QUALITY ASSURANCE IN MEDICAL RECORDS DEPARTMENT OF A HOSPITAL

QUALITY ASSURANCE IN MEDICAL RECORDS DEPARTMENT

Guided by:
Dr,Puneet Kapoor

Guided by:

Dr.Puneet kapoor

SUBMITTED BY: Dr.Richa Rattan SUBMITTED BY: MBA Hospital Admn Roll no-14 Rattan Dr.Richa MBA Hospital Admn Roll no.-14

DEFINITION OF A MEDICAL RECORDA clinical, scientific, administrative and legal document related to patient care in which is recorded sufficient data in the sequence of events to justify the diagnosis and warrant the treatment and the end results. (Mc Gibony)

HISTORICAL DEVELOPMENT OF MEDICAL RECORDS

First medical record dates back to 1667 of 1st Bartholomews Hospital England

Maintenance of patients registration in Pennysylvania-USA-1752

Indexing of diseases in New York in 1862

Record maintenance was emphasized by American College of surgeons & American College of physicians in the first quarter of 20th century

CONT..
Association of medical records of librarstat was formed in 1928

Bhore committee recommended maintenance of medical records in India in 1946

It was reiterated by Mudaliar committee 1962 in India

Computerized medical records keeping in present era

ROLE AND IMPORTANCE OF MEDICAL RECORDS

To the patients To the clinicians To the hospital and hospital administration To the public health authorities To medical education and research Medico-legal cases

MEDICAL RECORDS DEPARTMENT

FUNCTIONS OF MEDICAL RECORD DEPARTMENT

Assembli ng of the medical records Quantitat ive analysis of the records

Retreival of records

Completi on of incomple te records

CODING

Functions of MRD

Storage and retention of records

Numbering and Filing Deficiency check

INDEXIN G

OTHER FUNCTIONS

Analysis of records and generation of statistics Submitting the periodic reports(births/deaths notifications, notification of communicable diseases, morbidity statistics)as required by the health statistics Daily ward census and monthly bed utilization statistics

Production in the courts of law, when summoned

QUALITY ASSURANCE OF MEDICAL RECORDS

Quality of services is defined as the totality of features
and characteristics of service that bear on its ability to satisfy the stated and implied needs of the client. -Client users (internal and external) who have to be satisfied are1.The patient 2.The clinicians 3.The management 4.The health authorities 5.The legal authorities 6.The insurance authorities

WHAT ALL IS REQUIRED TO SATISFY ALL THE CLIENTS?

1.Quality of structure

2.Quality of Process

1.QUALITY OF STRUCTUREA. Location and Layout

Should be located close to the admitting area, outpatient department, emergency room and the business office. Or Close to or on the corridor leading to the doctors lounge.

LOCATON OF A MEDICAL RECORDS DEPARTMENT

B. Space Requirement(i)Admission & Enquiry office: Space of

125-175sq feet is recommended.

(ii)Central Record Office: Space of 2-3sq feet per bed is sufficient (iii)OPD record section: Average of 2-3 sq feet per bed space is required
(iv) Offices for the medical records officer and assistant medical officer (v) Space for sectional supervisors

(vi) Work area for record processing, assembling, numbering, indexing, utilization review, discharge analysis, work processing etc.
(vii) Record storage for active and inactive files (vii) Space for copier

CONT..
(viii)

A room for medical staff to complete records, study cases with tables, chairs, dictating equipments

(ix) An area with bookcases or shelves to house the medical records (x) Transcription area with space for the central recording equipment, tables, computers etc for medical secretaries to transcribe information (xi) Space for master patient index depending on the kind of system used, for immediate identification of current and past patients (xii)Storage area for medical record carts (xiii) Supplies storage space for unused medical record file folders, forms.etc

(xiv) Staff facilities

(xv) An electrically operated dumbwaiter, if the MRD is on two floors

B.STAFFING- A hospital with 300 beds and above should have an Asst Medical records
officer and that with 500 beds a Medical records officer(MRO) as in charge of the department.

