressuresupportventiliation Phototherapyunit Periventricularhaemorrhage Periventricularleucomalacia Every Every2Hours Every4Hours EveryDay EveryHour Fourtimesaday Randombloodsugar Respiratorydistresssyndrome Respiration Radianthearttable Retinopathyofprematurity Respiratorysynctivalvirus Right RoadTrafficAccident Serumbilirubin Smallfordates SpecificGravity SmallforgestationalAge SynchronisedIMV SynchronisedIPPV Systemiclupuserythematosis Specimen Oxygensaturation Spontaneousruptureofmembrances SplitSkinGraft Atonce SpontaneousVaginalDelivery Tonsillectomy&Adenoidectomy Temperature Tablets TotalanomalouspulmonaryVenous Tuberculosis Totalbodywater Expiratorytime TetralogyofFallot

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TGA ABBREVIATION TI TKVOorTKQ TOF TPN TPR TTN TUR TV Type&Xmatch UAC URTI UTI UVC V/Q VDRL VG VLBW VSD Vx WBC Wt ZIG

Transpositionofthethegreatvessels MEANING Inspiratorytime Tokeepveinopen Trachealoesophagealfistula Totalparenteralnutrition Temperature,Pulse,Respiration Transienttachypnoeaofthenewborn TransurethralResection Tidalvolume Typeandcrossmatch Umbilicalarterialcatheter UpperRespiratoryTractInfection UrinaryTrackInfection Umbilicalvenouscatheter Ventilationperfusion VenerealDiseaseResearchLaboratory VolumeGuarantee Verylowbirthweight Ventricularseptaldefect vertex Whitebloodcount Weight Zosterimmuneglobulin

FoetalpositionandPresentation
ABBREVIATION LOA(ROA) Lop(ROP) LOT(ROT) LSA(RSA) LSP(RSP) LST(RST) MEANING LeftOcciputAnterior(right) LeftOcciputPosterior(right) LeftOcciputTransverse(right) LeftScrumAnterior(right) LeftScrumPosterior(right) LeftScrumTransverse(right)

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Abbreviationforuseontheabstracts(MedicalRecords)
ABBREVIATION Aband ve +ve ABD ADM AKA AMA ANESTH ASSESS BF BKA C CA Cardio CCU CxR D.U Derma Disc DOB DOD EBL ER FH FMW FRH FSI FSII G.A G.S Gyne HOSP HR ICU IM(int.Med) Lab LOS MM MOH MR MRH MSI MEANING Abandoned,Abandonment Negative Positive Abdomen Admission AbovekneeAmputation AgainstMedicaladvice Anesthesia,Anesthetist Assessment BlueFiles,BurmperFiles BelowKneeamputation Centigrade,Celsius Cancer Cardiology Coronarycareunit ChestXRay DuodenalUlcer Dermatology Discharge DateofBirth DateofDischarge EstimatedBloodLoss EmergencyRoom FamilyHistory FemaleMedicalWard FemaleRehabilittion FemaleSurgicalI FemaleSurgicalII GeneralAnesthesia GeneralSurgery Gynecology Hospital HeartRate IntensiveCareunit InternalMedicine Laboratory LengthofStay MaleMedical Ministryofhealth MedicalRecord MaleRehabilitation MaleSurgicalI

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MSII ABBREVIATION N.Sur NBN Nephro NpN NSG O.Surg O.T OB OH Onco OPDI OPDII Ophthal Ortho P&P PAT Pedia Phar Pl.Surg PMH PPN PT Pulmo Rehab RX,TX,TRT SICU Sur T0

MaleSurgicalII MEANING Neurosurgery Newborn Nephrology Nursingprogressnote(s) Nursing OralSurgery OccupationTherapy Obstetrics ObstetricalHistory Oncology OutpatientDepartmentI OutpatientDepartmentII Ophthalmology Orthopedic Policy&Procedures Patient Pediatrics Pharmacy PlasticSurgery PastMedicalHistory PhysicianprogressNote(s) Physiotheraphy pulmonary Rehabilitation Treatment SurgicalIntensiveCareUnit Surgery Temp

