Spba208h PDF

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SPBA 208 H
POSTGRADUATE COURSE
MBA
SECOND YEAR
FOURTH SEMESTER
ELECTIVE PAPER
INSTITUTE OF DISTANCE EDUCATION

UNIVERSITY OF MADRAS
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MBA ELECTIVE PAPER- HOSPITAL MANAGEMENT
SECOND YEAR - FOURTH SEMESTER HOSPITAL RECORDS MANAGEMENT
WELCOME
Warm Greetings,
It is with a great pleasure to welcome you as a student of Institute of Distance
Education, University of Madras, It is a proud moment of the Institute of Distance
education as you are entering into a cafeteria system of learning process as envisaged
by the University Grants Commission. Yes, we have framed and introduced Choice
Based Credit System (CBCS) in Semester pattern from the academic year 2019-20.
You are free to choose courses, as per the Regulations, to attain the target of total
number of credits set for each course and also each degree programme. What is a
credit? To earn one credit in a semester you have to spend 30 hours of learning
process. Each course has a weightage in terms of credits. Credits are assigned by
taking into account of its level of subject content. For instance, if one particular course
or paper has 4 credits then you have to spend 120 hours of self-learning in a semester.
You are advise to plan the strategy to devote hours of self-study in the learning
process. You will be assessed periodically by mean of tests, assignments and quizzes
either in class room or laboratory or field work. In the case of PG (UG), Continuous
Internal Assessment for 20(25) percentage and II nd Semester University Examination
for 80(75) percentage of the maximum score for a course / paper. The theory paper in
the II nd semester examination will bring out your various skills: namely basic
knowledge about subject, memory recall, application, analysis, comprehension and
descriptive writing. We will always have in mind while training you in conducting
experiments, analyzing the performance during laboratory work, and observing the
outcomes to bring out the truth the experiment, and we measure these skills in the II nd
semester examination. You will be guided be well experienced faculty.
I invite you to join the CBCS in Semester System to gain rich knowledge leisurely
at you will and wish. Choose the right courses at right times so as to erect your flag of
success. We always encourage and enlighten to excel and empower. We are the cross
bearers to make you a torch bearer to have a bright future.
With best wishes from mind and heart,
DIRECTOR
(i)
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MBA ELECTIVE PAPER- HOSPITAL MANAGEMENT
SECOND YEAR - FOURTH SEMESTER HOSPITAL RECORDS MANAGEMENT
Dr. B. Rupa,
Assistant Professor,
Department of Pediatrics
Government Medical College
Omandurar Estate, Chennai - 600 002.
Dr. B. Devamaindhan
Associate Professor in Management Studies
Institute of Distance Education
University of Madras,
Chennai - 600 005.
c UNIVERSITY OF MADRAS, CHENNAI - 600 005.
(ii)
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MBA DEGREE COURSE
SECOND YEAR
FOURTH SEMESTER
ELECTIVE PAPER - HOSPITAL MANAGEMENT
HOSPITAL RECORDS MANAGEMENT
SYLLABUS
UNIT - I
Hospital Records: Meaning, Functions and Importance of medical records to
Patients, Doctors, Hospitals, Public Health, Press, LIC, Police – Court of Law,
Education and Research.
UNIT – II
Records Management: Registers, Forms: Meaning and importance – Principles
of records keeping – Merits and Limitations – Principles of records keeping – Merits
and limitations – Latest trends in record maintenance – Electronic forms of records
maintenance.
UNIT – III
Types out – patient record, in-patient records, causality, emergency, surgery,
obstetrics and gynecology, pacdiatries, investigation and diagnosis.
UNIT – IV
Records Organisation and Management: Classification of records – Bases for
Classification – Indexing and filling of records – Problems associated with medical
records.
UNIT – V
Medical registers: Meaning – Types – Purpose – Advantages – Principles of
designing records Registers in various departments common issues.Medical Forms
and Reports: Meaning types and significance – Principles of designing – Statutory
registers and reports to be maintained – Specimens.
(iii)
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Reference Books
1. Rajendra Pal and Korlahalli J.S. Essential of Business Communication,
Sultan Chand and Sons, New Delhi
2. Prasantha Ghosh K. Office Management, Sultan Chand Sons, New

Delhi.
3. Francis CM and Mario C de Souza, Hospital Administration, 3 rd Ed.

Jaypee Brothers, New Delhi
4. George, M A, The Hospital Administrator, Jaypee Brothers, New Delhi.

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MBA DEGREE COURSE

SECOND YEAR
FOURTH SEMESTER
ELECTIVE PAPER - HOSPITAL MANAGEMENT
HOSPITAL RECORDS MANAGEMENT
SCHEME OF LESSONS
Sl. No. Chapters Page No.
1. Importance of Hospitals Management 1
2. Records Management 17
3. Electronic Forms Of Record Keeping 29
4. Outpatient And Inpatient Services 47
5. Medical Services 71
6. Record Organisation And Management 108
7. Problems With Medical Records 127
8. Medical Registers 145
9. Medical Forms And Reports 157
10. Hospital General Services 172
11. Hospital Information System 189
12. Quality Issues For Medical Record Services 198
(iv)
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LESSON – 1
IMPORTANCE OF HOSPITALS MANAGEMENT
Learning objectives
After reading this lesson, you will be able to discuss
Hospital Records Meaning and Functions

Importance of hospital records to Patients, Doctors, Hospitals,
Importance of hospital records to Public Health, Press, Police – Court
of Law, Education and Research.
Structure
1.1 Introduction
1.2 Functions of Maintaining Hospital Records
1.3 Importance of Maintaining Hospital Records
1.4 Implications of Medical Records for life Insurance
1.5 Etiquettes in Maintaining a Good Hospital Records for Police –

Court of Law & Education and Research.
1.6 Legal issues
1.7 Release of Records
1.8 Certificates
1.9 Summary
1.10 Keywords
1.11 Review Questions
1.12 Suggested Readings

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1.1 Introduction
Hospital record keeping is integral to good professional practice and the delivery
of quality healthcare. Hospital record keeping is an integral component in good profes-
sional practice and the delivery of quality healthcare. Regardless of the form of the
records (i.e. electronic or paper), good hospital record keeping should enable continuity
of care and should enhance communication between different healthcare profession-
als. Consequently, hospital records should be updated, where appropriate, by all mem-
bers of the multidisciplinary team that are involved in a patient’s care (physicians, sur-
geons, nurses, pharmacists, physiotherapists, occupational therapists, psychologists,
chaplains, administrators or students). Should the need arise patients themselves should
have access to their records to be able to see what has been done and what has been
considered. Hospital records are also valuable documents to audit the quality of
healthcare services offered and can also be used for investigating serious incidents,
patient complaints and compensation cases. In this lesson we will present the impor-
tance of keeping good hospital records, ways of facilitating this and an overview of legal
aspects linked with hospital record keeping. There is also a list of suggested reading
from several countries that may prove useful. Records management is the system used
to control an organization’s records from the creation of the record until the record is
archived or destroyed. A records management process is comprised of identifying records,
classifying records, and storing records, as well as coordinating internal and external
access. The process may also incorporate policies and practices on how to create and
approve records, as well as the enforcement of those policies and practices.
Many organizations must deal with large amounts of information on a daily basis.
Productive organizations incorporate a comprehensive, effective records management
process into their daily operations.
The record can be stored on paper or electronically via email, digital file, database,
or spreadsheet. Records also can be photographs, audio files, or videos. Some ex-
amples of record classifications are legal, financial, historical, and daily operations. An
effective records management process contains at least five components: record cre-
ation, internal and external record distribution, record usage, record maintenance, and
record archival and disposal.
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1.2 Functions of Maintaining Hospital Records
Monitoring of the actual patient
Hospitalresearch
Medical/dental or parahospitaleducation
For insurance cases, personal injury suits, workmen’s compensation case,

criminal cases, and will cases
For malpractice suits
For hospitalaudit and statistical studies
1.3 Importance of Maintaining Hospital Records

A good hospital record serves the interest of the hospital practitioner as well as his
patients. It is very important for the treating doctor to properly document the manage-
ment of the patient under his care. Hospital record keeping has evolved into a science.
The key to dispensability of most of the hospital negligence claim rest with the quality of
the hospital records. Record maintenance is the only way for the doctor to prove that the
treatment was carried out properly. Hospital records are often the only source of the
truth. They are likely to be far more reliable than memory.
Figure 1.1 Importance of Medical Records

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The management and preservation of the hospital records in Indian context present
a very gloomy picture. Despite the intensive effort at national and international level, the
fundamental health care needs of the population of the developing countries are still
unmet. The lack of basic health data renders difficulties in formulating and applying a
rational for the allocation of limited resources that are available for patient care and
disease prevention. It is recommended that more efforts should be made by the institu-
tions/hospital managements, all clinicians and hospital record officer to improve the
standard of maintenance and preservation of hospital records. In this article, we are
discussing the various aspects of the hospital record management.
Who has Access to Medical Records?

Medical records are the property of the hospital or patient’s medical practitioner. It
is a confidential communication of the patient and cannot be released without his per-
mission.
All patients have right to access their records and obtain copy of those
records.
Patient’s legal representative has the right to those records as long as

patient has signed a release of records to accompany any request from the
legal representative
Other health care providers have the right to the records of the patient, if
they are directly involved in the care and treatment of the patient.
Parents of a minor also have access to patient’s medical records.
Medical records are usually summoned in a court of law in certain cases

like-road traffic accident, medical negligence, insurance claim etc.
The impersonal documents have been used for research purposes as the
identity of the patient is not revealed. Though the identity is not revealed, the
research team is privy to patient records and a cause of concern about the
confidentiality of the information. Recently a need has been felt to regulate the
need of medical research, effectively restricting the manner in which this type
of research is conducting. An ethical review is required for using the patient’s
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1.4 Implications of Medical Records for Life Insurance
Doctors and hospitals often contract with insurance companies to become part of
the company’s “network.” The contracts spell out what they will be paid for the care they
provide. If you go to a doctor in your insurance company’s network, you will pay less out
of your own pocket than if you go to a doctor who doesn’t have a contract with your
insurer. Some insurance plans will not pay anything if you do not use a network provider
(except in the case of an emergency). So it is important to consult the plan’s network
before seeking care.
Everybody with health insurance should have a doctor who will oversee their medical
care. That means you will need to find a doctor — also called your primary care
physician — who is taking on new patients. If you have young children, you will need to
find a pediatrician or family practice physician for their care. Call doctors on the list your
insurance company gives you to confirm they are still in the plan’s network. Once you’ve
found a doctor who will take you as a patient, set an appointment for your first checkup.
Urgent care centers can treat some serious injuries and illnesses. For instance,
you can go there to get stitches for a bad cut or to be checked if you have a high fever.
Call your insurance company first to make sure it will pay for treatment there. Your
insurance may also cover care at a retail-based clinic like the ones at large stores with
pharmacies. They are usually staffed by nurse practitioners but cannot treat serious
illnesses or injuries. If you need to be tested for strep throat or need a flu vaccine and
can’t get an appointment with your regular doctor, an in-store clinic is another choice.
Before going to a walk-in clinic, check with your insurance company to make sure they
will pay for any care you receive there.
If you have a life-threatening medical emergency, go to the hospital emergency

room. For instance, if you’re having a heart attack or are bleeding badly from a wound.
Get treatment at an emergency room, no matter what type of insurance you have — but
it may cost you more than if you went to a doctor’s office or an urgent care clinic for
treatment. If possible, call your insurance company before you go to an emergency
room.
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Most health plans are required to cover preventive care without any cost-sharing.
This means even if you haven’t met your annual deductible, you can still receive pre-
ventive care services for free. Preventive care benefits include immunizations, some
cancer screenings, cholesterol screening, and counseling to improve your diet or stop
smoking.
Good clinical notes document the medical history of the patient. By documenting
all relevant clinical information you are recording this information for future reference.
Remember, if you did not write it down, it did not happen. This is of particular relevance
in the case of a contested medical decision but most importantly it ensures continuity.
Continuity in clinical notes is of vital importance to patient care as, in the current medical
environment, many different healthcare professionals are involved in the treatment of a
single patient. Making sure that clinical notes are up to date and completed accurately
with sufficient information will ensure that the proper information is provided to all rel-
evant healthcare workers and will aid them in potential future decisions. This, in turn,
will benefit the patient through less time lost on repeating tests and by averting inaccu-
rate diagnoses or the prescription of inappropriate treatments. Moreover, there is a
benefit to the healthcare organisation in that good clinical records facilitate decision
making for a single patient, thus freeing up time that can be spent with patients most in
need. Finally, poor clinical records might have a profound impact on a patient’s lifelong
health. An NHS report on patient information, which says “the duty to share information
can be as important as the duty to protect patient confidentiality”.
Table 1.1 : Advantages of keeping good clinical records and the

disadvantages of poor clinical records
Good clinical records Poor clinical records

Aid the sharing of relevant information and multidisciplinary team communication
Misinform healthcare professionals and patients
Aid coordination of care Increase medico-legal risks
Aid continuity of care Lead to unnecessary repetition of tests
or other investigations
Aid informed decision making for patient Prolong hospital admission
management
Improve availability of data for risk Jeopardise patient care
assessment
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Improve availability of data for route cause Lead to serious incidents

analysis in the investigation of serious incidents
Improve audit capabilities
Provide informative evidence in a court of law
Aid targeting of diagnostics and treatment plans
without unnecessary repetition
Improve time management
1.5 Etiquettes in Maintaining a Good Hospital Records for

Police – Court of Law & Education and Research
Patient demographics
Reasons for the current visit
The scope of examination
Positive exam findings
Pertinent negative exam findings
Key abnormal test findings
Diagnosis or impression
Clear management plan and agreed actions
Treatment details and future treatment recommendations
Medication administered, prescribed or renewed and any drug allergies
Written (or oral) instructions and/or educational information given to the
patient
Clear documentation and justification for resuscitation status and ceiling

of care (if inpatient)
Documentation of communications with patient and family/friends (level
of awareness of the situation and acceptance of the plans)
Recommended return visit date

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Table 1.2 : Basic Do’s and Don’ts in Medical Record Entries
Do Do not
Use timed entries Use abbreviations
Make objective comments Make offensive, humorous or
personal comments
Document any noncompliance Use ambiguous terms
Document oral communications Delete or alter the contents of clinical notes
(phone calls, in person conversationsetc) in a way that is
and actions taken untrackable
Document informed consent
State objections regarding care or
case management
Every entry in the medical record should be dated, timed (24 h clock) and legible.
Each should be signed by the person making the entry and should be made as soon as
possible after the event to be documented (e.g. change in clinical state, ward round,
investigation etc) and before the relevant staff member goes off duty. If there is a delay,
the time of the event and the delay should be recorded as well as the reasons for the
delay. Abbreviations should be avoided because they might be ambiguous. For instance,
PID could mean prolapsed intervertebral disc or pelvic inflammatory disease. On the
other hand, it is acceptable to use short forms in situations where the short form is in
common usage in society and would be more easily recognised by the public than the
whole term (e.g. HIV, a.m., p.m. etc). It is also important to avoid unnecessary com-
ments in the patient report. Any offensive, personal or humorous comments could dam-
age your credibility. Remember, patients have a right to access their records and a
flippant remark in a patient’s notes might be difficult to explain.
Medical record entries should be objective. For example, it is risky to refer to a

patient as “an alcoholic” or write that they “abuse drugs” without objective substantiation
of these potentially harmful assertions. Instead, the doctor can conclude that the patient
has demonstrated “drug-seeking behaviour”. Furthermore, the physician should
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document objectively what the patient did or said that led the doctor to conclude that the
patient demonstrated this behaviour. Use of quotation marks might be helpful in situa-
tions where a physical exam fails to provide an objective explanation for a patient’s
complaints (e.g. I am unable to find an objective explanation for the patient’s complaint
of “pain”). On the other hand, using too many quotation marks in a report might be
distracting. Terms such as “moderate”, “heavy”, or “occasional” are subject to broad
interpretation and the use of quotations is probably unnecessary. Referral recommen-
dations should be documented in unambiguous terms. For example, if the patient needs
to understand urgency, this should be obvious from the written comments (i.e. “patient
urged to see his gastroenterologist for right upper quadrant abdominal pain and jaun-
dice” instead of “to see GI” and “patient says she will call today for an appointment with
orthopaedist for hip pain” in place of “hip pain-needs ortho”).
Physicians should document noncompliance in the progress record, such as a

patient’s failure to follow advice, take medication, obtain requested diagnostic studies,
keep an appointment with a consultant, or other actions the patient takes or fails to take
that could cause or contribute to an injury or delay in resolution of a medical problem.
Patient phone calls should be documented effectively with names, dates and content,
including actions taken in response to the patient’s call. It is also necessary to make
notes regarding patient after-hours phone calls or any consultation with colleagues about
the patient case. Informed consent discussions should be documented carefully, as
well as discussions with family members, using the same structure as noted above.
For correction of any error draw a single line through the entry, document the
correct info, add the date and time, and sign off on the correction. It should be possible
to track any deletions or alterations back to a named individual at a given time and date.
To obtain an idea of the level of a patient’s awareness and needs, a physician might
want to consider the ICE model (Ideas, Concerns, Expectations) during each visit where:
1) Ideas are “What are your ideas of what is going on?” 2) Concerns are “What are you
most worried about?” 3) Expectations are “What are you expecting that I can do?”.
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1.6 Legal Issues
The content and handling of clinical records is strictly regulated by the law in most
countries, not only because they are fundamental to high quality patient care but also
because they are increasingly used in the courts and represent an important source of
confidential personal information. There are three main pillars of relevant legal obliga-
tion. 1) Accuracy and legibility of clinical records content. 2) Confidentiality and data
protection. 3) Patients’ access to their medical records. While we describe general rules
here and give some examples from different countries, we strongly recommend that
you should look up the relevant legal requirements in your own country and familiarise
yourself with them.
Accuracy and Legibility of Content

The “Good Medical Practice” guidelines issued by the government bodies states
that clinical records represent the formal record of a clinician’s work and must be clear,
accurate, legible and written in a scientific manner. They should include: 1) All relevant
clinical findings. 2) A record of the decisions made and actions agreed as well as the
identity of who made the decisions and agreed the actions. 3) A record of the informa-
tion given to patients. 4) A record of any drugs prescribed or other investigations or
treatments performed. 5) The identity of who is making the record and when. More
important for healthcare providers is that the courts tend to consider that if a medical
decision, treatment or procedure is not recorded in the clinical notes then it has not
been performed. Thus, in a court of law, it does not matter if you have done your best for
your patient unless you have accurately documented this fact. However, the legal bur-
den of proof can depend on the specific setting and circumstances in which the notes
are being scrutinised.
Confidentiality and Data Protection

Medical records, including patient identifiers and data on the diagnosis, prognosis
or treatment of any patient or subject, are considered confidential globally and can only
be shared with the prior written consent of the patient or the subject with respect to
whom the record is maintained. Exceptions differ slightly from country to country and it
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is worth checking the relevant national legislation. For example, the law suggests that
clinical records may be shared without consent, to the extent necessary to treat a medi-
cal emergency, with other medical practitioners. They may also be shared with qualified
research personnel, to federal, state or local public-health authorities in cases of HIV
infection and to state-controlled substance monitoring programmes.Confidentiality can
be breached in the public interest if failure to disclose such information may expose
others to a risk of death or serious harm (e.g. reporting of gunshot and knife wounds,
acts of terrorism, risks of serious communicable disease transmission and concerns
relating to the ability to drive a motor vehicle). Law is less specific, stating that clinicians
can disclose confidential data without consent in order to safeguard a higher-ranking
legally protected interest.
An additional component of confidentiality in the era of technology and the internet

refers to data management and data safety. A recent report suggests that 15 out of 28
member countries have adopted specific rules on the content of electronic healthcare
records and many of them have specific rules regarding data safety and data sharing.
Electronic health records are also strictly regulated in various other countries. Data
safety and data sharing law can be very strict in some countries, such as in the United
Kingdom for example. The National Health Service, that are closely monitored in order
to preserve the safety of personal data and medical records. It is not permitted to share
patients’ data via Gmail, Dropbox, iCloud or personal nonencoded flash drives. Simi-
larly, it is strictly forbidden to share pictures with identifiable patients’ data on Facebook,
Twitter or other social media platforms.
1.7 Release of Records

Request for medical records by patient or authorized attendant should be
acknowledged and documents should be issued within 72 hours.
Maintain the register of certificates with the detail of medical records issued
with at least one identification mark of the patient and his signature.
Effort should be made to computerize the records for quick retrieval

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Certain document must be given to the patient as a matter of right.
Discharge summary, referral notes, or death summary are important document
for the patient. Therefore, these documents must be given without any charge
for all including patients who discharge themselves against medical advice.
Doctors are not under any obligation to produce or surrender their medical
records to the police in the absence of valid court warrant.
A subpoena to produce clinical records is a form of court order. Failure to

comply is in contempt of court and may be punished. Medical records which
are subpoenaed are to be made over to the court and not to the solicitor who
sought the subpoena.
1.8 Certificates
A medical certificate is defined as a document of written evidence vouching for the
truth of a fact as determined by the doctor issuing such a document. If medical certificate
is admitted in a court of law as evidence and is proved to be false, the issuing doctor is
liable for punishment. While issuing a medical certificate following things should be kept
in mind,
Medical certificate should be on institution/doctor letter pad.
Date, time, and place should be mentioned.
Issue it only for legitimate purpose and only when necessary.
It has to be true and clear without any ambiguity.
There should be an identification mark of the patient, preferably a thumb

impression.
Period of illness should be clearly mentioned.
Diagnosis disclosure of the diagnosis should be only after the patient’s

express consent, unless required by the law
Doctor should maintain the duplicate copy of every certificate.

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Check your progress 1 (CYP)
Fill in the blanks:

1. A ________________is comprised of identifying records, classifying records,
and storing records, as well as coordinating internal and external access.
2. A _________________is defined as a document of written evidence vouching

for the truth of a fact as determined by the doctor issuing such a document.
1.9 Summary
An organizational record is any document that contains information about a
transaction, activity, or event related to the organization. Records management
activities include the creation, receipt, maintenance, use and disposal of records.
Hospital record keeping is integral to good professional practice and the delivery of
quality healthcare. Hospital record keeping is an integral component in good
professional practice and the delivery of quality healthcare. Many organizations must
deal with large amounts of information on a daily basis. Productive organizations
incorporate a comprehensive, effective records management process into their daily
operations. Hospital records are often the only source of the truth. They are likely to be
far more reliable than memory. Despite the intensive effort at national and international
level, the fundamental health care needs of the population of the developing countries
are still unmet. The lack of basic health data renders difficulties in formulating and
applying a rational for the allocation of limited resources that are available for patient
care and disease prevention. Doctors and hospitals often contract with insurance
companies to become part of the company’s “network.” The contracts spell out what
they will be paid for the care they provide. The following are the major etiquettes in
maintain good medical records such as Patient demographics ,Reasons for the current
visit, The scope of examination, Positive exam findings, Pertinent negative exam
findings, Key abnormal test findings and Diagnosis or impression. Every entry in the
medical record should be dated, timed (24 h clock) and legible. Each should be signed
by the person making the entry and should be made as soon as possible after the event
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to be documented (e.g. change in clinical state, ward round, investigation etc) and before
the relevant staff member goes off duty. Physicians should document noncompliance in
the progress record, such as a patient’s failure to follow advice, take medication, obtain
requested diagnostic studies, keep an appointment with a consultant, or other actions
the patient takes or fails to take that could cause or contribute to an injury or delay in
resolution of a medical problem. The content and handling of clinical records is strictly
regulated by the law in most countries, not only because they are fundamental to high
quality patient care but also because they are increasingly used in the courts and repre-
sent an important source of confidential personal information. A medical certificate is
defined as a document of written evidence vouching for the truth of a fact as determined
by the doctor issuing such a document. If medical certificate is admitted in a court of law
as evidence and is proved to be false, the issuing doctor is liable for punishment.
1.12 Keywords
Data Extraction (or Abstraction) – A process by which information on documents

(structured or unstructured) is saved off in another format that canbe then used for other
purposes.
Document Management System (DMS) – An internal computer system within

the organization that is the repository for patient documents. The
documents are generally organized so that the documents can be found in a patient’s
electronic medical record.
Document Classification – A process by which documents are sorted by the type

of information represented on the document. Some specific examples of document
types include, but are not limited to, lab results, prescription refills, patient history orx-
ray results. Often document classification is performed by manually sorting through all
of the documents that arrive into the organization either by fax or paper.
Electronic Medical Record (EMR) – The digital collection of a patient’s medical

data in one provider’s office (i.e. hospital, clinic…etc) that can be shared across differ-
ent health care settings.
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Electronic Medical Record Software – The piece of software that collects, stores
and allows for the viewing of the patient’s medical data. Examples include Epic and
Cerner.
Encounter – Anytime a patient receives help from a health care provider. Each
encounter is usually assigned a number for tracking.
Epic – A company that specializes in Electronic Medical Record software out of

Verona, Wisconsin offering software solutions across the globe.
Extract Systems – A company that specializes in the classification and the cap-
ture of unstructured data from documents.
1) Why to maintain hospital records?

2) List down the Functions of maintaining Hospital records.
3) Discuss the Importance of maintaining Hospital records?
4) Who has Access to Medical Records?
5) What are the Advantages of keeping good clinical records and the
disadvantages of poor clinical records?
6) Narrate on Etiquettes in maintaining a good hospital records for Police –
Court of law & Education and research.
7) How hospital medical records will be sued for Legal issues?
8) Write a short note on Medical records Confidentiality and data protection.
9) Explain the nature of hospital records management and the context within
which hospital records management programmes work.
10) Understand the principles behind the management of other hospital

records, such as X-rays, specimens, patient registers, administrative and
policy files, financial and personnel records, nursing records, pharmacy
records and educational records.
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Check your progress 1 (CYP) Answers
1. Records management process
2. Medical certificate
Implementing Electronic Document and Record Management Systems,By

Azad Adam
Essentials of Hospital Management & Administration, By D L Ramachandra
https://pdfs.semanticscholar.org/e888
2023a43f5266449c6eed35f092f02e47163f.pdf
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LESSON – 2
RECORDS MANAGEMENT
Learning Objectives
After studying this lesson, you should be able to :
Describe the Records Management
Principles of records keeping
Explain meaning and importance of Records Management
Discuss the merits and demerits of Records Management
Latest trends in record maintenance
Electronic forms of records maintenance.
Structure
2.1 Introduction
2.2 Meaning of Records Management
2.3 Importance of Medical Records Management
2.4 Disadvantages of Medical Records Management
2.5 Risks of Unmanaged Medical Records
2.6 Principles of Record Keeping
2.7 Latest Trends in Records Maintenance.
2.8 Electronic Record Keeping
2.9 Summary
2.10 Keywords
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2.1 Introduction
Records management is the practice of maintaining the records of an organization
from time they are created up to their eventual disposal. This may include classifying,
storing, securing, and destruction of records.
A record can be either a tangible object or digital information: for example, birth
certificates, medical x-rays, office documents, databases, application data, and e-mail.
Records management is primarily concerned with the evidence of an organization’s
activities, and is usually applied according to the value of the records rather than their
physical format.
2.2 Meaning of Records Management

Medical records management is the part of records management that relates to
the operation of a healthcare practice. It is the field of management that is responsible
for all records throughout their lifecycle from creation, receipt, maintenance, and use to
disposal.
Figure 2.1 Medical Records and Information Life Cycle Management

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Sometimes referred to as health information management (HIM) or health records
information management (HRIM), medical records management can involve anything
and everything about a practice and a patient, including but not limited to a patient’s
history, clinical findings, diagnostic test results, pre- and postoperative care, patient
progress, and medications.
2.3 Importance of Medical Records Management

As the requirements for medical records change, it is important for medical prac-
tices, hospitals, skilled nursing facilities, and long-term care facilities to have a medical
records management system in place that includes automating, capturing, storing, and
disseminating records. The system improves record location and tracking, even for
records people don’t frequently use. It can also preserve historical and vital information
about a medical facility in case of a disaster or legal requirement.
A records management system can also make it easy to transfer or release infor-
mation between offices — both patients and physicians can access the information in a
timely manner without duplicating efforts. Arguably, this type of visibility can increase
patient safety, reduce mistakes, and increase confidence in a treatment plan. From a
productivity standpoint, medical records management might address litigation risks, lower
operating costs (due to reduced physical storage needs), and boost employee produc-
tivity, mobility, and efficiency.
2.4 Disadvantages of Medical Records Management

Disadvantages of medical records management are:
Data Retrieval and Sharing

A leading reason why many organizations have gone paperless is the ease with
which an electronic system allows for information retrieval and sharing. When data is
held on paper and stored in a registry, retrieving it presents a challenge.
Moreover, the information can only be used by one individual at a time. While
electronic systems solve this problem, they too come with other challenges.
20
Equipment Cost and Potential for Obsolescence
When an organization goes paperless, there are huge volumes of data held on
paper that have to be scanned and stored in a digital format. The hardware and soft-
ware needed for this exercise cost a substantial amount of money. Initial costs aside, a
significant disadvantage with electronic systems is that both hardware and software
become obsolete in a relatively short time.
Electronic Systems and the People Issue

Implementation of an electronic records management system calls for a change in
the employee’s attitudes. Any radical change in an organization is viewed with skepti-
cism by many employees who are not sure how such changes will affect them. When
older ways of organizing files are replaced by new ones, the employee feels a loss of
control and this needs to be addressed by assurances from the employer — and backed
by the success of the system implemented.
Security and Other Issues

With the increased info sharing that an electronic records management system
makes possible comes the issue of security. Unless adequate measures are put into
place, it becomes possible for confidential company information to end up in the wrong
hands. Moreover, management of records could become a problem when the system is
clogged with unnecessary records (such as document copies). It is not uncommon to
find situations where a substantial amount of records held are actually junk mail.
2.5 Risk of Unmanaged Medical Records

Not having easy access to potentially life-saving or life-changing health informa-
tion is a significant risk that unmanaged medical records present. A lack of organization
with regard to record keeping can also pose a legal threat. Additionally, when staff are
constantly struggling to find things, patients might view the lack of structure and policy
as a signal that a practice is behind the times. Inefficiency can also lead to a loss of
productivity, duplication of efforts, or an inability to complete necessary tasks. Billing
errors could arise as a result of poor records that ultimately cost the practice money.
21
Paper records also require a physical storage area and can sometimes result in
practices needing to purchase additional office space, which can be expensive. When
individuals create their own non-standardized systems, they are exposing an organiza-
tion to more potential issues. For example, it could lead to insufficient backup plans and
increased costs to convert records from formats that adhered to technology that eventu-
ally became obsolete. Simply having backups of data in multiple places is pointless if it
is not accessible or usable.Unfortunately, many medical facilities do not see medical
records management as a critical or necessary function. As a result, they do not provide
training or structure to create an efficient and compliant policy.
2.6 Principles of Records Keeping

The overall principles of record-keeping, whether you are writing by hand or mak-
ing entries to electronic systems, can be summed up by saying that anything you write
or enter must be honest, accurate and non-offensive and must not breach patient con-
fidentiality. If you follow these four principles, your contribution to record-keeping will be
valuable.
More specifically, you should always try to ensure that you:

Handwrite legibly and key-in competently to computer systems and sign
all your entries
Make sure your entries are dated and timed as close to the actual time of
the events as possible
Record events accurately and clearly – remember that the patient/client

may wish to see the record at some point, so make sure you write in language
that he or she will understand
Focus on facts, not speculation
Avoid unnecessary abbreviations – as you’ll find, the health care system

uses many abbreviations, but not all workplaces use the same definitions: for
instance, ‘DNA’ means ‘deoxyribonucleic acid’ in some places, but ‘Did Not
Attend’ (meaning a patient/client who does not show up for an appointment) in
others – avoid abbreviations if you can!
22
Record how the patient/client is contributing to his or her care, and quote
anything he or she has said that you think might be significant
Do not change or alter anything someone else has written, or change

anything you have written previously; if you do need to amend something you
have written, make sure you draw a clear line through it and sign and date the
changes
Never write anything about a patient/client or colleague that is insulting or

derogatory.
When you’re writing, always follow the principles described in the section
written communication and remember, if you find something you feel is
significant when you are working with a patient/client, your first duty is to report
it to the registered nurse in charge before you would consider writing it in the
patient’s/client’s record. Always report first, record later.
The guiding principle of records management is to ensure that information is avail-

able when and where it is needed, in an organized and efficient manner, and in a well
maintained environment. Organizations must ensure that their records are:
Authentic - It must be possible to prove that records are what they purport to be
and who created them, by keeping a record of their management through time. Where
information is later added to an existing document within a record, the added informa-
tion must be signed and dated. With electronic records, changes and additions must be
identifiable through audit trails.
Accurate - Records must accurately reflect the transactions that they document.
Accessible - Records must be readily available when needed.
Complete - Records must be sufficient in content, context and structure to recon-

struct the relevant activities and transactions that they document.
Comprehensive - Records must document the complete range of an organisation’s

business.
23
Compliant - Records must comply with any record keeping requirements result-
ing from legislation, audit rules and other relevant regulations.
Effective -Records must be maintained for specific purposes and the information
contained in them must meet those purposes. Records will be identified and linked to
the business process to which they are related.
Secure - Records must be securely maintained to prevent unauthorized access,

alteration, damage or removal. They must be stored in a secure environment, the de-
gree of security reflecting the sensitivity and importance of the contents. Where records
are migrated across changes in technology, the evidence preserved must remain au-
thentic and accurate.
2.7 Latest Trendings In Records Maintenance

