Medical Ethics
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- Title
- Medical Ethics
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RF_MP_5_SUDHA
m ef
:I
GROWTH MONITORING ? A PREREQUISITE FOR HEALTH PROMOTION
Dr. TARA.M.S
Assistant Director,
National institute of
public co-operation &
Child Development,
BANGALORE.
Growth monitoring forms gn integral part of continuing health
care services. As an important' tool for measurement, it
facilitates early detection of growth falteri-ng, thereby
enabling one to institute necessary rehabilitative and promotive
measures for improvement in health status of children.. Over
the years, growth monitoring programme h=,s come to define two
strategies - the first being an educational strategy emphasising
on family and community responsibilities for child health, the
second is the creening strategy, which is directed to improve
the quality and efficiency of health system in providing care
to the young children. The unifying of those two strategies
to create growth monitoring programme capable of delivering
.quality1 services necessitates active involvement of worker of
both health and non health sectors.
in the integrated Child Development services scheme, in which
the programme for growth monitoring of children is undertaken
on a large
large scare,
scale. the role of functionaries is vital. They are
primarily responsible for delivering of nutrition and health
services and in attaining the objectives envisaged in thfe scheme.
The block and the district level functionaries are principal
executives and coordinators pf■thF LCDS scheme, who are entrusted
with the responsibilities of'providing on the job training to
peripheral and middle level worker.'' Their guidance in s election
of beneficiaries and proper coverage for interventions,
besides
providing continuing education in relation to child's growth is
also significant. In executing these tasks, it is imperative that
one is sensitive to the following aspects s
consideration for Growth Monitoring
1. Operational
of standard equipment for appropriate weighing
Availability
of children is an essential pre-requisite, While using weight as
the weighing scale and bar
a parameter, it is imperative that
scales, which are commonly used, should frequently be checked
with known weights for accuracy. The ‘zero error' of the scale
should always be corrected forga prior use., Careful reading of
the scale is possible only when one is familiar with divisions
on the. scale.
2
Tljie actual weight noted without any error, hAs to be plotted
on the growth chArt accurately. To carry out this, there is
a need for correct age assessment of the child even before it
is weighed. The location of the point for plotting on the chart
calls for considerable skill, care and patience. in this chain
of operation, there are potential sources of errors, to be
guarded againt. The growth charts used in the ICDS scheme follow
the classification recommended by the academy of Indian Paediatricso
The classification of grades i.e., first, second, third and
fourth degree malnutrition is based on the fact that the weight
for age is in the range of 70-80%, 60-70%, 50-60% and below 50%’
of the Harvard standard respectively. ^hildren whose weights are
normal in their
80% and above of Harvard median are categorised
nutritional status. The severely malnourished children are those,
whose weight fall in grade III or iv. Any deviation in the trend
is when the curve becomes flat or shows descent indicates growt
faltering and deterioration in the nutritional status. Although
the above concept seems simple it requires proper skill for
execution. 1he supportive services and supervision appropriate
training of the workers, establishing the
valgity of the data
collected are some of the key issues that need consideration.
Growth chart-an Educational Tool
Growth monitoring is not merely a means to strengthen delivery
of the services but it is a tool for building awareness on felt
needs of child care and growtho This can further enhance a sense
of empowerment for mothers to take initiative in this area, whi'-’h
would lead into community level action.
Counselling mothers on concepts of monitoring is possible
with the help of growth chart, as this tool serves as a means of
visualising the growth trend. The growth trend could be explained
to the-mother by showing a growth curve. An upward curve which
is in the same direction as the reference curve can be considered
as good and signifies that the child is growing well.
This tool also aids in determining the nutritional status
and helps in delivering the specific and appropriate message to
the mother. Further, the chart helps mother visualise her child's
growth and acts as reinforcement for behaviour which positively
influence the growth. These aids help the worker determine the
specific advice needed by the mothers at appropriate time.
Further,
it helps the workers to ‘target* timely advice for the mothers for
taking specific actions. For instance the growth trend in the
contd....3.
3
child could be referred to, while demonstrating the importance of
adequate feeding, initiation of weaning foods, problems associated
with delayed introduction of solids, the deleterious efforts of
diarrhoea or the value and timing of immunisation etc.
The eff!~ five use of the growth chart, then, depends on the
knowledge and the skill that a worker has. It is only with an
appropriate, use, that the objectives of the growth monitoring
can be attained.
improved Monitoring ^g A suggestion for Exploration
in effectively implementing the task of growth monitoring,
ICDS Is face4 with a number of short comings like, inadequate
supply of tools, untrained/poorly trained personnel, poor response
from the community etc.
TO overcome the several shortcomings which currently beset the
monitoring system may not be possible in a short period,, However,
it may be useful forthe field functionaries to implement growth
monitoring in the phased manner, To begin with one anganwadi could
be taken up in each project for intensive efforts directed towards
promotion of quality health and nutrition services, In suih an
endeavour, emphasis must be placed on developing a close functional
linkage between the existing health system and the ICDS services.
As a part of comprehensive system of maternal and child health care
the concept of growth monitoring be introduced tothese functionaries
for early detection of growth faltering.
A joint venture by the
parallel functionaries of both ICDS and health department and their
regular domicilliary visits to the houses of pregnant, lacfating
mothers and children, under three years periodically, can ensure
During
lasting confidence among mothers for availing the services
their visits to these critical houses enough time should be spent
with mother, not for getting the children weighed alone, but for
educating the mothers, especially for building awareness on felt
needs of the children.
Only under such circumstances that the growth monitoring will
be meaningful, from the point of view of instituting interventions.
The model Anganwadi could serve as
as a
a demonstration cum training
centre in each project. V^hen tried out successfully there could
be a phased programme.for extension to the other anganwadi of the
project. so that in due course of time, they too may be able to
achieve impress.’ve improvement in child's health.
********
S'
GOVERNMENT OF KARNATAKA
WOMEN AND CHILD DEVELOPMENT DEPARTMENT
UNIT.
L'TIOIS CHILDREN'S FUND
CENTRE FOR YOUTH
•k
CULTURAL DEVELOPMENT
-k
*
* ★
"HEALTH FOR ALL BY 2000 A.D."
M. i. N 1.71N,
Consultant,
( less arc a -nd Training).
THE PHILOSOPHY OF "HEALTH"
1.
Health is a state of positive well being and not
merely the absence of disease.
Health is a means and a measure of development/
health and general development are interlinked and inter
2.
dependent.
3.
Health and development need a team of people who
can work to-gether with the community government and volun
tary agencies have a positive role to play.
4.
peoples participation and involvement in their
own future is essential for meaningful alround development
of which health is a prominent component.
5.
There is need for a general awareness in the
community/ society/ professional groups and other develop
ment agencies about the conditions of the community and
what could or should be done to ameliorate
6o
The process of education is central to the
approach to development.
7.
It is a fallacious to believe that Doctors alone
are responsible to ensure health for all.
8.
Health care is not only every one's responsibility
but also informed self care is an insurance against illhealth .
Contd/..2
2
9.
Ordinary people provided with clear simple infor
mation can prevent and treat most of the common health
problems in their own homes-darlier-cheaper and often
better than what Doctors can do.
10.
community
Medical knowledge applicable to common
health should not be the guarded secret to a select few
but should be freely shared by everyone.
Doctors have very important role not only in
treating sick, but in educating the sick as well as others
lie
in prevention, protection and promotion with regard to health.
12.
Basic health care could be a better reality when
it is encouraged as a self-help programme rather than as a
health care delivery programme to prevent dependence.
’’SCOPE OF COMMUNITY HEALTH"
Community health has several dimensions.
health care forms the basis.
individual
Social, economic and cultural
dimensions of health cannot be ignored in solving health
problems.
poverty and ignorance are the twin basic causes
. for illhealth, out of around 5000 million population in the
world. nearl-j 800 million people come under the category
of poor of which more than 60% come from the third world
countries.
