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MEDICAL RECORDS DEPARTMENT 1of 3

1. PURPOSE

To define procedure for the preparation, issue, and storage of patient records.

2. SCOPE

Covers all types of medical records, both for outpatient and inpatient.

3. RESPONSIBILITY

Vice President,Human Resource Manager, M.R.O, Staff.

4. PROCEDURE

1.1 Out Patient

1.1.1 In the case when the patient attending the hospital for the first time, either the
patient himself or his bystander is reporting to the new registration counter, wherein the
requisite fees for consultation shall be collected and patient identification cards as well as the
bill shall be issued.

1.1.2 The O.P card for each patient shall be prepared with a Hospital number. The
patient details like name hospital number, Address, etc shall be collected and entered in the
O.P card.

1.1.3 The O.P number shall be numeric.

1.1.4 In the case when the patient requires consultation, the relevant O.P card along
with other documents like investigation reports etc, shall obtained from the storage rack.

1.1.5 In case when a patient requires consulting more than one O.P department, the
same O.P card shall be used, marking the different OP name.

1.1.6 The O.P cards for different departments, after registration, shall be kept
separately so that the concerned staff can transfer the case file to the O.P.D concerned.
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MEDICAL RECORDS DEPARTMENT 2of 3

1.1.7 After the day’s consultation, observations, test/investigation, diagnosis,

treatment etc. The ANM concerned shall return case file along with relevant
reports to them M.R.D. The O.P cards hence collected shall be stored in the
appropriate place in the racks provided. The O.P serial number shall be the
base reference for the identification & storage of O.P cards.

1.1.8 The storage racks shall be properly identified with hospital numbers, so that
the case files can be easily retrieved without any delay for future use. The
registers for issue/return for the case files shall be maintained only for I.P.

1.1.9 MRD in charge sees that all files are returned by the end of the day and are
stacked at the correct location wise. A consolidated list of records not
returned over a period of time is also maintained to follow for proper return
of records.

1.1.10 The case files and other relevant records pertaining to the medical care,
including reference letters, for a particular patient shall be attached together.
The issue, use, return, storage etc are to be handled with at most care.

1.2 In Patient

1.2.1 In case when the medical officer recommends for admission for a particular
patient, the ANM / Causality shall bring the case file from the MRD.

1.2.2 I.P file having details like patient name, O.P number, I.P number, etc in the
cover page shall be prepared. The records, investigation reports, consent
forms duly filled by patient/bystander, and blank copies of forms for future
use etc are attached to the file.

1.2.3 The IP number shall be numeric.

1.2.4 After the discharge, the I.P file shall be taken off and the same shall be
stored in appropriate place in the records storage racks. Investigation reports
shall be stored in I.P file storage racks systematically.

1.2.5 Incase more than one admissions take place then also the same number and
the relevant IP record shall hold good.
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Revision status 00
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MEDICAL RECORDS DEPARTMENT 3of 3

1.2.6 The old files are issued as per the requirement, and shall be returned and
stored back at the appropriate location after use. The records of issue/return
of files shall be maintained.

4.3 General – Other Activities.

4.3.1 The patient records viz. O.P card and I.P file, for medico legal aspects shall
be issued and safe return ensured by authorized person.

4.3.2 Claims / Reimbursement Certificates etc are issued on request.

4.3.3 Discharge certificates are issued for IP cases, after discharge.

5 RECORDS

New Registration Register

Expired Register
I.P & O.P Register
Birth Register
Dispose Register