Todd Wheelers Staffing scaleManpower requirement for medical records Department:

BEDS 500 STAFF 12 100 4 200 6 300 8 400 10

FOR EXAMPLE.STAFF REQUIREMENT RECOMMENDED FOR A 500 BEDDED HOSPITAL AT A SCALE OF:
1.Medical record officer 2.Medical record technician 3.Clerks 01 04 03

4.Peon
5.Statistician

01
01(part time)

Additional staff 1.Admission and enquiry officeAssistant medical record officer Medical record technician Medical record attendant Receptionist 01 05 04 05

CONT..
2.Central record office

Assistant medical record officer Medical record technician Medical record attendant Statistical assistant

01 08 08 01

C.EQUIPMENT AVAILABILTY
a. b. c. d. e. f.

g.
h. i.

Computerization/Microfilming/Manual Storage of hard copies The storage racks/almirahs- type size,quantity depending upon the volume of records being generated Type writers Data storage devices Printers Camera File cabinets Photo copiers, Fax machines, Phone, etc Instruments and stationary items like poker,staplers,spiral binding machine,laminating machines etc

D.ENVIRONMENT CONTROLControl of dust, humidity, pests and availability of adequate light/ventilation

2.QUALITY OF PROCESS
1.Availability of Quality manualShould contain in a documented form, the policies and procedures essential to meet the information needs of the various organisations

2 .Standard Operating Procedures-(SOP)Procedures governing every activity of the department and should be reviewed once a year/earlier .

3.DATA MANAGEMENT 4.MEDICAL RECORDS COMMITTEE(MRC)To frame and review various policies and procedures about efficient functioning of the department and periodic monitoring of the quality of records generated. 5.PATIENTS RECORDS

Complete-sufficient data to identify the patient, justify diagnosis, treatment, outcome Adequate- with all necessary forms, all clinical information, and Accurate- capable of quantitative analysis

follow up and

6.STANDARDIZED CONTENTS OF RECORDS Order ,accuracy and brevity should result from the use of these forms Filing of records in appropriate sequence and manner: Summary sheet Operation record History Tissue report Physical examination Death certificate Laboratory reports Authority for autopsy Physicians order Hospital infection report Progress notes X-ray reports Nurses records and charts ECG reports Labour record Urology reports Birth certificate Other graphic records and charts Authority to operate

7.STANDARDIZED FORMAT Collection of data/generation of records should be as per standardised formats in the form of printed forms made available in the hospital. Good quality paper should be used to withstand frequent handling

8.PROCESS FLOW CHART FOR MOVEMENT OF MEDICAL RECORDS

9.NUMBERING SYSTEM(Serial numbering/unit numbering/serial unit numbering)Single permanent number is assigned for each patient which can be used for future subsequent admissions 10.FILING SYSTEM- Facilitates sorting, filing and retreival
Alphabetic al method

Terminal digit systems

Numerical method

METHODS OF FILING SYSTEM

Mid-digit systems

Chronolog ical method

11.INDEXING SYSTEM- Facilitates quick retrieval for research and education

Operation Index

Alphabetical Index INDEXING

Disease Index

Physicians Index

Unit Index

12. CODINGClassifyng the record of inpatient by diseases using ICD coding system.
Coding to provisional diagnosis(at the time of admission)

Coding to death certificate.

13.DICTATING AND TRANSCRIPTION SYSTEMDoctors dictate their notes or discharge summaries from various locations in the hospital and the medical secretaries then transcribe the recorded dictation. 14.TRACKING/TRACING OF RECORDS- To ensure confidentiality and safety

15.ISSUE OF RECORDSTo ensure the issuance of records to the authorized personnel and their return in time without any damage or loss, strict policy and procedures for the issue and return of medical records must be followed:
a) Medico-legal records b) Panel cases(non-medico legal) c) At the time of discharge - Discharge summary(duly checked and signed by physician) Copies of investigation reports Copies of case records(on payment)

