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Jun 15, 2008

SOP Medical Record Department (MRD)

STANDARD OPERATIVE PROCEDURES MEDICAL RECORDS

DEPARTMENT
INSURANCE CASES
Life insurance policy (LIC) for death cases
Medi claim policy
Any other insurance claim

Life Insurance Policy Claim (death cases only):
· The claimant should submit the blank prescribed LIC claim form (s) to the Medical Records Department.
· Following documents are required before completing the prescribed form(s):
i. Application from the claimant with the details of the deceased.
ii. Xerox copy of letter from LIC.
iii. Xerox copy of policy’s front page to verify the claimant’s authenticity.
· In some cases life insurance cooperation will directly approach for completing the prescribed form(s).
· Collect the necessary service charges as prescribed by the Hospital Management from both the parties and issue official receipt.

PROCESS OF COMPLETING THE PRESCRIBED LIC CLAIM FORM (S):
· Retrieve the respective inpatient health record charts of the deceased. Tally the deceased particulars with the claimant ‘s provided particulars.
· Attach the blank LIC claim forms with the respective inpatient health charts of the deceased and forward the documents to the respective consultant for completing them.
· Time frame for completing the forms by the consultant should not exceed more than three days (excluding the receiving day).
· The completed forms along with the health record charts should be returned back to the Medical Records Department.
· Inform the claimant to collect the completed forms. In case it is the LIC authorities that have approached, then the forms should be dispatched to them.
· Before handing over or dispatching the completed LIC forms should be xeroxed and those Xerox copies should be kept in the deceased in patient health record chart for future reference.

Medi claim policy:
· The General Insurance company representative (Investigator) approach Hospital authorities to have access to the inpatient Health record chart of the patient, to ensure the accuracy of the history given by the patient or their relative to the treating doctor.
· To have an access to the concerned health record chart the representative has to complete the following formalities:
i. Application requesting to have access and provide patients details.
ii. Name , age ,sex and address of the patient
iii. IPD# and PNT#.
iv. Father’s / husband name
v. Authorization letter from the concerned Insurance company that he/ she (representative) has been depute for the job.
vi. Own identity card.
vii. A letter of authorization from the patient for the disclosure of his record information.
· The access of the chart will be limited and to be more specific not the entire chart.
· After accessing the inpatient health record chart the representative may ask for the Xerox copy of particular information i.e. history part of the patient recorded by the doctor. The necessary should be given and the record maintained.
· The document provided by the representative will become the part of the respective health record chart and will be placed under the guide divider “Miscellaneous” for future reference.

Any other Insurance claim:
Same policy and procedure will be followed as given under LIC and Mediclaim.
STANDARD OPERATIVE PROCEDURES

ACCESSING OF THE INPATIENT HEALTH RECORD CHARTS BY DOCTORS AND ADMINISTRATIVE STAFF FOR VARIOUS PURPOSES
The treating consultants and the other clinical doctors are authorized to have access to the discharged inpatient health record charts. The non – clinical doctors and other administrative staff can access the charts with the written approval of the Medical Superintendent. When a patient is re-admitted the treating doctor can request for previous admission file through respective In charge Nursing Station.

· A form has to be filled by the concerned for requesting for the inpatient health record chart(s).
· In case the no. of charts are more than 20 , then at least 24 hrs. to be provided to complete the retrieval process and placing the tracer card in place of the retrieved health record chart.
· In all MLC and death cases the Medical Superintendent’s written permission is a must to access them.
· The completed form should be submitted to the MRD. The following details should be provided to access the chart:
i. IPD#
ii. PNT#
iii. Patients’ name
iv. DOA and DOD
v. Consultant’s name
vi. Reason for borrowing that can be readmission, study/ review, court evidence, research or any other.
· The chart will be borrowed for 07 (seven) days excluding the borrowing day.
· The borrower with date and time should duly sign the completed form.
· The required health record chart is then provided to the concerned person.
· After the chart is retuned back in MRD and returned date and time is written on the form with the signature.
STANDARD OPERATIVE PROCEDURES
ISSSUE OF THE MEDICAL CERTIFICATE

