SolutionA medical record, health record, or medical chart is a systematic documentation of a patient's individual medical history and care. The term 'Medical record' is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient's health history. Medical records are intensely personal documents and there are many ethical and legal issues surrounding them such as the degree of third-party access and appropriate storage and disposal. Although medical records are traditionally compiled and stored by health care providers, personal health records maintained by individual patients have become more popular in recent years. Structure of a Medical Record * Name, birth date, residence and emergency contact * Sex, Blood type * Date of last physical examination * Dates and results of tests and screenings * Major illnesses and surgeries, with dates * List of medication, dosages and duration of prescription * Any allergies * Any chronic diseases * Any history of illnesses in the family

b. Enumerate department?







In brief the major and important ones are: 1. Computerised new and revisit registration of ambulatory care (OPD) patient (between 8.00 AM –11.00 AM) & collection of annual fee/ duplicate card fee under token and display system. 2. Computerised new and revisit registration of emergency care patient (round the clock service) & collection of annual fee/duplicate card fee. 3. Issue of health care clinical notes to various ambulatory care (OPD) clinics. 4. Pasting of various types of reports in the respective ambulatory care-health record charts (OPD file) 5. Providing case summary of Medico-Legal cases to police authorities & patients on written request. RAHUL GUPTA, MBAHCS (3RD SEM), SUBJECT CODE-MH0041, SET-2 Page 1

6. Providing medical information to insurance agency on prescribed form of insurance company on written request by deceased nominee/insurance authorities. 7. Collection of various investigations/tests charges etc. and issue of receipt at both the counters, emergency (round the clock) and at fee section of OPD from 8.00AM to 12.30 PM. 8. Round the clock admission registration, documentation, security collection at the emergency and issue gate passes. 9. Round the clock discharge of patients at the emergency counter, security adjustment/ refund services. 10. Providing information and guidance to patients, attendants and visitors. 11. Compiling statistics of various data & services. 12. Issue of health record charts to faculty members, administrative authorities for various purposes. 13. Medical records department and management is the CUSTODIAN of ambulatory, emergency and in–patient care health record charts, including Medico-Legal and death cases etc.

c. Draw the Organizational Structure of a medical records department?
Solutiona. The First Axis: Specifications of a Health Information Management Division
The Health Information Management Division is responsible for integrating all hospital information resources and providing comprehensive, integrated health information management services in line with the goals of the hospital. This division consists of three organizational departments: 1. a medical library department, mainly responsible for preserving, maintaining, and providing information services related to library information resources 2. an information technology department, mainly responsible for carrying out information and communication technology (ICT) affairs for hospitals 3. a healthcare information management department, mainly responsible for providing medical records and healthcare information management services


All these departments are to be organized under the direction of a new top manager known as the health information manager. The health information manager's activities include those related to information resource integration, information strategic planning, development and coordination of policies and procedures for information technology, and information management. In order to coordinate the work of the Health Information Management Division with the appropriate establishments related to clinical and nonclinical hospital affairs, the health information manager will be under direct supervision of the hospital president with an indirect relationship with the hospital manager. The organizational structure of the Health Information Management Division suggested for

b. The Second Axis: Specifications of a Healthcare Information Management Department
Since many inappropriate names are used to designate MRDs in Iran, and considering the goals and functions of this department as well as the philosophy of organizational restructuring, the name of this department in hospitals in Iran should be changed to Healthcare Information Management Department. In addition, according to the first axis, as described above, this department should be in the Health Information Management Division, under the direction of the health information manager.

c. The Third Axis: Functions of the Healthcare Information Management Department
According to the House of Delegates of AHIMA, HIM is a profession that focuses on healthcare data and the management of healthcare information resources. HIM professionals collect, integrate, and analyze primary and secondary healthcare data, and disseminate information and manage information resources related to research, planning, provision, and evaluation of healthcare services. The functions of the Healthcare Information Management Department therefore include those related to healthcare data/information gathering, processing, and distribution, as follows: 1. Healthcare data/information gathering
• •

Cooperation with form designing committee for designing information form Data/information quality analysis

2. Healthcare data/information processing
• •

Data/information organizing Data/information classifying (coding)


• •

Extraction and classifying of information other than disease and operation data

Compiling administrative and health statistics

3. Healthcare data/information storage and distribution
• •

Storage and retrieval of medical records Maintenance of a variety of indices and registries (paper-based or electronic)
• • •

Release of information Research coordination Support for quality assurance, risk management, and utilization management

d. The Fourth Axis: Units of the Healthcare Information Management Department
The Healthcare Information Management Department should consist of three organizational units based on service line departmentalization as follows: 1. A data gathering and maintenance services unit, responsible for medical record storage, cooperation with form designing committee in form design/redesign, and analysis of data quality 2. A data processing services unit, responsible for organizing data, classifying (coding) data, and compiling administrative and health statistics 3. An information distribution services unit, responsible for release of information, research coordination, and cooperation in utilization review, risk management, and quality assurance.

