SYSTEM OF MEDICAL RECORDS AT HINDU RAO HOSPITAL, DELHI

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SYSTEM OF MEDICAL RECORDS AT HINDU RAO HOSPITAL,
DELHI

• BY SATENDRA KUMAR
• CHIEF MEDICAL RECORD OFFICER
• HINDU RAO HOSPITAL
• DELHI

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INTRODUCTION

• Hindu Rao Hospital 980 beded general Hospital.
• Under Municipal Corporation of Delhi.
• For the management and systematic maintenance of
  Medical Records in the Hospital a Medical Record
  Department was established in the year, 1970
• To begin with MRS was started with one Medical
  Record Keeper and 3 class IV employees.

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• At present the Medical Record Deptt. has
• Medical Record Officer
• Medical Record Technicians
• Medical Record Clerks
• Medical Record Attendants.
• 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 Deptt.

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SYSTEM OF MEDICAL RECORD

• DEFINITION
• Medical Record of the patient stores the
  knowledge concerning the patient and his care.
  It contains sufficient data written in sequence
  of occurrence of events to justify the diagnosis,
  treatment and outcome.
• In the modern age, Medical Record has its
  utility and usefulness and is a very broad based
  indicator of patients care.

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• It has various uses to
• Patients
• Doctors
• Hospital
• Teachers
• Students
• For research work
• National International agencies
• ORIGIN -
• The inpatient Medical Record in originated at
  the admission office based on the admission order
  made by the clinician or at Casualty Deptt. and
  various OPDs of the Hospital.

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Flow of Medical Record -The flow chart of
inpatient Medical Record is as under -
Wards
Central Admission Office
Medical Record Department
Afetr completion of Reccords
1. Assembling
2. ADMN. Discharge analysis

Hospital statistics prepared Monthly/Yearly
Medical Record is filled for perusal of
Patients/claims/research purposes.
3. Storage Area
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• 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.

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OUTPATIENT DEPARTMENT

• There is a decentralized system for registration
  of OPD patients.
• Patients are registered at different registration
  counter specialty wise.
• Clerks posted for registration have been made
  responsible for the preparation and submission of
  statistical data of their respective OPD

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FUNCTIONS OF MEDICAL RECORD DEPARTMENT

• 1. Daily receipt of case sheets pertaining to
  discharge, 2 A.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 upto 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.

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SYSTEM OF COLLECTION, COMPILATION AND FORWARDING
STATISTICAL REPORTS

• Medical Record officials posted for registration
  of OPD patients have been made responsible for
  the preparation and submission of statistical
  data on their OPDs.
• One Medical Record Officer visits to the wards
  daily and collects the disease wise reports of
  the discharged patients and submits the same in
  the medical record section. One official of the
  Medical Record Section classifies the data
  according to the different performa. Following
  reports are compiled forwarded to various
  departments.
• National list for Tabulation of Morbidity and
  Mortality
• Monthly Health Bulletin
• Monthly report of Polio Cases
• Monthly report of GWEP
• Report of cataract operations
• Monthly report of communicable diseases
• Monthly report of Measles cases
• Monthly report of Japanese Encephalitis
• Monthly report of MNT (Paed Gynae)

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• 10. Monthly report of AIDS cases
• 11. Monthly report of Anti Rabic cases
• 12. Monthly report of STD
• 13. Monthly report of cases Death due to
  snakebite.
• 14. Monthly report of Sex Ratio (Birth Death)
• 15. Monthly report of Malaria cases.
• 16. Monthly report of Deliveries
• 17. Monthly report of Family Planning
• 18. Monthly report of Medicine, DRT, Polio, TT
• 19. Monthly report of Leprosy cases
• 20. Weekly report of Polio
• 21. Weekly report Statement showing the no. of
  cases treated (OIVS)
• 22. Weekly report of National Programme for
  surveillance of communicable disease (DHO)
• 23. Weekly report of Dengue fever cases
• 24. Weekly report of Pyogenic Meningitis
• 25. Weekly report of Gastro-enteritis, Cholera
• 26. Daily report of Noticeable Disease under
  surveillance.

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