Records management trends continue to emphasize digital content and rely less
and less on the cataloguing and storage of physical medium. Given that the costs for
doing so compare quite favorably with the old method, investing in a digital document
management and storage system has the potential to save you money for many years
to come.
Cloud Servers Reign Supreme

The primary and indispensable feature of a cloud server is accessibility. Simply
put, putting your documents on a virtual server and granting exclusive access to various
parties with the provision of login details leaps over geographical and time boundaries.
If the relevant parties have access to an internet connection, your business partners or
employees can always refer to the files they need for any reason.
Collaboration Is Everything
By having your high-level employees literally on the same page, they can bring
their collective talents and resources to bear on a project in real-time. The act of updat-
ing documents will not make mistakes irreparable, given the editing history features
available in any records management platform worthy of the name.
24
Enhanced Workflow
If you’ve ever worked in a large company before, then you know how hectic main-
taining a workflow between different platforms used to be in times past. Although there
was project management software to facilitate the collaboration, it couldn’t integrate
other platforms into it and documents weren’t shared automatically. One of the most
beneficial of the records management trends is to significantly improve workflow. The
cloud storage in conjunction with powerful workflow tools that can even facilitate load
leveling automatically changes the way that we work. Many records management soft-
ware tools will automatically sync documents and send the right documents to the right
departments without the normal delays associated with moving physical records through
an approval process.
Competition Breeds Better Services and Prices

Affordability is a godsend to just about all but the largest multinational corpora-
tions – and not even they would turn their noses up at significant savings. The improve-
ments in electronic records management software have led to service providers tailor-
ing the software to the specific needs of various companies, because that’s what the
market has demanded that they do to remain competitive. Today, the ever-presence of
cloud computing, maturation of content management software and other technological
advancements have aligned to make these software packages much more affordable.
Customer Access via Portals

Another one of the records management trends making waves in the industry is
the client portal. With security better than ever, it has become expedient to provide your
customers their own portals which they can use to access important documents, typi-
cally in a limited capacity and as chosen by the system administrator. This enables
customers to participate in the discussion and also ensures that everyone is working
with the most current set of documents, because they are working with the same docu-
ments.
25
2.8 Electronic Record Keeping
Most businesses use accounting software programs to simplify electronic record
keeping, and produce meaningful reports. There are many other advantages to using
electronic record keeping, as listed below.
Advantages
Helps you record business transactions, including income and expenses,
payments to workers, and stock and asset details.
Efficient way to keep financial records and requires less storage space.
Provides the option of recording a sale when you raise an invoice, not
when you receive a cash payment from a client.
Easy to generate orders, invoices, debtor reports, financial statements,

employee pay records, inventory reports.
Automatically tallies amounts and provides reporting functions.
Keeps up with the latest tax rates, tax laws and rulings.
Many accounting programs have facilities to email invoices to clients,

orders to suppliers, or BAS returns to the Australian Taxation Office.
Allows you to back up records and keep them in a safe place in case of
fire or theft.
Electronic backup
Set up a secure electronic backup system to ensure records are safely stored and
regularly backed up. Daily backups are recommended, particularly for important records.
Make sure the backup copies are stored in a separate location to your business in case
of fire, theft or a natural disaster. For small businesses, the cheapest backup options
are CDs and memory sticks. If your business has large amounts of data, external hard
drives are a popular backup option.
26
Cloud backup
Cloud computing provides a way for your business to manage your computing
resources and records online. The term has evolved over recent years, and can be
used to describe the use of a third party for your storage and computing needs.
Cloud backup services are becoming more popular and can be automated for
your convenience, but you should make sure the method you choose protects the pri-
vacy and security of your business and customers.
Fill in the blanks:
1. ______________________is the part of records manage
ment that relates to the operation of a healthcare practice.
2. Latest trends in records maintenance are __________ and ________.
2.9 Summary
Records management is the practice of maintaining the records of an organization
from time they are created up to their eventual disposal. This may include classifying,
storing, securing, and destruction of records. Medical records management is the part
of records management that relates to the operation of a healthcare practice. It is the
field of management that is responsible for all records throughout their lifecycle from
creation, receipt, maintenance, and use to disposal. The following are some of the
disadvantages such as Data Retrieval and Sharing, Equipment Cost and Potential for
Obsolescence, Electronic Systems and the People Issue and Security and Other Is-
sues. Not having easy access to potentially life-saving or life-changing health informa-
tion is a significant risk that unmanaged medical records present.
A lack of organization with regard to record keeping can also pose a legal threat.
The overall principles of record-keeping, whether you are writing by hand or making
entries to electronic systems, can be summed up by saying that anything you write or
27
enter must be honest, accurate and non-offensive and must not breach patient
confidentiality. The guiding principle of records management is to ensure that
information is available when and where it is needed, in an organized and efficient
manner, and in a well maintained environment. Records management trends continue
to emphasize digital content and rely less and less on the cataloguing and storage of
physical medium. Given that the costs for doing so compare quite favorably with the old
method, investing in a digital document management and storage system has the
potential to save you money for many years to come. Most businesses use accounting
software programs to simplify electronic record keeping, and produce meaningful
reports.
2.10 Keywords
Active Record : A record needed to perform current operations or ongoing business
matters. It is consulted frequently, and it must be conveniently available for immediate
reference, either manually or via a computer system.
Administrative Retention Criteria : The standards or rules concerned with the

availability of records for long-term administrative consistency and continuity, as well as
for day-to-day operations of individual program units.
Audit : Independent review and examination of records and activities to test for
compliance with established policies or standards, often with recommendations for
changes in controls or procedures.
Database : A file containing records organized into one or more data elements,
called fields, which store particular categories of information.
Directory : A table of contents for an electronic storage medium.

1. Discuss about computerization of medical records.
2. Explain the sources and uses of medical records.
3. Explain the principles of record keeping.
4. How do these trends affect your organization?
5. Create a database information for an electronic health record (EHR)?

28
6. Conduct a survey on Apps implied for medical records maintenance and
the impact of smart phones in its usage.
Check Your Progress Answers

1. Medical records management.
2. Cloud Servers Reign Supreme and Accessing via portals.
Records Management 10th Edition, by Judith Read (Author), Mary Lea

Ginn.
Records Management Handbook, Ira A. Penn, ýGail B. Pennix.
Records Management: A Guide to Corporate Record Keeping, Jay

Kennedy, ýCherryl Schauder - 1998 .
29
LESSON – 3
PATIENT RECORD MANAGEMENT
Learning Objectives
Describe the patient record
Classification of patient record ( Inpatient and outpatient)
Structure
3.1 Introduction
3.2 In Patient Record
3.3 Outpatient Record
3.4 Causality
3.5 Emergency
3.6 Surgery Records
3.7 Pediatric Records
3.8 Obstetrics and Gynecology Patient Records
3.9 Summary
3.10 Keywords

30
3.1 Introduction
The patient record is the principal repository for information concerning a patient’s
health care. It affects, in some way, virtually everyone associated with providing, receiv-
ing, or reimbursing health care services. The purpose of complete and accurate patient
record documentation is to foster quality and continuity of care. It creates a means of
communication between providers and between providers and members about health
status, preventive health services, treatment, planning, and delivery of care. A medical
chart is a complete record of a patient’s key clinical data and medical history, such as
demographics, vital signs, diagnoses, medications, treatment plans, progress notes,
problems, immunization dates, allergies, radiology images, and laboratory and test re-
sults. The medical history, or H&P, includes the following components: patient demo-
graphics. This section includes the patient’s name, birth date, address, phone number,
gender, race, and marital status and the name of the attending physician.Health records
are used for a number of purposes related to patient care. The primary purposes of the
health record are associated directly with the provision of patient care services. The
secondary purposes of the health record are related to the environment in which
healthcare services are provided.
3.2 In Patient Record

Patient record is a collection of documents that provides an account of each epi-
sode in which a patient visited or sought treatment and received care or a referral for
care from a health care facility. The primary function of a hospital, clinic or other health
care facility is to provide quality patient care to all patients, whether an inpatient, outpa-
tient or emergency patient. The hospital administration is legally responsible for the
quality of care given to patients. Responsibility for direct patient care and documenta-
tion in the patient’s medical record is delegated to doctors, nurses and other health care
professionals. The accuracy and completeness of this documentation is the responsi-
bility of those who are recording the data.
The record is confidential and is usually held by the facility, and the information in
it is released only to the patient or with the patient’s written permission. It contains the
31
initial assessment of the patient’s health status, the health history, laboratory and radio-
logical reports of tests performed, notes by nurses, physicians, and other health care
professionals regarding the daily condition of the patient, and notes by consultants, as
well as order sheets, medication sheets, admission records, discharge summaries, and
other pertinent data. A problem-oriented medical record also contains a master problem
list. The patient record is often a collection of papers held in a folder, but it may be
computerized.Patient record improvement could make major contributions to improving
the health care system of this nation. A 1991 General Accounting Office (GAO) report
on automated medical records identified three major ways in which improved patient
records could benefit health care (GAO, 1991). First, automated patient records can
improve health care delivery by providing medical personnel with better data access,
faster data retrieval, higher quality data, and more versatility in data display. Automated
patient records can also support decision making and quality assurance activities and
provide clinical reminders to assist in patient care. Second, automated patient records
can enhance outcomes research programs by electronically capturing clinical informa-
tion for evaluation. Third, automated patient records can increase hospital efficiency by
reducing costs and improving staff productivity.
The medical record begins with the patient’s first admission as an inpatient or
attendance as an outpatient (if a combined medical record) to the health care facility.
This begins with the collection of identification information, which is recorded on the
Front Sheet or Identification and Summary Sheet. The name of the first form in the
medical record varies from hospital to hospital and country to country. If the patient has
been an inpatient previously, the admission clerk must look for and find the old number
in the Master Patient Index (See Basic Medical Record Procedures). If the patient has
not been an inpatient previously, the next number in the Number Register is allocated.
An Inpatient is a patient who has been admitted to the health care facility.
Inpatientsusually occupy a bed in a health care facility for at least four hours to over-
night.
32
While in the ward, the medical record develops with many forms added as the
patient istreated and cared for by health professionals. The physical medical record will
eventuallyconsist of the following:
medical record forms;
a clip or fastener to hold the papers together;
dividers between each admission and outpatient notes; and
a medical record folder.
The basic set of forms in the inpatient medical record includes

front sheet or identification and summary sheet, which covers identification,
finaldiagnoses, disease and operation codes, and the attending doctors
signature;
consent for treatment is often on the back of the Front Sheet and must be
signedby the patient at the time of admission. There are two parts to this form.
The firsthalf of the form is a general consent for treatment and the bottom half
is consent torelease information to authorised persons;
correspondence and legal documents received about the patient, e.g.,

referral letter,
Requests for Information, etc.,

discharge summary, if required by the hospital/health authority;
admission notes, including the patient’s family medical history, the patient’s
pastmedical history, presenting symptoms, results of a physical examination,
provisional
diagnosis (the reason the patient came or was brought to hospital),

proposed testsand care;
clinical progress notes recording the patient’s daily treatment and reaction
to that treatment written by the attending doctor and other health care
professionals;
33
nurses’ progress notes recording daily nursing care including temperature,
pulseand respiration charts, blood pressure charts etc.;
operation report if an operation or operations are performed;
other health care professional notes, e.g., physiotherapy, Social Workers,

etc.;
pathology reports including haematology, histology, microbiology, etc.;
other reports – X-ray, etc.;
orders for treatment and medication forms listing daily medications ordered
and given with signatures of the doctor prescribing the treatment and the nurse
administeringit; and
special nursing forms for observation of head injuries etc.
3.3 Outpatient Record

The responsibility for correctly identifying a patient rests with the clerk who inter-
views the patient in the admission office or outpatient department. The clerk must care-
fully question the patient or a person accompanying the patient if in case the patient is
unable to give the necessary information (e.g., child, elderly relative,etc.). It should be
made sure that the questions asked are clear and understood by the person being
interviewed. Many people who come to a hospital or clinic are nervous and may have
difficulty with some simple questions. They should be put at ease and be given time to
respond. The data collected must be written clearly on the correct form. Correct patient
identification enables hospital staff:
To find a particular patient’s medical record whenever they come to the

health care facility;
To link a patient’s previous admission or outpatient attendance to the

currentadmission using his or her medical record number;
To find the correct medical record of patients when there are more than
one patient with the same name.
34
Patient identification is a key issue for medical record services. Ideally, the staff in
the Admission Office should be responsible to the MRO to enable them to be trained in
identification procedures. It would also enable the MRO to monitor their performance
and re-train if required
In addition, if combined with the inpatient notes, all outpatient notes can be stored
behind an outpatient divider.For specialist outpatient records, a separate divider could
be used for the clinic, e.g., “hypertension clinic”, “heart clinic”, etc. All medical record
forms should be kept in a medical record folder. This should be a folder and, if possible,
stronger cardboard folders should be purchased.
3.4 Causality
Causality is a genetic connection of phenomena through which one thing (the
cause) under certain conditions gives rise to, causes something else (the effect). The
essence of causality is the generation and determination of one phenomenon by an-
other. ... A cause is an active and primary thing in relation to the effect. For example, the
simple temporal sequence of phenomena, of the regularities of accompanying processes.
For example, a pinprick causes pain. Brain damage causes mental illness. Causality is
an active relationship, a relationship which brings to life some thing new, which turns
possibility into actuality. A cause is an active and primary thing in relation to the effect.
But “after this” does not always mean “because of this”. It would be a parody of justice if
we were to say that where there is punishment there must have been a crime.
Causality is universal. Nowhere in the world can there be any phenomena that do
not give rise to certain consequences and have not been caused by other phenomena.
Ours is a world of cause and effect or, figuratively speaking, of progenitors and their
progeny. Whenever we seek to retrace the steps of cause and effect and find the first
cause, it disappears into the infinite distances of universal interaction. But the concept
of cause is not confined to interaction. Causality is only a part of universal connection.
The universality of causality is often denied on the grounds of the limited nature of
human experience, which prevents us from judging the character of connections be-
yond what is known to science and practice. And yet we know that no scientist restricts
his reasoning to what he can immediately perceive. The whole history of humanity, of all
35
scientific experiment knows no exception to the principle of determinism.
To sum up, all processes in the world are evoked not by a one-way or one-sided
action but are based on the relationship of at least two interacting objects. Just as
various paths may lead to one and the same place, so various causes lead to one and
the same effect. And one and the same cause may have different consequences. A
cause does not always operate in the same way, because its result depends not only on
its own essence but also on the character of the phenomenon it influences. Thus, the
heat of the sun dries out canvas, evokes extremely complex processes of biosynthesis
in plants, etc. Intense heat melts wax but tempers steel. At the same time an effect in
the form of heat may be the result of various causes: sun rays, friction, a mechanical
blow, chemical reaction, electricity, disintegration of an atom, and so on. He would be a
bad doctor who did not know that the same diseases may be due to different causes.
Headache, for instance, has more than one hundred. To sum up, then, what we have is
selection without a selector, self-operating, blind and ruthless, working tirelessly and
ceaselessly for countless centuries, choosing vivid external forms and colours and the
minutest details of internal structure, but only on one condition, that all these changes
should benefit the organism. The cause of the perfection of the organic world is natural
selection! Time and death are the regulators of its harmony.
3.5 Emergency
Inpatients may be admitted through the Emergency room, general outpatient clin-
ics or through specialist outpatient clinics.When a person attends and receives health
care services in the hospital without being admitted, he or she is referred to as an
Outpatient or an Emergency Patient.
Emergency patients come to the hospital/health care center’s emergency depart-

ment needing immediate attention for a disease or injury. The collection of emergency
medical information must be easy to carry out while focusing maximum attention on the
patient.
If a patient is brought to the hospital by ambulance, the data collection starts with
theambulance service transporting the patient to the hospital. At this time, a record is
36
made of vital signs, condition during transportation, the nature of the illness or injury,
and any procedures performed. Upon arrival at the emergency department, a copy of
the ambulance record may be included in the hospital emergency service record.
Emergency patients are identified in the same manner as inpatients and outpa-
tients. If the patient has been an inpatient or outpatient, previous records must be made
available for emergency care if needed.
Identification information may need to be obtained from the patient within the emer-
gency treatment room or from a relative or person accompanying the patient. The infor-
mation recorded in an emergency record should include:
the time and means of arrival in the emergency department, e.g., by

ambulance, etc.;
Medical Records Manual A Guide for Developing Countries
pertinent history relating to the reason for attending the emergency

department;
emergency care given prior to arrival;
diagnostic and therapeutic orders;
clinical observations;
reports of procedures, tests, etc.;
diagnostic impression; and
conclusion and disposal of the patient, i.e., sent home following treatment
with no further care required, referral to the general or specialist outpatients,
admission to the hospital, died in the emergency room.
The contents of an emergency record, how they are to be kept, and for how long
are often decided by the hospital administration or by government regulation.
It is recommended that for Specialist and Emergency visits, the visit be

documented in the medical record held by the hospital and not in a patient held health
37
record. A Summary of The Visit or Admission, however, should be included in the
Patientheld Health Record.
3.6 Surgery Records

It is inevitable that reactions of any individual patient to the same disease may
vary. In addition, treatment options for some diseases also may vary. For example,
surgery may be performed on some patients while it may not be appropriate for others,
despite the fact that both have the same primary diagnosis. The performance of an
operation can make a considerable difference to the average length of stay and thus
needs separate consideration.Treatment may also be associated with complications
that require further procedures and add to the total cost incurred. it is important that all
diagnoses, pre-existing conditions and surgical procedures are fully documented or the
patient may be placed incorrect category.
Discharge lists should be kept in date order in the Medical Record Department.
The list should contain the patient’s name, age, treating doctor, ward, and service, that
is, whether medical, surgical, obstetric, orthopaedic, etc., and whether the patient is
alive or dead. Discharge lists are usually used to prepare the hospital inpatient statis-
tics.
Check that if an operation or other surgical procedures were performed that they
are recorded, and the doctor has signed the Front Sheet. The signature of the doctor is
important as it shows that the doctor has completed the medical record and takes re-
sponsibility for the content.Surgical procedures are coded using the International Clas-
sification of Procedures in Medicine (ICPM) or the classification system currently being
used in each country.
Before discussing the clinical coding procedure, we should take time for a brief
look at disease classification and the International Statistical Classification of Diseases
and Related Health Problems. if surgical procedures are to be coded, the ICPM is often
used, but some countries now have a local procedure classification. If this is the case in
your country, use the local system and follow the guidelines for use. Most of the above
38
are collected to assess the workload of each clinic and to plan for future needs. It may
be found that the surgical clinic staff see twice as many patients than other clinics. If this
is the case, more staff will be required in the clinic area on the surgical clinic days.
Patient waiting time may be too long and the administration decides to look at the statis-
tics for each clinic to see if it is because too many patients are given appointments when
insufficient medical staff are available.If surgical procedures are to be coded, the ICPM
is often used, but some countries now have a local procedure classification. If this is the
case in your country, you should use the local system and follow the guidelines for use;
check that if an operation or other surgical procedures were performed that they are
recorded, and the doctor has signed the Front Sheet. The signature of the doctor is
important as it shows that the doctor has completed the medical record and takes re-
sponsibility for the content. check that if an operation or other surgical procedures were
performed that they are recorded, and the doctor has signed the Front Sheet. The signa-
ture of the doctor is important as it shows that the doctor has completed the medical
record and takes responsibility for the content.
3.7 Pediatric Records

At a minimum, pediatric medical records should be retained for 10 years or the
age of majority plus the applicable state statute of limitations (time to file a lawsuit),
whichever is longer. In some states, the statute of limitations does not start until the
patient turns 18. So in a state with a two-year statute of limitations, a malpractice case
related to newborn care could be filed 20 years after delivery, meaning newborn records
need to be kept at least 20 years. Additionally, depending on the circumstances, medi-
cal record retention may be dictated by state law, federal regulation or even the Joint
Commission.
If a lawsuit is filed and the medical records have been destroyed, it will be hard to
defend the care provided. Therefore, medical records must be kept for at least as long
as there is a possibility of a malpractice lawsuit. In fact, many medical liability insurers
stipulate how long the physicians they insure should keep patient charts. In addition to
state laws, pediatricians should check with their malpractice insurers to make sure their
patient records are available as long as the insurance carrier says they need to be.
39
Personal health records may enhance pediatric care and outcomes. Few systems
have been developed or customized for pediatrics, and evaluations are scarce. Special
considerations in pediatrics include pediatric content such as growth charts, complex
privacy and confidentiality considerations, and the changing developmental needs of
children and adolescents.
Pediatricians have long used tools such as immunization cards and well-child book-
lets to provide families with access to key information about their children’s health. In
the past 15 years, electronic records and the Internet have become increasingly impor-
tant and available mechanisms through which to provide families with data about their
children’s health and to assist families in tracking their children’s health and develop-
ment. Families also create their own paper and electronic records of their children’s
health and health care needs.Electronic systems, known as personal health records
(PHRs), may play key roles in enhancing partnerships between families and health care
providers, promoting self-care, and enhancing family decision-making regarding the
health of children and adolescents. Furthermore, they can provide key health informa-
tion when a child becomes ill away from home or in a disaster.
In the early 1990s, many commercial vendors developed Internet-based, stand-

alone systems. These systems required consumers to enter and to maintain their own
health information. Although some of these systems remain, they have never become
popular, likely because of the onerous nature of maintaining the information. Therefore,
PHRs linked to electronic health records (EHRs) and other sources of health informa-
tion have become the preferred model.Recently, several large software makers an-
nounced their plans to develop secure PHRs that could link to physicians’ and hospitals’
EHRs.Once these systems overcome the technical challenges of integrating informa-
tion from multiple sources that code and store data in disparate ways, they likely will
face consumer concerns about privacy and the security of the health information. Previ-
ous consumer surveys found that privacy and security are concerns of 90% of potential
users, although many think that adequate technology exists to protect them.
40
3.8 Obstetrics and Gynecology Patient Records
Obstetric information such as deliveries, maternal deaths, multiple births, foetal
deaths and infant deaths are also keyed in at this time, if not already recorded on
file. Obstetric history taking involves a series of methodical questioning of an obstetric
patient with the aim of developing a diagnosis or a differential diagnosis on which further
management of the patient can be arranged.
Obstetric ultrasound uses sound waves to produce pictures of a baby (embryo or

fetus) within a pregnant woman, as well as the mother’s uterus and ovaries. It does not
use ionizing radiation, has no known harmful effects, and is the preferred method for
monitoring pregnant women and their unborn babies.
The medical significance of the obstetric history. A carefully obtained obstetric

history can provide the family physician with useful clues to his patients’ health risks. A
previous infant’s birth weight and certain congenital malformations may indicate a pre-
disposition to vascular hypertensive or diabetic illness.
Evaluation of the Obstetric Patient

Ideally, women who are planning to become pregnant should see a physician be-
fore conception; then they can learn about pregnancy risks and ways to reduce risks. As
part of preconception care, primary care clinicians should advise all women of repro-
ductive age to take a vitamin that contains folic acid 400 to 800 mcg (0.4 to 0. 8 mg)
once a day. Folate reduces risk of neural tube defects. If women have had a fetus or
infant with a neural tube defect, the recommended daily dose is 4000 mcg (4 mg).
Taking folate before and after conception may also reduce the risk of other birth defects.
Once pregnant, women require routine prenatal care to help safeguard their health
and the health of the fetus. Also, evaluation is often required for symptoms and signs of
illness. Common symptoms that are often pregnancy-related include
41
Vaginal bleeding
Pelvic pain
Vomiting
Lower-extremity edema
Specific obstetric disorders and nonobstetric disorders in pregnant woman

are discussed elsewhere.
The initial routine prenatal visit should occur between 6 and 8 weeks gestation.
Follow-up visits should occur at

About 4-week intervals until 28 weeks
2-week intervals from 28 to 36 weeks
Weekly thereafter until delivery
Prenatal visits may be scheduled more frequently if risk of a poor pregnancy

outcome is high or less frequently if risk is very low.
Prenatal care includes

Screening for disorders
Taking measures to reduce fetal and maternal risks
Counseling
What are gynecological procedures?

Evaluation of abnormal uterine bleeding includes ultrasound, endometrial biopsy
or D&C.Surgical procedures include hysteroscopy, endometrial ablation, uterine artery
embolization, hysterectomy, exploratory laparatomy through an abdominal incision,
vaginal approach, laparoscopy or robotic assistance.
42
Diagnosis and treatment
Evaluation of abnormal uterine bleeding includes ultrasound, endometrial biopsy
or D&C. Typical diagnosis include: unexpected pregnancy, fibroid uterus, polyps,
endometriosis, perimenopausal or menopausal uterine changes, cysts and tumors.
Treatment typically includes, a trial of hormonal birth control using oral, injection or
IUD delivery to reduce bleeding, cramps and pain. Other prescription medication may
be prescribed to either slow bleeding down.
In some cases, surgical treatments to address abnormal uterine bleeding may be

the best option. Surgical procedures include hysteroscopy, endometrial ablation, uter-
ine artery embolization, hysterectomy, exploratory laparatomy through an abdominal
incision, vaginal approach, laparoscopy or robotic assistance. Hysterectomy is consid-
ered only when a permanent treatment is required and fertility is no longer desired.
Hysteroscopy – Procedure that takes a look inside the uterus through a scope.
The physician can see the lining of the uterus (endometrium) and the openings of the
fallopian tubes. It allows direct view of the uterine lining and the ability to take samples
of tissue. This procedure is minimally invasive and may be performed in an office or
outpatient setting.
Operative Hysteroscopy – While the physician is visualizing the uterus and en-
dometrial lining, he may remove polyps, fibroids or perform a D&C. This procedure is
typically performed in a surgi-center setting.
Endometrial Ablation – A procedure using either heat or cold energy to destroy

the endometrial lining of the uterus. This procedure can be performed in the office or
surgi-center setting. Bleeding tends to be significantly less than before the procedure.
An endometrial ablation should only be considered for women who no longer wish to
become pregnant and permanent treatment is desired .
Endometrial biopsy – This procedure is obtains a sample of the endometrial

lining and is usually performed at your physician’s office. It involves the insertion of a
43
plastic pipelle (a small flexible tube), thru the opening of the cervix, into the uterus.
Using suction, the pipelle plucks off a sample of tissue from the uterine lining and it is
removed for laboratory examination.
D & C – A procedure performed to obtain samples of the endometrium, the lining

of the uterus to evaluate abnormal uterine bleeding or abnormal cells that may be from
the uterus that were found during routine screening for cervical cancer. A D&C is typi-
cally performed when an endometrial biopsy is not possible or if the sample of the tissue
was inadequate. This procedure typically is performed in the office or surgi-center set-
ting
Laparoscopy – A surgical procedure using key-hole sized incisions and a thin

telescope like instrument that allows the physician to visualize operate on the uterus,
fallopian tubes, ovaries and surrounding tissue. This procedure is performed in a surgi-
center.
Hysterectomy – A surgical procedure performed by laparoscopy, robotic assis-

tance, vaginally or by an open incision that removes the uterus with or without ovarian
removal. This procedure typically is performed in a hospital setting and requires a
period of observation.
Check your progress

Fill in the blanks:
1. A _______________________________is a complete record of a patient’s

key clinical data and medical history, such as demographics, vital signs, diagnoses,
medications, treatment plans, progress notes, problems, immunization dates, allergies,
radiology images, and laboratory and test results.
2. ____________reduces risk of neural tube defects.

44
3.9 Summary
The patient record is the principal repository for information concerning a patient’s
health care. It affects, in some way, virtually everyone associated with providing, receiv-
ing, or reimbursing health care services. The primary function of a hospital, clinic or
other health care facility is to provide quality patient care to all patients, whether an
inpatient, outpatient or emergency patient. The medical record begins with the patient’s
first admission as an inpatient or attendance as an outpatient (if a combined medical
record) to the health care facility. They should be put at ease and be given time to
respond. The data collected must be written clearly on the correct form. Causality is a
genetic connection of phenomena through which one thing (the cause) under certain
conditions gives rise to, causes something else (the effect). The essence of causality is
the generation and determination of one phenomenon by another. inpatients may be
admitted through the emergency room, general outpatient clinics or through specialist
outpatient clinics.when a person attends and receives health care services in the hospi-
tal without being admitted, he or she is referred to as an outpatient or an emergency
patient.
At a minimum, pediatric medical records should be retained for 10 years or the

age of majority plus the applicable state statute of limitations (time to file a lawsuit),
whichever is longer. In some states, the statute of limitations does not start until the
patient turns 18. Obstetric information such as deliveries, maternal deaths, multiple
births, foetal deaths and infant deaths are also keyed in at this time, if not already
recorded on file.
Ideally, women who are planning to become pregnant should see a physician
before conception; then they can learn about pregnancy risks and ways to reduce risks.
As part of preconception care, primary care clinicians should advise all women of
reproductive age to take a vitamin that contains folic acid 400 to 800 mcg (0.4 to 0. 8
mg) once a day. Evaluation of abnormal uterine bleeding includes ultrasound, endome-
trial biopsy or D&C.Surgical procedures include hysteroscopy, endometrial ablation,
uterine artery embolization, hysterectomy, exploratory laparatomy through an abdomi-
nal incision, vaginal approach, laparoscopy or robotic assistance.
45
3.10 Keywords
Document: Recorded information regardless of form or medium.
Public Records: According to Wisconsin Statutes, “means all books, papers, maps,
photographs, films, recordings, or other documentary materials or any copy thereof,
regardless of physical form or characteristics, made or received by any agency of the
state or its officers or employees in connection with the transaction of public business”
Records Schedule: The timetable and description of a records series’ lifecycle,

including instructions for disposition. In Wisconsin State government, the retention sched-
ule takes the form of the Records Retention/Disposition Authorization (RDA).
Research Value: The usefulness of records for research by the government, busi-
ness, private organizations, individuals, and scholars
Retention: The process of holding documents for use.
Retention Period: The length of time an office must keep particular records. This
is usually expressed in terms of years, months, days and may be contingent upon an
event or specification.
Retrieval. The process of locating and withdrawing documents and delivering them
for use.
Scheduling: The process of analyzing and appraising the value of a given set of
records, and then preparing a retention schedule showing the disposition of the records.

