|Year : 2020 | Volume
| Issue : 1 | Page : 418-423
Facts and figures on medical record management from a multi super specialty hospital in Delhi NCR: A descriptive analysis
Stuti Verma1, Manish Midha2, Ajeet Singh Bhadoria3
1 Department of Hospital Administration, Institute of Liver and Biliary Sciences, New Delhi, India
2 Department of Amity Institute of Hospital Administration, Amity University, Noida, Uttar Pradesh, India
3 Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttrakhand, India
|Date of Submission||03-Aug-2019|
|Date of Decision||10-Dec-2019|
|Date of Acceptance||16-Dec-2019|
|Date of Web Publication||28-Jan-2020|
Dr. Stuti Verma
Department of Hospital Administration, Institute of Liver and Biliary Sciences, New Delhi - 110 070
Source of Support: None, Conflict of Interest: None
Aim of Study: A study of the medical records department of a multi super specialty secondary care hospital in NCR. Materials and Methods: Primary data was collected through direct observation and retrospective study of documents maintained in MRD. Secondary data was collected from quality control department books, journals, scholarly articles, and internet. Results and Conclusion: Sample sizes of 350 retrospective and current medical records were thoroughly scrutinized. Conclusion revealed the hospital has published as exhaustive medical records manual listing and the scope, objective, hierarchy chart, job description, policies, procedures, and processes. The MRD has a well-documented flow process of medical records, but on checking the flow of patient records between Nov 2016 to Feb 2017; it was revealed that in month of Nov 2016, out of the total 278 patients discharged only 276 files were received in MRD and 0.72% files were not received. Moreover, it took over 31 days for 71 patients (23.67%) to receive files in MRD. In Jan 2017, out of 286 patients discharged, only 237 files were received in MRD contrasting to 10.14% files not received. Moreover, it took over 31 days for 28 patients (9.80%) to receive files in MRD. In Feb 2017, out of 268 patients discharged, only 206 files were received in MRD and 22.39% files were not received as on 11 March 2017. This study concluded that there is no effective system in place to monitor/track files from ward/billing section to MRD once the patient is discharged. Clinical Significance: Medical records are valuable to patients, physicians, healthcare institutions, researchers, National Health agencies, and International health organizations. Memories fade, people lie, witnesses die; however, medical records live forever. A thorough system of flow process of monitoring/tracking files is to be in place to ensure accountability, smooth functioning, and quality of care being provided without violating basic patient sight of confidentiality of information.
Keywords: Medical records, medical records department, multi super specialty
|How to cite this article:|
Verma S, Midha M, Bhadoria AS. Facts and figures on medical record management from a multi super specialty hospital in Delhi NCR: A descriptive analysis. J Family Med Prim Care 2020;9:418-23
|How to cite this URL:|
Verma S, Midha M, Bhadoria AS. Facts and figures on medical record management from a multi super specialty hospital in Delhi NCR: A descriptive analysis. J Family Med Prim Care [serial online] 2020 [cited 2020 Jun 4];9:418-23. Available from: http://www.jfmpc.com/text.asp?2020/9/1/418/276750
| Introduction|| |
Medical Records  is defined as “a clear, concise and accurate history of a patient's life and illness, which is written from a medical view point”. Mc Gibbon defined Medical Record  as “a clinical, administrative, scientific and legal document which is related to patient care, in which sufficient data is recorded, which is written in sequence of events, to justify the diagnosis, and warrant treatment and end results”.
History of medicine  runs parallel to history of Medical Records. This is substantiated by the fact that the father of modern medicine “Hippocrates” is known to have kept records of fever cases. In present era, Medical Records Department is the hub of patient activities which are related to quality initiatives in form of peer review, clinical research, hospital statistics, medico legal cases, and a host of other activities. We have tried to summarize the functional activity flow chart of the Medical Records department which is shown in the [Figure 1].
A good medical record serves the interest of the medical practitioner as well as his patients. It is very important for the treating doctor to properly document the management of the patient under his care. Medical record keeping has evolved into a science. The key to dispensability of most of the medical negligence claim rest with the quality of the medical records. Maintenance of the record is the only way for the doctor to prove that the treatment was carried out properly. Medical records are often the only source of the truth. They are likely to be far more reliable than memory.
The management and preservation of the hospital records in Indian context present a very gloomy picture. Despite the intensive effort at national and international level, the fundamental health care needs of the population of the developing countries are still unmet. The lack of basic health data renders difficulties in formulating and applying a rational for the allocation of limited resources that are available for patient care and disease prevention. Multiple researches have been carried out across globe relating to management of medical records some of them have been discussed below.
