SURYA CLINIC SOP REV-00

Policy: Medical Record Services

Prepared by:
Policy type: Departmental
Policy Number:
Date Approved:
Approved by
Dept: Medical Record Review on
No of Pages 9

1.0. INTROD!TION
Medical records play an important role in the functioning of any clinic in terms
of giving vital information for conducting research, statistical data on utilisation
of clinic services, mortality morbidity profiles, and to evaluate performance
of clinical outcomes! "t is beyond doubt that a well organised and managed
Medical Records Department will go a long way in providing #$A%"&'
services to our clients!
(alue of complete and accurate records for legal purpose is well established
especially after the institution of the )onsumer Protection Act! &he basic
principles of medical record department are similar in all clinics regardless of
si*e and scale of services being provided!
O"#$!TI%$S O& M$DI!'( R$!ORDS
&o maintain a central system of complete medical records of all
clients
&o provide database for medical education and research activities!
&o assist administration in +uality chec, for the services provided!
&o -erve as effective managerial tool for future planning and
control of the services
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).0. OR*'NO*R'M

+.0. &N!TIONS
.!/! Develop a system of record storage and retrieval
.!0! Maintain the +uality of medical records in terms of completeness of
its contents
.!1! &o establish policies for retention and disposal of medical records,
under legal frame wor,
M$DI!'( R$!ORD ,I(( !ONSTITT$ T-$ &O((O,IN*
Medical record is a chronologically arranged record of the events from the
first contact of the client with the clinic! "t includes all the information
pertaining to admission, billing, diagnosis, treatment, and discharge of the
client! A medical record would primarily contain the following records,
5.1. Admission and demographic details of the client
5.2. Medical history forms &his would contain the medical history of the
client
2!1! )linical Notes and Provisional34inal diagnosis
5.4. Investigation reports All investigation reports with final diagnosis
signed by a
+ualified clinician
2
District Manager
In-charge Councilor
MIS Head
SURYA CLINIC SOP REV-00

5.5. Operation theatre notes Anaesthetist5s notes3charts, medications
given, diagnosis, time and name of operation, name of operating surgeon and
nurses, surgeon5s findings and detailed descriptions of the procedure performed
5.6. )lient progress report with re+uired charts &he attending
doctor3nurse is to note the progress of the client5s physical status and
any specific observation made during clinic stay! 67amples: &PR38P
chart, etc!
..0. ST'ND'RDIS'TION O& M$DI!'( R$!ORDS
&he -tandardisation of the proposed Medical records will be carried
out under the guidelines of M"- Department. &he department5s
functions would be as given below:
9!/! Review the policies and guidelines and recommend changes
for improving the +uality of the contents of the Medical
Records
9!0! Review and approve all new formats of the medical reports
and records
9!1! &he department is responsible to review and evaluate the
functioning of the medical records department in terms of
flow of the records from the departments, completeness of
the record data that is mandatory to be entered!
9!.! &he department will periodically evaluate reports for
management review, +uality of clinical services rendered,
and medical research
9!2! Provide recommendations on management issues li,e filing
procedures, storage, and preservation of certain sections of
the medical records which have legal implications
9!9! Provide directives to DMs3clinical team for completing
medical records
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/.0. M$DI!'( R$!ORD PRO!$SSIN*
7.1. All in:clients would be assigned a uni+ue clinic number which would also
become the code number for their Medical Records
7.2. Admission After payment of the deposit amount, a receipt bearing the
clinic number would be generated !&his would become the first document
to be attached to the Medical Records!
7.3. Disharge completeness of the record is to be chec,ed by the medical
records supervisor in terms of the following :
Admission and Demographic details
"nformed consent
Provisional and 4inal Diagnosis entries
"nvestigation results
)linical diagnostic and therapeutic notes
Discharge summary
"f it is found that certain information is not complete, a de0iciency slip
;Anne7ure "< mentioning the shortfalls would be sent to the respective
persons, who would be re+uired to come to the DM office and complete the
same!
1.0PO(I!I$S 'ND PRO!$DR$S
1.1 PO(I!I$S
"nde7ing enables easy identification and retrieval of the re+uired
Medical Records!
"nde7ing of Medical Records will be carried out by,
o Inde!ing o" ID n#m$ers and the %ini name for
administrative functions of the Medical Records Department
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2.0PRO!$DR$S
2.1STOR'*$ 3 R$TRI$%'(
-torage of medical records will be based on chronological order as
per the clinic coding pattern
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DISCH!"# $% &H# C'I#(&
M#DIC' !#C$!D D#)!&M#(&
!ecei*t o+ ,edical record +ro, the -ard a+ter discharge
!e.ie- the record/
Chec0 all records are aligned and signed 1 record has
2een correctl3 inde4ed
I+ the records are not aligned5 then contact the
res*ecti.e -ard in-charge to co,*lete the +ile
I+ records are not signed5 then contact the
res*ecti.e *erson and re6uest to sign the *a*ers
lign the +iles chronologicall3 as *er the ID nu,2ering
!etrie.al o+ +iles as *er re6uest onl3 as gi.en 2elo-