1. Discuss about inpatient and outpatient records.
2. What is the purpose of maintaining patient medical records?
3. Write short note on Causality patient records.
4. Discuss on Pediatric record management and its uses for parents and
doctors.
46
5. How do you categorize data for emergency patients?
6. Explain in detail on Obstetrics and Gynecology Patient Records.
Check your progress Answers

1. Medical chart
2. Folate

https://www.library.wisc.edu/archives/records-management/training/glossary-of-
records-management-terms/
47
LESSON – 4
OUTPATIENT AND INPATIENT SERVICES
Learning Objectives
After studying this lesson, you should be able to discuss :
The outpatient services
The infrastructure and outpatient facilities
The nursing services
Structure
4.1 Introduction
4.2 Outpatient Services
4.2.1 Meaning of Outpatient
4.2.2 Importance of Outpatient department
4.2.3 Classification of Outpatients
4.3 Infrastructure and Facilities in Outpatient Department
4.4 Working of Outpatient Department
4.5 Inpatient Services
4.6 Medicare : Outpatient vs Inpatient
4.6.1 Difference between Inpatient and Out Patient
4.7 Function of Inpatient Department
4.8 Summary
4.9 Keywords

48
4.1 Introduction
Outpatient services are medical procedures or tests that can be done in a medical
center without an overnight stay. Many procedures and tests can be done in a few
hours. Outpatient services include:
Wellness and prevention, such as counseling and weight-loss programs.
Diagnosis, such as lab tests and MRI scans.
Treatment, such as some surgeries and chemotherapy .
Rehabilitation, such as drug or alcohol rehab and physical therapy .
Outpatient services usually cost less, because you don’t need to stay overnight.
Staff members at outpatient centers are well trained in the service they provide. Most of
the time, these centers specialize in one kind of treatment or procedure. Often all the
care you need can be provided in one place.
Inpatient care refers to medical treatment that is provided in a hospital or other

facility and requires at least one overnight stay. Inpatient care tends to be directed to-
wards more serious ailments and trauma that require one or more days of overnight
stay at a hospital. For the purposes of healthcare coverage, health insurance plans
require you to be formally admitted to a hospital for a stay for a service to be considered
inpatient. This means a doctor has to write a note to give the order to admit you, so if
you were in the emergency room and were asked to stay overnight for “Medical Obser-
vation”, it does not make you an inpatient.
Over half of all inpatient hospital admissions come through the emergency room
department. Health insurance plans break out emergency room vs. inpatient facility
care when it comes to your share of the costs. In some plans, the copays for emergency
room services are waived if the patient is then admitted to the hospital.
Inpatient care is broken into two parts: the facility fee and those related to the
surgeon/physician. Generally speaking, copays for inpatient services are structured ei-
ther on a per stay or per day basis for the facility.
49
4.2 Outpatient Services
4.2.1 Meaning of Outpatient
Outpatient services are medical procedures or tests that can be done in a medical
center without an overnight stay. Many procedures and tests can be done in a few
hours. Outpatient services include: Wellness and prevention, such as counseling and
weight-loss programs. Diagnosis, such as lab tests and MRI scans.
Outpatient care, sometimes called ambulatory care, is defined as medical care or

treatment that does not require an overnight stay in a hospital or medical facility. Outpa-
tient care may be administered in a medical office or a hospital, but most commonly, it is
provided in a medical office or outpatient surgery center.
Outpatient care can include routine services such as check-ups or visits to clinics.
Even more involved procedures such as surgical procedures, so long as they allow you
to leave the hospital or facility on the same day, can still be considered as outpatient
care. Many surgical services, rehabilitation treatments, as well as mental health ser-
vices are available as outpatient services. Outpatient care tends to be less expensive
than inpatient care since it is often less involved and does not require a patient’s contin-
ued presence in a facility, which uses up less of the hospital or medical clinic’s re-
sources.
4.2.2 Importance of Outpatient Department
The importance of the outpatient department lies in the following :

1. An outpatient department is the patient’s first point of contact with the
hospital and entry point into the health care delivery system.
2. It is an inseparable link in the hierarchical chain of health care facilities.
3. It contributes to reduction in morbidity and mortality.
4. It is a stepping stone for health promotion and disease prevention.
5. It helps reduce the number of admission to inpatient wards, thus,

conserving scarce beds.
50
6. It acts as a filter for inpatient admissions, ensuring that only those patients
are admitted who are most likely to benefit from such care.
7. It is the “shop window” of the hospital
4.2.3 Classfications of Outpatients

The outpatients are of three types. They are:
General Outpatient: General outpatient is a person who is given diagnostic or

therapeutic services and care, who has not been directly referred for such services
by his attending physician or dentist; and who is not coming for emergency situa-
tion. The responsibility for continuing care and disposition of the patient is assumed
by the hospital.
Referred Outpatient: A person referred directly to the outpatient department

by his attending medical practitioner for specific diagnostic or treatment procedures,
for other than an emergency condition, and who will return to the practitioner for
further care and disposition is called Referred outpatient.
Emergency Outpatient: Emergency outpatient is a person who is given

emergency or accident care for conditions determined clinically or by allied services.
4.3 Infrastructure and Facilities in Outpatient Department

Essential services and facilities Hospital security and access
The security and accessibility of the hospital are of paramount importance,
especially given the relative lack of police resources in many resource- limited
countries. There is also a need for governmental and international agencies to ensure
that hospitals are protected and do not become targeted during armed conflict. At
the local level, the hospital should have a perimeter fence with secure entrances
where all persons attending have to demonstrate a legitimate reason for entry. No
weapons should be allowed into the hospital, and in some countries it may be
necessary to have a metal detector to screen all visitors.
A well-organized car parking system is required, with strictly policed access

areas for emergency vehicles and for parents or relatives bringing very sick patients
to and from the hospital.
51
Safety and cleanliness
There should be clear written evacuation and fire policies, together with
appropriate equipment (e.g. fire extinguishers). The perimeter fence should be of a
construction that will keep out animals.
Communication systems
Good communication systems for staff, visitors and patients are essential. Ideally
both outside and internal telephone systems should be available. If telephone systems
are not feasible, alternative effective reliable systems of communication should be
used. A hospital paging system for doctors, senior nurses and managers aids
communication in emergency situations.
Internet access is invaluable for information sharing and education, both within
a country and globally. Provision can be sought via governmental or non-
governmental donor sources. A nominated person with overall responsibility for
hospital computer systems predisposes to a cohesive service both internally and
externally, avoiding duplication and ensuring appropriate usage.
Effective communication between groups of staff improves the effectiveness

and efficiency of care. Regular meetings should discuss individual patients, debrief
following deaths and clinical incidents, and audit specific aspects of clinical and unit
management, such as infection control. The outcome of audit, particularly any
changes in practice, needs to be available to those staff it affects, but such meetings
should be educational and not used for apportioning blame.
Utilities Water and sanitation

Hygiene within the hospital is paramount, and is dependent on a constant and
high- quality water supply and adequate sanitation and washing facilities (i.e.
bathrooms, showers, toilets and accessible sinks with an effective, functioning
drainage system), all of which are vital if hospital- related infection is to be minimized.
Electricity
An electricity supply within the hospital, which functions independently of any
power losses to the rest of the area, is mandatory. Therefore a generator of sufficient
power should be an essential item of equipment (the generator size is calculated
52
from bed dependency and operating theatre requirements). In resource- limited
countries where an erratic power supply is common due to high fuel costs, solar
backups are needed for hospitals to function efficiently and effectively. There should
be special emergency circuits. Power- cut simulations should be carried out regularly
to test the system.
Heating and ventilation

Ideally there should be a functioning central heating system within the hospital.
For this to work there will also need to be a continuous water supply. If either of
these cannot be ensured, electric heaters should be installed in all areas where
there are patients. In hot weather, there should be sufficient windows (that can be
opened) to allow a comfortable temperature to be maintained during the hottest part
of the day. An air conditioning system or fans, either electric or manual (to be operated
by relatives), should be available in areas of the hospital that become particularly
hot, and for patients who must be kept cool (e.g. children with high fevers or head
injuries).
Laundry service
Bedding and other items must be frequently washed. Therefore the hospital
must have a staffed laundry service, ideally with a sufficient number of industrial
washing machines and drying facilities. Where hand washing is the only option,
staff should wear protective clothing and high quality thick gloves. Clean bedding,
towels and nappies must be available. A small supply of nightwear and other clothing
may be needed on the wards for families who do not have a change of clothes with
them.
4.4 Working of Outpatient Department

The outpatient clinic of a hospital, also called an outpatient department provides
diagnosis and care for patients that do not need to stay overnight. This is distinct
from clinics independent of hospitals, almost all of which are designed mostly or
exclusively for outpatient care and may also be called outpatient clinics.
The outpatient department is an important part of the overall running of the

hospital. It is normally integrated with the in-patient services and manned by
53
consultant physicians and surgeons who also attend inpatients in the wards. Many
patients are examined and given treatment as outpatients before being admitted to
the hospital at a later date as inpatients. When discharged, they may attend the
outpatient clinic for follow-up treatment.
The outpatient department will usually be on the ground floor of the hospital
with car-parking facilities nearby. Wheelchairs and stretchers are available for non-
ambulatory patients. Patients will register at a reception desk and there is seating
for them while they wait for their appointments. Each doctor will have a consulting
room and there may be smaller waiting areas near these. Pediatric clinics are often
held in areas separated from the adult clinics. Close at hand will be X-ray facilities,
laboratories, the medical record office and a pharmacy. In the main waiting area
there are a range of facilities for the patients and their families including toilets, public
telephones, coffee shop or snack bar, water dispenser, gift shop, florist and quiet
room. Not all hospitals have separate outpatient departments, so outpatients may
be treated in the same departments as patients that stay overnight.
4.5 Inpatient Services

Inpatient care is the care of patients whose condition requires admission to
a hospital. Progress in modern medicine and the advent of comprehensive out-patient
clinics ensure that patients are only admitted to a hospital when they are extremely
ill or have severe physical trauma. Inpatient care refers to medical treatment that is
provided in a hospital or other facility and requires at least one overnight stay.
For example, hospitalists are physicians who practice only inpatient care, and
no office-based or outpatient care.
Inpatient care tends to be directed towards more serious ailments and trauma
that require one or more days of overnight stay at a hospital. For the purposes of
healthcare coverage, health insurance plans require you to be formally admitted to
a hospital for a stay for a service to be considered inpatient. This means a doctor
has to write a note to give the order to admit you, so if you were in the emergency
room and were asked to stay overnight for “Medical Observation”, it does not make
you an inpatient.
54
Over half of all inpatient hospital admissions come through the emergency
room department. Health insurance plans break out emergency room vs. inpatient
facility care when it comes to your share of the costs. In some plans, the copays for
emergency room services are waived if the patient is then admitted to the hospital.
Inpatient care is broken into two parts: the facility fee and those related to the
surgeon/physician. Generally speaking, copays for inpatient services are structured
either on a per stay or per day basis for the facility. For some plans, copays are often
a few hundred dollars per admission and up to as much as $1,000. In a few cases,
cost sharing including both a multi-hundred dollar copay and coinsurance on top of
it.
4.6 Medicare : Outpatient Vs Inpatient

If you have Medicare, you should ask whether or not you are considered inpatient
or outpatient. Your hospital status (whether the hospital considers you an “inpatient”
or “outpatient”) affects how much you pay for hospital services (like X-rays, drugs,
and lab tests) and may also affect whether Medicare will cover care you get in a
skilled nursing facility (SNF) following your hospital stay. You’re an inpatient starting
when you’re formally admitted to a hospital with a doctor’s order. The day before
you’re discharged is your last inpatient day.
You’re an outpatient if you’re getting emergency department services,

observation services, outpatient surgery, lab tests, X-rays, or any other hospital
services, and the doctor hasn’t written an order to admit you to a hospital as an
inpatient. In these cases, you’re an outpatient even if you spend the night at the
hospital. The decision for inpatient hospital admission is a complex medical decision
based on your doctor’s judgment and your need for medically necessary hospital
care. An inpatient admission is generally appropriate when you’re expected to need
2 or more midnights of medically necessary hospital care, but your doctor must
order such admission and the hospital must formally admit you in order for you to
become an inpatient.
4.6.1 Difference Between Inpatient and Outpatient

In the most basic sense, an inpatient is someone admitted to the hospital to
stay overnight. That can include a person who remains in the hospital for weeks to
55
recover from a complicated surgery as well as an individual who only needs to stay
briefly. Physicians keep these patients at the hospital to monitor them more closely.
Outpatient care, also called ambulatory care, is anything that doesn’t require
hospitalization. An annual exam with your primary care physician and a consultation
with your neurologist are both examples of outpatient care. But emergent cases can
also be considered outpatient care. If you leave the emergency department the same
day you arrive, you’re still considered an outpatient. And of course, any appointment
at a clinic or specialty facility outside the hospital is considered outpatient care.
While there’s a clear difference between an inpatient and an outpatient, there

is a little bit of grey area as well. Occasionally, physicians will assign a
patient observation status while they determine whether hospitalization is required.
This allows doctors a bit more time to evaluate you and make the most appropriate
decision. That said, there are instances where a patient can remain under observation
status for more than 24 hours.
Note that the location itself doesn’t define whether you’re an inpatient or
outpatient. It’s the duration of stay, not the establishment, that determines your status.
Inpatient Vs Outpatient : Comparing Services

You’re probably starting to get a sense of what types of circumstances fit under
each category. Here’s a little more detail about the types of treatments and services
that are common for these two types of care.
Inpatient Care Examples

Complex surgeries
Serious illnesses or medical issues that require substantial monitoring
Delivering a baby
Rehabilitation services for some psychiatric conditions, substance

misuse, or severe injuries
56
Outpatient Care Examples
X-rays, MRIs, and other types of imaging
Bloodwork and other lab tests
Minor surgeries
Colonoscopies
Mammograms
Consultations or follow-ups with a specialist
Routine physical exams
Stitches and other same-day emergent care
Chemotherapy or radiation treatment
Inpatient Vs Outpatient
The Providers In Each Setting
Primary care physicians have traditionally been considered outpatient providers
while specialists are thought of as inpatient physicians. But that’s really an
oversimplification, particularly when you consider that hospitalists bridge the gap by
providing general medical care to inpatients. Effective care requires a team effort
anyway. Doctors need to work together, regardless of their specialty and setting.
Many physicians also divide their time between inpatient and outpatient services.
OB/GYNs, for example, provide inpatient care when delivering babies and outpatient
care when consulting with pregnant women during their prenatal checkups.
Generally speaking, inpatients interact with a larger group of providers. When

you stay in a hospital, you could interact with physicians, nurse practitioners, lab
technicians, physical therapists, pharmacists, and physician assistants.
57
Inpatient Vs Outpatient
Cost Considerations
You may be asking yourself whether the difference between inpatient versus
outpatient care really matters that much from a patient’s perspective. Your status
might not influence the quality of care you receive, but it will ultimately affect your
eventual bill. While you’re not usually able to influence your status, it’s still good to
know what you can expect.
The cost of outpatient care consists of fees related to the doctor and any tests
performed. Inpatient care, on the other hand, includes facility-based fees on top of
those existing expenses. Overall cost for inpatients can range anywhere from a few
thousand dollars to tens of thousands of dollars, depending on the length of stay
and the treatment involved. The exact amount you pay also hinges on your insurance.
Things get a little more complicated if you have Medicare. Outpatient care and
physician-related services for inpatient care are covered by Part B. Hospital services
like rooms, meals, and general nursing for inpatients are covered by Part A.
4.7 Main Function of Inpatient Department

1. Enquiry or Reception
Modules
Admitted Patients
Doctors Reports
Appointment Fixing
New Registration
OP Billing Birth Registration
Death Registration
Room Booking
58
Admitted Patients
This process undergoes if any patients get admitted. Admission form will be
issued in that patients name, age, sex ,doctors name, admission date etc, will be
mentioned.
Doctors Report
This Process undergoes for doctors particular patients only. Doctor will write
complete details of the patients from the date of admission to discharge like
medicines, if diet necessary etc,
Appointment Fixing
This process undergoes for the patients who needs appointment to their
particular doctors. That means they call by phone to hospital book appointment with
doctor directly or particular person who handle it. Like time of coming, day. etc,.
Birth Registration
This process undergoes while the birth of new baby in the hospital. While the
new baby born that should be registered in the form like, Mother name ,Father Name,
Particular Doctor. Birth time etc,.
Death Registration
This Process Undergoes if any person dies in the hospital. The particular staff
will register the death report like Person’s name cause of death, etc,.
Room Booking
This process under goes if the patient need room. The Room Booking form will
be issued if room available like patients name. floor No., Ward name, Doctor’s name
etc,.
New Registration
This process will undergoes while the patient is coming first time to hospital.
So the patient should register his name, age, sex, doctor’s name etc,.
59
OP Billing
This process undergoes the patient will come as out -patient to seethe doctor.
In that way they will issued OP bill. The Help Desk Module automates the day-to-
day functions of the Front office management of a hospital. This module helps in
assisting patient with accurate information and supports in handling patient related
enquiries efficiently. This module having excellent features and advanced search
facilities improves the quality of services rendered to the user.
It Provides For Queries Relating To The Following :

a) Patient related enquiries
b) Bed Allotment
c) Admission Details
d) Demographic Details
f) Payment Details
g) Discharge Details
h) Doctor related enquiries
i) Bed Allotment
2. Search
Modules
Patients
Doctors
Patients Search
This Process undergoes while if any person needs to see the particular patients
then search the patients by telling the patient’s name and particular doctor’s name
etc,.
60
Doctors Search
This process undergoes while if anybody wants to Know the details of Particular
doctor’s name by searching doctor’s name, department etc,.
The Registration module is an integrated patient management system, which

captures complete and relevant patient information. The system automates the patient
administration functions to have better and efficient patient care process. Appointment
scheduling deals with scheduling of physician appointments for the patients. The
user can view the schedule for a particular doctor; the appointments scheduled for
the doctor, the free slots available, blocked slots. Based on the slot availability, the
appointment can be fixed. The appointment can be rescheduled and Cancelled based
on the scenario. The hospital can track and manage Scheduled Visits,
Emergency Visits, and Visit cancellations. The user can view all patients’
previous visitations to the hospital and also No- show patients list. Telephonic
appointments for unregistered patient scan also be scheduled.
Patient Registration Details

a) Inpatient and Outpatient Registration
b) Medical Alerts Details
c) Appointment Scheduling (Patient / Doctor wise)
d) Doctor’s Schedule Summary
e) Doctors Daily Schedule List
f) Patient Visit History
g) Medical Record Movements
h) Patient Visit Slip
It provides for enquiries about the patient, the patient’s location, admission,
and appointment scheduling and discharge details. Furthermore, this system even
takes care of package deals for a
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patient for a fixed cost. Medical Record keeps an abstract of clinical data about
patients. It allows easy retrieval of medical records on patients.
3. Inpatient (IP)
Modules
New IP Entry
IP Discharge Sheet
New IP Entry
This Process undergoes the entry of new IP’s which had admitted in the hospital
like at which department, under which doctor etc,.
IP Discharge
This process undergoes while IP Patient get discharge. In that sheet mentioned
like IP Patients Name, Sex, Age, From which department, doctor’s name, Taken test
details etc,.
Inpatient Management Modules handles the Admission Discharge and Transfer

Functions, Ward management Functions and Operation.
Theatre Management Functions. This module automates the day-today

administrative actives and provides instant access to other modules, which leads to
a better patient care. It provides comprehensive data pertaining to Admission of
Patients &Ward Management: Availability of beds, Estimation, Agreement
preparation, Collection of advance, Planned admission, Emergency
admission and so on. The Inpatient module also deals with Ward Management:
Shifting from one ward to the other, Bed availability, Surgery, Administration of drugs,
nursing notes, charge slip and so on.
a) Admission Cost Estimation
b) Admission Approval
c) Admission Request
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d) Doctor Transfer Details
e) Nursing Notes
f) IP Medical Observation
g) Pending Drug Request
4. Lab
Modules
Lab Testing Billing
Lab Testing Billing

This Process undergoes of the billing of lab Results of the particular patients
like test name, amount, doctor’s name etc,. The Patient Billing module handles all
types of billing for long-term care. This module facilitates cashier and billing operations
for different categories of patients like Outpatient, Inpatient and Referral. It provides
automatic posting of charges related to different services like bed charges, lab tests
conducted, medicines issued, consultant’s fee, food, beverage and telephone charges
etc. This module provides for credit partly billing and can be seamlessly integrated
with the Financial Accounting Module. The billing module is extensively flexible by
which each of your billing plans can be configured to automatically accept or deny.
The system is tuned to capture room and bed charges along with ancillary charges
based on the sponsorship category. The Billing Screens is used for In-patient and
Outpatient Billing and In voicing. Further more the charges for various services
rendered can be recorded through service module and this can be used for billing
purposes.
Patient Billing Details

Possibility to apply Sponsorship conditions to pharmacy drugs and anyother
department and services as required The system supports multiple reports utilizing
various print options with user-defined parameters.
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5. Pharmacy
Modules
Sales
sales returns
Procedure Bill
Pharmacy Reports
View Stock
Issue Medical Equipments.
Sales
This Process undergoes for selling the medicines for particular patients like
Patients name, ward, doctor’s name and medicine name etc,.
Sales Returns
This Process undergoes whiled the sold goods returning.
Procedure Bill
This Process undergoes Procedures done the department of pharmacy and
issue the bill.
Pharmacy Reports
This process undergoes for the reports of pharmacy’s about sold or purchase
goods.
View Stock
This process undergoes to know the complete stock details of pharmacy.
Issue Medical Equipments

This process undergoes for issuing the medical equipment’s report. Pharmacy
module deals with the automation of general workflow and administration
64
management process of a pharmacy. The pharmacy module is equipped with bar
coding facility, which makes the delivery of medical items to the patient more efficient.
This Module Deals with The Activities Suchas :

a) Purchase order
b) Online approval
c) Pharmacy drug configuration
d) Pharmacy stores configuration
e) Drug issue to patients and billing
f) Unit dosage facility
g) Supplier information
h) Maintenance of drug inventory
i) Automatic reorder level setting
j) Purchase Requisitions
k) Purchase Order
l) Online request for stock from various sub-stores
m) Online stock transfer
n) Maintenance of stock at different sub-stores
o) Return of items nearing expiry
p) Destruction of expired items
q) Physical stock verification and adjustment
r) Goods receipt
s) Stock Transfer (inter store stock transfer)

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t) Stock Adjustment
u) Stock in Hand reports
In addition the Online prescription facility assists and facilitates thephysicians

to track the patient’s prescription details and as wellreflects the medication billing
details in the Billing module.
6. Employee
Modules
Employee Information
Employee Search
This process undergoes for keeping the information’s of employeesin the
hospital records as name of employee, age, sex, department,position, etc,.
Employee Search
This process undergoes to help for searching the employee like typein hospital
records as name, department, position, etc,.
Nursing module is a tool provided in the hospital management systemsoftware

to the nurses to manage their routine tasks with theobjective of improving patient
care. It is tightly integrated with theInpatient module and other clinical modules for
smooth flow ofinformation.
Some of the Feature of This Module are
Patient Charting:
A patient’s vital signs, admission and nursing assessments and nursing notes
can be entered into the system. These are the stored in a central repository and
retrieved when needed.
Nurse can self schedule their shifts using scheduling rules provided in shift
modules. The shifts can later be confirmed or changed by a scheduling coordinator
or manager.
66
Clinical Data Integration :
Here clinical information from all thedisciplines can be retrieved, viewed and
analyzed by nursing staff.
Improved workload functionality :

Staffing levels and appropriate skillmix per shift can be more easily determined
by the shift modules.
Better care planning :

Time spent on care planning is reduced, whilethe quality of what is recorded is
improved. This makes for morecomplete care plans and more complete assessments
and evaluations.
Better drug administration :

Electronically prescribed drugs are morelegible, thus making it less likely that
drugs would be wrongly administered to patients.
The Nursing Module Comjprises of the Following Features, VIA :

a) Nurse duty roster
b) Change in duty roster
c) Medical observations
d) Patient activity charting
e) Task Allocation (general)
f) Recording vitals, nursing notes
g) Recording dispensing of medicine
h) Admission, Discharge and Room Transfer

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7. General Entries
General entries mainly deals with the general information about
Modules
Consultation Charges
Employee information
Department\
Room Type
Floor Type, Block
Add Rooms
General Settings
Add Procedures.
Consultation Charges
This process undergoes for consultation charges which the patientseen by
doctor then consultation is charged as name of doctor,patient consultation charge,
department, etc,.
This Process undergoes to know the information of employee atparticular
department by name of employee, department, positionetc,.
Employee Department
This Process undergoes for knowing the department of particularemployee.
Room Type
This Process undergoes to know the room type like Deluxe, SuperDeluxeetc,.
Floor Type
This Process under goes to know the floor type Like B-Block, C-BlockEtc,.
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Add Procedure
This process undergoes to add procedures of hospital.
8. Reports
The General Reports Hospital Managements are
Modules
Daily Closing Reports\
Sales Reports
Sales Returns Reports
Procedure Billing Reports
Procedure Reports
Daily Closing
This Process Undergoes for closing the daily reports.
Sales Reports
This Process undergoes for knowing the reports of daily sales.
Sales Returns Reports

This Process undergoes for knowing the reports of daily sales returnsgoods.
Procedure Billing Reports

This Process Undergoes for knowing producers of hospital Billing.

Fill in the blanks :
1. ______________-are medical procedures or tests that can be done in a
medical center without an overnight stay.
2. ______________refers to medical treatment that is provided in a hospital or

other facility and requires at least one overnight stay.
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4.8 Summary
The outpatients are becoming more and more important. Ambulatory care
reduces dislocation of work, is cheaper and at the same time gives access to the
various investigative and diagnostic facilities of the hospital. There are 3 types of
outpatient: General outpatient, referred outpatient and emergency outpatient.
Outpatient department is the linkage to other departments in the hospital; it

should be located near the main entrance recovery room, etc. The outpatient
department faces some common problems like prolonged waiting time, dissatisfaction
of amenities and heavy workload to the doctors and misplacement of medical records.
Inpatient department is the heart of the hospital. It provides the quality of service
through nursing services, wards and rooms with sufficient space, dietary services
and sanitary facilities.
4.9 Keywords
General hospital. A hospital that provides a range of different services for
patients of various age groups and with varying disease conditions.
Specialized hospital. A hospital admitting primarily patients suffering from a

specific disease or affection of one system, or reserved for the diagnosis and
treatment of conditions affecting a specific age group or of a long-term nature.
Nurses. All persons who have completed a programme of basic nursing

education and are qualified and registered or authorized to provide responsible and
competent service for the promotion of health, prevention of illness, the care of the
sick, and rehabilitation, and are actually working in the country.
Pharmacists. All graduates of any faculty or school of pharmacy, actually

working in the country in pharmacies, hospitals, laboratories, industry, etc.
Inpatient. A person who is formally admitted to a health-care facility and who is

discharged after one or more days.
Outpatient. A person who goes to a health-care facility for a consultation, and

who leaves the facility within three hours of the start of consultation. An outpatient is
not formally admitted to the facility.
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1. Define outpatient and different types of outpatient.
2. Explain the location of an outpatient department.
3. Differentiate between Outpatient and Inpatient.
4. Explain infrastructure facilities available in Outpatient department.
5. Describe the main function of inpatient department.
6. Discuss issues regarding diagnosis, prognosis and management with your

house staff and attending before talking with patients and families.
7. Rationale your assessment and plans with respect to Patient write-ups
Check your progress Answers

1. Outpatient services
2. Inpatient care

Inpatient medicine, Scott Kahan, Wolters Kluwer Health.
Patient management simulations: a resource catalog, University of

Michigan. Medical Center. Office of Educational Resources and Research.
Learning Resource Center -
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LESSON – 5
MEDICAL SERVICES
Learning Objectives
After studying this lesson, you should be able to:
Explain Causality and Emergency
Describe surgery and obstetrics
Outline various types of clinical services
Discuss Hypertext and Hypermedia Concepts
Describe how multimedia applications are influencing clinical services
Structures
5.1 Introduction
5.2 Medical/clinical services
5.3 Types of Medical / Clinical services
5.3.1 Anesthesia
5.3.2 Cardiology
5.3.3 Dermatology
5.3.4 Endocrinology
5.3.5 Gastroenterology
5.3.6 Nephrology
5.3.7 Neurology
5.3.8 Oncology
5.3.9 Orthopedics
5.3.10 Plastic surgery

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5.3.11 Urology
5.3.12 Obstetrics
5.4.13 Gynecology
5.4 Summary
5.5 Keywords
5.1 Introduction
In the previous unit, you have studied about basics of clinical services. In this
unit, you will study about clinical services in detail. A clinic is a healthcare facility
that is primarily devoted to the care of outpatients. Clinics can be privately operated
or publicly managed and funded, and typically cover the primary healthcare needs
of populations in local communities, in contrast to larger hospitals which offer
specialized treatments and admit inpatients for overnight stays. Some clinics grow
to be institutions as large as major hospitals, or become associated with a hospital
or medical school, while retaining the name “clinic”.
5.2 Medical / Clinical Services
The clinical service ensures the safe and effective use of medicines throughout
the hospital.
Function
It aims to assist the Trust in obtaining the best possible value for money for the
medicines used and to provide an efficient transfer of information at admission and
discharge.
Staff Involved
Clinical services manager supported by the clinical principal pharmacist, which
lead a team of 14 pharmacists of varying grades and experience who are supported
by six technicians.
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Clinical Pharmacy Activities
Most wards are visited daily by a pharmacist and some also have a technician.
Each patient’s prescription chart is reviewed for appropriateness of medicines usage
taking into consideration individual needs.
5.3 Types of Y Medical / Clinical Services

Maternity Services Radiology
General Medicine Oncology Psychiatry
Dental Services Endocrinology
Cardio thoracic ClinicalServices Neurology
Gastroenterology Ophthalmology
Urology Medical Services
Nephrology Operation theatre Surgical Services
Figure 5.1 : Types of Clinical Services
5.3.1 Anesthesia
Anesthesia is a medical treatment that prevents patients from feeling pain during
surgery. It allows people to have procedures that lead to healthier and longer lives.
To produce anesthesia, doctors use drugs called anesthetics. Scientists have
developed a collection of anesthetic drugs with different effects. These drugs include
general, regional, and local anesthetics. General anesthetics put patients to sleep
during the procedure. Local and regional anesthetics just numb part of the body and
allow patients to remain awake during the procedure.
Depending on the type of pain relief needed, doctors deliver anesthetics by

injection, inhalation, topical lotion, spray, eye drops, or skin patch.
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Effects of Anesthesia
If you’re having surgery, you most likely will have some type of anesthesia to
keep you from feeling pain during the procedure. While anesthesia is very safe, it
can cause side effects both during and after the procedure. Most side effects of
anesthesia are minor and temporary, though there are some more serious effects to
be aware of and prepare for in advance.
Types of anesthesia and their side effects

There are four main types of anesthesia used during medical procedures and
surgery, and the potential risks vary with each. The types of anesthesia include the
following:
General anesthesia
General anesthesia causes you to lose consciousness. This type of anesthesia,
while very safe, is the type most likely to cause side effects. If you’re having general
anesthesia, a physician anesthesiologist should monitor you during and after your
procedure to address any side effects and watch for the possibility of more serious
complications.
Side effects of general anesthesia can include :

Nausea and vomiting – This very common side effect can occur within the
first few hours or days after surgery and can be triggered by a number of factors,
such as the medication, motion and the type of surgery.
Sore throat – The tube that is placed in your throat to help you breathe while
you’re unconscious can leave you with a sore throat after it’s removed.
Postoperative delirium – Confusion when regaining consciousness after

surgery is common, but for some people — particularly older patients — the confusion
can come and go for about a week. You may feel disoriented and have problems
remembering or focusing. This can worsen if you are staying in the hospital for a few
days after the procedure, especially in intensive care, because you are in an unfamiliar
place. Having a loved one with you helps, along with doing some other simple things:
wearing your glasses or hearing aids as soon as you can after the procedure and
making sure you have family photos, familiar objects and a clock and calendar in
your room.
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Muscle aches – The medications used to relax your muscles so a breathing
tube can be inserted can cause soreness.
Itching – This is a common side effect of narcotics, one type of pain medication
sometimes used with general anesthesia.
Chills and shivering (hypothermia) – This occurs in up to half of patients as

they regain consciousness after surgery, and it might be related to body temperature.
Rarely, general anesthesia can cause more serious complications, including:
Postoperative delirium or cognitive dysfunction – In some cases, confusion

and memory loss can last longer than a few hours or days. A condition called
postoperative cognitive dysfunction can result in long-term memory and learning
problems in certain patients. It’s more common in older people and those who have
conditions such as heart disease, especially congestive heart failure, Parkinson’s
disease or Alzheimer’s disease. People who have had a stroke in the past are also
more at risk. It’s important to tell the physician anesthesiologist if you have any of
these conditions.
Malignant hyperthermia – Some people inherit this serious, potentially deadly

reaction to anesthesia that can occur during surgery, causing a quick fever and
muscle contractions. If you or your family member has ever had heat stroke or suffered
from malignant hyperthermia during a previous surgery, be sure to tell the physician
anesthesiologist.
Monitored anesthesia care or IV sedation. For some procedures, you may

receive medication that makes you sleepy and keeps you from feeling pain. There
are different levels of sedation — some patients are drowsy, but they are awake and
can talk; others fall asleep and don’t remember the procedure. Potential side effects
of sedation, although there are fewer than with general anesthesia, include headache,
nausea and drowsiness. These side effects usually go away quickly. Because levels
of sedation vary, it’s important to be monitored during surgery to make sure you
don’t experience complications.
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Headache – This can occur a few days after the procedure if some spinal fluid
leaks out when regional anesthetic is delivered through the spine, as in an epidural or
spinal block for child birth.
Minor back pain – Soreness can happen at the site where the needle was
inserted into the back.
Difficulty urinating – If you were numbed from the waist down, it may be difficult
to urinate for a little while after the procedure.
Hematoma – Bleeding beneath the skin can occur where the anesthesia was
injected.
More serious but rare complications include:
Pneumothorax – When anesthesia is injected near the lungs, the needle may
accidentally enter the lung. This could cause the lung to collapse and require a
chest tube to be inserted to re-inflate the lung.
Nerve damage – Although very rare, nerve damage can occur, causing
temporary or permanent pain.
Local anesthesia
This is the type of anesthesia least likely to cause side effects, and any side
effects that do occur are usually minor. Also called local anesthetic, this is usually a
one-time injection of a medication that numbs just a small part of your body where
you’re having a procedure such as a skin biopsy. You may be sore or experience
itching where the medication was injected. If you’ve had this type of reaction to local
anesthesia in the past, be sure to tell your physician. You may be given a different
type of anesthetic or a medication to counteract the side effects.
5.3.2 Cardiology
The term cardiology is derived from the Greek words “cardiac,” which refers to
the heart and “logy” meaning “study of.” Cardiology is a branch of medicine that
concerns diseases and disorders of the heart, which may range from congenital
defects through to acquire heart diseases such as coronary artery disease and
congestive heart failure.
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Figure 5.2 Normal Blood Flow

