MEDICAL RECORDS DEPARTMENT

Bharati Hospital & Research centre.

Dhankawadi, Pune-43.

MANUAL
1) INTRODUCTION –
Medical record is a document containing sufficient data written in sequences of events to justify
the diagnosis, warrant the treatment given & the results. It should be complete, accurate, reliable,
relevant, timely & easily accessible. For sound and smooth functioning of the hospital, an update MRD is
very much necessary. It stores all the medical records of the in patients & OPD patients. In Bharati
Hospital, MRD stores all IPD documents &OPD papers are stored at Registration counter. Medical
Records are important for M.L.C. as well as academic purposes & for M.C.I. inspection.

2) LOCATION- On third floor of the hospital.

3) AREA- Approx. 2500 sq. feet

4) SCOPE OF SERVICES- a) Issuing IPD files of the patients.

b) Ensuring completeness of records before storage.

c) Storage & retrieval of files.

d) Provide data for Research purpose &education.

e) Medical Audit for quality.

f) Providing statistical data to Govt. bodies.

g) Ensuring confidentiality of Medical Records.

5) ORGANOGRAM-
Executive Director

Medical Director

Deputy Medical Director

In charge MRD

Staff
6) STAFFING-
Category Total no.

I/C & Medical Record Officer 1

Clerks 5

MPW 2

7) Timings of staff-
9.00am to 5pm.

8) S.O.P.
a) Allocation of Registration No. This remains same for OPD & IPD patients at the registration
counter when patient comes in hospital.

b) For IPD patients new files are furnished with Primary data of the patient including Reg. No.
IPD No. name, age sex, address, contact No., next kin’s name & address & phone no. doctor’s
name under whom admitted, ward No., Date of Admission.

c) Files are then sent to wards along with the patients.

d) After the patient is discharged, Sister sees for primary completion (like discharge card &
reports) of files & then files are sent to billing.

e) Once the billing is done, files are sent to MRD.

f) MRD checks for completion of files. If any documents are missing, files are sent to respective
Wards for completion.

g) If the file is complete, papers are checked & assembled properly.

h) The, entry is made in separate register for received files.

I ) ICD coding is checked which is done in the ward by resident doctors, verification is done ,if
necessary modified in MRD by MRO & entered in system; file is scanned & stored.
 j) Files are stored according to IPD No. serially & year wise.

k) Retrieval & issuance of files document retrieval as per the request.

l) Receiving & storing of files with due documentation.

m) Discharge summary/ Cards written by residents and signed which is then checked &
countersigned by lecturer or H.O.U. whoever is present.

n) Before giving the discharge card to patent, it is Xeroxed & attached to the files.

o) All original reports are given to patients when demanded. Xerox of all the reports are kept in
files. In MLC files attested Xerox copies of reports are given to patients & original reports are
kept in file.

9) Process flow of M.R.D.

Files received in M.R.D. from billing

Check for deficiency

Incomplete complete

Return to Ward or Billing Entry in Daily Register

Complete ICD coding verification

Scanning

Stored serially with IPD No. &

Year wise.
 Process flow
Request for files

Wards in case from billing & admin. From CMO in case Mediclaim
dept.
Of readmission dept. (Only in Exceptional Cases) of MLC.

Filling of requisition form with due signature.

Final bill & yellow sheet is removed in case of Wards.

Receivers sign is obtained in file issue register.

File issue entry in system

Issue period

 Ward – For Readmission Till Patient is discharged

 Billing & Admin. – 10 days. (Only In Exceptional Cases)
 CMO – 7 days. (MLC)
 Mediclaim dept. -3 days.

File deposited within period File not deposited within period

Attach final bill & yellow sheet to file Follow up letter to ward with copy to admin.

Entry in file register / in system Follow up letter to billing HOD with copy to admin.

Storage Follow up letter to CMO with copy to admin.

Follow up letter to Mediclaim dept. with copy to admin.

