Question

write down the government rules and regulations towards maintenance of medical record department

Answer 1

1. ROLE & IMPORTANCE OF MEDICAL RECORDS Mahboob ali khan MHA,CPHQ Consultant Healthcare2. Location & Days and Hours of Operation • The Medical Records Department should be located adjacent to the Front Office • The Medical Record department have to function 24 hours on all the days to cater the Medical Records immediately.3. About MRD – Bridges the gap between medical and non-medical departments. – Enables continuity of care to the patients without difficulty at appropriate time – Headed by MS 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. – Primary role is safe guarding the records and to issue them on demand4. Guiding Principles of the Department • 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, WHO5. CODE OF ETHICS MEDICAL STAFF • Bound by Professional Secrecy and Oath PARAMEDICAL STAFF • MEDICAL RECORD PROFESSIONALS, NURSES, OTHER PARA MEDICAL STAFF TO MAINTAIN. • Confidentiality about patients, disease, treatment & end results. • Not to divulge any type of information about patients. • Abides by Ethical principles.6. What is a medical record ? • It is a document containing sufficient data written in sequences of events to justify the diagnosis, and warrant the treatment given and the end results. 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 record7. 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.8. HOSPITAL STATISTICS • 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.9. Registration counter Consultants I.P O.P Admission Medical records Deficiency check Assembling and coding Computer entry Scanning Permanent filing Wards Indexing