A Comparative Study on MEDICAL RECORDS

DEPARTMENT carrying out at Sambhunath Pandit

Hospital for partial fulfilment of BHM

UNDER

MAULANA ABUL KALAM AZAD UNIVERSITY OF

TECHNOLOGY

FROM

DINABHANDU ANDREWS INSTITUTE OF

MANAGEMENT & TECHNOLOGY

PRESENTED BY –

Name- SAHELI SARKAR

Class- BHM 6TH SEMESTER

Roll No- 15403315026

Registration No- 151541310026

Session- 2015-2018

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ACKNOWLEDGEMENT

Every successful work is backed by sincerity and hard work. During

this two month tenure of my work, I was able to gain a lot of

knowledge both application and theory wise. Every moment of my

training period was full of lesson-learning and acquiring

experience. My training period would not have been possible

without the wonderful support and guide of respected trainers and

official staffs.

I am very grateful to those people who have helped me in every

ways of training report.

I would like to thank Dr. Sanjukta Nandy (Principal,

DAITM), Mr. Surajit Das (HOD of BHM, DAITM) for giving me

opportunity to complete my internship from Sambhunath Pandit

Hospital, Kolkata.

This project has been done in the SNP HOSPITAL, Kolkata and the

work would not have been possible without the help and guidance of

Mr. SOUMABHA DUTTA (Hospital Superintendent), Mr.

SOUMYA RANJAN DAS (In charge of MRD) & Mr. ABHIJEET

SINHA, Mrs. MOUMITA ROY AKULI, Mrs. PARAMITA

BANERJEE GHOSH (Faculty of BHM) as my project guides. They

provided me continuous support and valuable suggestions during the

entire period of my training. I am really indebted to them.

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DECLARATION

This is to certify that the dissertation entitled “Training Report on

MEDICAL RECORDS DEPARTMENT” at SAMBHUNATH

PANDIT HOSPITAL; KOLKATA has been prepared by Saheli

Sarkar herself in partial fulfilment of the requirement of BHM degree

in Maulana Abdul Kalam Azad University of Technology, West

Bengal.

I, Saheli Sarkar, hereby declare that all the information and facts

provided here are based on my own findings and studies at SNP

HOSPITAL. The contents of report are a true experience of my

efforts.

___________________

Signature of the student

Place: Kolkata

Date:

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EXECUTIVE SUMMARY

As a part of a special internship program, I have learnt about the

ensures medical record availability by routing records to admissions

and emergency departments, physicians, and other authorized hospital

staff; maintaining chart location systems.

My overall experience has been a very fruitful one. It was a good

learning experience for me and gave me the first exposure to gain

knowledge about the working of the hospital industry.

As it is a comparative study on Medical Record Department between

Government and Private Hospitals in Kolkata. Private hospital is

much more efficient than government hospital as it is containing

sufficient data, and keep them under safe custody and make the ready

available as and when required for patients, doctors, hospital

administrator, and other purposes. But in comparison to private

hospital, government hospital is not so systematic; sometimes it takes

a little time for serve documents or there may be any printing

mistakes in any medical documents. But on the other hand, facilities

are also available in government hospitals.

Both types of hospitals have different range of facilities and they have

to face criticism on the basis of their performance.

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TABLE OF CONTENTS

SERIAL

NUMBER

TOPIC

1 Hospital Profile

2 Introduction To Specialised Department

3 Review Of Literature

4 Objective

5 Broad Overview

6 Methodology

7 Data Collection & Interpretation

8 Summary Of Findings

9 Conclusion

10 Bibliography

11 Annexure

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ABOUT THE HOSPITAL

SAMBHUNATH PANDIT HOSPIATAL is a 570 bedded general

hospital under Municipal Corporation of Kolkata.

For management and systematic maintenance of hospital medical

record department has been established.

In Kolkata, SAMBHUNATH PANDIT HOSPITAL is a recognized

name in patient care. They are one of the well-known Hospitals in

LALA LAJPAT RAI SARANI.

Backed with a vision to offer the best in patient care and equipped

with technologically advanced healthcare facilities, they are one of

the upcoming names in the healthcare industry.

