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Medical record services are broadly classified into the following three different categories:

  1. Out-patient service
  2. Accident and emergency services
  3. In-patient service

A. Out-patient Service:

The outpatient medical record services are classified into three sections:

1. Central Registration: A central registration system with 24 hours services throughout the year with three shifts of 8 hours each in operation should ideally be maintained for all out-patients and in-patients. With this system, each patient will have one unit record and one permanent number used for all episodes of care. The personnel employed in this service perform the following functions:

  • Control of hospital numbers
  • Preparation of pre-numbered folders
  • Registration of new cases.
  • Registration of follow-up cases.
  • Supply of records to outpatient clinics.

2. Outpatient Clinic: The clerk posted in this unit performs the following functions:

  • Collection of new and follow-up registered patient records.
  • Maintenance of accounts of patient’s treatment in the clinic.
  • Maintenance of accounts of patients referred to and received from other clinics, investigations and admissions.
  • Collection and return of medical record files.

3. Casualty Service: This unit functions around the clock throughout the year with three shifts in operation. The personnel Employed in this service perform the following functions.

  • Registration of casualty cases.
  • Referral of patients for follow-up appointments, admissions, and so on.
  • Registration of medico legal cases.
  • Collection of statistics and filing of A/ E record.

Numbering System:
Six digit numbers are generally used for outpatients and inpatients starting from 00 00 01 and continuing to 99 99 99. A new patient receives a new hospital number only to the first time of registration.

Patient-ID and Appointment Card:
An identification information card should be given to each new patient registered for outpatient or inpatient service

B. Accident and emergency Services:

Of the three accident and emergency forms, the first copy is to be retained in the casualty department, the second copy is presented by the patient in the pharmacy to obtain medications, and the third copy is retained by the patient. It this patient is admitted to an outpatient or an inpatient service, the second and third copies becomes part of the main patient file. The first copy however, is retained in the casualty department. If a patient has a unit record in the hospital and the casualty medical officer desires to review it, the medical record department should forward the record to him. All diagnostic investigation reports of a casualty patient are attached to the casualty forms. If a patient is referred as either an outpatient or an inpatient, the reports become part of main patient file. All of the casualty records including the x-rays must be kept for one year in the A/E department. Later they may be transferred to the medical record department.

C. Inpatient Service:

The inpatient medical record services are classified into two sections:
1. Admission Office: This office functions around the clock throughout functions.

  • Maintenance of waiting list of patients.
  • Registration of admissions and discharges.
  • Maintenance of the bed occupancy board.

2. Ward: The work relating to medical records in the ward will be performed by the ward nurse, or ward clerk / secretary. The following are the main functions:

  • Registration of admissions and discharges.
  • Receipts and mounting of investigation reports in the appropriate records.
  • Maintenance of accounts of bed position.
  • Scheduling of appointments for follow-up cases.
  • Preparation and submission of ward daily census reports.

Processing of Outpatient Records:

All out patient files are handed over to consent patient.
Processing of Inpatient Records: The main functions of this unit are as follows:

  • Collection and checking of daily ward census reports along with the discharged patient records and collection of late investigation reports.
  • Analysis of discharged patient’s records.
  • Assembly of records in a prescribed standard order and checking for deficiencies.
  • Coding and indexing of completed records as per the latest revision of ICD.

Collection and Analysis of Hospital Statistic:
The main function of this unit is to collect statistics of outpatient, accident and emergency, inpatient, and administrative statistics, to analyze these statistics, and to prepare reports on a daily, monthly, and yearly basis.

Referral of patient:
Patient referred from either outside or within the hospital should receive three referral copies, the first two copies are presented to the hospital by the patient whereas the third copy is retained by the referring health centre or clinic. After treatment, the first copy is forwarded to the health centre or hospital as feedback information and the second copy is retained in the hospital. All three copies of the referral from patients referred within the hospital become part of main patient file.

Health Centre:
The health center or clinic generally directs patients to the hospital with a referral letter. The hospital and health centre should develop a clear referral and appointment system for both new and established patients.

Correspondence: Contains referral letter forms, admission request form, consultation form, consent to operations and investigations, preoperative check list, notification of stillbirth form, birth notification, A/E report, medical report, and infection control form incident report.

Against Medical Advice:
The patient who leaves against medical advice should be considered as discharge. It should be ensured that the signature of the patient or his or her nearest relative is obtained in the prescribed form.

Absconded patients:
Information about absconded patients must be recorded in the patients file with details concerning the date and time the patient was discovered to the missing from the ward. The treating physician should note and sign the record accordingly. The matter must also be communicated to the police.

Declaration by the patient:
Any patient, who wishes to make a declaration before his death, should have such statements recorded in the patients file in the presence of a magistrate. In the absence of a magistrate, the declaration may be recorded in the presence of three persons including the treating physician, a nurse, and the hospital administrator or his representative.