Russel Sage Foundation president wildavsky
declares ’’According to the great equation, medical Care
equals health
But the great equation is wrong.
More
available medical care does not equal better health.
The
best estimates are that the Medical system (doctors, drugs,
hospitals and some other infrastructure) affect about 10%
of the usual indices for measuring health.
live at all (infant mortality)
Whether you
how well you live (adult
*
mortality).
The remaining 90% are determined by factors
over which Doctors have little of no control at all.
indi
vidual life styles viz smoking. drinking, no exercise or
.3
3
recreation; worry etc;; social conditions viz<> income; status,
eating habits, dwelling^ physiological inheritance and phy
sical environment - air> water; ecological factors and other
influences that work on human beings are beyond the reach
of medicine.
DANGEROUS DRUGS
TO HEALTH
UNBRIDLED INDUSTR. I AL IS AT I ON
HAZARDOUS
Iatrogenesis is one of the major problems of health in
developed countries.
in
Drugs are the greatest killers.
U.S.A. alone 50 million hospital patient days a year are
caused by drugs, and these drugs kill more zictims thaii
does cancer.
Added to this is industrial pollution.
Rivers,
sea. air, soil and the entire environment get polluted due
to various industries and scientific nuclear experiments.
The entire ecology is getting ill-balanced.
No doctor can
ensure health when mother nature herself cannot protect us.
Rober Hutchison wrote in 1954 which is even more germane
todays"From inability to let well aone, from too much zeal
for the new and contempt for what is old, from putting
knowledge before wisdom. science before art and cleverness
before common sense. from treating patients as cases, and
from making the cure of the disease more grievous than the
endurance, Good Lord deliver us".
HEALTH IS AN INTEGRAL PART OF DEVELOPMENT
Th& new ways of thinking about the problems of health
andhealth services stem from worldwide concern for social
justice and for improvement of well being of all people;
specially the disadvantaged.
Contd/- 4
4
The concern is expressed as dissatisfaction with the
uneven distribution; rising costs, and uncertain outcome of
health services.
WHO and other member countries are in
creasingly awarethat the health of population is the result
of many influence and involves many sectors concerned with
social development other than health; effective planning
for health therefore requires co-ordination between the
health abd other sectors.
Today there is need to study the conventional medical
model in comparison xkx with behavioural and socio-political
models.
The conventional model of medical approach to the
problems of health and disease has tended to emphasis the
role of singl
casual agents, especially micro organisms
and in th~ past to minimise the role of the environment and
of personal or host factors in the genesis of disease.
This approach has emphasised the role of biologically
defined disease and underplayed the role in the genesis or
illhealth of psychological/ social and cultural factors
such as
emotional reactions, inadequate housing and atti-
tude towards smoking.
The implications of this approach
when applied to the political and social sphere is illhealth
consists of "disease" whose "cure" or "eradication" will
maintain or festore ’•health1' •
Health planning is too often restricted to health
sector and is usually based solely on mortality and morbi
dity statistics to which are sometimes added data on physi
cian and hospital use.
It should instead be based on measures
of the health and health care needs of the total popula-
tion, users and non-users of the health services alike.
Contd/..5
■
5
policy decisions in the other social sectors affect both the
le-zel of health of the population and the type of amount of
health services needed
Health planners and administrators
do not operate in a vaccum, the solution to health problems
should refloat the social, political and economic values
of the society as a whole.
Illness can be described in terms of three concepts
the traditional medical model-a social interaction model
and a model bAsed on individual and collective perception
of ill health.
Ultimately investment in health care should be reflected
in the improved capacity of a country to achieve its specific
national goals, health policy making involves weighing the
effects of more than one sector; viz; agriculture - industry
housing - education etc..
The decision maker also needs indicators reflecting
the social.
live.
rultural and economic setting in which people
These include measures of educational achievemnet
exercise and recreation. nutrition, transport and communications, housing, delinquency, criminality, working of
judicial system.
welfare.
productivity, consumption and economic
It is this information, considered along with the
values and aspirations of the community and its resources.
that will keep the policy maker decide what emphasis it to
be placed on the health sector.
Alma Ata declaration in 1978 "Health for all by 2000
A.D- ” meant that all people of the world would have the
opportunity to attain by AD 2000a level of health permitting
them to lead a socially and economically productive life.
Condt/..
6
Thus health is a very important component and an integral
part of total development.
WHAT IS PRIMARY HEALTH CARE
It is an approach that ' * should encompass the entire
health system of a country.
(reaching into the home, the
work place, the local community, right upto the most advanced
hospital or research institute).
It is based on the active and responsible participation
of the people-individually and collectively-'
a11 levels
of complexity of the health system and in .all the procc
sses that make the system work.
From planning, which
decides the priority problems to be tackled, upto the
management, supervision and control needed to assess whether
these priority problems really are tackled and how effici
ently and effectively and efficiently.
participation of
the people is much more than the use of free labour to
carry out certain activities.
It is the permanent presence
of the people as decision - makers. as active subjects
responsible for their own individual and collective health.
peoples participation, real health n?eds, and the actual
resources of the countries and their local communities
should govern the type of techonology to be used By the
health system at its different levels-
That is why within
the concept of "primary care " we talk of .’’appropriate tech-
nology” which besides being scientifically sound and ef
ctive must be adjusted to the possibilities of the country
concerned and acceptable both to those who will use it
and to those who will benefit from it.
Contd/o.7.
7
The above elements indicate the absolute necessity of
multisectoral action. for many of the factors influencing
the presence of diseases are outside the sc-jailed health
sector.
There are many instances of countries where better
education, proper nutrition, the provision of drinking
water and sanitation good housing, suitable working environ-
ments. etc., have made a more significant contribution to
improving the level of health than any conventional system
of curative medical care could have done.
■Thus, primary
health care is unavoidably multisectoral.
The above components also /govern the oos.>iute necessity
of gradually delegating responsibilities for health activitias-
Finally,
’’Primary Health care" must be a component
of and never isolated from a national socio-economic
development strategy.
Its implementation requires the
political will and decision of governments, not just the
good will of institutions and authorities in the health
sector. It also requires constant political pressure from
the people.
"as active participants” in such implementa-
tion for it is only this constant political pressure that
con guarantee the continuity and permanence of the initial
political decisions taken by government.
Thus "PRIMARY HEALTH CARE" is clearly not a level of
medical car. that is elementary. rudimentary..
orimit? ve
even , with no scientific basis, using crude technology, and
provided by non professionals with a little trainingA
Nor
is it a second or third class vertical programme operating
parallel with and independent of the conventional health
care system. it is not a campaign separate o\' isolated from
Contd/o.8.
8
the health sector which by means of a set of simplified
activities decided upon by some organisatio n or other, is
directed paternalistically st the rural inhabitants or the
urb^n pobr as some form of charity to relieve some of their
mi sry o
Far from it.
Spa.ch by nr0A.Tejado-de-Rivero, ADGZ Mexico city -1984
world Health organisation, Geneva
HEALTH
Health is a product of total development
It
physical, biological, social. cultural and spiritual.
is an important investment in the deyelopment process with
an outcome of better health, which in .turn. re-inforce the
development cycle*
All sectors of development contribute
towacds health and not just the health sector only.
CONCEPTS OF PRIMARTY HEALTH CARE ?-
"primary health care
is ESSENTIAL health care made universally ACCESSIBLE
to
individuals and families in the community by means ACCEPTABLE
to them, through their PARTICIPATION and at a cost that the
community and country can AFFORD«,
PA T
It forms an INTEGRAL
both of country's health systems of which it is the
NUCLEUS and of the OVERALL SOCIAL AND ECONOMIC DEVELOPMENT
of the community".
primary health care innovates and applies APPROPRIATE
TECHNOLOGY For health promotion, prevention of disease.
tr jatment of disease and in rehabilitation.
