Professional Documents
Culture Documents
KALABURAGI
DEPARTMENT OF MEDICAL RECORD TECHNOLOGY
A REPORT ON STUDY
TOUR PROJECT
SUBMITTED IN PERTIBAL FULFILMENT OF THE REQUIREMENT OF
KALABURAGI
This is to certify that, Mr. Mohit Yadav has completed
Satisfactorily the project work, in partial fulfilment of
award of ‘Diploma in Medical Record Technology’
prescribed by the Para-Medical Board, Bangalore for
the session 2021-2023.
With Regards
Mohit Yadav
DMRT Final year.
S.NO Index
1. ESIC Medical College and Hospital
2. Introduction About Medical Records
3. Histroy of Medical Records
4. Organization of Medical Record Department
5. Objective of Medical Records Department
6. Function of Medical Records Department
7. Standard procedure of MRD
8. Function and Responsibility of Medical Records
Technician
ESIC HOSPITAL, KALABURAGI
ESIC Medical College and Hospital
Kalaburagi
Employee State Insurance Co-operation Medical College Kalaburagi is
one of the famous Government Medical colleges in Karnataka . It is
also known as ESIC kalabuargi .It is situated in kalabuargi Karnataka.
2. GREEK PERIOD :-
In Greek period the Greek medicine was not
only for the greacian.
Form older civilization , especially those of Egypt , Babilonia ,
Assyria the Medicine in greace was cultivated by Asclepiadae.
The hippacrales knoes as a father of medicine was born about
460 BC in island of COS.
5. JEWISH PERIOD :-
The principal sources of information
regarding Jewish Medicine are bible and the Talmud contain
more detailed Medical information than bible.
6. MOHAMMEDAN PERIOD :-
Christain schoiars , versed both in
greck and Arabic , translated works of thippocrates and Galen
in Arabic and these stimulated medical studies among Arabs.
7. MEDIEVAL PERIOD :-
St.Bartho Lomew’s Hospital landon the
hospital still in existenses form Medical period founded in this
period . It is still has some records of the patients form the
beginning
8. SVENTEENTH CENTURY :-
The Writing of case records was
established and that it was the responsibility of the doctors to
write is one orders.
9. EIGHTEETH CENTURY :-
Benjamin Franklin was one of the
leaders in the movements to established the first in corporate
hospital within the US from the begning the only Medical
records kept where who’s registers in which patient name
Address , DOA ,DOD have recorded.
MEDICAL RECORD
MEDICAL RECORD
OFFICER TECHNICIAN
ASSEMBLING
GGG
DEFICIENCY
CHECK
ACCESSION
WARDS
CODING
MEDICAL
RECORD INDEXING
DEPARTMENT
FILLING
RETERIVELING
RE - STUDY PATIENT
ADMISSIO PURPOSE DISCHARGE
N
ASSEMBLING :-
It arrangement of Medical records form as per
the hospital guidelines.
Commonly Following Assembling :-
a) Admission and summary Record.
b) OPD slip (Admission request form).
c) Death summary or discharge summary.
d) Death reporting from No-2 (single).
e) MCCD form.
f) History.
g) Doctors orders.
h) Progress Notes.
i) Investigation Reports.
j) Consultation Reports.
k) Nurse’s Notes.
l) Graphic Notes.
m) Miscellaneous.
DEFICIENCY CHECK :-
After assembling the case files MRD staff
has to check and deficiencies in check list and keeping the
records separate for completion . In the same hospital all the
received files are entered in a registration for easy retrieval and
there files are sending for coding.
CODING :-
All the files are coded as per international statistical
classification of disease and related health problem (ICD-10).
INDEXING :-
Here we entering patient data in an index card
with code.
FILLING :-
In this stage all files are arranging as per MR number
in ascending order. For filling specialization racks are arrange in
MRD.
RETRIEVAL :-
Here we are reporting permanently filed case
sheet for various purpose such as study follow up etc. Only
trained person can case file with the order of
superior.
CENSUS :-
It is the number of inpatient present at any one time.
Daily Inpatient Census :-
It is the of number of inpatient present at the census
taking time each days plus any inpatient who where
both admitted and discharge after the census taking
previous days.
The census may be complete by the admitting
department or MRD.
Nurse usually compile the census for each floor or
each inpatient care unit of the hospital at a specified
census taking time.