A research manual was published by Fairview Health Services regarding research in the Electronic Medical Records with the purpose to provide guidelines for its use for research purpose. The manual listed out a policy that healthcare providers should be aware of all treatments and medications which a patient is exposed, in order to maximize safety and quality of care. Hence, researchers include information in medical records that a healthcare provider can reasonably identify and contact research personnel for more information and the medicare requirements for research documentation are met. The study further stated that research activities must be documented or initiated by researchers within their scope of practice and additional information is encouraged.
Another research study which was carried out by Randall D Cebul, stated findings that EHR improve the quality of diabetes care at Better Health Greater Cleveland. The study showed that physician practices using EHR had significantly higher achievement and improvement in meeting standards of care and outcomes in diabetes than practices using paper records. To substantiate the findings, various facts were put across, i.e. nearly 51% of patients in EHR practices received care that met all endorsed standards, whereas only 7% of patients at paper-based practices received the same level of care. After accounting differences in patients characteristics between EHR and paper based practices, EHR patients received 35% more of care standards. Less than 16% patients with paper-based practices had comparable results. After accounting for patient differences, the adjusted gap was 15% higher for EHR practices. The outcomes of EHR practices were better with nearly 44% of these patients met at least 4 out of 5 outcome standards for diabetes.
A paper was published by Paul D Clayton on confidentiality and medical information. It stated that since individuals prefer to keep information in their medical records confidential and misuse of information could cause economic harm or embarrassment to them or their providers, confidentiality is a topic of major concern in health care. The primary motive behind the conversion of medical records from paper to electronic form are improved quality of care, i.e. convenient access to organized and legible information, computer generated alerts and reminders, context specific links to pertinent literature, reduced cost as a result of better use of resources and early intervention and improved services. Finally, the paper highlighted that the major attribute that characterizes electronic records, i.e. convenient access, is a major factor that increases concerns about privacy and confidentiality.
Another paper was published by Randolph C. Barrows and Paul D. Clayton on privacy, confidentiality and EMRs. The paper highlights the fact that enhanced availability of health information in an electronic format is strategic for industry wide efforts to improve the quality and reduce cost of health care. However, it brings along with it concerns of greater risk for loss of privacy among health care participants. The paper reviews the conflicting goals of accessibility and security for EMRs and further discusses the technical and nontechnical aspects that constitute a reasonable security solution. It was safely summed up that with guiding policies and existing technology, an EMR may offer better security than a traditional paper record.
A study was carried out by Mehnke and Anne MSN on managing a breach in patient's confidentiality, by putting across a hypothetical situation and question “Suppose a nurse purposely checks medical records of friends or relatives and then acts on that information.” “When the nurse is caught at a later stage, how should a nurse manager handle this breach in patient confidentiality?” The study elaborated that since the act of the nurse was a breach of confidentiality, the nurse's manager should contact human resources, nursing administrator and legal department for advice and guidance on the best way to investigate the issue. After careful deliberations and considerations, the study recommended that the nurse be suspended until the investigation was completed. Once the investigation ends, all parties involved should unanimously decide to expel the nurse, incase breach in confidentiality, including the severity of breach is proved. The study further states that most breaches of confidentiality are unintentional, the nurse in this situation did not consider the consequences of her actions which led to the breach in patient confidentiality. As a result of this situation, the managers should prevent this from happening again. The study recommended that this situation be developed into a teaching situation to guide the staff in understanding what constitutes a breach of confidentiality and the consequences that can occur.
Another research study was done by Lisa M. Kern, Alison Edwards and Rainu Kaushal on the patient centered medical home (PCMH), EMRs and quality of care. The objective of the study was to compare quality of care provided by physicians in PCMHs with that provided by physicians using paper medical records and, separately, with that provided by physicians using EMRs without the PCMH, to determine whether effects were driven by EMRs. 675 primary care physicians in 312 practices and 143 489 patients participated in the study. The PCMH group improved significantly than either paper group or EHR group for 4 of the 10 measures: eye examinations and hemoglobin, testing for patients with diabetes, chlamydia screening, and colorectal cancer screening. The odds of overall quality improvement in the PCMH group were 7% higher than paper group and 6% higher than EHR group.
A study was carried out by Nicholas Wald, Malcolm Law, Tom Meade, George Miller, Eva Alberman and John Dickinson on use of personal medical records for research purposes. The norms of doctors using medical records for research purposes is threatened by the recent proposed guidelines from Department of Health, the BMA, and the European Commission. The European Commission has proposed that explicit consent should be obtained from each patient before his medical records can be used. The proposals from the Department of Health and the BMA states that all research needing access to personal medical records be submitted to an ethics committee. The study states that these proposals will seriously impair a category of research and further suggests that another set of guidelines as proposed by Royal College of Physicians working group be used to modify the proposals. The guidelines of the working group encourages use of medical records for research and further ensures that such use can be made in a confidential manner without causing harm to anyone.
