Coding & Indexing
Coding & Indexing
14.0 OBJECTIVES
After going through this unit, you should be able to:
define the medical record ;
enlist the purposes of medical records in relation to patient, doctor,
hospital and medical education and research; and
enumerate the steps in planning and organization of medical records
department in a hospital.
14.1 INTRODUCTION
In the first unit of this block, you have learnt about the planning and the
organization of CSSD. In this unit you will learn about another important area of
hospital i.e. Medical Record Department. In the beginning you will learn about
the definition of medical record including its purpose, planning, organizing and
staffing consideration. You will also learn about physical facilities planning,
procurement and flow of medical records. Further you will learn about the storage
and retrieval of medical records including functions and reports and return in a
hospital. Towards the end of this unit, you will learn about the medico legal
aspects of medical records.
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Medical Record
14.2 DEFINITION Department
Continuous development has taken place in the field of medical records over the
period from the initial primitive form. The first medical records unit was
established in 1667 at St. Barthlomew’s Hospital in England followed by the
practice of maintaining Patient’s register in Pennsylvania Hospital in the USA in
1752. The impetus to the idea of proper medical records in the form of standardized
inpatients records came in USA from the American College of Physicians and
American College of Surgeons in the first quarter of the current century.
In India, medical record keeping has not developed to the same extent as in
western hospitals. Bhore Committee (1946) first stressed the importance of
keeping adequate medical records, which was repeated by Mudaliar Committee
in 1962. Subsequently Health and Hospital Review Committees (Jain Committee
and Rao Committee) highlighted the poor state of medical records in Indian
hospitals and recommended the establishment of a proper medical record section
in each hospital.
With the technological advancement, the medical record keeping in hospitals
has undergone a rapid change over the last few decades. The computers are now
being extensively used for record generation, analysis, and retrieval. Effective
method such as microfilming was introduced for easy storage and retrieval.
The medical record is defined as a clinical, scientific, administrative, and legal
document relating to patient care in which are recorded sufficient data written in
the sequence of events to justify the diagnosis, warrant the treatment and results.
During the course of hospitalization, the skills of many medical and paramedical
specialists are utilized. They examine a patient, undertake required investigations
and institute the therapy. Recording of the entire finding results in the medical
records, which is necessary so that the record of the care and treatment given is
available to the physicians attending the patient.
The medical record therefore is:
A document of facts, which contains statements by trained observers of
condition found and the application and the result of the examination and
therapy.
It also indicates whether the efforts of the doctors, supplemented by the
hospital and related facilities are in accordance with the reasonable
expectations of the present day’s scientific medicine.
You must have gone through medical records of a patient admitted in hospitals.
You will appreciate that the medical record as such is a package of forms, case
sheets placed in chronological order of occurrence of events and investigation
reports. The nature of forms, lab reports and even case sheet recording may vary
from hospital to hospital. Classically the medical record of a patient contains the
documents arranged in the following sequence:
Admission form
Case sheet comprising of:
- Medical history
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Support and - Clinical findings
Utility Services-I
- Investigation ordered
- Treatment instituted
- Progress reports
- Consent form for surgery or specialized procedures
- Anaesthesia check record, if applicable
- Notes on surgical/special procedure, if applicable
- Lab reports in chronological sequence of their ordering
- Films along with their reports.
You must also have noticed that at the time of discharge a narrative summary is
usually made. This along with the discharge form is generally placed in the first
position when the record is finally stored so that the reviewer can quickly see the
course of the patient’s hospital stay.
Medical records for the outpatients should also be prepared, processed, and stored
in the same manner as the inpatient’s records. This is done in most modern
hospitals attached to teaching and research institutions. Each individual attending
an OPD is given a registration number and all the medical records are kept in a
folder bearing the same number. The patient is issued a ticket/token bearing the
registration number.
The individual at the OPD record room sends the folder to the appropriate
department on the presentation of token. The folder is deposited back after the
visit.
To achieve the unique task of maintaining and storing medical records in good
order, a medical record department is an integral part of hospitals irrespective of
its size and type. In a smaller hospital, PHC or a subdivisional hospital it may be
in the form of medical record section rather than a full-fledged medical record
department.
