Facts and figures on medical record management from a multi super specialty hospital in Delhi NCR: A descriptive analysis

AIM OF STUDY: A study of the medical records department of a multi super specialty secondary care hospital in NCR. MATERIALS AND METHODS: 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. RESULTS AND CONCLUSION: 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. CLINICAL SIGNIFICANCE: 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.