BASIC MEDICAL RECORD DEPARTMENT PROCEDURES
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1 BASIC MEDICAL RECORD DEPARTMENT PROCEDURES 1
2 Four essential Medical Record Department procedures: 1. Admission procedure and the master patient index (MPI). 2. Discharge procedure. 3. Disease classification and clinical coding. 4. Filing medical records. 2
3 Admission Procedure and the Master Patient Index (MPI) the medical record starts with the admission of a patient to hospital or their attendance at an Outpatient Department or presentation to an Emergency department. 3
4 During the admission of a patient, the staff member in the Medical Record Department responsible for patient identification and the MPI is required to check to see if the patient has been an inpatient or outpatient previously and has a medical record number. 4
5 This is usually done by: A telephone inquiry about a patient from the admission clerk to the medical record department where the mpi, (which is kept in the medical record department), is checked to see if the patient has been in hospital previously and already has a mrn; If the answer is yes, the number is given to the admission clerk to record on the front sheet of the patient's medical record; If no, the admission clerk assigns the next unused number from the numberregister. 5
6 Admission Register Contents of the Admission Register Family name and given name. Reason for admission (presenting disease/illness). Date of admission. Date of discharge. Discharge alive/dead. Doctor's name, Gender, Date of birth/age, Ward, 6
7 DISCHARGE PROCEDURE While in hospital, the patient s medical record develops with the recording of clinical information by doctors and other health professionals. Results of pathology tests etc., are added as they are received. Nurses record daily progress notes and special observations. If a patient has any special tests and/or surgical procedures, relevant information is included. On discharge/death of the patient the medical record, including ALL forms relating to the admission plus any previous records, should be sent to the Medical Record Department as soon as possible or within 24 hours. Medical record staff responsible for the discharge procedure should be trained to ensure that the medical records are completed promptly and correctly. 7
8 Receipt of Medical Records The discharge procedure begins with the receipt of the medical records of discharged/dead patients. 1. The medical records of discharged patients or patients who have died should be sent to the Medical Record Department by the ward staff the day of discharge or death, or the next morning. 8
9 2. Admission Office staff is responsible for the daily bed census, which they receive from each ward at the beginning of the day. From the bed census forms, staff are able to record details of discharges and deaths and prepare a DAILY DISCHARGE LIST. This list is important and should be duplicated and sent to a number of sections in the hospital including the Accounts, and the Medical Record Department. 9
10 3. Discharge lists should be kept in date order in the Medical Record Department. The list should contain the patient's name, age, treating doctor, ward, and service, that is, whether medical, surgical, obstetric, orthopedic, etc., and whether the patient is alive or dead. Discharge lists are usually used to prepare the hospital inpatient statistics. 10
11 Death Register death register, is a list in date order of all inpatients that died in the hospital/health care center. The death register DOES NOT INCLUDE persons who are DEAD ON ARRIVAL (DOA) at the hospital as they are not formally admitted. It also does not include patients who die in outpatients or emergency. The death register ONLY includes inpatients that die during their stay in a hospital or other health care facility. 11
12 Contents of the death register include the patient s family name and given name; age and sex; home address; treating doctor and ward; underlying cause of death as recorded by the attending doctor on the death certificate. 12
13 Medical Record Completion Procedure check to ensure that all the forms are in the medical record. This procedure is often called the discharge analysis. For example, the record is checked to ensure that if the patient has had an operation, an Operation Report is in the record. In addition, the clerk needs to check that all progress notes, pathology and x-ray forms, nursing notes etc. are included. There should also be a final discharge note made by the attending doctor indicating to where the patient has been discharged and arrangements for follow-up. 13
14 Sort the forms into the correct order In the case of a new patient, the forms are attached to a medical record folder with a clip or fastener and the patient's name and MRN are clearly written in the correct place on the folder. If the patient has been in hospital before, the old records are retrieved and the latest admission forms are added by placing them behind the appropriate admission divider. 14
15 Check if the doctor has completed the lower part of the front sheet. That is, the main condition has been recorded along with any other condition treated while in hospital. The main condition is defined in the section on disease classification. It is referred to as the principle diagnosis, which is defined as the diagnosis established after study to be chiefly responsible for occasioning the patient's episode of care in hospital. 15
16 Discharge Summary A discharge summary is a summary of the patient s stay in hospital written by the attending doctor. The minimum detail provided in a discharge summary is: Patient identification; Reason for admission; Examinations and findings; Treatment while in hospital; Proposed follow up. 16
17 Disease Classification and Clinical Coding Clinical coding is the translation of diseases, health related problems and procedural concepts from text to alphabetic/numeric codes for storage, retrieval and analysis of health care data. 17
