AIM oF THE MANuAL

The aim of this Manual is to help medical record workers to develop and manage the medical
record services of health care facilities in developing countries in an effective and efficient
manner

NAME CHANGES AND DEFINffiONS

In some countries, the title of persons responsible for the medical record service has changed
from Medical Record Officer and Medical Record Administrator to Health Information Manager
and Health-Information-Administrator;- In-many-developing - countries, the title Medical Record
Officer or Medical Record Clerk is still used. In this Manual, the title MEDICAL RECORD OFFICER
(MRO) or MEDICAL RECORD CLERK will be used, but should be substituted for the title commonly
used in your country.
• Also, in many countries, the Medical Record Department is often referred to by another name,
such as Medical Record Room, Clinical Information Services or Health Information Department.
Again, in this Manual, it will be referred to as the MEDICAL RECORD DEPARTMENT You should
also substitute this with the name commonly used in your country.

The Medical Record Department is a busy department and the work of medical record clerks is
highly demanding. Although staff are not directly involved in patient care, the information
recorded in the patient's medical record is an essential part of that care. The Medical Record
Department staff are, therefore, required to perform an essential service within the hospital.

. Medical record staff, therefore, must be resourceful and dedicated to worlcing in a busy and
important section of the hospital. With knowledge and experience, they will fmd the job both
satisfying and rewarding.

To maintain an effective medical record service, medical record officers need the support of a
Medical Record Committee. They need to be able to bring important issues relating to medical
record services to the Committee for discussion. In doing so, they also need to ensure that the
issues are carefully recorded and presented to the Committee in a clear and objective manner.
The Medical Record Committee will be discussed in more detail later.

FUNCTIONS oF A MEDICAL REcoRD DEPARTMENT

• development and maintenance of the master patient index (MPI) for patient identification;
• retrieval of medical records for patient care and other authorized use;
• discharge procedure and completion of medical records after an inpatient has been
discharged or has died;
• coding diseases and operations of patients discharged or having died;
• filing medical records;
• evaluation of the medical record service;
• completion of monthly and annual statistics; and
• medico-legal issues relating to the release of patient information and other
legal issue

The main uses of the medical record are:

• to document the course of the patient's illness and treatment;
• to communicate between attending doctors and other health care professionals
providing care to the patient;
• for the continuing care of the patient;
• for research of specific diseases and treatment; and
• the collection o f health statistics.
ONE PATIENT ~ ONE MEDICAL REcoRD NuMBER = ONE MEDICAL REcoRD

COMPONENTS OF A MEDICAL RECORD:

From this time, the medical record develops with many forms added as the patient is treated and
cared for in the ward. The physical medical record will eventually consist of the following:
• medical record forms;
• a clip or fastener to hold the papers together;
• dividers between each admission and the outpatient notes; and
• a medical record folder.

MEDICAL REcoRD FoRMs:

The medical record is made up of a number of forms, which are all used for a specific purpose.
The basic set of forms in the inpatient medical record includes:
• front Sheet or identification and summary sheet, which contains identification, fmal diagnoses
and the doctor's signature;
• consent for treatment is often on the back of the Front Sheet and must be signed by the patient
at the time of admission. There are two parts to this form. The first halfof the form is a general
consent for treatment and the bottom half is consent to release information to authorized
persons;
correspondence and legal documents received about the patient, e.g., referral letter, requests for
information, etc.;
discharge smnmary, if required by the hospital/health authority;
admission notes, including provisional diagnosis (the reason the patient came or was brought to
hospital), presenting symptoms, physical examination and proposed care. progress notes are the
daily recording of the patient's treatment and progress written by doctors and other health care
professionals;
nursing progress notes chart the daily nursing care;
operation report is used if an operation or operations are performed;
other health care professional notes, e.g., physiotherapy; social workers, etc.; pathology reports
include haematology; histology; microbiology, etc.;
other reports - X-rays, etc.;
medication chart - daily medications given; and
nursing observations - special nursing form for observation of head injuries, etc.
THE ORDER oF FoRMS AS LISTED ABoVE IS REcoMMENDED.

