THE STUDY ON MEDICAL RECORD DEPARTMENT

CARRIED OUT AT
FORTIS HOSPITAL ANANDPUR

SUBMITTED BY
MONU ANAND
REG. NO. : 151541310014 OF 2015-2018
ROLL NO. : 15403315014

DATE:-
DECLARATION
I do hereby declare that this project work “ A Study on Medical
Record Department “, at FORTIS HOSPITAL ANANDPUR at
Kolkata for 3 months ( 18TH JANUARY to 18APRIL ), submitted
by me in practical fulfillment for the requirement of Bachelor
Degree in Hospital Management (BHM) from Dinabandhu
Andrews Institute of Technology and Management with the
collaboration of West Bengal University of Technology (WBUT)
is the result of my original and independent research work
carried out under the supervision and guidance from
Dinabandhu Andrews Institute of Technology and Management
.
I further declare that this
project work or any part of this has not been submitted by me
any where for the award of any degree or other similar title
before .
Monu Anand
(STUDENT OF HOSPITAL MANAGEMENT)
ACKNOWLEDGEMENT
I am using this opportunity to express my gratitude to everyone who
supported me throughout the course of this training. I am thankful for
their aspiring guidance, invatualualy constructive criticism & friendly
advice during my training & the project work.
I express my warm thanks to MS. SANJUKTA
NANDI (PRINCIPAL MAM) , MR. SUROJIT SARKAR(HOD), MS.
MOUMITA AKULI ROY AND MS. PARAMITA BANERJEE ( INTERNAL
GUIDE OF OUR COLLEGE) ,
MR. SUJAN DHAR ( HOD OF MEDICAL RECORD), MR. SOUGATA
PAUL & KOUSHIK GHOSH ( ASSISTANT OF MEDICAL RECORD)
AND MR.PRASANT SIR( HR) for their support & guidance
& all the faculties who provided me with the facilities being required &
conductive conditions for my projects.

THANK YOU

MONU ANAND

( HOSPITAL MANAGEMENT 6TH SEM)

CONTENT:
 Executive summary
 Introduction
 Objectives of the project
 Methodology
 Hospital profile
 Observation of the department
 Name of the department
 Location
 Objectives of the department
 Staffing
 Physical facilities
 Layout of the department
 Data Analysis
 Problem and recommendation
 Conclusion
 Bibliography
 Annexure
EXECUTIVE SUMMARY:-
I have done this “ summer training project on Medical Record
department” at Fortis Hospitals Anandapur for 3 months under the
guidance of Mr. Sujan Dhar (HOD).

