(HSO) Unit 4

Medical Record
Operations Unit 3
Session Objectives
 At the end of this unit, learners should be able
to:
 Discuss basics of a MR operations
 Describe purpose of MR
 Explain medical recording & reporting standard

procedures
Definitions
 Health Record: A single record of all data on an
individual’s health status - including birth records,
immunizations, reports of all physical examinations
as well as all illnesses & treatments given in any
health care setting. Often used interchangeably with
“MR” but is a broader concept.
 Medical Record (MR): A collection of facts about a

patient’s health history, including past and present
illness(es) and treatment(s) written by the health care
professional treating the patient.
Value of the Medical Record
 An accurate & complete MR has value:
 To the patient
 To health facility
 To the doctor and other health professionals
 For research, statistics, disease & service reports

and teaching
 For patient billing

For Patient
 As the MR contains a complete report of a
patient's illness & results of treatment, it is of
great value to the patient for:
 Future care for the same or other illnesses
 Informing them (by giving access) of their care

and treatment
 As a legal document to support claims for injury,

or malpractice/quality of health service provided
For Hospital, HC or other HF
 The MR may be used by the health facility:
 To evaluate the standard of care rendered by

healthcare providers & the end results of
treatment.
 If adequate records are not kept, the facility

cannot justify the results of treatment.
 For medico legal & disease & service reporting

purposes as a source of relevant information.
For Doctors & other health
professionals
 MR is of value to all health professionals caring
for a patient.
 It enables pertinent clinical, social or other

relevant information to be readily available for
continuing patient care.
 In addition, MR is of value for review of certain

diseases, treatment and response to treatment.
For medical research,
statistics and teaching
 In scientific research, the MR is a major tool as
source of data.
 The information within a MR supplies a practical

& reliable source of material for the
advancement of medical science.
 MR is also valuable in the collection of statistics

on health services & the incidence of diseases,
and for teaching future health professionals.
For patient billing
 Without the information within a MR, payment
for services could not be justified.
 Often the health insurance agencies require

supporting evidence for claims - this evidence
is found in the MR.
MR are kept for purpose of:
1. Communication
2. Continuity of patient care
3. Evaluation of patient care
4. Medico legal (as legal document)
5. Statistical
6. Research and education
7. Historical purposes
Functions of MRU
 Patient Registration
 Retrieval of MR
 MR filing (includes record retention and tracing)
 Record assembly, analysis and processing
 Coding (HMIS disease classification)
 Completion of monthly & annual statistics
 MRU administration
 Maintenance of MR & MR services
Functions of MRU …
 Maintain privacy & confidentiality of the information
 Developing & maintaining MR policies & procedures
 Discharge procedure & completion of MR
 Evaluation of the MR service
 Medico-legal issues
 Generally, the staff of a MRU are responsible for the
initiation, completion & maintenance of a MR for
every person attending the facility as an inpatient,
outpatient or accident/emergency case.
Medical Recording & Reporting
standard procedures
 Practices
 Premises
 Professionals
 Products
Practices
 MR shall be maintained in written form for every
patient seen at all points of care.
 The hospital shall maintain individual MR in a

manner to ensure accuracy and easy retrieval.
 The hospital shall establish a MPI with a unique

number for each patient.
 Each piece of paper that contains a MR shall have

the appropriate identification on the paper.
 The hospital shall have a written policy and
procedure that are reviewed at least once
every three years which include at least:
a. Procedures for record completion
b. Conditions, procedures, and fees for releasing medical
information
c. Procedures for the protection of MR information against
the loss, tampering, alteration, destruction, or
unauthorized use.
 Any MR shall be kept confidential
 The MR forms shall be prepared in line with the

national guideline and approved by the hospital
management.
 All entries in the patient's MR shall be written
legibly in permanent ink, dated, and signed
by the custodian/recording person.
 Each MR shall at least contain the following

information:
a. Identification (MRN, name, age, sex, address)
b. History, P/Examination, investigation results & D x
c. Medication, procedure and consultation notes

e. Consent form (where applicable)
 There shall be a mechanism for MR

controlling & tracing.
 The patient's death shall be documented in the

patient's MR upon death.
 Original MR shall not leave hospital premises

unless they are under court order.
 A copy of the MR shall be given when a

patient/patient's legally authorized representative
requests in writing.
 There shall be a mechanism to make MR with
appointment ready for use & return seen
cards back to the central MRU within 24hrs.
 If the hospital ceases to operate, the regulatory body

shall be notified in writing about how and where MR
will be stored at least 15 days prior to cessation.
 The hospital shall establish a procedure for removal

of inactive MR from the central MRU.
 MR shall be destroyed as per the law by using

techniques that are effective enough to assure
confidentiality of MR.
Premises
 There shall be a separate MR room.
 The premises shall have one meter wide space in
b/n & around shelves.
 MR shall be shelved 20-30cm above from the floor.
 MRU shall have adequate space to accommodate
the following:
A. Central filing space C. Archive space
B. Work space D. Supply/Storage room
 The MRU shall have adequate light & ventilation.

 There shall be a room for archiving dead files until
they are permanently destroyed.
Professionals
 There shall be a full-time custodian or MR
personnel (HIT/statistician or any person trained on
data collection & processing) with basic computer
skill & ability to organize MR.
 Other additional staffs (like card sorter and runner)

to perform patient registration, retrieving, filing and
recording chart location.
 The actual number of staff shall be determined

based upon workload analysis.
Products
 The MR room shall have:
a) Shelves e) Ladder
b) MPI boxes
f) Patient folder
c) Computer
g) MPI Cards
d) Cart
h) Log book
MRU working procedure
 Some of the most important procedures are:
 Registration procedure: allow you to register new
or repeat patient for health services
 Filing procedure: helps you to arrange & locate

MRs in such a way that access to a MR is simple.
 Retrieval procedure: a set steps and rules to

retrieve a MR from the shelf.
 Archiving procedure: allows you to store MRs

which are inactive during the archiving time.

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Medical Record

 Discuss basics of a MR operations

 Explain medical recording & reporting standard

 Medical Record (MR): A collection of facts about a

 To the doctor and other health professionals

 For research, statistics, disease & service reports

 For patient billing

 Future care for the same or other illnesses

 Informing them (by giving access) of their care

 As a legal document to support claims for injury,

 To evaluate the standard of care rendered by

 If adequate records are not kept, the facility

 For medico legal & disease & service reporting

 It enables pertinent clinical, social or other

 In addition, MR is of value for review of certain

 The information within a MR supplies a practical

 MR is also valuable in the collection of statistics

 Often the health insurance agencies require

 The hospital shall maintain individual MR in a

 The hospital shall establish a MPI with a unique

 Each piece of paper that contains a MR shall have

 Any MR shall be kept confidential

 The MR forms shall be prepared in line with the

 Each MR shall at least contain the following

a. Identification (MRN, name, age, sex, address)

b. History, P/Examination, investigation results & D x

c. Medication, procedure and consultation notes

 There shall be a mechanism for MR

 The patient's death shall be documented in the

 Original MR shall not leave hospital premises

 A copy of the MR shall be given when a

 If the hospital ceases to operate, the regulatory body

 The hospital shall establish a procedure for removal

 MR shall be destroyed as per the law by using

 The MRU shall have adequate light & ventilation.

 Other additional staffs (like card sorter and runner)

 The actual number of staff shall be determined

 Filing procedure: helps you to arrange & locate

 Retrieval procedure: a set steps and rules to

 Archiving procedure: allows you to store MRs

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