A team of well-trained medical staff, non-medical staff and

experienced clinical technicians work round-the-clock to offer various

services. Their professional services make them a sought after

Hospitals in Kolkata. A team of doctors on board, including

specialists are equipped with the knowledge and expertise for

handling various types of medical cases.

At SAMBHUNATH PANDIT Hospital in LALA LAJPAT RAI

SARANI, the various modes of payment are accepted.

This is all about hospital floors and buildings:

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CASUALITY BLOCK

GROUND FLOOR

i) Emergency Dept.

ii) Medical Records Department

iii) RSBY & Rogy Sahayata Kendra

iv) Pathology

v) ICTC

vi) Physical Medicine

vii) Acupuncture

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viii) X-RAY Indoor

ix) Dark Room

x) Server Room

xi) Emergency O.T

xii) Nursing Superintendent office

xiii) Seminar Room

xiv) House Staff / Interns Doctor’s Room

1ST FLOOR

i) Gynae-i

ii) Gynae-ii

2ND FLOOR

i) Female Medicine Ward

ii) Female Surgical Ward

iii) Male Surgical Ward

iv) Male Surgical Ward (Orthopedic)

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ADMINISTRATIVE BLOCK

GROUND FLOOR

I. Superintendent Office

II. Assistant Superintendent Office

III. Receiving and Despatch

IV. Telephone Operator

V. Head Clerk

VI. Cash Counter

VII. OPD Medicine Dept.

VIII. OPD Orthopedic Dept.

IX. OPD Skin Dept.

X. OPD Eye Dept.

XI. OPD Surgical Dept.

XII. OPD Gynae Dept.

XIII. OPD E.N.T Dept.

XIV. OPD Ticket Counter-1

XV. OPD Ticket Counter-2

XVI. OPD Ticket Counter-3

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1ST FLOOR

I. Account Officer

II. Library

III. Assistant Clerk

JD BUILDING

I. JD-I

II. JD-II

III. JD-III

VISION

Our vision is to deliver world class tertiary healthcare services at an

affordable cost.

MISSION

Our mission is to continuously improve the quality of the entire range

of hospital services and to emerge as the most reputed hospital in the

country.

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Medical Records Department

The medical record is a legal document providing a chronicle of a

patient's medical history and care. Physicians, nurse practitioners,

nurses and other members of the health care team may make entries in

the medical record. The medical record includes a variety of types of

"notes" entered over time by health care professionals, recording

observations and administration of drugs and therapies, orders for the

administration of drugs and therapies, test results, x-rays, reports, etc

USE OF MEDICAL RECORDS

• To document the course of patient’s illness & treatment.

• Communicate between attending doctors and other health Care

professional providing care to the patient

• Collection of health Statistics.

• Legal Matters & Court Cases

• Insurances Cases

COMPONENTS OF MEDICAL RECORD Front Sheet or

identification Summary Sheet Consent for Treatment Legal

Documents like referral letter, request for Information etc Discharge

Summary, referral slip Admission notes, clinical progress notes,

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Nurses progress note Operation report if operation has been

performed Investigation reports like, X-ray, pathology etc Orders for

treatment and medication forms listing daily medications ordered and

given with signatures of the doctor prescribing the treatment and the

nurse administering it.

LABELING OF MEDICAL RECORD FOLDER The following

should be written on the medical record folder: Patient’s name;

Patient's medical record number Year of last attendance

ISSUE OF MEDICAL RECORD NUMBER / UID NUMBER

Medical Record Numbering Systems are HOW WE GIVE A

NUMBER to Medical Records. The MRN should be issued in straight

numerical order from the NUMBER REGISTER commencing with

the number 1. For example, if the last number given to a patient were

342, the number issued to the next patient would be 343 and the next

344 and so on. Manual System In a Computerized System, UID / MR

Number is auto generated and there is OPD visit number & IPD Visit

Number UID Number is permanent but OPD Visit number/ IPD

number may change

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FUNCTIONS OF MEDICAL RECORD DEPARTMENT Filing

of Medical records

• Retrieval of medical records for patient care and other authorized

use.

• Completion of medical records after an inpatient has been

discharged or died.

