SYSTEM OF MEDICAL
RECORDS AT HINDU RAO
HOSPITAL, DELHI
BY SATENDRA KUMAR
CHIEF MEDICAL RECORD OFFICER
HINDU RAO HOSPITAL
DELHI
INTRODUCTION
• Hindu Rao Hospital 980 beded general Hospital.
• Under Municipal Corporation of Delhi.
• For the management and systematic maintenance
of Medical Records in the Hospital a Medical
Record Department was established in the year,
1970
• To begin with MRS was started with one Medical
Record Keeper and 3 class IV employees.
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At present the Medical Record Deptt. has
Medical Record Officer
Medical Record Technicians
Medical Record Clerks
Medical Record Attendants.
The Reception, Enquiry and Admission office functions
round the clock under the charge of Medical Record
Officer.
• Presently only inpatients records are maintained in the
Medical Record Department.
• Registration work of OPDs are also managed by the
Medical Record Officer.
• Statistical information about the functioning of OPDs is
regularly submitted by the Medical Record Officials in the
Medical Record Deptt.
SYSTEM OF MEDICAL RECORD
• DEFINITION
Medical Record of the patient stores the
knowledge concerning the patient and his care. It
contains sufficient data written in sequence of
occurrence of events to justify the diagnosis,
treatment and outcome.
In the modern age, Medical Record has its utility
and usefulness and is a very broad based indicator
of patients care.
 It has various uses to
 Patients
 Doctors
 Hospital
 Teachers
 Students
 For research work
 National & International agencies
ORIGIN :The inpatient Medical Record in originated at the
admission office based on the admission order
made by the clinician or at Casualty Deptt. and
various OPDs of the Hospital.
Flow of Medical Record :The flow chart of inpatient Medical Record is as under :Central Admission Office
Wards
Medical Record Department
1.
2.
Assembling
ADMN. &
Discharge analysis
3.
Storage Area
Afetr completion of Reccords
Hospital statistics prepared
Monthly/Yearly
Medical Record is filled for perusal of
Patients/claims/research purposes.
FILING OF MEDICAL RECORDS
• The inpatients Medical Record is filed by the
serial numbers assigned at central Admitting
Office.
• The Record is bound in bundles 100 each and are
kept year wise according to the serial number.
RETENTION OF MEDICAL RECORD
• The policy is to keep indoor patient Records for
10 years
• The OPD registers for 5 years
• The record which is register for legal purposes in
Maintained for 10 years or till final decision at the
court of Law.
OUTPATIENT DEPARTMENT
• There is a decentralized system for
registration of OPD patients.
• Patients are registered at different
registration counter specialty wise.
• Clerks posted for registration have been
made responsible for the preparation and
submission of statistical data of their
respective OPD
FUNCTIONS OF MEDICAL RECORD DEPARTMENT
1.
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Daily receipt of case sheets pertaining to discharge, 2 A.M. an expired
patients from various wards, there checking and assembly.
Daily compilation of Hospital census report.
Maintains & retrieval of records for patient care and research study.
Completion and Procession of Hospital statistics and preparation on
different periodical reports on morbidity and mortality.
Online registration of vital events of Birth & Death
Issuing Birth & Death certificated upto one year.
Dealing with Medico Legal records and attending the courts on
summary.
Arrangement & Supervision of enquiry and admission office.
Arrangement & Supervision of OPD registration
Management of disability boards.
Management of Medical Examination
Management of Mortality Review Committee Meetings (Twice
month)
Assistance to Hospital Administration in various matters.
SYSTEM OF COLLECTION, COMPILATION
AND FORWARDING STATISTICAL REPORTS
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Medical Record officials posted for registration of OPD patients have been
made responsible for the preparation and submission of statistical data on
their OPDs.
One Medical Record Officer visits to the wards daily and collects the
disease wise reports of the discharged patients and submits the same in the
medical record section. One official of the Medical Record Section
classifies the data according to the different performa. Following reports
are compiled forwarded to various departments.
National list for Tabulation of Morbidity and Mortality
Monthly Health Bulletin
Monthly report of Polio Cases
Monthly report of GWEP
Report of cataract operations
Monthly report of communicable diseases
Monthly report of Measles cases
Monthly report of Japanese Encephalitis
Monthly report of MNT (Paed & Gynae)
10. Monthly report of AIDS cases
11. Monthly report of Anti Rabic cases
12. Monthly report of STD
13. Monthly report of cases & Death due to snakebite.
14. Monthly report of Sex Ratio (Birth Death)
15. Monthly report of Malaria cases.
16. Monthly report of Deliveries
17. Monthly report of Family Planning
18. Monthly report of Medicine, DRT, Polio, TT
19. Monthly report of Leprosy cases
20. Weekly report of Polio
21. Weekly report – Statement showing the no. of cases treated (OIVS)
22. Weekly report of National Programme for surveillance of communicable
disease (DHO)
23. Weekly report of Dengue fever cases
24. Weekly report of Pyogenic Meningitis
25. Weekly report of Gastro-enteritis, Cholera
26. Daily report of Noticeable Disease under surveillance.
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