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Location: It should be located near the enquiry office and main entry of the hospital. It should be in close proximity to the OPD and emergency department.
Admission & Enquiry Office: A space of 125 to 175 sq. feet is recommended.
Central Record Office: The space requirement as rough guide is 2-3 sq. feet per bed is sufficient.
OPD record section: Average of 2-3 sq. feet per bed space is requirement of the outpatient department record section.
| Office | 10’x12’ | 3 |
| Medical record office | 1200 sq.ft. | 1 |
| Records Room no. | 16’x20’ | 3 |
| Records room storage | 120-500 sq.ft. | 1 |
| Equipments | Recommendation for 250-600 bedded hospital |
| Filing rack (10’x3’x1’) | 20 |
| Cabinet index (5’x 8’) | 6 |
| Cabinet index (3’x 5’) | 6 |
| Steel almirahs | 6 |
| Record basket cart | 3 |
| Magnetic Board/ simple board for notices and circulars | 2 |
| Label dispensor | 3 |
| Numbering machine | 5 |
| Automatic date and time stamper | 2 |
| Ladders | 2 |
| Typewriters (computers/ laptops) | 3 |
| Duplicators (scanners) | 1 |
| Electric calculator | 2 |
| Photostat machine / Photocopiers | 1 |
| Printers | 2 |
| Cutting machine for trimming records | 2 |
| Calculators/ staplers (small/ large) | 5 |
| Microfilming machine/ equipment with processor, developer, duplicator, jacket filler and other accessories | 2 |
| Rubber stamps:10*2
Died Microfilmed X-Ray Canceled Medico legal Inactive Duplicate |
2 each |
| Furniture:
Tables Chairs Working tables |
1125
1 |
| Filing space (liner feet) | 450 ft. |
| Communication equipments: telephones/ intercoms/dictaphone | 5 |
1. Latest ICD revision (one set)
2. Medical dictionary (one)
3. Manual of medical records (one)
Adequate provision of stationery & medical records forms & registers should be ensured for efficient functioning of medical records department.
| Hierarchy | Recommendation for 250-600 bedded hospital |
| Senior medical record officer | – |
| Medical record officer | 1 |
| Assistant medical record officer | 1 |
| Medical record technician | 3 |
| Medical record clerk cum typist | 6 |
| Attendant (office boy) | 4 |
Staff requirement are recommended for 500 bedded hospital at a scale of:
Medical Record Office:
Medical Record Officer
Medical Record Technician
Clerks
Peon
Statistician
Admission and Enquiry Office
Assistant Medical Record Officer
Medical Record Technician
Medical Record Attendant
Reception
Central Record Office
Assistant Medical Record Officer
Medical Record Technician/ clerks
Medical Record Attendant
Statistical Assistant
1. Prompt record service, for any information.
2. Convenient and adequate accommodation. It is ideal if both inpatient and outpatient records can be kept in one location. The department should be so located where it is easy for the doctors to come and go.
3. Easy availability & Retrieval of records
4. Simple procedures
1. To initiate process and check the patient records from inpatient, outpatient and emergency services to ensure that all the necessary forms and information are available.
2. To cooperate with the medical, nursing and other healthcare professionals in order to obtain comprehensive patient records and to design and develop effective medical record forms.
3. To assemble medical records in accordance with the prescribed standard order.
4. To code and index medical records as per International Classification of diseases and operations.
5. To maintain and preserve patient records including X-Rays and diagnostic reports in a scientific way for the period recommended in the ‘retention schedule’.
6. To retrieve medical records to meet the needs of patient care, medical education, medical training, medical research, medico legal problems and the evaluation of patient care.
7. To provide and maintain a system for transcription of selected reports.
8. To control movement of patient files in order to achieve a unit record system, to protect files from unauthorized disclosure, to ensure confidentiality for the legal interests of the patient, the hospital and the physician through proper custody of the records.
9. To participate and cooperate with committees such as medical records, quality assurance, infection control, administrative, financial and other committees.
10. To carry out the work of central registration for initiating new patient records including the master patient index.
11. To schedule and register follow up appointment cases and referral cases in the accident and emergency department.
12. To register and maintain records for emergency cases including medico-legal cases in the accident and emergency department.
