As a general rule, “the most successful man is, the man who has the best information”.
The Medical Record is a scientific document, containing patient’s identification dates, illness, history, physical examination, clinical findings, investigations, diagnosis, treatment given and end results.
The Medical Record serves as a personal, impersonal and also legal document depend upon the place and tine of usage.
Knowing the significant, the Medical Record Department has been organized at C.M.C.H. & R.C, Irungalur, Trichy, as per the Medical Records maintenance principles, from the beginning of the institution 2008.
The Out-Patient, In-Patient registration sections and Medical Record Department are computerized with net connection.
Since it us a teaching hospital, the following staff members are working in the Medical Records Department as per the norms prescribed by the Medical Council of India.
Total 17 Staff Members
Medial Record Officer
The In-patient discharged case records are received from the office of the Nursing Superintendent along with the daily census register.
Such received records are verified with the ward census registers for accuracy.
Medico Legal Case records and Death case records are separated from other case records.
The Death Register is being maintained, containing sufficient information about the patients died along with diagnosis and code no.
The Accident Registers are received from the Casualty daily and details of treated patients are entered in a separate Nominal Register for Medico Legal Cases for reference.
Medico Legal Cases and Death case records are separately filed and kept under safe custody.
The In-Patient discharged case records with are received daily, are being processed by coding clerk as follows:-
Coding of diagnoses as per International Classification of Diseases X th Revision Published by W.H.O
Coding of operative procedures
Such coded records are computerized
To avoid wrong filing, colour folders are being used for each month
Keeping the such completed records in the respective prenumbered folders
OUT PATIENT REGISTRATION
The centralized Out-Patient Registration section is functioning with two divisions, one for New cases and another one for Revisit case registration.
In order to facilitate the physically challenged and senior citizens separate counters on each section are being maintained. Necessary computer operators for registration have been posed in the centre registration section.
The In-Patients admission registration is also attached along with the O.P. Registration wing. Whenever patients are advised for admission, the desk clerk will take up the responsibility to get preliminary admission order from the Admission counter and shall take the patient to the concerned wards.
COMPILATION OF STATISTICS
Pattern of Medico Legal Case treated.
Statistics on Notifiable Diseases
In-Patient, Out-Patient department wise statistics
Compilation of statistics of investigations done at various laboratories
Speciality wise operation statistics
Compilation and presentation of any other kind of statistics as required by the M.C.I., are prepared
Case sheet issue register is being maintained
CALCULATION OF RATES SUCH AS
All the above Hospital Statistics are compiled monthly & yearly, and presented to the Hospital Administrators regularly for perusal and planning for future developments.
Every month on a specific day, the Medical Audit Meeting is being conducted as per procedures laid down in the Medical Record Science.
Neo-Natal Mortality rate
Net death rate
Gross death rate
Still birth rate
Besides, the Medical Record Department is attending the duties of Issuing of wound certificated in the Medico Legal Cases.
Treatment particulars to the insurance authorities.
Assisting the Medical Officers in filling up of various types of insurance claim forms.
Producing the In-Patient records in the court on receipt of summons.
Furnishing statistical data’s to various clinical & non-clinical departments while conducting continuing education programmes.
Issuing of old case records on readmission on proper requisition
Production of case records to the inspectors belonging to Chief Minister Comprehensive Health Scheme for verification.
Arrangements are made for maintenance of common death register in the hospital.
Issuing of Mortuary Cards to the relatives of the deceased to enable to get Death Certificate / Post- Mortum Certificate.
Knowing that, the Medical Record is the best source of hospital statistics, legal validity and also the value of Medical records, proper attention is being given to maintain a good Medical Record System in this Hospital with cooperation of all other Department & Management.