It is built on
the local culture and value systems, using COMMUNITY
RESOURCES to the maximum.
It is health by people, for
people and of people wherein people are ^OUAL PARTNERS with
th a health providers.
Contd/. .9
9
COMPONENTS OF PRIMARY HEALTH CAREr 1. Education concerning prevailing health problems
and the methods of preventing and controlling them.
2. promotion of food supply and proper nutrition
3. An adequate surely of safe water and basic sanitation.
4. Maternal and child hi alth care including family
planning.
5. immunization against major inf ction diseases
6. prevention and. control of locally endemic diseases
7. Appropriate treatment of common diseases and injuries
Providing of essential drugs.
Source s South East India Regional Bureau, No.6, V.R.Road,
Madhavanagar P.O/ Bangalore-1.
HEALTH EDUCATION
Health is a highly personalised an ? i ndi 7 i diia 1 va 1 ue
system.
and traditions prevalent
It has roots in stereotypes
in the community.
importance to health is ascribed among
There
a hierarchy of life goals usually economic goals.
level of aspiration
is a close relationship between the
has to be directed
and health adoption. An action programme
in the value system
to bring about an attitudenal change
through an appropriate strategy, Health Education is an
important vehicle in this regard.
2.
order to
Health education is changing health habits in
achieve better health. people will have to be to Id
how they should be healthy by doing certain things and by
taking certain precautions to prevent sickness. improvement
io all-round health
in mental and physical well being i.e a
ah
improvemjnt is the aim of health education
protection from
contd/.. olOr
10
non-hygienic conditions to prevent spread of diseases from
one to another is the purpose of health education.
3.
Health education has not so far attainted the status
of a discipline or a profession in our country, though it
has attained the status of an approach
health education is old
The concept of
It received formal recognition
in the old Mysore state in 1929 itself through establish mg
of a publicity unit in the Directorate of Health services.
The process began in other states from 1940 onwards.
Emphasis was laid on the importance of health education
by the planning commission in the First five year plan.
Health publicity Bureaus at central and state levels were
recommended.
Shore committee also stressed the importance
of health education.
4.
The central Health Education Bureau was established
during 1956-57.
A three months certificate course in health
education was introduced at the 2VI India institute of
Hygience and public Health/ Calcutta.
5.
The process was stepped up further by another
major step in the year 1964 to integrate health education
at the district
level by launching training programmes
for the district level Health Extension Educators at the
Central Health Education Bureau, New Delhi, Rural Health
Centre, candhigram and the family planning Training and
Resoardh centre, Bombay.
The National institute of Health
Administration and Education was established a t Nev.* Delhi
in the same year with a view to provide leadership and
post-graduate training for health’ education -.nc
aIminis-
tration for the higher level’workers in the field of
health.
contd/o.11.
11
6.
in the year 1966 a division w?.s created in the
Central Health Education Bureau to review, develop. co
implement intensive
ordinate and
health education activi-
ties for various National Health programmes
Lectures in
health education, supply of educational material.
Provi-
ding of syllabus for training. identification of' resource
persons, film shows, exihibitions, visits to adult educa-
tion centres, publicity campaigns, seminars. conferences.
training programmes. constitution of school health educa
tion committee in some places. co-ordination with other
units/institutions, integration of health education in
health programmes were the numerous activities that were
launched•
7.
The following difficulties are reportedga. inadequate funds
bo
inadequate transport facilities
Co
inadequate staff
d. Lack of trained persons
0. Non—recognition to health education activities
fo Lack of co-ordination.
8.
The above mentioned difficulties are faced by the
District Health Education units also.
PoHoC’s are deliver
ing health and medical care services through the following
activities ga. individual talks
b. croup meetings
Co
Exhibitions
d» Film shows
e. Distribution of pamphlets
f. cultural programmes.
Contd/e.14.
12
9.
in 84% of schools health education is not taught
as a separate subject.
Hygienc,
nutrition/ family plann-
ing, preventive medicine, immunization etc., are taught.
Health education is not an examination subject.
It is.
however/ integrated in the curriculum.
10.
Hospitals carry on health education activities
through film shows, individual talks, group talks, demons-
trations, exhibitions, poster displays, community work
tc /
Health education activities in hospitals have to be streng-
thened through home visits, group meetings and mass meetings
to serve wider
population effectively.
Hospitals require
a separate health education cell and mass madia Officers
to bring about attitudenal change in the poopl
on health
matt ?rso
11.
cell for
Social aspects of diseases and their treatment
greater attention.
Courses of social diseases
such as parental inadquacy/ mal-nutrition/ environmental
hazards/ insanitary habitsz smoking/ occupational diseases
etc./ should be investigated and people enlightened thereon.
The behaviour of
individuals and the society has to be
changed in order to
realise the social good.
Major
improvements in the health of the people/ particularly the
poor/ cannot be achieved with hospitals/ doctors and drugs
but with wells, latrines, family planning/ personal and
community hygience etc.z and the health professionals should
accept a 1 social responsibility* for the health needs of
the people in rural and urban areas so that they can act
as agents for 'social change1.
Health education, is there-
fore, an imperative necessity to be used as an effective
tool for the promotion of the concept of ‘total health'
Contd/..13.
13
and to combat common health problems particularly of
vulnerable groups such as pregnant women, lactating mothers
a nd young cr. i 1 d ren.
12.
Growth monitoring, can be an effective entry point
f-)r health education to mothers and also to the community
whether poor or rich. marriage, and child birth are great
events in the life of an individual; and particularly so in
developing countries, where closely knit family is the main
feature of social pattern.
All the family members in general.
and mother in particular can be motivated through child ::or
health education because normally they are all emotional..y
attached to the child.
Child is still
proud possession
of a family in Developing countries. and male child is
considered as an asset.
£
1*
GROUTH MONITORING AmD PROMOTION
BASIC PRINCIPLES AND OPLRATIONaL IMPLICATIONS
Lukes H^ndrata
INTRODUCTION
Growth Monitoring and Promotion (GMP) Programme uas expanded
in many countries during the early seventies without having the
benefit of a solid body of principles and guideline for implemen
tation.
Policy makers and programme managers developed their
programme primarily on the basis of their own understanding and
vision and learning from each other’s experience.
It is to be expected, therefore, that the understanding of
the principles and their operationalization varied widely from
programme to programme.
This paper is an attempt to examine those
principles in the light of recent developments in nutrition
strategies with a view to finding the linkages between GMP and the
broader strategy of Growth Promotion,
BASIC PRINciPLtS
Among mAny definitions of GMP the one adopted by the Integrated
Child Development Services, India, is perhaps the most comprehensive
one.
It defines GMP as ” an operational strategy of enabling mothers
to visualize growth or lack of growth and to receive specific,
relevant and practical guidance in ways in which she, her family
and community can act to assure health and continued regular growth
in her child.
Three basic principles could bo derivod from this dufinition
1 . GMP is a preventive and promotive
before malnutrition occurs.
strategy
aimed at
action
2
GMP is a behaviour change strategy carried out through
effective communication to achieve adequate growth
through home and community action.
3.
GMP deals with the total environment of the growing child 9
encompassing not on 1 y food but also health, physical
en vi ron ment, psychosocial development an.d intellectual
stimulation,
OPLRATIONAL IMPLICATIONS
rowontiu
a^d
(oro motive
strat^qy
Most nutrition programmes have suffered from the samo curative
Both the providers abd
bias found in health oroorammos in general,
tho community perceived thom to bu curative
The attitude has too
often bo an to find tho malnourished and try to rehabilitate them,
basically by giving thom food,
This approach clearly, cannot bring
satisfactory results. Malnourished children are frequently
identified in their third, fourth or even fifth year of life and
their rehabilitation is difficult,
xpen give and partial at best0
. . .