Q.2 a. Draw a flowchart of discharge procedure for inpatients?
Patient requests self discharge


Health care professional discusses request and implications with patient, identifies problems, and implements any appropriate action RD




Patient agrees to stay NO Ensure Pt understands implications of request, and is able to make informed decisions? ** NO YES Request visit from Dr, inform NOK, MM. Record in patient’s notes. Dr to advice on appropriate action Inform Pts Dr and NOK. Explain to pt contents of self discharge form, and implications on PCT responsibilities. Patient signs form if continues to request discharge. Record events, including reasons for self discharge in pts notes. Complete complaints form if applicable Ensure Pt has medication & transport, and that any relevant services, and social worker have been informed of pts self discharge prior to pt leaving

Rectify Pt concerns, inform NOK, Dr, & MM of events, record in Pts notes, complete complaints form if appropriate

Patient agrees To stay YES NO

b. Outline the functions of the following
Solution1. Bin card- Bin card is a record of receipt and issue of materials Quantity of store received is entered with receipt column and the quantity of store issued is recorded in the issue column of Bin Card. Balance of quantity of stores is ascertained after every receipt or issue 2. Stores ledger- This ledger is kept in the costing department and is identical with the bin card except that receipt, issues and balances are shown along with their money values. This contains an account for every item of stores and makes a record of the receipts, issues and the balances, both in quantity and value. Thus, this ledger provides the information for the pricing of materials issued and the money value at any time of each item of stores. 3. Stock identification card- An identity document (also called a piece of identification or ID) is any document which may be used to verify aspects of a person's personal identity. If issued in the form of a small, mostly standard-sized card, it is usually called an identity card (IC). In some countries the possession of a government-produced identity card is compulsory while in others it may be voluntary. In countries which do not have formal identity documents, informal ones may in some circumstances be required. RAHUL GUPTA, MBAHCS (3RD SEM), SUBJECT CODE-MH0041, SET-2 Page 5

4. Materials requisition slip- A source document that indicates the types and quantities of material to be placed into production or used in performing a service; it causes materials and its cost to be released from the Raw material Inventory warehouse and sent to Work in Process Inventory. 5. Materials transfer note- A form that records the transfer of material from one accounting code to another.

Q.3 Distinguish between autoclaving and ethylene oxide sterilization
Solutiona. Autoclaving
An autoclave is a device to sterilize equipment and supplies by subjecting them to high pressure steam at 121 °C or more, typically for 15 to 20 minutes depending on the size of the load and the contents. It was invented by Charles Chamberland in 1879 although a precursor known as the steam digester was created by Denis Papin in 1679. The name comes from Greek auto, ultimately meaning self and Latin clavis meaning key — a self-locking device.

A notable growing application of autoclaves is in the treatment and sterilization of waste, such as pathogenic hospital waste. Machines in this category largely operate under the same principles as the original autoclave in that they are able to neutralize potentially infectious agents by utilizing pressurized steam and superheated water. A new generation of waste converters is capable of achieving the same effect without any pressure vessels to sterilize culture media, rubber material, gowns, dressing, gloves etc. It is particularly useful for materials which cannot withstand the higher temperature of hot air oven. For all glass syringes, hot air oven is a better sterilizing method. b. Ethylene Oxide Sterilization Ethylene oxide (ETO) gas uses relatively low temperatures for sterilization. Using a heated unit, sterilization can be achieved in 2-3 hours at 120°F. However, a lengthy aeration time must follow each cycle. Materials such as suction tubing, hand pieces, radiographic film holders, and prosthetic appliances may be sterilized without adverse effects. Follow the manufacturer’s instructions for safety precautions, operation, and maintenance. Because of the serious Occupation Safety Health Agency (OSHA) problems with ETO gas, COs of RAHUL GUPTA, MBAHCS (3RD SEM), SUBJECT CODE-MH0041, SET-2 Page 6

Naval Dental Clinics (NDCs) should not purchase new ETO equipment. Large naval hospitals with ETO capabilities in their CSR may use them to sterilize non heat stable dental instruments and equipment


** Does Pt have cognitive problems, confusion, dementia or any other condition that may affect judgement?