Medical Records Department is an integral part of patient care, which houses the medical records of all the patients who have utilized the services of the hospital.

• A medical record is a systematic documentation of the patient’s medical history and care provided in the hospital. The information thus collected and stored in an orderly manner is useful for patients, their relatives, healthcare team members, hospital management, Government Agencies, Public Health Agencies, Research Organizations, etc.
• Its purpose is to ensure seamless integration of Medical Information across the hospital by maintaining timely, accurate and complete health records and ensuring safety and confidentiality of the information.
• Apart from Medical Recordkeeping the department also collects the information from all departments and prepares statistics, which is useful for planning and organizing the hospital services.
• IPD data is maintained in HIS and is accessible to authorized persons during off working hours.
• MRD is having computerized Document Management System (DMS). DMS is scanning the patient’s all data, written during throughout patients hospitalization including consent, daily order sheets, nursing sheets everything without hampering original data. It will help in retrieving medical records very fast. Limited access control is given to provide security.
• Electronic Medical Records (EMR) is also part of MRD.

Scope of services

• Preparation of Patient Files
• Checking for deficiency of patient files
• Processing of patient files
• Storing of patient files
• Retrieval of Records
• Preparation of Statistics

Objectives

To provide guideline instructions & process of Management of Medical Records with the aims that

• Medical Records are readily retrievable, and
• A feedback loop is established for continuous improvements in Health Indicators.
• The primary objective of the Medical Record Department is to develop good Medical Records containing sufficient data written in a sequence of events to justify the diagnosis, treatment and end result of all patients treated in a hospital, keep them under safe custody and make them readily available as and when required fo

For Patient, it

• Serves to document the clinical history and activities of patient treatment
• Serves to avoid omission or repetition of diagnostic and therapeutic measures
• Assists in continuity of Care even in future illness whether it requires attention in or out of the Hospital
• Serves as evidence in Medico-legal Cases
• Give necessary certification for employment purposes

For The Doctor, it

• Assures quality and adequacy of diagnostic and therapeutic measures Undertaken
• Serves as an assurance of continuity of medical care
• Evaluates Medical Practices
• Protection in litigation

For Hospital Administrator

• To document the type and quantity of work undertaken and accomplished
• To evaluate the proficiency of Medical Staff for administrative and clinical purposes
• To evaluate the services of the hospital in terms of accepted norms and standards
• To serve as an administrative record and Performance
• To assist in futures Programmers for Planning and developments of hospital

For Medico-Legal Purposes, it serves

• As a documentary evidence
• To dispose of claims of the Insurances
• Patient’s WILL to indicate if the patient was of normal mental state or not
• Authorization for an operation etc. signed document for consent for the operation will prove that the Patient / Relative have allowed the performance of such procedure.

Development of Hospital Performance Statistics (EMR)

Statistical and Epidemiological Data are needed to implement and manage medical care planning and to obtain Health Indicators to monitor and evaluate their effectiveness for Hospital Management as follows: some examples

• Bed Occupancy Rate
• Average No. of Our Patients
• Average No. of Admissions
• Sex wise Admissions
• Sex, age, disease wise statistical data
• Average Length of Stay of Patients.
• Mortality Rate.
• Number of Types of Operations performed
• Number of X-ray / C.T. Scan, Ultra Sound etc.
• Laboratory Tests.;

Reporting to Health Authorities:

This is the responsibility of the department to submit the following.

• Diagnostic Reports to Health Agencies like D.H.S. and other departments under the ambit of Health & Family Welfare department, Government of Maharashtra.
• Daily / Weekly / Monthly Malaria and Dengue Fever cases
• All Communicable Diseases to the D.H.S
• Morbidity / Mortality Statistics to the D.H.S., on a yearly basis or as and when required by the Directorate of Health and Family Welfare Department Government of Maharashtra

Process of creating medical records

Medical Record contains different sections for recording the information as

1. Identification Section
2. Medical Section
3. Nurses Section

All entries made in the medical and nursing section of the patient record are entered by authorized care providers who authenticate the entries made so as to facilitate identification of the particular author of patient’s Medical Records.

