|Year : 1982 | Volume
| Issue : 4 | Page : 363-365
Medical records in speciality hospitals
C Ramanand Bhat, Chandran Abraham, SS Badrinath
Sankara Nethralay'. Ophthalmic research hospital, Madras, India
C Ramanand Bhat
Sankara Nethralay'. Ophthalmic research hospital, Madras
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bhat C R, Abraham C, Badrinath S S. Medical records in speciality hospitals. Indian J Ophthalmol 1982;30:363-5
|How to cite this URL:|
Bhat C R, Abraham C, Badrinath S S. Medical records in speciality hospitals. Indian J Ophthalmol [serial online] 1982 [cited 2020 Jun 5];30:363-5. Available from: http://www.ijo.in/text.asp?1982/30/4/363/29473
To the hurried doctor, the medical record at times may appear typically symbolic of administrative red tape of complicated forms which consume a lot of time to fill in. At other times he fully realises and appreciates that only thorough maintaining adequate and accurate medical records, the present and future health and welfare of the patient for whom he eares, can be protected, that research and improved education be fostered, that his own status and growth be enhanced.
In this article, we wish to highlight the features of the medical records system adopted at Ophthalmic Research Hospital, Madras (India)
There are various methods available for keeping the Medical Records but ours being a specialty hospital with mainly referral practice, we have adopted `Unit Records' system to make our task more easy and useful.
| Unit numbering system|| |
Individual records are maintained on every patient, who is recognised by a single number allotted in series at his first visit to the hospital, irrespective of his ocular ailment or nature of service rendered. All records regarding a patient are kept in a single cloth-bound manilla cardboard file, which results in Unit Record System.
| Advantages|| |
The main advantages of this system are as follows
1. One record provides all finite details of the ease in chronological order which helps the physician to quickly review the entire record and plan further management ;
2. Avoids multipie charts for one patient and saves time of the Record Staff in bringing forward the old records as well as in keeping them up to date.
3. It is economical as the stationary consumed is kept to a bar minimum and this also saves separate filing space for in-patient records and fluorescein angiograms.
| Identification data|| |
For recording data, we follow the Bradma data writing system on all the records. The Bradma card made of plastic contains the patient's name, record No., address, year of birth, telephone number etc. This ensures that the patient can be positively identified. The card is also used to take imprints on all the sheets of records and on master index, eliminating possible errors in writing down the record No. and provides uniform identity on all the sheets of the record. These cards are given to the patient and have to be produced at all future visits.
| Contents of the record|| |
At the first visit of the patient, the file contains only the Ophthalmology Record and referral letter, if any. The ophthalmology record has been devised in such a way that a basic but detailed and complete ocular examination is peasible. No part of the case sheet is left unfilled. Once the diagnosis is made and further management decided, a firm base is established, which serves as a Foundation for building up the record.
Special medical record forms specific to the care of a particular patient have been designed. This includes photacoagulation record and ultrasound record. Forms have also been designed for patients who need hospitalisation of less than 48 hours duration. Visual field charts, retinal drawings, fluorescein angiogram pictures with their interpretation, laboratory investigations and the general physician's findings and opinion, all are filled chronologically in a proper order. Fundus photographs and clinical photographs which are at present kept separately will soon be kept in the patient record,
If the patient had in-patient hospitalisation. in-patient records are filed as follows
Admission record, Discharge summary, Progress notes, Operative orders, Anaesthesia record, Retina drawings, Graphic sheet.
Admission Record contains provisional diagnosis, final diagnosis, secondary diagnosis and complications, operative procedures, consultant's name, result, signature of the House Staff as well as signature of Unit Head. This will be written by the doctor at the time of discharge. The diagnosis are written accurately. completely and in standard nomenclature for indexing the record. The backside of this record is used for consent or authorisation for operation and treatment etc.
Discharge Summary is given to all in-patients at the time of discharge and a copy of the same is filed immediately behind the admission record. This record is very concise and contains only essential data such as date of admission and discharge, final diagnosis, operative procedures and discharge instructions. More importance is given to specific eye care, the medicines to be used and the date of next appointment.
Progress Notes begins with admission note, progress notes which contain all procedures also give chronological picture of the patient and discharge note.
Operative Orders printed routine order forms are used where all preoperative and post operative routine orders are printed. This not only saves time but ensures that no detail is missed.
Anaesthesia Record is used only for the patients who underwent surgery under general anaesthesia.
| Serial filing system|| |
By means of filing these records serially, they are made easily available on demand. Multi-use tracer cards are used to ensure that the whereabouts of issued records are known. We have just incorporated colour coding system. Coloured adhesive tapes are used on the corner of the chart folder for identifying the case sheets of the patients who had surgery. Different colours are used to identify different surgeries.
| Flow of record|| |
All the out-patient records are received after the consultation and these records are checked for their accuracy and adequacy. These records are then coded and indexed before filing.
In-patient records after discharge of the patients are received by the Medical Record Department along with census daily. All these case sheets are further processed in the department. Assembling, deficiency check, coding and indexing, discharge analysis and completion of records are the main steps involved in the process before filing these records in permanent filing area.
| Coding and indexing|| |
After completion of the record with all medical data, the record is coded and indexed according to ICD-9CM, which is the 9 Revision of World Health Organisation's International Classification of Diseases. This is the latest and most elaborate classification used in United States for the same purpose. Diseasewise, operationwise coding and indexing helps in data storage and retrieval and aids in presenting uniform statistics.
| Indexes|| |
The following indexes are maintained in order that all necessary information for patient care and research are stored and can be easily retrieved.
Patients' Alpha Index : This is a card catalogue containing names of all patients, arranged in strict alphabetical order. This is the main source to locate any medical record for a patient, and also helps one to get basic information of the patient without looking into the record.
Patients' Number Index : (Accession Register) This is a list of all patients seen in the hospital for the first time in chronological order according to the Hospital or MRD No. This is used as a cross index to know the particular hospital number is assigned to whom.
Diagnostic Index : This includes the list of patients with identical disease. This is of great help for analysing the natural history of a disease and its variants as well as for retrospective studies to judge efficacy of various treatment modalities and change in the disease pattern.
Operation Index : This is a index for the various surgeries done and helps in retrieving the data from identical surgical procedure. By analysing them one is able (a) to know about outcome of various surgical procedures, (b) to compare different surgical modalities offered for identical diseases and (c) to modify the technique so as to minimise complications and procure better results.
| Statistics|| |
Statistics are being presented monthly and yearly which enables one to analyse the activities of the hospital at a glance. This comprises of out patient census, inpatient census, geographical distribution, diseasewise and surgerywise statistics
| Duties of medical record administrator|| |
Medical Record Administrator besides keeping an eye on all these things and seeing that they are performed properly, also helps in hospital administration in providing better patient care by proper and timely planning of the things. He does this by providing statistics regarding outpatient census, bad occupancy rate etc., medical auditing data on various diseases prevalent among the patients, treatment rendered and outcome.
Finally we find this system to be useful and workable towards fulfilling the objectives of the hospital.