MEDICAL RECORD

MANAGEMENT
WHAT IS MEDICAL RECORD?
• The medical record is a legal document providing a chronicle of a patient's
medical history and care.
• Physicians, nurse practitioners, nurses and other members of the health
care team may make entries in the medical record.
• The medical record includes a variety of types of "notes" entered over time
by health care professionals, recording observations and administration of
drugs and therapies, orders for the administration of drugs and therapies,
test results, x-rays, reports, etc.

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 USE OF MEDICAL RECORDS
1. To document the course of patient’s illness & treatment.
2. Communicate between attending doctors and other health Care
professional providing care to the patient
3. Collection of health Statistics.
4. Legal Matters & Court Cases
5. Insurances Cases

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USE OF MEDICAL RECORDS

6. Filing & retrieving records necessary for continuity

of care as well as for audits & research
7. Assembling of records in a logical order
8. Deficiency check of the records

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Meaning of medical Record Management

• The planning, controlling, directing, organizing, training,

promoting, and other managerial activities related to the creation,
maintenance and use, and disposition of medical records to
achieve adequate and proper documentation of A health
care organization's policies and transactions.

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 COMPONENTS OF MEDICAL RECORD
– Front Sheet or identification Summary Sheet
– Consent for Treatment
– Legal Documents like referral letter, request for Information etc
– Discharge Summary, referral slip
– Admission notes, clinical progress notes, Nurses progress note
– Operation report if operation has been performed
– Investigation reports like, X-ray, pathology etc
– Orders for treatment and medication forms listing daily medications
ordered and given with signatures of the doctor prescribing the treatment
and the nurse administering it.

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SEQUENCE OF MEDICAL RECORD
• Information & identification sheet
• Clinical Notes
• Doctor’s progress notes
• Blood Transfusion notes
• Nurse Notes
• Informed Consent
• Diagnostic reports
• Discharge Report
X-ray Films are stored Separately

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For the department to function efficiently the medical record
must be Accurate, Complete, and Timely. Of course, the
caregivers shall Legibly write it.
Primary role is safe guarding the records and to issue them on
demand.
• 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

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RECEIVE OF PATIENT RECORD IN MRD

Nursing Unit keeps the patient

record after the discharge of the
patient

A list of patient records is prepared & given to

MRD with patient case Sheet

After sorting of records, details Yes No MRO conveys to the Nursing

are written in the Death register, Checking unit In-charge for the same
patient record register as per the of Records & returns the record
case sheets

MRD is filed in cabinets/racks

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after labelling
FUNCTIONS OF MEDICAL RECORD
DEPARTMENT
• Filing of Medical records.
• Retrieval of medical records for patient care and other authorized
use.
• Completion of medical records after an inpatient has been discharged
or died.
• Coding diseases and operations of patients discharged or having died
• Evaluation of the Medical Record Service.
• Completion of monthly and annual statistics.
• Medico-legal issues relating to the release of patient information and
other legal matters.
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• MRD maintains records of treatment of patients and generates
statistical information important from the administrative, public
health, research and evaluation point of view. The significance of
records as documentary evidence, liable be summoned in the
courts of law, further underlines the necessity of efficient
management of the department.

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 Quality of service in this department
The most important yard sticks for are-the time taken
for retrieval of information, its accuracy and
completeness. For that it is essential that MRD has
the infrastructure as per the norms and follows
standardized policies and procedures

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Policies of MRD with medical
records are

numbering,
checking,
indexing, filing,
safe storage,
preservation,
confidentiality and
retention of records.

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ISSUE OF MEDICAL RECORD NUMBER / UID
NUMBER
• Medical Record Numbering Systems are HOW WE GIVE A
NUMBER to Medical Records.
• The MRN (Medical Record Number) should be issued in
straight numerical order from the NUMBER REGISTER
commencing with the number 1. For example, if the last number
given to a patient were 342, the number issued to the next
patient would be 343 and the next 344 and so on.
• In a Computerized System, UID / MR Number is auto generated
and there is OPD visit number & IPD Visit Number

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LABELING OF MEDICAL RECORD FOLDER
• The following should be written on the medical record folder:
• Patient’s name;
• Patient's medical record number
• Year of last attendance

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CODING
oAfter analysing the record for completeness, medical records are received
for coding.
oThe discharged inpatient medical records are coded daily, the MRD
technician will refer the list of the discharges for the medical records that
are to be coded.
oAt the time of coding, review is done of the inpatient admission sheet,
discharge summary, history and physical examination sheet, progress
notes, consultation notes, operation notes and all investigations.
oThe final diagnosis mentioned in the admission record, is compared with
the discharge summary and also compared with history – physical
examination report, operative and pathological report to identify
discrepancies.
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INDEXING
oEach medical record is coded according to the diagnosis and
treatment given.
oAfter coding the records are received for indexing. In indexing the
entries are made in the register and in the computer.
oIn the register the entries are made according to continuous IP nos.
oThe details included are: IP number, date of admission, date of
discharge, name of the patient and other demographic details,
addresses permanent and present, final diagnosis, ICD -10
oAfter the entries is done in the register, its then entered in the
computer according to the codes given.

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oEnsure that the primary diagnosis has been listed first
and any secondary codes are listed in the correct
coding sequence.
ICD coding
o ICD refers to International Coding of Disease.
oThis is done in the department using a book of ICD
codes.
oThe code is different for different disease.
E.g.: malaria B50.9 , viral fever A92.8
oCode is given to the identified diagnosis, operation and
procedure, which is written on the inpatient admission
record in the column marked ICD code.
oThe analyst has to sign against the blank space
provided in the in-patient admission record. 19
SEQUENCING AND FILING THE RECORDS
• The records are first arranged as per the IP number and then
set of 50 are made to file these up in the storing section.

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 RETENTION OF MEDICAL RECORDS
Sl.No Particulars Period of retention disposal

1 OP records(non MLC) 5years Destroyed after completion of 5

years from last visit of the patient
2 IP records(non MLC) 10 years Discharge summary stored as a
soft copy, IP records are destroyed.

3 IP records( MLC) permanent Do not destroy

4 IP death records permanent Do not destroy
5 Radio diagnosis permanent Do not destroy
films(MLC/death)
6 Radio diagnosis 10 years Destroy after 10 years completion
films(credit)

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FOLLOWING IS THE LIST OF REPORTS
ARE SENT TO THE REGULATORY BODIES

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