The patient / attendant can directly request the treating doctor for issue of the Medical Certificate.
PROCEDURE:
· The concerned treating consultant will issue the required medical certificate on his/her letterhead and send it to the Medical records Department.
· All the Medical Certificate should be routed through the MRD for the verification of the following data:
i. PNT# and IPD#.
ii. Patients’ name
iii. Age and sex
iv. DOA and DOD
v. Diagnosis
vi. Operation/procedure
· After the necessary verification of the patient data, the MRD will forward the Medical Certificate to the Medical Superintendent for the counter signature. It is a mandatory requirement.
· Every effort will be made to provide the completed medical Certificate to the patients / relatives as soon as possible.
· The Hospital will not take the responsibility of authenticity of a certificate issued without the verification and counter signature of the Medical Superintendent.
STANDARD OPERATIVE PROCEDURES
DEPOSITING OF THE DAILY DISCHARGE INPATIENT HEALTH RECORD CHART (S) TO THE MEDICAL RECORDS DEPARTMENT
Patients who are discharged previous night (till 12 ‘O Clock midnight), their health record charts must be deposited in the Medical Records within 48 hrs.
All discharged health record charts should be borrowed from the MRD and not from the Nursing Station.
The Nursing Station sister in charge should maintain a register with the following data:
Date of sending the health record charts.
IPD#
PNT#
Patient’s name
DOA
DOD
Consultants name
No. of CCFS.
Remarks if any
· These health record charts are dispatched to the MRD through a Ward Aide.
· The receiving person in the Medical Records Department should sign these details.
· Any reports / documents that come after the deposition of the health record charts should be sent as soon as possible by the shift in charge to the MRD within 24 hrs. of their receipt.
DEPOSITING OF THE EXPIRED PATIENTS’ HEALTH RECRD CHARTS:
Dispatch of the expired Health Record Charts along with the death notification form both in English and Hindi should be made within 24 hrs. of the death.
These charts should be placed under the lock and key. And a paper sheet tracer card to be placed on the IPD# of the chart for future reference.
The MRD should ensure the following particulars:
The death notification form in English and Hindi is complete in all respects.
The concerned doctor has documented death events including the time of declaring the death in the Doctors’ Progress Note.
· It is mandatory for the MRD to maintain a Death Register which includes the following details:
i. S.no.
ii. PNT/IPD no.
iii. Name of the diseased
iv. Name of the doctor
v. Age
vi. Sex
vii. Address
viii. DOA
ix. DOD
x. Time of death
xi. Name of the procedure
xii. Date of the procedure
xiii. No. of days from the procedure till death Only in computer
xiv. No. of days stayed in the Hospital
xv. Place of death
xvi. Cause of death
xvii. Name of the informer
xviii. Address of the informer

· The original Hindi death notification form must be delivered to the Panchayat Authorities, Jolly Crant, Dehradun and obtain date and the signature of the receiving concerned official of Birth and Death registration Office.
· The death details are then passed over to Medical Superintendent’s office.



STANDARD OPERATIVE PROCEDURES

ARRANGEMENT OF DOCUMENTED SHEETS IN THE IN-PATIENT HEALTH RECORD CHART FILE COVER
· The discharged/expired patients’ documented papers to be transferred from Nursing Station folder (File Cover) to In-patient Health Record Chart File Cover (present in yellow color) in following order i.e. division wise.
· In MRD, the documents are arranged in the chronological order from Date of admission to the date of discharge or death.
· All the blank sheets with or without patients’ identification data should be removed.
· In case any document is found without the patients’ identification data i.e . name , age, sex, IPD no., PNT no., it should be filled.

The arrangement of the documents are to be done from Top to Bottom according to the following heads:
(Place documented sheets behind the guides)

CLINICAL NOTES
· Face Sheet or final summary sheet
Discharge / expired summary
General Case Notes
Doctors’ Progress Notes in chronological order – admission to discharge
Operation / Procedure Notes
Anesthesiology Record & Anesthetic Sequence
Doctor’s Order Sheet – Post Procedure Orders
Standing Physician Orders
Previous Discharge Summary of HOSPITAL
Transfer Notes.
DIAGNOSTIC STUDIES
Reports (in chronological order)
Invasive
Non Invasive
X-Ray
CT Scan
Ultrasound
Laboratory Medicine
Other HOSPITAL and multispeciality reports.

