Medical Record Depatment

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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) :

  1. Maintenance if Inpatient medical Record i.e. Case of the patients since 2005 till date.
  2. 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.
  3. Maintaining Medico Legal Registers since 2005 till date.
  4. 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.
  5. Medico Legal Correspondence with the police authorities regarding issue of Discharge Summaries, Injury/ medical reports and the MLC Reports.
  6. 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.