ANALYSIS OF MEDICAL RECORDS

Medical Record

A record of health information uniquely assigned to a single person generated by one or more encounters and maintained in written paper base or electronic format, or a combination of both,. The health record connects the physicians and other caregiver’s entries. Included-but not limited to – in this information are patient demographics, progress notes, problems, medications, medical history, and post-operative summary (if applicable), laboratory data, radiology reports and discharge summary.

Quantitative Analysis

check and analyze the components parts of the Medical Record to ensurethat it is complete, adequate and accurate and its available at all times for legitimate needs of the patients, the hospital, and the Physician.

Qualitative Analysis

A review of medical record entries for inconsistencies and omissions which may signify that the medical record is inaccurate or incomplete.

Completion of Medical Records

Completing the medical records, which are deficient in number of forms or contents as per the established standard. The medical record staff reviews each case and notes down the deficiencies and (doctors visit the MRD weekly and complete them) verify with concerned staff.

Duties and RESPONSIBILITIEs of hospital staff

Analyst 

The cardinal rule for analyzing records is to verify that the patient’s name and medical record number is reflected on each report (Patient identification or addressograph)

Physician / Nurse

  • 1Analyze each record to verify completeness including legibility and timeliness, using the guidelines listed below:
  • Registration: contains Diagnosis/Operative procedure on admission and signature of the admitting doctor.
  • Discharge Summary: A discharge summary of all inpatients should be provided for all patients.
  • Emergency Medical Services form: Must be filled in properly and signed by the physician and nurse with date and time.
  • 2Assessment form:
  • Inpatient: All admitted patients must have properly filled up assessment form.
  • checkOutpatient: when seen for the first time in the OPD, patients should have properly filled up OPD assessment form.
  • 3Obstetrical Record: The record is placed in their respective medical record after completion of postpartum care. Dates and signatures are required in all instances.
  • 4Consultation Form: Must contain documentation of request by the referring physician and a reply by the consulted physician and signature of both physicians.
  • 5Order/Notes:
  • Each order/notes must be dated, timed and signed.
  • checkAll verbal orders shall be countersigned and stamped by the ordering physician either before leaving the unit / area or within four (4) hours after the order has been given.
  • checkTelephone orders shall be countersigned and stamped by the ordering physician within twenty four (24) hours after the order has been received.
  • 6Final Progress: Final progress notes may be substituting of the discharge summary those patients who stayed less than 24 hours including newborn infants and uncomplicated obstetrical deliveries. The final progress notes include any instruction given to patient.
  • 7Death Report: ln the event of death, a death report indicating the reason(s) for admission, physical and laboratory findings, course in the hospital and the possible cause(s) of death must be completed.
  • 8Operative Reports: Necessary on all patients that had an operation/procedure. If an operation was performed, these should be full set of the following: consent for surgery, pre- operative checklist, and anesthesia record, report of operation, recovery room record and post-operative orders.
  • 9Diagnostic Result: (Laboratory, X-ray, etc): Match orders with diagnostic results. If reported are missing, follow—up with respective departments.
  • 10Nurse’s Notes: Verify that you have nurses note accounted for all days from admission date to the discharge date. Nursing discharge note/time/signature is necessary.
  • 11Identification Data: Medical Records should contain at minimum adequate information to identify the patient such as Patient Name, a unique identification number, age, sex, and nationality. Label will be produce to stick it in front and on each page of the medical record for proper identification of the patient.

Analyst

  • 1Mark actions to be taken by using an X in the appropriate section of the deficiency checklist slip (attached copy) attaches with folder for completion attach it with.
  • 2If an allergy is documented in the record, place an allergy sticker in the middle, front of the medical record folder.
  • 3Initial charts in the lower right-hand corner indicating you responsibility for completion.