Another research study was carried out by Gena Kanas, Libby Morimoto, Fiona Mowat, Cynthia O'Malley, Jon Fryzek and Robert Nordyke on use of EMRs in oncology outcomes research. The study stated that oncology outcomes research could benefit from use of oncology specific EMR network. The benefits and challenges of using EMR in general health research have been investigated; however, utility of EMR for oncology outcomes research has not been explored. Compared to current available oncology databases and registries, an oncology specific EMR could provide more comprehensive and accurate information on clinical diagnoses, personal and medical histories, planned and actual treatment regimens and post treatment outcomes, to address research questions from patients, policy makers, pharmaceutical industry, and clinicians/researchers. Specific challenges related to structural, clinical, and research-related issues must be addressed when building an oncology specific EMR system. The study further stated that researchers should engage with medical professional groups for development of EMR systems that would ultimately help improve quality of cancer care through oncology outcomes research.
It becomes significant to study the efforts made by the institutions/hospital managements, all clinicians and medical record officer to improve the standard of maintenance and preservation of medical records. Hence, in this article, we are analyzing the medical records department of a multi super specialty secondary care hospital in NCR.
| Materials and Methods|| |
The methodology which was adopted during course of the study was as follows:
The objectives of this dissertation is to identify and analyze the existing processes and procedures being followed in the MRD among the medical records and to check the conformity level of the processes of MRD with respect to NABH guidelines in respect to a Multi Super Specialty, Secondary Care Hospital in NCR. For this purpose, a sample size of 350 retrospective and current medical records were thoroughly checked/scrutinized. The Study Area selected for the present study was Medical Records Department of Multi Super Specialty, Secondary Care Hospital in NCR. The study was descriptive and observational in nature. The time duration for conducting the study was from 26 December 2016 to 31 March 2017. The primary data has been collected through direct observation and through the retrospective study of documents maintained by medical records department.
| Results and Discussion|| |
Medical record manual
Hospital has published an exhaustive Medical Record Manual, which lists out the scope, objectives, hierarchy chart, job description, various policies, procedures, and processes. The manual is a guideline to establish standardized policies and procedures for use of Medical Records in respect of the patient and smooth functioning of the MRD without violating the basic patient's rights of confidentiality of information.
Department hierarchy chart
Though the Medical Record manual states a hierarchy chart of a Medical Superintendent, Medical Record Officer, Store in Charge, supervisor and support staff, the MRD is functioning with a depleted strength on ground, thereby affecting the quality of work in MRD.
| Location of Medical Records Department|| |
- To provide prompt services for the care of all patients (IPD, OPD, and emergency) at any given time and to foster close working relationship and good communication with concerned departments, the MRD must be located near the admitting area, OPD, emergency area, and the office. However, the department is was found slightly far off from other departments.
- The Medical Records storage room is located at a further distance in the lower basement.
- There should be a storage room for inactive medical records, but no such room was found.
| Functions of Medical Records Department|| |
- Broadly, Medical Records are divided into three areas where different activities are carried out- admission and enquiry office, inpatient wards and OPD, including registration counters and Medical Record office. However, neither any records of OPD are included in the MRD, nor any correspondence takes place with OPD.
- Statistics which can be generated from OPD records not included by MRD.
| Dictating and Transcription System|| |
- In advanced systems, doctors dictate their notes or discharge summaries from various locations in and out of the hospital, using either remote dictating equipment which is linked to the central transcription room in MRD, where the dictation is tape recorded and the recorded dictation is transcripted. However, no dictating and transcription system exists in the hospital as of date.
| Layout of Medical Records Department|| |
- MRD is located in the upper basement and presently occupies portion of the utility services room which consists of utility equipment panels.
- Storage room of MRD is located in the lower basement and adjoins the mortuary area.
| Assembling|| |
- Physical scrutiny of 350 retrospective and current medical records revealed that majority of documents assembled were not being done sequentially as per the medical records manual.
- Moreover, neither majority of the medical records checked were assembled in different sequences, nor were they color coded.
| Incomplete Record Control|| |
- At the time of assembling of files, the files are checked for correctness and all incomplete patient files are returned to the department from where they have been received for making corrections and re-submitting to the MRD duly completed. However, the entry of files is only done at the time the same have been received in MRD the first time.