13. To carry out admitting procedures for patients requiring hospitalization.
14. To coordinate with other services related to those of the medical record department for effective filing and retrieval of records.
15. To prepare and complete procedures related to medical reports, certificates and birth and death reports and to submit data to appropriate authorities.
16. To register admitted and discharged cases in ward register, schedule appointments for follow up cases and to carry out the related ward clerk duties.
17. To receive and preserve the patient’s property in the admissions office in the absence of relatives who assume these responsibilities.
18. To expedite the procedures of the department in accordance with the standards and rules established by the hospital.
19. To develop and maintain an information base and mechanism for providing statistical data, and for submitting monthly reports concerning activities of the hospital and department, and for providing suggestions for effective functioning and future developments.
20. To develop educational programs for the training of medical record personnel.
21. To observe the ethics of the medical record profession and to strive for new innovations to improve departmental functions.
22. To expedite any responsibilities related to the medical record department allocated by the Chief of the Medical Record or Central Information Department of the Hospital.
1. To establish, organize, and manage a medical record department with appropriate systems to provide an effective service in the hospital.
2. To develop policies and procedures relating to the medical record of department in accordance with the Health Directorate/Ministry of Health.
3. To assist the medical record committee in the design and development of different forms required for hospital use.
4. To review the medical records of out-patients, admitted patients, and emergency patients to ensure that they include all important documents and pertinent information.
5. To cooperate with the medical, nursing, and other staff persons in competing patient medical records.
6. To participate and assist in quality assurance, utilization review, infection control, and other committees and programs.
7. To prepare and maintain medical reports, medical certificates, and birth and death registers, and to notify concerned authorities in duly completing the required procedures.
8. To prepare monthly statistical reports concerning the hospital activities carried out, and to submit to concerned authorities any suggestions for improvements.
9. To observe professional ethics and to protect the confidentiality of information from unauthorized persons to keep medico legal records under sage custody and to attend court whenever required.
10. To participate and assist in research programs to develop new methods and procedures for improving administrative activities and financial control.
11. To select appropriate personnel for the medical record department and train them for performing their jobs efficiently.
12. To prepare and carry out educational and training programs such as certificates, diplomas, and degrees for medical record personnel.
13. To accept the responsibility for the safe preservation of patient property during hospitalization.
14. To effectively carry out registration systems and to control the movement of patient files in order to achieve a unit record.
15. To introduce computer services for the effective function of the outpatient, inpatient, and emergency registration systems to collect clinical and administrative statistics.
16. To supply patient files in accordance with the established procedures for medical care, medical education, medical training, medical care evaluation management, and legal purpose.
17. To maintain and protect medical records in accordance with the policies relating to preservation and destruction.
18. To cooperate with the medical, nursing, heads of departments, patients, health agencies, other hospitals, and legal authorities for smooth and efficient functioning of the hospital in general, and of the medical record department in particular.
19. To supervise the work of the medical record department staff, medical secretaries, and medical transcriptions.
20. To participate in educational programs such as seminars, workshops, and conferences related to the medical record profession.
21. To carry out any other duties and functions related to medical record services as instructed by the immediate chief.
1. To carry out technical analysis and evaluation of medical records in accordance with hospital standards.
2. To collect medical, administrative, and other statistics required by the hospital and to provide health information for planning and evaluation of health care is the color assigned to the digit 4, a chart numbered 169484 in a terminal digit file is color coded with a brown band on top, with a green band directly beneath it.
1. To establish, organize and manage MRD with appropriate systems to provide an effective service in the hospital.
2. To develop policies and procedures relating to the medical record of department in accordance with the Health Directorate/ Ministry of Health
3. To assist the medical record committee in design and development of different forms required for hospital use
4. To review the medical records of outpatients, admitted patients and emergency patients to ensure that they include all important documents and patient information
5. To cooperate with the medical, nursing and other staff persons in completing patient medical records.
6. To participate and assist in quality assurance, utilization review, infection control and other committees and programs.
7. To prepare and maintain medical reports, medical certificates and birth and death certificates and to notify concerned authorities in duly completing the required procedures.
