1. ORGANIZATION & MANAGEMENT
MEDICAL RECORDS DEPARTMENT
KESHAVARAO.T
ASST., MEDICAL RECORD OFFICER,
BELGAUM INSTITUTE OF MEDICAL SCIECES,
BELGAUM-590001. T.Keshavarao Mob.9880569550

2. T.Keshavarao Mob.9880569550
IP REGISTRATION OR SERVICES
The IP Medical records classified into 2 section
1.Admission office
2. Ward
Functions of Admission office
Admitting office functioning 24 hours. In this section staff posted 3 shifts.
Prepare the case sheets
Collection of Identification data through the Patients At tenders.
Allot the MRD Number.
Record the hospital number with sociological data with date of admission,
Time, Department, Unit etc in the admission register.
Take the consent from the patients or his relatives for treatment and
operation purpose.
Prepare daily admission list and hand over to the census clerk
Maintainance of Patient Master Index
Maintainance of Bed Occupancy board

3. T.Keshavarao Mob.9880569550
WARD
The ward medical record will be performed by the ward nurse.
Functions of the Medical records in the ward
Registration of admitting patients on the ward admission book.
Maintainance of vacant bed position.
Kept the all investigation in the appropriate case folder.
Preparation and submission of ward daily census report.

4. T.Keshavarao Mob.9880569550
Numbering RECORD DEPARTMENT
MEDICAL
Numbering system is facilitate easy to identification of the patient present
and future visits. Easy to retrieve the case folders for continuity care. Filing
purpose.
Confidentiality purpose.
Mainly there are 2 types of MR Numbering systems recognized.
1.Unit numbering system-This numbering system has been preferred large
no. Of MRDs. The method involves the use of a number, which is
thereafter applied permanently to the same patient. This patients has only
one medical record. All data about the patients are collected together one
folder.
2. Serial Numbering system- It consists of assigning the patients a new
number
Each time the patients visits the hospital. One patients will have many
records, as times he has been seen and each records will file under the
different numbers.

5. T.Keshavarao Mob.9880569550
CONTAINS AND COMPONENTS OF MEDICAL RECORDS
Contains of Medical records:
As a minimum information should contain in each Medical Record.
I.e.,. Sufficient information to identify the patient. Date of contact, reason
for contact, findings, treatment and recommendations etc.
Components of Medical records
When a patient has been admitted to the hospital they become an IP
and front sheet is beginning the IP Medical record.
IP usually occupies a bed in a health care facility for at least 4 hours or
overnight.
The Physical Medical Record will eventually consist of the following.
1. MR Form
2. Divider between each admission IP and OP
3. Clip or fastener to hold the papers together
4. Folder

6. T.Keshavarao Mob.9880569550
It should be all in sameFORMS
MEDICAL RECORD size Usually A4 size.
The patient Medical record number and the name of the form should be in
the same place on every form.
Medical record forms approved by administration or Medical record
committee
Should be included in MRO.
Medical Record divider.
It is good practice to separate each admissions by a divider, the divider
will be slightly wider than the forms in the Medical records and have a tab in
which to write 1st admission 2nd admission.etc.
In addition combined with the IP notes all OP Notes can be stored
behind an OP divider.
Clip or fastener
Staples should not be used as they tend to rest and additional forms. If use
large
Fastener which is secured in the top left hand corner of MR.
Plastic rather metal clip also best for use of MR.

7. T.Keshavarao Mob.9880569550
FOLDER
All medical record forms should be kept in Medical Record Folder.
This should be a thick folder(Manilla)of if possible stronger card board
should be purchased.
Medical record folder should be filled on their spine so that medical record
number is clearly visible for filing purposes.
Every medical record Folder should contain MRD No. Hospital Name &
Process check ie. Assembling ,Deficiency check, Accession Register,
Discharge Analysis, Patients Index, Diagnostic Index, Operation Index,
Surgeon Index
Cheked by, Filing clerk, Date of filing etc.,

8. T.Keshavarao Mob.9880569550
CENSUS
Each and every Hospital should maintain Mid night census.
The hospital inpatient Census is the number of inpatients occupying beds in
the hospital at a given time.
Procedure.
a) Collect daily admissions from the admitting office.
b) Collect from the sister-in charge of the ward the following
Daily census report form.
Discharged case sheets whether complete or incomplete. Including
Investigation reports.
c) Check the No of admissions & Discharges with actual No of admission
list and
and discharge Records.
d) Check the Transfer in and Transfer out case records.
e) Hand over to the Census report at Census or statistics desk
f) Hand over all discharged case records to Assembling and Deficiency
check desk.

9. T.Keshavarao Mob.9880569550
ASSEMBLING AND DEFICIENCY CHECK
Assembling and deficiency check section collects the discharge records of
the previous day and make discharge details on the computer or register.
All the deficiencies are pointed out of the deficiency are marked at the
deficiency check list. It is helpful to the doctors for complete the records
weekly visit.

10. T.Keshavarao Mob.9880569550