The inpatient census for the hospital is usually taken
midnight.
It may be taken any convenient time but must be
taken at the same hour of each time.
They send the individual 24 hours reports to the
department responsibility for combining the into for
complete marter census.
STATISTICS :-
Statistics is the study of principle and Methods
used in collection , presentation , analysis and interpretation
of numerical data in any sphere of enquiry.
Uses of Statistics :-
To utilization of hospital.
To provide a basis for preparing operation budget.
MCI (Medical council of India) needs hospital.
ASSEMBLING NURSARY OR
WARD
DEFICIENCY INCOMPLE
CHECK RECORD CONTROL
INDEXING CODING
FILLING
RETERIVAL
BASAVESHWAR TEACHING AND
GENERAL HOSPITAL, KALABURAGI
BASAVESHWAR TEACHING AND GENERAL HOSPITAL,
KALBURAGI
ACCESSION:-
Accession Register is maintained mannual manner.
CONTENT OF ACCESSION REGISTER:-
Serial number
Inpatient number
Name of patient
Age/Sex
Date of data entry
Department
CODING:-
Coding is done from the ICD International Statistical
classification of disease related health problem. And also
procedure coding is done. They are doing both.
INDEXING:-
Indexing is doing both Mannual and computerise.in
this BTGH there is there types of register maintained.
1. Diagnostic Indexing
2. Operative Indexing
3. Physician Indexing
FILLING:-
Filling is doing according to serial number and six digit
number system. Stable racks are used for filling.
STATISTICS:-
Average Daily OPD 1300 to 1400
Average Daily IPD 95 to 100
Average Daily Brith 8 to 12
Average Daily Death 1 to 2
Average Daily MLC cases 10 to 15.
SOME OTHER REGISTERS
MLC Register:-
All the types of MLC cases records are
maintained. MLC register is mannual and computerise Both.
CONTENTS OF MLC REGISTER:-
IP number, Date
Patient name, Age/sex
Address
Signature of attender
Details of incidents
BIRTH REGISTER:-
They maintain birth register. They also doing
online registration for birth certificate.
CONTENTS OF BITRTH REGISTER:-
Serial number
IP number
Patient name, Age/Sex
Method of delivery
Date of delivery
Weight of delivery
DEATH REGISTER:-
They are doing online registration for death
certification.
CONTENTS OF DEATH REGISTER
Serial number
IP number
Patient name, Age/Sex
Cause of death
ABOUT HOSPITAL
RECEIVING:-
They received the complete records sheet and
incomplete case sheet returned to their treating department.
ACCESSION:-
After receiving the case sheet form the ward they
are doing accession of the sheet. They are Maintain one
separate register for accession for the General files. They are
maintain only Mannual data in register.
CONTENT OF ACCESSION REGISTER:-
Serial number
Name of patient
Age/Sex
Department
Diagnosis
INDEXING:-
They are doing indexing Mannual Manner. Or
computerized manner.
FILLING:-
In district hospital of Medical Records they are doing
filling according to department wise and order of monthly. They
are making bundle of files of department for one months only.
And they are seperatly doing filling of OBG and LR department
according to months.
In this hospital for filling they are using stable racks for filling.
STATISTICS:-
Daily Average OPD = 2000 to 3000
Daily Average Admission = 250
Daily Average Birth = 20 to 25 (15to20 LSCS)
Daily Average Death = 4 to 5
MLC CASES:-
In this hospital they are handle MLC cases they all
packs the weapons By that’s patient is injured is happned. And
they put seal of the hospital on the weapons after packing and
handover to the police to the further investigation of the cases.
In this this hospital Average Case of MLC in per Months more
than 400 to 500.
CONTENT OF MLC REGISTER:-
Serial number
IP number
Patient name
Address
Age/Sex
Weapons by patient is injured
Signature of treating doctor.
DISTRICT HOSPITAL, BAGALKOT
DISTRICT HOSPITAL, BAGALKOT
This 400 Beded hospital in this hospital. They have their own
software where they are feed the online data Name of
software HIMS Health Management Information system.
RECEIVING:-
They received the complete records sheet and
incomplete case sheet returned to their treating department.
Indexing:-
They are not doing indexing.
ACCESSION:-
Accession register they are Maintain. In the
Accession Register they are maintain following details of
patients:-
Serial number
IP number
Patient name
Age/Sex
Department of date od admission and date of
discharge
Diagnosis
Date of entry
CODING:-
They are not doing coding.