Cardiac electrophysiology
Cardiac electrophysiology is the science of elucidating, diagnosing, and treating
the electrical activities of the heart. The term is usually used to describe studies of
such phenomena by invasive (intracardiac) catheter recording of spontaneous activity
as well as of cardiac responses to programmed electrical stimulation (PES).
These studies are performed to assess complex arrhythmias, elucidate

symptoms, evaluate abnormal electrocardiograms, assess risk of developing
arrhythmias in the future, and design treatment. These procedures increasingly
include therapeutic methods (typically radiofrequency ablation, or cryoablation) in
addition to diagnostic and prognostic procedures. Other therapeutic modalities
employed in this field include antiarrhythmic drug therapy and implantation of
pacemakers and automatic implantable cardioverter defibrillators.
The cardiac electrophysiology study (EPS) typically measures the response of

the injured or cardiomyopathic myocardium to PES on specific pharmacological
regimens in order to assess the likelihood that the regimen will successfully prevent
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potentially fatal sustained ventricular tachycardia (VT) or ventricular fibrillation
VF (VF) in the future. Sometimes a series of EPS drug trials must be conducted to
enable the cardiologist to select the one regimen for long-term treatment that best
prevents or slows the development of VT or VF following PES. Such studies may
also be conducted in the presence of a newly implanted or newly replaced cardiac
pacemaker or AICD.
Clinical cardiac electrophysiology

Clinical cardiac electrophysiology is a branch of the medical specialty of
cardiology and is concerned with the study and treatment of rhythm disorders of the
heart. Cardiologists with expertise in this area are usually referred to as electro
physiologists. Electro physiologists are trained in the mechanism, function, and
performance of the electrical activities of the heart. Electro physiologists work closely
with other cardiologists and cardiac surgeons to assist or guide therapy for heart
rhythm disturbances (arrhythmias). They are trained to perform interventional and
surgical procedures to treat cardiac arrhythmia.
Figure 5.3 Stethoscope

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Cardio geriatrics
Cardio geriatrics, or geriatric cardiology, is the branch of cardiology and geriatric
medicine that deals with the cardiovascular disorders in elderly people.
Cardiac disorders such as coronary heart disease, including myocardial

infarction, heart failure, cardiomyopathy, and arrhythmias such as atrial fibrillation,
are common and are a major cause of mortality in elderly people. Vascular disorders
such as atherosclerosis and peripheral arterial disease cause significant morbidity
and mortality in aged people.
Echocardiography
Echocardiography uses standard two-dimensional, three-dimensional, and
Doppler ultrasound to create images of the heart.
Echocardiography has become routinely used in the diagnosis, management,

and follow-up of patients with any suspected or known heart diseases. It is one of
the most widely used diagnostic tests in cardiology. It can provide a wealth of helpful
information, including the size and shape of the heart (internal chamber size
quantification), pumping capacity, and the location and extent of any tissue damage.
An echocardiogram can also give physicians other estimates of heart function, such
as a calculation of the cardiac output, ejection fraction, and diastolic function (how
well the heart relaxes).
Echocardiography can help detect cardiomyopathies, such as hypertrophic

cardiomyopathy, dilated cardiomyopathy, and many others. The use of stress
echocardiography may also help determine whether any chest pain or associated
symptoms are related to heart disease. The biggest advantage to echocardiography
is that it is not invasive (does not involve breaking the skin or entering body cavities)
and has no known risks or side effects.
Interventional cardiology
Interventional cardiology is a branch of cardiology that deals specifically with
the catheter based treatment of structural heart diseases. A large number of
procedures can be performed on the heart by catheterization. This most commonly
involves the insertion of a sheath into the femoral artery (but, in practice, any large
80
peripheral artery or vein) and cumulating the heart under X-ray visualization (most
commonly Fluoroscopy).
The main advantages of using the interventional cardiology or radiology

approach are the avoidance of the scars and pain, and long post-operative recovery.
Additionally, interventional cardiology procedure of primary angioplasty is now the
gold standard of care for an acute Myocardial infarction. This procedure can also be
done proactively, when areas of the vascular system become occluded
from Atherosclerosis. The Cardiologist will thread this sheath through the vascular
system to access the heart. This sheath has a balloon and a tiny wire mesh tube
wrapped around it, and if the cardiologist finds a blockage or Stenosis, they can
inflate the balloon at the occlusion site in the vascular system to flatten or compress
the plaque against the vascular wall. Once that is complete a Stent is placed as a
type of scaffold to hold the vasculature open permanently.
Preventive Cardiology and Cardiac Rehabilitation

In recent times, the focus is gradually shifting to Preventive cardiology due to
increased Cardiovascular Disease burden at an early age. As per WHO, 37% of all
premature deaths are due to cardiovascular diseases and out of this, 82% are in low
and middle income countries. Clinical cardiology is the sub specialty of Cardiology
which looks after preventive cardiology and cardiac rehabilitation. Preventive
cardiology also deals with routine preventive checkup though non invasive tests
specifically Electrocardiography, Stress Tests, Lipid Profile and General Physical
examination to detect any cardiovascular diseases at an early age while cardiac
rehabilitation is the upcoming branch of cardiology which helps a person regain his
overall strength and live a normal life after a cardiovascular event.
Cardiac arrest
Cardiac arrest is a sudden stop in effective blood flow due to the failure of
the heart to contract effectively. Symptoms include loss of consciousness
and abnormal or absent breathing. Some people may have chest pain, shortness of
breath, or nausea before this occurs. If not treated within minutes, death usually
occurs. The most common cause of cardiac arrest is coronary artery disease. Less
common causes include major blood loss, lack of oxygen, very low potassium, heart
81
failure, and intense physical exercise. A number of inherited disorders may also
increase the risk including long QT syndrome. The initial heart rhythm is most
often ventricular fibrillation. The diagnosis is confirmed by finding no pulse. While a
cardiac arrest may be caused by heart attack or heart failure these are not the same.
Prevention includes not smoking, physical activity, and maintaining a healthy

weight. Treatment f or cardiac arrest is immediate cardiopulmonary
resuscitation (CPR) and, if a shockable rhythm is present, defibrillation. Among those
who survive ta rgeted temperature managem ent m ay improve
outcomes. An implantable cardiac defibrillator may be placed to reduce the chance
of death from recurrence.
In the United States, cardiac arrest outside of hospital occurs in about 13 per
10,000 people per year (326,000 cases). In hospital cardiac arrest occurs in an
additional 209,000 Cardiac arrest becomes more common with age. It affects males
more often than females. The percentage of people who survive with treatment is
about 8%. Many who survive have significant disability. Many U.S. television shows,
however, have portrayed unrealistically high survival rates of 67%.
Congenital heart defects

A congenital heart defect, also known as a “congenital heart anomaly” or
“congenital heart disease”, is a problem in the structure of the heart that is present
at birth. Signs and symptoms depend on the specific type of problem. Symptoms
can vary from none to life-threatening. When present they may include rapid
breathing, bluish skin, poor weight gain, and feeling tired. It does not cause chest
pain. Most congenital heart problems do not occur with other diseases. Complications
that can result from heart defects include heart failure.
The cause of a congenital heart defect is often unknown. Certain cases may
be due to infections during pregnancy such as rubella, use of certain medications or
drugs such as alcohol or tobacco, parents being closely related, or poor nutritional
status or obesity in the mother. Having a parent with a congenital heart defect is
also a risk factor. A number of genetic conditions are associated with heart defects
including Down syndrome, Turner syndrome, and Marfansyndrome. Congenital heart
defects are divided into two main groups: cyanotic heart defects and non-cyanotic
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heart defects, depending on whether the child has the potential to turn bluish in
color. The problems may involve the interior walls of the heart, the heart valves, or
the large blood vessels that lead to and from the heart.
Congenital heart defects are partly preventable through rubella vaccination,

the adding of iodine to salt, and the adding of folic acid to certain food products. Some
defects do not need treatment. Other may be effectively treated with catheter based
procedures or heart surgery. Occasionally a number of operations may be
needed. Occasionally heart transplantation is required. With appropriate treatment
outcomes, even with complex problems, are generally good.
Heart defects are the most common birth defect. In 2013 they were present in
34.3 million people globally. They affect between 4 and 75 per 1,000 live births
depending upon how they are diagnosed. About 6 to 19 per 1,000 cause a moderate
to severe degree of problems. Congenital heart defects are the leading cause of
birth defect-related deaths. In 2013 they resulted in 323,000 deaths down from
366,000 deaths in 1990.
5.3.3 Dermatology
Dermatology is the branch of medicine dealing with the skin, nails, hair
(functions & structures) and its diseases. It is a specialty with both medical and
surgical aspects. A dermatologist is specialist doctor that manages diseases, in the
widest sense, and some cosmetic problems of the skin, hair and nails.
Immuno Dermatology
This field specializes in the treatment of immune-mediated skin diseases such
as lupus, bullous pemphigoid, pemphigus vulgaris, and other immune-mediated skin
disorders. Specialists in this field often run their own immunopathology labs.
Immunodermatology testing is essential for the correct diagnosis and treatment of
many diseases affecting epithelial organs including skin, mucous membranes,
gastrointestinal and respiratory tracts. The various diseases often overlap in clinical
and histological presentation and, although the diseases themselves are not common,
may present with features of common skin disorders such as urticaria, eczema and
chronic itch. Therefore, the diagnosis of an immunodermatological disease is often
delayed. Tests are performed on blood and tissues that are sent to various laboratories
from medical facilities and referring physicians across the United States.
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Cosmetic Dermatology
Dermatologists have been leaders in the field of cosmetic surgery. Some
dermatologists complete fellowships in surgical dermatology. Many are trained in
their residency on the use of botulinum toxin, fillers, and laser surgery.
Some dermatologists perform cosmetic procedure including liposuction ,

blepharoplasty, and face lifts. Most dermatologists limit their cosmetic practice to
minimally invasive procedures. Despite an absence of formal guidelines from
the American Board of Dermatology, many cosmetic fellowships are offered in both
surgery and laser medicine.
Mohus Surgery
The dermatologic subspecialty called Mohs surgery focuses on the excision of
skin cancers using a tissue-sparing technique that allows intraoperative assessment
of 100% of the peripheral and deep tumor margins developed in the 1930s by
Dr. Frederic E. Mohs. The procedure is defined as a type of CCPDMA processing.
Physicians trained in this technique must be comfortable with both pathology and
surgery, and dermatologists receive extensive training in both during their residency.
Physicians who perform Mohs surgery can receive training in this specialized
technique during their dermatology residency, but many will seek additional training
either through preceptorship to join the American Society for Mohs Surgery or through
formal one to two years Mohs surgery fellowship training programs administered by
the American College of Mohs Surgery.
This technique requires the integration of the same doctor in two different
capacities: surgeon as well as pathologist. In case either of the two responsibilities
is assigned to another doctor or qualified health care professional, it will not be
considered to be Mohs surgery.
Pediatric Dermatology
Physicians can qualify for this specialization by completing both a pediatric residency
and a dermatology residency. Or they might elect to complete a post-residency
fellowship. This field encompasses the complex diseases of the neonates, hereditary
skin diseases or genodermatoses, and the many difficulties of working with
the pediatric population.
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Figure 5.4 An Examination of Newly Born Baby
Teledermatology
Teledermatology is a form of dermatology where telecommunication
technologies are used to exchange medical information via all kinds of media (audio,
visual and also data communication, but typically photos of dermatologic conditions)
usually made by non-dermatologists for evaluation off-site by dermatologists). This
subspecialty deals with options to view skin conditions over a large distance to
provide knowledge exchange, to establish second-opinion services for experts or to
use this for follow-up of individuals with chronic skin conditions. Teledermatology
can reduce wait times by allowing dermatologists to treat minor conditions online
while serious conditions requiring immediate care are given priority for appointments.
Dermatoepidemiology
Dermatoepidemiology is the study of skin disease at the population level. One
aspect of dermatoepidemiology is the determination of the global burden of skin
diseases From 1990 to 2013, skin disease constituted approximately 2% of total
global disease disability as measured in disability adjusted life years (DALYS).
Therapies
Therapies provided by dermatologists include, but are not restricted to the
following:
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Excision and treatment of skin cancer
Cryosurgery – for the treatment of warts, skin cancers, and other
dermatitis.
Cosmetic filler injections
Hair removal with laser or other modalities
Hair transplantation – a cosmetic procedure practiced by many
dermatologists.
Intralesional treatment – with steroid or chemotherapy.
Laser therapy – for both the management of birth marks, skin disorders
(like vitiligo), tattoo removal, and cosmetic resurfacing and rejuvenation.
Chemical peels for the treatment of acne, melasma, and sun
damage.
Photodynamic therapy – for the treatment of skin cancer and
precancerous growths.
Phototherapy – including the use of narrowband UVB, broadband
UVB, psoralen and UVB.
Tattoo removal with laser.
Tumescent liposuction – liposuction was invented by a gynecologist. A
dermatologist (Dr. Jeffrey A. Klein) adapted the procedure to local infusion of
dilute anesthetic called tumescent liposuction. This method is now widely
practiced by dermatologists, plastic surgeons and gynecologists.
Radiation therapy – although rarely practiced by dermatologists, many
dermatologist continue to provide radiation therapy in their office.
Vitiligo surgery – Including procedures like autologous melanocyte
transplant, suction blister grafting and punch grafting.
Allergy testing – ‘Patch testing’ for contact dermatitis.
Systemic therapies – including antibiotics, immunomodulators, and
novel injectable products.
Topical therapies – dermatologists have the best understanding of the
numerous products and compounds used topically in medicine.
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5.3.4 Endocrinology
Endocrinology (from endocrine +-ology) is a branch of biology and medicine
dealing with the endocrine system, its diseases, and its specific secretions known
as hormones. It is also concerned with the integration of developmental events
proliferation, growth, and differentiation, and the psychological or behavioral activities
of metabolism, growth and development, tissue function, sleep, digestion,
respiration, excretion, mood, stress, lactation, movement, reproduction and sensory
perception caused by hormones. Specializations include behavioral endocrinology.
The endocrine system consists of several glands, all in different parts of the
body, that secrete hormones directly into the blood rather than into a duct system.
Therefore, endocrine glands are regarded as ductless glands. Hormones have many
different functions and modes of action; one hormone may have several effects on
different target organs, and, conversely, one target organ may be affected by more
than one hormone.
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Endocrine System
Endocrinology is the study of the endocrine system in the human body. This is
a system of glands which secrete hormones. Hormones are chemicals which affect
the actions of different organ systems in the body. Examples include thyroid
hormone, growth hormone, and insulin. The endocrine system involves a number of
feedback mechanisms, so that often one hormone (such as thyroid stimulating
hormone) will control the action or release of another secondary hormone (such
as thyroid hormone). If there is too much of the secondary hormone, it may provide
negative feedback to the primary hormone, maintaining homeostasis.
In the original 1902 definition by Bayliss and Starling (see below), they specified
that, to be classified as a hormone, a chemical must be produced by an organ, be
released (in small amounts) into the blood, and be transported by the blood to a
distant organ to exert its specific function. This definition holds for most “classical”
hormones, but there are also paracrine mechanisms (chemical communication
between cells within a tissue or organ), autocrine signals (a chemical that acts on
the same cell), and intracrine signals (a chemical that acts within the same
cell). A neuroendocrine signal is a “classical” hormone that is released into the blood
by a neurosecretory neuron (see article on neuroendocrinology).
Hormones
Griffin and Ojeda identify three different classes of hormones based on their
chemical composition:
Amines
Amines, such as norepinephrine, epinephrine, and dopamine (catecholamines),
are derived from single amino acids, in this case tyrosine. Thyroid hormones such
as triiodothyronine (T3) and tetraiodothyronine (thyroxin, T4) make up a subset of
this class because they derive from the combination of two iodinated tyrosine amino
acid residues.
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Figure 5.6 Examples of Amine Harmones
Peptide and protein

Peptide hormones and protein hormones consist of three (in the case
of thyrotropin-releasing hormone) to more than 200 (in the case of follicle-stimulating
hormone) amino acid residues and can have a molecular mass as large as 31,000
grams per mole. All hormones secreted by the pituitary gland are peptide hormones,
as are leptin from adipocytes, ghrelin from the stomach, and insulin from
the pancreas.
Figure 5.7 Peptide Harmones

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Steroid
Steroid hormones are converted from their parent compound, cholesterol.
Mammalian steroid hormones can be grouped into five groups by the receptors
to which they bind: glucocorticoids, mineralocorticoids, androgens, estrogens,
and progestogens. Some forms of vitamin D, such as calcitriol, are steroid-like and
bind to homologous receptors, but lack the characteristic fused ring structure of true
steroids.
5.3.5 Gastroenterology
Gastroenterology is the branch of medicine focused on the digestive system and
its disorders. Diseases affecting the gastrointestinal tract, which include the organs
from mouth into anus, along the alimentary canal, are the focus of this specialty.
Physicians practicing in this field are called gastroenterologists.
They have usually completed about eight years of pre-medical and medical
education, a year-long internship (if this is not a part of the residency), three years
of an internal medicine residency, and two to three years in the gastroenterology
fellowship. Gastroenterologists perform a number of diagnostic and therapeutic
procedures including colonoscopy, endoscopy, endoscopic retrograde
cholangiopancreatography (ERCP), endoscopic ultrasound and liver biopsy.
Hepatology, or hepatobiliary medicine, encompasses the study of

the liver, pancreas, and biliary tree, while proctology encompasses the fields of anus
and rectum diseases. They are traditionally considered sub-specialties of
gastroenterology.
Disease Classification
1. International Classification of Disease (ICD 2007)/WHO classification:
Diseases of the digestive system
2. MeSH subject Heading:
Gastroenterology (G02.403.776.409.405)
Gastroenterological diseases (C06.405)
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3. National Library of Medicine Catalogue (NLM classification 2006) :
Digestive system (W1)
5.3.6 Nephrology
Nephrology is a specialty of medicine and pediatrics that concerns itself with
the kidneys: the study of normal kidney function and kidney disease, the preservation
of kidney health, and the treatment of kidney disease, from diet and medication
to renal replacement therapy. Nephrology also studies systemic conditions that affect
the kidneys, such as diabetes and autoimmune disease; and systemic diseases that
occur as a result of kidney disease, such as renal osteodystrophy and hypertension.
A physician who has undertaken additional training and become certified in

nephrology is called a nephrologist. Nephrology concerns the diagnosis and treatment
of kidney diseases, including electrolyte disturbances and hypertension, and the care
of those requiring renal replacement therapy, including dialysis and renal
transplant patients. Many diseases affecting the kidney are systemic disorders not
limited to the organ itself, and may require special treatment. Examples include
acquired conditions such as systemic vasculitides (e.g. ANCA vasculitis)
and autoimmune diseases (e.g., lupus), as well as congenital or genetic conditions
such as polycystic kidney disease.
Patients are referred to nephrology specialists after a urinalysis, for various

reasons, such as acute kidney failure, chronic kidney disease, hematuria,
proteinuria, kidney stones, hypertension, and disorders of acid/base or electrolytes.
Nephrologist
A nephrologist is a physician who specializes in the care and treatment of kidney
disease. Nephrology requires additional training to become an expert with advanced
skills. Nephrologists may provide care to people without kidney problems and may
work in general/internal medicine, transplant medicine, immunosuppression
management, intensive care medicine, clinical pharmacology, perioperative medicine
or pediatric nephrology.
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Nephrologists may further sub-specialise in dialysis, kidney
transplantation, chronic kidney disease, cancer-related kidney diseases
(Onconephrology), procedural nephrology or other non-nephrology areas as
described above.
Procedures a nephrologist may perf orm include native kidney and

transplant kidney biopsy, dialysis access insertion (temporary vascular access lines,
tunnelled vascular access lines, peritoneal dialysis access lines), fistula management
(angiographic or surgical fistulogram and plasty), and bone biopsy.
Diagnosis
History and physical examination are central to the diagnostic workup in
nephrology. The history typically includes the present illness, family history, general
medical history, diet, medication use, drug use and occupation. The physical
examination typically includes an assessment of volume state, blood pressure, heart,
lungs, peripheral arteries, joints, abdomen and flank.
Examination of the urine (urinalysis) allows a direct assessment for possible

kidney problems, which may be suggested by appearance of blood in the urine
(haematuria), protein in the urine (proteinuria), pus cells in the urine (pyuria) or
cancer cells in the urine. A 24-hour urine collection can be used to quantify daily
protein loss (see proteinuria), urine output, creatinine clearance or electrolyte
handling by the renal tubules.
Basic blood tests can be used to check the concentration of hemoglobin,

platelets, sodium, potassium, chloride, bicarbonate, urea, creatinine, calcium,
magnesium or phosphate in the blood. All of these may be affected by kidney
problems. The serum creatinine concentration can be used to estimate the function
of the kidney, called the creatinine clearance or estimated glomerular filtration
rate (GFR). More specialized tests can be ordered to discover or link certain systemic
diseases to kidney failure such as infections (hepatitis B, hepatitis C), autoimmune
conditions (systemic lupus erythematosus, ANCA vasculitis), paraproteinemias
(amyloidosis, multiple myeloma) and metabolic diseases (diabetes, cystinosis).
Structural abnormalities of the kidneys are identified with imaging tests. These
may include Medical ultrasonography/ultrasound, computed axial tomography
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(CT), scintigraphy (nuclear medicine), angiography or magnetic resonance imaging
(MRI).
In certain circumstances, less invasive testing may not provide a certain

diagnosis. Where definitive diagnosis is required, a biopsy of the kidney (renal biopsy)
may be performed. This typically involves the insertion, under local anaesthetic and
ultrasound or CT guidance, of a core biopsy needle into the kidney to obtain a small
sample of kidney tissue. The kidney tissue is then examined under a microscope,
allowing direct visualization of the changes occurring within the kidney. Additionally,
the pathology may also stage a problem affecting the kidney, allowing some degree
of prognostication. In some circumstances, kidney biopsy will also be used to monitor
response to treatment and identify early relapse.
Treatment
Treatments in nephrology can include medications, blood products, surgical
interventions (urology, vascular or surgical procedures), renal replacement
therapy (dialysis or kidney transplantation) and plasma exchange. Kidney problems
can have significant impact on quality and length of life, and so psychological support,
health education and advanced care planning play key roles in nephrology.
Chronic kidney disease is typically managed with treatment of causative

conditions (such as diabetes), avoidance of substances toxic to the kidneys
(nephrotoxins like radiologic contrast and non-steroidal anti-inflammatory
drugs), antihypertensives, diet and weight modification and planning for end-stage
kidney failure. Impaired kidney function has systemic effects on the body.
An erythropoetin stimulating agent may be required to ensure adequate production
of red blood cells, activated vitamin D supplements and phosphate binders may be
required to counteract the effects of kidney failure on bone metabolism, and blood
volume and electrolyte disturbance may need correction.
Auto-immune and inflammatory kidney disease, such as vasculitis or transplant

rejection, may be treated with immunosuppression. Commonly used agents
are prednisone, mycophenolate, cyclophosphamide, ciclosporin, tacrolimus, everolimus,
thymoglobulin and sirolimus. Newer, so-called “biologic drugs” or monoclonal
antibodies, are also used in these conditions and include rituximab,
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basiliximab and eculizumab. Blood products including intravenous immunoglobulin
and a process known as plasma exchange can also be employed.
When the kidneys are no longer able to sustain the demands of the body, end-
stage kidney failure is said to have occurred. Without renal replacement therapy,
death from kidney failure will eventually result. Dialysis is an artificial method of
replacing some kidney function to prolong life. Renal transplantation replaces kidney
function by inserting into the body a healthier kidney from an organ donor and
inducing immunologic tolerance of that organ with immunosuppression. At
present, renal transplantation is the most effective treatment for end-stage kidney
failure although its worldwide availability is limited by lack of availability of donor
organs.
Most kidney conditions are chronic conditions and so long term followup with a
nephrologist is usually necessary.
5.3.7 Neurology
Neurology is a branch of medicine dealing with disorders of the nervous system.
Neurology deals with the diagnosis and treatment of all categories of conditions and
disease involving the central and peripheral nervous systems (and their subdivisions,
the autonomic and somatic nervous systems), including their coverings, blood
vessels, and all effector tissue, such as muscle. Neurological practice relies heavily
on the field of neuroscience, the scientific study of the nervous system.
A neurologist is a physician specializing in neurology and trained to investigate,

or diagnose and treat neurological disorders. Neurologists may also be involved
in clinical research, clinical trials, and basic or translational research. While neurology
is a nonsurgical specialty, its corresponding surgical specialty is neurosurgery.
5.3.8 Oncology
Oncology is a branch of medicine that deals with the prevention, diagnosis,
and treatment of cancer. A medical professional who practices oncology is
an oncologist. Cancer survival has improved due to three main components including
improved prevention efforts to reduce exposure to risk factors (e.g., tobacco
smoking and alcohol consumption), improved screening of several cancers (allowing
for earlier diagnosis), and improvements in treatment.
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Cancers are often managed through discussion on multi-disciplinary cancer
conferences where medical oncologists, surgical oncologists, radiation oncologists,
pathologists, radiologists, and organ specific oncologists meet to find the best possible
management for an individual patient considering the physical, social, psychological,
emotional, and financial status of the patient. It is very important for oncologists to
keep updated with respect to the latest advancements in oncology, as changes in
management of cancer are quite common.
Risk factors
Tobacco
The leading cause of cancer, and death from cancer. Smoking is associated
with increased risk of cancers of the lung, larynx, mouth, oesophagus, throat,
bladder, kidney, liver, stomach,pancreas, colon, rectum, cervix and acute myeloid
leukemia. Smokeless tobacco (snuff or chewing tobacco) is associated with increased
risks of cancers of the mouth, oesophagus, and pancreas.
Alcohol
Can increase risk of cancer of the mouth, throat, oesophagus, larynx, liver, and
breast. The risk of cancer is much higher for those who drink alcohol and also use
tobacco.
Obesity
Obese individuals have an increased risk of cancer of the breast, colon,
rectum, endometrium, oesophagus, kidney, pancreas, and gallbladder.
Age
Advanced age is a risk factor for many cancers. The median age of cancer
diagnosis is 66 years.
5.3.9 Orthopedics
Orthopedics is a medical specialty that focuses on the diagnosis, correction,
prevention, and treatment of patients with skeletal deformities - disorders of the
bones, joints, muscles, ligaments, tendons, nerves and skin. These elements make
up the musculoskeletal system.
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Your body’s musculoskeletal system is a complex system of bones, joints,
ligaments, tendons, muscles and nerves and allows you to move, work and be active.
Once devoted to the care of children with spine and limb deformities, orthopedics
now cares for patients of all ages, from newborns with clubfeet, to young athletes
requiring arthroscopic surgery, to older people with arthritis. The physicians who
specialize in this area are called orthopedic surgeons or orthopedists.
Role of the Orthopedist

Orthopedists use medical, physical and rehabilitative methods as well as surgery
and are involved in all aspects of heath care pertaining to the musculoskeletal system.
It is a specialty of incredible breadth and variety. Orthopedists treat a immense variety
of diseases and conditions, including fractures and dislocations, torn ligaments,
sprains and strains tendon injuries, pulled muscles and bursitis ruptured disks,
sciatica, low back pain, and scoliosis knock knees, bow legs, bunions and hammer
toes, arthritis and osteoporosis, bone tumors, muscular dystrophy and cerebral palsy,
club foot and unequal leg length abnormalities of the fingers and toes, and growth
abnormalities.
Figure 5.8 Orthopedist

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In general, orthopedists are skilled in the:
Diagnosis of your injury or disorder
Treatment with medication, exercise, surgery or other treatment
plans
Rehabilitation by recommending exercises or physical therapy to
restore movement, strength and function
Prevention with information and treatment plans to prevent injury or
slow the progression of diseases
Typically, as much as 50 percent of the orthopedist’s practice is devoted to
non-surgical or medical management of injuries or disease and 50 percent to surgical
management. Surgery may be needed to restore function lost as a result of injury or
disease of bones, joint, muscles, tendons, ligaments, nerves or skin.
The orthopedist also works closely with other health care professionals and
often serves as a consultant to other physicians. Orthopedists are members of the
teams that manage complex, multi-system trauma, and often play an important role
in the organization and delivery of emergency care.
5.3.10 Plastic Surgery

Plastic surgery is a surgical specialty involving the restoration, reconstruction,
or alteration of the human body. It can be divided into two categories. The first is
reconstructive surgery which includes craniofacial surgery, hand surgery,
microsurgery, and the treatment of burns. The other is cosmetic or aesthetic surgery.
While reconstructive surgery aims to reconstruct a part of the body or improve its
functioning, cosmetic surgery aims at improving the appearance of it. Both of these
techniques are used throughout the world.
Sub-specialties
Plastic surgery is a broad field, and may be subdivided further. In the United
States, plastic surgeons are board certified by American Board of Plastic Surgery.
Sub disciplines of plastic surgery may include:
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Aesthetic surgery
Aesthetic surgery is an essential component of plastic surgery and includes
facial and body aesthetic surgery. Plastic surgeons use cosmetic surgical principles
in all reconstructive surgical procedures as well as isolated operations to improve
overall appearance.
Burn surgery
Burn surgery generally takes place in two phases. Acute burn surgery is the
treatment immediately after a burn. Reconstructive burn surgery takes place after
the burn wounds have healed.
Craniofacial surgery
Craniofacial surgery is divided into pediatric and adult craniofacial surgery.
Pediatric craniofacial surgery mostly revolves around the treatment of congenital
anomalies of the craniofacial skeleton and soft tissues, such as cleft lip and palate,
craniosynostosis, and pediatric fractures. Adult craniofacial surgery deals mostly
with fractures and secondary surgeries (such as orbital reconstruction) along with
orthognathic surgery. Craniofacial surgery is an important part of all plastic surgery
training programs, further training and subspecialisation is obtained via a craniofacial
fellowship. Craniofacial surgery is also practiced by Maxillo-Facial surgeons.
Hand surgery
Hand surgery is concerned with acute injuries and chronic diseases of the hand
and wrist, correction of congenital malformations of the upper extremities, and
peripheral nerve problems (such as brachial plexus injuries or carpal tunnel
syndrome). Hand surgery is an important part of training in plastic surgery, as well
as microsurgery, which is necessary to replant an amputated extremity. The hand
surgery field is also practiced by orthopedic surgeons and general surgeons. Scar
tissue formation after surgery can be problematic on the delicate hand, causing loss
of dexterity and digit function if severe enough. There have been cases of surgery to
women’s hands in order to correct perceived flaws to create the perfect engagement
ring photo.
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Microsurgery
Microsurgery is generally concerned with the reconstruction of missing tissues
by transferring a piece of tissue to the reconstruction site and reconnecting blood
vessels. Popular subspecialty areas are breast reconstruction, head and neck
reconstruction, hand surgery/replantation, and brachial plexus surgery.
Pediatric plastic surgery

Children often face medical issues very different from the experiences of an
adult patient. Many birth defects or syndromes present at birth are best treated in
childhood, and pediatric plastic surgeons specialize in treating these conditions in
children. Conditions commonly treated by pediat ric plastic surgeons
include craniofacial anomalies, Syndactyly (webbing of the fingers and toes),
Polydactyly (excess fingers and toes at birth), cleft lip and palate, and congenital
hand deformities.
Techniques and procedures