SoME IMPORTANT PoiNTS ABOUT FoRMS IN THE MEDICAL RECORD

• Forms should all be of the same size, usually A4.
• The patient's name and medical record number, and the name of the form should he: in
the same place on EVERY form.
• Only official forms approved by the administration or Medical Record Committee (if
there is one) should be included in the medical record.
The following is a sample medical record form. Sections A, B, C, D and E of the sample form
remain the same on all forms. Section F is different for every form, as it is where the content of
each form is written.

CLIP OR FASTENER
• Papers should be held together in the medical record either by a clip or fastener. Staples should
N O T be used as they tend to rust and additional forms cannot be easily added. Some countries
use a large fastener, which is secured in the top left-hand corner of the medical record.
• A two-pronged clip can be threaded through clip holes in the folder or can be attached to the
folder by the adhesive backing.
• It is best to use plastic rather than metal clips. Metal clips can cut fmgers or rust.

MEDICAL REcoRD DIVIDERS

• It is good practice to separate each admission by a divider; the divider will be slightly wider
than the forms in the medical record and have a tab on which to write "l" Admission," "2nd
Admission," etc.
• In addition, if combined with the inpatient notes, all outpatient notes can be stored behind an
outpatient divider.
• For specialist outpatient records, a separate divider could be used for the clinic, e.g.,
"hypertension clinic," "heart clinic," etc.

MEDICAL REcoRD FoLDER

• All medical record forms should be kept in a medical record folder. This should be a manila
folder and, if possible, stronger cardboard folders should be purchased.
• Medical record folders should be filed on their spine so that the medical record number is
clearly visible for filing purposes.
Everyhospital,healthcentreandDepartmentofHealthshouldBUDGETANNUALLY for medical record
stationery.
On the medical record folder should be written the
• patient's name;
• patient's medical record number; and • year o f last attendance.

MEDICAL INFORMATION SHOULD NoT BE REcoRDED oN THE FOLDER.

REsPONSIBILITY FOR MEDICAL REcoRDs:

The primary function of a hospital, clinic or other health care facility is to provide quality patient
care to all patients, whether an inpatient, outpatient or emergency patient. The hospital
administration is legally responsible for the quality of care given to patients and relies on the
doctors, nurses and other health care professionals to see that the care given is documented
correctly in the patient's medical record.
The MRO or person in charge ofthe Medical Record Department is responsible for the functions
of that department and for seeing that the medical record is available when needed for the
continuing care of the patient. They are also responsible for:
• seeing that all forms relating to the care of a particular patient are in that patient's medical
record;
• that the medical record has been completed by the doctor;
• diseases and operations are coded accurately; and
• all information produced for statistics is accurate and readily available when required by
the administration, Ministry of Health or other government agency.

MEDico-LEGAL IssuEs
The medical record is an important legal document
It is important that the MRO is aware of the need to maintain confidentiality and the patient's
right to privacy. As the person in charge ofthe Medical Record Department, they are responsible
for seeing that UNAUTHORIZED PERSONS DO NOT have access to the medical record and that
information is not given out without the patient's written consent

The physical medical record is the property of the hospital and the information in the medical
record is the PROPERTY OF THE PATIENT and cannot be released without the consent of the
patient. Exceptions to this rule include the use of the information
• by doctors and other health professionals for the continuing care of the patient;
• for medicL research where the patient is NOT identified; A.Lld
• for the collection of health care statistics when the individual patient is NOT identified.

PATIENT IDENTIFICATION AND NUMBERING:

AN INPATIENT IS A pATIENT WHO HAS BEEN ADMITTED TO THE HEALTH CARE FACILITY.

RESPONSIBILITY FOR PATIENT IDENTIFICATION

The responsibility for correcdy identifying a patient rests with the clerk who interviews the
patient in the admission office or outpatient department

UNIQUE PATIENT CHARACTERISTIC

In order to identify patients, we need a UNIQUE PATIENT CHARACTERISTIC. The type and number
of unique patient characteristics used will change from country to country and are defined as:
SoMETHING ABOUT A PATIENT THAT DoEs NoT CHANGE.
In some countries, the unique patient characteristic often used is the patient's mother's maiden
name, that is, the mother's name before she was married. This is something that does not
change .
In many countries, however, patients attending a health care facility do not know their mother's
maiden name or their own date of birth, and are often unsure of their exact age. Each country
will need to decide on a unique patient characteristic that will assist with the identification of a
particular patient. There is no limit to the number of unique patient characteristics that can be
used. Some useful unique patient characteristics are:
• a national identification number or social security number;
• date of birth;
• health insurance number;
• mother's maiden name;
• mother's first name;
• father's first name; and
• biometric characteristic, e.g., fmgerprint or footprint in the case of a new-born infant.
The following are NOT considered unique characteristics.
• Where a person lives is NOT a unique patient characteristic because it can change.
• A person's age is NOT a unique patient characteristic because it DOES change.
• Although this should not change, it is important that a patient's birthplace NOT be
used, as it is often identified by most people as being the place where they "come from" as
opposed to the place where they were actually born.