Identification section:

This section fills up the Bio-Data / Socio-economic data / Patient Identification Data at the time of Registration and Admission. OPD file is generated at OPD registration counter. Personal data for the following particulars are provided at OPD registration and Admission counter by the Patient / Relatives.

• Name of Patient
• Father’s / Husband’s Name
• Age & Sex
• Occupation
• Permanent / Emergency Address
• Telephone / Mobile Numbers
• These details are fed in the EMS manually and the patient is given an IPD No. which is entered in the designated area of the patient.

Medical Section:

The Medical Section is filled up by the Attending Consultant/doctor in charge and pertains to History, Physical examination, Treatment/progress of the patient, if the operation is to be performed, then Operation notes are also recorded, the information is recorded in the following Medical Record Forms, keeping in view two types of forms – Basic + Special

All treatment plan and orders would be signed, dated and timed by the concerned consultant in charge and the duty doctor

Basic:–

• Clinical Record,
• Nursing Record
• Daily Orders on Continuation Sheet – (Progress, Treatment Record and Different Investigations)
• Physiotherapy sheet,

In Special cases-

• Consent Forms,
• Operation Record Form
• A discharge summary is given in case of Discharged – cured, DAMA, Discharge on request or Death Summary. A copy of the same is preserved in the patient’s medical record.

In the case of Death:

Medical Certification of cause of death forms is to be filled up by the attending consultant or emergency medical officer according to the Registration of Birth and Death Act 1969.

A copy of the death certificate is preserved in the patient’s medical records file.

Nurses Section

The Nurses Section is responsible for filling up the following

• Nurses Chart –Order Sheet, Monitoring Sheet, (Medication Record Forms, T.P.R. Chart. INTAKE and OUTPUT Record, Diet sheet)
• All Doctor’s & Sister’s Progress Notes sheets of IPD records are completed simultaneously computerized record is completed on a daily basis.

The flow of medical record from admission to post-discharge

The Medical Record Department ensures a smooth flow of Medical Record of the patient from the day of his admission to the day of his discharge and onward maintenance until the retention period.

1. A formality for admission of the patient is carried in the registration counter. First admission paper with General Consent is sent to the respective nursing station
2. The inpatient case paper is prepared at the time of admission in the respective inpatient nursing counters after an initial assessment of the patient.
3. All data pertaining to the patients stay in the hospital and care provided are preserved at the nursing counter by the nursing staff and duty doctors of the concerned ward where the patient is admitted.
4. All entries made in the respective case paper by respective staff in a chronological manner and authenticated by the designated author of the particular entry clearly mentioning the time and date of the entry.
5. After getting the orders of discharge of the patients from the treating Consultant, the duty doctor prepares the discharge summary.
6. The file is sent to the Billing Department for necessary payment and again recollected.
7. ICD Coding is done as per disease. For ICD code refer ICD – 10 for final diagnosis.
8. Necessary payment is done at the Billing Department after getting clearance from all departments. The receipt is given to patient relative.
9. Nursing staff discharges the after getting clearance slip from the billing department. The patient file is sent to the medical record room.
10. In case the patient is transferred or referred to another hospital the medical record contains information regarding reasons for transfer, name of the hospital where the patient is being transferred
11. In the case of Indoor case papers of the patient from clinical trial whose SAE is reported are kept in Xerox and original are with the respective authority.
12. The discharged/expired patients’ documented papers removed from IPD file and arranged in the chronological order from Date of admission to the date of discharge or death and arranged in division wise
13. Diagnostic Studies i.e. all radiological and Pathology investigation are not attached to the Health records kept in hospital, as all investigations are entered on Discharge Summary or Death Summary and investigation are available in Hospital Software.
14. All the blank sheets with or without patients’ identification data should be removed.
15. In case any document is found without the patients’ identification data i.e. Name, Registration No., it should be filled.
16. Discharge Summary or Death Summary is completed on Computer and rechecked by Consultant or CMO, and then dispatched to Patient from reception.
17. In case of Death, all Death Certificate are dispatched with Death Summary. 