The department observed by me :-

Medical record
INTRODUCTION:
Patient care includes a systematic and chronological record of care and
treatment which necessitates the establishment of medical records
department in hospitals. The medical record is a storehouse of knowledge
concerning the patient.
Today technology is transforming the4
way healthcare is delivered ,managed ,and assessed with a continued shift
from record management to data management so MRDs are moving from
surveillance and archival functions to prospective functions and process
intervention.
THE MEDICAL RECORD Consider that this is an INITIAL
evaluation of the problem. A clinician will need to look at the progress
notes for any changes in status or treatment. The primary MD may provide
the initial dictation but then may consult other specialists (pulmonologist,
endocrinologist, gastroenterologist, n nephrologist, psychologist, etc) to
dictate their assessment This is the MD’s or consulting MD’s initial
assessment of the patient and his/her problem when a patient is first
admitted to facility or hospital. It may be several pages long and tends to be
very thorough. RDs and DTRs should go here FIRST to review!DICTATION:
1. This is where you will find quick pertinent info (vital signs) like daily
weights, temperature, blood pressure, fluid intake, basic idea of pot intake
(%), etc. Graphics are usually completed or logged by the nurse.GRAPHICS:
2. This is where you find the daily orders for tests, procedures, labs, diets,
medications, consultant lts, etc. *RDs/DTRs should go to the MD orders to
verify and confirm the DIET ORDER as well as supplements!PHYSICIANS OR
MD ORDERS:
3. MD or other specialists follow up with patients daily (more or less
frequently) and reassess the patient’s progress usually AFTER the initial
consultation or dictation. *The RD or DTR will read this section to receive
the most up to date review of the patient’s status. A patient’s status or
diagnosis can changePROGRESS NOTES:
4. This section includes the RN/LDNs review of physical symptoms, patient’s
functional status, patient’s or families’ complaints or concerns, etc.
*RDs/DTRs may go to this section to find more specific information about
the patient’s dietary intake, appetite, functional ability, orientation, affect,
etc.NURSING NOTES:
5. This includes all lab tests of serum, urine, sputum, stool. *RD/DTR would
look here for the most current information (ie, Alb, Hgb, Hct, Chol,
etc).LABORATORY:
6. This will include updated lists of medications the patient is receiving orally
and via IV fluids during the hospital stay. You will likely see a list of meds
the patient takes at home and perhaps a discharge medication listing. This
will also include nursing documentation of date/time the medication is
administered.MEDICATIONS OR MAR (MEDICATIONADMINISTRATION
RECORD):
7. Allied health professionals (RDs, pharmacists, speech pathologists, social
workers, etc) often include their full assessments and documentation in this
section of the chart.MULTIDISCIPLINARY:
8. This includes reports from radiology, MRIs, scans, EKGs, etc.RADIOLOGY:
9. Documentation in the healthcare/medical records is crucial and necessary
to ensure excellence in healthcare. The saying “if you didn’t document it, it
didn’t happen” is common in the healthcare setting. Documentation is a
legal record that must hold up in defense and justification of care. It is
required!MEDICAL RECORD DOCUMENTATION
10. 1. Documentation must be in black pen---no pencils or erasing should ever
be used,2. If mistakes occur the practitioner must mark through the error
with one line, add the word “error”, initial beside the error, and add the
correction.3. Abbreviations must be approved by the facility---you are not
allowed to make up your own!4. All documentation must be dated5. There
should be no large gaps (blank space) between entries in a medical record6.
Do not express your personal opinions or make criticisms of the patient or
other caregivers. Remember that others are reading your notes!7. Date all
entries---Sign all entries with your title8. Be BRIEF, be THOROUGH, be
ACCURATE!9. Do not make a suggestion of medical diagnosis—that is not in
your scope
11. There are various forms of medical record documentation. Regardless of
the format the information included or reviewed is consistent in all
forms.TYPES OF MEDICAL RECORDDOCUMENTATION
12. A system of collection data that focuses on the primary client problems. A
problem list is generated, updated, and continually reviewed. The plan
addresses this problem list.PROBLEM ORIENTED MEDICAL RECORD(POMR)
13. Often a brief notation as a followup to an original assessment. This note
will review the problem, evaluate the effectiveness of plan, and indicate
change. Progress notes are documented at pre-established intervals (daily,
twice a week, monthly, etc).PROGRESS NOTE:
14. Many physicians and health care providers document in this format and it
is easy to follow. Some facility use pre-printed forms and practitioners fill
out the blanks. Others simply provide lined sheets that the provider will
simply write out S: then info, O: then info, on so on. Acronym for
Subjective, Objective, Assessment, Plan (see handout on Basics of Soap
Documentation).SOAP:
15. The provider writes out information about the patient in an organized way
(similar data clustered together). Often this is in long phrases or sentences
reviewing the patient’s problems.NARRATIVE FORMAT:
16. Similar to SOAP but without the subjective component (all data, whether
subjective or objective is clustered together)DAP (DATA, ASSESSMENT,
PLAN):
17. Intervention: the “actions” to address problem (food delivery,
education/counseling, coordination of care) Diagnosis: Includes a PES
statement that is “pulled” from 3 domains (intake, clinical, behavorial
/environmental) Assessment: ABCD and pertinent client historyADIME:
This type of charting follows the Nutrition Care Process steps. Facilities may
decide to order notes in this format OR address the initial problem of the
patient (in acute care).
18. Evaluation: Have desired outcomes been achieved? How will this be
tracked? On what time farm  Monitoring: what will be “tracked” or
followed— loop back to the Assessment data terms (but not all are
selected!)CONTINUED. . .
OBJECTIVES OF THE PROJECT:

 To get overview of the entire system prevailing in the hospitals.

