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NEEDS FLOW CHART OF IN PATIENT RECORD NEW FILE DOCUMENTS TYPES OF FILE FINDING RECOMMENDATION INTRODUCTION : INTRODUCTION Medical records through which hospital statistics are generated and medical records are important to the hospital for evaluation of its services for better patient care DEFINITION : DEFINITION “ Medical record 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 diagnosis and warrant treatment and end results” Mc Gibony FUNCTIONS OF MEDICAL RECORD DEPARTMENT : FUNCTIONS OF MEDICAL RECORD DEPARTMENT 1. Daily receipt of case sheets pertaining to discharge, 2 P.M. an expired patients from various wards, there checking and assembly. 2. Daily compilation of Hospital census report. 3. Maintains & retrieval of records for patient care and research study. 4. Completion and Procession of Hospital statistics and preparation on different periodical reports on morbidity and mortality. 5. Online registration of vital events of Birth & Death 6. Issuing Birth & Death certificated up to one year. Dealing with Medico Legal records and attending the courts on summary. Arrangement & Supervision of enquiry and admission office. Arrangement & Supervision of OPD registration Management of disability boards. Management of Medical Examination Management of Mortality Review Committee Meetings (Twice month) Assistance to Hospital Administration in various matters. Which data to record? : Which data to record? Personal info: age, sex, occupation, training, family... Risk factors: tobacco, alcohol, life styles... Allergies and drug reactions Problem list Disease history: diseases, operations. . . The disease process: main problem, history, exam, lab. Management plan: advice, education, medication. . . Progress notes: in the P S O A P format / 29 6 PSOAP : PSOAP Problem Everything the patient reports and doctor’s findings which are regarded as problems Subjective History of the problem; what the patient feels or thinks about the problem Objective Doctors findings related with the problem Assessment Evaluation of the problem; the diff. diagnosis Plan Prescription, consultation, advice, control visit... / 29 7 Division : Division MRD has following functional unit:- Receiving area Checking area IT room Record storage area (monthly wise) Why to keep records? : Why to keep records? Helps in medical decisions (is the size of a lymph node or nodule increasing with time?) Helps to share responsibility with the patient Legal obligation. Protects the patient as well as doctor in front of the court / 29 9 CONTD….. : CONTD….. Has economic benefits Useful to produce health statistics Provides epidemiological data Assists practice management / 29 10 NEEDS : NEEDS Patient needs Physician needs Institution needs Health authorities needs Flow chart of inpatient record : Flow chart of inpatient record analysis ,,, Assembling – checking-incomplete- coding-indexing--- ----- filling reporting retrieval Central admission Office census Nursing unit Slide 13: Medical Record Officer Medical Record Technicians Medical Record Clerks Medical Record Attendants. Ward Boy The Reception, Enquiry and Admission office functions round the clock under the charge of Medical Record Officer. Presently only inpatients records are maintained in the Medical Record Department. Registration work of OPDs are also managed by the Medical Record Officer. Statistical information about the functioning of OPDs is regularly submitted by the Medical Record Officials in the Medical Record Dept. Staffing NEW FILE DOCUMENTS : NEW FILE DOCUMENTS File folder General case sheet Investigation Progress record Treatment sheet Vital chart Nursing notes Intake/output chart Temperature chart Hospital charges chart Type of file : Type of file General file M.L.C. file Ward register All register of dept. Slide 16: FILING OF MEDICAL RECORDS The inpatients Medical Record is filed by the serial numbers assigned at central Admitting Office. The Record is bound in bundles 100 each and are kept year wise according to the serial number. RETENTION OF MEDICAL RECORD The policy is to keep indoor patient Records for 10 years The OPD registers for 5 years The record which is register for legal purposes in Maintained for 10 years or till final decision at the court of Law. Slide 17: THANK YOU You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.