• Coding diseases and operations of patients discharged or having

died

• Evaluation of the Medical Record Service.

• Completion of monthly and annual statistics.

• Medico-legal issues relating to the release of patient information and

other legal matters.

The information contained in the medical record allows health care

providers to determine the patient's medical history and provide

informed care. The medical record serves as the central repository for

planning patient care and documenting communication among patient

and health care provider and professionals contributing to the patient's

care. An increasing purpose of the medical record is to ensure

documentation of compliance with institutional, professional or

governmental regulation.

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REVIEW OF LITERATURE

1. Lewis KS (August 12, 1991)

”Medical record review for clinical pertinence”.

This clinical pertinence review process described was in effect for

seven months, after which the author terminated affiliation with the

hospital. Despite resistance by many physicians, this monthly review

process focused the medical staff's attention on good documentation

practices. To the author's knowledge, the plan is still in use.

2.Kristiina Häyrinena, KaijaSarantoa, Pirkko

Nykänenb(Received 12 April 2006, Revised 22 June 2007,

Accepted 13 September 2007, Available online 22 October 2007)

This paper reviews the research literature on electronic health record

(EHR) systems. The aim is to find out

(1) How electronic health records are defined

(2) How the structure of these records is described

(3) In what contexts EHRs are used

(4) Which data components of the EHRs are used and studied

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(5) What is the purpose of research in this field

(6) What methods of data collection have been used in the studies

reviewed and

(7) What are the results of these studies.

3.Kabiru Danladi Garba (Oct 12, 2016)

Medical records are a vital asset in ensuring that hospitals are run

effectively andefficiently. They support clinical decision-making,

provide evidence of policies andsupport the hospitals in cases of

litigation. This paper revealed the numeroussignificance and

challenges of medical records generally. The study x-rays the

concept,types and significance of medical records, taking into

consideration the challengesaffecting the medical records as a whole

4.Albert Boonstra, Manda Broekhuis (3 March 2010Accepted: 6

August 2010Published: 6 August 2010)

The main objective of this research is to identify, categorize, and

analyze barriers perceived by physicians to the adoption of Electronic

Medical Records (EMRs) in order to provide implementers with

beneficial intervention options.This review assessed the use of

electronic medical record (EMR) systems in outcomes research. We

systematically searched Pub Med to identify articles published from

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January 2000 to January 2007 involving EMR use for outpatient-

based outcomes research in the United States. EMR-based outcomes

research studies (n = 126) have increased six fold since 2000.

Although chronic conditions were most common, EMRs were also

used to study less common diseases, highlighting the EMRs’

flexibility to examine large cohorts as well as identify patients with

rare diseases. Traditional multi-variant modelling techniques were the

most commonly used technique to address confounding and potential

selection bias. Data validation was a component in a quarter of

studies, and many evaluated the EMR’s ability to achieve similar

results previously achieved using other data sources. Investigators

using EMR data should aim for consistent terminology, focus on

adequately describing their methods, and consider appropriate

statistical methods to control for confounding and treatment-selection

bias.

5.Anisa J. N. Jafar, Ian Norton, Fiona Lecky and Anthony D.

Redmond (09 February 2015)

Medical records are a tenet of good medical practice and provide one

method of communicating individual follow-up arrangements,

informing research data, and documenting medical intervention.

The objective of this review was to look at one source (the published

literature) of medical records used by foreign medical teams (FMTs)

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in sudden onset disasters (SODs). The published literature was

searched systematically for evidence of what medical records have

been used by FMTs in SODs.

The style and content of medical records kept by FMTs in SODs

varied widely according to the published literature. Similarly, there

was great variability in practice as to what happens to the record

and/or the data from the record following its use during a patient

encounter. However, there was a paucity of published work

comprehensively detailing the exact content of records used.

Without standardization of the content of medical records kept by

FMTs in SODs, it is difficult to ensure robust follow-up arrangements

are documented. This may hinder communication between different

FMTs and local medical teams (LMTs)/other FMTs who may then

need to provide follow-up care for an individual. Furthermore,

without a standard method of reporting data, there is an inaccurate

picture of the work carried out. Therefore, there is not a solid

evidence base for improving the quality of future response to SODs.

