STANDARD OPERATIVE PROCEDURES: MEDICAL RECORDS
INPATIENT DEPARTMENT
1.0 Object: The object of this SOP is to provide guidelines to the staff of The Gastro
Liver Hospital towards managing medical records of inpatients encompassing entire cycle
from admission to discharge including post discharge 9of patient) management of medical
records.
1.1 GLOSSARY:
Medical record is a systematic documentation of information about a patient's past medical
history and treatment.
Medical Record Technician is a person who maintains the medical record by entering,
compiling, reviewing, and filing appropriately into a computer or on paper.
Medical Records Department (MRD) is the department which is entrusted with the safe -
keep and maintenance of the medical records.
1.2 TYPES OF MEDICAL RECORD
There are generally two types of medical records depending on the way the patients are
seen in the medical facility:
Inpatient Medical Record (when patient is admitted into hospital for treatment and is
hospitalized until discharged)
Outpatient Medical Record (when patient is treated in the physician’s office,
emergency, or ward of hospital but is not hospitalized)
1.3 PREPARATION OF PROPER MEDICAL RECORDS
Staff at reception of The Gastro Liver Hospital shall ensure that medical records are
prepared by hand, (in admission file) details entered in the patient’s medical records are
legible.
1.3.1. The basic details needs to be entered against each patient are as follows:
Patient’s Name
Date of Birth (DOB) / Age (verify from AADHAAR / GOVT ID)
Gender / Nationality / Marital Status
Patient Husband / Fathers Name
Patient Contact information (Permanent / Local address, Email, Phone, etc.)
Date & Time of admission
Ward allocated/Chosen
Consultant I/C / Doctor Admitted
Name of patient attendant/ Address / Contact No.
1.3.2 Making entries in IPD file
Only authorized staff members shall be allowed to make entries in Medical Record. Staff
authorized includes following:
Physicians
Nurse
Physiotherapists
Dietician
Medical Record Technicians
Other Health Care Providers deployed for in-patient care.
1.3.3 Procedure to be followed while making entries
All the entries shall be made in English or Hindi language (as appropriate). Detailed cilical
assessments shall be entered in a legible manner. Computer generated UHID to be
endorsed over IPD file for every patient. Reception or otherwise nursing staff needs to insist
for ID of patient from their attendant which is to be endorsed over right corner of the IPD
patient file. Each ID to be prefixed with appropriate code mentioned below.
UID -AADHAAR
EID -Election ID
PAN - Pan Number
GID - Any other ID issued by Govt or any Autority
Nursing staff needs to observe that doctors name below signatures of doctors in IPD files
and their own names against the entries made by them. The date and time for the
appropriate entries are also need to be endorsed wherever applicable. Following also need
to be endorsed and completed (as applicable) by concerned staff before submitting the file
for discharge to reception.
Personal History
Investigation Chart
Progress & doctors Order
Observation Chart (as applicable)
Number Chart / Drug Sheet
Diabetic Chart
Consent for Blood Transfusion
Consultant visit Record
Nursing staff needs to check all ibid records in IPD file as soon as discharge has been
cleared by duty doctor / consultant I/C. IPD files to be forwarded doctor for preparing
discharge summary only after checking all relevant and possible details/diagnose of patients
in their IPD files.
Note: Special care to be taken by the nursing staff while finalizing medical section
billing.
1.3.4 Finalising the Bill
Reception staff needs to ensure no dues are pending at Pharmacy & Pathology of
concerned IPD patient who is being discharged. Staff needs to ensure that a copy of final bill
is being handed over to the attendant of the patient and other copy of the same has been
enclosed with IPD file. Also a receipt is to be acknowledged by the attendant by signing in
hospital copy of final bill. Staff handling final discharge formalities needs to observe the
name and relation of attendant clearing final bill is been endorsed.
1.3.5. Discharge Summary
Staff handling discharge shall handover copy of original discharge to the attendant/patient
and a copy of same is to be enclosed in IPD file. Staff needs to ensure that Date, Time,
Doctors name & signature are endorsed in the discharge summary.
1.4 STORING OF MEDICAL RECORDS AT MRD
The records shall be stored in a place free from dust, insects and other pests/rodents.
Proper infection control practices including pest/rodent control measures and frequent
dusting shall be done. All the Medico Legal case records shall also be stored under lock and
key. The records of death cases should be maintained in a separate register and the death
case records shall also be stored under lock and key.