FILLING:-
They are doing filling date wise/department wise and
month wise.
And they are doing and keeping MLC and death case sheet
separately. According to months.
STATISTICS:-
Daily Average OPD =
Daily Average Admission =
Daily Average Birth =
Daily Average Death =
Daily Average MLC =
MLC:-
They are maintain Medio Legal Cases. They are keeping
seperatly MLC case according to months wise. They maintain
data computerized or Mannual Both.
CONTENTS OF MLC:-
Serial number , IP number
Patient name
Ward
Age/sex
Date of admission and date of discharge
Cause of admission
Referred by doctor
X-ray, CT scan (investigation)
Doctor name also
S. NINJLINGAPPA MEDICAL COLLEGE AND
H.S.K HOSPITAL AND RESEARCH CENTRE
H.S.K HOSPIATL AND RESEARCH CENTR
CENTRAL WARD
ADMITTING OFFICE
DEFICIENCY CHECK
ACCESSION AND
ASSEMBLING
ADMISSION
INCOMPLETE
AND
RECORDS
DISCHARGE CONTROL
ANALYSIS
FILLING
MEDICAL RECORDS DEPARTMENT: -
In Medical Records Department there is all types of record are
mentained in the department.
In Hospital MRD is divided into three part.
1. OPD = 12 OPD counter is working
2. IPD = 3 IPD counter is working and 2 to 4 counters for Billing
and those who are not able to stand.
3. MRD: -
General Cases: - General Cases are kept in
department only 3 to 4 year.
MLC Cases: - MLC cases are kept in department life
time.
Death Cases: - Death cases are kept in Department
life time.
RECEIVING: -
In this Medical Record Department they kept only
complete records if the records is incomplete they returned to
the department or ward where the files is comes.
ACCESSION: -
They are doing accession Mannual and
Computerized Both. They maintain Accession Register.
CONTENTS OF ACCESSION REGISTER:-
Serial number
IP number
Patient name
Age/sex
Ward
Entry date
Diagnosis
ICD CODING: -
In this hospital they are doing or using ICD-10
International Statistical Classification of Disease Related to
Health Problem. They are doing Diagnostic and procedure
coding Both.
INDEXING:-
In this hospital they are doing Mannual and
Computerized Both. But the are doing Operative Indexing,
Diagnostic Indexing, Physician Indexing.
FILLING:-
In this hospital they are doing filling according the
numerical system and department wise.
MLC and Death files they are keeping separately.
They are making a bundle of 100 Case sheet according to
department and serial number system.
In Medical Record section for the filling they are using moveable
racks. Because it is easy to move and searching the files.
STATISTICS:-
Daily Average OPD = 2800
Daily Average IPD = 185
Daily Average Birth = 11 to 12
Daily Average Death = 1 to 2
MLC: -
They are maintained MLC Register and also maintained
data Mannual and Computerzied manner.
CONTENT OF MLC REGISTER: -
Serial number
IP number
Patient name
Age/sex
Ward
Diagnosis
Name of treating doctor
Signature of person who brought that person
PHC UHC
(PRIMARY HEALTH (UNIVERSAL HEALTH
COVERAGE)
CENTER)
TALUK CHC
HOSPITAL (COMMUNITY HEALTH
CENTER)
DISTRICT
HOSPITAL
MEDICAL
COLLEGE
In PHC there is 170 out-patient department daily.
There is 15 to 20 In-patient department daily Females are more
because in PHC only More delivery is happened.
In PHC all data is avialable Computarized. In PHC ANC delivery
and PNC delivery patient is routine Immunization.
In PHC National Programme is going on ACF (Active Case
Found).
Lab Investigation all done like:-
HB
Urine
HIV
HBSAG
6 Beds is avialable in PHC.
8 to 10 Birth in a per months.
Temperature 2-8 Celicus Freez. Ice Refrigirator they keep
all types of vaccine immunization Covid-19 Vaccine is available.
Deep Freeze ice-pack also available Temperature (-15 to 25).
One Reception.
Two Consultation Room.
Pharmacy.
Dressing Room.
Injection.
Six Beds LR.
Laboratory.
Meeting Hall.
E.C.G Room.
THE END CONCLUSION
THANK YOU