Further research targeting FMTs and LMTs directly is essential to

inform any development of an internationally agreed minimum data

set (MDS), for both recording and reporting, in order that FMTs can

reach the World Health Organization (WHO) standards for FMT

practice.

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OBJECTIVE OF THE PROJECT

To understand the proper overall Procedure and principle of

functioning of Medical Records Department in government as

well as in private hospital.

To have a clear concept of how the Medical Record department

work in both government and private hospitals and knowing

their respective functions.

To understand the application of managerial tools techniques

involved in the organizations.

To put the theoretical knowledge into practical experiences.

To observe the flow of work with proper coordination and

synchronization as it happens.

To look after the collection of key information about patients,

their medical conditions and clinical care in both government

and private sector.

To identify and make correction if there are any drawbacks or

problems occurring in the Medical Record Department in both

sectors.

To be able to provide proper suggestions for the betterment or

improvement of the respective problems in government and

private hospitals.

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BROAD OVERVIEW

The purpose of this study was to find out the differences of Medical

Records Department between government and private hospitals. From

the following data, I observe the existing procedure of medical

records department.

The Medical Records Department (MRD) of any hospital is its

repository of information for patient care, planning of health care

services and research. It is the hospital backbone and its “wealth”.

Without records, no epidemiological information, on which public

health policies and government health expenditure is based, is

possible. Medical records refer to records either in paper or electronic

form of the results of medical tests, diagnoses and treatments for

individuals. At present government hospitals give efforts to digitalize

and computerize the entire MRD system have been initiated. These

records are confidential and only authorized personnel can have

access to them.

The medical record coordinator is responsible for planning the

departmental procedures, which provide for standardization of tasks.

Carefully planned procedures may result in greater productivity with

less time and effort.

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The following criteria should be observed:

1. There is a unique identifier (Name and Employee Number) for each

staff member.

2. Physicians shall be expected to have a stamp bearing both (Name

and Employee Number)

3. Nursing and other staff members shall be expected to have a stamp

or may use their name and employee number (handwritten) in signing

entries into medical records. These steps are followed in private

hospitals.

4. All entries into the Medical Records by Staff Members have to be

signed and authenticated with a stamp whenever applicable, dated and

timed.

5. All the entries in the file should be in English Language. 6. All

results from Radiology and Laboratory have to be signed by a

member of the medical team before being inserted into the medical

records.

7. Each entry must be dated according to Gregorian calendar in

day‐month‐year sequence.

8. Time entries are made using 12 hours clock system

In a medical records department procedures may be written for

assembly and analysis of medical records, coding and indexing of

medical records, filing and retrieval of medical records, and admitting

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and discharging of a patient. Once procedures in the department have

been planned and tested, it is important to record them in writing,

describing each of their phases in step-by-step detail and including

correctly completed samples where appropriate. In this case, the

standard of government hospitals is lower than private hospitals.

The medical history is a longitudinal record of what has happened to

the patient since birth. It chronicles diseases, major and minor

illnesses, as well as growth landmarks. It gives the clinician a feel for

what has happened before to the patient. As a result, it may often give

clues to current disease state. It includes several subsets detailed

below:

Surgical history, Obstetric history, Medications and medical allergies,

Family history, Social history, Habits, Immunization history. Private

hospitals are very committed to maintain medical records

management. But in government hospitals, there is lack of care, there

seems to be no interest among the hospital staff to store it in a proper

manner. There are several differences between the government and

private hospitals.

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METHODOLOGY

PLACE OF STUDY:

SAMBHUNATH PANDIT HOSPITAL

11, Elgin Road, Lala Lajpat Rai Sarani,

Kolkata – 700020

Near Netaji Bhawan

Phone: 033-22870078

DURATION OF STUDY:

6TH MARCH – 6TH APRIL

SOURCES OF DATA:

Secondary Observation

The Medical Records Department (MRD) is an important source for

evaluating and planning of healthcare services.