MRD shall follow following color codes of covers while storing IPD files:
IPD Files (Normal Files) : Green Covers
IPD Files (Medico Legal Files) : Red Covers
IPD Files (Death Files) : Black Covers
1.4.1 Arrangement of files at Store
MRD Technician shall ensure that each cupboard is to be marked and arranged in
order with respect to the files, year / month / date of admission of patient.
MRD Technician after completion of month and on 1st of every following month will
take custody of all IPD files of the patients already discharged. He shall check all files
for their entries to be completed by nursing staff or the concerned person. He may
seek help from other paramedical staff or from physician for updating entries into the
files for any discrepancy, if any.
MRD technician will take a list of patient being discharged and mark each file with the
listed serial number. He will take care of all files listed in the final list and will pack
them as per appropriate colour cover. All files should be marked and numbered
sequentially as per the discharge date of patient.
MRD Technician shall be responsible for further arrangement of files in the racks at
MRD and their future upkeep.
1.4.2 Transaction of records from/into MRD
A register shall be maintained at MRD by MRD technician for the transaction of any kind of
medical records between from/into MRD and other departments. Register is to be
maintained with Date, Patients Name, UHID, Purpose of transaction, Transfer date,
Received back on date, Approved by and Sign of technician facilitating the transfer. No
transaction (R) no transaction of records to be carried out without prior approval of
concerned authority and absence of MRD Technician. Entry in the register shall be
made meticulously without fail.
1.5 RETENTION PERIOD OF RECORDS
Guidelines:
As per Medical Council of India, medical records should be maintained of indoor patients for
a period of 3 years from the date of commencement of the treatment in a standard proforma
laid by MCI.
National Accreditation Board for Hospitals & Health Care Providers (NABH) accredited
hospitals in India follow the retention period of medical records as follows:
Inpatient records : 7 years
Outpatient records : 5 years
Medicolegal cases : 15 to 30 years or until final court hearing
Minor patient : Maintain record until patient reaches age 23 (18
+5 years) or 10 years from last date of treatment
whichever is the greater.
The entire Outpatient case sheets shall be maintained for a period of 5 years after the last
visit made by the patient. All the Inpatient IPD files shall be maintained for a period of 7
years after the last visit made by the patient. The MLC case sheets shall be retained lifelong
or till the final judgment from the Supreme Court. The records which have crossed the
retention period shall be selected and destroyed as per documented procedure.
THE GASTRO LIVER HOSPITAL Policy:
IPD files shall be maintained for a period of 7 years after discharge for all normal
patients.
The MLC case IPD files shall be retained lifelong or till the final judgment from the
Supreme Court.
The Death case IPD files shall be retained lifelong.
The records which have crossed the retention period shall be selected and destroyed
as per documented procedure.
1.6 METHOD OF DESTRUCTION
In order to retain the medical records for prolonged periods of time, our hospital need to
bear the impact of secure storage costs of the records. Since medical record contains
sensitive protected health information, it needs to be stored securely.
To avoid the high maintenance costs to store the medical records, we need to opt to destroy
the medical records after the completion of the retention period.
1.6.1 Steps that need to be taken as a good practice before destroying the medical
records:
Publish an advertisement in a regional and a national newspaper giving the details
about the period of medical records to be destroyed.
Proper choice of method for destruction of the medical records. Maintain a log of
medical record destruction for reference in the future by filling medical record
destruction form. A simple medical record destruction form would contain the following
heads:
Name of the authoriser,
Period for which the records are destroyed,
UHID number,
Date of destruction,
Method of destruction,
Name of the destroyer and witness, if any.
A list of patients with UHID number needs to be prepared for which the IPD files has been
destroyed and to be signed by management authority and witnesses thereof. Final list to be
countersigned by the MD of the hospital. Final list to be preserved in a separate folder by
MRD Technician.
1.7 RELEASE OF PATIENT INFORMATION
All medical records information is deemed to be strictly confidential and cannot be
disclosed to any unauthorized personnel under any circumstances without proper
authorization.
Certain exceptions which require hospitals to release the medical information of a
patient are as follows:
o If the medical record needs to be shared with a different physician or hospital
in order to provide better medical treatment of the patient.
o If a court order for its release is obtained in medico legal cases such as
accidents, medical negligence, etc.
o If patient asks for copies of the medical records to seek second opinion from
another physician.
A health care power of attorney of the patient has the right to access the medical
records as long as patient has signed a release of records but the extent of access
will be limited to those information which will be required to make an informed
decision.
If a health insurance company, asks medical records for claim settlement.
If the patient is a minor, the parents have the right to seek copies of the child’s
medical records.
