Submitted by Poly Nandi

Bachelor in Hospital Management

Paramedical College Durgapur
NAME: - POLY NANDI
SEMESTER: - 3RD
PROJECT ON: - MEDICAL Record
DEPARTMENT
REGISTRATION NO.:-141611310013
ROLL NO.:- 16103314013

(1)
 HOSPITAI PROILE

Medica Super speciality Hospital is a

tertiary care hospital with state-of-the-art
facilities in Cardiology and Cardiac surgery,
Neurology and Neuro surgery, Orthopedics,
Joints and spine treatment, a large Dialysis
facility and a host of other support services,
all under the same roof.

Medica Super Speciality Hospital is a 500

bedded Hospital, 24*7 emergency support
in Kolkata and pride ourselves as one of the
best hospital in eastern India.

Medica Super speciality Hospital will serve

as the hub for our smaller hospitals in
Siliguri, Asansol and various others in the
Northeast.

(2)
 ACKNOWLEDGEMENT

‘Inspiration and motivation always plays a

key role in the success of any project.’

I am one of those fortunate student whose

path is enlightened by expertise and
component guidance of Dr. Sudipta
Ghoshal (HOD of our Department) and
Sumana Ghoshal for completing this
project successful.

Signature

(3)
(4)
(5)
 CONTENT
Subject Page
Introduction 7-8
Objective 9
Research Methodology 10
a) Primary data collection
i. Purpose of Medical Record 11
ii. Functions of the Medical 12
Record 13
iii. Retention of Medical Record 14
iv. Retention period of Medical
Record 15
v. Coding 16
vi. Indexing 17
vii. Storage and retrieval of
medical record 18-19
viii. Filing system 20
ix. Physical facilities 21
x. Staffing 22
xi. Equipments 23
b) Secondary data collection
Findings 24

Problems 25-26

Recommendation 27

Conclusion 28

Bibliography 29

(6)
 INTRODUCTION
First medical record dates back to 1667 of 1st
Bartholomew’s Hospital England

Maintenance of patient’s registration in Pennsylvania –

USA - 1752

Indexing of diseases in New York in 1862

Record maintenance was emphasized by American

College of Surgeons & American College of Physicians in
first quarter of 20th century

Association of medical records 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.

(7)
Medical Records through which hospital
Statistics are generated serves as eyes and ears
to the hospital administrator. Medical Records
are of importance to the hospital for evaluation
of its services for better patient care. They also
serve as a resource for education and training of
physicians and others, also being the basic for
clinical research.

(8)
 OBJECTIVE

i) Situation analysis of infrastructure in

terms of the organisation, functioning,
logistics and human resources along
with their training and skills in a
Medical Record Department/ units in
the hospital from CHC through
tertiary level.
ii) To study the present system of record
generation, compilation, analysis,
storage and retrieval of medical
records in the hospitals.
iii) To study the usage of ICD-10 for
morbidity and mortality coding along
with major constraints and fessible
solution.

(9)
RESEARCH METHODOLOGY:-

i) Primary data collection

ii) Secondary data
collection

(10)
PRIMARY DATA COLLECTION

PURPOSE OF MEDICAL
RECORDS:
 To provide a means of communication
among physicians nurses and other aligned
health care professionals.
 To serve as an easy references for providing
continuity in patient care.
 To furnish documentary evidence of care
provided in the health care facility.
 To serve as an informational documentary
to asset in the quality review of patient care.
 To protect the patient, physician, as well as
the health care institutions and its employs
in the event of litigation.
 To render clinical and administrative data
required for budgeting, management service
development, planning, review, medical
education and medical research.
 To supply pertinent patient care information
to authorized organization and third party
payers.

(11)
 FUNCTIONS OF MEDICAL
RECORD
The medical records department of the hospital
is responsible for the following functions-
1. Assembling of the medical records.
Quantitative analysis of records.
2. Deficiency check.
3. Completion of incomplete records.
4. Coding
5. Indexing
6. Analysis and statistics
7. Reporting
8. Numbering and filing
9. Storage and retention of records
10. Retrieval

(12)
RETENTION OF MEDICAL
RECORD

The period for which the medical records

can be retained in the hospital vary from
hospital to hospital depending upon the
teaching and training or research facilities
available. In general the periodicity is:

1. OPD Records 5 years

2. Inpatient Records 10 years
3. Medico legal Records permanently

The recommendation as per the

hospital policy of one such hospital is
being given as under.

(13)
 RETENTION PERIOD OF
MEDICAL RECORD

1. Outpatient records not linked with

inpatient records to be preserved for 5
years.
2. Outpatient records linked with inpatient
records to be preserved for 10 years.
3. Inpatient records to be preserved for 25
years.
4. All medico-legal cases to be preserved for
posterity.
5. All medical records other than those
mentioned above to be disposed off
6. All old x-ray relevant to the outpatient files
that are being disposed off to be destroyed.

(14)
 CODING

Coding of the diseases is done as per the

International Classification of the
diseases, for making national and
international comparisons. This is to bring
uniformity in classification of the diseases.

(15)
 INDEXING

various methods of indexing are used to

name few , the following indexing methods
are used.