2/-
.*
1
2
is
Gnu of the key operational implications of the
the importance to reach young infants soor a^t'^r
r
following
reasons
GMP strategy
birth for the
:
Host children under 6 months will show a rapid growth
u w Li i
pattern.
This period is therefore ideal to give positive
[----reinforcement to mothers and to demonstrate to them th'
value and feasibility of maintaining good o outh in their
c hildren ;
•
Responses to early growth faltering
arej u-ually efftoctive
mothers
have
more
control
over
child’s environ
since mothers have more control over the
t'
ment and more home-based effective actions ire available
to overcome growth faltering while the child is still on
the breast (e.g introduction of complementary feeding
increased frequency of fetoding).
Although the prFvPience of malnutrition is,generally
highest in oldtr children, above age two, tn^ inc i d e-n eg
of growth faltering (the process of becoming malnourished)
occurs maximally from about
six months to two years.
Beyond this agt9 growth trends are nearer to normal,
although attained size may be far below t~e desired norm.
Thus, the promotion of continued good growth and early
action in the case of faltering, even 'jofcr-- any mal
nutrition is evident, prevents the development of
main utr ition.
2.
GMP
as behaviour ( “
onto
strategy
One fundamental plaw in our co mmun ic at io n/e drcation strategy
It
is that is
basicaJ.y a knowledge di ss&mi n a, t ic n strategy,
is based on a faulty assumption that dissemina t: on of f actual
knowledge will in it- If bring about changes in practice and
behaviour.
The best ■ xample of this approach ;i n n utrit ion
education is the prer -.tion of the ■? four f o o‘ groups ’’ to bring
The approach has
;iet of th»=j population0
about changes in the
bjectives
were
formula!td.
btohavioural
o
failed since no clear
•toctive
In order to be
communication toxerci-to should
in its behaviour "hnnge impact, a
fulfill the folloi, ing requirements:
It must be bastd on suffieiunt knowledge of the
behaviour pattern and the reasons behind ito
existing
The messages must take into account the environment (sociocultural, economic) in which the changes are to take g1ac e o
This is to guarantee the credibility and relevance of the
practice.
message and f^asibility of the recommended
j
It must be action-orion ted, dealing primarily with ” what
It must be presented
to do ” and th to reasons behind it.
persuasive
way
leadin.i
to. ^ction.
in a convincing and
It must bt specific and individualized
The proof of benefits must
relatively short periodo
be
available
wi thin
a
.. . 3/-
3
' great potential
-J practic
recognist;do
Here is t he
ptobl&m.
Hence~the Tm^Trf1
II|Ba8Ure t
-—
and actually see the
Visualization of a DX
Plight plotted
of ?
;
■
the
^re too lies the value of ^h^uls^ not seen or on a care
the Value
even
perceived.
more commonly Ugeri * ,H
thfci trend line , ~
0 f ,gro wth,
J nutritional
rather than the
to sue the problem
sar"
X st3tus lines (^r^
early? before malnutrition i3 colours) -• ue uan t
“it4’taair^1xsLnb: 'rtifrd“5-“on lnto
obvious.
Second, L
we
must
facilitate
the
mnbh,
(
.
to analyse
the
grouth is not oocuring
as
(and othurs
con cepned)
analysis gnTTn dbrstnndiOg musL iJrbJ4S expected and desired
This
^ntion
in ord6sr to
any offljrt at adyiatj
qr
assure the mother
accepts the Jnoin n r rArj
au, I. i o<, o
sth> ifj
Advice based on ... Jcrsr
„n
„
wn d e r
s t'
d i1n'9
g cd the
raltbrinq is hv
LS
problem behind the c hild
very nature sPfecific
deals with that partipul
particular
child
and
■Should therefore1 start
month, action-□rian ted; it
Communication’
in GHP
about the child's
health
e listening
J^tening f what
t
mothers hawe to
family situation.s health
It
b®tln9 and care in
say
the context c ~ '
It is
of the
in analysing the possib Te" r L'19109 Ub bfctweun
'
possible
this month.
In thi!
1
reasons behind the mother and the
-* ^CoUngclgp
t
child's failure tc
In this pracess the
deal more ef Pecti vel y'^ith
th& mot'lt;r is
gro u
empowered to be ablt
------- 1 the problem.,
to
.
As part of develonino
individual
in di vi dual communication 9 s positive ejn vironmen t to
there
support the
Basically,? this is an
^ort
to must b
Basically
created a demqnd f'or
an efport eto intensively
thing valuable and desirable
"growth".
yrobrn
for
or bVa
*/ market
-grouth as SO
e p
nance of grouth is desirable
Only if the sign)fi»
conimuni.ty Cgn be individual
i
_3 demanded by the
in t er ac 12.o n
an d take
designed tn assess,
a qo. • oo
'J sPbclfic action for pro mt h “
r ~~ 1'
'o ur product")
desired behavi
!,f.
,
i^r'
S
’
.
an^ysb
In short
it will r
cli
tn
ts
.
s ll0
When rmothef’s 's’ttk nr
+.|_n^s it—i. ° ur rrorodLctn
When
watch the
' -9 and
3 plotUno J9 thh8y
^ uiU ’^louely 9
open th a"’"'- (“
‘■iShlnd
end
(ueig
hi
and be
and tak B action i
grouth )
Without an
tQ_ aehiave
0 of the impo rtan ce
- -J goal.
h
tion for its ovet.u
t
- 1 of
or an
-^ction
o f child
be expected to
atSpiK • C0r,8t
'r^d
resdumei
mo(th^ cajno*
auuli
con strain ed resources of'time a mother
effort in an ;
obtain the
9 mon e y an d
healthy grobth
.■) o
Pio uct we are promoting'- regUiar
■ -dr?tood hd Sh i,
3horf,0ur°bss'-?h. iib'-b'"’ 1Bad
.
3.
G^P_deals_L/ith
'
C1Jhents
the
to tai
S2yi£22lli2n_t_of_the child
In an alysing
; \ _
the possible rhave ito examin
causes Tor r
,b the Sreas or faod
growth fait ring on e wi 11
in fection ,
-J
■»
T he underlying cauScr a^ailabilit y> child
care and health/
This uill lead
fcs could be- in
t0 action which will
sny of those cr
Prescriptive adv’ice^
areas.
-------- go beyOnd the
-- ' tr a ditional
...
4/-
I
i
- 4
It may involve action the mother herself can take5 but more
often will require the concurrence
cone urr^nct of her family decision makers
(husband, mother-in-lau etc).
Invariably, it will call for some
fatek
type of resource mo bil iz at ion , and women seldom control resources,
Be it her own time
increase frequency of breast feeding or other
food), family diet
s-t
set asidt
aside a reasonable portion of food for the
child), other family resources (build a latrine 9 consult a doctor)
or even community action ( a child care creche, loan of a garden
plot, small credit), action will require collaboration and mutual
help.
Hence, the importance of conducting GflP in the community
itself, where in small groups, others can hear, participate and
understand.
Here too is the reason to separate GMP from the
widely held^expectation of food supplement distribution, an
activity which will throttle any chance of meaningful analysis
and household or community action,
By addressing the total
environment of the child - indeed, the growth of the child becomes
the indicator of the wellbeing of th e family (and quite logically
the sum total of the growth of the >youngest children is a
sensitive indicator of the wellbeing of the community).
The
mother, family and community are tn couraged and empowered to
identify the actions within their (control that can give a measurable
improvement in the quality of life of the most sensitive and
vulnerable member of the family,
io reality,
reality a development
BMP is, in
strategy.
i
i
SURUULLAmCl
NUTRITION
surveillance is the regular provision of
Nutrition
information and its use for decision making on policies and
It
programmes which directly or indirectly affect nutrition,
is common
to confuse nutrition
monitoring.
ctives,
In fPct,
the two
surveillance with growth
activities have different obj fa-
procedures and outcome.
