Health Records

Lecture 7
Organization and Management of
Medical Record Department
Prepared by Dr. Fahad Khan
Edited by Abdulrahman Muslihi

Department of Health Informatics

Faculty of Public Health and Tropical
Medicine
Organization

The medical record services are classified into

four following categories:
1. Out-Patient Services
2. Accident and Emergency (Casualty) Services
3. Inpatient Services
4. Medical Record Library
Organizational chart of MRD by Staff
Organizational chart of MRD by function
Job Descriptions
Medical Record Officer
– Establish, organize and manage MRD
– Develop policies and procedures
– Assist the committee to develop forms
– Review the records
– Prepare monthly statistical reports
– Prepare and carry out educational and training
programs
– Ensure privacy and security of records
Job Descriptions
Medical Record Technician

– Carrying out technical analysis and evaluation

– To collect medical, administrative and other
statistics
– To code and index diseases and operations
– To input the patient care information into the
computer for processing, storage and retrieval
– Ensuring the privacy and confidentiality of
medical records
Job Descriptions
Assistant Medical Record Technician
– To prepare pre-numbered folders with color coding
– To collect basic identification data from the patient
and record it in patient file
– To register new and old patients and arrange
appointments
– Prepare patient master index
– Collect reports from labs and mount them in
appropriate records
– Maintain the confidentiality
Operational Policy
• The main purpose of an operational policy is to guide the functions
of the medical record department effectively and efficiently.
• The following are some of the activities included by an operational
policy
– Working hours and shifts – Communication
– Monthly duty rosters – Transportation
– Implementation of – Transcription of medical
instructions Reports
– Organizational Charts – Housekeeping and the
– Training of new staff physical environment
– Departmental meetings – Protection from fire
– Submission of reports – Safety Control, Infection
Control
– Equipment, furniture and
supplies – Disaster and Emergency plans
MR Functions
Typical functions
– Storage and Retrieval
– Transcription
– Release of Information
– Clinical coding

Additional functions
– Research and statistics
– Cancer and/or trauma registries
– Birth certificate completion
Storage and Retrieval
In Paper-based system:
• Patient care information documented on paper
and housed in file folders.
• Records retrieved for patient care purposes,
quality improvement studies, audits, and other
authorized uses.
• Records are delivered to nursing units,
outpatient surgery, and emergency room as the
patient is admitted or being treated.
Storage and Retrieval
In Hybrid system:
• Patient care information documented both on
paper and in the computer.
• Record is accessible to patient care areas via
the computer by use of an electronic document
management system (EDMS).
• If hospital is transitioning to the EHR, portions
of the health record may be printed for use on
the patient care unit.
Storage and Retrieval
In EHR system:
• Patient care information captured at point of
service and/or electronically transmitted to the
EHR.
• Same electronic components utilized in the
hybrid record, but the record resides entirely in
electronic format with work processes
performed via the computer.
Record Processing/Completion
In Paper-based System
• After the patient discharging, the record is retrieved from the nursing
unit. The record is then assembled or put in an order prescribed by
the facility’s policy and procedure manual.
– e.g, the face sheet is usually the first page in the paper record.

• Receipt of the health record is checked with a discharge list in a

process called record reconciliation.
• The post discharge record order is usually different than the order
of the record on the nursing unit.
• After the assembling, it is analyzed for deficiencies, such as
missing reports and signatures.
• Physicians visit the MR department to complete deficiencies in
records.
• The record is reanalyzed after completion to assure completeness
of the process. Deficiencies are cleared from the computer.
Record Processing/Completion
In Hybrid System
• Portions of the record can be directly inputted into the EHR
through computer interfaces.
• e.g, transcribed reports, laboratory reports, emergency records, etc.
• After the patient is discharged from the hospital, the paper record
is prepared for imaging (scanning).
• Receipt of the health record is checked with a discharge list in a
process called record reconciliation.
• Physicians complete the record from a computer that may be
located remotely from the hospital.
• If electronic signatures, computer key, and electronic completion
rules are applied, the deficiency system is updated once the
physician completes his/her records.
• Records are analyzed for deficiencies either manually by the MR
staff and/or by rules built into the computer system.
Record Processing/Completion
In EHR system
• Receipt of the health record is checked with a
discharge list in a process called record
reconciliation.
• Entire health record available via the computer
for completion. Work queues in the computer
are used to route health records to appropriate
person or area for completion.
Transcription
In Paper-based system:
• May be completed in-house or outsourced to an
outside service.
• Physician dictates reports into a dictation system
that records the voice. The transcriptionist types
(transcribes) what the physician has dictated.
• The transcribed report is placed in the chart.
• Reports commonly transcribed include: operative
reports, history and physicals, discharge
summaries, radiology reports, pathology reports,
and consultations.
Transcription

In Hybrid and EHR system:

• The process is basically the same as in the
paper-based system, except that the transcribed
reports are electronically added to the health
record that resides within the computer.
• Speech recognition technology may be
applied to the front-end and back-end of the
transcription process to facilitate the process.
Release of Information
In Paper-based system:
• Reviews requests for health records for validity to assure
compliance with regulations.
• Logs and verifies validity of requests for patient
information.
• May copy the record in response to valid requests or may
provide record for an outsourced copy service to process.
• May go to court in response to a subpoena or court order.
• Must have in-depth knowledge of laws and regulations
governing the release of information
Release of Information

In Hybrid and EHR system:

• It is basically the same as in the paper-based
environment.
• As the EHR evolves, there may be
opportunities for the HI professional’s role to
be expanded.
Clinical coding
In Paper-based system:
• A code number(s) is/are assigned to the diagnoses and
procedures documented in the health record.
• The coder looks the code number up in a coding book or
by entering key words into the computer using software
called an encoder.
• ICD-9-CM and CPT are the two primary coding systems
used in a hospital setting. ICD-10-CM and ICD-10-PCS
will replace ICD-9-CM.
• Other information is abstracted from the record for
reporting and reimbursement purposes.
• Coding takes place on-site within the HIM department.
Clinical coding
In Hybrid and EHR system:
• The process is the same as the paper-based
system, except that in the EHR, the record that
is reviewed is the electronic health record.
• Coding may be remote to hospital; home-based
coding is possible.
• Computer-assisted coding may be utilized.
• Data abstracting may be reduced or eliminated
as automatic data capture is implemented
Additional functions

• Research and statistics

• Cancer and/or trauma registries

• Birth certificate completion

References
• Mogli, G.D. (2016) Medical Records
Organization and Management, Jaypee Brothers
Medical Publishers (P) Ltd, 2nd Edition
• World Health Organization. Regional Office for
the Western Pacific. (2002). Medical records
manual : a guide for developing
countries. Manila : World Health Organization,
Regional Office for the Western Pacific
Thank You