File received Files not received

Enquiry by Admin.
10) POLICY-
a) Safeguard of Medical Records.

b) To maintain confidentiality of reports of the patient.

c) Once file is received, deficiency will be checked & if the file is complete, it will be
marked in register. ICD coding is checked which is done in the ward, entered in system;
file is scanned & stored.

d) Xerox copy of duly signed discharge card is compulsorily attached to the file. Patient gets
signed discharge card. Even if patient goes DAMA , he will get discharge card.

e) No short forms in final diagnosis to be used by residents. It creates problems for coding.

f) If the file is incomplete in any form, it will be sent to the wards. It will be the responsibility of
the Sister I/C or next Incharge in case of her absence. She will sign the register.

g) If the file is issued to Ward for Re-admission of the patient, entry will be made in the separate
register, as well as in computer.
Old file not to be sent to billing along with new file after the patient is discharged, it should come
to MRD.

h) Files will be issued to residents for academic purpose only, after H.O.U. signs the
requisition form.

I) In case file is required by TPA or for any insurance claim, patient brings letter of insurance
company along with request application.

j) If paper or reports are missing from the file, ward I/C sister is informed & file will be returned.
It will be responsibility of the sister incharge to return the file duly completed.

k) If there is deficiency in entry by the residents, reminders are sent to Residents.

l) Xerox copies of all reports should be attached to the file.

m) Policy for MLC files-

- All original reports should be maintained.

- In case original reports are demanded by the patient, true copy of reports are
maintained, taking sign. of the patient for carrying the original reports.

- Red sticker is put on the MLC file.

- MLC file must be signed by the C.M.O. in case the file has deficiency, CMO does
not sign the file and returns to the wards.

- If the investigations are done outside, then also, copy of reports should be
maintained in the file.

n) Death files carry black sticker on it.

o) M.L.C., files should be compulsorily given back to wards for completion after billing is

done. Then only they will be received by MRD.

p) Policy for retention of files-

 IPD files - 5years

 OPD Papers - 3years
 Death files - 10years
 MLC files - 30years

q) Policy for destruction of Medical documents of more than five years

IPD medical documents of general files are destroyed after 5 years none of which are
MLC or death files, after taking consent of Board of officers.

Files are discarded by the method of shredding.

11) Check list of documents – present in the file –

1) Final bill, yellow sheet

2) Xerox of discharge card.

3) Death Certificate (if any) form for PMC signed by the doctor.

4) Continuation sheets having history, physical examination notes of the patient.

5) Consent forms.

6) Preoperative anesthesia checkup.

7) Operative notes.

8) Anesthesia notes.

9) ICU transfer summary.

10) ICU daily notes.

11) Nutritional profile/diabetes sheet.

12) Nurses Records & charts (TPR, BP, I/O)

13) Lab. Investigations form containing note of samples sent to Lab.

14) All reports .

12) SCANNING IN MRD-
1) Scanning plays important role in operation of MRD.

2) Scanning has been recently started in MRD i.e. from 1st April 2013. Presently scanning

of files from 1st April 2013 has started. Backlog files will soon be scanned.

3) 2 scanners of Fujitsu (model fi-6125, A4 Size) have been installed.

4) Software of scanning is in cooperation with e-biz India.

S.O.P.
1) Files of discharged patients come to MRD next day.

2) Once files come to MRD, they are checked thoroughly for completion.

3) After checking, assembling of papers in proper order is done.

4) Group of different papers in IPD files are separated by attaching barcode stickers of

different cabinets on that.

5) Scanning is then done according to PRN.

6) After scanning, indexing is done, but soon the papers to be scanned will have

preprinted barcode so that indexing will be done automatically.

7) Once indexing is done, quality check by MRO is done. After Q.C. file is ready to be

viewed by doctors in the hospital. In DRM (Doctors Retrieval Module ) special

passwords are given to treating doctors for reviewing these records in OPD when

required. It is purposely done for making confidentiality.

 COMPUTERIZATION OF MRD
It is done since January 2011. Patients detail data including Name, Age, Sex, Address, IPD No.,

OPD No, Ward, Date of Admission, Date of Discharge, Doctor under whom he/she admitted, diagnosis is

entered in the Computer. For this process Lifeline software developed by Manorama Info solutions

Pvt. Ltd is used.