Receiving IPD health records of the discharged and expired patient to MRD

• Indoor Paper of Daily discharged and expired patients’ health record charts (files) from the nursing station are being sent to the MRD on the same (in case of 1-day chemo) or following day in between 9:00 AM to 6:00 PM.
• Patients who are discharged / expired previous night (till 12 ‘O Clock midnight), their health record file must be deposited in the Medical Records within 24 hours in MRD.
• The receiving person in the Medical Records Department should sign these details.
• Check all the files received for all required records by using checklists for IPD files
• Tie complete file.
• All records are arranged as per Patient Reg. No. from Jan 2013 onwards. If one patient is admitted multiple times, all files will be kept together.
• Write the patient name, MR Number with the month & year and treating doctor’s name on the envelope. Write the ICD code also on the envelope.
• Place the file in the respective rack.
• Any reports/documents that come after the deposition of the health record file should be sent as soon as possible to the MRD.
• Dispatch of the expired Health Record file along with the death notification form, both in English and Marathi should be made within 48 hrs. of the death
• Check all the patient files thoroughly for the completeness and accuracy of the contents.
• Check whether any report or record is missing in the file.
• Check the contents are appropriately filled.
• Check whether the records are signed along with name, date & time.
• The sorting order of the folder
• Completeness of initial assessment and diagnosis
• Completeness of the report
• Signature of the consultants/clinicians
• Completeness of Diagnosis and discharge status
• Completeness of the consent forms
• Completeness of operation reports
• In case any of the records are missing or contents are not complete inform the concerned ward/ unit and ask them to come to MRD & complete the file. The maximum time limit to complete the file and return to the MRD is 72 Hrs. In case of MLC and death cases, the file must return back within 24 Hrs.
• Make a note of the deficient files in the Deficiency Checking Sheet
• All the deficiencies’ by the doctor are put in the deficiency record folder( Pink colour) and sent to concerned OPD to get it completed. Even then if the files are not completed within 48 hours it is escalated to Medical Administrator for further action.

Record keeping for IPD Papers 

Daily Morning print out from HIS is taken for a patient discharged a day before.

This printout is used to verify record received in MRD and signed for the received record.

1. Registration No. / IPD No.
2. DOA
3. DOD
4. Name & Address of the Patient
5. Age /Sex
6. Consultant’s name
7. Treatment ( Surgery / Supportive / Chemotherapy )
8. Diagnosis

Discharge or death summary is acknowledged and is checked for 

1. History Details,
2. Diagnostic Details
3. Treatment Given Details
4. Surgical Record
5. Provisional Diagnosis
6. Final Diagnosis
7. Next F/U
8. Date & Time of Death, Death Certificates if Death Summary
9. Signature
10. Chronological Order of health record file is checked as mentioned if not then Reassembling of papers is done accordingly
11. The MRD will inform the concerned doctor, nurse or concern department regarding the deficient data in health record file(s).
12. The doctors are to complete the deficient health record file within the stipulated time without alerting any data.
13. A deficiency checklist (Quantitative Analysis) is being prepared and a summary of incomplete/complete data is prepared.
14. Storing of IPD Health Record file is done according to the IPD no.
15. The death notification form in English and Marathi is complete in all respects.
16. The concerned doctor has documented death events including the time of declaring the death in the Doctors’ Progress Note.

Death register

Death Register is also maintained separately for notification to the Municipal Corporation, which includes the following details:

1. no.
2. Registration No. / IPD No.
3. Date & Time Of Death
4. Date & Time of Admission
5. Name & Address of the Patient
6. Age / Sex
7. Cause of death Sign
8. Name & Address of the informer
9. Sign of receiving concerned officer.

The original death notification form must be submitted at Birth and Death registration Office and the Death register is signed and dated form the receiving concerned officer.

Retrieval of records

The hospital identifies its responsibility as custodian of medical records and observes the following procedure to maintain its confidentiality, security and integrity.

The patient is the owner of his medical record and no form of it would be made available to any third party without written authorization from the patient. The hospital observes the following guideline instruction for the purpose:

• To retrieve appropriate IP medical records for the OP consultation and IP admission of patients within the turnaround time.
• Medical records files are retrieved for the staff for study/research etc. Only after receiving the request through proper channel by mail or file loan slip.

