Maintenance of Patients Records, Its Security, Sharing of Information and Safe Disposal
Maintenance of Patients Records, Its Security, Sharing of Information and Safe Disposal
Maintenance of Patients Records, Its Security, Sharing of Information and Safe Disposal
PHC/
Date issue:
COMMUNITY
Prepared by: HEALTH
Smt. Rama Rani CENTER Shoghi
Thakur SHIMLA(H.P)
Page 1 of 7
Maintenance of Patients Records, its Security, Sharing of
Information and Safe Disposal
A. Purpose:
To provide guideline instructions & process of Management of Medical Records with the aims that
Medical Records are readily retrievable, and
Feedback loop is established for continuous improvements of Health Indicators.
B. Scope:
It covers all patient medical records in the hospital.
C. Responsibility:
Senior Medical Officer and Pharmacist, Lower Division Assistant(LDA)- (Record Section)- Medical Records is
responsible for maintaining medical records.
D. Objectives:
The Primary objective of the Medical Record Department is to develop good Medical Records containing
sufficient data written in sequence of events to justify the diagnosis, treatment and end result of all patients
treated in a hospital, keep them under safe custody and make the readily available as and when required for
The Patient.
The Doctor
Hospital Administrators.
Medico Legal Purposes.
External Reporting.
1. For Patient, it
Serves to document the clinical history and activities of patient treatment.
Serves to avoid omission or repetition of diagnostic and therapeutic measures.
Assists in continuity of care even in future illness whether it requires attention in or
out of the hospital
Serves as evidence in Medico-legal Cases.
Give necessary certification for employment purposes.
1. Identification
This section fills up the Bio Data / Socio economic data / Patient Identification Data at the time of
Registration and Admission.
OPD file is generated at OPD registration counter; on the Admission Request of the doctor. Indoor patient
Admission record is prepared. Personal data for following particulars are provided at OPD registration and
Admission counter by the Patient / Relatives.
Name of Patient
Father's / Husband's Name
Age & Sex
Occupation
Permanent / Emergency Address.
Telephone / Mobile Numbers
Nationality
Religion
Medico Legal Case if any.
These details are fed in the register manually and the patient is given a unique identification number which is
entered in the designated area of the patient.
2. Medical Section
The Medical Section is filled up by the Attending doctor, and pertains to History, Physical
examination, Treatment / progress of the patient, , the information is recorded in the following Medical Record
Forms, keeping in view two types of forms - Basic + Special
Basic:-
Initial diagnosis Record Sheet
History Record Form
Physical Examination Record Form
Progress And Treatment Record Form
Investigations Report Forms
3. Nurses Section
The Nurses Section is responsible for filling up the following
Medication Record Forms
T.P.R. Chart.
INTAKE and OUTPUT Record Form.
Diet sheet
Discharge summary is given in case of discharge cured, LAMA, DOR or death
1. The Medical Record Department ensures a smooth flow of Medical Record of the patient from the day
of his admission to the day of his discharge and onward maintenance till the retention period.
2. Admission request form is filled by the treating doctor of the patient. Formalities for admission of the
patient is carried in the registration counter (during working hours ) or in the emergency department of
the hospital (during non peak hours) .The general inpatient case sheet for patients is prepared at the
time of admission in the respective inpatient admission counters.
3. All datas pertaining to the patients stay in the hospital and care provided are preserved in the patients
bed head ticket which is maintained by the nursing staff of the concerned ward where the patient is
admitted, all entries made in the Bed Head Ticket is recorded in a chronological manner and
authenticated by the designated author of the particular entry clearly mentioning the time and date of
the entry.
4. After getting the orders of discharge of the patients from the treating doctor, the Nursing Staff, on duty
get the discharge summary prepared from the Medical officer, staff nurse on duty hand over the DC
summary to the patient and discharge him/her
5. Patient file is sent to medical record room.
6. In case the patient is transferred or referred to another hospital the medical record contains
information regarding reasons for transfer, name of the hospital were the patient is being transferred
G. Midnight Census :
Ward Census Reports from each ward is generated by nursing staff at night duty and entry made in the
midnight census register
The midnight census register is to be checked and verified from time to time by the MO IC
I. Retention Policy :
i. Policy : The PHC is responsible for consolidation of all Forms belonging with patient is sent for storage in a
manner with the help of Medical Record Number(MRN), which is assign at the time of Admission. These
records are stored in the Medical Record Departments for the following Retention Period as per the Govt.
Orders
In - Patient Record :
Out- Patient Record :
Medico Legal Record : Life time
ii. Security :
iii. At the end of the designated retention period the medical record clerk will seek written approval from the
director for destruction of the medical records who have crossed the retention period. Only after obtaining
written approval from the designated authority, the medical records will be destructed by the MO IC
J. Medical Audit :
1. Medical Audit Committee:
Scope of Work: Evaluate medical record keeping, quality, content, format, accuracy, pertinence, staff
compliance with documentation policies .Review and evaluate fatal cases/ Deaths in hospital.
Frequency of meeting: Quarterly/ as required
3. Process:
The Medical Audit Committee meets at periodic interval to evaluate the patients medical records. The
Committees reviews both active and discharged patients inorder to have an objective review of the
completeness of patients record.