In plastic surgery, the transfer of skin tissue (skin grafting) is a very common
procedure. Skin grafts can be derived from the recipient or donors:
Autografts are taken from the recipient. If absent or deficient of natural

tissue, alternatives can be cultured sheets of epithelial cells in vitro or synthetic
compounds, such as integra, which consists of silicone and bovine tendon
collagen with glycosaminoglycans.
Allografts are taken from a donor of the same species.
Xenografts are taken from a donor of a different species.
Usually, good results would be expected from plastic surgery that emphasize
careful planning of incisions so that they fall within the line of natural skin folds or
lines, appropriate choice of wound closure, use of best available suture materials,
and early removal of exposed sutures so that the wound is held closed by buried
sutures.
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Reconstructive surgery
Reconstructive plastic surgery is performed to correct functional impairments
caused by burns; traumatic injuries, such as facial bone fractures and breaks;
congenital abnormalities, such as cleft palates or cleft lips; developmental
abnormalities; infection and disease; and cancer or tumors. Reconstructive plastic
surgery is usually performed to improve function, but it may be done to approximate
a normal appearance.
The most common reconstructive procedures are tumor removal, laceration

repair, scar repair, hand surgery, and breast reduction plasty. According to the
American Society of Plastic Surgeons, the number of reconstructive breast reductions
for women increased in 2007 by 2 percent from the year before. Breast reduction in
men also increased in 2007 by 7 percent. In 2012, there were 68,416 performed.
Some other co mmon reconstructive surgical procedures include breast
reconstruction after a mastectomy for the treatment of cancer, cleft lip and palate
surgery, contracture surgery for burn survivors, and creating a new outer ear when
one is congenitally absent.
Plastic surgeons use microsurgery to transfer tissue for coverage of a defect

when no local tissue is available. Free flaps of skin, muscle, bone, fat, or a
combination may be removed from the body, moved to another site on the body, and
reconnected to a blood supply by suturing arteries and veins as small as 1 to 2
millimeters in diameter.
5.3.11 Urology
Urology also known as genitourinary surgery, is the branch of medicine that
focuses on surgical and medical diseases of the male and female urinary-tract system
and the male reproductive organs. Organs under the domain of urology include
the kidneys, adrenal glands, ureters, urinary bladder, urethra, and the male
reproductive organs (testes, epididymis, vas deferens, seminal vesicles, prostate,
and penis).
The urinary and reproductive tracts are closely linked, and disorders of one
often affect the other. Thus a major spectrum of the conditions managed in urology
exists under the domain of genitourinary disorders. Urology combines the
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management of medical (i.e., non-surgical) conditions, such as urinary-tract
infections and benign prostatic hyperplasia, with the management of surgical
conditions such as bladder or prostate cancer, kidney stones, congenital
abnormalities, traumatic injury, and stress incontinence.
Urological techniques include minimally invasive robotic and laparoscopic

surgery, laser-assisted surgeries, and other scope-guided procedures. Urologists
receive training in open and minimally invasive surgical techniques, employing real-
time ultrasound guidance, fiber-optic endoscopic equipment, and various lasers in
the treatment of multiple benign and malignant conditions. Urology is closely related
to (and urologists often collaborate with the practitioners of) oncology, nephrology,
gynaecology, andrology, pediatric surgery, colorectal surgery, gastroenterology and
endocrinology.
Urology is one of the most competitive and highly sought surgical specialties
for physicians, with new urologists comprising less than 1.5% of United States
medical-school graduates each year.
Urologic surgeons, or urologists, undergo a post-graduate surgical training

period for a minimum of five years, of which 12 months must be completed in general
surgery and 36 months must be completed in clinical urology. The remaining 12
months are spent in general surgery, urology, or other clinical disciplines relevant to
urology.
Endourology
Endourology deals with the closed manipulation of the urinary tract. The field
has grown to now include minimally invasive surgical procedures. Procedures are
carried out using endoscopes inserted into the urinary tract and examples include
prostate surgery, stone removal surgery and simple urethral or ureteral surgeries.
Urologic Oncology
This deals with genitourinary malignancies such as cancers of the kidney,
adrenal glands, prostate, bladder, ureters, testicles or penis.
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Neurology
Neurology concerns the management of conditions that involve the nervous
control of the genitourinary system or abnormal urination. Examples of neurological
conditions that may lead to these conditions include Parkinson’s disease, multiple
sclerosis, stroke and spinal cord injuries.
Pediatric urology
This involves the correction of genitourinary problems arising in children such
as undescended testes or cryporchidism, underdeveloped genitalia and vesicoureteral
reflux.
Figure 5.9 Pediatries

Andrology
Andrology focuses on disorders of the male reproductive system such as erectile
dysfunction, ejaculatory disorders, infertility and vasectomy reversal.
5.3.12 Obstetrics
Obstetrics is the field of study concentrated on pregnancy, childbirth, and
the postpartum period. As a medical specialty, obstetrics is combined
with gynecology under the discipline known as obstetrics and gynecology (OB/GYN)
which is a surgical field.
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Figure 5.10 Obstetrics
Functions of an obstetrician
Gynecologists and obstetricians both deal with the wellbeing of females
and obstetricians especially deal with pregnant mothers. The procedures and
functions that they perform include:-
Normal delivery and performing essential assisting steps. Obstetricians
are responsible for working in collaboration with midwives to monitor and assist
normal delivery in a woman during labour.
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Their functions include facilitating delivery by performing episiotomy
that involves placing strategic cuts over the perineum of the pregnant mother
to enlarge the birth canal.
Sometimes prolonged labour might require assistance to speed up the
process in order to reduce maternal fatigue and fetal distress (rising heart
rate and possible brain damage to the baby). This uses techniques like forceps
delivery and vacuum assisted delivery.
Caesarean (or C) section that requires surgical removal of the baby
from the mother’s womb to reduce the complications that arise during labour.
These complications in turn may cause death or damage to the newborn unless
delivery is expedited with C section.
Diagnosis and treatment of ectopic pregnancy. Ectopic pregnancy
occurs when the fertilized ovum gets implanted in any place other than the
womb. Commonly it gets implanted in the fallopian tubes.
5.3.13 Gynecology
Gynaecology or gynecology is the medical practice dealing with the health of
the female reproductive systems (vagina, uterus, and ovaries) and the breasts.
Outside medicine, the term means “the science of women”. Its counterpart
is andrology, which deals with medical issues specific to the male reproductive
system.
Therapies
As with all surgical specialties, gynaecologists may employ medical or surgical
therapies (or many times, both), depending on the exact nature of the problem that
they are treating. Pre- and post-operative medical management will often employ
many standard drug therapies, such as antibiotics, diuretics, antihypertensives,
and antiem etics. Additiona lly, gynaecologists make f requent use of
specialized hormone-modulating therapies (such as Clomifene citrate and hormonal
contraception) to treat disorders of the female genital tract that are responsive
to pituitary or gonadal signals.
Surgery, however, is the mainstay of gynaecological therapy. For historical and

political reasons, gynaecologists were previously not considered “surgeons”, although
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this point has always been the source of some controversy. Modern advancements
in both general surgery and gynaecology, however, have blurred many of the once
rigid lines of distinction. The rise of sub-specialties within gynaecology which are
primarily surgical in nature (for example urogynaecology and gynaecological
oncology) have strengthened the reputations of gynaecologists as surgical
practitioners, and many surgeons and surgical societies have come to view
gynaecologists as comrades of sorts. As proof of this changing attitude,
gynaecologists are now eligible for fellowship in both the American College of
Surgeons and Royal Colleges of Surgeons, and many newer surgical textbooks
include chapters on (at least basic) gynaecological surgery.
Some of the more common operations that gynaecologists perform include:

Dilation and curettage (removal of the uterine contents for various reasons,
including completing a partial miscarriage and diagnostic sampling for dysfunctional
uterine bleeding refractive to medical therapy)
Hysterectomy (removal of the uterus)
Oophorectomy (removal of the ovaries)
Tubal ligation (a type of permanent sterilization)
Hysteroscopy (inspection of the uterine cavity)
Diagnostic laparoscopy – used to diagnose and treat sources of pelvic and

abdominal pain; perhaps most famously used to provide a definitive diagnosis
of endometriosis.
Exploratory laparotomy – may be used to investigate the level of progression

of benign or malignant disease, or to assess and repair damage to the pelvic organs.
Various surgical treatments for urinary incontinence, including cystoscopy and

sub-urethral slings. Surgical treatment of pelvic organ prolapse, including correction
of cystocele and rectocele.
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Appendectomy – often performed to remove site of painful endometriosis
implantation or prophylactically (against future acute appendicitis) at the time
of hysterectomy or Caesarean section. May also be performed as part of
a staging operation for ovarian cancer.
Cervical Excision Procedures (including cryosurgery) – removal of the surface

of the cervix containing pre-cancerous cells which have been previously identified
on Pap smear.
1._________________is the medical practice dealing with the health of the female
reproductive systems (vagina, uterus, and ovaries) and the breasts.
2._________________focuses on disorders of the male reproductive system such

as erectile dysfunction, ejaculatory disorders, infertility and vasectomy reversal.
5.4 Summary
Physiotherapy clinics are usually operated by physiotherapists and psychology
clinics by clinical psychologists, and so on for each health profession. Some clinics
are operated in-house by employers, government organizations or hospitals and
some clinical services are outsourced to private corporations, specializing in provision
of health services. Gynaecology or gynecology is the medical practice dealing with
the health of the female reproductive systems (vagina, uterus, and ovaries) and the
breasts. Outside medicine, the term means “the science of women”. Its counterpart
is andrology, which deals with medical issues specific to the male reproductive system.
In China, for example, owners of those clinics do not have formal medical
education. Healthcare in India, Russia, China and Africa is provided to vast rural
areas by mobile health clinics or roadside dispensaries, some of which integrate
traditional health practices.
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5.5 Keywords
Medical record number (MRN).
POS place of service
(PHR) Personal Health Record A PHR includes all healthcare information from
all sources, compiled and maintained by the patient.
(OCR) Optical Character Recognition. OCR is recognition of printed or written

characters by a computer.

1. What are the objectives of physical therapy department?
2. Explain the following terms in brief:
Gastroenterology
Endocrinology
Dermatology
Cardiology
Anesthesia
3. A woman was admitted to a maternity unit at 39 weeks with vaginal bleeding.
A midwife mistakenly recorded that she was rhesus positive in her medical record;
consequently, she was not given Anti-D immunoglobulin. The error came to light two
days later when another midwife reviewed the laboratory report in the patient’s notes.
Analyse this case and provide suggestions to maintain accurate medical record.
4. Is a unique patient identifier used in your hospital/country?
_____________________________________________________________
If yes, what is it?
_____________________________________________________________
If no - what should or could be used?

107
_____________________________________________________________
Do you have a problem in your hospital with patient identification?
_____________________________________________________________
What is the main problem?
_____________________________________________________________

1. Gynaecology or gynecology
2. Andrology.

The Medical Record, Volume 62, George Frederick Shrady, Thomas Lathrop
Stedman W. Wood., 1902 - Medicine
http://www.wpro.who.int / publications / docs / Medical Records Manual.pdf
Electronic Health Records: A Guide for Clinicians and Administrators, Jerome

H. Carter
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LESSON – 6
RECORD ORGANISATION AND MANAGEMENT
Learning Objectives
Explain Classification of Record

Discuss Indexing and Filing of Records
List out the Disadvantages of Database Management System
Structure
6.1 Introduction
6.2 Classification of Records
6.3 Indexing and Filing of Records
6.4 Types of Database
6.5 Data Warehouse
6.6 Summary
6.7 Keywords
6.1 Introduction
A good medical record serves the interest of the medical practitioner as well as
his patients. It is very important for the treating doctor to properly document the
management of the patient under his care. Medical record keeping has evolved into
a science. The key to dispensability of most of the medical negligence claim rest
with the quality of the medical records. Record maintenance is the only way for the
doctor to prove that the treatment was carried out properly. Medical records are
often the only source of the truth. They are likely to be far more reliable than memory.
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The management and preservation of the hospital records in Indian context
present a very gloomy picture. Despite the intensive effort at national and international
level, the fundamental health care needs of the population of the developing countries
are still unmet. The lack of basic health data renders difficulties in formulating and
applying a rational for the allocation of limited resources that are available for patient
care and disease prevention. It is recommended that more efforts should be made
by the institutions/hospital managements, all clinicians and medical record officer to
improve the standard of maintenance and preservation of medical records. In this
article, we are discussing the various aspects of the medical record management.

activities include the creation, receipt, maintenance, use and disposal of records. In
this context, a record is content that documents a business transaction.
Documentation may exist in contracts, memos, paper files, electronic files, reports,
emails, videos, instant message logs or database records. Paper records may be
stored in physical boxes on-premises or at a storage facility. Digital records may be
stored on storage media in-house or in the cloud.The goal of records management
is to help an organization keep the necessary documentation accessible for both
business operations and compliance audits. In some small to mid-sized businesses,
spreadsheets are used to track where records are stored, but larger organizations
may find records management software suites that are tied to both a taxonomy and
a records retention schedule to be more useful. Such software suites may be
marketed as enterprise information management (EIM) products that are capable of
helping an organization to manage both records and ordinary content.
Objectives of Maintaining Medical Records :

a) Monitoring of the actual patient
b) Medical research
c) Medical/dental or paramedical education
d) For insurance cases, personal injury suits, workmen’s compensation
case, criminal cases, and will cases
e) For malpractice suits
f) For medical audit and statistical studies
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Care While issuing Certain Medical Records :
Prescription
The prescription should be preferably on the OPD slip of the institution or on
the letter pad of the doctor. Drug company or chemist prescription pad should never
be used. Prescription must contain—patient’s name, age, sex, address and institution/
hospital name. Prescribed drug should be preferably in capital letter or else clearly
visible. One should mention its strength (especially in paediatric age group), its dose
frequency, duration in days, and total quantity (number of tablets and capsules).
Below the main drug, also mention other instructions of precautions and what to
avoid. If any investigation is advised, do not forget to mention it on the prescription
slip and call the patient after the investigation. If patient fails to keep follow up date
and if then some complication occurs, then patient is also considered negligent
(contributory negligence)
Reports
All reports i.e. lab investigation, X-ray reports, ultrasound reports, computed
tomography (CT-scan)/magnetic imaging resonance (MRI) reports, and histo-
pathological reports should be issued by a qualified person. Biopsy report should
preferably be issued in duplicate so that the referring doctor/hospital can keep the
original copy. If the pathologist does not give a duplicate copy the referring doctor
should get it xeroxed and should be handed over to the patient.
Referral Notes
Always keep the carbon copy of referral note especially in case of critically ill
patient. Referral note should mention the date and time of writing the note. Also
write the treatment given.
Discharge Card
Consultant in-charge should himself fill or supervise the discharge card.
Condition of the patient on the admission, investigation done, the treatment given
and detail advice on discharge should be written on discharge card. Operation notes
if mentioned have to be correct otherwise just mention the name of the operation
and give separate note in detail if asked for. If any complication is expected after
discharge ask the patient to report immediately. Instructions while discharge must
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be very clear and elaborative. Keep in mind that abbreviations may not be understood
by others. Also do not use code messages, sarcasm or poor opinion to the patient.
Certificates
A medical certificate is defined as a document of written evidence vouching for
the truth of a fact as determined by the doctor issuing such a document. If medical
certificate is admitted in a court of law as evidence and is proved to be false, the
issuing doctor is liable for punishment. While issuing a medical certificate following
things should be kept in mind,
1. Medical certificate should be on institution/doctor letter pad.

2. Date, time, and place should be mentioned.
3. Issue it only for legitimate purpose and only when necessary.
4. It has to be true and clear without any ambiguity.
5. There should be an identification mark of the patient, preferably a thumb
impression.
6. Period of illness should be clearly mentioned.
7. Diagnosis disclosure of the diagnosis should be only after the patient’s
express consent, unless required by the law
8. Doctor should maintain the duplicate copy of every certificate.
9. Ideally records of adult patient are maintained for 3 year.

10. 21 year for neonatal patient (3 + 18 year).
11. For children 18 year of age + 3 year.
12. For mentally retarded patient forever till hospital/institution is working.
13. From income tax point of view for 7 years.
How to Destroy the Records :

1. Public notice of destroying the records in English news paper and in
one vernacular paper mentioning the specific date up to which destruction will
be sought .
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2. Give a time limit of 1 month for taking away records for those who want
the records with written consent
3. After 1 month destroy the records up to date specified except for
following
a. Where litigation is going on.
b. Where future trouble is expected.
c. Mentally ill or retarded patient.
d. Pre-litigation process of notice exchange is going on.
Hard Copy Records :

Computers are now widely used in institution/hospitals for electronic patient
records but still hard copy is required for following documents
1. Consent need to be on hard copy.

2. Referral to doctor need hard copy.
3. Police case need hard copy.
4. Certificate of fitness should be on hard copy.
Records management is the system used to control an organization’s records

from the creation of the record until the record is archived or destroyed. A records
management process is comprised of identifying records, classifying records, and
storing records, as well as coordinating internal and external access. The process
may also incorporate policies and practices on how to create and approve records,
as well as the enforcement of those policies and practices.
Many organizations must deal with large amounts of information on a daily

basis. Productive organizations incorporate a comprehensive, effective records
management process into their daily operations. Before developing a records
management process, an organization must be able to determine what constitutes a
record. Let’s begin by defining an organizational record. An organizational record is
any document that contains information about a transaction, activity, or event related
to the organization.
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The record can be stored on paper or electronically via email, digital file,
database, or spreadsheet. Records also can be photographs, audio files, or videos.
Some examples of record classifications are legal, financial, historical, and daily
operations. An effective records management process contains at least five
components: record creation, internal and external record distribution, record usage,
record maintenance, and record archival and disposal.
Problems of Record Management :
There are many problems faced by institution/hospital for the proper

maintenance of the records.
1. Constant revision of the outdated form is needed .

2. Always trained personnel are needed for the maintenance .
3. Inactive records need storage at appropriate place .
4. There must be a need of determination of record retention .
5. Unwanted records must be destroyed.
6. Record storage entail into 2 stages.
A. Moving the records from active to inactive file and from there to storage
room.
B. Destruction and disposal of the unimportant records.
There are various type of damage which may be found in paper documentation
like-aged paper may become weak, colour alteration from white to yellow, dirt and
dust may be present on the surface, insect and fungus is a big threat for the records,
if paper is kept folded, it may become weak at the crease, dampness and water
leakage in storage room also destroy the paper.
Record Creation
At the beginning of any records management process is the creation of the
record. There are many ways to create business records. Sending or receiving an
email, creating a spreadsheet, database or document, or receiving a document from
outside the organization all create records. And contracts, budgets, bank statements,
policy manuals, and meeting minutes are all things that can be considered records.
It is important to note that every piece of paper or email may not be worth keeping.
It is up to the organization to determine the criteria for record creation.
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Let’s use a policy change document as an example. Say the Human Resources
department makes a change to the vacation policy. They update a digital copy of the
employee handbook and send an email to all employees indicating the change. The
sent email could constitute the creation of a new record.
Record Distribution
Once a record is created, an organization must determine its distribution method.
Should the record be emailed, or printed and physically distributed? For externally
distributed records, will it be emailed or delivered via mail or a delivery service?
In the example of the vacation policy update, the record has been emailed to
all employees. By using an internal, secured email system, the organization can use
‘’read receipts’’ to ensure that all employees received notification of the change.
The organization should have policies in place that determine internal and external
distribution methods.
Record Usage
After a record is created or received, a records management process can assist
in determining how the record should be used. Will the record be used to make a
decision, determine a direction, or in some other way? An organization needs to
have a way to classify records.
6.2 Classification of Records

Records managers use classification or categorization of record types as a
means of working with records.[citation needed] Such classifications assist in
functions such as creation, organization, storage, retrieval, movement, and
destruction of records.
At the highest level of classification are physical versus electronic records.

(This is disputable; records are defined as such regardless of media. ISO 15489
and other best practices promulgate a functions based, rather than media based
classification, because the law defines records as certain kinds of information
regardless of media.)
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Figure 6.1 ER Model Hospital
Physical records are those records, such as paper, that can be touched and
which take up physical space.
Electronic records, also often referred to as digital records, are those records
that are generated with and used by information technology devices.
Classification of records is achieved through the design, maintenance, and

application of taxonomies, which allow records managers to perform functions such
as the categorization, tagging, segmenting, or grouping of records according to
various traits.
Enterprise records
Enterprise records represent those records that are common to most
enterprises, regardless of their function, purpose, or sector. Such records often
revolve around the day-to-day operations of an enterprise and cover areas such as
but not limited litigation, employee management, consultant or contractor
management, customer engagements, purchases, sales, and contracts.
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The types of enterprises that produce and work with such records include but
are not limited to for-profit companies, non-profit companies, and government
agencies.
Industry records
Industry records represent those records that are common and apply only to
a specific industry or set of industries. Examples include but are not limited to medical
industry records (e.g., the Health Insurance Portability and Accountability Act),
pharmaceutical industry records, and food industry records.
Legal Hold Records

Legal hold records are those records that are mandated, usually by legal counsel
or compliance personnel, to be held for a period of time, either by a government or
by an enterprise, and for the purposes of addressing potential issues associated
with compliance audits and litigation. Such records are assigned Legal Hold traits
that are in addition to classifications which are as a result of enterprise or industry
classifications.
Legal hold data traits may include but are not limited to things such as legal
hold flags (e.g. Legal Hold = True or False), the organization driving the legal hold,
descriptions of why records must be legally held, what period of time records must
be held for, and the hold location.
6.3 Indexing And Filing of Records

‘Indexing’ is the process of capturing relevant metadata associated with your
records. Some of the metadata is used to index the records to make retrieval easier;
some of the metadata is used for later management of those records. So capturing
the most appropriate metadata to enable easier retrieval and management is
important.
The process of capturing the metadata can be manual or automatic and the
metadata itself can be captured from information from a variety of sources. For
example, when using standard desktop applications such as Microsoft Office, the
electronic records management (ERM) system may capture useful information about
the document from the ‘document properties’.
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Other sources of metadata are :
the classification scheme for retention information,
the ERM system itself for metadata like the ‘unique record number’
and
the underlying operating system for information such as date and time
of capture.
The actual amount and type of metadata required will be dependent on your
organization’s business needs. Many of your records will be evidence of an important
business activity or transactions, so it is important that you capture relevant metadata
relating to:
the people involved in the activity or transaction

the nature of the activity or transaction itself
the outcome of the activity or transaction
reference to any other important related records
If your organization has not been using an ERM system, it is highly likely that
you and the rest of the people in your organization have not been capturing metadata.
Therefore, asking them to start manually capturing metadata as you move to ERM
will not be popular and could undermine the success of the ERM Project.
Consequently, you will need to restrict the amount of manual metadata capture to
an absolute minimum, ideally no more than one element. Indexing should be as
automated as possible.
A crucial part of the indexing process is to provide an audit trail of what has
happened to a record over its lifecycle. Therefore, as a minimum during the indexing
process, the following metadata should be captured:
the Unique Identifier – this is usually a unique number (or alphanumeric

string) assigned to the record by the ERM system
the date and time of capture of the record
the title of the record
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the author of the record. This may be one person or an organization,
such as a company or a team (sometimes called a “corporate author).
Those of us who have worked in records management have applied labels to

folder and boxes, inventoried file cabinets and drawers and created content listings
of our holdings. All of this represented applying metadata to the records and
information we managed. With an ERM system, we can collect even more metadata
than in the past and get the information from the computer system much more without
burdening the users.
6.4 Types of Database

Centralised Database
The information (data) is stored at a centralized location and the users from
different locations can access this data. This type of database contains application
procedures that help the users to access the data even from a remote location.
Various kinds of authentication procedures are applied for the verification and
validation of end users, likewise, a registration number is provided by the application
procedures which keeps a track and record of data usage. The local area office
handles this thing.
Distributed Database
Just opposite of the centralized database concept, the distributed database
has contributions from the common database as well as the information captured by
local computers also. The data is not at one place and is distributed at various sites
of an organization. These sites are connected to each other with the help of
communication links which helps them to access the distributed data easily. You can
imagine a distributed database as a one in which various portions of a database are
stored in multiple different locations(physical) along with the application procedures
which are replicated and distributed among various points in a network.
There are two kinds of distributed database, viz. homogenous and

heterogeneous. The databases which have same underlying hardware and run over
the same operating systems and application procedures are known as homogeneous
DDB, for eg. All physical locations in a DDB. Whereas, the operating systems,
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underlying hardware as well as application procedures can be different at various

sites of a DDB which is known as heterogeneous DDB.
Personal Database
Data is collected and stored on personal computers which are small and easily
manageable. The data is generally used by the same department of an organization
and is accessed by a small group of people.
End User Database

The end user is usually not concerned about the transaction or operations
done at various levels and is only aware of the product which may be a software or
an application. Therefore, this is a shared database which is specifically designed
for the end user, just like different levels’ managers. Summary of whole information
is collected in this database.
Commercial Database
These are the paid versions of the huge databases designed uniquely for the
users who want to access the information for help. These databases are subject
specific, and one cannot afford to maintain such a huge information. Access to such
databases is provided through commercial links.
Operational Database
Information related to operations of an enterprise is stored inside this database.
Functional lines like marketing, employee relations, customer service etc. require
such kind of databases.
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Figure 6.2 Hospital Management System
Relational Databases
These databases are categorized by a set of tables where data gets fit into a
pre-defined category. The table consists of rows and columns where the column has
an entry for data for a specific category and rows contains instance for that data
defined according to the category. The Structured Query Language (SQL) is the
standard user and application program interface for a relational database. There
are various simple operations that can be applied over the table which makes these
databases easier to extend, join two databases with a common relation and modify
all existing applications.
Centralised database
The information(data) is stored at a centralized location and the users from
different locations can access this data. This type of database contains application
procedures that help the users to access the data even from a remote location.
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Various kinds of authentication procedures are applied for the verification and
validation of end users, likewise, a registration number is provided by the application
procedures which keeps a track and record of data usage. The local area office
handles this thing.
6.5 Data Warehouse

A data warehouse is a federated repository for all the data collected by an
enterprise’s various operational systems. Data warehousing emphasizes the capture
of data from different sources for access and analysis.
Typically, a data warehouse is a relational database housed on an

enterprise mainframe server or, increasingly, in the cloud. Data from various online
transaction processing (OLTP) applications and other sources are selectively
extracted for business intelligence activities, decision support and to answer user
inquiries. Data warehouses are also used for online analytical processing (OLAP).
Basic Components of A Data Warehouse

A data warehouse stores data that is extracted from data stores and external
sources. The data records within the warehouse must contain details to make it
searchable and useful to business users. Taken together, there are three main
components of data warehousing:
1. Data sources from operational systems, such as Excel, ERP, CRM or

financial applications.
2. A data staging area where data is cleaned and ordered.
3. A presentation area where data is warehoused.
These can also be understood as tiers, where the bottom tier is the database
server, the middle tier is the analytics engine and the top tier is data warehouse
software which presents reporting and analysis. Data analysis tools, such as business
intelligence software, access the data within the warehouse. Data warehouses can
also feed data marts, which are decentralized systems in which data from the
warehouse is organized and made available to specific business groups, such as
sales or inventory teams.
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In addition, Hadoop has become an important extension of data warehouses
for many enterprises because the data processing platform can improve components
of the data warehouse architecture — from data ingestion to analytics processing to
data archiving.
Data Warehouse Benefits And Options
Data warehouses can benefit organizations from both an IT and a business

perspective. For example:
Separating the analytical processes from the operational processes c a n

enhance the operational systems and enable business users to access a n d
query relevant data faster from multiple sources.
Data warehouses can offer enhanced data quality and consistency, thereby
improving business intelligence.
Businesses can choose on-premises, the cloud or data-warehouse-as-a-

service.
On-premises data warehouses offer flexibility and security so IT teams

can maintain control over their data warehouse management and configuration;
from IBM, Oracle and Teradata as an example.
Cloud-based data warehouses such as Amazon Redshift, Google

BigQuery, Microsoft Azure SQL Data Warehouse and Snowflake enable
companies to quickly scale while eliminating the initial infrastructure investments
and ongoing maintenance requirements.
Types of Data Warehouses

There are three main approaches to implementing a data warehouse. Some
organizations have also adopted hybrid options.
Top-down approach: Inmon’s method calls for building the data

warehouse first. Data is extracted from operational and possibly third-party
external systems and may be validated in a staging area before being integrated
into a normalized data model. Data marts are created from the data stored in
the data warehouse.
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Bottom-up method: Kimball’s data warehousing architecture calls for
dimensional data marts to be created first. Data is extracted from operational
systems, moved to a staging area and modeled into a star schema design,
with one or more fact tables connected to one or more dimensional tables. The
data is then processed and loaded into data marts, each of which focuses on a
specific business process. Data marts are integrated using a data warehouse
bus architecture to form an enterprise data warehouse.
Hybrid method: Hybrid approaches to data warehouse design include

aspects from both the top-down and bottom-up methods. Organizations often
seek to combine the speed of the bottom-up approach with the integration
achieved in a top-down design.
Uses of Data Ware House :

Airline : In the Airline system, it is used for operation purpose like crew
assignment, analyses of route profitability, frequent flyer program promotions, etc.
Banking : It is widely used in the banking sector to manage the resources
available on desk effectively. Few banks also used for the market research,
performance analysis of the product and operations.
Healthcare : Healthcare sector also used Data warehouse to strategize and
predict outcomes, generate patient’s treatment reports, share data with tie-in
insurance companies, medical aid services, etc.
Public sector : In the public sector, data warehouse is used for intelligence
gathering. It helps government agencies to maintain and analyze tax records, health
policy records, for every individual.
Investment and Insurance sector : In this sector, the warehouses are primarily
used to analyze data patterns, customer trends, and to track market movements.
Retain chain : In retail chains, Data warehouse is widely used for distribution
and marketing. It also helps to track items, customer buying pattern, promotions
and also used for determining pricing policy.
Telecommunication : A data warehouse is used in this sector for product
promotions, sales decisions and to make distribution decisions.
124
Hospitality Industry : This Industry utilizes warehouse services to design as
well as estimate their advertising and promotion campaigns where they want to target
clients based on their feedback and travel patterns.

Fill in the blanks:
1. An _________________ is any document that contains information
about a transaction, activity, or event related to the organization.
2. Condition of the patient on the admission, investigation done, the treatment
given and detail advice on discharge should be written on __________________
6.6 Summary
activities include the creation, receipt, maintenance, use and disposal of records. A
records management process is comprised of identifying records, classifying records,
and storing records, as well as coordinating internal and external access. At the
beginning of any records management process is the creation of the record.
There are many ways to create business records. Sending or receiving an email,
creating a spreadsheet, database or document, or receiving a document from outside
the organization all create records.
Once a record is created, an organization must determine its distribution method.

Should the record be emailed, or printed and physically distributed? For externally
distributed records, will it be emailed or delivered via mail or a delivery service?
After a record is created or received, a records management process can assist in
determining how the record should be used. Will the record be used to make a
decision, determine a direction, or in some other way? An organization needs to
have a way to classify records. Records managers use classification or categorization
of record types as a means of working with records.[citation needed] Such
classifications assist in functions such as creation, organization, storage, retrieval,
movement, and destruction of records. Classification of records is achieved through
the design, maintenance, and application of taxonomies, which allow records
managers to perform functions such as the categorization, tagging, segmenting, or
grouping of records according to various traits.
125
‘Indexing’ is the process of capturing relevant metadata associated with your
records. A data warehousing is defined as a technique for collecting and managing
data from varied sources to provide meaningful business insights. It is a blend of
technologies and components which aids the strategic use of data.
6.7 Keywords
Electronic records
Electronic, or machine-readable records, are records on electronic storage

media (A Glossary for Archivists, Manuscript Curators, and Records Managers,
Society of American Archivists: Chicago, 1992 p. 12). Electronic record, as defined
in NARA regulations (36 CFR 1234.2), means any information that is recorded in a
form that only a computer can process and that satisfies the definition of a Federal
record per the Federal Records Act definition supplied above. Federal electronic
records are not necessarily kept in a “recordkeeping system” but may reside in a
generic electronic information system or are produced by an application such as
word processing or electronic mail.
Metadata
Metadata is a term that describes or specifies characteristics that need to be
known about data in order to build information resources such as electronic
recordkeeping systems and support records creators and users.
Records Management
There are many (similar) definitions of records management. One common
one is “...the field of management responsible for the systematic control of the
creation, maintenance, use and disposition of records.” (A Glossary for Archivists,
Manuscript Curators, and Records Managers, Society of American Archivists:
Chicago, 1992 p. 29.) From the Federal perspective, it is the planning, controlling,
directing, organizing, training, promoting, and other managerial activities involved in
records creation, maintenance and use, and disposition in order to achieve adequate
and proper documentation of the policies and transactions of the Federal Government
(36 CFR 1220.14).
126
Electronic Records Management [ERM]
Electronic records management [ERM] is using automated techniques to
manage records regardless of format. Electronic records management is the broadest
term that refers to electronically managing records on varied formats, be they
electronic, paper, microform, etc. Electronic recordkeeping [ERK] is a subset of ERM,
because ERK focuses on electronically managing electronic records.
Electronic Recordkeeping [ERK]

Electronic recordkeeping [ERK] is the development of automated processes
an agency uses to manage its electronic records. These automated processes support
not only the preservation of an electronic record’s content, but also its context and
structure over time. These first Fast Track documents specifically address ERK
issues.