This policy aims at retrieving the medical records for review purpose during follow up or for study/research or another purpose.

• Physician / Surgeon generally did not require case paper for follow up purposes, as all records of investigation; day to day treatment is in EMR.
• If in case, Indoor papers are required, they can be accessed by getting permission from MS and get the records.
• Check whether the approval is obtained from the appropriate authority.
• Handover the files to the concerned person and take the signature in Outgoing Files Book
• Maximum 5 files can be taken by an employee at a time for a maximum of 5 days only
• The files should not be tampered at any cost.
• In case the files are not returned within 5 days, call up the doctor/ staff and enquire about the files.
• If the file has not reached even after the intimation, inform the HOD
• Maintain records in proper accessibility manner.
• Hand over the records as & when required for administrative purposes by getting register signed by the person receiving the record.
• Records required for Medico-Legal Cases in the Court of Law by the Consultant
• Patient’s relatives will require written authorization from the patient for obtaining information from the medical records. However such information would not be given in original, a Xerox of the same would be handed over to the patient and signature taken in a specific format.
• Incase loss or tampering of patient’s medical record data is reported, the medical record clerk would immediately inform the same to the Medical Superintendent who would be responsible for taking appropriate action and would submit the report to the Medical Director. In case it confirms any sort of negligence or discrepancy on part of any hospital employee, MS would inform the same to higher for further action.
• The hospital maintains inpatient medical records as per IPD number. The Medical Record Department is responsible for proper storage, retrieval and maintenance of confidentiality and security of the record. During normal working hours, it is the policy of the hospital to have at least one staff available in the department.
• At the end of the day, a medical record clerk is responsible to lock the department in the presence of security staff. The key is handed over to the concerned staff.
• Thereafter the security department is made responsible for the protection of the medical record room.

Release of information and confidentiality

Medical records information is made available only on receipt of written consent from the patient/patient attender and confidentiality of information is maintained and information is shared for authorized bodies

• Information about the patient is kept confidential throughout the care process. No staff member can handover complete Patient file to patient or relative at any circumstances.
• Only Medical Records Department is authorized to issue any of the records from the patient file.
• In case of any request from the patient/ patient relative for records, ask for a letter requesting for the same. In case of a relative requesting for the report the relationship with the patient to be mentioned in the letter.
• Take photocopy and handover the photocopy to the patient/relative only after filing the original copies in the file.
• Apart from the patient/ relative, other occasions where information can be revealed are:
  • When demanded by the court. If the courts require the original document, keep photocopy without fail
  • When requisitioned by the police with a requisition letter
  • When demanded by insurance companies. Check the authorization given by the patient to reveal the information.
  • When asked for by income tax authorities.
  • When asked by any government agencies where information is required for public health concerns
  • HIV status cannot be divulged to anybody other than patient himself, not even to the spouse.
• In these cases, HOD – MRD or Medical Records Officer is the authorized personnel.

Medico-legal cases

In the case of medico-legal cases, the intimation should be sent to concerned police Station which is done by the duty doctor.

• In case of the arrival of any MLC, the Emergency or Admission Department must inform the MRD to label it as MLC Case
• The emergency department should fill up the “Information to the Police” form and inform the police regarding the case.
• Intimate the police on discharge or death of the patient complete record
• In case of medico-legal files, when records are received at MRD, they are marked with MLC label in the records

Out of working hours protocol

Medical Records Department functioning from 9:00 AM to 6:00 PM. Generally, No record is required for reference for further follow-up treatment, majorly all records are available in HIS.

• Even, if there are any emergency cases during night time they will contact the person with the transport facility and they will issue the files.

Issue of records in case of death

The patient’s death reports should be prepared by the doctors, and copies of the report shall be issued to patient relatives, corporation and maintained in the hospital.