Gro-wth monitoring refepes to regular assessment of growth
and development in order to detect growth faltering in indivi
and to apply appropriate interventions ^'utritijn
dual children
surveillance is based on
groups of
children.
the detection of undepnutrition in
Growth monitoring focusses on
the mainte
nance of good nutrition in the individual child and therefore 9
should include all
children in
llance focuses on
the nutritional
a community.
Nutrition survei
status of’a population and
therefore measures the nutritional status of a representative
sample of
children of that population.
growth monitoring is early intervention
nutritional
Thus the outcome of
in
the home and that of
surveillance is early intervention
The two approaches are complementary in
and development,
at a higher level.
promoting child growth
easpecially in children from 0-3 years of agd.
Concentrated efforts to improve the implementation of growth
monitoring and nutrition
/
surveillance should recive grater
priority.
Nutrition
general
types.
different
surveillance activities may be divided into three
each requires different
types of data for
types of dicision making needs.
National level planning
These include
(2) Programme management
and (3) Timely warning And intervention.
(l)
and evaluation
A national nutrition
surveillance
system may include on« or all of these areas
depending on
specific needs.
The first step in
the development
of any nutritional surveillance system is to identify WHO will
be using the information
pnd For
WHAT purpose.
..
2/-
2
It is recognised that many countries may already be
producing food an d.. n u tr it ion
adequately collected,
data though these are often not
analyses or used.
therefore, is both to make better use of
be made available,
uhat is or
could early
gS uei1 gS establishing neu systems uhere
there is little already in place.
practical,
The objective,
The emphasis should be on
lou cost approaches within the context of the country's
infrastructure and the available supporting resources.
on
the country circumstances,
efforts should be ma^e to
o r health centre based information
clinic or
community surveillance,
systems,
Depending
expand
establish
establish sentinel monitoring sites etc.
It is especially important
co ensury regular coverage of the
particularly vulnerable parts as ueli as vulnerable population
of the country,.
The choice of indicators to be monitored in nutrition
survei1lance systems uill depend on
the objectives, cost and
timetable of policy makers uho u i 11 u s c the data emphasis should
frequency,
be on
time 1ineS£ 9
ixiik
mpro
ved coverage and un derstandabl e
iuv«=u
presentation of a feu s i m p1e useable population based outcome
in dicators.
status indicators r ecommended as common or
core indicators of nutrition sucjeiiiance a rb
The three nutrition
*
Lou birth u-eigh t
*
Weight for ag u o f chi 1 u pen un dep five
*
Hieght for age of primary school
entran ts.
The incedence of low birth-weight babies can
c an be reduced if
pregnant at-risk uomen’ are identified and steps taken to reLCe
th ir risks.
Since
Sin ct screening is done at the community level
9
more uomtn can be reached and uo.men potentially ’ at risk’
can
be detected before pr&grancy,
Simple screening methods, properly
f O1 io ue d up. can help reduce the number of lou birth - ueight
babies.
GROWTH WITORP'G flMD
PROMOTION (CMP)
CO^’CLPT
” Growth monitoring and promotion
is an operational
strategy of enabling mothers to visualise growth or lack of it
an
receive specific,
in
which she,
relevant and practical guidance in
her family and community can
and continued regular growth of
*
act
hep child .
to
ways
assure health
”
GMP is a preventive and promotive strategy aimed at action
before malnutrition occurs.
*
GNP is a behaivioural change strategy carried out predo
minantly
through effective communication
to achieve adiquate
growth through home action.
GMP deals with the total
environment of the growing chile
encompassing not only nutrition but
development,s
*
physical
also
health,
psychological
environment and intellectual
stimulation.
GMP is a preventive strategy aimed at early recognition
preventive action
faltering.
and
against the earliest signs of growth
it is an
early response to individual,?
family
an d community needs.
GROUTH IWITORF’G CAM
education
Y
Sl-RVl mLTJPLt ORJ-uCTIVtS :
and motivation.
*
screening,
*
entry point for comprehensive
*
entry point for women’s participation,
*
mechanism to promote community awareness,
early detection
and risk assessment,
health care
o rgani satio n
and empowerment.
*
health indicator; impact assessment,
*
instrument for supervision.
*
advocacy.
...
2/-
i
I
)
I
2
✓
THE
MOST COMMON PRACTICAL PROBLEMS TO BL ADDRESSED IN
GMP PROGRAMME ARE
AMY
:
*
weighing
*
format of growth charts.
*
field procedures
*
reporting mechanisams.
*
health education and social mobilisation.
devices and their use.
THl host COMMON PITFALLS OF GROWTH MONITORING AmD PROMOTION ARl:
*
The curative approach to nutritional problems.
*
Focus on wrong age.
Nutritional status rather than growth is emphasised.
I
*
Lack of feud back.
*
No individualised advice or interaction.
*-
Belief that GMP is simple gnd therefore must be easy.
*
GMP is seen and conducted as an
isolated activity
related to nutrition.
*
Lack of community particepation.
*
Food takes over the central stage.
False expectation abocend.
-x-
I
5
it
<
Lack of
analysis.
"MEDICAL RECORDS AND NURSES RESPONSIBILITY"
by
Sri.C.P.B.KURUP
. Principal, College of Nursing, Fort, Bangalore.
Records are administrative tools which are useful in
many areas of functioning, They are not an end in themselves. Record keeping is a time consuming activity,
Duplication of information on records should be- avoided.
No records should be kept which does not contribute to
the attainment of an administrative educational or
research objectives.
Nursing department is responsible in maintaining
certain records in the hospital which could be classified
under two headings viz.. the Nursing Unit Records and
Nursing Office Records. The Nursing Unit Records ares
1. Patients Records
2. Medical Orders
J. Nurses orders
/
4. Assignment Records
5. Time Records
6. Inventory
7. Narcotic Records etc.
Nursing Office Records include Records of Nursing Hours,
Personal Records and Attendance Records. For todays
discussion we will be mostly concentrating on Nursing
Unit Records specially the patients records, medical
orders, nurses orders/notes etc.
Patients Records:
W ell kept patients records are necessary for
providing good patient care. Nurses spent a lot of time
in assisting and maintaining these records, Duplication
and Error in information should be avoided.
Purpose of Patients Recordss
1. It aids in diagnosis and treatment
2. It records the services the hospital is providing
to the patients.
3. It aids in Teaching and Research.
4. It adds to the knowledge which results in the
improvement of patient care,
5. It is an important source of evidence in Medico Lega..
.. .2
cases.
•**>
’■
V.. .....
‘I
Responsibility of the Nursing Personnel in relation to
Medical' Records:1. Assembling the Unit record for each patient on
a dmission.
2. Pilling the identifying data such’l as Patients Name
no. date .
Address and other particulars, hospital
I"'
on the form.
3. Keeping the nurses notes.
4. Keeping the graphic chart
5. Incorporting Laboratory, X-ray and'other special
department reports..
6. Incorporation of Physicians order sheet for patients
when it is filled or when the patient is discharged.
7. Checking the unit record for conplcteness, correct
order and accuracy of identifying data,/before it
is sent to the record room for filing.
Certain specific responsibility of the Head Nurse for
the Clinical Record (Patients record) are explained below.
1 . Prot ection, from Loss:
The Head Nurse is responsible for safe guarding the
patients record, from loss or destruction. If it is
misplaced effort should be made to locate it immediately.
No individual sheet to be separated from the complete
record unless it is specifically needed.