1) Why record management is important?
2) Explain Classification of Records.
3) Discuss on Indexing and Filing of Records.
4) Classify the types of databases.
5) Explain in data ware house in detail?
6) Sketch about the cause and effect relationship between goals and
indicators of the Medical Records Department.

1. An organizational record
2. discharge card.

Records Management,Judith Read, Mary Lea Ginn
https://www.archives.gov/records-mgmt/initiatives/context-for-erm.html
127
LESSON – 7
PROBLEMS WITH MEDICAL RECORDS
Learning Objectives
Identify standards and policies of medical records.

Discuss legal aspects of medical records.
Describe problems with medical records.
Structure
7.1 Introduction
7.2 Issues with Medical Records
7.3 General Standards and Policies]
7.4 Documentation and Legal Aspects of Medical Records
7.5 Summary
7.6 Keywords
7.1 Introduction
The medical record, or chart, resides at the top of the healthcare food chain as
the ultimate testimony of the care rendered. While initially serving as a communication
tool to aide multidisciplinary healthcare team members, the medical record now has
the dubious task of serving as a key piece of evidence in the growing number of
lawsuits between patients and their healthcare providers.
Litigation due to non healing wounds, unintended weight loss, and malnutrition
has become all too common. Generally, litigation arises from someone’s
dissatisfaction with the level of service or quality of a product. In the healthcare
128
business, that service is often a matter of life and death. In every lawsuit, the medical
record is scrutinized to determine the quality and quantity of care rendered.
Frequently, the patient’s chart does not support the fact that optimal care was
delivered in accordance with accepted standards — illegible, illogical, or incomplete
documentation cannot be defended in a court of law and often leads to out-of-court
settlements, even though the care was perfectly acceptable. Healthcare providers
and their insurers pay out millions of dollars each year because documentation is
subpar.
This is an awful waste of money, especially at a time when reimbursement

rates are stagnant and denied insurance claims abound. In almost every case, the
same sections of the chart are problematic. The most common trouble areas are
presented.
Purpose of the standards

The purpose of these standards is to:
Maximise patient safety and quality of care
Support professional best practice
7.2 Issues with Medical Records

Intake and Output Records
Intake and output records, commonly referred to as I & O’s, are intended to
measure a patient’s fluid balance. Intake refers to all the liquids consumed, either
enterally or intravenously, in a 24-hour period. Output refers mainly to urine output,
although other loses such as excessive sweating or vomiting also are considerations.
Ideally, intake and output are approximately the same or in balance. Excessive gains
or losses may indicate edema or dehydration, both of which require intervention and
additional documentation.
I & O records are notoriously incomplete and illegible. Plaintiff’s attorneys will
ask if it is our (ie, the clinician’s) duty to keep accurate records. The answer is
always a resounding yes. The I& O record then is introduced and the clinician is
asked if it is complete. If the answer is no, there is a gap in care.
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Figure 7.1. Medical Records
Incontinent patients pose a special challenge unless they have a Foley catheter
in place. Simply writing the word incontinent across the entire output section makes
no sense. In this case, only intake is being recorded; if that is the intention, it should
be indicated in the physician’s order. Many of the forms used to record I& Os are not
user-friendly — they feature miniscule boxes, “total” lines that do not coincide with
shift changes, and lack of instructions. Examining the forms and the facility policy
are first steps in correcting this problem.
Wound Documentation
Not every wound is a pressure ulcer. In many charts, all skin integrity problems
are labeled pressure ulcers. Calling every wound a pressure ulcer sets up
expectations for certain interventions, which may not be indicated for other types of
wounds. Arterial ulcers, diabetic ulcers, and venous stasis ulcers are not treated the
same way as pressure ulcers. Another common problem is describing the anatomical
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location of the wound. The words buttocks, sacrum, and coccyx often are used
incorrectly and interchangeably. When staff members use different words to describe
the location of the wound, it causes confusion in the medical record. Other related
problems are inaccurately denoting right and left and being inconsistent in the order
of length, width, and depth when documenting wound measurements.
Silent Charts
Charts in long-term care often will demonstrate extended time gaps with no
entries. For example, notes may be missing in the chart for four consecutive days;
on the fifth day, the patient is noted to have a fever and lethargy. Gaps, or silent
charts, always raise questions in litigation. Was any care rendered in the four days
previous to noticing the patient was ill? Because most lawsuits are brought years
after the fact, it is impossible to recall from memory alone. Without any documentation,
what actually occurred is unknown.
Height and Weight

During the course of an extended illness, a patient may be transferred between
acute and long-term care facilities several times. It is not uncommon to see vastly
different heights and weights reported between various facilities and even within the
same facility. For example, Mr. J was noted to weigh 150 lb on Friday at in his
nursing home. On Saturday, he was transferred to the hospital. After 2 days at the
hospital, Mr. J returned to the nursing facility where the staff documented a re-
admittance weight of 133 lb. Did the patient lose 17 lb in 2 days? Is that even possible?
Weight inconsistencies are so common in charts, some staff members deem it
acceptable to chart “weight appears erroneous.” But what does this say about the
care we are giving if we cannot properly record the body weight? Imagine the family’s
attorney explaining to the judge, “The people working at this facility could not even
weigh Mr. J properly, so how were they able to manage his diabetes, hypertension,
and advanced dementia?”
Meal Intake Records

Most healthcare facilities have adopted a system of recording meal consumption
for each meal on a flow sheet using terms such as excellent, good, fair, poor, or
refused meal. Consider a typical month in long-term care. The chart should contain
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90 entries (30 days with three meals per day). Most charts have several boxes left
blank. Does a blank mean the patient did not receive a meal? Usually not. But some
testimonies have stated that “based on the meal consumption records, the patient
only received 80 out of 90 meals this month.” In other words, it can be made to
appear that the patient did not receive a meal because the box is not filled in. In
other instances, it is obvious that the entire flow sheet was filled out at one time with
the same pen, the same intake amounts every day, and in the same handwriting. In
the trade, this process is known as dry-labbing; it is a form of cheating. Keep in mind
that time sheets often are subpoenaed and that the initials of the employee on the
flow sheet can easily be correlated with the days that employee was scheduled to
work. Often, even boxes corresponding to days the patient was not in the facility are
filled in. It is quite embarrassing to be asked why Monday and Tuesday are all filled
in when the patient was discharged the prior Sunday.
Communication Issues
The medical record had signed standard consent forms but minimal narrative
notes. Clearly, this was a life-altering miscommunication. Listening and hearing are
two very different acts; healthcare providers need to ensure their patients hear them
and can repeat back what was said. A related issue is the desire not to be the bearer
of bad news. In American culture, we shy away from discussing death and this attitude
may even permeate healthcare. Speaking frankly with patients requires finesse.
Practice and simulations may help improve communication and avoid subsequent
problems.
Incomplete Assessments
Three-page-long nursing admitting assessment forms with entire sections left

blank are not unusual. Blank sections on forms always raise questions. Was the
nurse supposed to complete that part and just forgot? Was the information
unavailable? When a clinician is questioned about missing information during
depositions, a typical reply involves explaining that the section in question is never
completed. The information is collected somewhere else in the chart and clinicians
“just don’t do that part of the form.” Forms that do not match current policies should
be redesigned to avoid confusion.
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Calorie Counts
A calorie count often is ordered when a patient is losing weight or not eating
adequate amounts of food. The typical order requires that 3 days of meals be recorded
and the number of calories and grams of protein consumed each day documented
in the medical record. Communication is of utmost importance because serving the
meal, removing the used tray, recording what was consumed, and performing the
nutritional calculations are likely to be done by three or four different staff members.
The reality is that unless a system is in place, meal trays often go to the dish room
without being recorded; thus, the calorie count is incomplete. This creates a gap in
care because the clinician is duty-bound to follow to physician orders. Policies on
calorie count procedures should be reviewed with staff to avoid any problems.
7.3 General Standards And Policies

To establish guidelines for the contents, maintenance, and confidentiality of
patient medical records that meet the requirements set forth in Federal and State
laws and regulations, and to define the portion of an individual’s healthcare
information, whether in paper or electronic format, that comprises the medical record.
Patient medical information is contained within multiple electronic records systems
in combination with financial and other types of data. This policy defines requirements
for those components of information that comprise a patient’s complete “Medical
Record.”
Key recommendations
The patient’s complete medical record should be available at all times
during their stay in hospital.
Every page in the medical record should include the patient’s name,
identification number (NHS number) and location in the hospital.
Ø The contents of the medical record should have a standardised structure

and layout.
Ø Documentation within the medical record should reflect the continuum of

patient care and should be viewable in chronological order.
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Ø Data recorded or communicated on admission, handover and discharge
should be recorded using a standardized proforma.
Ø Every entry in the medical record should be dated, timed (24 hour clock),
legible and signed by the person making the entry. The name and designation
of the person making the entry should be legibly printed against their signature.
Deletions and alterations should be countersigned, dated and timed.
Ø Entries to the medical record should be made as soon as possible after

the event to be documented (e.g. change in clinical state, ward round,
investigation) and before the relevant staff member goes off duty. If there is a
delay, the time of the event and the delay should be recorded.
Ø Every entry in medical record should identify the most senior healthcare
professional present (who is responsible for decision making) at the time the
entry is made.
Ø On each occasion the consultant responsible for the patient’s care changes,
the name of the new responsible consultant and the date and time of the agreed
transfer of care, should be recorded.
Ø An entry should be made in the medical record whenever a patient is seen

by a doctor. When there is no entry in the hospital record for more than four
days for acute medical care or seven days for long-stay continuing care, the
next entry should explain why.
Ø The discharge record/discharge summary should be commenced at the

time a patient is admitted to hospital.
Ø Advanced Decisions to Refuse Treatment, Consent, Cardio-Pulmonary

Resuscitation decisions must be clearly recorded in the medical record. In
circumstances where the patient is not the decision maker, that person should
be identified e.g. Lasting Power of Attorney.
7.4 Documentation and Legal Aspect of Medical Records

Every medical record reveals patient-centered information. The patient is the
recipient of the medical care, which is offered to him by a team, which usually consists
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of the doctor, the nurse and the paramedical worker. All activities by the team are for
the benefit of the patient and this is recorded, thus making the existence of the
hospital medical record possible. With the advancement in medical knowledge and
the complexity of modern medical and surgical treatment, an accurate and adequate
medical record is essential as a documented reference of the patients treatment,
while in the hospital.
The hospital compiles and keeps medical records for the benefit of the patient,
as well as the protection of the hospital and physician. However, the personal data
contained therein, considered confidential, is a property of interest of the patient. In
addition to being kept for the benefit of the patient, medical records are also kept as
a guide to consultants, for the education of undergraduates and postgraduates, for
the training of nurses, for medical statistics research, and for the protection of the
physician, hospital staff and hospital against unjust criticism.
Ownership and Records :

The medical record, although kept for the benefit of the patient, the physician,
of the hospital, is the property of the hospital. Therefore, the hospital, may restrict
the removal of the record from the medical record files or hospital premises. Moreover
it may determine who may have access to it (except when a court order directs that
a record be produced). But the patient or those who represent the patient may also
have right to see the information if they can show good cause.
In a nutshell, both the legal and moral responsibilities of the hospital require
adequate safeguard to present unauthorised persons from gaining access to a
patients medical record. Security begins at the time the record in initiated and extends
throughout the patients hospitalization and also after his discharge.
Confidentiality :
It is a universally accepted notion that the information found in medical records
is confidential. But when analyzing the concept of confidentiality, it will be found that
there are number of questions arising such as: to whom is the record confidential &
under what circumstances is it confidential?
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Information in the medical record in basically of two types.
Identification Data :
It consists of entries in the record which do not specifically relate to the patient
care or treatment in the hospital. E.g., name, sex , age, etc. These items are often
found in the admission record or face sheet of the health record and are generally
not considered to be confidential information. This means that upon receipt of a
legitimate request, it is generally acceptable to release the information without the
patients permission.
Clinical data :
This includes all items entered in the medical record relating to the patients
diagnosis and treatment. E.g.: reports generated by physicians, nurses, allied health
personnel and results of tests will fall under him category. Clinical information in
medical records in confidential because it is held that the relationship between patient
and physician is special and that their communication should be protected from
disclosure.
Patient Access :
The patient and those who represent the patient and those who have
authorization from the patient with a legitimate reason may see his record. The
patient has the following rights:
To get considerate and respectful treatment from all staff in the hospital (from
consultant to cleaner) and to receive safe care at all times.
To obtain from his or her physician complete, current information concerning

his diagnosis, treatment and prognosis in terms that the patient can reasonably
understand.
To receive necessary information for informed consent from his or her physician
prior to the start of any procedure or treatment.
To have every consideration of privacy concerning his or her own medical care
program.
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To expect that all communications and records pertaining to his or her care
should be treated as confidential.
Whom to release information?
The major consideration bearing upon disclosure should be the nature of the
information requested and the person or agencies requesting the information.
Majority of the request will come from :

The provider and the relatives.
The member of the medical staff, other physicians and hospitals concerned
with the care of patients.
The third party payers, government and other agencies.
In these cases the confidential information may be released with appropriate

authorization. The consent generally may be given by the patient himself or by legally
qualified representatives. Such as the parent of a minor, the spouse, the guardian of
an infant or an agency designated by the court as guardian. The consent of the
patient is not required when a subpoena or an order of a court directs that records
be produced.
Without the consent of the patient, the hospital may allow physicians to consult
its medical records for purposes of study, statistical evaluation, research and
education. If the records are requested for such purposes by persons other than the
hospitals staff or an affiliated organization it is wise to obtain the approval of the
administrator or of the medical record committee.
The hospital shall not disclose to an insurance company any patient identifiable
medical record information maintained by the hospital unless the request in
accompanied by the patients authorization for disclosure of information necessary
to process the insurance claim.
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Preservation of medical records
The length of time medical records should be retained will vary depending on
the purpose for which the record in being kept. In formulating a record retention
policy a health care institution must be guided by its own clinical, scientific and audit
needs, and the possibility of future patient litigation. It is recommended that complete
patient medical record in a hospital usually be retained, either in original or reproduced
form, for 10 years (depending upon workload). After 10 years such records may be
destroyed; however, the hospital may follow such retention guidelines as:
Retain basic information such as date of admission and discharge, names

of responsible physicians, records of diagnosis and operations, surgical
procedure report, pathology report and discharge summary for all records so
destroyed.
Retain complete medical records of minor and mental disability patients.
Retain complete patient medical records for longer periods when requested
in writing by one of the following,
An attending consultant or physician of the patient.
The patient or someone acting legally in his behalf.
Legal counsel for a party having an interest affected by the patient medical
records.
Thus the length of time that medical records are to be retained is dependent
upon the need for their use in continuing patient care and for legal, research or
educational purpose.
Impact of the Consumer Protection Act in the medical field

In 1986, the consumer protection act in the healthcare field came into existence.
According to this act, health care providers including doctors, nurses, paramedics
and hospital administrators have to be meticulously careful in understanding the full
responsibilities that they have to fulfill in the legal and administrative sense. This
becomes imperative to ensure whatever the services rendered have been properly
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documented in patient records to safe guard the staff involved in the consumer
service.
Who is a consumer?
Any person who buys any goods against consideration is a consumer. From
the health point of view the paying patient who receives health services from clinics,
health institution, nursing home, etc. is considered to be the consumer.
Why is there a need for a Consumer Protection Act?

The legislature has enacted the Consumer Protection Act, 1986 to arm each
and every consumer with rights to seek speedy, cheap and efficacious remedies
and for better protection of the interests of the consumer .
What is service?
It is defined as medical / health service of any type received in any recognized
health institution, clinic, or nursing home from a qualified medical, nursing,
paramedical professional, by a patient.
What is deficiency?
Under the Act, deficiency in relation to any service means any fault, imperfection,
shortcoming, inadequacy in the quality, nature and manner of performance which is
required to be maintained under law.
Medical record in court

The presentation of information from medical records as evidence in a court is
quite relevant. Indeed as it has been indicated that the record is maintained not only
to provide information for medical and administrative purposes but also because it
contains data of the highest value of the individuals and organization. The court has
a legitimate interest in accessing its contents.
When a subpoena or court order is given to the hospital to disclose the

information in medical record of a concerned patient, the steps that should be taken
to prepare the record to submit in the court are as follows:
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1. Determine if the patient has a record at your hospital and where it is located.
2. Check the record to make sure it is complete, signature and initials are
identifiable, each sheet contains the patients name and number.
3. If the record in complete take steps to expedite its completion.
4. Become familiar with the contents of the record, for you may be called to
read from the record on the witness stand.
5. Obtain additional records specified in the subpoena. E.g.: X ray films, bills,
etc.
6. Remove any notes concerning a psychiatric condition unless the patient

and psychiatrist have agreed to admit this information into evidence.
7. Remove all correspondence, duplicate copies of reports.
8. Number each page of the record and record the total number on the record
folder.
9. Photocopy the record and complete a statement which certifies that a copy
is an exact duplicate of the original.
10. Finally a receipt may be accepted from the court in case the medical record
is retained for an indefinite period.
Confidential Communication:
Medico-legal problem often concern the hospital administrator, but are then
transmitted to the responsibility of the records department personnel; if there is no
medical record department, this responsibility is usually vested with the casualty
medical officer. The treating of medico-legal cases are day-to-day problems and it is
necessary that policies governing the release of confidential information be clearly
defined by the administrator; the medical record must be safely guarded from
unauthorized inspections. The medical record is used either as a personal or an
impersonal document.
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Personal Document :
As a personal document the record is used to identify the patient with the history
of his illness, the physical findings and the treatment given to the individual. The
information is confidential and may not be released to anyone without the patients
permission. However, the executors of an estate or their legal representative, in as
much as they are to act in the best interest of the deceased, should be allowed
access to the record if this becomes necessary for the performance of their duties.
This access to the records may be permitted only after presenting proof of authority.
Neither relatives nor friends of the patient, not even the husband or wife, have any
right to review a record unless authorization has been received from the patient.
The authorization should always be in writing and should be filed with the record,
together with a carbon copy of the information released.
It must be recognized that if a record is subpoenaed it must be produced in

court. Usually a member of the records department represents the hospital in
producing this record in court. It is recommended that a photocopy of the record be
retained in the hospital and the original sent to the court. In the past, at times, the
court has retained the original sent to the court, for an indefinite amount of time, or
permanently.
If the patient should be readmitted under the care of a second physician, the
second physician should be allowed access to the record of the previous
hospitalization. If the patient is subsequently admitted to another hospital, a summary
may be sent upon request from the hospital or the physician. In such an instance, an
authorization is not usually considered necessary, as the information is being released
in the interest of better patient care.If the patient personally requests information
from his own record, it is not always in the best interest of the patient that he knows
all the details concerning his illness. It is a wise policy, in all such instances, to
consult the physician.
It is doubtful, however, whether the hospital would be justified in refusing the

information to the patient even against the advice of the attending physician. It must
always be kept in mind that laws differ from country to country and even from state
to state, and therefore, one should acquaint oneself with the legal requirements of
the particular state.
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Impersonal document :
As an impersonal document, the record may be used for research or study.
Such caution need not be exercised when it is used as personal document because
it has no connection with the patient as an individual. Moreover, it is used in this
manner only by physicians, house surgeons, undergraduate and postgraduate
student, nurses and paramedical staff, all of whom are bound by the code of
professional secrecy. If the research is being done by a staff physician and is not for
publication, it is not necessary to obtain the permission of the attending physician to
use the record, although this is done as a matter of courtesy.
The medical record, as an order of business, is the property of the hospital.

The personal data contained in the record are considered as a confidential
communication in which the patient has a critical interest. It is compiled, preserved,
and protected from unauthorized inspection for the benefit of the patient, hospital
and physician. This is required by law in some states and by administrative practice
in others.
When releasing any information, the medical record department must ascertain
whether the record is to be used as an impersonal document or a personal document.
If it is to be used as personal information, written authorization must be obtained
from the patient or his authorized representative. An authorization for release of
information should be honored only for the period of hospitalization covered by the
dates on the authorization. If the record is to be used within the hospital for purposes
of quality assurance, continuing education, research or other scientific investigations,
permission is not necessary from the patient or from the attending physician, unless
the information is to be published. In such an instance it is desirable to secure the
consent of the attending physician.
Since the medical record itself must frequently be used as evidence in court, it
can serve as a protection to the hospital physician and patient, only when it clearly
shows the treatment given the patient, states the details of the attending physician,
and dates when treatment was given. It must show that the care and service given
by the hospital and by the physician were consistent with good medical practice.
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Fill in the blanks:
1.______________________ due to non healing wounds, unintended weight
loss, and malnutrition has become all too common.
2. Every medical record reveals .____________________ information.
7.5 Summary
The medical record, or chart, resides at the top of the healthcare food chain as
the ultimate testimony of the care rendered. While initially serving as a communication
tool to aide multidisciplinary healthcare team members, the medical record now has
the dubious task of serving as a key piece of evidence in the growing number of
lawsuits between patients and their healthcare providers Charts in long-term care
often will demonstrate extended time gaps with no entries. For example, notes may
be missing in the chart for four consecutive days; on the fifth day, the patient is
noted to have a fever and lethargy.
During the course of an extended illness, a patient may be transferred between

acute and long-term care facilities several times. It is not uncommon to see vastly
different heights and weights reported between various facilities and even within the
same facility. Most healthcare facilities have adopted a system of recording meal
consumption for each meal on a flow sheet using terms such as excellent, good,
fair, poor, or refused meal. Consider a typical month in long-term care. The chart
should contain 90 entries (30 days with three meals per day). Most charts have
several boxes left blank. If the record is to be used within the hospital for purposes
of quality assurance, continuing education, research or other scientific investigations,
permission is not necessary from the patient or from the attending physician, unless
the information is to be published.
7.6 Keywords
Beneficiary: Individual who is eligible to use health insurance benefits.
Co-Insurance (coinsurance): A cost-sharing requirement under a health
insurance policy that provides that the insured will assume a portion or percentage
of the costs of covered services according to either a fixed percentage or fixed
amount.
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Co-Payment (Co-pay) : A cost-sharing arrangement in which a health insurance
plan enrollee pays a specified flat amount for a specific service. A Co-pay does not
vary with the cost of the service and is usually a flat sum, unlike co-insurance that is
based on a percentage of the cost.
Medical Informatics : The analysis of data about medical care services to

improve decisions made by physicians and managers of health care organizations.
MMIS : Medical Management Information System. A computer system that

allows payers to track health care expenditure and usage. It may also be referred to
as Health Information System (HIS), Health Information Management (HIM) or
Information System (IS).

1. Discuss on standards and policies of medical records.
2. Write a short note on legal aspects of medical records.
3. Describe problems with medical records.
4. What is the purpose of the standards?
5. In all health related fields, the data-holders—i.e., pharmaceutical firms,
medical device companies, health systems, and now burgeoning electronic
health record vendors—are simultaneously facing pressures to protect their
intellectual capital and proprietary platforms, ensure data security, and adhere
to privacy guidelines, without hindering research which depends on access to
these same databases. List down the strategies for overcoming it.
6. Lean management is a process improvement technique to identify waste
actions and processes to eliminate them. The benefits of Lean for healthcare
organizations are that first, the quality of the outcomes in terms of mistakes
and errors improves. The second is that the amount of time taken through the
whole process significantly improves. How to improve medical records by lean
management practices?
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Fill in the blanks:

1. Litigation
2. patient-centered
1. Riskin D (2012) Big data: opportunity and challenge. HealthcareITNews,

12 June 2012. URL: http://www.healthcareitnews.com/news/big-data-
opportunity-and-challenge.
2. Harrison C (2012) GlaxoSmithKline opens the door on clinical data
sharing. Nat Rev Drug Discov 11(12):891–892. doi: 10.1038/nrd3907 [Medline:
23197021]
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LESSON – 8
MEDICAL REGISTERS
Learning Objectives
Explain the purpose and types of Medical Registration

Listout the advantages of maintaining Registers
Discuss registers in Various Departments
Structure
8.1 Introduction
8.2 Medical Registration
8.3 Advantages of Medical Records
8.4 Information in Registers
8.5 Medical Record Inconsistencies
8.6 Summary
8.7 Keywords
8.1 Introduction
Registers are used as a way to capture a list of items and record information
about key safety matters or events. The terms are used for the written (paper notes),
physical (image films) and digital records that exist for each individual patient and
for the body of information found therein.
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Figure 8.1 Medical Registers

8.2 Medical Registration
Indian Medical Registry Search section of the website publishes the Registered
Doctors with the various State Medical Councils across India upto to the year 2018
(Except: Haryana for the Year - 2011 and Bihar,Haryana for the year 2012 and
Bihar, Haryana for the year 2013 and Haryana for the year 2014 and Bihar, Haryana
for the year 2015 Goa, Gujarat, Jharkhand, Madhya Pradesh for the year 2016,
Assam,Andra Pradesh, Goa, Kerala,Mizoram, Sikkim , Tripura for the year 2017,
Assam,Andra Pradesh,Madhya Pradesh, Maharashtra,Punjab,Sikkim, Uttar
Pradesh,West Bengal for the year 2018)
To search the database for Registered Doctors , please enter / Select the Name,
Qualification, Registration Year, Registration No, Registered Council that you want
to search, given in the website.
8.3 Advantages of Medical Records

The ability to exchange health information documentation can help you provide
higher quality and safer care for patients while creating tangible enhancements for
your organization. It help providers better manage care for patients and provide
better health care by:
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Providing accurate, up-to-date, and complete information about patients
at the point of care.
Enabling quick access to patient records for more coordinated, efficient

care
Securely sharing electronic information with patients and other clinicians
Helping providers more effectively diagnose patients, reduce medical

errors, and provide safer care
Improving patient and provider interaction and communication, as well as

health care convenience
Enabling safer, more reliable prescribing
Helping promote legible, complete documentation and accurate,

streamlined coding and billing
Enhancing privacy and security of patient data]
Helping providers improve productivity and work-life balance
Enabling providers to improve efficiency and meet their business goals
Reducing costs through decreased paperwork, improved safety, reduced

duplication of testing, and improved health.
Take the First Step:
Contact your local REC to find out if you are eligible for free or reduced-
price support. Your local Regional Extension Center (REC) can help you realize
the benefits of electronic health records. RECs are located in every region of
the country to help health care providers select, implement, and become adept
and meaningful users of EHRs.
Download Health IT Implementation Resources.
Review the 6 Implementation Steps.

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Other Advantages.
Transformed Health Care.
Electronic Health Records (EHRs) are the first step to transformed health care.
The benefits of electronic health records include:
Better health care by improving all aspects of patient care, including

safety, effectiveness, patient-centeredness, communication, education,
timeliness, efficiency, and equity.
Better health by encouraging healthier lifestyles in the entire population,
including increased physical activity, better nutrition, avoidance of behavioral
risks, and wider use of preventative care.
Improved efficiencies and lower health care costs by promoting
preventative medicine and improved coordination of health care services, as
well as by reducing waste and redundant tests.
Better clinical decision making by integrating patient information from
multiple sources.
Meaningful Use.
One of the best ways to ensure you take full advantage of the benefits
of electronic health records is to achieve meaningful use. By achieving
meaningful use, you can reap benefits beyond financial incentives.
8.4 Informations in Registers

Medical history
The medical history is a longitudinal record of what has happened to the patient
since birth. It chronicles diseases, major and minor illnesses, as well as growth
landmarks. It gives the clinician a feel for what has happened before to the patient.
As a result, it may often give clues to current disease state. It includes several
subsets detailed below.
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Surgical history
The surgical history is a chronicle of surgery performed for the patient. It may
have dates of operations, operative reports, and/or the detailed narrative of what
the surgeon did.
Obstetric history
The obstetric history lists prior pregnancies and their outcomes. It also includes
any complications of these pregnancies.
Medications and medical allergies

The medical record may contain a summary of the patient’s current and previous
medications as well as any medical allergies.
Family history
The family history lists the health status of immediate family members as well
as their causes of death (if known). [11] It may also list diseases common in the
family or found only in one sex or the other. It may also include a pedigree chart. It
is a valuable asset in predicting some outcomes for the patient.
Social history
The social history is a chronicle of human interactions. It tells of the relationships
of the patient, his/her careers and trainings, and religious training. It is helpful for
the physician to know what sorts of community support the patient might expect
during a major illness. It may explain the behavior of the patient in relation to illness
or loss. It may also give clues as to the cause of an illness (e.g. occupational exposure
to asbestos).
Habits
Various habits which impact health, such as tobacco use, alcohol intake,
exercise, and diet are chronicled, often as part of the social history. This section
may also include more intimate details such as sexual habits and sexual orientation.
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Immunization history
The history of vaccination is included. Any blood tests proving immunity will
also be included in this section.
Growth chart and developmental history
For children and teenagers, charts documenting growth as it compares to other
children of the same age is included, so that health-care providers can follow the
child’s growth over time. Many diseases and social stresses can affect growth, and
longitudinal charting can thus provide a clue to underlying illness. Additionally, a
child’s behavior (such as timing of talking, walking, etc.) as it compares to other
children of the same age is documented within the medical record for much the
same reasons as growth.
Medical Encounters
Within the medical record, individual medical encounters are marked by discrete
summations of a patient’s medical history by a physician, nurse practitioner, or
physician assistant and can take several forms. Hospital admission documentation
(i.e., when a patient requires hospitalization) or consultation by a specialist often
take an exhaustive form, detailing the entirety of prior health and health care. Routine
visits by a provider familiar to the patient, however, may take a shorter form such as
the problem-oriented medical record (POMR), which includes a problem list of
diagnoses or a “SOAP” method of documentation for each visit. Each encounter will
generally contain the aspects below:
Chief complaint
This is the main problem (traditionally called a complaint) that has brought the
patient to see the doctor or other clinician. Information on the nature and duration of
the problem will be explored.
History of the present illness

A detailed exploration of the symptoms the patient is experiencing that have
caused the patient to seek medical attention.
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Physical examination
The physical examination is the recording of observations of the patient. This
includes the vital signs, muscle power and examination of the different organ systems,
especially ones that might directly be responsible for the symptoms the patient is
experiencing.
Assessment and plan

The assessment is a written summation of what are the most likely causes of
the patient’s current set of symptoms. The plan documents the expected course of
action to address the symptoms (diagnosis, treatment, etc.).
Orders and prescriptions

Written orders by medical providers are included in the medical record. These
detail the instructions given to other members of the health care team by the primary
providers.
Progress notes
When a patient is hospitalized, daily updates are entered into the medical record
documenting clinical changes, new information, etc. These often take the form of a
SOAP note and are entered by all members of the health-care team (doctors, nurses,
physical therapists, dietitians, clinical pharmacists, respiratory therapists, etc.). They
are kept in chronological order and document the sequence of events leading to the
current state of health.
Test results
The results of testing, such as blood tests (e.g., complete blood count) radiology
examinations (e.g., X-rays), pathology (e.g., biopsy results), or specialized testing
(e.g., pulmonary function testing) are included. Often, as in the case of X-rays, a
written report of the findings is included in lieu of the actual film.
Other information
Many other items are variably kept within the medical record. Digital images of
the patient, flowsheets from operations/intensive care units, informed consent forms,
EKG tracings, outputs from medical devices (such as pacemakers), chemotherapy
protocols, and numerous other important pieces of information form part of the record
depending on the patient and his or her set of illnesses/treatments.
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Administrative issues
Medical records are legal documents that can be used as evidence via a
subpoena duces tecum,and are thus subject to the laws of the country/state in which
they are produced. As such, there is great variability in rules governing production,
ownership, accessibility, and destruction. There is some controversy regarding proof
verifying the facts, or absence of facts in the record, apart from the medical record
itself.
Demographics
Demographics include patient information that is not medical in nature. It is
often information to locate the patient, including identifying numbers, addresses,
and contact numbers. It may contain information about race and religion as well as
workplace and type of occupation. It also contains information regarding the patient’s
health insurance. It is common to also find emergency contact information located
in this section of the medical chart.
Production
Written records must be marked with the date and time and scribed with indelible
pens without use of corrective paper. Errors in the record should be struck out with
a single line (so that the initial entry remains legible) and initialed by the author.
Orders and notes must be signed by the author. Electronic versions require an
electronic signature.
Ownership of Patient’s Record

Ownership and keeping of patient’s records varies from country to country.
8.5 Medical Record Inconsistencies

This process for making this type of correction can be as simple as just letting
your doctor know that something was recorded incorrectly so your doctor can change
it. But sometimes corrections aren’t so simple, and you need to familiarize yourself
with the rules for amendment of protected health information so that you can get the
corrections taken care of.
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Reviewing Your Records
While many patients are not interested in looking at their own medical records,
it is a good idea to do do. Some healthcare systems will provide you with a patient
portal that provides easy access to all of your medical records within that system.
Even if you don’t have that type of access, you are entitled to look at your own
medical records and obtain copies. Sometimes there is a cost for getting copies of
your records.
Once you have your medical records, you can review them. If you see any
inaccuracies, you can determine whether they are important and require an
amendment.
Types of errors can include:

Some typographical spelling errors may or may not require correction. For
example, if mesenteric is incorrectly spelled “mesentiric,” you might not go through
the trouble of having it corrected because there won’t be any impact on your health
or medical care. Errors in the spelling of your name do require correction because
this can prevent your records from being shared properly among different providers,
and it can affect payment for services.
If your phone number or address is incorrect or outdated, you’ll want to make

sure it gets corrected immediately. Failure to do so will result in the wrong information
being copied into future medical records or an inability for your medical team to
contact you if needed. Any inaccurate information about your symptoms, diagnosis,
or treatment should be corrected. For example, if your record says that you have
temporal tumor instead of a testicular tumor, this is completely different and requires
correction.
If the record says your appointment was at 2 p.m., but you never saw the
doctor until 3:30 p.m., that may not have any bearing on your future health or billing
information needs, and it isn’t worth correcting.
Overall, you have to make your own judgment about which parts of your medical
record need to be corrected if you find errors. If you are on the fence, it is better to
correct something than to leave it incorrect.
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Making Your Request
Contact the hospital or your payer to ask if they have a form they require for
making amendments to your medical records. If so, ask them to email, fax, or mail a
copy to you.
Sending in your request

Be clear, concise and write the correction exactly as you think it should be
noted. The idea is to make it very easy for your provider’s office amend your records.
Make a copy of the page(s) where the error(s) occur. If it’s a simple correction,
then you can strike one line through the incorrect information and handwrite the
correction. By doing it this way, the person in the provider’s office will be able to find
the problem and make the correction easily. If they sent you a form to fill out, you
can staple the copy to the form. If the correction is complicated, you may need to
write a letter outlining what you think it is wrong and what the correction is. If you do
write a letter, make sure you include some basics, such as your name and the date
of service of your letter, then staple your letter to the copy of the page that contains
the error.