• Death Report is prepared by the doctor and signed by Medical Superintendent
• Form No. 4: 1 copy is handed over to the relatives in the ward/unit.
• 2 copies of Form No. 4 is sent to the Corporation within 48 hours.
• 1 copy is kept inpatient case file
• Form No. 2: 1 copy is handed over to the relatives in the ward/unit.
• 1 copies of Form No. 4 is sent to the Corporation within 48 hours.
• 1 copy is kept inpatient case file
• As per corporation rule, these document must be submitted by the hospital within 21 days

Amendments and corrections in the patient files

If the patient or relatives come for any amendments or correction in the patient file it is done after the collection of an application and valid identity proof.

• Any change in demographics of the patient admitted or seen in the OPD should provide an affidavit
• Minor demographics corrections can be done for live patients with correction letter and proper valid I.D copy.
• In case of death, a written request from Patient attendant (Blood Relation) for Amendment/Correction of Patient Identification received with an Affidavit from the Court or Notary.

Storage and retention of medical records

The medical record department should ensure the medical records are adequately safeguarded & retained for the protection of data.

• Store the Medical Records in a Chronological Order in movable racks to protect from insects, termites, water and dampness.
• Follow Fire safety measures.
• The hospital policy on the retention of medical records is that the records are maintained forever. Store the medical records until there is a change in the hospital policy.
• Active & inactive files separation.
• Old inactive files are scanned and hard copies are shredded.
• All records are arranged as per Patient Reg. No. from Jan 2013 onwards. If one patient is admitted multiple times, all files will be kept together. (Previous case papers are kept as ID number and month wise)

Retention Policy

The Department is responsible for the consolidation of all Forms belonging with the patient is sent for storage in a manner with the help of Indoor Admission Number, which is assigned at the time of Admission. These records are stored in the Medical Record Departments for the following Retention Period as per the Govt. Orders

1. In-Patient Record (Above age 21): 7 (Seven) Years
2. In-Patient Record (Pediatric cases): Till the patient becomes 21 years old
3. Medico-Legal Record and death records: Lifetime
4. Other clinical/diagnostic registers, files & documents:    7 years

Security

• Access to Medical Records Department is limited only to the authorized department staff.
• In case any record is issued to any designate individual as per the retrieval policy; the same is recorded in the MRD register for accountability.
• No form of record is issued to any person without proper authorization from the designated authorities.
• During non-working hours the security staff is responsible for the safety of the department.
• Incase loss or tampering of patient’s medical record data is reported, the medical record clerk would immediately inform the same to the MRD HOD who would be responsible for taking appropriate action and would submit the report to the Medical Director. In case it confirms any sort of negligence or discrepancy on part of any hospital employee, MRD HOD would inform the same to higher for further action.
• For physical records pest and rodent control measures are carried out thrice in a month
• The electronic data is protected against Virus by using original antivirus software which will be updated automatically at regular intervals.
• Backup is maintained on a regular basis for HIS data.
• The record room is not accessible to outsiders
• All medical record files are scanned before filing it in the MRD. Appropriate back up is taken for all the scanned documents at regular interval.

Destruction

At the end of the designated retention period, the medical record clerk will seek written approval from the director for the destruction of the medical records who have crossed the retention period. Only after obtaining written from the designated hospital authority, the medical records will be destructed by the department staff.

Notifiable Diseases 

Under the international health regulation (WHO‘s International Health Regulations 2005) the following diseases are notifiable to WHO:

• Smallpox
• Poliomyelitis due to wild-type poliovirus
• Human influenza caused by a new subtype
• Severe acute respiratory syndrome (SARS)

In India, the following is an indicative list of diseases which are also notifiable, but may vary from state to state:

• Polio
• Influenza
• Malaria
• Rabies
• HIV/AIDS
• Louse-bornetyphus
• Tuberculosis
• Leprosy
• Leptospirosis
• Viral hepatitis
• Dengue fever

The various diseases notifiable under the factories act

• Lead poisoning
• Byssinosis
• Anthrax
• Asbestosis

The channel of information – The Notifiable disease is informed to:

• The Infection control nurse by the Ward in the charge nurse
• The Infection control nurse informs the MRD in-charge and Microbiologist
• Medical Records Department informs the Govt. Offices in local format