2. Safe guarding,the Content:
The Head Nurse is committed to the protection of
patient by guarding the content of his record. Case
records are kept in a place which is not accessible to
the patients and visitors. None otherthan authorised
persons are permitted to read the records. The Head
Nurse should ba. f emiliar with the procedure adopted -by
the particular institution in ■ dealing with such legal
natters. Patient has a right to insist that his recores
to be confidential. The hespital is obligated to legally
and ethically to.protect the- information in hid chaxt.
from the eyes of th.e curious people. Only thede
individuals who hayea legitimate purpose are permitted
to read the patients history. Visiting doctors read-the
case history only after obtaining the permission of the
patients physicians. Only nurses, doctors who are
atterding on the patient and those who need information
cither to care the patient or for study purpose are
allowed to read the case records.
.. .3
: 3 :
?• Completeness:
It is the responsibility of the head nurse to compile
records with complete identifying data on each page in the
form approved by the hospital. The nursing-service is
wholly responsible for the vital graphic sheet and the
nurses observation/nurscs notes.
4• Nurses Notes:
The Nurses Notes forms an important part of the
medical record. Hence it is the responsibility of the
head nurse to see that the nurses notes are written by
the nurses and affiliating students in the accepted form
by the institution. The format of nurses notes vary
widely, but the essential aspects of it should be induce
in the report, namely the patients nursing needs, the
measures taken by the nurse to meet the needs and the
outcome. Also the medication, treetfjaen't, diet etc., also
should be included.
a) legal Value of NurscgJiote^:
-- 3 legal document$ the
Since the clinical records are
clearly stated and
nurses notes should be accurate, c_
the individuals who
legible. All entries are signed oy
be indicated by drawing a
.write then. Errors should
’ sentence. Accurate
single line thorugh che word or
which the patient manifest
observations of the symptoms
well as the hospital which
will protect the nurse as
to negligence.
may be otherwise attributed
t--
b) Admission HecorC.:
is important
From legal encl di gnostic points it is ,
of patients
at the
.
to record, carefully the observation <
to take
t im. e of a dm i s s 1 on • It has become a practice
i which is essential
history of the patient by the nurses
nursing problems which
to assess and find out the
to solve. This problem
the nurse- can help the patient
- is increasingly in
solving process or nursing process
important part of the
many countries and has become an .
curr icularu
...4
: 4 :
Nurses do need higher educational preparation to use
nursing process. Whatever method the nurse are using
the nurses notes on admission should include general
physical and mental condition of the patients like
condition of skin, condition of the mouth and teeth,
condition of hair, any abnormality noticed about the
functioning of the different systems of the body, mental
state, orientation, conciousness, mood etc. Any conditon
which may influence the nursing care of the patient
should be included in the nursing notes. In short it
should be possible to gain from the patient notes a
picture of physical and mental progress of the patient
from day to day.
The treatment and medications administered should
be briefly stated. Emphasis should be plaedd on the
reason fcr giving them, results and their general effect
on the patient rather than merely mentioning that these
are administered.
c) Record of Medical Orders carried out:
Sone where in the patients permanent record the
medications and treatments which are administered by
the nurses on the orders of the doctor must be recorded.
The method nay vary from hospital to hospital. When
doctors write full notes on his patients, the nurse finds
the clinical chart a rich source of information. 5y
reading the patients medical history and doctors notes the
nurse will be able to follow the patients daily pEDgress.
The nurses notes hhould give a clear picture of the
patient, how he seems to feel, how he acts, the objective
evidence of disorder ahd of change in condition, effects
and result of medical treatment and nursing care, The
information servos as a guide for the new nurse in
writing her observations.
...5
: 5 :
Nurses notes which portrays clearly the results of
nursing measures are excellent source material for
research in nursing methods*
To conclude patients medical records are the most
important administrative record for which the head nurse
ward incharge nurse is responsible. It has legal,
scientific and educational value and should be accurate
neat and legible.
Reference:
!• Jean Barett, Ward Management and Teaching
2. Stella G-oostray and etal, Hospital Nursing Service
Manual, 1950.
PRACTICAL APPROACHES EOR PREVENTING MISS1MG CASE-_NOTES
by
D.M.JOSEPH
Medical Records Officer
&
P.ARUNACHALAM
Medical Records Supervisor
NIMHANS, Bang alore = 29
INTRODUCTION;
It is generally considered by most members of a
hospital’s professional staff, that the most important - if
not the only - criterian of the efficiency and effectiveness
of Medical Records Department is the production of patients
case notes at clinics concurrently with the patient to who
those case notes refer.
" case notes going
In some hospitals, have missing list of
not the sort of
as nign
high ar
at oz®.
5%. In our experience this is 1.percentage often
often found.
found, However not very much research seems
to have been done
done out
out in
in this
this field.
field. The following systematic
process has been developed to approach the problem and
suggested the preventing method:
A systematic process has been develope<l_on, the following basis?
S R E P I M
Select
Record
Examine
Develop
Instal
Maintain
I.
the problem area
the appropriate facts
the present methods
Alternative Methods
New Methods'
the working of the
New Methods
Select - The Problem area;
a) Outpatient Clinics
b) Wards
c) Accident & Emergency Clinics
d) Medical Records Section
..2
- : 2 : -
II.
Records - The appropriate facts:
In the outpatient clinics the files are sent from
Registration counter and Medical Records Department.
These files are to be returned to the Medical Records
Department on the same day. Often it has been found
that some of the files are not returned* When the
patients comes for revisits it is a tough problems for
Medical Records Personnel to answer to the Consultant
or to the patient for nonavailability of case notes.
Discharged patient’s case notes are collected from the
wards by the Medical Records staff daily. In some casjs
it has been found that the Junior Residents are taking
away the Case files to write discharge sunnary, to
discuss with consultant or for their study purposes and
they do not return the case files in time and this causes
problems to Medical Records Officer and tc the patients.
Accident and Ernergency Clinic:
This is an important area which works round the clock
for the Accident & Emergency patients. Here Emergency crrecords are issued for New patients and the ECR is given
to C.M.O. on duty. When the old patients attended to
the files are.issued from the MRD. Patients
the Casulty,
are kept here for observation purposes. These records
are to be returned to MRD after the cases are disposed
off. Rut still we find missing case notes from this
area, which are not sent, to MRD.
Medical Records Department:
Here the following problems are encountered which needs
immediate streamlining;
a) Misfilings - This is the general problems everywha
difficult job
job to
to
Files are misfiled and it is a difficult
b)
traceout the files.
Issued files - Files are issued for many purposes
and not received back. Some of the examples:
1. Files issued to doctors for writing discharge
aiimary. for case discussion, for case conference,
for study purposes.
...3
J 5 :
i-.,
2. Files sent to the Medical Reimbursement Section
3» Files sent to the Hospital Administrator
4. Files sent to the Consultant
III.
The Present Method?
1. Files are collected from the outpatient clinics at
the end of the OPP.
2. Files are collected from the wards daily by the
Medical Records Staff.
3. Daily files like discharge of the patients,, from
the observation ward and ECR are received from
. the casualty.
4. When the files are misfiled attempts are made to
traceout the case files*
5. Checking the issue register for pending outstanding
case files
IV.
Alternative methods or new methods?
Outpatient clinics
1) Outpatient Register
2) Role of Medical Records Clerk in each OPP
3) Issue Register
4) Role of Junior Consultant
5) File to be handled by only hospital staff
Discharp;e files from the wardsj.
a) discharge register
b) Files to be sent to the MRD within 24-hrs of
discharge of patient.
c ) disincentive to defaulters
Accident & Emergency, Clinic
a) Issue Register
b) Responsibility of GMO
c) Responsihlity of Nursing Staff
d) Outgoing files register
...4
: 4 :
Medical Records Department
a)
c)
d)
e)
f)
g)
h)
i)
j)
V.
