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Medical Record Auditing at Delhi

  • Rashmi Chaudhary
  • Agency : Medical Record, Record Auditing, Electronic Medical Record System
  • Objective : 1.To study medical record department of the Hospital and suggesting best practices 2.To understand process flow of medical records in different departments 3. To audit manual medical records, 4. To study electronic medical record system in the hospital and Manual Records, identifying needs, problems and suggesting implementable solutions, 5. To highlight major observations, 6. To recommend implementable solutions.
  • Background : Medical   record serves as a means of doctor’s self assessment.Medical records provide pertinent patient care information to authorized organizations.The records are important to the public health authorities as they contain reliable information regarding morbidity and mortality patterns,Medical Records provide patient care information to third party payers.Medical Records protects the patient, physician, as well as the health care institution and its employees in the event of litigation.
  • Methodology : Stratified random selection of MRs to assess their contents and the no. of records depends upon the no. of records available the medical record department, selection of a respondent (doctors & MR persons) and department visit to understand their record flow process, records of patient admitted, records of patient getting operated in hospital and consulting doctors was selected as tool. Survey, Interview direct observation method was done to collect data. Documents (MR files and forms, policies, procedures), HIS Hospital and MR department persons & doctors were the data sources
  • Findings : The study found that medical record department follows the one-unit numbering and filing system (i.e. the patient has one MR for outpatient visits, admission, and emergency). Filing systems are standardized. There is cabinets and shelving system of record keeping. Percentage of compliance of one unit numbering system ranges from 95% to 100% in the hospital.
  • Recommendations : Not Available
To study medical record department of the Hospital and suggesting best practices