Accessing of the IPD health record file

In case any IPD Health Record file is issued to any designate individual as per the retrieval policy; the same is recorded in MRD register for accountability. All following details are written in the MRD register

• Registration No. & IPD No.
• Name of the Patient
• Reason for Accessing Record
• Name of Person & Authority Accessing Record
• Sign of Person Accessing Record
• Time & Date of Accessing Record
• Time & Date of Return of Record
• Sign of Person Returning Record
• All records returned Yes / No
• Any Miscellaneous Attachment ( In details)
• Xerox Copy of Health Record issued – Yes / No

By doctors, administrative staff, anyone for various purposes

• When a patient is re-admitted, the treating doctor can access previous admission record from the computer.
• However, the treating consultants and the other clinical doctors are authorized to have access to the discharged IPD health record file from MRD.
• The non – clinical person and other administrative staff can access the health record file after signing on MRD register with the date.
• In all MLC and death cases, the Medical Superintendent / Sr. Manager Medical Services’ written permission is necessary to access them.
• Reason for borrowing that can be readmission, study/ review, court evidence, research or any other.
• The borrower has to sign on MRD register with the date.
• After the health record file is returned back in MRD and returned date is written on the MRD register with the signature.

For insurance cases

• Life Insurance Policy Claims (LIC) for death cases
• Medi Claim Policy
• Any other insurance claim

Life Insurance Policy Claims (LIC) for death cases

• The claimant should submit the blank prescribed LIC claim form (s) to the MRD.
• Following documents are required before completing the prescribed form(s):
• Application from the claimant with the details of the deceased,
• Xerox copy of the letter from LIC,
• Xerox copy of policy’s front page to verify the claimant’s authenticity,
• In some cases, life insurance cooperation will directly approach to completing the prescribed form(s).
• Retrieve the respective inpatient health record file of the deceased. Tally the deceased particulars with the claimant‘s provided particulars.
• Attach the blank LIC claim forms with the respective inpatient health file of the deceased and forward the documents to the respective Consultant or Medical Officer for completing them.
• The time frame for completing the forms by the consultant should not exceed more than three days (excluding the receiving day).
• The completed forms along with the health record file should be returned back to the Medical Records Department.
• Inform the claimant to collect the completed forms.
• In case it is the LIC authorities that have approached, then the forms should be dispatched to them.
• Before handing over or dispatching the completed LIC, forms should be Xeroxed and those Xerox copies should be kept in the deceased inpatient health record file for future reference.

Mediclaim Policy

• The General Insurance company representative (Investigator) approach Hospital authorities to have access to the inpatient Health record file of the patient, to ensure the accuracy of the history given by the patient or their relative to the treating doctor either during admission or after discharge.
• To have access to the concerned health record file during admission the concerned consultant or on-duty doctor clarifies the query by limited access of health record file.
• To have access to the concerned health record file after discharge then representative has to complete the following formalities:
• Application requesting to have access and provide patients details.
• Name, age, sex and address of the patient
• Registration No. / IPD No.
• Authorization letter from the concerned Insurance Company that he/she (representative) has been depute for the job.
• Own identity card.
• A letter of authorization from the patient for the disclosure of his record information.
• The access of the file will be limited and to be more specific not the entire file.
• After accessing the inpatient health record file the representative may ask for the Xerox copy of particular information i.e. history part of the patient recorded by the doctor. The necessary should be given and the record maintained.
• The document provided by the representative will become part of the respective health record file and will be placed under the guide divider “Miscellaneous” for future reference.
• ANY OTHER INSURANCE CLAIM: Same policy and procedure will be followed as given under LIC and Mediclaim.

Issuing the medical certificate by accessing the IPD health record file 

The patient/attendant can directly request the treating doctor for the issue of the Medical Certificate.

• The concerned treating consultant will ask the Medical Record Department to issue the required medical certificate on his / her letterhead and send.
• All the Medical Certificate should be routed through the MRD for the verification of the following data:
• Registration No. / IPD No.
• DOA
• DOD
• Name & Address of the Patient
• Age /Sex
• Treatment ( Surgery / Supportive / Chemotherapy )
• Diagnosis
• After the necessary verification of the patient data, the MRD will forward the Medical Certificate to the CMO for the counter signature. It is a mandatory requirement.
• Every effort will be made to provide the completed medical Certificate to the patients/relatives as soon as possible.

