Aruna Asaf Ali Govt Hospital
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.
The medical record is an important compilation of facts about a patient’s life and health. It includes documented data on past and present illnesses and treatment written by health care professionals caring for the patient. The medical record “must contain sufficient data to identify the patient, support the diagnosis or reason for attendance at the health care facility, justify the treatment and accurately document the results of that treatment” (Huffman, 1990). The main purpose of the medical record is:
- To record the facts about a patient's health with emphasis on events affecting the patient during the current admission or attendance at the health care facility, and
- For the continuing care of the patient when they require health care in the future.
A patient’s medical record should provide accurate information on:
1. who the patient is and who provided health care
2. what, when, why and how services were provided and
3. the outcome of care and treatment. The medical record has four major sections
- Administrative, which includes demographic and socioeconomic data such as the name of the patient (identification), sex, date of birth, place of birth, patient’s permanent address, and medical record number
- Legal data including a signed consent for treatment by appointed doctors and authorization for the release of information
- Clinical data on the patient whether admitted to the hospital or treated as an outpatient or an emergency patient.
The main uses of the medical record are:
- To document the course of the patient's illness and treatment
- To communicate between attending doctors and other health care professionals providing care to the patient
- For the continuing care of the patient
- For research of specific diseases and treatment; and
- The collection of health statistics.
Functions of Medical Records Department (MRD) :
- Maintenance if Inpatient medical Record i.e. Case of the patients since 2005 till date.
- Forwarding the Birth and Death Reports of this hospital to the District/Zone Sub- Registrar. The patients/relatives may obtained the Birth or Death Certificates from the said office within one year after that it may be obtained from their head office of Registrar Births and Deaths, NDMC, Mandir Marg, New Delhi.
- Maintaining Medico Legal Registers since 2005 till date.
- Receipt of Summons from the Court of law and deputing the records clerks or the doctors as the case may be to attend the court with the requisite records.
- Medico Legal Correspondence with the police authorities regarding issue of Discharge Summaries, Injury/ medical reports and the MLC Reports.
- Correspondence regarding patients of this hospital i.e. regarding
- Issue of letter to District/Zone Sub- Registrar for any correction/modification in the birth & death reports sent to NDMC, if required by the inpatients/relatives in their particulars on the basis of written application,submitted by the patients or their relatives.
- Preparing Monthly and yearly Hospital Statistical data of this hospital.
- Coding (ICD-10 i.e. International Classification of Diseases, Tenth Revision) on the case sheets for generating Diagnostic data of the inpatients of this hospital.
- Answering the Parliament Questions for the information available in this Department and Sending various diagnostic data reports to various health agencies as and when required.
- Answering the RTI Queries for the information available in this Department
- Any other work assigned by the Head of this Institution.