1. ___________are used as a way to capture a list of items and record
information about key safety matters or events.
2. Errors in the spelling of your name do require correction because this can
prevent your records from being shared properly among different providers, and it
can affect _______________.
8.6 Summary
Registers are used as a way to capture a list of items and record information
about key safety matters or events. Better health care by improving all aspects of
patient care, including safety, effectiveness, patient-centeredness, communication,
education, timeliness, efficiency, and equity. The medical history is a longitudinal
record of what has happened to the patient since birth. Within the medical record,
individual medical encounters are marked by discrete summations of a patient’s
medical history by a physician, nurse practitioner, or physician assistant and can
take several forms.
155
The results of testing, such as blood tests (e.g., complete blood count) radiology
examinations (e.g., X-rays), pathology (e.g., biopsy results), or specialized testing
Medical records are legal documents that can be used as evidence via a subpoena
duces tecum, and are thus subject to the laws of the country/state in which they are
produced. This process for making this type of correction can be as simple as just
letting your doctor know that something was recorded incorrectly so your doctor can
change it.
8.7 Keywords
Master Patient Index: An index referencing all patients known to particular
organization.
Multi-Specialty Group: A group of doctors who represent various medical

specialties and who work together in a group practice.
Referral: Most health insurers require a referral by the individual’s Primary

Care Physician for certain procedures or visits to specialists.

1. How do you maintain medical register?
2. Discuss on Medical Registration sources available.
3. Mention few Advantages of Medical Records Information in Registers.
4. Write a short note on Medical encounters.
5. How the medical Record Inconsistencies are determined?
6. Explore your role in management and leadership in patience registration data.
Assume that someone else in the team will pass on information needed for patient
care. List down the other services involved in providing care and patients and those
close to them.
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Fill in the blanks:
1. Registers
2. payment for services.

Exploring Medical Language: A Student-Directed Approach, by Myrna LaFleur
Brooks RN BEd and Danielle LaFleur Brooks MEd MA
Medical Device Register 2011 (2 Vol Set): The Official Directory of Medical
Manufacturers (Medical Device Register, Domestic Edition)
157
LESSON – 9
MEDICAL FORMS AND REPORTS
Learning Objectives
Explain medical Forms and Reports

Understand the Principles of Designing
Know the Statutory Registers and Reports to be Maintained
Structures
9.1 Introduction
9.2 Medical Records
9.3 Medical Record Department – Functions
9.4 Types of Forms
9.5 Clinical Audit
9.6 Qualitative Analysis and Medical Audit
9.7 Rights and Responsibilities of Patients
9.8 Summary
9.9 Keywords

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9.1 Introduction
Medical/health records form an essential part of a patient’s present and future
health care. As a written collection of information about a patient’s health and
treatment, they are used essentially for the present and continuing care of the patient.
In addition, medical records are used in the management and planning of health
care facilities and services, for medical research and the production of health care
statistics. Doctors, nurses and other health care professionals write up medical/
health records so that previous medical information is available when the patient
returns to the health care facility. The medical/health record must therefore be
available. This is the job of the medical record worker. If a medical record cannot be
located, the patient may suffer because information, which could be vital for their
continuing care, is not available. If the medical/health record cannot be produced
when needed for patient care, the medical record system is not working properly
and confidence in the overall work of the medical/health record service is affected.
9.2 Medical Records

The terms medical record, health record, and medical chart are used somewhat
interchangeably to describe the system at ic documentation of a
single patient’s medical history and careacross time within one particular health care
provider’s jurisdiction. The medical record includes a variety of types of “notes”
entered over time by health care professionals, recording observations and
administration of drugs and therapies, orders for the administration of drugs and
therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate
medical records is a requirement of health care providers and is generally enforced
as a licensing or certification prerequisite.
The terms are used for the written (paper notes), physical (image films) and
digital records that exist for each individual patient and for the body of information
found therein. Medical records have traditionally been compiled and maintained by
health care providers, but advances in online data storage have led to the
development of personal health records (PHR) that are maintained by patients
themselves, often on third-party websites.
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Purpose
The information contained in the medical record allows health care providers to
determine the patient’s medical history and provide informed care. The medical record
serves as the central repository for planning patient care and documenting
communication among patient and health care provider and professionals contributing
to the patient’s care. An increasing purpose of the medical record is to ensure
documentation of compliance with institutional, professional or governmental
regulation.
The traditional medical record for inpatient care can include admission
notes, on-service notes, progress notes (SOAP notes), preoperative notes, operative
notes, postoperative notes, procedure notes, delivery notes, postpartum notes,
and discharge notes. Personal health records combine many of the above features
with portability, thus allowing a patient to share medical records across providers
and health care systems.
9.3 Medical Record Department - Functions

Traditionally, medical records were written on paper and maintained in folders
often divided into sections for each type of note (progress note, order, test results),
with new information added to each section chronologically. Active records are usually
housed at the clinical site, but older records are often archived offsite.
The advent of electronic medical records has not only changed the format of
medical records but has increased accessibility of files. The use of an individual
dossier style medical record, where records are kept on each patient by name and
illness type originated at the Mayo Clinic out of a desire to simplify patient tracking
and to allow for medical research. Maintenance of medical records requires security
measures to prevent from unauthorized access or tampering with the records.
9.4 Types of Forms

The medical history is a longitudinal record of what has happened to the patient
since birth. It chronicles diseases, major and minor illnesses, as well as growth
landmarks. It gives the clinician a feel for what has happened before to the patient.
As a result, it may often give clues to current disease state. It includes several
subsets detailed below.
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Surgical history
The surgical history is a chronicle of surgery performed for the patient. It may
have dates of operations, operative reports, and/or the detailed narrative of what
the surgeon did.
Obstetric history
The obstetric history lists prior pregnancies and their outcomes. It also includes
any complications of these pregnancies.
Medications and Medical Allergies

The medical record may contain a summary of the patient’s current and previous
medications as well as any medical allergies.
Family history
The family history lists the health status of immediate family members as well
as their causes of death (if known). It may also list diseases common in the family or
found only in one sex or the other. It may also include a pedigree chart. It is a valuable
asset in predicting some outcomes for the patient.
Social history
The social history is a chronicle of hum an interactions. It tells of
the relationships of the patient, his/her careers and trainings, and religious training.
It is helpful for the physician to know what sorts of community support the patient
might expect during a major illness. It may explain the behavior of the patient in
relation to illness or loss. It may also give clues as to the cause of an illness (e.g.
occupational exposure to asbestos).
Habits
Various habits which impact health, such as tobacco use, alcohol
intake, exercise, and diet are chronicled, often as part of the social history. This
section may also include more intimate details such as sexual habits and sexual
orientation.
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Immunization history
The history of vaccination is included. Any blood tests proving immunity will
also be included in this section.
Growth chart and developmental history

For children and teenagers, charts documenting growth as it compares to other
children of the same age is included, so that health-care providers can follow the
child’s growth over time. Many diseases and social stresses can affect growth, and
longitudinal charting can thus provide a clue to underlying illness. Additionally, a
child’s behavior (such as timing of talking, walking, etc.) as it compares to other
children of the same age is documented within the medical record for much the
same reasons as growth.
Medical encounters
Within the medical record, individual medical encounters are marked by discrete
summations of a patient’s medical history by a physician, nurse practitioner, or
physician assistant and can take several forms. Hospital admission documentation
(i.e., when a patient requires hospitalization) or consultation by a specialist often
take an exhaustive form, detailing the entirety of prior health and health care. Routine
visits by a provider familiar to the patient, however, may take a shorter form such as
the problem-oriented medical record (POMR), which includes a problem list of
diagnoses or a “SOAP” method of documentation for each visit. Each encounter will
generally contain the aspects below:
Chief complaint
This is the main problem (traditionally called a complaint) that has brought the
patient to see the doctor or other clinician. Information on the nature and duration of
the problem will be explored.
History of the present illness

A detailed exploration of the symptoms the patient is experiencing that have
caused the patient to seek medical attention.
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Physical examination
The physical examination is the recording of observations of the patient. This
includes the vital signs, muscle power and examination of the different organ systems,
especially ones that might directly be responsible for the symptoms the patient is
experiencing.
Assessment and plan

The assessment is a written summation of what are the most likely causes of
the patient’s current set of symptoms. The plan documents the expected course of
action to address the symptoms (diagnosis, treatment, etc.).
Orders and prescriptions

Written orders by medical providers are included in the medical record. These
detail the instructions given to other members of the health care team by the primary
providers.
Progress notes
When a patient is hospitalized, daily updates are entered into the medical record
documenting clinical changes, new information, etc. These often take the form of
a SOAP note and are entered by all members of the health-care team (doctors,
nurses, physical therapists, dietitians, clinical pharmacists, respiratory therapists,
etc.). They are kept in chronological order and document the sequence of events
leading to the current state of health.
Test results
The results of testing, such as blood tests (e.g., complete blood
count) radiology examinations (e.g., X-rays), pathology (e.g., biopsy results), or
specialized testing (e.g., pulmonary function testing) are included. Often, as in the
case of X-rays, a written report of the findings is included in lieu of the actual film.
Other information
Many other items are variably kept within the medical record. Digital images of
the patient, f lowsheets f rom operations/intensive care units, inf ormed
consent f orms, EKG tracings, outputs from medical devices (such
163
as pacemakers), chemotherapy protocols, and numerous other important pieces of
information form part of the record depending on the patient and his or her set of
illnesses/treatments.
9.5 Clinical Audit

The clinical audit process seeks to identify areas for service improvement,
develop & carry out action plans to rectify or improve service provision and then to
re-audit to ensure that these changes have an effect.
Clinical audit can be described as a cycle or a spiral, see figure. Within the
cycle there are stages that follow the systematic process of: establishing best practice;
measuring against criteria; taking action to improve care; and monitoring to sustain
improvement. As the process continues, each cycle aspires to a higher level of quality.
Figure 9.1 Clinical Audit

These processes are related to change management methodology and use
the techniques of PDSA cycles, LEAN, Six Sigma, root cause analysis and process
mapping.
Stage 1 : Identify the problem or issue

This stage involves the selection of a topic or issue to be audited, and is likely
to involve measuring adherence to healthcare processes that have been shown to
produce best outcomes for patients. Selection of an audit topic is influenced by
factors including:
164
where national standards and guidelines exist; where there is conclusive
evidence about effective clinical practice (i.e. evidence-based medicine).
areas where problems have been encountered in practice.
what patients and public have recommended that be looked at.
where there is a clear potential for improving service delivery.
areas of high volume, high risk or high cost, in which improvements
can be made.
Stage 2 : Define criteria and standards

Decisions regarding the overall purpose of the audit, either as what should
happen as a result of the audit, or what question you want the audit to answer,
should be written as a series of statements or tasks that the audit will focus on.
Collectively, these form the audit criteria. These criteria are explicit statements that
define what is being measured and represent elements of care that can be measured
objectively. The standards define the aspect of care to be measured, and should
always be based on the best available evidence.
A criterion is a measurable outcome of care, aspect of practice or

capacity. For example, ‘parents / carers are involved in negotiating or planning
their child’s care’.
A standard is the threshold of the expected compliance for each criterion

(these are usually expressed as a percentage). For the above example an
appropriate standard would be: ‘There is evidence of parent / carer in care
planning in 90% of cases’.
Stage 3 : Data collection

To ensure that the data collected are precise, and that only essential information
is collected, certain details of what is to be audited must be established from the
outset. These include:
The user group to be included, with any exceptions noted.

The healthcare professionals involved in the users’ care.
The period over which the criteria apply.
165
Sample sizes for data collection are often a compromise between the statistical
validity of the results and pragmatical issues around data collection. Data to be
collected may be available in a computerised information system, or in other cases
it may be appropriate to collect data manually or electronically using data capture
solutions such as Formic, depending on the outcome being measured. In either case,
considerations need to be given to what data will be collected, where the data will be
found, and who will do the data collection.
Ethical issues must also be considered; the data collected must relate only to
the objectives of the audit, and staff and patient confidentiality must be respected -
identifiable information must not be used. Any potentially sensitive topics should be
discussed with the local Research Ethics Committee.
Stage 4: Compare performance with criteria and standards

This is the analysis stage, whereby the results of the data collection are
compared with criteria and standards. The end stage of analysis is concluding how
well the standards were met and, if applicable, identifying reasons why the standards
weren’t met in all cases. These reasons might be agreed to be acceptable, i.e. could
be added to the exception criteria for the standard in future, or will suggest a focus
for improvement measures.
In theory, any case where the standard (criteria or exceptions) was not met in
100% of cases suggests a potential for improvement in care. In practice, where
standard results were close to 100%, it might be agreed that any further improvement
will be difficult to obtain and that other standards, with results further away from
100%, are the priority targets for action. This decision will depend on the topic area
– in some ‘life or death’ type cases, it will be important to achieve 100%, in other
areas a much lower result might still be considered acceptable.
Stage 5 : Implementing change

Once the results of the audit have been published and discussed, an agreement
must be reached about the recommendations for change. Using an action plan to
record these recommendations is good practice; this should include who has agreed
to do what and by when. Each point needs to be well defined, with an individual
named as responsible for it, and an agreed timescale for its completion.
166
Action plan development may involve refinement of the audit tool particularly if
measures used are found to be inappropriate or incorrectly assessed. In other
instances new process or outcome measures may be needed or involve linkages to
other departments or individuals. Too often audit results in criticism of other
organisations, departments or individuals without their knowledge or involvement.
Joint audit is far more profitable in this situation and should be encouraged by the
Clinical Audit lead and manager.
Re-audit: Sustaining Improvements

After an agreed period, the audit should be repeated. The same strategies for
identifying the sample, methods and data analysis should be used to ensure
comparability with the original audit. The re-audit should demonstrate that the changes
have been implemented and that improvements have been made. Further changes
may then be required, leading to additional re-audits.
This stage is critical to the successful outcome of an audit process - as it verifies

whether the changes implemented have had an effect and to see if further
improvements are required to achieve the standards of healthcare delivery identified
in stage 2.
Results of good audit should be disseminated both locally via the Strategic
Health Authorities and nationally where possible. Professional journals, such as
the BMJ and the Nursing Standardpublish the findings of good quality audits,
especially if the work or the methodology is generalisable.
9.6 Qualitative Analysis and Medical Audit

The evaluation of health care and efforts to maintain and improve quality in
health care have very largely drawn on quantitative methods. Quantification has
made possible precise expression of the extent to which interventions are efficient,
effective, or appropriate and has allowed the use of statistical techniques to assess
the significance of findings. For many questions, however, quantitative methods may
be neither feasible nor desirable. Qualitative methods may be more appropriate
when investigators are “opening up” a new field of study or are primarily concerned
to identify and conceptualise salient issues.
167
Various qualitative methods have been developed which potentially have an
enormous role in assessing health care. This paper examines some of the more
important forms that have been used in that assessment and outlines principles of
good practice in the application of qualitative methodology. It is intended to encourage
a wider use of qualitative methods in assessing health care and a greater appreciation
of how much such methods have to offer.
The term “qualitative” is sometimes used quite loosely. We will review some of
the methods to which the term is properly applied, but first what is not a qualitative
study should be emphasised. Research based on a small number of patients or
respondents should not be considered qualitative just because the sample size is
too small to assess statistical significance.
This is more likely to prove to be an inadequate quantitative study. Similarly, a

study is not qualitative because it is based on answers to a questionnaire about
subjective matters nor because data are collected by personal interview. If such
data are analysed and reported largely in terms of frequencies and proportions of
respondents expressing particular views, that is also a quantitative study. Qualitative
research depends upon not numerical but conceptual analysis and presentation.
It is used where it is important to understand the meaning and interpretation of

human social arrangements such as hospitals, clinics, forms of management, or
decision making. Qualitative methods are intended to convey to policy makers the
experiences of individuals, groups, and organizations who may be affected by policies.
Clinical audit is a process that has been def ined a s “a quality

improvement process that seeks to improve patient care and outcomes through
systematic review of care against explicit criteria and the implementation of change”.
9.7 Rights and Responsibilities of Patients

Rights and Responsibilities are as follows:
A patient has the right to be treated with courtesy and respect, with
appreciation of his or her individual dignity, and with protection of his or her
need for privacy.
168
A patient has the right to a prompt and reasonable response to questions
and requests.
A patient has the right to know who is providing medical services and
who is responsible for his or her care.
A patient has the right to know what patient support services are
available, including whether an interpreter is available if he or she does not
speak English.
A patient has the right to know what rules and regulations apply to his
or her conduct.
A patient has the right to be given by the healthcare provider information
concerning diagnosis, planned course of treatment, alternatives, risks, and
prognosis.
A patient has the right to refuse any treatment, except as otherwise
provided by law.
A patient has the right to be given, upon request, full information, and
necessary counseling on the availability of known financial resources for his or
her care.
A patient who is eligible for Medicare has the right to know, upon request
and in advance of treatment, whether the health care provider or health care
facility accepts the Medicare assignment rate.
A patient has the right to receive, upon request, prior to treatment, a
reasonable estimate of charges for medical care.
A patient has the right to receive a copy of a reasonably clear and
understandable, itemized bill and, upon request, to have the charges explained.
A patient has the right to impartial access to medical treatment or
accommodations, regardless of race, national origin, religion, handicap, or
source of payment.
A patient has the right to treatment for any emergency medical condition
that will deteriorate from failure to provide treatment.
169
A patient has the right to know if medical treatment is for purposes of
experimental research and to give his or her consent or refusal to participate in
such experimental research.
A patient has the right to express grievances regarding any violation of
his or her rights, as stated in Florida law, through the grievance procedure of
the health care provider or health care facility which served him or her and to
the appropriate state licensing agency.
A patient is responsible for providing to the healthcare provider, to the
best of his or her knowledge, accurate and complete information about present
complaints, past illnesses, hospitalizations, medications, and other matters
relating to his or her health.
A patient is responsible for reporting unexpected changes in his or her
condition to the healthcare provider.
A patient is responsible for reporting to the health care provider whether
he or she comprehends a contemplated course of action and what is expected
of him or her.
A patient is responsible for following the treatment plan recommended
by the healthcare provider.
A patient is responsible for keeping appointments and, when he or she
is unable to do so for any reason, for notifying the healthcare provider or health
care facility.
A patient is responsible for his or her actions if he or she refuses
treatment or does not follow the health care provider’s instructions.
A patient is responsible for assuring that the financial obligations of his
or her healthcare are fulfilled as promptly as possible.
A patient is responsible for following healthcare facility rules and
regulations affecting patient care and conduct.
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Check your progress 1 (CYP)Fill in the blanks:

1. The terms __________and ____________chart are used somewhat
interchangeably to describe the systematic documentation of a single patient’s
medical history and careacross time within one particular health care provider’s
jurisdiction
2. _____________charts documenting growth as it compares to other children
of the same age is included, so that health-care providers can follow the child’s
growth over time.
9.8 Summary
Accurate and adequate medical records are essential for clinical, legal, fiscal
and research purposes and is based on the principle “people forget, but records
remember”. Medical Records Department [MRD] has become an essential
department of every hospital. Printed performs developed by hospitals are widely
used to achieve regularity and uniformity in the recording and presentation of
information.
Medical Audit brings out the facts of the quality care rendered in the hospital. It
gives a chance to know how efficient or inefficient the care provided by the healthcare
professionals is. Medical Audit should be conducted periodically to ensure good
patient care in the hospital.
9.9 Keywords
Transcription: The process by which medical transcriptionists convert
physician’s dictation into written (typed) words.
Treatment: The provision of health care for an individual. HIPAA provides for
the use and sharing of protected health information for treatment purposes without
authorization.
171
VPN: Virtual Private Network. A way to communicate securely to a corporate
network over the internet using software installed on a computer.

1. What are the Medical Records Contents?
2. List the important functions of the medical records department.
3. Explain the concept of medical audit.
4. Explain the types of medical audit.
5. Explain the importance of medical audit.
6. Create a new form for Medical Forms issuing to the patient and explore
the necessary fields needed in it.
7. List down the ethical issues in medical reports.

1. medical record, health record, and chart
2. For children and teenagers.

Exploring Medical Language: A Student-Directed Approach, by Myrna LaFleur
Brooks RN BEd and Danielle LaFleur Brooks MEd MA
Medical Device Register 2011 (2 Vol Set): The Official Directory of Medical
Manufacturers (Medical Device Register, Domestic Edition)
172
LESSON – 10
HOSPITAL GENERAL SERVICES
Learning Objectives
Describe the important aspects of transportation services

Brief an overview of communication system of the hospital
List out the mortuary services provided by the hospital
Structure
10.1 Introduction
10.2 Transportation Services
10.3 Communication Systems
10.4 Summary
10.5 Keywords
10.1 Introduction
Health and well-being are inextricably linked to the social and economic
conditions in which people live. Research has shown that only 20 percent of health
can be attributed to medical care, while social and economic factors—like access to
healthy food, housing status, educational attainment and access to transportation—
account for 40 percent. Individuals struggling with food insecurity, housing instability,
limited access to transportation or other barriers may experience poor health
outcomes, increased health care utilization and increased health care costs.
Addressing these determinants of health, commonly referred to as social determinants
of health, or simply social determinants, will have a significant positive impact on
173
people’s health, including longer life expectancy, healthier behaviors and better overall
health.
10.2 Transportation Services

Transportation is an economic and social factor that shapes people’s daily lives
and thus a social determinant of health. Transportation barriers can affect a person’s
access to health care services. These barriers may result in missed or delayed health
care appointments, increased health expenditures and overall poorer health
outcomes. Transportation is interrelated with other social determinants of health
such as poverty, social isolation, access to education and racial discrimination.
Transportation also can be a vehicle for wellness.
Developing affordable and appropriate transportation options, walkable

communities, bike lanes, bike-share programs and other healthy transit options can
help boost health.
Transportation and Health

Transportation connects people from their origin to their destination, affects
land use and shapes our daily lives. Transportation is necessary to access goods,
services and activities such as emergency services, health care, adequate food and
clothing, education, employment, and social activities because transportation touches
many aspects of a person’s life, adequate and reliable transportation services are
fundamental to healthy communities. Barriers to transportation greatly affect the
quality of people’s lives.
These statistics highlight the scope of the problem:

3.6 million people in the do not obtain medical care due to transportation
barriers.
Regardless of insurance status, 4 percent of children (approximately 3
million) in the miss a health care appointment each year due to unavailable
transportation; this includes 9 percent of children in families with incomes of
less than $50000.
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Transportation is the third most commonly cited barrier to accessing
health services for older adults.11 Transportation challenges affect urban and
rural communities.
Overall, individuals who are older, less educated, female, minority, or low
income—or have a combination of these characteristics—are affected more by
transportation barriers.12 Children, older adults and veterans are especially
vulnerable to transportation barriers due to social isolation, comodities, and greater
need for frequent clinician visits. Transportation issues affect people at varying levels
depending on how different challenges overlap. For example, a low income person
struggling with travel may have an increased burden if he or she experiences a
temporary physical disability.
Limited health literacy, cognitive impairment, fragmentation of health history,

access to health insurance, poverty or food insecurity can intersect at any period of
time and affect individuals and communities.
Transportation Issues
Transportation issues include lack of vehicle access, long distances and lengthy
travel times to reach needed services, transportation costs, inadequate infrastructure
and adverse policies that affect travel. Like other social determinants of health,
transportation barriers are interconnected so the presence of one may exacerbate
or create other barriers.
Transportation Infrastructure
Limited availability and routes
Overcrowding on trains or buses
Roads and transport stations in disrepair
Safety issues
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Transportation Costs
High cost of fares
Personal vehicle expenses such as insurance
Credit card or bank account requirements
Vehicle Access
Lack of a personal vehicle
Lack of access to a vehicle through friends or family
Distance and Time Burden

Long travel distances and lengthy wait times
Erroneous or inconvenient time schedules
Policy
Budget cuts resulting in bus and train shortages, routes removed, and
strikes
Driver’s license barriers
Lack of adequate transit in underserved areas
Types of Medical Transportation

Non-emergency Medical Transportation
Non-emergency medical transportation is a professional service to transport
individual(s) with a health condition or injury that does not pose an immediate threat.
Doctors schedule transportation for patients who have a medical condition that
prohibits them from travel. Law firms depend on these services to transport an
injured client to a deposition, court appearance, or interview.
Ambulatory Transporatation (SEDAN)

Ambulatory transportation is the most common form of non-emergency medical
transportation. It is for patients who do not need equipment to travel and who are
able to walk, or only need basic assistance.
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Stretcher
In addition, stretcher medical transport is available, specifically for patients
who suffer from back conditions or who cannot sit upright. Scheduling this service
implies that emergency assistance is not required in transit or at time of arrival.
Wheelchair
Wheelchair transport services offer help to those who are confined to a
wheelchair or who cannot walk on their own. CPR-trained drivers operate the vans
and wheelchair lifts. Wheelchairs are available for rent and special consideration is
given to patients with disabilities. Again, the use of this service implies that the
patient does not need immediate emergency care at the time of service.
Flight Escorts
Medical flight escort services are for patients who are well enough to travel by
air but require medical supervision because they cannot converse or sit upright.
Using this escort service means that a private air ambulance is not necessary.
With this in mind, we arrange flight escort services with a commercial airline. An
on-board nurse will accompany the patient to monitor their condition for the flight’s
duration. Upon arrival, the nurse coordinates ground transportation (taxi, family
members, medical transportation, etc.) to get the patient to the final destination
Courier Service
Medical courier services exist to transport human blood, organs and other
biological matter to and from hospitals and research facilities. It’s important to note
that our contracted drivers are carefully screened and adhere to the strictest
confidentiality and privacy standards, including the Health Insurance Portability and
Accountability Act (HIPAA).
Emergency Medical Transportation

Basic Life Support Ambulance (BLS )
A Basic Life Support ambulance is for patients who need medical assistance
while in transit. Emergency Medical Technicians (EMTs) provide bandages, EpiPens,
cardiac monitoring, splints, oxygen tanks, and other medical supplies on board at all
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times. A transportation representative will coordinate BLS transportation prior to the
patient’s discharge date to transport him/her to their home, another medical facility,
rehabilitation clinic, assisted living community or psychiatric clinic.
Advanced Life Support Ambulance (ALS)

Similarly, Advanced Life Support ambulances are operated by highly
skilled paramedics. While on board, paramedics administer shots, medication,
monitor vitals, and stabilize the patient for transport to an emergency room or trauma
unit.
Transportation Interpreters
Foreign language and American Sign Language interpretation services
are paired with transportation (upon request) to accommodate the needs of patients
with limited English proficiency or who are Deaf or Hard-of-Hearing. A medical
interpreter can mean the difference between life and death provided that he or she
is qualified. We strongly advise against the use of a family member or friend on the
ride because of the lack of training in medical vocabulary. In addition, being unaware
of confidentiality policies and being unable to be impartial puts patients at risk. The
same goes for legal interpretation. Qualified legal interpreters specialize in legal
jargon and ensure the patient understands all legal formalities. For example, in a
personal injury case, medical transportation is arranged to bring the patient to court.
While in court, the legal interpreter interprets on the spot.
Interpreters Unlimited developed a niche in the Health and Human

Services sector to streamline transportation process for legal, healthcare, mental
health, workers’ compensation and insurance clients. We contract qualified
interpreters (versus non-qualified interpreters) because of the advanced knowledge
and specialized training.
10.3 Communication Systems

Communication Space Accounts for the Bulk of Information
Transactions in Healthcare
We can conceive of all the information that gets exchanged in health care as
forming a ‘space’. The communication space is that portion of the total number of
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information transactions that involves interpersonal interaction. For example, face-
to-face conversations, telephone calls, letters and e-mail all generate transactions
that would fall into the communication space.
Even small clinical teams have the capacity to generate large and complex
communication spaces. Theoretically, the number of different conversations that
could take place at any one time is determined by the number of individuals who
may have a need to communicate. With three members in a clinical team, three
separate conversations could take place between any two individuals. If we increase
the size of the team to five individuals, the number of possible conversations increases
to 10, and for a team of 10 the number of possible conversations blows out to 45
(Figure 10.1). This is because the number of possible conversations is determined
by a combinatorial formula:
Figure 10.1 Communication Support
The number of possible conversations increases combinatorially with the

number of individuals who need to communicate
number of conversations = n!/(r!(n”r)!