18 Why code medical records? Coded data are used to collect statistics on the types and incidence of diseases and injuries. Enable the retrieval of information on diseases and injuries. This information is used at a national level for planning health care facilities, Determining the number of health care personnel required. Educating the population on health risks within the country. used at an international level to compare health status of countries in a region or globally. 18
19 the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) is used to code diseases, injuries, and external causes of injuries. Prior to 2000 ICD-9 or ICD-9-CM was used in most countries and one or the other is still being used in some. 19
20 ICD10 ICD10 is a statistical classification. it contains a limited number of mutually exclusive code categories which describes disease concepts. It uses an alphanumeric coding scheme of one letter followed by three numbers, at the four character level. The classification system is made up of three volumes: 20
21 Vol. 1 the Tabular list; Vol. 2 an introduction to and instructions on how to use volume 1 and 3, together with guidelines for certification and rules in Mortality coding; Vol. 3 the Alphabetical index of the diseases and conditions found in the Tabular list. 21
22 Clinical Coding Procedure Before proceeding to code, the MRO or person responsible for coding should check the medical record to ensure all forms are present and the doctor has completed the record. That is, they should take the following steps: Review the front sheet for completeness and accuracy, The main condition has been recorded on the FRONT SHEET and the doctor has signed in the space provided; Read the discharge summary for information relating to the diagnosis; 22
23 Check that the diagnosis is supported by evidence in the medical record such as pathology report, x-ray, etc.; Review the progress notes; Check the medical record to determine what items should be coded; If is has been determined that only the main condition is to be coded, the coder should find the code number for that condition and record it on the FRONT SHEET in the correct place; If hospital has decided to code the external causes of injuries. You need to know if this is the case and code accordingly; If all diagnoses/injuries are to be coded, the MRO follows the same procedure by identifying associated conditions and other diagnoses and allocating the correctcodes. 23
24 MEDICAL RECORD FILING PROCEDURE When the medical record has been assembled after discharge, completed by the medical officer, coded, and the relevant statistics collected the final procedure is filed. It is important that careful planning be given to the filing area for medical records. 24
25 Medical Record File Area Plenty of space must be available for filing medical records and that the file area is clean, tidy and has good light. The file area should have desks for the medical record clerks to sort medical records and make out tracers; and space for records awaiting filing or completion. 25
26 How much space is needed? It is easy to calculate the amount of space required for medical record files. 1. Measure one full shelf. 2. Count the number of files on the shelf. 3. Calculate the number of files per linear metre. 4. Count the number of new files created last year. 5. Calculate the number of linear metres required per year. 6. You can then calculate the number of linear metres required for one, five or 10 years. 26
27 A bay of filing shelves. 27
28 Filing: Systems and Methods There are two types of medical record systems: A decentralized medical record system Centralized medical record system. 28
29 Decentralized medical record system Inpatient and outpatient departments have their own individual medical records and should file them independently. Inpatient medical records are filed in the medical record department and outpatient medical records are filed in the outpatient department. There is usually no connection between the services. If a patient has two medical records, This system is not recommended as all data concerning a patient are not instantly available at all times. 29
30 Centralized medical record system All medical records about a patient, whether inpatient or outpatient, are filed together in the one folder and kept in the medical record department. That is, a patient has one medical record regardless of the number of times he or she has been admitted or attended the outpatient department. 30
31 To illustrate - john lee is admitted to hospital for the first time and is issued the medical record number He keeps this number for Future admissions and attendances. All medical information about john lee is kept in one record and filed by his MRN in the medical record department. The number assigned identifies him in any department of the hospital in which he may be treated. That is, the record of this patient's medical care is continuous with all data concerning the patient immediately available at all times. 31
32 Types of filing methods used in hospitals: 1. Alphabetical filing; 2. Straight numeric filing; 3. Terminal digit filing. 32
33 The best filing method straight numeric filing. In this method, medical records are filed in strict number order according to the MRN starting with the lowest number and ending with the highest number. For example, 542 is followed by 543 which is followed by 544, etc. 33
34 With straight numeric filing, it is a good idea to have one medical record clerk responsible for the filing procedure. Examples of Straight numeric filing:
35 Terminal Digit Filing This method is not recommended where the number of records is small. It is also not recommended when clerks are not trained in its implementation and use. Incorrect implementation could cause problems and confidence in the staff of the medical record department will be affected. 35
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