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DentalAbbreviations
ABBREVIATION GC Abg Adh AG AgPt AL Alg Amg ApRep B BAWON Beh BL BOP BLUP BW CA CA(OH)2 Carbo Cav CR&BR CUDET CLDET Cem ChX CL CPTIN CR CTG Cutt Cx D DB DFDBA DI DO DPC DSK E/IOE Epi ETB ETTB MEANING ThreequarterGoldCrown Autogenousbonegraft Adhesive Attachedgingival Silverpoint Attachment Alginate Amalgam Apicallyrepositioned Buccal Brokenappointmentwithout Behavior Bonelevel/loss Bleedingonprobing Buildup Bitewingradiograph Citricacid Calciumhydroxide Carbocaine Cavitron Crownandbridge Completemaxillarydenture Completemandibulardenture Cementation Chlorhexidine CrownLength Communitybasedperiodontalindexoftreatmentneeded Crown Connectivetissuegraft curretage Cancelled Distal Distoincise Demineralizedfreezedrilledboneallogant Dsitolingual Ditsoligual Directpulpcap Drysocket Extraoral/infroaralexamination Epinephrine Electrictoothbrush Endtufttoothbrush

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EXT ABBREVIATION F FB FBImp FGCR FGG FI Fin&pol FL FMX FPCR FPDET GCR GI GP GTR I IUCDET ILUDET IE Imp IP IPE IPX IRM KF Ks L L(cricted) LA LHA Lido

Extract/extraction MEANING Facial Fissureblock Fullbonyimpaction Fullgoldcrown Freegingivalgraft Flossinstruction Finishandpolish Floride Fullmouthxrays Fullprocelan FixedpatialDenture Goldcrown Glasslonomer Guttapercha GuidedTissueRegulation Incisal ImmediateUppercompletedenture Lowerimmediatecompletedenture Initialexamination Impression Initialpreparation Initialperodntal Interproximal Intermediatedrestrorative Kelacf Ketlacsilver L:ingual Left Localanesthesia Lingualholdingarch Liocaine

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AbbreviationNOTtobeused
ABBREVIATION BT D/C C.S.T IJ Mg SC,SQ,SUBQ TIW U IU Q.D.,Q.O.D X.Omg Ms,MSo4,MGSO4 H.S T.I.W S.C.orS.Q. D/C c.c. A.S.,A.D.,A.U. MEANING BedTime Usedinmorethanonesenseoftheword Discontinue. Discharge. ContinueSameTreatment Injection Microgram Subcutaneous Twiceorthricetimesaweek Unit Internationalunit Everyotherday Trailingzero Magnesiumsulfate,MorphineSulfate HalfstrengthorLatinabbreviationforbedtime Threetimesaweek Subcutaneous Discharge Cubiccentimeter Latinabbreviationforleft,right,orbothears

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IPPNO:.MR026

INDEX
Sl.No. 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 TITLE RegistrationofNewpatients AuthorizationofStaffMembersMakingEntryIntoMedicalRecordsCharts (File) RetentionofMedicalRecords ConfidentialityofMedicalRecords SecurityofMedicalRecords ICD10AMCodingandDataAbstracting MedicalRecordsTrackingSystem PatientMedicalRecordIdentification RecordingByVariousHealthCareProvidersInpatientsMedicalCharts/File ContentsofMedicalRecords CompletionofMedicalRecords ReviewofMedicalRecordsForQuality PhysicianOrderTelephone&VerbalOrders QuantitativeAnalysis StaffingofMedicalRecordsDepartment FilingAndRetrievalofMedicalRecords TranscriptionofDischarge/DeathSummariesandOperativeReports ReleaseofMedicalRecordsorInformation ExecutiveInformationaboutThepatientsShallBeLocatedIntheFaceSheet GuidelinesofCorrectionofEntriesIntheMedicalRecords EnteringLaboratoryResultsIntoPatientsRecords ParticipationofMedicalDirectorIntheRecordsQualityManagement Program MedicalRecordAnalysisandCompletion StorageRecordAnalysisAndCompletion Abbreviations PolicyNo. 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018 019 020 021 022 023 024 025

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