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where n is the number of individuals, and r is the number of individuals involved
in a single conversation.
There are few studies that have attempted to directly quantify the actual size of
the communication space in health settings. Those studies that do exist all paint a
similar picture. Covell et al. reported that colleagues rather than document sources
met about 50% of information requests by clinicians in clinic. In a similar study, Tang
et al. found that about 60% of clinician time in clinic is devoted to talk. Safran et al.
reviewed the information transactions in a hospital with a mature computer-based
record system, and still found about 50% of information transactions occurred face-
to-face between colleagues, with e-mail and voice-mail accounting for about another
quarter of the total. Only about 10% of the information transactions occurred through
the electronic medical record. In some specialised clinical units like the emergency
room, where a large number of staff are physically co-located and engage in
teamwork, the communication space can account for almost all information
transactions. In one study, communication between staff represented almost 90%
of all the information transactions that were measured in two emergency rooms.
The sheer scale and complexity of these interactions within the healthcare
system puts a heavy burden on the process of communication, and miscommunication
can have terrible consequences. Not only is the communication space huge in terms
of the total information transactions and clinician time, it is also a source of significant
morbidity and mortality. Communication failures are a large contributor to adverse
clinical events and outcomes. In a retrospective review of 14,000 in-hospital deaths,
communication errors were found to be the lead cause, twice as frequent as errors
due to inadequate clinical skill. Further, about 50% of all adverse events detected in
a study of primary care physicians were associated with communication difficulties. If
we look beyond the raw numbers, the clinical communication space is interruption-
driven, has poor communication systems and poor practices. At the administrative
level, the poor communication of information can have substantial economic
consequences. It is now clear, for example, that the healthcare system suffers
enormous inefficiencies because of the poor quality of communication systems that
are often in place.
So, in summary, the communication space is apparently the largest part of the
health system’s information space. It contains a substantial proportion of the health
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system information ‘pathology’, but is still usually ignored in our thinking. Yet it seems
to be where most of the information in the clinical workplace is acquired and
presented. A Communication System Includes People, Messages, Mediating
Technologies, and Organisational Structures
Communication systems are the formal or informal structures organisations

use to support their communication needs. A communication system involves people,
the messages they wish to convey, the technologies that mediate conversations,
and the organisational structures that define and constrain the conversations that
are allowed to occur. Elements of communication systems include:
Communication channel : The channel is the ‘pipe’ along which a message

is conveyed, and there are a wide variety of different communication channels
available, from basic face-to-face conversation, through to telecommunication
channels like the telephone or e-mail, and computational channels like the medical
record. Channels have attributes like capacity and noise, which determine their
suitability for different tasks. When two parties exchange messages across a channel
at the same time, this is known as synchronous communication. Telephones are
one of the commonest two-way synchronous channels. It is the nature of synchronous
communication that it is interruptive, and these interruptions may have a negative
impact on individuals who have high cognitive loads.
Types of message : Messages are structured to achieve a specific task using

available resources to suit the needs of the receiver. Informal messages, which
have variable structures, include voice and e-mail messages. Structured or formal
messages include hospital discharge summaries, computer-generated alerts and
laboratory results. When these messages are computer generated, they typically
will be in a format that complies with a standard, and the HL7 standard is now arguably
the international de facto messaging standard within healthcare.
Communication policies : A communication system can be bounded by formal

procedure rather than technology, e.g. clinical handover. A hospital may have many
different policies that shape their communication system performance, independent
of the specific technologies used. For example, it might be a policy to prohibit general
practitioners to obtain a medical record directly from the records department without
the permission of a hospital clinician.
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Agents : A communication system can be specifically constructed around the
agents involved in the different information transactions. For example, in a busy
clinical unit, one could devise a system where a ward clerk can be tasked to field all
incoming telephone calls. The clerk’s specific communication role is thus an
organisational structure created in support of a policy to minimise interruption to
clinical staff, who might otherwise have to answer the phone. Agents have attributes
like their understanding of specific tasks and language.
Communication services : Just as computer systems can run a number of

different software applications, we can think of a communication system providing a
number of different communication services. Thus voice communication is only one
of the many services available across a telephone line. Fax transmission of
documents is an entirely different kind of service that uses the same underlying
channel. For example, a mobile phone may provide voice-mail, text messaging.
Communication device : Communication services can run on different

communication devices. Examples of devices include the telephone, fax machine,
and personal digital assistant (PDA). Different devices are suited to handle different
situations and tasks. Communication devices are a source of continuing innovation,
and will continue to evolve. One area of recent interest has been the area of wearable
computing, where devices are small enough to become personal accessories like
wristwatches or earrings.
Interaction mode : The way an interaction is designed determines much of

the utility of different information systems, and this is just as true for communication
systems. Some modes of interaction for example, demand that the message receiver
pays attention immediately, such as the ringing tone of a phone, while others can be
designed to not interrupt. An asynchronous service that is inherently not interruptive,
like e-mail, may still be designed with an interruptive interaction mode, such as the
ringing of a computer tone when a message arrives, altering the impact of the service
on the message receiver.
Security protocol : In health care, patient privacy concerns make it important

that unauthorised individuals do not access clinical records. To protect privacy,
messages can be scrambled or ‘encoded’ as a means to prevent unauthorised
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individuals intercepting and interpreting them. For example, mobile phone
conversations can be scrambled to protect unauthorised eavesdropping, and reports
of medical investigations sent by e-mail can similarly have their contents encrypted.
Only those with access to systems that understand the encoding, for example, through
the possession of a ‘key’, should be able to read them. A widely available public
method for encoding messages is through use of the Public Key Infrastructure. As is
now widely known, there are always individuals with the time and capacity to try and
‘hack’ security protocols and read privileged information. Fortunately, most important
communications typically have extremely strong security protocols that are
exceedingly hard to be cracked. For example, internet banking systems are only
possible because customers have faith that system security is for practical purposes
impenetrable. The use of similar encryption methods in healthcare will typically afford
the same degree of protection, and confidence in the system. The choice of security
protocol used will reflect the degree of risk associated with unauthorised access to
message content.
A communication system is thus a bundle of different components and the

utility of the overall system is determined by the appropriateness of all the components
together. If even one element of the system bundle is inappropriate to the setting,
the communication system can under perform. For example, sending an X-ray to a
small PDA is unlikely to be useful, both because the size of the device may limit the
view of the image, as well as the size of the image may exceed the capacity of the
wireless channel used by the PDA.
Communication and Hospitals

Telemedical systems, as we have seen, have been actively explored at the
interface between hospital-based specialist services and primary care. Similar
problems exist between small hospitals, which may not have access to the highly
specialised personnel that can be found in larger institutions like teaching hospitals.
Indeed, with the growing number of sub-specialities in clinical medicine, it is now
unlikely that any one institution has a representative from every feasible medical
sub-speciality within their institution. For this reason, there is a need to share highly
specialised expertise across different hospitals, sometimes involving large distances.
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Inter-hospital Communication
There is now some evidence that remote consultation, using telemedical facilities
like video-conferencing, is able to assist with this problem of distribution of expertise. It
has been shown for example, that when a general radiologist is able to consult with
a remote specialist, sharing views of X-ray images using low resolution video, then
the general radiologist’s diagnostic accuracy improved. It now seems accepted that
with appropriate technology, digitally transmitted images can in principle match
existing imaging methods. The cost of achieving such results varies with the type of
imaging task being attempted.
Triage models, similar to those explored in primary care, can limit the number
of patients who need to be seen by limited sub-speciality resources. For example, in
one study, general pathologists reviewed and reported on cases, and referred difficult
cases to remote specialists by sending them high-resolution images.
In another study, patients were offered access to specialist medical practitioners

in a different country. Patients were able to travel there or to have a consultation by
video-link. Choosing the video-conferencing option changed patients’ desires to travel
overseas. Of those seeking consultation, 20% initially wished to travel for treatment,
but after the tele consultation only 6% chose this option.
Most of these studies throw up evidence that advanced communication systems

and services are valuable. What remains unclear is whether there is any real cost-
benefit from this approach. Indeed, it is becoming clear that the application of such
technologies is only beneficial in particular sets of circumstances.
Overall, the cost savings from installing any communication system must vary
for different communities. The amount of resource saved, however measured,
depends upon many variables. These include the size of population served the
utilisation rates of the services that are being augmented by the communication
option the distances workers or patients might otherwise need to travel the
effectiveness of local services in comparison to the telemedical options.
There is also evidence that some types of task are not entirely suited to the
remote consultation model. Microbiologists, for example, probably need 3 dimensional
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image information, as well as non-visual data like smell, before remote interpretation
of microbiology specimens becomes feasible.
As always, it is important to not overlook simpler solutions to communication

problems, if they exist. It is not always appropriate or necessary, for example, to use
video-based consultation. In many cases, the communication needs of a specialist
consultation may be met by use of the telephone alone. Rather than purchasing
systems permitting real-time video conferencing, images can be sent across computer
networks. Standard e-mail systems are capable of transmitting text and image, and
are more than able to manage the task of sending still images, such as pathology
slides or X-ray images. Once images have been received remotely, they can be
viewed simultaneously and discussed over the telephone. Simple methods now exist
to enhance this further, so that viewers can mark or point to sections of an image,
and have these markings appear at the remote site.
Intra - Hospital Communication

Almost all of the current telemedical research is focused on the interfaces
between hospitals and community services or the home. Very little work has been
done to understand the internal communication dynamics and requirements of
hospitals. Yet it should be apparent that any hospital is a complex organisation, and
that good communication processes must be fundamental to its operation.
Thus, while much effort has been devoted to developing the electronic patient
record, there has been minimal exploration of what communication systems can be
developed to support hospital operation. However, a critical examination of the
characteristics of the hospital as a workplace can identify clear areas in which there
is significant potential for improvement. Two areas in particular deserve discussion;
the need to support mobility, and the need for asynchronous messaging.
Mobility
In contrast to other populations such as office workers or clinic-based healthcare
workers, hospital workers are highly mobile during their working day. Nursing staff
are perhaps least mobile, spending most of their day moving around their home
ward. Medical staff may have to move widely across a hospital campus. Senior
medical staff may also have to move off campus, to attend other hospitals or clinics.
Nevertheless, it is important that staff remain within reach during the working day.
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At present the most common solution to this problem of contacting mobile staff
is provided by radio-paging. Pagers are almost ubiquitous in modern hospitals, and
staff may carry several of these. For example, a pager might be issued to each
individual. Other pagers are issued to members of teams, for example a ‘crash’
team that needs to respond to critical emergencies like cardiac arrests within the
hospital. Pagers thus serve to permit communication both with named individuals,
and individuals occupying labelled roles like ‘surgeon on call’.
Pagers have several drawbacks. Invariably in a busy work environment, people

move about and telephones are a pooled resource that quickly become engaged.
As someone is paged, they answer the call to find either that the number given is
now engaged, or that the caller has moved on to another ward location. The end
result is often a game of ‘telephone tag’. The provision of mobile telephones bypasses
many of these problems. The call set-up delays inherent in paging are eliminated,
and the number of communication access points is multiplied through personal
handsets. The value of mobile communications in a clinical environment is starting
to be appreciated, but at present remains an under-utilised option. As with any
technology there are some drawbacks. At a practical level, some healthcare workers
can choose to hide behind a paging system, effectively choosing which calls to answer
based upon their current state. This form of call-screening may no longer be possible
if individuals have personal mobile telephones. The reduced costs of contacting
colleagues and increased benefits of being contactable may be at the cost of
decreased control of communication and increased interruption. At present it appears
that the benefits significantly outweigh the costs, but formal studies are needed to
confirm this.
Asynchronous communications
Hospitals are highly interrupt-driven environments. Interruptions to the normal
flow of work are caused by the paging and telephone systems, as well as the result
of impromptu face-to-face meeting by colleagues (e.g. being stopped in the corridor).
The team-based nature of work also demands that subjects communicate frequently
with team members throughout the working day.
For example, nearly a third of communication events in a study of emergency

room practice were classified as interruptions, meaning that they were not initiated
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by the observed subject, and occurred using a synchronous communication channel
such as face-to-face conversation. This gave a rate of 11.15 interruptions per hour
for all subjects. Even higher interruption rates were identified for individual clinical
roles. Medical registrars and nurse coordinators experienced rates of 23.5 and 24.9
interruptions per hour. In contrast, nurses and junior doctors had rates of 9.2 and
8.3 interruptions per hour.
The consequence of such frequent interruptions is that hospital workers have

to repeatedly suspend active tasks to deal with the interruption, and then return to
the previous task. Suspending tasks and then returning to them imposes a cognitive
load, and may result in tasks being forgotten, or left incomplete. There thus is a cost
in time and efficiency arising out of the interrupt-driven nature of the hospital work
environment.
In part, the interruptive nature of hospitals is a result of the communication

practices and systems in place in these organisations. For example, external
telephone calls are one major source of interruption in emergency rooms, especially
if clinical staff is expected to suspend their current tasks to handle the calls. A simple
organisational change such as the introduction of a dedicated communications clerk,
who fields all incoming calls, has the potential to significantly reduce the
communication load on clinical staff.
More generally, many hospitals do not at present routinely offer asynchronous

channels like voice-mail or e-mail. It is likely that some of the interruptions delivered
through synchronous systems like the telephone and pager system could be handled
by asynchronous channels. For example, updates on patient results or non-urgent
requests to complete tasks could be sent by voice-mail or e-mail. As long as it is felt
by those sending such messages that they definitely will be attended to, then some
of the cause of interruption can be shifted onto these asynchronous systems. Thus
there seems to be a need for a concomitant change in communication process as
well as the technology for such changes to be effective. The evidence that such
asynchronous systems are of genuine benefit is slowly accumulating.
One of the limitations to the introduction of e-mail systems is the lack of access
points around a campus, for many of the same reasons that access to telephony is
187
limited. The mobility of workers is perhaps one of the main issues. It is for this
reason that mobile computers are being introduced into the hospital environment.
Connected by wireless links, these small devices provide access to the hospital
computer network.
The main driver for introducing such systems is to provide an easy way to
capture clinical data and enter it into the hospital record system, or to retrieve data
from it. One additional benefit of mobile computing will be mobile access to e-mail.
However, more advanced systems will be able to provide even richer services.
Integrating mobile telephony, paging, and access to the hospital network through
lightweight portable devices, newer systems can combine the functionality of the
telephone with that of the computer.

1._________________ connects people from their origin to their destination,
affects land use and shapes our daily lives.
2. Very little work has been done to understand the

____________________dynamics and requirements of hospitals
10.4 Summary
Hospital occupies such an important place in modern world. The changing
pattern of hospital will result in dominance of “Consumers” as against “Providers”.
The successful hospital will be the one, which provide good patient care services.
Patient care is not only curing and managing the patient’s disease through different
functional areas such as nursing, food and nutrition, patient’s safety, pharmacy etc.
The hospitals are much like other organizations but it has some special features
like individual care, emergency service and it cannot make many mistakes because
it may cause life threatening conditions. Patient care is highly significant in hospitals,
to satisfy the patients and their attenders. Hospital administrator’s role is very
important in providing care services in the hospitals.
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10.5 Keywords
WHO: World Health Organisation
Treatment: The provision of health care for an individual.
Primary Care: Basic or general health care usually rendered by general

practitioners, family practitioners, internists, obstetricians and pediatricians who are
often referred to as primary care practitioners.

1. What are the special features in the hospital?
2. What is the significance of patient care services?
3. Define hospital.
4. Healthcare as a Lifelong Journey—Not Simply An Episodic Event. Discuss
on this statement.
5. As per WHO report Close to 800 000 people die due to suicide every
year. Is suicide really a problem? How many people die by suicide every year?

1. Transportation
2. internal communication

Hospital library service — a selected bibliography , Marie Peltier and Helen T.
Yast
Abbasi, B. and S. Z. Hosseinifard. 2014. On the issuing policies for perishable

items such as red blood cells and platelets in blood service. Decision Sciences
45(5): 995-1020.
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LESSON – 11
HOSPITAL INFORMATION SYSTEM (HMIS)
Learning Objectives
Explain the role of information system in hospital.

Discuss the trends and advances in HIS.
Outline the need of HIS in all departments and core function.
Structure
11.1 Introduction
11.2 Definition of HMIS
11.3 Classification of HMIS
11.4 HMIS Stakeholders
11.5 Evolution of HMIS
11.6 Key Concepts of Health Information Systems
11.7 Development of Health Information Systems
11.8 Summary
11.9 Keywords

190
11.1 Introduction
Hospitals are the key institutions in providing relief against sickness and disease.
They have become an integral part of the comprehensive health services in India,
both curative and preventive. Significant progress has been made in improving their
efficiency and operations. Effectiveness of a health institution - hospitals or nursing
homes, depends on its goals and objectives, its strategic location, soundness of its
operations, and efficiency of its management systems. The administrator’s
effectiveness depends upon the efficiency with which he is able to achieve the goals
and objectives. Some of the major factors determining the effectiveness of a health
institution include patient care management and patient satisfaction.
Hospitals are very expensive to build and to operate. Administrators and

professionals have to be extremely cost conscious. Effective computerized systems
and procedures need to be implemented to ensure proper utilization of limited
resources toward quality health care. Certainly, computers with their intrinsic power
can play a major role in a hospital. Computers can act as a communication link
between departments and allows the common database to be shared by them. They
can perform the complex task of matching, tabulating, calculating, retrieving, printing
and securing the data as required. Well designed, integrated computer system can
be a great tool in the hands of the hospital management in improving services,
controlling cost, and ensuring optimal utilization of facilities.
11.2 Definition of HMIS

Hospital Management Information System (HMIS) is a system for patient care
and hospital management. Most hospital information systems (HIS) in advanced
countries are comprehensive, integrated and specialized information systems has
been developed to help in achieving best clinical outcomes, perfect financial
performance and most importantly patient and employee satisfaction. They are
regarded one of the most important focal points on which the delivery of healthcare
within hospitals and different types of medical institutions depends. The hospital
management system (HMS) consists of a computerized web based application in
order to record storing, tracking and prescriptions with monitoring.
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11.3 Classification of HMIS
Categories according to type of functions
i. Patient Care Services
II. Clinical Services
III. Hospital Admin And
IV. Ancillary Services
11.4 HMIS Stakeholders

It is very important to determine the IS users. All users of an HIS are stakeholders
who are involved in its operation and functionality.
According to HIS users category include:

Conceptual Architecture of a HIS
1- Internaluser: The nursing staff, doctors, the administrative staff, and generally
all those directly related to HIS use are grouped under internal users.
2- Externalusers: the patients, suppliers, insurance providers, and everyone

that is indirectly related to an HIS belong to external user group.
11.5 Evolution of HMIS

Medical informatics as a discipline is still young, in particular when compared
with other medical disciplines However approaches to the data processing in medicine
and health care have over 50 years of history. A historical analysis shows major
milestones of the development of global medical informatics and HIS:
1959, Robert Ledley and Lee B. Lusted published a widely read paper on
diagnostic decision-making appeared in Science, in which the authors expressed
hope that by using computers, much of physicians’ work would become automated
and that many human errors could therefore be avoided.
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1965 – one of the first clinically-oriented health care Information Systems
Technicon Medical Information System was developed as a collaborative project
between Lockheed and El Camino Hospital in California.
1967 – Health Evaluation through Logical Processing (HELP) was the first
hospital information system to integrate clinical data accumulation and clinical
decision support.
1967 – International Medical Informatics Association (IMIA) was established. It

has close ties with the World Health Organization (WHO) as a Non Government
Organization, and with the International Federation of Health Information
Management (IFHIMA).
1968 – Computer Stored Ambulatory Record (COSTAR), an electronic medical

record, was developed by the Laboratory of Computer Science at Massachusetts
General Hospital between for Harvard Community Health Plan by Octo Barnett and
Jerome Grossman.
1960s – first hospital information systems were first introduced. The staff used
them primarily for managing billing and hospital inventory. Major work on: signal
analysis, laboratory applications, modeling and simulation of some biological
processes, databases; first attempts on decision support (diagnosis).
1973 - in the Netherlands at the Free University in Amsterdam the department

of Medical Informatics started under the chairmanship of Jan van Bemmel. 1974 -
the department of Medical Cybernetics and Informatics was established in the Soviet
Union, headed by S.A. Gasparyan.
1976 - The Problem-Oriented Medical Information System, or PROMIS, was

designed for maintaining health care records at the University of Vermont by Jan
Schultz and Dr. Lawrence Weed, M.D.
1980 - Edward H. Short life founded one of the earliest formal degree programs
in biomedical informatics at Stanford University, emphasizing a rigorous and
experimentalist approach.
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1986 - European Society for Artificial Intelligence in Medicine (AIME) was
established.
1970s - 1980s - a shift from a paper-based to computer-based records system;

founding most national and international organizations, conferences; attempts to
systematize major areas of medical informatics; first specialized schools and courses;
principles of clinical and hospital information systems, security and medical data
protection; advanced decision support systems expert systems.
1990s–2000s - medical Informatics consolidates its position as an independent

discipline and is mandatory in most medical schools; hospital information systems
are implemented in some hospitals, mainly for management; first e-health and
telemedicine research; notable progress in data bases, medical imaging; more visible
importance and complexity of electronic health record (HER), including confidentiality,
data protection, standards etc.
2000 – 2010 - clearer understanding of e-health potential as a specialized

industry and business; hidden gaps and difficulties in real implementation: integration
and interoperability, modest rate of user acceptance, quality assessment. Clear
contour of sub disciplines: bioinformatics, neuroinformatics etc.
11.6 Key Concepts of Health Information Systems

In recent decades medicine and health care have changed significantly. Major
companies (IBM, Cisco, Microsoft, AGFA, GE et al.) are involved in the development
of hardware and software solutions for health care. Special attention is paid to
standards of digital medicine, HIS and their components. For Russian conditions (a
lot of remote parts of the country) implementation of e-health programs including
telemedicine systems, networks and data banks is of great current interest.
Intended use and functional options of HIS depend on the territorial level of
health care, as well as the special features of a particular health care organization.
The main objectives of HIS usage are enhancement of efficiency of treatment
(reducing of medical errors), and optimization of diagnosis and treatment expenses
including health and clinical management and patient records. The most urgent and
challenging task is considered to develop computer-based medical decision-support.
194
Healthcare information systems, health information systems and hospital
information systems are often used today to refer to the same concept. A series of
terms such as computerized patient records, electronic medical records, and
electronic health records, have been have been mentioned in scientific papers in
the evolution of this phenomenon from its early foundations in the 1960s. They are
commonly used almost interchangeably. Thus there are two main types of HIS:
Electronic Medical Records (EMR)

Electronic medical records maintain patient information and physician notes in
a computerized data base. Electronic records allow the provider to track the patient’s
health over time, read the input of other consulting physicians, or recall his own
clinical assessment from a previous day or hospital visit.
Clinical Decision Support (CDS)

Clinical decision support provides timely reminders and suggestions to medical
practitioners. Decision support may recommend screening tests based on a patient’s
age and medical conditions, and drug allergy information.
Electronic medical records and clinical decision support systems together form
the backbone of the hospital information system. The main application fields and
functions of HIS consist of:
Patient management (patient registry, scheduling of appointments, admittance

and bed control; emergency care; in-patient/out-patient system);
Clinical management (hospital releases; medical reports, electronic

prescriptions; surgery appointments);
Diagnostics and treatment ( lab exams);

Supplies management (stockroom; ordering of supplies; pharmacy; current
assets);
Financial management (accounts payable and receivable; banking control);
Support services (hospital infection controls; assets maintenance; vaccine

control);
195
Research and education (library; convention center scheduling, recruiting and
personnel).
11.7 Development of Health Information Systems

HIS is a set of software, hardware, and data for automation of health care
processes in medical institutions health and recreation resorts. Besides the above
mentioned main application fields and functions a corporate HIS carries out the
following tasks:
- maintaining of common information space, intended for immediate

access to data;
- improvement of the quality of medical records; - control of health care
quality and reduction of medical errors;
- increasing transparency of a medical institutions;
- constant analysis of economic aspects of health care;
- reduction of time of examination and treatment.
The developers of health information systems have to deal with a constantly
changing subject area. The most important sources of these changes are:
- development of social and economic spheres;

- development of medical science;
- the influence of information technologies on patients’ behavior (they
become more informed) and health management in general.
Unlike most industries, in medicine there are three sides of financial and
economic relations: the party that receives services (patient), the party that provides
services (medical organization), and the party who pays for services (patient,
insurance company, government). Another special feature of health information which
must be always considered is privacy
196

1.______________________ as a discipline is still young, in particular when
compared with other medical disciplines.
2. ___________________is a system for patient care and hospital management.
11.8 Summary
A comprehensive HIS typically addresses the automation needs of all
departments or functionality covering the administrative, clinical, back office and
peripheral activities of a hospital. Implementation of an integrated HIS assists
hospitals in a number of ways. An integrated system avoids redundancy of data
entry and makes data available at necessary points.
Medical informatics as a discipline is still young, in particular when compared

with other medical disciplines.Clinicians can conduct data mining on a wealth of
repository of patient records, which can assist them in medical research. HIS is a
set of software, hardware, and data for automation of health care processes in medical
institutions health and recreation resorts.
List down the Hospital Management Information System (HMIS) vendors in the
market? Justify which is less sophisticated implementation.
How you plan for data migration from HMIS with Front office management
system?
11.9 Keywords
Hospital Management Information System (HMIS) is a system for patient
care and hospital management.
International Classification of Diseases (ICD)
International Classification of Functioning, Disability and Health (ICF)
197
1. Describe the evolution of Hospital Information System.
2. Explain classification of Hospital Information System.
3. What are the development of Hospital Information System?
4. Explain the trends and advances in Hospital Information System.

1. Medical informatics
2. Hospital Management Information System (HMIS)

https://easysolution.in/solution.html
https://darpg.gov.in/sites/default/files/
59.%20Health%20Management%20Information%20System.pdf
198
LESSON – 12
QUALITY ISSUES FOR MEDICAL
RECORD SERVICES
Learning Objectives
After studying this lesson, you should be able to discuss :
Quality issues in medical records.

The problem without any delay.
Structure
12.1 Introduction
12.2 Evaluation of Medical Record Procedures
12.3 Evaluating the Content of the Medical Record
12.4 Summary
12.5 Keywords
12.1 Introduction
Over recent years, the quality of documentation in the medical record has
become an important issue, not only with the need to promote better health care,
but also, the need by governments to reduce health care costs. In some countries,
when funding began to be based on medical record data, it was found that more
attention should be paid to the quality of the medical record and documentation of
the original health care data.
In many countries, some problems facing administrators and government

authorities include:
199
poor medical record documentation;
large backlogs of medical records waiting to be coded;
poor coding quality; and
poor access to, and utilization of, morbidity data.
To address these problems and improve the quality of data collected, and the
information generated from that data, quality control measures need to be
implemented. The Medical Record Department is often the first department in a
hospital to introduce quality assurance. As the Medical Record Department has
connections with most other departments within the facility, the medical record is
the best place to check the medical care and treatment of the patient. It should be
noted that quality checking of the medical record often results in action being required
by staff outside the Medical Record Department.
One approach to quality checking is for the MRO to ask staff from other
departments to check the services of the Medical Record Department using a check-
list. The results of these quality checks (or audits) are kept on a chart (or graph) in
the Medical Record Department. They should also be presented to the Medical
Record Committee for review. As the results improve, the figures on the chart are a
source of pride for the Medical Record Department staff. This process is often the
beginning of a reciprocal quality-checking program with other departments, which
could result in an improvement in the quality of procedures throughout the health
care facility
12.2 Evaluation of Medical Record Procedures

There are a number of procedures in the Medical Record Department that can
and should be evaluated. Some study questions that could be used to evaluate the
work of the Medical Record Department staff could include:
Are medical records filed promptly?
Is the file room clean and tidy?

200
Are Master Patient Index cards filed promptly? Are all discharges
returned to the Medical Record Department the day after discharge?
Are medical record forms filed in the correct order?
Are all medical records completed within a specified time after

discharge?
Are medical records coded correctly?
Are all discharges for last month coded by the middle of the next month
Are the monthly and yearly statistics collected within a specified time?
To conduct an evaluation study, the MRO should select a time period for the
study (e.g., one-month), prepare a questionnaire, and determine the standard
or acceptable level of compliance considered appropriate for the work to be
studied. The results can be used to improve the services in areas below the
required standard of performance.
12.3 Evaluating the Content of the Medical Record

The content of the medical record can be evaluated by reviewing to see if the
following has been done:
the consent form for treatment has been signed by the patient;
patient identification details (name and medical record number) are

correct and entered on all forms;
doctors have recorded all essential information;
doctors have signed and dated all clinical entries;
the front sheet has been completed and signed by the attending doctor;
nurses have recorded and signed all daily notes regarding the condition
and care of the patient;
201
all the orders for treatment have been recorded in the medication form
and signed;
medication administration has been recorded and signed;
the anaesthetic form (if any) has been completed and signed;
the operation form (if any) has been completed and signed;
the main condition/principle diagnosis has been recorded on the front

sheet;
operations and/or procedures have been recorded on the front sheet;

and
the MRO or staff member responsible for coding has accurately coded
the main condition/principle diagnosis and any other condition listed (if
required).
Again, a study questionnaire should be prepared and a standard determined,

e.g., 100% compliance.
Sample Check - List or Audit Form :
*N/A = not applicable

202
Check your progress 1

1. In many countries, some problems facing administrators and government
authorities include: ____________________
2. MRD abbreviate ________________
12.4 Summary
In some countries, when funding began to be based on medical record data, it
was found that more attention should be paid to the quality of the medical record
and documentation of the original health care data. To address these problems and
improve the quality of data collected, and the information generated from that data,
quality control measures need to be implemented.
The Medical Record Department is often the first department in a hospital to

introduce quality assurance. As the Medical Record Department has connections
with most other departments within the facility, the medical record is the best place
to check the medical care and treatment of the patient. There are a number of
procedures in the Medical Record Department that can and should be evaluated
12.5 Keywords
Medical Record Department (MRD) fThe Medical Record Department is often
the first department in a hospital to introduce quality assurance.

1. Is Medical Record Department staff conduct quality control studies on the
content of the medical record?
2. How to control problems in quality department in hospital management?
3. Mention few innovative ideas for an effective medical record department

maintenance in an hospital.
203
1. poor medical record documentation; and large backlogs of medical
records waiting to be coded.
2. Medical records department.
Annual health survey report, institute of economic growth,Delhi university
enclave, North campus,Delhi 110007
Maternal and Child Health Deprivation Index, Delhi University enclave, North
campus, Delhi 110007
Model Question Paper
Master of Business Administration
Fourth Semester
Elective Paper – Hospital Management
Hospital Records Management

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1

INSTITUTE OF DISTANCE EDUCATION

c UNIVERSITY OF MADRAS, CHENNAI - 600 005.

2. Prasantha Ghosh K. Office Management, Sultan Chand Sons, New

3. Francis CM and Mario C de Souza, Hospital Administration, 3 rd Ed.

4. George, M A, The Hospital Administrator, Jaypee Brothers, New Delhi.

MBA DEGREE COURSE

Sl. No. Chapters Page No.

1. Importance of Hospitals Management 1

3. Electronic Forms Of Record Keeping 29

4. Outpatient And Inpatient Services 47

6. Record Organisation And Management 108

7. Problems With Medical Records 127

8. Medical Registers 145

9. Medical Forms And Reports 157

10. Hospital General Services 172

11. Hospital Information System 189

12. Quality Issues For Medical Record Services 198

Hospital Records Meaning and Functions

1.2 Functions of Maintaining Hospital Records

1.3 Importance of Maintaining Hospital Records

1.4 Implications of Medical Records for life Insurance

1.5 Etiquettes in Maintaining a Good Hospital Records for Police –

1.6 Legal issues

1.7 Release of Records

1.11 Review Questions

1.12 Suggested Readings

For insurance cases, personal injury suits, workmen’s compensation case,

For malpractice suits

For hospitalaudit and statistical studies

1.3 Importance of Maintaining Hospital Records

Figure 1.1 Importance of Medical Records

Who has Access to Medical Records?

Patient’s legal representative has the right to those records as long as

Parents of a minor also have access to patient’s medical records.

Medical records are usually summoned in a court of law in certain cases

If you have a life-threatening medical emergency, go to the hospital emergency

Table 1.1 : Advantages of keeping good clinical records and the

Good clinical records Poor clinical records

Improve availability of data for route cause Lead to serious incidents

1.5 Etiquettes in Maintaining a Good Hospital Records for

Clear documentation and justification for resuscitation status and ceiling

Recommended return visit date

Medical record entries should be objective. For example, it is risky to refer to a

Physicians should document noncompliance in the progress record, such as a

Accuracy and Legibility of Content

Confidentiality and Data Protection

An additional component of confidentiality in the era of technology and the internet

1.7 Release of Records

Effort should be made to computerize the records for quick retrieval

A subpoena to produce clinical records is a form of court order. Failure to

Medical certificate should be on institution/doctor letter pad.

Date, time, and place should be mentioned.

Issue it only for legitimate purpose and only when necessary.

It has to be true and clear without any ambiguity.

There should be an identification mark of the patient, preferably a thumb

Period of illness should be clearly mentioned.

Diagnosis disclosure of the diagnosis should be only after the patient’s

Doctor should maintain the duplicate copy of every certificate.

Check your progress 1 (CYP)

Fill in the blanks:

2. A _________________is defined as a document of written evidence vouching

Data Extraction (or Abstraction) – A process by which information on documents

2. Latest trends in records maintenance are __ and .