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This research was an analytical cross-sectional study in which data

was collected by secondary observation. To analyze the existing

working procedure of medical records department, first, objectives of

the MRD, according to the mission and perspectives of the hospital,

were redefined and, second, indicators were measured. Subsequently,

findings from the performance were compared with the expected

score. In order to achieve the final target, the programs, activities, and

plans were reformed.

The Medical Records Department (MRD) has become an essential

department in every hospital, which provides multiple services not

only to the patients but also to running a hospital efficiently.

1. STORAGE OF MEDICAL RECORD FILES:

RECORD is a in scripted information that can be retrieved at any

time. It includes all original documents, letters, photographs, books,

blueprints, sound & video recordings and electronic data. The medical

record is a clinical, scientific, administrative, & legal document

relating to patient care. It records sufficient data written in the

sequence of events to identify and locate the patient and justify the

diagnosis, the treatment given and the final outcome. MRD is also

known as Central admission office.

As the requirements for Medical Records Management continue to

change, practices need to stay updated on the latest Regulations and

ensure that they're in compliance with the latest Records. But in

government hospitals, there is lack of proper care that is why medical

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records cannot found at the right time, when it is needed for the

patients, doctors, nurse practitioners, nurses, physicians. Medical

Records Management can be a significant challenge, so there should

be proper maintenance as it is a responsibility of every hospital to

secure medical document storage in records management facility.

They can efficiently store and track patient charts in hard copy format

using advanced barcode technology and enable fast retrieval in the

event that a chart is needed, which is not available in a good manner.

2. MAINTENANCE OF MEDICAL RECORD FILES

With the increasing use of medical insurance for treatment, the

insurance companies also require proper record keeping to prove the

patient's demand for medical expenses. Improper record keeping can

result in declining medical claims. It is disheartening to note that in

spite of knowing the importance of proper record keeping it is still in

a nascent stage in government hospitals. It is wise to remember that

“Poor records mean poor defence, no records mean no defence”.

Medical records include a variety of documentation of patient's

history, clinical findings, diagnostic test results, preoperative care,

operation notes, post operative care, and daily notes of a patient's

progress and medications. A properly obtained consent will go a long

way in proving that the procedures were conducted with the

concurrence of the patient.

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Medical record keeping is a specialized area in bigger teaching and

corporate hospitals with separate medical records officers handling

these issues. However, it is yet to develop into a proper process in the

large number of smaller clinics and hospitals.

3. CHECKING INPATIENT DEPARTMENT FILES

This is a crucial piece of evidence regarding the inpatient treatment of

a patient. It is important to give due importance to making a proper

discharge summary as this is the summary document that will be kept

by the patient which reflects the treatment received. The discharge

summary should mirror the case notes of the patient records with a

brief summary, relevant investigations, and operative procedures. The

dates of admission, discharge, and surgery are useful when the

sequence of events is an important issue in litigation later. But

government hospitals are not so active like private hospitals.

A copy of discharge summary of every patient must be preserved in

the case file for future use if required. Discrepancies in the summary

given to the patient and what is kept in the hospital records can cause

suspicion about tampering with the medical records. These

discrepancies should be avoided at all costs as the benefit of this

usually goes in favour of the patient. It is imperative to record the fact

that the doctor has advised a course of action with all its implications

if not followed. The fact that the patient has understood this and has

refused it on his volition should be recorded. This should be signed by

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the doctor, patient, or relative and duly witnessed. This document has

to be retained along with the patient records. It will help the doctor in

situations where the patient alleges negligence later.

4. RETENTION PERIOD/DESTRUCTION OF MEDICAL

RECORDS FILES

Retention period refers to the period of time that the medical records

should be kept for following:

i. The date of the last discharge from hospital or last attendance at a

clinic;

ii. The patient being considered “inactive” (e.g. not having been to the

HCI in the last 3 years);

iii. The patient’s death.

It is advised that the retention periods “kick in” only after patients

have turned inactive, or have passed away. This ensures that the

majority of patients who have chronic medical conditions, or are

likely to require their medical records in the future, will have access

to them. But there are so many problems like, before retention period,

destruction of medical records files are occur due to lack of sanitation,

absence of proper maintenance

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DATA COLLECTION & INTERPRETATION

TABLE NO. 1

Measuring of MRD staff satisfaction level

SL.