EFFECTIVE pATIENT IDENTIFICATION IS THE BEGINNING OF AN EFFICIENT NlEDICAL REcoRD

SYSTEM.

MEDICAL REcoRD NuMBERING SYsTEM

The term used for this number varies from hospital to hospital and country to country and can
be referred to as the hospital number, patient identification number, unit record number, or
medical record number. We will call it the MEDICAL RECORD NUMBER (MRN).
PATIENT IDENTIFICATION AND NUMBERING
17

MEDICAL REcoRDs MANuAL

•
The MRN is a permanent identification number assigned in STRAIGHT NUMERICAL SEQUENCE by
the admission staff and recorded on all medical record forms relating to that particular patient.
An important point is that THIS NUMBER IS THEN USED TO FILE THE MEDICAL RECORD. Thus, it is
important to malce sure that the number is correctly assigned and recorded on all forms in the
patient's medical record.
Note that MEDICAL RECORD NUMBERING SYSTEMS are HOW WE GIVE A NUMBER to medical
records.

NUMBER REGISTER
As mentioned above, MRNs are issued from the NUMBER REGISTER, which is the origin of the
patient identification numbering system and is a numerical list of numbers issued to patients.
That is, it is a book of numbers in numerical order. This method of issuing numbers
is simple, easy to assign and easy to control
ONE PATIENT ~ ONE MEDICAL REcoRD NuMBER= ONE MEDICAL REcoRD

ADMISSION REGISTER
At the time of admission, a patient may already have a medical record number and a medical
record, so a new number is NOT issued. The hospital, however, needs to keep a daily list of ALL
admissions. ALL patients admitted, whether admitted for the first time or the second, third or
fourth time, are listed in the ADMISSION REGISTER. From this register, a daily list of ALL
admissions is made.
D o N o r CoNFUSE THE ADMISSION REGISTER WITH THE NUMBER REGISTER.
••••••
CONTENTS

CONTENTS OF THE ADMISSION REGISTER

Family name and given name.
Reason for admission (presenting disease/illness).
Date of admission.
Date of discharge.*
Discharge alive/dead.·
Other details may include doctor's name, sex, date of birth/age, ward, etc.
*Include date ofdischarge and alive/dead ifadmission and discharge register are combine

You MusT NoT MisTAKE THE NuMBER REGISTER FOR THE ADMISSION REGISTER

The NUMBER REGISTER is where a number is given to each patient on his or her first admission
to the hospital to IDENTIFY THE PATIENT, and to IDENTIFY HIS or HER MEDICAL RECORD and to
FILE THE MEDICAL RECORD.
• The ADMISSION REGISTER is a register listing ALL admissions - re-admissions as well as new
admissions. The ADMISSION REGISTER is used to produce the admission statistics.

DAILY ADMISSION LIST

The Admission Office usually prepares a DAILY ADMISSION LIST containing the patient's full name,
patient's MRN and the ward where the patient has been sent. A copy of the ADMISSION LIST is
sent to the Medical Record Department to check that a Master Patient Index card has been made
for all new patients. This is why it is best that the Medical Record Department staff control the
Number Register. A copy of this list is also sent to the Accounts Office and inquiry desk.

FRONT SHEET
Identification data are collected and recorded on a FRONT SHEET, which is the first form in the
medical record. The information is also recorded on an ADMISSION CARD. In some countries, this
task can be performed at the same time using carbon paper to save duplication and subsequent
errors. The FRONT SHEET goes with the patient to the ward (with the old medical record, if any)
and the admission card is sent to the Medical Record Department to enable the preparation of
the MASTER PATIENT INDEX CARD. The business/accounts office where the patient's accounts are
prepared may also require this information and the Admission Card may be sent there first for
processing before being sent to the Medical Record Department.