Medical Records
Department
“Good Medical Care Means Good Medical Records”
Medical Records (MR) documentation at AVMC is in accordance with predetermined standards; medical information coding process; creation and maintenance of statistical information database for planning and budgeting for hospitals; organizing outpatient and emergency medical records.
The Medical Records Department is primarily concerned with the documentation of patient care. It does not deal directly with reviews of actual treatment given or set standards of care. By ensuring that all personnel comply with regulations regarding documentation of patient care, the Medical Records department supports various medical staff committees by providing data from medical records.
Medical records play an important role in the functioning of our hospital in terms of giving vital information for conducting research, statistical data on utilization of hospital services, mortality and morbidity profiles, and evaluating the performance of clinical facilities.
MRD in hospital includes the following four units, each of which undertakes special functions:
- Admission: Registration of outpatients and inpatients who are admitted to the hospital wards and the Accident and Emergency Department
- Archive: Checking to ensure that a complete discharge summary and all other necessary notes and reports are present in the MRs; assembling and internally organizing the MR and filing them in an orderly and timely manner; retrieving these records for various users, for treatment and the provision of other services
- Statistics: Preparing statistics for administration, hospital wards, and external agencies such as the Ministry of Health; providing health information for physicians, nurses and students for medical research purposes
- Coding: Analysing the MRs of all inpatients, the following discharge and assigning a set of numeric codes to the diagnostic data based on the International Classification of Diseases-10 and the International Classification of Procedures in Medicine.
Objectives:
- To maintain a central system of the complete medical records of all patients.
- To serve as an effective managerial tool for future planning.
- To provide data for quality checks, medical research and education.
- To fulfil the legal requirements.
Value and Uses:
- The documentation information is always useful in defending the patient, physician and hospital against any malpractice suits.
- It helps the patient to remember his/her problems and the treatment rendered during the time
- It hastens the treatment given to any patient during emergency admission.
- It acts as a communication tool between all the health care professionals.
- It helps in the collection of statistical data related to diagnosis, procedure, infection rates and mortality rates, length of stay, occupancy ratio and medical research and education.
- It helps justify the quality of treatment rendered to patients by physicians, nurses and other health care professionals.
Policies:
Our well-organized medical record department has clearly laid down written medical record policies in accordance with the institutional mission, goals, objectives and resources for the effective functioning of the hospital.
- A central registration system with 24 hours service is maintained for all OPs and IPs.
- All medical records are stored centrally in a secured place under the control and supervision of the department in charge.
- Access to the medical record department is limited to only its personnel.
- All staff are provided with a uniform code to have control over the records department.
- Patients are registered with full sociological (identification) data.
- We follow the assembling order to maintain a system for handling inpatient records.
- It is ensured that doctors and paramedics complete all deficient records prior to the discharge of the patient.
- All the patients’ records are coded as per the international classification of diseases and procedures book prescribed by WHO.
- Medical Records can be retrieved only with a requisition from the medical or paramedical professionals, authorized only by the Medical Records-In-Charge.
- Medical Record is the property of the hospital. But, the contents in it are the property of the patient.
- Photocopy of the Medical Record or the summary of the medical treatment can be given to the patient at his / her request.