8. To prepare monthly statistical reports concerning the hospital activities carried out and to submit to concerned authorities may suggestions for improvements.
9. To observe professional ethics and to protect the confidentiality of information from unauthorized persons to keep medico legal records under sage custody and to attend court whenever required.
10. To participate and assist in research programs to develop new methods and procedures for improving administrative activities and financial control.
11. To select appropriate personnel for the MRD and train them for performing their jobs efficiently.
12. To prepare and carry out educational and training programs such as certificates, diplomas and degrees for MR personnel.
13. To accept the responsibility for the safe preservation of patient property during hospitalization.
14. To efficiently carry out registration systems and to control the movement of patient files in order to achieve a unit record.
15. To introduce computer services for the effective functioning of OPD, IPD and Emergency registration systems to collect clinical and administrative statistics.
16. To supply patient files in accordance with the established procedures for medical care, medical education, medical training, medical care evaluation management and legal purpose.
17. To maintain and protect medical records in accordance with the policies relating to preservation and destruction.
18. To cooperate with the medical, nursing, heads of department, patients, health agencies, other hospitals and legal authorities for smooth and efficient functioning of the hospital in general and MRD in particular.
19. To supervise the work of medical record department staff, medical secretaries and medical transcriptionists.
20. To participate in educational programs such as seminars, workshops and conferences related to medical profession.
1. Absconded Patients
Information about absconded patients must be recorded in the patients file with details concerning the date and time the patient was discovered to the missing from the ward. The treating physician should note and sign the record accordingly. The matter must also be communicated to the police.
2. Against Medical Advice
The patient who leaves against medical advice should be considered as discharge. It should be ensured that the signature of the patient or his or her nearest relative is obtained in the prescribed form.
3. Referral of Patient
Patient referred from either outside or within the hospital should receive three referral copies, the first two copies are presented to the hospital by the patient whereas the third copy is retained by the referring health center or clinic. After treatment, the first copy is forwarded to the health center or hospital as feedback information and the second copy is retained in the hospital. All three copies of the referral from patients referred within the hospital become part of math patient file.
4. Patient Having Multiple Records
As a general rule, each patient should have one record and one number, due to improper system or negligence of the MRD staff, the patients may have more than one record. In that situation, it becomes necessary to retain one record by cancelling others. The appropriate procedure is to retain a record as a priority, which is medico legal nature, secondly obstetrics records, thirdly admitted record and fourth priority is oldest records, the remaining records have to be cancelled and given a cross reference numbers and bring all the documents including the investigation reports into the retained record. The cancelled empty folders with the cross reference number should be placed in their respective area. Any cancelled record number should never be allocated to a new patient.
5. Missing Records
Despite the strenuous measures adopted to have good control of records, and not to lose, some percentage of records, however do not find in the respective place where they are supposed to be. This could be due to non-receiving, not keeping in appropriate place and wrongly filing. Under this circumstances, when a patient attends either for outpatient or inpatient record. At times, the physicians insist on original record for rendering care. The MRO might be able to retrieve them later, but at that stage the only option left for him to create a duplicate record with a similar number and with all previous ID data. The duplicate record should be retained by the MRO without filing and immediately should trace out the original records and incorporated all this forms of duplicate record into the original record and then the record should be filled.
Medical Records at Admitting Office
Admission Check Desk
Census Desk
Assembly & Deficiency Check Desk
Incomplete Records Control Desk
Vital Statistics Desk
Discharge Analysis Desk
Coding and Indexing desk
Various methods of indexing are used to name few; the following indexing methods are used
1. Alphabetical Indexing: Patient name sequenced in alphabetical order.
2. Disease Index: The medical records are of patient having the same diagnosis is placed at one place.
3. Unit Indexing: Unit wise indexing of medical records are done like Cardiology, Nephrology or Unit I or Unit II of surgery department.
4. Physicians Index: All patients treated by a particular physician are indexed.
5. Operation Index: Details of patients, who have undergone surgery, are indexed.
Filing is the process of classifying, arranging and storing records systematically so that these can be easily retrieved.
“Filing is the systematic arrangement for keeping of business correspondence and records so that these may be found and delivered quickly when needed for reference in future.”
