Medical Records Department is the Brain of the Hospital
Medical records must be accurately written, well preserved and easily retrievable. Timely access to medical records not only help in maintaining a high level of patient care but can be widely used for teaching and research purposes. It also serves immensely for any medico-legal cases of accidents, litigation for negligence or malpractice.
The Medical Records Department maintains critical records and documents related to patient care. The main functions of the department are – filing, indexing and retrieving medical records.
OBJECTIVES of the Medical Record Department
- To initiate, process, and check the patient records from in-patient, out-patient, and emergency services to ensure that all the necessary forms and information are available.
- To co-operate with the medical, nursing, and other health care professionals in order to obtain comprehensive patient records and to design and develop effective medical record forms.
- To assemble medical records in accordance with the prescribed standard order.
- To code and index medical records as per international classifications of diseases (ICD-10) and operations.
- To maintain and preserve patient records including diagnostic reports in a scientific way for the period recommended in the “retention schedule”.
- To retrieve medical records to meet the needs of patient care, medical education, medical training, medical research, medico-legal problems, and the evaluation of patient care.
- To provide and maintain a system for the transcription of selected medical reports.
- To control the movement of patient files in order to achieve a unit record system, to protect files from unauthorized disclosure, to ensure confidentiality for the legal interests of the patient, the hospital, and the physician through proper custody of the records.
- To participate and cooperate with committees such as medical records, quality assurance, infection control, administrative, financial, and other committees.
- To register and maintain records for emergency cases including medico-legal cases in the accident and emergency department.
- To carry out admitting procedures for patients requiring hospitalization.
- To co-ordinate with other services related to those of the medical record department for effective filing and retrieval of patient records.
- To prepare and complete procedures related to medical reports, certificates, birth and death reports, and to submit data to appropriate authorities.
- To register admitted and discharged cases in the ward registrar, schedule appointments for follow-up cases and to carry out the related ward clerk duties.
- To receive and preserve the patient’s property in the admissions office in the absence of relatives who supposedly assume these responsibilities.
- To expedite the procedures of the department in accordance with the standards and rules established by the hospital.
- To develop and maintain an information base and mechanism for providing statistical data, and for submitting monthly reports concerning activities of the hospital and department, and for providing suggestions for effective functioning and future developments.
- To develop educational programs for the training of medical record personnel.
- To observe the ethics of the medical record profession and to strive for new innovations to improve department functions.
- To expedite any responsibilities related to the medical record department allocated by the chief of the medical record or central information department of the hospital.