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    Medical Record Department: Alva'S Health Center

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    aarti Hinge
    The document outlines the scope of services and standard operating procedures for the Medical Record Department at Alva's Health Center, including issuing and storing patient files, providing data for research and education, and ensuring file confidentiality and completeness according to checklists. It also describes processes for file registration, retrieval, ICD coding, and compliance with policies for medico-legal cases and death records.

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    Medical Record Department: Alva'S Health Center

    Uploaded by

    aarti Hinge
    40 views12 pages
    The document outlines the scope of services and standard operating procedures for the Medical Record Department at Alva's Health Center, including issuing and storing patient files, providing data for research and education, and ensuring file confidentiality and completeness according to checklists. It also describes processes for file registration, retrieval, ICD coding, and compliance with policies for medico-legal cases and death records.

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    The document outlines the scope of services and standard operating procedures for the Medical Record Department at Alva's Health Center, including issuing and storing patient files, providing data for research and education, and ensuring file confidentiality and completeness according to checklists. It also describes processes for file registration, retrieval, ICD coding, and compliance with policies for medico-legal cases and death records.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    40 views12 pages

    Medical Record Department: Alva'S Health Center

    Uploaded by

    aarti Hinge
    The document outlines the scope of services and standard operating procedures for the Medical Record Department at Alva's Health Center, including issuing and storing patient files, providing data for research and education, and ensuring file confidentiality and completeness according to checklists. It also describes processes for file registration, retrieval, ICD coding, and compliance with policies for medico-legal cases and death records.

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    You are on page 1of 12

    MEDICAL RECORD DEPARTMENT

    ALVA’S HEALTH CENTER


    Scope of services
     Issuing IPD files of the patients.
     Ensuring completeness of records before storage.
     Storage & retrieval of files.
     Provide data for Research purpose &education.
     Medical Audit for quality.
     Providing statistical data to Govt. bodies.
     Ensuring confidentiality of Medical Records
    SOP for generation of medical record
    IPD and OPD registration no. Remain same
    when patient comes in hospital.

    IPD patient file completed with primary data.

    File send to the ward along with patient.

    After discharge, nursing staff checked primary


    completion.

    After completion file send to the billing.


    And then MRD.
    Process flow
    Files received in M.R.D. from billing

    Check for deficiency

    Incomplete Complete

    Return to Ward or Billing Entry in Daily Register

    Complete ICD coding verification

    Scanning

    Stored serially with


    IPD No. & Year wise.
    Process for Retrieval
    Filling of requisition form with signature

    Receivers sign is obtained in file issue register

    File issue entry in system


    Issue period
    Ward – For Readmission Till Patient is discharged
    Billing & Admin. – 10 days. (Only In Exceptional Cases)
    CMO – 7 days. (MLC)
    Mediclaim dept. -3 days.

    File deposited within period File not deposited within period

    Entry in file register / in system


    Follow up

    Storage
    Policy for MLC files
     All original reports should be maintained.
     In case original reports are demanded by the patient,
    true copy of reports are maintained, taking sign. of the
    patient for carrying the original reports.
     Red sticker is put on the MLC file.
     MLC file must be signed by the C.M.O. in case the file
    has deficiency, CMO does not sign the file and returns to
    the wards.
     If the investigations are done outside, then also, copy of
    reports should be maintained in the file.
     Death files carry black sticker on it.
     M.L.C., files should be compulsorily given back to wards
    for completion after billing is done. Then only they will be
    received by MRD.
    ICD 10
     It is introduce WHO, for categorization of diseases for
    morbidity and mortality reporting.

     Medical classification system is used for -


     Statistical analysis of diseases
     Reimbursement purposes
     For decision based support system
     Direct surveillance of epidemic or pandemic outbreaks
    SOP For ICD-10
     For ICD coding Principle /final diagnosis is taken into
    consideration.
     As stated earlier mostly coding is done in wards by
    resident Doctors.
     This already given code is again verified by MRO in MRD.
     If correct entered in software system by clerk.
     If any change required, modified by MRO.
     For this correction ICD-10 book published by WHO is
    used.
     If necessary help of treating doctors is also being taken
    for confirmation.
     Also the software for coding is downloaded in system for
    reference.
     After confirmation code is entered in system & thus the
    file with complete data of patient with ICD code is
    stored permanently in the system.
    Checklist
     Case sheet
     Admission form
     Xerox of Discharge Card with final diagnosis.
     Death Certificate (if any)
     Doctor's notes
     Consent forms
     Pre-anesthesia check-up notes
     Operative notes
     I.C.U. sheets including transfer sheets.
     Nursing sheets, charts.
     Reports: Xerox of X-ray report, USG, 2D Echo, CT Scan,
    MRI – compulsory. If lab reports & ECG are taken by the
    patient, signature of the patient should be there on file.
     In case of DAMA, stamp on the file and consent of the
    patient for DAMA.
     Signature and stamp of the resident doctor on the case
    sheet.
     Final Bill

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