Retrieval of file is easier with computerization as it can be easily found out to whom the file has

been issued. With recent software, it is possible to find out IPD No. of the file if the patient has lost his

discharge card. By the name/diagnosis/date of admission the IPD No. can be found out. Also

statistical data of the patients for the particular disease and for particular period can be known. Also,

MRD maintains on line issue/receipt register of files. IPD No of files, to whom the file is issued e.g.

Ward/billing/CMO/resident, date of issue and also from where the file is received, date of receipt is

entered in the computer

 ICD 10
ICD is the most widely recognized medical classification maintained by WHO.

Its primary purpose is to categorize diseases for morbidity and mortality reporting. Medical

coding is the process of transforming descriptions of medical diagnosis and procedures into universal

medical code numbers.

Medical classification system is used for

1) Statistical analysis of diseases

2) Reimbursement purposes
3) For decision based support system
4) Direct surveillance of epidemic or pandemic outbreaks

ICD 10 was endorsed by 43rd WHO assembly in May 1990 & came into use in WHO member states

from 1994.It is important because it provides common language for reporting and monitoring diseases.

This allows the world to compare and share data in a consistent and standard way between hospitals,

regions, countries and over periods of time.

SOP
1) For ICD coding Principle /final diagnosis is taken into consideration.

2) As stated earlier mostly coding is done in wards by resident Doctors.

3) This already given code is again verified by MRO in MRD.

4) If correct entered in software system by clerk.

5) If any change required, modified by MRO.

6) For this correction ICD-10 book published by WHO is used.

7) If necessary help of treating doctors is also being taken for confirmation.

8) Also the software for coding is downloaded in system for reference.

9) Lecture to create awareness about accurate coding is conducted once in a year for Resident

Doctors.

10) After confirmation code is entered in system & thus the file with complete data of patient

with ICD code is stored permanently in the system.

 BHARATI HOSPITAL, PUNE
MEDICAL RECORD ROOM

CHECK LIST FOR GENERAL IPD FILES

1. Final Bill, Yellow sheet

2. Xerox of Discharge Card with final diagnosis.

3. Death Certificate (if any)

4. Case Sheets.

Includes - 1) Doctor's notes

2) Consent forms

3) Pre-anesthesia check-up notes

4) Operative notes

5. I.C.U. sheets including transfer sheets.

6. Nursing sheets, charts.

7. Reports: Xerox of X-ray report, USG, 2D Echo, CT Scan, MRI - compulsory

If lab reports & ECG are taken by the patient, signature of the patient

should be there on file.

8. In case of DAMA, stamp on the file and consent of the patient for DAMA.

9. Signature and stamp of the resident doctor on the case sheet.

 BHARATI HOSPITAL, PUNE
MEDICAL RECORD ROOM

CHECK LIST FOR MLC IPD FILES

1. MLC record filled by CMO.

2. CMO signature & stamp.

3. OPD paper of CMO.

4. Bill & Yellow sheet.

5. Discharge card (Original or Xerox copy).

6 Case sheets.
Includes - 1) Doctor's notes.
2) Consent form.
3) Pre-anesthesia check-up notes.
4) Operative notes.

7. ICU case sheets, transfer papers.

8. Nursing papers

9. Investigations - All the reports (Original or true copy) of Lab, X-ray, ECG, USG,
2D echo, CT scan, MRI. & other investigations.
If original reports are demanded by the patient, signature of the patient
for receiving the same is taken & true copy of reports is retained.

10. In case of DAMA, stamp on the file and consent of the patient for DAMA.

11. Check for discharge given by the physician.

12. Sister In charge should sign the file after discharge, when it is duly completed.

13. In case of MLC , sister should ask for application from the patient if he requires
x-ray, CT-MRI, plates. She takes the sign of the patient on application after
handing over the plates to him. She should write down the name of x-ray, x-ray
no., no. of x-ray plates in the envelope.

14. Signature and stamp of the resident doctor on the case sheet.