George R Terry defines, “Filing is the placing of document and papers in acceptable containers according to some predetermined arrangement so that any of these when required may be located quickly and conveniently.”
1. Centralized System: Centralized filing system is one, where all the filing equipments and personnel are located in a single area of the office, accessible to all departments by messengers; controlled by a centralized plan or index of the filing. All the medical records whether OPD or IPD are filed in medical records department of the hospital.
2. Decentralized: Decentralized filing system, also called departmentalized filing system is one, where each organization makes its own arrangement for filing. For example, the OPDs have their own records department. If a patient is transferred from one department to another department, the file is transferred on loan basis.
1. It ensures uniformity and standardization of the filing equipment and procedure which can help in easy and quick location of records.
2. It eliminates the need of duplication and distribution to all concerned sections. It encourages completeness of related documents.
3. It enhances economy of time for both file users and file personnel because there is only one place to send material to be filed, and one place to find it.
4. Control is exercised more effectively since one person or group alone is responsible, which minimises oversights and loss of valuable records.
5. It promotes economy of filing equipment and floor space.
6. To be most effective, a compromise has to be struck between centralized and decentralized filing system. Decentralized filing should be kept to a minimum.
The various methods are used by the hospitals for filing of records. Some of them are being given below:
1. Types of Files: Different colour files can be used for different years, for easy identification and files of standard size should be used for uniformity.
2. Filing system: It has two components:
a. Filing arrangement
b. File indexing
The files may be arranged in either of the following methods depending on the organization:
i. Alphabetical method
ii. Numerical method
iii. Chronological method
iv. Mid digit system
v. Terminal digit system
vi. Geographic method
File indexing is a key to locate the files. Index is a reference list used for locating a particular document in the filing equipment. The following types of indexing may be used for locating:
i. Vertical card indexing- The files are arranged vertically on its spine or edge and supported by other file.
ii. Visible card indexing
iii. Loose leaf book indexing
iv. Horizontal system: The medical records are inserted in folders/files and are kept one upon another in chronological order.
a. Suspended filing system: The medical records are suspended from frames in drawers and cabinets.
b. Microfilming of medical records: It saves money, space and also easily retrievable and safe.
c. Computerized records: In modern hospitals, where the hospitals are fully computerized and connected in a network, it has virtually replaced the manually filing system. The medical records are password protected and can only be edited and retrieved by the authorized people.
Completed medical records are stored in safe custody of the medical record department. Following factors are taken into consideration for the storage of the records:
1. Compactness
2. Easy accessibility
3. Simplicity for understanding
4. Elasticity for expansion
5. Economical
6. Easily retrievable
7. Safety from fire, moth, insects and dampness etc
8. Controllability
The medical records are retrieved under the following situation:
1. Patient attends for follow up
2. File issued for research work
3. Files summoned by court of law
4. Patient admitted to IPD
For medical claims
The period for which the medical records can be retained in the hospital vary from hospital to hospital, depending upon the teaching and training or research facilities available. In general the periodicity is:
1. OPD Records 5 years
2. Inpatient Records 10 years
3. Medico legal records permanently
The recommendation as per the hospital policy of one such hospital is being given as under:
1. Outpatient records not linked with inpatient records to be preserved for 5 years.
2. Out-patient records linked with inpatient records to be preserved for 10 years.
3. In-patient records to be preserved for 25 years.
4. All medico-legal cases to be preserved for posterity.
5. All medical records other than those mentioned above to be disposed off on a regular basis.
6. All old X-rays relevant to the out-patient files that are being disposed off to be destroyed.
As per Medical Council of India, medical records should be maintained of indoor patients for a period of 3 years from the date of commencement of the treatment in a standard Performa laid by MCI.
Generally hospitals retain medical records longer than the retention period for Research purposes and avoiding any medico legal issues.
National Accreditation Board for Hospitals and Health care providers accredited hospitals in India follow the retention period of medical records as of United States.
In United States, the general rule defines the period of sorting the medical records as follows;
Inpatient record…………..…7years
Outpatient records…………5 years
Medico legal cases………….15 to 30 years or until final hearing of the case
Minor patient maintain record until the patient reaches the age 23 or 10 years from last date of treatment whichever is greater.
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