Preparation of files

IPD Files

• Files with separators are available all over indoor wards.
• The formats to be arranged as per separator in the file include
• Initial assessment records
• Daily Progress Notes
• Daily Medicine Order Sheet
• Chemotherapy Administration sheet
• Monitoring Charts
• Surgical record
• Consents
• Physiotherapy case sheets
• Nutrition Records
• Diagnostics Record
• At the time of discharge, all paper is taken out from file and tied for further movement of the discharge
• Empty file is kept back for the next patient

OP Files

All assessment records like IPD History & Physical Examination Form, Cancer Treatment Plan and Oncology Flow Sheets are filled up In HIS. No extra hard copy is maintained.

Census and Statistics

Census & statistics are collected and given to the management for the comparison of present and past performance and for guidance for future developments

• Census is obtained from each department in the excel sheet format from registers/sheet/checklist maintained by that department.
• Many censuses are obtained from HIS as per date/month/year/years.

Hospital information system

HIS is used for collecting all information pertinent to patient care and hospital administration and for the storage of data regarding patient care, where all clinical (OPD & IPD), Diagnostic Reports (Laboratory & Radiology) all electronic data are maintained in HIS.

Following guidelines shall be followed for effective management of information and data

• The hospital software shall be able to incorporate, modify, add or delete the existing information in the system
• There shall be a provision in the software to update and retrieve the information as and when the need demands
• The electronic information shall be stored such that only authorized personnel can gain access to it
• The information shall be kept appropriately secured by using passwords and online security systems effectively
• The confidential information (esp., online policy documents, hospital statistics etc) shall be kept under strict security of limited personnel and on limited systems to prevent its misuse
• In case of power failure/system failure, there shall be a provision of back up such that there is no risk of data loss from the electronic data storage system
• Special cases, like patients and/or their relatives, third parties shall be allowed to see records (e.g.; medical records) only after a documented procedure has been adhered to
• In case of a breakdown of the software system, staff can use a manual system. These data shall be updated in software as soon as software starts functioning
• Different departments shall be given access to the required module and the system shall be secured by assigning an individual password.
• Medical records shall be kept under the supervision of authorized personnel so as to ensure security and confidentiality.

The hospital HIS software comprises of following different modules

Different modules for HIS are:

• Reception
• Nursing
• Cashier
• Pathology
• Radiology
• Consulting
• Radiotherapy
• Accounts
• Oncology
• Radiation therapy reception
• MIS
• Medical
• Surgical Oncology
• Mediclaim

The medical records reflect the continuity of care

• The organization has identified the contents of medical records to ensure that it reflects the continuity of care. The medical record provides information on the reason for admission, diagnosis and plan of care. A format has been developed which is a part of the patient file. The information that is available in the medical records provides evidence on continuity of care. And the final diagnosis shall follow ICD 10.
• The medical record contains the results of tests carried out and the care provided.
• The medical records generated by the organization cover operative and other procedures performed on the patient. It also provides a brief operative note prior to transfer out of patients from the recovery area.
• The organization has established a system to make it mandatory to mention the clinical condition of the patient before the transfer is affected. When the patient is transferred to another hospital the medical record contains the date of transfer, the reason for the transfer and name of the receiving hospital and other relevant information.

The clinical condition of the patient is documented before the transfer is effected. If the patient has been transferred at his/her request, a note is added to that effect. In such instances, the name of the receiving hospital will be the name where the patient desires to go to. If the patient has been transferred by the organization, it shall document the same.

All available details of the transfer are documented.

• The medical record contains a discharge note duly signed by the consultant under whom the patient is admitted.
• The organization provides the death certificate as per the international certification of cause of death. This includes the date & time of death.
• The organization provides access to medical records to designated healthcare providers. The information provided meets the current & past medical records through HIS to authorized personnel only.

By giving requisition through medical record requisition register to the MRD, care providers can access the medical record file.