Professional Documents
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Medical Record Committee
Medical Record Committee
This Committee
makes decisions on medical record policy, medical record procedures,
medical record forms, and procedures in other departments / wards relevant
to the management of medical records and patient information. An active
Medical Record Committee should act as a liaison between the MRO and
other departments. Members should be representatives of the various
clinical services of the hospital, rotating on a yearly basis so that all services
will eventually be represented. Such a Committee, with a strong Chairperson,
can do much to stimulate interest in developing and maintaining a high
standard of medical records and medical record services. The Committee
should support the MRO and assist with the implementation of regulations
regarding the completion of medical records.
The Medical Record Committee is responsible for all matters relating to the
content of medical records and the provision of medical record services in
the hospital. The Medical Record Committee in large hospitals meets every
month and less frequently in smaller hospitals. It should meet at least four
times per year. The Committee should be made up of people who are
interested in good medical records and who are prepared, by their own
example, to provide an incentive to others, particularly junior doctors. The
Committee should consist of not less than three members and not more than
six. Too large a committee could be unwieldy. For example, membership of
the Medical Record Committee should consist of:
1. a representative of doctors from both medicine and surgery;
2. a representative of nursing administration;
3. a representative of the hospital administration (management);
4. a representative from allied health staff - physiotherapy, social work
etc.; and
5. the MRO.
Other members may be invited onto the committee if their input is required,
such as orthopaedic, paediatric and obstetric doctors. In a larger health care
facility, representatives from nurses on the ward may also be included.
The Medical Record Committee cannot perform efficiently without rules and
regulations. These need to be clearly defined and recorded and understood
by all medical staff. Functions and responsibilities of the Medical Record
Committee include:
1. review of medical records to ensure that they are accurate, clinically
pertinent, complete and readily available for continuing patient care,
medico-legal requirements, and medical research;
2. ensure that medical staff complete all the medical records of patients
under their care by recording a discharge diagnosis and writing a
discharge summary (where required) for each discharged patient
within a specified period of time;
3. determine the standards and policies for the medical record and the
medical record services of the health care facility;
dimasukkan.
Medical Komite Rekam tidak dapat melakukan efisien tanpa aturan dan
peraturan. Ini perlu didefinisikan secara jelas dan dicatat dan dipahami oleh
semua staf medis. Fungsi dan tanggung jawab Komite Rekam Medis meliputi:
1. meninjau catatan medis untuk memastikan bahwa mereka akurat, secara
klinis relevan, lengkap dan tersedia untuk melanjutkan perawatan pasien,
persyaratan medis-hukum, dan penelitian medis;
2. memastikan bahwa staf medis lengkap semua catatan medis pasien di
bawah perawatan mereka dengan merekam diagnosis debit dan menulis
ringkasan debit (di mana diperlukan) untuk setiap pasien dipulangkan dalam
jangka waktu tertentu;
3. menentukan standar dan kebijakan untuk catatan medis dan layanan
rekam medis dari fasilitas kesehatan;
4. merekomendasikan tindakan ketika masalah timbul dalam kaitannya
dengan catatan medis dan layanan rekam medis;
5. menentukan format rekam medis dan menyetujui dan mengontrol
pengenalan bentuk rekam medis baru yang digunakan di fasilitas pelayanan
kesehatan (semua bentuk harus dibersihkan oleh Komite Rekam Medis
sebelum mulai digunakan); dan
6. membantu dan mendukung MRO dalam penghubung dengan staf /
departemen lain di fasilitas pelayanan kesehatan.
Adalah penting bahwa aturan dan peraturan untuk penyelesaian catatan
medis yang dikembangkan dan disetujui oleh staf medis dan ditaati oleh
semua. Dengan dukungan dari Komite Medis dan Administrasi Rekam Medis,
MRO harus dapat mengatasi masalah kualitas seperti dokumentasi miskin
dan catatan medis lengkap. MRO harus mempersiapkan ringkasan laporan
untuk setiap pertemuan Medis Komite Rekam. Ringkasan ini harus mencakup
jumlah catatan medis menunggu penyelesaian oleh dokter.