BLOOD TRANSFUSION NOTES
Compatibility report
And other blood band stickers
NURSES NOTES
ER Nurses Flow Record
Nurses Progress Notes
Graphic record
Medication Record
Nurses Flow Sheet (Temp, Pulse, BP, Resp, Intake & Output)
Physiotherapy sheet
IV Therapy Placement Document
Pre-catheterization nursing checklist
Diabetic Flow Sheet
HOSPITAL Cardex
Pre-operative Checklist
Property check list
Reports handover list
Resuscitation record
Cardiac output chart
Other nursing sheets

MISCELLANEOUS
Informed Consent
Consent for Cardiac Procedure
Admission Checklist (Package)
Case Sheet – Patient’s Demographic data
Various other notes, letters/ correspondence etc
Clearance for surgery/procedure
Clearance for discharge
Death Notification Form

Note : Critical Care Flow Sheets are filed separately.
: X- ray films are filed separately.
STANDARD OPERATIVE PROCEDURES
COMPLETION OF THE HEALTH RECORD CHARTS
The MRD will inform the concerned doctor regarding the deficient health record chart(s).
The doctors are to complete the deficient charts within the stipulated time period.
The place of completion is Medical Records Department during working hours.
Documents to be completed:
Final Summary Sheet
Ø Provisional Diagnosis
Ø Final Diagnosis
Ø Complications
Ø Surgical procedures
Ø Result
Ø Signature

Discharge /death Summary
Cardiac/General case note
Operation note
STANDARD OPERATIVE PROCEDURES
HEALTH RECORD CHARTS MANAGEMENT
The daily discharges and expired patients’ health record charts (files) from the respective Nursing Station are being sent to the MRD the following day in between 9:00am to 5:30pm., through GDA. Following discharge / expired patients’ details are written in the register:
· Date of sending the health record charts
· S.no
· Name of the patient
· PNT/IPD
· Age /Sex
· DOA
· DOD
· Consultant’s name
· No. of CCFS (Critical Care Flow Sheets)

Before acknowledging the file, tallying the details written on the register and the file is done. Then acknowledging is done. Then the details are being entered in the computer to have updated record. The details are:
· PNT
· IPD
· Name
· Mothers name
· DOA
· DOD
· Address

The color-coding is being done for the readmitted and death patients:
Blue – two times admission
Red – three times admission
Green – four times admission
Brown – five times admission
Light green - six times admission
Pink – Fourteen-time admission
Black - death
The re - assembling of these files are being done in the chronological order according to the following criteria:
1. Clinical
2. Diagnostic study
3. Nursing
4. Miscellaneous
Then it is being entered in the daily discharge /death register being maintained by the Medical records Department. This register is being maintained to monitor, follow N’ control that all the discharge and death files are being received in the MRD. Then the name of the patient and the IPD no. is written on the file with blue and with black for the death cases. The health record charts which are not received from the respective Nursing Stations , a Email reminder is sent for it and a copy to Asst. Nursing Superintendent (Ms. Thankham Gomes).
A deficiency check list (Quantitative Analysis) is being prepared and a summary of incomplete/complete files data is prepared consultant wise. Filing is done according to the IPD no. A daily report is made and is submitted to the Medical Director.
If ever any Doctor wants any file for review then a form is being signed by the concerned person and that file is being given to him/her.
Linkages for the re – admission patients are being done side by side. Death register is also maintained separately for notification to the Municipal Council Dehradun, which includes the following details :

· S.no.
· PNT/IPD no.
· Name of the diseased
· Name of the doctor
· Age
· Sex
· Address
· DOA
· DOD
· Time of death
· Name of the procedure
· Date of the procedure
· No. of days from the procedure till death Only in computer
· No. of days stayed in the Hospital
· Place of death
· Cause of death
· Name of the informer
· Address of the informer
And this is maintained in the computer also.