16.ANALYSIS OF RECORDS AND GENERATION OF STATISTICS 17.PROVISION OF INFORMATION TO THE EXTERNAL AGENCIESA checklist for the information to be forwarded to the regulatory body in the form of periodic reports should be prepared

18.POLICY AND PROCEDURE FOR SAFETY AND SECURITY OF RECORDSa) No ad-hoc or temporary staff b) Medico legal case records to be kept in steel cabinets under lock and key c) Storage area should be free from seepage/dampness and termite nuisance

19.POLICY FOR PRESERVING THE INTEGRITY OF MEDICAL RECORDS GENERATEDa) Entries must be made only by doctors/nurses/technicians involved directly with the treatment of the patient. b) Entries should be at relevant places c) Entries should be updated real time d) No alterations of any kind should be allowed after completion of records.

20.POLICY AND PROCEDURE REGARDING THE CONTINUITY OF CAREAccording to NABH guidelinesThe medical record should contain Information regarding reasons for admission, diagnosis and plan of care. Operative and other procedures performed should be incorporated In case of transfer of patient to other hospital In case of death Clinical autopsy

Access to current and past medical records

21.POLICY AND PROCEDURE FOR MAINTAINING CONFIDENTIALITY/PRIVACY OF MEDICAL RECORDSA. As an impersonal document- for training and research A. As personal document- When required by LIC or income tax authorities For proving the validity of patients will For settling the queries about birth and deaths C.Medical records and information must be protected from public access and any information released must comply with Health Insurance Portability and Accountability Act (HIPAA) guidelines.

22.PRESERVATION OF RECORDSThe policies and procedures are in consonance with the local and national laws and regulations(NABH) HIPAA requires that Protected Health Information (PHI) must be kept secure for at least six years, or two years after a patient's death. i. OPD cases :depending upon the policy of the hospital ii. Indoor records : 5years iii. Medico-legal cases:10 years or permanently/until the case is finally settled

23.OWNERSHIP OF MEDICAL RECORDSMedical records are the property of the hospital which is responsible for their safe custody and the confidentiality of the information contained in them.

24.DESTRUCTION OF OLD RECORDSThe destruction of medical records, data and information is in accordance with the laid down policy (NABH) Documented procedure should be followed and a public notice must be issued before destroying the old records.

25.HANDLING OF MEDICO-LEGAL CASESDocumented procedure for receipt, registry and timely response to the summons should be followed.

26.POLICY AND PROCEDURE FOR REGULAR AUDIT OF PATIENT CARE SERVICESThe organisation should regularly carry out medical audits carried out by identified care providers(NABH)

A qualitiy assurance committee (QAC) can be formed for the same and may consist of followingMedical Administrator Two Clinicians Pathologist Radiologist Nurse Administrator(Matron) Medical records officer-secretary

Objective elements of QAC-(NABH):

The medical records are reviewed periodically The review is conducted by identified care providers. The review focuses on the timeliness, legibility and completeness of the medical records The review process includes records of both active and discharged patients The review points out and documents any deficiencies in records Appropriate corrective and preventive measures undertaken are documented

QUALITY INDICATORS FOR EVALUATION OF SERVICES:

1. 2. 3. 4. 5. Number of records found incomplete during random checks Number of records found damaged Percentage of records found missing/untraceable Complaints from front desk staff/consultants about delays in retrieval Complaints from patients/relatives/health authorities about delay or non availability of records Observations by courts/insurance agencies Instances of breach of confidentiality of information

6. 7.

8.

Poor physical condition of records as seen during periodic

References:
Principles of Hospital Administration and Planning-BM Sakharkar Quality Management in Hospitals-SK Joshi Hospital Facility planning and Management-GD Kunders

Hospital Administration-DC Joshi

NABH standards and guidelines for hospitals http://in.wikipidia.org/wiki/recordsmanagement http://laico.org/v2020.resource/files/numberingandfilingsys tem.html

Thank you!