Support and

Utility Services-I UNIT 14 MEDICAL RECORD DEPARTMENT

Structure
14.0 Objectives
14.1 Introduction
14.2 Definition
14.3 Purpose
14.4 Planning, Organization and Staffing
14.5 Physical Facilities
14.6 Processing of Records and Their Flow
14.7 Coding and Indexing
14.8 Storage and Retrieval
14.9 Reports and Returns
14.10 Medico Legal Aspects of Medical Records
14.11 Computerization
14.11.1 Hospital Information System (HIS)
14.11.2 Electronic Medical Record (EMR)
14.11.3 Electronic Health Record (EHR)
14.12 Let Us Sum Up
14.13 Answers to CheckYour Progress

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.

32
 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

33
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.
34
 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.

14.4 PLANNING, ORGANISATION AND STAFFING

Medical record department is generally organized as per requirement of individual
hospital. However, at times, such department in a larger hospital may cater for a
group of smaller hospitals in situations where computerization of record keeping
has been done. The main factors that govern the organization of work in a medical
records department are:
 Medical records should always be available when required and in the form,
they are required.
35
Support and  Adequate liaison should exist between different groups of staff using medical
Utility Services-I
records to enable to give due consideration to matters such as design and
contents, method, and storage availability, use and movement of records.
 Procedures should cause patients the minimum of waiting and inconvenience.
The overall responsibility for the efficient functioning of the medical record
department is that of the administrator. However, the department should function
under the direct supervision of medical record officer/librarian who should be
given authority commensurate to the responsibility assigned.
Necessary assistance to the functioning of medical record department is given by
the ‘Medical Records Committee’ which is policy making body and which meets
periodically to reviews the forms, records, existing policies, and procedures. It
evaluates the functioning of medical record department. The committee is
composed of:
 Representative of the clinical discipline
 Representative of the nursing staff
 Member from the pathology services
 Administrator
Organization
The medical record department is generally organized as under:
Admission and Enquiry Office: You must be knowing that all admission to the
hospital takes place through this office. You will also appreciate that this office
initiates documentation of inpatients, maintains records of all admissions,
discharges, and deaths, collects the documents after discharge and forwards the
same to the central record office for further processing. It keeps up to date
information of bed occupancy status of each ward. This office operates round the
clock and provides all necessary information to the patients and their relatives.
In the hospital where charges are levied for any services, this office may also be
performing the task of collecting and depositing the cash unless there is a separate
billing section.
To perform the assigned tasks the office has the following sections:
 Admitting office
 Admission check desk
 Census desk and
 Enquiry office
Central Record Office: The central record office is organized to perform the
following functions:
 Receipt, checking, assembly and storage of all medical records of discharged
patients.
 Discharge analysis and statistics.
 Coding of all diagnosis as per International Classification of Disease.
 Indexing of all discharged patients by disease, doctor and so on.
36
 Making records available for medic legal purpose. Medical Record
Department
 Issue of medical certificates of various types.
 Send notification of all communicable diseases to the public health authorities.
 Issue of all records to the medical officers whenever required.
 Preparation of monthly abstracts and annual statistical details.
 Dealing with inquiries from Life Insurance Corporation regarding disease
and cause of death of the insure.
 Training of all categories of personnel.
 Storage of all types of forms used in the hospital.
Keeping this in view, the medical record department is organized as under:
 Office for Medical Record Officer (MRO) and Asst. MRO.
 Document processing area consisting of:
- Assembly and deficiency check desk
- Incomplete record control desk
- Coding and indexing desk
- Discharge analysis and vital statistics desk
 Record storage
- Active record storage
- Inactive record storage
Outpatient Record Section: As discussed earlier, in all modern hospitals attached
to teaching institutions, an elaborate system of documentation and storage is
established for outpatients. These records are as important as that of inpatients.
However, with the overwhelming load of outpatients and other factors, most
hospitals in the governmental sector do not maintain OPD records in India.
Staffing
The staffing of medical record department depends upon the size, type and services
being provided by the hospital. Dr. J. R. McGibony had suggested staffing pattern
for a 500 bedded non - teaching hospital as under:
 Medical Record Officer : 1
 Medical Record Technician : 4
 Clerks : 3
 Peon : 1
 Statistician : 1 (on part time basis)
For comprehensive services, in addition to MRO staff as under may be considered
for a teaching hospital of 500 bed and above. Each category of personnel should
be computer literate.
 Admission and Enquiry Office
 Asst. Medical Record Officer : 1
 Medical Record Technicians : 5
37
Support and  Medical Record Attendants : 4
Utility Services-I
 Receptionist : 5
 Central Record Office
 Asst. Medical Record Officer : 1
 Medical Record Technicians/Asst.
Medical Record Technician/ Clerks : 8
 Medical Record Attendants : 8
 Statistical Asst. : 1