No.

Questions Yes No

1. How would you describe the

level of your overall job

satisfaction with your work at

Hospital?

2

(40%)

3

(60%)

2. There is no issue of sorting file. 0

(0%)

5

(100%)

3. There is enough space in medical

record department.

0

(0%)

5

(100%)

4. Well-developed hospital

information System helps to

reduce heavy workload

4

(80%)

1

(20%)

5. All staff works in a good

synchronized way

3

(60%)

2

(40%)

6. Communications with other

departments are frequent enough

3

(60%)

2

(40%)

7. Supervisor gives adequate

support to his subordinates.

4

(80%)

1

(20%)

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1) How would you describe the level of your overall job

satisfaction with your work at Hospital?

2) There is no issue of sorting file.

2, 40%

3, 60% Yes

No

-2 -1 0 1 2 3 4 5 6

1

2

3

Series2 Series1

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3) There is enough space in MRD

4) Well-developed hospital information system reduce the heavy

workload.

-1

0

1

2

3

4

5

1

2

3

0

5

0%

-100%

Series2

Series1

-2 -1 0 1 2 3 4 5

Well-developed hospital information Systemhelps to reduce heavy workload

no yes

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5) All staff works in good synchronized way .

6) Communication with other department is frequently enough.

60%

40%

yes

no

-1 -0.5 0 0.5 1 1.5 2 2.5 3 3.5

1

2

3

Series2 Series1

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7) Supervisor gives enough support his subordinates.

1, 4

2, 1

1

2

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SUMMARY OF FINDINGS

Problems of Medical Records Department:

It requires keeping a unique, individual record for each patient,

which is not available in MRD.

Absence of record-keeping system which is to ensure that

medical records are easily retrievable for review and available

for use when needed, including at each patient visit.

Store and maintain medical records in a centralized and secured

location accessible only to authorized personnel and provide

equivalent security for electronic medical records, but there is

no security.

They do not maintain and organize documents within medical

records in a specified order.

It cannot ensure that documents are fastened securely within a

paper medical record.

Provide periodic training in confidentiality and security for

patient information.

SOLUTION OF MEDICAL RECORDS DEPARTMENT:

All medical records including patients files, register books, etc.,

relating directly to patient care have to be maintained by the

medical Records Department.

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The old files, register books, are to be preserved in a secure

place for a prescribed period. Later the records have to be

disposed off as per the “Record Retention Schedule” procedures

mentioned in the NABH manual.

Special care has to be taken to reserve the safety of records.

Records have to be protected from

Insects, termites and prevent them from being exposed to heat,

fire, dampness and dust.

Adequate fire extinguishers should be available in the filling

area.

Medical Records can be taken out of Medical Records

Department only by authorized persons.

4. If the file/s are required for a purpose, other than patient

appointment, the persons requesting.

The file/s should fill up a “file request form within the

organization“, available from Medical.

Records Department.

5. For emergency patient the medical records staff will promptly

deliver the file to ER nurse.

ER staff can collect the file from Medical Records Department

with proper identification.

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CONCLUSION

The differences of medical records department between government

and private hospitals present a clear picture about these two types of

hospitals.

A good medical record serves the interest of the medical practitioner

as well as his patients. It is very important for the treating doctor to

properly document the management of the patient under his care in

both government and private hospitals. Medical record keeping has

evolved into a science. The key to dispensability of most of the

medical negligence claim rest with the quality of the medical records.

Record maintenance is the only way for the doctor to prove that the

treatment was carried out properly. Medical records are often the only

source of the truth. They are likely to be far more reliable than

memory.

The Medical Records Department (MRD) has become an essential

department in every hospital, which provides multiple services not

only to the patients but also to running a hospital efficiently and plays

a key role in health promotion and patient care quality.

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BIBLIOGRAPHY

http://v2020eresource.org/

https://en.wikipedia.org/wiki/Medical_record

Adequate medical records in group medical practice

Medical Records Organization and Management

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ANNEXURE

In its study, the committee reviewed the needs of patient record users,

as well as existing and emerging computer technologies.

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THANK YOU