1. Alphabetical indexing: patient name

sequenced in alphabetical order.
2. Disease index: the medical records, are of
patient having the same diagnosis is place at one
place.
3. Unit indexing: unit wise indexing of medical
records are done like cardiology, nephrology or unit
1 or unit 2 of surgery department.
4. Physician index: all patients treated by a
particular physician are indexed.
5. operation index: patients, who have
undergone surgery, are indexed.

(16)
 STORAGE AND RETRIEVAL OF
MEDICAL RECORDS

Completed medical records are stored in safe

custody of the medical record department.
Following factors are taken into consideration
for the storage of the records:
1. compactness
2. easy accessibility
3. simplicity for understanding
4. elasticity for expansion
5. economical
6. easy retrieval
7. safety from fire, moth, insects and
dampness, etc.
8. Controllability

(17)
FILING SYSTEM

(18)
1. CENTRALIZED SYSTEM:

All the medical records whether OPD are

field in medical records department of the
hospital.

2. DECENTRALIZED SYSTEM:-

In this system the OPDs have their own

records department. If a patient is
transferred from one department to
another department, the file transferred
on loan bases.

(19)
 PHYSICAL FACILITIES

i) LOCATION: It should be located

near the enquiry office and main
entry of the hospital. It should be in
close proximity to the OPD and
emergency department.

ii) SPACE REQUIREMENT:

a. Admission and enquiry office: a
space of 125 to 175 sq feet is recommended.
b. Central record office: the space
requirement as rough guide is 2-3 sq feet
per bed is sufficient.
c. OPD record section: average of 2-3 sq
feet per bed space is requirement of the
outpatient department record section.

(20)
 STAFFING

Staff requirement are recommended for

500 bedded hospital at a scale of:

Medical record office:

Medical record officer 01
Medical record technician 04
Clerks 03
Peon 01
Statistician 01
(part time)

(21)
 EQUIPMENTS

The equipments which are required in medical

records department are:

1. Type writers
2. Computers with CD/ DVD writer
3. Printers
4. Microfilming processors
5. Camera
6. File cabinets
7. Cub board, table, chairs
8. Photocopies, fax machine, phone, etc.
9. Data storage devices, CD/DVD or
magnetic tapes.
10. Instruments and stationery items like
poker, staplers, spiral binding
machine, laminating machines, etc.

(22)
 SECONDARY DATA
COLLECTION

The data collection for

internal journal books.

(23)
 FINDINGS

The findings of the study based on the

situational analysis in the previous chapter is
summarized in the following points:

1. Existence of medical record department/

unit hospitals in medical colleges.
2. Availability of space and human resources
and other logistic infrastructure in the
Medical Record Department or various
level of hospitals.
3. Status of performance of various functions
by the Medical Record Department.
4. Status of availability of computers and
related infrastructure and their use in
Medical Record Department.

(24)
 PROBLEM AREAS

PHYSICIAN RELATED:
 Entries in record are perfunctory,
inadequate and do not reflect patient’s
condition and treatment given.
 Entries illegible, not traceable to respective
doctor, not signed, not dated, use of
inappropriate abbreviations.
 Iatrogenic complications not factually
documented nosocomial infections not
reported.
 Timing/date of discharge differs from
nurses’ notes.
 Admission-discharge summary sheet
incomplete and hence record cannot be
indexed and.
 Non-return of records taken for research or
case presentation.

NURSE RELATED:
 Pages in record lack patient identification
data.
 Wrong hospital numbers entered manually.
 Charts held up in wards, not returned
following discharge.
(25)
  Census incorrect, especially transfers.

 Investigation reports not correctly filed,

especially for patients transferred to other
wards.

MEDICAL RECORD RELATED:

 Records misplaced, wrongly filed, unavailable
when required.
 Patient file can get to bulky, covers are
invariably tattered.
 Investigation report not filed.
 Delay in coding and indexing.
 No follow-up on non-returned records.

(26)
 RECOMMENDATION

For effective and efficient planning and

formulation of health policies and programmes,
their monitoring and evaluation and timely
corrective measures, country needs reliable,
accurate and valid information on morbidity
burden and its pattern by age, sex and socio
economic status of the people for every
administration and geographical areas. The
health records generated in various hospitals
and health care institutions in the process of
delivery of health services by the respective
institutions contain very basic and valuable
information on morbidity.

(27)
 CONCLUSION
This study has highlighted the problems
associated with the IT implementation process.
It has revealed why the adoption stages is
extremely slow. The implementation of IT will
be of immense benefit in the student clinic. The
university hospital has begun a good thing by
introducing information technology into their
processes. So far the benefits reaped from the
first stage of implementation may be
summarized as preparing timely bills for clients,
realizing the correct revenue generated by the
hospital, and stocking of items on time, as well
as determining the number of visits by the
various categories of clients easily.
 (28)

BIBLIOGRAPHY

1. Joshi Mamta and Joshi DC: Jaypee

Brothers Medical Publishers.
2. Sakharkar BM: Principles of Hospital
Administration and Planning. 2009,
3. Tabish Amin Sayed: Hospitals and Nursing
Homes planning, organisations and
Management. 2003, Jaypee Brothers
Medical Publishers LTD. New Delhi,

(29)
(30)