- The movement of incorrect files returned to the department for corrections are neither documented nor monitored.
| Flow Process of Medical Records|| |
- MRD has a well-documented flow process of Medical Records.
- As per policy, patient files shall not be retained at any place without information/documentation at MRD for more than 24 hours. However, on checking the flow of patient files from the month November 2016 to February 2017, the observation was made which is given in the [Table 1].
- From data derived as mentioned above in [Table 1], it seems that there is no effective system in place to monitor/track files from the ward or billing section to MRD once the patient has been discharged, thereby making it very difficult to pin point the reasons or source of delay in receipt of patient files in MRD.
- This process seriously hampers the smooth functioning of the MRD thereby affecting the quality of care being provided in the hospital.
- Lack of effective system of monitoring/tracking files is best highlighted by the summary of days taken for the flow process of medical records from the discharge of patients to receiving of the files in MRD as shown in the [Table 2].
| Conclusions|| |
It has been revealed that the hospital has published as exhaustive medical records manual listing and the scope, objective, hierarchy chart, job description, policies, procedures, and processes. The MRD has a well-documented flow process of medical records, but on checking the flow of patient records between Nov 2016 to Feb 2017; it was revealed that in month of Nov 2016, out of the total 278 patients discharged only 276 files were received in MRD and 0.72% files were not received. Moreover, it took over 31 days for 71 patients (23.67%) to receive files in MRD. In Jan 2017, out of 286 patients discharged, only 237 files were received in MRD contrasting to 10.14% files not received. Moreover, it took over 31 days for 28 patients (9.80%) to receive files in MRD. In Feb 2017, out of 268 patients discharged, only 206 files were received in MRD and 22.39% files were not received as on 11 March 2017. This study concluded that there is no effective system in place to monitor/track files from ward/billing section to MRD once the patient is discharged.
| Clinical Significance|| |
Well established standardized policies and procedures for use of medical records exist in Hospital. The proper maintenance of these records in right quantity and quality is the essence of the MRD. To ensure further satisfaction in proper maintenance of medical records and that the MRD fully confirms to the NABH guidelines, following measures are further recommended to be addressed/implemented:
- Strength of manpower be increased in the MRD, from the existing strength of 2 medical records technicians. Acute shortage of manpower at times leads to backlog of workload in the department, thereby affecting quality of care.
- MRD to be located near the admitting area, OPD, emergency area, and office are to provide prompt services for the care of all patients (IPD, OPD, and emergency) at any given point of time, and to foster close working relationship and good communication with concerned departments.
- Requirement of an isolated storeroom for old medical records is not immediately felt since hospital is in its infant stages, but same may be planned in the future.
- For safety and security purposes, both the MRD office and medical records storeroom be segregated from the utility services room and mortuary area.
- Patient records from OPD to be linked with MRD and the data obtained be included in the generation of health statistics.
- Dictation and transcription system be implemented in the department to provide more effective and efficient quality of services in the hospital.
- Assembling of medical records to be done sequentially as per the medical records manual and color code be used.
- Training classes be conducted on periodic basis (half yearly) for the MRD staff to brush up their knowledge on MRD matters. Moreover, all new employees be made to attend subject classes as a part of orientation to functioning of MRD.
- As the medical records have to be stored for a long time period of time, they should be able to withstand the natural wear and tear resulting from normal usage of these records. Hence, folders made of durable plastic material could be used.
- The present medical records filed have metal fasteners with sharp edges which may lead to an injury. The same can be avoided by replacing metal fasteners with plastic ones.
- As a fire safety precaution, fire extinguishers placed in the medical storage area should be further supplemented by catering for additional firefighting equipment like buckets, hooks, beaters, etc., Moreover, adequate quantity of sand and water be also stored in the vicinity of the medical storeroom.
- Fire extinguishers be periodically tested (quarterly basis) and refilled and records to this effect be maintained.
- Periodic fire-fighting practice be held (quarterly basis) in the hospital to prevent any untoward fire-related incident and a record to this effect be maintained.
- The evaluation criteria using the Self-Assessment toolkit indicate that there is conformity level of processes of MR with respect to NABH guidelines. However, emphasis be made to ensure conformity of certain processes which partially/don't comply to the requirements:
Effective medical record management system is the need of hour, not only at tertiary or secondary level of medical care but also at primary care delivery levels. Primary care physicians should understand the importance of an effective documentation of medical records for clinical as well as legal purposes. However, there are significant challenges associated with the introduction of medical record system, especially electronic one as they are costly initiatives to implement, requiring time to tailor systems to suit local contexts, and to train end users. This can prove a particular barrier for resource-poor settings, who may lack the qualified and experienced workforce to support their effective adoption.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]