 To study the workflow and functions of various departments of the
hospital.
 To know the procedures followed in the hospital.
 To record the staffing pattern and gather information about the
responsibilities of the personnel.
 To find the drawback or deficiencies (if any) of the department.
 To suggest few recommendation for the existing problems; an
approach for addressing and dealing with loop holes with efficiency
and effectiveness.
METHODOLOGY:-

The methodology of my assignment is purely based on personal observation on

the working activities of the Human Resource Department and other department.

NATURE OF DATA:-

Primary data

The primary data has been collected through personal observation.

Secondary data

The secondary data has been collected from t hospital information system.
HOSPITAL PROFILE:-

Fortis Hospital Anandapur

Fortis Hospital, Anandapur, Kolkata is a world-class super-specialty NABH
accredited tertiary care healthcare hospital. The 10-storied, 400 bed hospital is
built on a 3 lakh square feet area, equipped with the latest technologies in the
medical world. This state-of-the-art facility specializes in cardiology and cardiac
surgery, urology, nephrology, neurosciences, orthopedics’, digestive care,
emergency care and critical care. Among the various amenities, the hospital has a
24-hour accident and emergency service including trauma treatment, critical care
ambulance service, blood bank, cardiac operation theatre, preventive health
check, diagnostic and catheterization laboratory, critical and emergency care, diet
counseling, physiotherapy and rehabilitation, laboratory and microbiological
services, stress management, 24x7 pharmacy, endoscopy unit and emergency
room.
The intensive care unit (ICU) is well-equipped with over 70 beds that include a
Medical Intensive Care Unit (MICU), Coronary Care Unit (CCU), and recovery and
isolation beds, with separate high-dependency units. The hospital also has a
nephrology department with over 28 advanced dialysis units. The hospital,
governed by integrated Building Management System (IBMS), has a pneumatic
chute system, for quick vertical and horizontal transportation between floors,
facilitating speedy transfer of patient specimens, documents, reports, and
medicines to the concerned departments. This saves time for rendering effective
and efficient healthcare to the patients.

VISION

"Saving & Enriching Lives

MISSION

"To be a globally respected healthcare organisation known for Clinical Excellence

and Distinctive Patient Care"

PURPOSE

“To create a world-class integrated healthcare delivery system in India, entailing

the finest medical skills combined with compassionate patient care”
OBSERVED
department
MEDICAL RECORDS DEPARTMENT
NAME OF THE DEPARTMENT:-
Medical Record Department

LOCATION OF THE DEPARTMENT:-

Medical Records Department is situated on 3rd level, side of administration block.

OBJECTIVES OF THE DEPARTMENT:-

 To study the functions of the record department of the hospital.
 To assess the daily TPA/CORPORATE/CASH PATIENT REPORT.
 To evaluate methods of the discharge file with proper filing (with ICD
Code).
 To identify the gaps of the maintenance of the MR.
 To provide probable suggestions.
WORKFLOW OF MEDICAL RECORD DEPARTMENT:-

Registration
counter

Consultants

I.P O.P

Admission Medical
Records
Wards
Assembling

Deficiency
check and
coding

Indexing

Computer
entry

Scanning
Permanent
filing
STAFFING:-

 Senior M.R.D Facilitator.

 Junior Facilitator.
 Trainees.

PHYSICAL FACILITIES:-
 Personal Computer
 Photocopy machine
 Printers
 Desk phone and intercom.

LAYOUT OF THE DEPARTMENT:-

Layout of Medical Record Department(3rd floor)

DAILY ACTIVITY OF MEDICAL RECORDS DEPARTMENT

 Early morning during the work hours printouts of the previous day discharges
list is taken from the ‘HIS’ system. The patient records are collected and taken to
the Medical Record Department.