SURYA CLINIC SOP REV-00

9!0!0! Retrieval of records would be based on the clinic code and the client
"D
9!0!/! "n case any of the medical records are incomplete, the respective
person will have to come to the DM to do so!
9!0!0! "ssue of medical records:
7 )onsultants and other clinical professionals "f the
person3s are listed in the authorised persons list, as, the
person to get an authorisation in writing from the Program
Director and provide them with the medical record and ta,e
a signature from the person on the issue register!
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d,ission and
!egistration
Counter
MIS
!etrie.al o+ the Medical
!ecord
Deter,ine the date8 3ear
o+ last ad,ission
Identi+3 the record
Send the +ile to the
res*ecti.e clinic
Con+ir,ation that the +ile
has 2een trans+erred +ro,
M!D 8MIS De*t. to the
res*ecti.e clinic
uthori9ed )ersons
Consultants 1 Doctors
d,inistrati.e Sta++
M!D Sta++
!etrie.al $+ Medical
!ecord
Sort the clinic code
Inde48ID code
Identi+3 !ecords
#nsure &he !e6uisition Is
:3 uthori9ed )erson
!ecei.e Con+ir,ation $+
&rans+er $+ Medical
!ecord
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9!0!1! "nde7ing of medical records for the consultants and other staff will
be accessible only from the Medical record Department
10.0. Re4isters:
1;.1. Medical Record "ssue Register All issues are to be recorded,
with authorisations slips attached
11.0. (e4al Re5uirement to Retain Medical Records:
All the medical records have to be retained by the clinic authorities for
legal re+uirements,
11.1. )lient Medical records will be retained by the clinic for minimum
period of 2 years
11.2. Destruction of the medical records are to be carried by burning or
incinerating the records and NOT by selling the records! An advertisement would
be given in national newspapers giving at least /2 days notice about the
destruction of the records!
12.;. Statistics:
)ertain vital statistics are to be generated through the Medical Records
Department the formulae which will be followed for determining vital
information are as given below:

1+.0. Security Measures:
All Medical records are the property of the )linic! -tringent measures are to be
ta,en to safe guard against destruction and access by unauthorised personnel!
/1!/! Access to information in the medical records will be authorised only
by the Program Director
/1!0! -tratify the list of medical and related professionals who would
re+uire access to the records for research
13.3. )orrection or Amendments "n case of corrections and
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amendments the consultants will ta,e the prior permission in writing, from the
Program Director
1..0. INT$RN'( 'DIT:
/.!/! 6nsure that there e7ist definite retention and destruction
schedules
/.!0! 6nsure that the Retention schedules meet all the regulations
within legal framewor,
14.3. 6nsure that the systems and schedules for issue of medical
records, to clients, consultants and legal officers is ade+uate
and authorised by the Management
/.!.! 6nsure that the records are organised for +uic, retrieval and
accuracy in the filing of medical records
/.!2! 6nsure that the Medical Record Department is optimally
staffed
/.!9! -crutiny of the security systems of the department
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SURYA CLINIC SOP REV-00

'NN$6R$ 7 I
Medical Records Department
De0iciency Slip
Date: )linic concerned: $ni+ue No:
Name:
De0iciencies to be completed:
Demographic data Diagnosis
)linical details =perative details
Discharge summary "nvestigation Records
>indly ma,e sure that the concerned person completes the record within /2 days
of this notice!
Authorised by
Medical Records Supervisor
=