14.5 PHYSICAL FACILITIES

While planning physical facilities for a medical record department, you should
take the following into consideration:
Location
Central admission and enquiry office should be located near the main entry of
the hospital in close proximity of the outpatient department and accident and
emergency services as the majority of the patient in the hospital come to these
departments and admitted through these areas. The outpatient records section
should also be located in the outpatient department near its main entrance. Central
medical record office may form a part of administrative wing. Since this office
deals with inpatient records, it should be in close proximity to the inpatient areas.
Space and General Facilities Requirement
(a) Admission and Inquiry Office: A space of 125-175 sq.ft. is considered
adequate. Counter should be aesthetically made to facilitate easy
communication between staff and clientele. General office equipment will
mainly be required for the staff working here. Separate counters for admitting
clerk, receptionist handling information and billing clerk should be provided.
The room should have adequate waiting space with facilities for waiting,
toilet for the staff, patient, and their attendants. Telephone with facility local
calls/STD must be made available.
(b) Central Record Office
(i) The space requirement depends upon the size of hospital. As a rough
guide a space of 2 to 3 sq.ft. per bed may be sufficient. The details are
as under:
50 bedded hospital : 150-175 sq.ft.
100 bedded hospital : 225-250 sq.ft.
200 bedded hospital : 450-500 sq.ft.
500 bedded hospital : 1000-1200 sq.ft.
(ii) This area may be sufficient to store inactive medical records also. The
space for this may be in the general record storage area or on a separate
floor. Space ranging from 120 sq.ft. to 500 sq.ft. with adequate shelves
will be required.
38
 (iii) In addition to the computers if the functioning is computerized, general Medical Record
Department
office equipment for the medical record technicians/clerks will be
required. Adequate facility for holding meetings, medical staff/trainees
to pursue the record needs to be catered.
(c) Outpatient Record Section: Average 2-3 square feet per bed of space is
required for outpatient record section also. A space of 150 sq.ft. for the 50
bedded hospital to 1200 sq.ft. for a 500 bedded hospital may be adequate for
the outpatient records. Separate counters for the registration of old and new,
male, and female patients are to be provided. Counters 24" wide, 40" high
with file drawers beneath is required. Waiting area adjacent to registration
furnished with chairs, benches, announcement boards and health education
visual aids need to be catered.

14.6 PROCESSING OF RECORDS AND THEIR

FLOW
Steps in Initiating Records: Flow chart showing development and movement
of medical records upon the admission of a patient is given in Fig 14.1.
Admitting Office

Admission List Admission Records Copy of Admission List

Census Desk Nursing Unit Check Desk Admission

Information Desk Incomplete Patient

Index Card

Incomplete Records Control Desk

Fig. 14.1: Flow Chart Showing Development and Movement of Medical Records upon the
Admission of a Patient.

Whenever a patient present for admission the steps involved are:

 Initiate Inpatients Records: The admitting office keeps assembled set of
blank clinical record forms which are initiated whenever the admission of a
patient takes place.
 Fill in a Patient Index Card: Usually a 3" x 5" card with patients identifying
data such as name of the patient, address, date of birth, sex, name of father
and so on is filled at the time of admission of the patient. This card is retained
in a file in alphabetical order to give information regarding patient.
 Inscribe in an Admission Register: The identification data of a patient with
date of admission as and when admitted.
 Identifying Number: Each patient is given a unique identifying number,
which is recorded in all the documents. Unit or serial system is followed in
39
Support and assigning the number. Under the unit system the patient on his first admission
Utility Services-I
receives a number which is the identification of all the documents pertaining
to him in all subsequent visits/admissions. All documents are filed in the
same folder. This system is suitable for hospital serving a population of
defined catchment area and ordinarily gives repeated care to the patient over
a long period. Under the serial system the patient receives a new serial number
on each admission and records for each admission are filed separately or
brought forward and filed together in the folder of the most recent admission.
Most hospitals begin a new series of numbers at the beginning of each fiscal
year with the admission number followed by the year such as 1973-99.
 Medical records so initiated on admission containing patient’s admission
number and identification data are sent to the ward with the patient.
 The important actions taken by various functionaries at the admitting office
are summarized below:
(a) Admitting Office
 Initiates patient’s hospitalization record
 Assigns admission number
 Prepares Admission record:
(i) Admission number
(ii) Identifying Data
(iii) Signature of authorization
 Sends patient to nursing unit
 Sends admission record to nursing unit
 Sends copy of admission record to admission check desk
(b) Admission Check Desk
 Receives admission advice from Admitting office
 Checks patient index for previous admissions
 Enters this admission on patient index card of previous admissions
 If no previous admission, make new patient index card
 Sends index card to incomplete record control desk
 Sends records of previous admission to nursing unit
 Prepares record folder with admission record and name and sends it
to complete records control desk
 Makes entries to register.
(c) Census Desk
 Prepares admission list from admitting office
 Collects discharge patient records from nursing units daily
 Prepares discharge list
 Prepares census reports
Medical Records at the Inpatient Unit: The patient documents in the ward are
filled in by the attending doctors, residents and interns for history, physical
40
examination, orders for diet, treatment, operation procedures and progress notes. Medical Record
Department
Nurses fill in the charts for temperature pulse and respiration.
Medical Records Upon Discharge: The attending doctor completes all the entries
in the clinical case documents including preparation of discharge summary and
discharge slip. Case documents are submitted to the medical record department.
The movement of medical records and action taken upon discharge are depicted
in Fig. 14.2.

