Verma Stuti, Midha Manish, Bhadoria Ajeet Singh
Department of Hospital Administration, Institute of Liver and Biliary Sciences, New Delhi, India.
Department of Amity Institute of Hospital Administration, Amity University, Noida, Uttar Pradesh, India.
J Family Med Prim Care. 2020 Jan 28;9(1):418-423. doi: 10.4103/jfmpc.jfmpc_612_19. eCollection 2020 Jan.
A study of the medical records department of a multi super specialty secondary care hospital in NCR.
Primary data was collected through direct observation and retrospective study of documents maintained in MRD. Secondary data was collected from quality control department books, journals, scholarly articles, and internet.
Sample sizes of 350 retrospective and current medical records were thoroughly scrutinized. Conclusion revealed the hospital has published as exhaustive medical records manual listing and the scope, objective, hierarchy chart, job description, policies, procedures, and processes. The MRD has a well-documented flow process of medical records, but on checking the flow of patient records between Nov 2016 to Feb 2017; it was revealed that in month of Nov 2016, out of the total 278 patients discharged only 276 files were received in MRD and 0.72% files were not received. Moreover, it took over 31 days for 71 patients (23.67%) to receive files in MRD. In Jan 2017, out of 286 patients discharged, only 237 files were received in MRD contrasting to 10.14% files not received. Moreover, it took over 31 days for 28 patients (9.80%) to receive files in MRD. In Feb 2017, out of 268 patients discharged, only 206 files were received in MRD and 22.39% files were not received as on 11 March 2017. This study concluded that there is no effective system in place to monitor/track files from ward/billing section to MRD once the patient is discharged.
Medical records are valuable to patients, physicians, healthcare institutions, researchers, National Health agencies, and International health organizations. Memories fade, people lie, witnesses die; however, medical records live forever. A thorough system of flow process of monitoring/tracking files is to be in place to ensure accountability, smooth functioning, and quality of care being provided without violating basic patient sight of confidentiality of information.
对新德里国家首都辖区一家多专科二级护理医院的病历科进行研究。
通过直接观察和对病历科保存文件的回顾性研究收集原始数据。二级数据从质量控制部门的书籍、期刊、学术文章和互联网收集。
对350份回顾性和当前病历的样本量进行了全面审查。结论显示该医院已出版详尽的病历手册，列出了范围、目标、层级图、职位描述、政策、程序和流程。病历科有记录完善的病历流转流程，但在检查2016年11月至2017年2月期间的患者病历流转情况时发现，2016年11月，在总共278名出院患者中，病历科仅收到276份文件，0.72%的文件未收到。此外，71名患者（23.67%）的文件在病历科的接收时间超过31天。2017年1月，在286名出院患者中，病历科仅收到237份文件，10.14%的文件未收到。此外，28名患者（9.80%）的文件在病历科的接收时间超过31天。2017年2月，在268名出院患者中，病历科仅收到206份文件，截至2017年3月11日，22.39%的文件未收到。本研究得出结论，患者出院后，没有有效的系统来监测/跟踪从病房/计费部门到病历科的文件。
病历对患者、医生、医疗机构、研究人员、国家卫生机构和国际卫生组织都很有价值。记忆会消退，人们会说谎，证人会死亡；然而，病历却永远存在。需要建立一个完善的文件监测/跟踪流转系统，以确保问责制、顺畅运作以及在不侵犯患者基本信息保密权的情况下提供优质护理。
