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