 Medical Record Facilitator is the responsible person for performing the daily
retrieval of Records. The Process is known as ‘Internal’ audit which includes:

 OPEN RECORD REVIEW (which may include ‘Active Record Review’ For
special findings) (refer page no. 25)

 CLOSED RECORD REVIEW. (refer page no. 29)

 Last days retrieved Patient’s records are assembled in the specific order.
Particular department is been informed if there are any missing papers, the
Patient’s document is been kept on hold until the rightful papers are been
collected.

 Records are been arranged in the following order referrer (PG No– 24) and
only responsible persons are allowed access and make the appropriate entries.

 After the files are documented then the diseases are Coded by ICD – X
(System). (refer page no. 33)

 Records are Filled in appropriate rack with According to the MRD received
number.

 All the rack are numbered serially.

 The MRD Received numbers of the files in the rack are displayed on each shelf.

 Medico-Legal files are marked with a green sketch pen with MLC (Medico Legal
Case) written on it.
 Expired patients files are filed in a separate rack with Ex written on it. Entry of
expired patients files are maintain in a Death register. The copy of the Cause of
Death certificate is kept with the nursing supervisor and once the book gets over
the same is sent to the MRD. One copy of the Cause of Death certificate is also
maintained in the indoor case file.

 Municipal Death certificates are issued by the KMC (Kolkata Municipal

Corporation).

 Statements are prepared for the expired patients of the previous moth.

 Same is been tallied with the wards register.

 After confirmation the Medical Records Death Register is been updated.

REGISTERS MAINTAINED IN M.R.D
REGISTER NAME REGISTER CODE

Pathology Register (IP) - FHL-A-MRD/01/PR

Radiology Register (IP) - FHL-A-MRD/02/RR

Cath lab Register (IP)- FHL-A-MRD/03/CR

Outgoing Register- FHL-A-MRD/04/OUTR

Death Register- FHL-A-MRD/05/DR

OT Register- FHL-A-MRD/06/OR

Birth Register- FHL-A-MRD/07/BR

Birth Intimation Register- FHL-A-MRD/08/BIR

Death Intimation Register- FHL-A-MRD/09/DIR

DAMA Register- FHL-A-MRD/10/DAR

Document Handover Register- FHL-A-MRD/11/DHR

MRD Entry Register- FHL-A-MRD/12/MER

Oncology Register- FHL-A-MRD/13/ONCO

Oncology Intimation Register- FHL-A-MRD/14/OIR

Daily Census Register- FHL-A-MRD/15/DCR

DATA COLLECTION
PERFORMANCE OF MEDICAL RECORDS DEPARTMENT OF ANANDPUR BRANCH : -

VERY- GOOD FAIR POOR

GOOD

55 25 15 5
2. QUALITY OF SERVICE RENDERED WITHIN TIME BY MEDICAL RECORDS DEPARTMENT :

VERY- GOOD FAIR POOR

GOOD

65 15 15 5

VERY-GOOD
GOOD
FAIR
POOR
PROBLEMS AND RECOMMENDATION:-
 Not recording negative findings
 Not recording substance of discussions about the risks and benefits of
proposed treatments
 Not recording the results of investigations and tests
 Illegible entries
 Not reading the notes when seeing a patient
 Wrong patient/wrong notes.
 Out-patient records not linked with in-patient records to be preserved for 5
years.
 Out-patient records linked with in-patient records to be preserved for 10
years.
 In-patient records to be preserved for 25 years.
 All medico-legal cases to be preserved for posterity.
 All medical records other than those mentioned above to be disposed off
on a regular basis.
 All old X-rays relevant to the out-patient files that are being disposed off to
be destroyed.
CONCLUSION:
After a training of 90 days in Fortis Hospital, Anandapur. I have
observed & learnt that running a hospital is not that easy. Some of
the best Hospitals in Kolkata are now considered as among the
best in the world. These hospitals have reached this stage due to
their highly dedicated medical staff and their zeal to deliver the
best treatment to their patients. Apart from that, there are some
other reasons due to which a significant number of patients, from
all over the world, visit these hospitals to get treated.
BIBLIOGRAPHY

http://www.moneycontrol.com/news/results-boardroom/plan-
expansionindia-to-add-500-600-beds-
fortis_1095654.html?utm_source=ref_article.

www.wikipidia.org

www.managementinfo.com