14.3 PURPOSE
The medical record is indispensable from the standpoint of the patient, the doctor,
and the hospital and for medical education and research. The purpose it serves in
relation to these aspects is as under:
The patient: You will agree that the primary reason for record keeping is to
improve the care of the patient. It is essential for immediate diagnosis, treatment
and for the future welfare of the patient. Every illness, however, minor involves
study and examination to the extent that it is impossible for any individual to
keep all details in mind. The written report is evidence that the patient’s care is
being handled in a scientific manner. Other points in relation to this are:
It serves to document the clinical story of the patient’s illness and course of
the disease.
It serves to avoid omission or unnecessary repetitions of diagnostic and
treatment measures.
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It assists in continuity of care in the event of the future illness. Medical Record
Department
It serves as evidence in the event of when the legal question arises.
Provides necessary information for insurance, contributory health scheme or
for the employment purposes.
The doctor: From the point of view of doctor, the medical records serve as:
Assurance of quality, quantity and adequacy of diagnostic and therapeutic
measures undertaken.
An assurance of orderly continuity of medical care.
Evaluation of medical practice.
An aid in research and the continuing education of health professionals.
A protection in the event legal question arises.
The hospital: From the hospital point of view the medical records are necessary
for the following purposes to:
Document the type and quantity of work undertaken and accomplished.
Furnish proof of the type and quantity of care rendered to the patient.
Evaluate the proficiency of the individual doctor, for administration and
clinical purposes.
Evaluate the services of the hospital in terms of accepted norms and standards.
Protect the hospital in the event of legal matters.
Serve as an administrative record of personnel performance and staffing needs,
budget preparation, justification for physical facility allocation and utilization,
statistical data for administrative use and evaluation, estimating equipment
and supplies utilization and needs.
Assist in future programme planning.
Medical education and research: Medical records can also be used for the
medical education and research in the following ways:
Recorded observations are the basis for all clinical research.
Group studies of records by the medical staff serve to further the education
of doctors and other health personnel.
Medical records supply pertinent data for the use by public health authorities
in control of the diseases.
Incomplete Completed
Records Discharged
Control Desk Records
Coding and
Indexing Desk
Completed Discharge
Completed Patients Analysis Desk
Files
Records Index Card and Vital Statistics
Admission
Check
Desk
Fig. 14.2: The Chart Showing the Movement of Medical Records upon
Discharge of a Patient
Indexing
The various forms of indexing as under of the medical records is done depending
upon the purpose:
(d) Physician’s index: Catalog containing the details of all patients treated by
physician. Analysis of such records may be utilized for evaluating the
performance of a physician. Columns can be made in the card based on the
information desired.
(e) Unit index: Details of all the patients treated in a particular unit are indexed.
These records may ultimately be utilized to evaluate the performance of a
particular unit.
If the total number of annual deaths in regions are 200, then this population
needs 100 general beds. This formula is used extensively for planning medical
care facilities in a region.
Check Your Progress 1
Fill in the blanks:
The usual value of the following are:
(a) Maternal mortality rate ..............................................................................
(b) Post operative death rate ............................................................................
(c) Caesarian section rate ................................................................................
Medico legal records should always be kept in safe custody, i.e. under lock and
key. Separate medic legal record movement register should be maintained at the
medical record department. Any movement of the medic legal record along with
its purpose should be recorded in the aforesaid register. A responsible person
from the medical record department should be detailed to present the medic legal
records in the court of law whenever the need arises.
14.11 COMPUTERIZATION
14.11.1 Hospital Information System (HIS)
In present day life, emphasis of healthcare has shifted from just patient care to
delivery of quality patient care which can stand the scrutiny of peer review, medical
audit and the legal system. Information Technology (IT) is an integral part of the
hospital and the vast amount of data in hospital operations underscores the need
to integrate all information systems under a uniform umbrella of an integrated
Hospital Information System (HIS).
It should have the ability to store and retrieve accurate, timely & consistent data,
effectively report those data, and allow transferability of data to other applications
within a hospital environment. It is to enhance quality of care through an integrated
computerized clinical information system for improved hospital administration
and patient health care by managing all the aspects of a hospital’s operation,
such as medical, administrative, financial, and legal issues and the corresponding
processing of services. It should be installed keeping in mind the access control
system, patient identification system, data communication standards and data
security.
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HIS Modules Medical Record
Department
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