Arrange files in Serial Order
Make entry in the incoming register in serial order
File according to serial order
Role of Tracer card
Importance of colour folder
Issue register for outgoing register
Disincentive to defaulters
Periodical rearrangement of case files
Allied indexing system
Provision for doctors working area
Maintain - the working of the New Methods
The various desirable, feasible and affordable approaches
to improve the missing case notes are suggested. A lot
will depend upon the attitute^ skills end dedication of
members of the Medical Records Department and other
Medical & Paramedical staff of the hospital. It is the
duty of each individual of Medical Records Staff and of
the hospital to maintain the working of the New Method
and periodical reappraisal of new method to avoid to
possible extent of missing case notes.
CONCLUSION;
To facilitate the proper location of records the
importance of proper indexing and filing is obvious.
The old saying, ” A MISFILED CHART IS A LOST CHART” is
all too true. Each record must be available to the
consultant whenever the patient comes for checkup. I
hope that the above explained the systematic process
will help us to prevent the missing case notes.
.IP.
IKPQBTA’xCE OF hJA'OT i 3TArniT33
-3ri. A.. Viswtnt th
o ♦ • •
The teri ♦henth statistics* is ccnncnly understood to
■
IIHIW.-TI
-III—— ,
t
denote merely a mass of numerical information collected and arranged
in rowland columns of tables about the facts relating to events of
Health importance.
Actually the term also connotes scientific
techniques or methodology for dealing with numberical information, resting on the secure foundation of the laws of probability.
The term 'Statistics * is used in two ways. First, it refers to
the day to day use of data, numerical, observations and quantitative
information and ^econdj it refers to the decipline comprising of
statistical methods-which is the study of scientific methods of
collections, processing, reductions, presentation, analysis and inter
pretation of data and of making inferences and drawing conclusions froa
Statistical methods in health care delivery, both
at the levels of community as well as individual patients can be high
the numerical data.
lighted, since medicine deals with individuals who exhibit differences in
various churecteristics such as weight, height,blood pressure, cholestol
blood sugar, immunoglobulin levels and so on.
It can be observed that
no two patients or groups are ever exactly alike, yet decisions affecting
patients or community based on the experience with other patients or
communities of similar biological and social characteristics are made
by comparison and it must be recognised that the differences are not
exact and are accompanied by probability levesl which is called the
'Probabilistic nature of medicine L
It is essential to be conversant
with the proper technique for coping with such differences of uncertainly.
On °£
^atistics ' is also useful in developing a critical
Shining' faculty, ent bling thereby to
1) Think scientifically, logically and critically about medical
problems•
2) Assess properly available evidence for decision making.
3) Identify decisions and conclusions that lack a scientific and
logical basis.
...2
2
Important advances are made in statistical methodology.
While
a knowledge of advanced statistical theory is essential for professional
statisticians, the subject as practiced in health agencies raises several
problems in addition to methodology such as those related to administrative
social, economical, cultural or psychological considerations and. others
which are procedural , legal or financial. The main problem is how to
apply statistical knowledge in the day-to-day working of a health agency.
The puroose of elaborating so much on the technique rather
than just enumerating the uses of health statistics are two fold
l)Everyone knowingly or unknowingly implicity express factswith figures
only since complexisies of decription is reduced to tabular form!
percentages and so on and (2)of late in school mathematics statting
from 6th Std. Graphs averages and variations are taught and hence
invariably almost all data are presented graohically of late.
We have spent already too many years to know the utility of
’Health Statistics’ and now it is time we must know about the techniques
of this science or statistical methods.
Since it is difficult to high
light in such a. short tine the techniques an indirect method is adopted
to drive the point.
The first Woitld Health asse. ibly held in 1948- an international
regulation releting to health statistics was passed , wherein it was made
clear thrt unless there is a regular and swift flow of accurate statis
tical information bearing on birth, death, the incidence of individual
diseases and all the many hazards of life 3 the staff of the health
department, will be griping on the dark.
It is by now means an easy talk for setting up a system which
ensures accurate recording of numerical information,
T is is the only
way in which the level of health can be measured and effective
comparisons ben a cl e.
To take a specific examole- if a disease or the
cause underlying each death were carefully recorded for a particular
. ..3
- 3 place from city,P.H.C etc., over a number of years we could provide
valid answers to
a) Leading cause of deaths in the town,city or PHO
b) at what age the mortality is highest
hKI Preventive measures can be taken to reduce the mortality
dJwhjEt Comparison can be made of different places with
similar sizes.
e)to what, extent are the hospital facilities staffing, <JA
dru.^s
and equipment able to cope with the disease problem e.hd1 so > on
In the similar lines data orf)Sxjxtality and morbidity will
highlight the ongoing situation thereby enable to take connective
measures on the system.
The first step in the analysis of data is to establish a
classifications system so that items need not be distinguished
from each other are put together in groups.
Each item of informatJion
is arranged in such a way that "like is associated with the like".
For the classification of diseases, injuries and causes of deaths,
the internatonal statistical classification has a long history of
intensive work dating back to the pioneering attempts of Francois
Bossier de LaCroizf1706-1777),William Cullen(1710-1790), Willdus
Farr(1807-1883) and Jacques Bettillon(1851-1922).
A uniforn classification of causes of death applicable
to all countries are
adopted and is obligatory since the classifi
cations and publications of cause of deat^m statistics if governed
by W.H.O nomenclature regulations which stipulate the use of the
International statistical classifications of diseases, injuries and
cause of death.
Similar classifications are available for litfe births,age 9
marital status, occupations and industry 5 literacy,educations level
and so on. In the couseeof the work a stage is reached when inform*—
tion collected separately for each individual
born,healthy,sick 9
of dead, begins to file up and from these individual items and by
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the use of standard classifications results are presented by
tabulations from the records of events-aanely l)Vital staststics,
records of births,deaths etc. ,2)llospital records 3)Health department
service records collected as a routine and records obtained in
special investigations like morbidity and nutritional surveys♦
The steps in data handling and processing are a)Collection
of data b)Scrutiny of data(adequacy and accuracy) c)Sorting or
classification into classes or groups dComparing the necessary
statistical indices(Like Birth rate,death rate etc) and etabulation
& presentation.
By applying these methods systematicaly we can arrive at
the situation of leasuring health or indicators ofmeasuring health
can be obtained, since we are not in xxx possession of r..ny statistical
index or measuring rod which can really lell us in numerical teSfus the
level of health of a coniuunity.
The tern health has been defined by
the WHO as a state of complete. Physical,mental & social well being
& not merely the absence of disease or infirmity. This definition is
wide and sone of the indicators like 'Expectation of life at birth',
crude birth and deaths rates and infant norbality rate will certainly
through some light on the health status preventing in a particular
country at
point of time which enables to com^rare & thereby ci
relative picture is obtained.
Hence it can observed that fro..i the records these indicators
are obtained and further by caref-il study of these records a pattern
for the future can also be obtained. It is notjust presentation of
past years but also of ^resent as also of iaaediate future which is
the method & is known
s nathenatical statistics in health that is
to be understood and applied for furtherence of knowledge.
2.^7
nMEDICAP^RECORDg IN INDIA AND ABROADw - A COMPARISON
maria alphonsa e.j.
medical RECORD OFFICER
National Institute of Mental Health and IlBuro Sciences.
Bangalore - 560 029
Medical record is the only source document which records
the course of treatment given to a patient and serve as the
medium of communication among health care professionals for
direct and future care of the patient. In this article, I
would like to present an overview of the medical record field
and its functioning in India in comparision with advances made
in this field in inclustralized countries like U.S.A.