Nursing Unit Assembling and Assembled

Census Deficiency Discharged
Discharged Desk
Records Check Desk Records

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

At the medical record office action taken by the various functionaries is

summarized below:
(a) Assembling and deficiency check desk:
 Receives discharge patients record from census desk
 Assembles records in standard order and staple binds
 Checks deficient entries on record
 Sends records to incomplete control desk
(b) Incomplete Records Control Desk:
 Receives discharge record from assembling desk
 Receives index card from admission check desk
 Maintains “In hospital” file of index cards of patients not discharged
 Maintains gone “home file” of index cards of patients discharged but
whose records are incomplete
 Sends reminders to doctors of incomplete records
 Completes patient index card for discharge patients whose records are
complete
41
Support and  Sends index card to admission check desk for filling
Utility Services-I
 Sends records to discharge analysis desk.
(c) Vital statistics desk
 Collects birth reports, enters data into the birth register and submits reports
to municipal authorities
 Collects death report, enters data into death register and submits report
to the municipal authorities
 Collects infectious disease reports enters data into the register (If
maintained) and submits reports to the municipal authorities
(d) Discharge analysis and administrative statistics desk
 Receives records from incomplete records desk
 Enters discharge date in register
 Analyzes and develops statistics and daily, monthly or annual reports for
the entire hospital, each service, each doctor, as required, on such items
as:
(i) Admissions
(ii) Discharge
(iii) Births
(iv) Deaths
(v) Rates
(vi) Gross results
(vii) Hospital days
(viii) Length of stay
(ix) Occupancy
(x) Patient by age, sex, religion and geographic distribution
(xi) Operations
(xii) Autopsies
(xiii) Consultants
(xiv) Occupations
(xv) Others
(e) Coding and indexing desk
 Receives records from discharge analysis desk
 Codes diagnosis and operation on medical records, using International
Classification of Disease and Operations
 Enters data into 5x8 inch diagnostic and operation index cards
 Prepares medical statistics
(f) Completed records control desk
 Receives records from coding desk
 Checks for full processing
42
  Places records in folder and stores vertically in permanent file shelves Medical Record
Department
for quick and easy accessibility
 Make available records on readmission of patient and for research and
group studies
 Maintains records of withdrawn medical records, sends reminders for
return

14.7 CODING AND INDEXING

Coding

In each medical records International Code Number is assigned to the diagnosis

based on “International Classification of Disease” issued by the World Health
Organization. This is to bring about accuracy and uniformity in the reporting of
the diseases by the various hospitals.

Indexing

The various forms of indexing as under of the medical records is done depending
upon the purpose:

(a) Alphabetic or Master Index: Indexing based on patient’s name sequenced

in alphabetic order. The primary purpose of a name index is to provide entry
into the filing system and finding out medical record for a patient. The patient
index card is usually 3"x5" card giving identification data, registration number,
address, date of admission, date of discharge, diagnosis, and department to
which admitted.

(b) Disease index: Disease index is a catalogue of cards of 3"x5" or 5"x8",

maintained to find out groups of clinical records of patients having the same
diagnosis. Besides patient’s identification data, age, sex, result of treatment
and complication may also be mentioned.

(c) Operation index: It is a catalogue containing the details of patients who

have undergone the operations. Additional details such as site, procedure
used, postoperative complication as a result may be documented.

(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.

14.8 STORAGE AND RETRIEVAL

Storage
Completed medical documents are stored in the main medical records by
43
Support and following a filing system. The following factors are considered for an effective
Utility Services-I
filing system:
(a) Compactness to reduce physical effort and cost of storage space.
(b) Accessibility for speedy location and identification.
(c) Simplicity for understanding of all concerned.
(d) Economical both in the cost of installation and operation.
(e) Elasticity to expand according to future requirement.
(f) Tracer system for document in circulation.
System of Filing: Any one of the following can be followed for filing:
(a) Decentralized system: Under this system inpatient and outpatient department
have their own individual records and file them independently within the
department. If a patient is transferred from one department to another the
file may be loaned to other department. This system is labor intensive and
the operating cost is higher.
(b) Centralized system: In the centralized system, medical records are filed
centrally in the medical record department. The centralized system is more
efficient, provides better control and followed in most hospitals.
Methods of Filing: The various methods available are:
(a) Numerical method
(b) Alphabetical method
(c) Chronological order
(d) Terminal digit system
(e) Mid digit system
Numerical method of filing is the commonest method in use. As already discussed
in Section 14.6, each patient is given a unique number at the time of his
registration/admission and the filing is done in the numerical order. This method
is most suitable for retrieval of files. The disadvantage of the system is that the
files are added to one end of the system, which usually is the furthest from the
working area and most active for retrieval and filing purpose.
In alphabetical and chronological order, the filing is done in alphabetical sequence
of their names and sequence based on their date of admission respectively. The
system requires maintenance of indexes to allow access to the documents as
maintained in the libraries.
The terminal digit system consists of six numbers. In case the numbers are less
than six digits, zeros are added to precede the number. Terminal two digits are
the primary numbers, whereas the two middle digits become the secondary
numbers and the last two digits being the sequence number of a particular file.
Dividing the storage spaces into 100 equal parts running from 00 to 99 creates
the primary section. The primary section is further sub divided into 100 equal
parts again running from 00 to 99. To retrieve a particular file, say 123456; one
should locate primary section 56 and secondary section 34. Twelfth file is in the
secondary section will be the required file. In the middle digit system, the middle
44
two digits are the primary number, the first two digits the secondary number and Medical Record
Department
the last two digits the sequence of file in the secondary section.
Filing Procedure
Types of Files: It is useful to use files of different colors for different years for
easy retrieval and identification. Files should be of uniform standard size
depending upon the size of forms in use in a hospital. For the most forms a
standard size of 8½”x11" is preferable. The filing jacket should be½” bigger
than the length and width of the biggest form in use.
Filing: The three types of filing procedure are generally used as under:
(a) Vertical
(b) Suspended
(c) Horizontal
The vertical system is universally used in which the file is kept vertically on its
spine or edge and supported by the other files or cards within the section. Open
storage steel racks with shelves of standard size are suitable for the storage.
This system is economical, affords easy reference, adaptability, and scope for
extension.
In the suspended system especially made filing cabinets are required and the
records are suspended from frames in drawers in the cabinet. The system is costly
and not easily adaptable, but the security of the documents is better.
In horizontal filing the medical records are inserted in folders/files which are
kept one upon another in a chronological order of records is difficult and storage
in orderly manner cannot be maintained. Whenever any record is taken out, it
usually upsets the other records.
Microfilming of Medical Records for Storage: In large teaching hospital the
space for medical records storage may pose a big problem. Microfilming may be
the only answer for inactive storage of medical records. The advantages of
microfilming are:
(a) Saving of space: 90 % of the space can be saved if the records are
microfilmed.
(b) Easy accessibility: Due to easy storage in a smaller area, the accessibility of
the records to students, faculty and staff become very easy.
(c) Protection: Micro filmed records cannot be easily tempered.
(d) Elimination of misfiring: Incorrect filing of the records is impossible after
the same has been filmed. They can be easily classified and stored.
(e) Saving of time and manpower: More economical in the long run because it
reduces the waste of time and manpower.
Microfilming requires special equipment such as microfilming camera, processors,
viewing machine, duplicating and photostat machine in addition to certain
expendable items such as microfilming rolls, fixer and developer. Micro filming
technicians will also be required for the purpose.
45
Support and Computerization of Medical Records: Technological advances and decreasing
Utility Services-I
cost of computerization have brought about revolutionary changes in the medical
records system, their storage and retrieval. Key to the future is the computerization
of medical records. Today it is possible to even store all types of images such as
that of X-ray, CAT Scan and MRI. By networking the system throughout the
hospital, it is possible to give desktop access to doctors, nurses, technicians, and
administrators and yet maintaining the confidentiality of the whole system. It
has by and large replaced the need of microfilming
Retrieval of the Medical Records: The retrieval of medical records is usually
required for any of the following purposes:
(a) When the patient attends to follow up
(b) Patient is admitted in the ward or casualty for observation
(c) When the files are issued to research workers for academic purposes
(d) For medical reimbursement and
(e) For producing in the court of law for medic legal purposes
The method of retrieval will depend upon the system of storage being followed
in an institution. In a conventional system where, medical records have been
stored in shelves, the file is traced by the number allotted. The file folder is taken
out and a tracer card is placed in its place as a marker. The tracer card contains
basic information regarding the recipient of the document such as the name of
the borrower, purpose for which the documents are required, date of issue,
identification data of the documents issued and the signatures of the individuals
issuing and receiving the documents. The tracer card remains in its place until
the file is returned.

14.9 REPORTS AND RETURNS

Wide ranging reports and returns can be generated in the medical record
department. The basic purpose of these reports are:
(a) Evaluating the quality of care being rendered
(b) Locating the deficiencies in:
(i) Means: Staff, physical facilities, equipment including plants and machine
(ii) Methods: Operating policies and procedures
(iii) End results: Outcome of the benefits derived by the community from the
hospital
(c) Effectiveness of hospital administration and
(d) Prevention of the diseases
The types of reports and their frequency will vary with the type of hospital and
their administrative requirement. The reports may be generated daily, weekly,
monthly, quarterly and annually depending upon the requirement. The reports
generally pertains to:

46 (a) Vital Statistics

(b) ADT Analysis (Admission, Discharge and Transfer Analysis) Medical Record
Department
(c) General Health Statistics
Comprehensive list of such reports and returns cannot be laid out since there will
be so much variation from hospital to hospital. Some of the reports that can be
commonly generated by the hospital are:
(a) Reports Related to Hospital Bed
 Daily Census
 Maximum patients on any one day
 Minimum patients on any one day
 Daily average
 Bed occupancy rate
 Total patient days care
 Bed turnover interval
(b) Admission
 Daily admission
 Daily admission unit/specialty wise
 Total admission over a period
 Patients distribution by age, sex, religion and region
(c) Discharges
 Daily discharges
 Total patients discharged over a period
 Days of care to the patients discharged
 Average length of stay
(d) Deaths
 Daily number of deaths
 Total deaths over a period
 Total deaths over 48 hours
 Total deaths under 48 hours
 Net death rate
 Gross death rate
 Fetal death rate
 Maternal death rate
 Infant death rate
 Post operative death rate
 Anaesthetic death rate
(e) Workload Statistics
 Total number of outpatients:
- New cases
- Repeat cases 47
Support and  Total number of operations
Utility Services-I
 Total number of X-ray and other related investigations
 Total number of lab wise investigations/lab wise investigations
 Department wise workload statistics
(f) Hospital Care Evaluation Statistics
 Post operative infection rate
 Post operative complication rate
 Caesarian section rate
 Autopsy rate
 Rate of normal tissue removed
 Percentage of disagreement between final and pathological diagnosis
 Gross result of treatment, i.e. patients recovered, improved or not relieved
Following will give you clear understanding of some of the most commonly
used terms:
Admission
Admission is the acceptance of a patient by the hospital for inpatient service,
which may be for investigation and/or treatment. Normal babies born in the
hospital are not considered as admissions. The premature or diseased newborns
are considered admission. As a general rule the newborn figures are not mixed
up with other hospital data. These figures should be tabulated separately.
Discharge
Discharge is the release of an inpatient. Death of an admitted patient is also
considered as discharge.
Hospital Deaths
Death of an admitted patient is considered as a hospital death. Death of a patient
in the casualty, OPD or in an ambulance, before the actual admission of the
patient is not counted as the hospital death.
Total deaths of hospitalized patients is known as Gross Deaths. Total deaths after
48 hours of admission is considered net deaths.
A patient day is the period of service rendered to an inpatient between the census
taking hours of two successive days. While counting, the day of discharge of an
inpatient is not counted, irrespective of the time of discharge. Similarly, the day
of the admission is counted always regardless of the time of admission.
Patient day is a valuable unit used for expressing the various activities of a hospital
such as patient days of service rendered during a given period, cost of food per
patient per day etc.
Bed Complement
Bed complement is the number of hospital beds normally available for use by the
inpatient. It includes the following types of beds:
(a) Adult beds
48 (b) kids beds
(c) Bassinets for use of infants other than newborns Medical Record
Department
(d) Incubators for prematures
(e) Casualty ward beds
(f) Post-operative ward beds
(g) Intensive care unit beds
(h) Isolation beds
(j) Staff sickness beds
The following types of beds are not included in the bed complement of a hospital:
(a) Recovery room beds
(b) Observation beds of casualty
(c) Examination beds
The methods of calculation of some of the commonly used statistics are given
below:
Average Daily Census
Average daily census is the average number of patients in the hospital at a given
time per day and is expressed as:
Sum of daily census for a given period
Number of calendar days in the period
Death Rates
(a) Gross death rate:
Total number of hospital deaths during a given period x 100
Total discharges (including deaths) during the same period
(b) Net death rate:
Total deaths of in patients after 48 hrs of admission during a given period x 100
Total discharges (including deaths) during the same period
(c) Specific death rate:
Number of net deaths in a ward or department during a given period x 100
Total discharges (including deaths) in that department during the same period
Net death rate is used as an indicator of quality of care in an institution. In
advanced countries the value of this rate is about 4%. In India in the teaching
hospitals, it is about 6-7%. Similar institutions dealing with more or less the
same type of clinical material should show similar death rates. Excessive death
rates of the hospital should be investigated.
Percentage of Occupancy or Occupancy Rate
It is the ratio of actual patient days expressed as a percentage of the maximum
possible patient days (based on bed complement) during any given period. The
formula is:
Number of patient days (based on discharges) during a given period x 100
Bed complement x days during the same period 49
Support and Average Length of Stay
Utility Services-I
Average length of stay is the average number of days of service rendered to each
discharged patient during the given period of time. Patient days are compiled
from the discharge summary of discharged patient. The formula is:
Total patient days during a given period
Total discharges (including deaths) during the same period
Turnover Interval or ‘T’ Interval
‘T’ interval is the average period in days a bed remains vacant between one
discharge and another admission and is expressed as:
The maximum patient days-Actual patient days (Bed complement × period) during
a given period No. of discharges (including deaths) during that period
The value of ‘T’ may be negative or positive.
(i) A negative ‘T’ is indicative of scarcity of beds and over utilization.
(ii) A long positive ‘T’ is indicative of underutilization because of either defective
admission procedures or poorquality medical care.
(iii) A short positive ‘T’ is indicative of optimum utilization.
‘T’ interval is a very sensitive index of hospital utilization. It can also be used to
assess the bed utilization of different nursing units and departments.
Anaesthesia Death Rate
Number of deaths due to anaesthesia x 1000
Number of patients anaesthetised during a period
Post Operative Death Rate
Post operative deaths x 100
Total operative during a given period
The usual value of this rate is 1 to 2%. But it varies greatly with the type of
surgery being undertaken in an institution.
Maternal Death Rate
Total deaths of obstetric patients x 100
Total discharges (including deaths) of the obstetric wards
The usual value is less than 0.25%. Excessive rate should be enquired into.
Neonatal Death Rate
Total deaths of neonate during a given period x 100
Total viable newborns discharged (including deaths) during the same period
A neonatal death rate of more than 2% should be investigated.
Autopsy Rate
Number of pathological autopsies performed x 100
50 Number of deaths during a period
An autopsy rate of more than 15 to 20% indicates enquiry type of medical staff, Medical Record
Department
progressive in outlook.
Caesarean Section Rate
Total caesarean section performed x 100
Total viable births during a period
The normal value of this rate is 3 to 4%. A higher caesarean section rate should
be enquired into.
Consultation Rate
Total written consultation during a period x 100
Total discharge (including deaths) during that period
A consultation rate of more than 15 to 20% is indicative of high quality of medical
care.
Bed-Death Ratio
An extensive study of vital statistics and hospital data of different areas has
revealed that a close relationship exists between the deaths in a population and
number of hospital beds needed. It has been found that 0.5 general beds are
needed per annual death in a population.
In a population having 10 deaths per 1000, 5 beds per 1000 are needed in the
acute general hospitals for optimum medical care.

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 ................................................................................

14.10 MEDICO LEGAL ASPECTS OF MEDICAL

RECORDS
The medical records are not merely a collection of paper recounting the tale of
patient’s stay in the hospital. It is an important legal document and can help the
patient, aid and protect the doctor and act as a big shield to any institution. To
meet the legal requirement and avoid complication at a later date, medical records
must fulfill the following criteria:
(a) Complete: The records must contain sufficient data to identify the patient,
51
Support and justify the diagnosis, warrant treatment and outcome. These must contain all
Utility Services-I
basic records, nurses’ bedside records and special records as applicable.
(b) Adequate: The documents should not be sketchy. It must contain all necessary
form and all relevant clinical information.
(c) Accurate: Document should be so made that it is easily subjected to
quantitative analysis.
(d) Legible: The records must be legible which can be easily deciphered at a
later stage. The names of all the signatories must be written in capital letters/
affixed with the rubber stamp.
Ownership of the Medical Records
The medical record is the property of the hospital and not of the patient, the
clinical department or the attending doctor. The hospital is the owner and the
custodian of the document. The patient also has no proprietary right in the medical
record. The attending doctor should give the patient desired information. He is
also given a brief summary of his condition; the result of various tests and types
of treatment carried out in broad terms. Similarly, the doctor has no proprietary
right over the medical record. When he is given access to the record of a patient,
it is a courtesy extended by the hospital and not as a matter of right.
The medical records must be considered from two points of view:
(a) As a personal document: The information contained in the medical record
is confidential and privileged and cannot be publicly divulged without the
consent of the patient except under due process of law. If a patient is admitted
to another hospital, the written information can be forwarded through the
administration if requested for. Information with regards to the condition of
the patient and the date of admission, discharge, death or birth of child can
only be furnished to the friends or relatives.
(b) As impersonal document: As an impersonal document the contents of the
medical record can be used for education, research, and information to public
health authorities and so on without revealing patient’s identification data.
However, in public health interest some personal information is required to
be divulged whenever notification regarding disease is made.
Indian Evidence Act of 1872 as Amended
Medical records are the documentary evidence under the act and may be required
to be produced by a witness who may be a hospital representative or the treating
medical officer in some of the situations discussed below:
(a) In the court of law: The medical document may be summoned by the court
in the following types of suits:
 The hospital will be required to produce the same as and when asked for.
 Malpractice suits against the hospital employee or the hospital itself in
the civil court personal injury suits arising out of negligence or fault of
others and authorization for medical examination operation etc. Medical
examination carried out without the consent, expressed, or implied will
52
 usually amount to action assault. Similarly, any surgical intervention or Medical Record
Department
procedure without consent will also be tantamount to assault. The facts
rendered in the medical document can be invaluable evidence in deciding
all such cases.
 Cases in consumers courts.
 Medico legal cases in the criminal courts: As soon as the case is declared
medico legal, the medical officer is required by law to give a report
about injuries to the police whether treated outdoors or indoors. In all
such cases the hospital cannot be forced to hand over the original record
to the patient or to the police. They are however required to be produced
in the court whenever summoned to do so.
(b) Life Insurance Corporation of India: LIC frequently asks for details of
hospitalization or cause of death of the patient to dispose claim that arises
of insurance policy. Release of such information without the prior consent
of the patient is permissible because the patient has waived his claim of
this privilege at the time of taking a policy by signing a declaration to this
effect.
(c) Income tax: Under the proviso of section 38 (5) of the Act income tax officer
can call for the hospitalization records and the information have to be made
available for which no prior permission from the patient is necessary.
(d) Patients will: If a patient other than in mental hospital desire to make a will
he is ordinarily allowed to do so. If any questions arise at a subsequent stage
regarding the mental state of the patient at the time of making the will, hospital
medical records may be called for to decide on this point.
(e) Queries regarding birth or death: Vide Act 18 of Registration of Births
and Deaths Act, 1969, all birth and death occurring in the hospital are to be
notified to the registrar of births and deaths (Municipal bodies/cantonment
boards). This is done by making certificate to this effect and by making
necessary endorsement in the medical documents. Any questions arising to
this effect, the hospital may be required to produce the required certificates/
documents.
Retention of Medical Records
The factors affecting the retention period of medical records are:
 Need of the patient
 Medico legal requirement
 Education and research requirement
With the applicability of the Consumer Protection Act, it must be borne in the
mind that even an innocuous looking case may turn out to be very serious and
retention of documents must be done for sufficient long period. As a general
guide the documents,be retained for the following periods:
(a) OPD records : 5 years
(b) Indoor records : 10 years
(c) Medico legal records : permanently
53
Support and Safety of Records
Utility Services-I
Responsibility of safety of records lies with the administration. Proper records
of their movement must be kept during its transit from indoor to medical record
department or whenever a document is taken out for education/research. A
single person should control all medico legal records of the hospital, preferably
medical record officer or any other officer designated by the hospital
administrator.

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.

Check Your Progress 2

Fill in the blanks:

Medical records to be retained for the following period:

(a) Indoor patient .............................................................................................

(b) Medico legal case ......................................................................................

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).

Hospital Information System (HIS) is an integrated, computer-assisted system

designed to store, manipulate, retrieve, and analyze information concerned
with the administrative and clinical aspects of providing services within the
hospital.

