Garg Ruchi, Talwar Yatin, Garg Neeraj
Assistant Professor (Hospital Administration), AIIMS, Jodhpur, India.
Resident (Hospital Administration), AIIMS, Jodhpur, India.
Med J Armed Forces India. 2022 Jun 12;80(1):91-7. doi: 10.1016/j.mjafi.2022.04.015.
The Medical Record (MR) contains the information which is needed to plan, provide, and evaluate the care given to the individual. It also serves as a pivotal tool for communicating information to all the health personnel who manage the patient, and it contributes to the continuity of patient care. There is an unmet need of identifying and correcting the issues faced with MR and Medical Records Departments (MRDs) so that higher efficiency can be achieved. This study was conducted to study the deficiencies and discrepancies found in MRD files during COVID management and to correlate the deficiencies with the facilities available and the workflow. Later Lean Management (LM) was applied to ensure compliance and efficiency in the system.
An observational study was done on the audit of COVID 19 patient files and facilities in the care centres. Process mapping was done. The data for LM were collected by brainstorming, observation, interview, and workflow review of several processes, values, number of wastes, and suggestions were documented the MRD staff.
Area available was 400 m which is adequate against the norm of 350 m. The existing staff of 30 was adequate as per norms. Deficiencies were observed in physical examination, history, radiology, and laboratory reports. The findings showed that the MRD units had 13 current processes, 26 wastes, and 10 values were identified. In addition, they were offered a total of 25 comments on eliminating the waste.
Staff and equipment were adequate. Recommendations include regular staff training and usage of electronic medical records, focus on deficiency check by specific MRD staff on regular basis monitored by the administration and supported by the medical audit committee. The study also recommends that suggestions applied after LM should be implemented in letter and spirit and a repeat study of LM is advisable after regular intervals to maintain the quality standards and to maintain or further improve the efficiency.
病历包含了规划、提供和评估针对个体的护理所需的信息。它也是向所有管理患者的医护人员传达信息的关键工具，有助于患者护理的连续性。目前存在尚未满足的需求，即识别并纠正病历及病历部门（MRD）所面临的问题，以便实现更高的效率。本研究旨在调查在新冠疫情管理期间MRD文件中发现的缺陷和差异，并将这些缺陷与可用设施及工作流程相关联。随后应用精益管理（LM）以确保系统的合规性和效率。
对护理中心的新冠患者文件及设施进行了一项观察性研究。绘制了流程地图。通过头脑风暴、观察、访谈以及对多个流程、价值、浪费数量的工作流程审查收集了LM的数据，并记录了MRD工作人员的建议。
可用面积为400平方米，符合350平方米的标准。现有30名工作人员，符合标准。在体格检查、病史、放射学和实验室报告方面存在缺陷。研究结果显示，MRD部门有13个当前流程、26种浪费情况，并识别出10种价值。此外，共收到25条关于消除浪费的意见。
人员和设备充足。建议包括定期对工作人员进行培训并使用电子病历，由行政部门监督、医学审计委员会支持，特定的MRD工作人员定期进行缺陷检查。该研究还建议，LM实施后所提建议应切实贯彻落实，并且建议定期重复进行LM研究，以维持质量标准并保持或进一步提高效率。