Medical record profession is only in the preliminary
stages in India in comparision to developed countries. We
need research from its members to realise the barriers to its
full development. .Do. we need more schools to train this
technical personnel? Do we have enough trained people? Are
these trained people, are getting recognition in this field?/ot 9
are they, oeing used as clerical personnel without promotional
channels? Our educators and administrators should recognioe and
expand this body of knowledge. The reason for slackness in
progress are many. Wo- are aware that many professionals who
can organise people in this field and who can lead to further
progress in this area have already left India for better
opportunities. A detailed regional and National survey is
required urgently to find out the true position of our
profession and medical records, and what we propose to do to
rectify the situation.
VZ hat is the general pattern of functioning? At national
level if we take, major teaching hospitals in India like All
India Institute of Medical Sciences (AIIMS), PGI, Chandhighar,
JIBMIR, Pnndichery, Sree Chitra Tirunel Institute for Medical
Sciences and Technology, Trivandrum, NIMHANS, have standard
ized medic al record departments with trained people. In this
context, progress made in Medical Records Department in
Sred Chitra within a short period of tine is worth mentioning.
They have computerized records from 1986 onwards, and also
have started microfilming old records. At the registration
counters, they have not yet started on-line entry, At
present they feed the data the following day.
...2
2
In Earala, most district hospitals have at least one trained
person in the department and they maintain necessary information
at the time of registration, and during hospital stay to enable
health care of the pat itn't. The maintenance of these records
and retrieval rate is not of better quality on account pf
financial constraints, lack of personnel , and administrative
policies. The State of Tamil Nadu has more training
programme s, and trained people working in various hospitals.
The record keeping system used in major teaching hsspitals
are more or less the same with slight variations , that means
according to bed capacity, the services rendered , the needs
of the community, ft
financial
constraints, and administrative
nancial constraints
policies. In NIMHANS, for example the following system is
used. We- have records from 1957 onwards in three sepcialities
namely Neurology, Neurosurgery and Psychiatry. Prior to 1987,
Neurology, Neurosurgery section and cut patient section used
to function separately from psychatric section. In April
1987, these three sections of medical records were intergated
and are now filed in centralized area. Identification of the
patient is by the Hospital Number assigned at the time of
registration, and depending on the service in which they are
registering we assign N/ for Neurology, Neuro Srugery cases
and P/
for Psychiatry cases. Unit number filing system
is used where one serial hospital number is used for one
particular patient, and both inpatient and outpatient records
are filed in one single file. Por
|ent cascSj
For acci(
accident
cases we Gtarted
maintaining a card from 1987 December' onwards,
onwards, other than the
uersj in which exariining doctor can write necessary
details, so that a written record is available if required
for le£al settlement of cases and certificates,
Record
retrieval is by the
hospital number. The rate of
retrieval varies in each month, An average of about 350
case
records are taken out per day.
The following is h sample of statistics produced by our
department fur the year 1988.
REGISTRATIOKS;
Neurology
Neuro Surgery
Psychiatry
7091
3232
7813
.. .3
3 G-
Neurology
Neuro Surgery
Psychiatry
3253
Neurology
Neuro Surgery
Psychiatry
39128
8351
60045
Average total number of cases seen in
casulty per Month (Jan)
849
Average total number of Read Injury
cases per month
Head Injuries as % of tatal cases
261
30.74%
FOLLOW UPS:
Bed strength
1903
2298
650 Hr 155 ±= 805
Average length of stay
Neurology, Neurosurgery - I6days
Psychiatry
- 25days
Various indexes.are also maintained like diagnostic
index, patient name index and we are planning to introduce
Physician index and operation index. These indexes provide
sufficient detailed information regarding the number of cases
treated with a particular diagnosis and classification of
cases according to age and sex is also possible.
What is the situation in advances countries? The
field of medical records is much advanced in U.S.A, and
professionals in this field are not only limiting themselves
to hospital settings, but branching into consultancy services
in Indus tires, Insurance companies, software X&KkXK technology
Education and Rehabilitation programmes. An R.R.A. (Registered
Record Administrator) registration is required to become
the director of Medical Records Department in a hospital
setting. At present there is an increasing demand for RRA S
with Business qualifications.
Medical Records are maintained in.hospitals according to
the standards set by the Accreditation Committee for
hospitals and the State Laws. The important benefit of
Accereditation is that is represents a" professionally
motivated, voluntary committment to self-evaluation and
self improvement.
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Byobtaining accreditation, ■'*
the hospitals receive a kind of
Deemed Status11 which would enable them to receive Medicare
and Medicaid futding without undergoing a separate inspection
by the State Health Department. Another advantage is that
these <JCAH (Joint Commission on Accreditation of Hospitals)
surveyors .act as consultants by offering professional advice
and guidelines for improvement, And also, this accrediation
fulfills all or portions of some State’s licensure requirements. At present about 34 States use JCAH accreditation.
The spitaling cost of medical care in U.S. necessitated
Federal Government to develop criteria which could be used to
set standards for provision of medical services. Thus social
security Act' in 1972 man da. ted that ®StlO (‘Professional Standard^
Review Organization) be established to review the quality and
utilization of medical care. Various, audit committees, and
Utilizauion Review Committees also exists to monitor the
quality of care given to a patient. The purpose of an audit
is to identify problem areas, institute actions, and find
solutions, and primary goal is quality care.
■«
Record keeping system varies in each hospital. Certain
hospitals used Terminal digit filing system, and others used
Unit Number Filing System. At St.Joseph’s hospital, Syracuse,
&ew York where I had the' opportunity to work, used Unit
Number filing system. ICD-9 CM - of the American Medical
Record Association was used for coding of the diseases.
Emergency case rccor o.s are maintained seperately at the
emergency section itself. Microfilming of old records is
done every ten years. Lawyers are consulted before micro
filming, since each State has different laws regarding the
admissability of microfilmed records in courts. But no law
requires to maintain records for a specific period. Board
of registrations and Medical Association advises to retain
it 7-10 years-or 5. years. For impatient data analysis
(discharge analysis), data was abstracted in the prescribed
format, and were processed outside by computer services.
...5
- : 5 : The advancement of technology and high cost of medical
care in U.S. created new responsiblities for Medical Record
practioner s, and to meet the increasing demands of the payers
of services, many new. met hods for data collection emerged. As
an exapple Billing PopraJUffl^^aziL-geguires medical record &
departments to’ accurately code outpatient visits. UB 82
containes 96 data fields enough to cover information needs of
Medicare, Medicaid, B luecross, CHAMBUS, and all commercial
insurers. Each payer requires different data elements to be
supplied on the Bill when submitted by the hospital for
payment. Another classification system for discharged pateints
are DKG'S (Diagnostic Related Groups). This system classifies
discharged patients into 383-gsoa groups depending upon their
diagnosis, age/or surgical procedure significantly affect the
length of stay. Age, Length of Stay, Discharge status are
variables in determining certain DRG's. Once the group is
decided, DRG code is assigned, and rate- will be fixed
according to the system.
The introduction of MEDIC/Jj iNPORMATION SYSTEM began in
the late 1960's. The patient care support oriented MI.S's
started in 1970's. MIS in this context means "utilization of
electronic data processing and communications equipment to
provide on line processing with real tine responses for
patient data within the hospital and its outpatient department
including ancilliary services".
What are the major trends in Computer Technology in
America today. ?
The PROMTS system (Problem Oriented Medical Record)
computerizes a life time hospital record for the patient.
It provides clinical care access, stores the entire patient
record generated during the hospitalization in the problem
oriented system, and uses the computer to bring the clinician
into direct interface with the record. It also uses computer
technology to access current medical resources and research
to provide assistance in care and therapy. The COSTAR
(Computer 'Stored Ambulatory Record) computer system in
Ambulatory care
is another model. This programme includes
financial, administrative and patient record modules uniquely
designed to serve the ambulatory settings. (Summaries of the
patient's condition are available to clinicians upon demand).
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AHIS (Automated Hospital information System) is another
system.' In this there Level I anci Level‘ II., