Facts and figures on medical record management from a multi super specialty hospital in Delhi NCR: A descriptive analysis.
Medical records
medical records department
multi super specialty
Journal
Journal of family medicine and primary care
ISSN: 2249-4863
Titre abrégé: J Family Med Prim Care
Pays: India
ID NLM: 101610082
Informations de publication
Date de publication:
Jan 2020
Jan 2020
Historique:
received:
03
08
2019
revised:
10
12
2019
accepted:
16
12
2019
entrez:
29
2
2020
pubmed:
29
2
2020
medline:
29
2
2020
Statut:
epublish
Résumé
A study of the medical records department of a multi super specialty secondary care hospital in NCR. 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. 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. 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.
Identifiants
pubmed: 32110629
doi: 10.4103/jfmpc.jfmpc_612_19
pii: JFMPC-9-418
pmc: PMC7014864
doi:
Types de publication
Case Reports
Langues
eng
Pagination
418-423Informations de copyright
Copyright: © 2020 Journal of Family Medicine and Primary Care.
Déclaration de conflit d'intérêts
There are no conflicts of interest.
Références
Ann Intern Med. 2014 Jun 3;160(11):741-9
pubmed: 24887615
J Am Med Inform Assoc. 2015 Mar;22(2):479-88
pubmed: 25769683
BMC Health Serv Res. 2002 Dec 10;2(1):22
pubmed: 12473161
BMJ. 2011 Oct 17;343:d6054
pubmed: 22006942
BMC Med Inform Decis Mak. 2018 Nov 13;18(1):101
pubmed: 30424758
Ann Emerg Med. 2001 Sep;38(3):312-6
pubmed: 11524652
Clinicoecon Outcomes Res. 2010;2:1-14
pubmed: 21935310
J Am Med Inform Assoc. 1996 Mar-Apr;3(2):139-48
pubmed: 8653450