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.
54
HIS Modules Medical Record
Department

Ser Category of HIS Purpose of HIS Modules

No Modules
1 Operation Management/ Registration
Patient Administration Appointment Scheduling
System Admission
Bed Management
Discharge/Transfer
Billing
Medical Record Tracking
2 Finance and Human Financial Accounting
Resource (HR) System HR Management System
Budgeting
3 Hospital Management Information System
Management System Doctor’s Compensation Management
Material Management
4 Support Service System Pharmacy/ Stores
Laundry and Housekeeping
Kitchen Management
Engineering/Maintenance Services
5 Clinical System Electronic Medical Record (EMR)
containing clinical assessment
Clinical Decision Support System
Order and Result Communication
including scheduling
Laboratory Information System (LIS)
with instrument interfacing
Blood Bank Information System
(BBIS)
Radiology Information System (RIS)
with Picture Archival and
Communication System (PACS)

14.11.2 Electronic Medical Record (EMR)

An Electronic Medical Record (EMR) is a digital version of chart stored in a
computer which contains all information of the patient particulars and patient
medical history. It is a computerised medical record created in a hospital and it is
mostly used by providers for diagnosis and treatment. This is not designed to be
shared with other health care providers agencies and patient record doesnot
easily travel outside the practice. In fact, the patient’s medical record might even
have to be printed out and mailed for sharing with another provider to see it.

14.11.3 Electronic Health Record (EHR)

An Electronic Health Record (EHR) is a digital record of patient health
information. It can also contain other relevant information, such as insurance
55
Support and information, demographic data, and even data imported from personal wellness
Utility Services-I
devices. This can be shared with other health care providers agencies. This allows
patient’s medical information to move with them. Access to tools that providers
can use for decision making.
In simple terms EHR refers to a real time, unique longitudinal health record of a
single individual containing his or her entire personal health information including
medical details like history, medical examination, diagnosis, laboratory results,
allergies, details of immunization, treatment etc. in a digital format. The
information is entered electronically by the healthcare providers over the course
of his/her lifetime.
National e-health Authority of India (NeHA) was proposed be set up in the year
2015 under the Ministry of Health & Family Welfare (MoH&FW) with the goal
to establish the e-Health ecosystem in India. One of the objectives of the NeHA
was “To lay down data management, privacy and security policies, guidelines
and health records of patients in accordance with statutory provisions”. The
MoH&FW had put forward a draft for the establishment of an Act called Digital
Health Information in Healthcare Security (DISHA) of parliament as a statutory
body for promotion or adoption of e-Health standards. Digital Health Information
in Healthcare Security Act (2018) is “An Act to provide for establishment of
National and State eHealth Authorities and Health Information Exchanges; to
standardize and regulate the processes related to collection, storing, transmission
and use of digital health data; and to ensure reliability, data privacy, confidentiality
and security of digital health data and such other matters related and incidental
thereto”. “National Health Stack” a visionary digital framework was proposed
by the National Institution for Transforming India (NITI Aayog) with an aim to
create digital health records for all the citizens of India by the year 2022.
MoHFW’s National Digital Health Blueprint (NDHB) (2019) provides an action
plan for realizing digital health. It recognizes the need to establish a specialized
organization, the National Digital Health Mission (NDHM) to drive the
implementation of NDHB and facilitate the evolution of a national digital health
ecosystem. The key features of the blueprint include a federated architecture, a
set of architectural principles, a five-layered system of architectural building
blocks, Unique Health ID (UHID), privacy and consent management, national
portability, EHR, applicable standards and regulations, health analytics, My Health
App for increased patient participation, multiple access channels like call centers
for support, and the Digital Health India portal for increased data sharing between
healthcare providers and patients. While the NDHB (2019) lays out the blueprint
to create a National Health Exchange (NHE) accessible to all citizens, the NITI
Aayog (2019) discusses the key issues being faced as well as components and
standards required for the success of digital health in India. The report outlines
six “pillars” of digital health in India. These include the selection of a governance
entity, registries for health data, a strategy for the development of a unified health
information system, design for health insurance information systems, EHRs for
patients and health care providers, and the creation of a health information
infrastructure for the integration of all the mentioned components.
In India, EMR adoption gained popularity in the last decade, but it is still in
nascent stage. The GoI and the Indian health care industry understand the
56
widespread benefits of implementing EHR systems. India can learn from global Medical Record
Department
best practices of implementing EHR and customize it to the country’s
requirements.

14.12 LET US SUM UP

In this unit you have learn about medical record department. This unit deals with
importance of medical record. How the records flow in a hospital. How these
have to be processed and duration for which it has to be preserved. Staff and area
required depending upon the size of the hospital has been adequately covered.
You have also learnt about various hospital statistics, and the reports which are
prepared by the medical record department. In addition, you have also learnt
about the role of computerization in medical records which in turn had led to
development of HIS, EMR & EHR.

14.13 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1
(a) Less than 0.25%
(b) 1 to 2%
(c) 3 to 4%
Check Your Progress 2
(a) 10 years
(b) Permanently

57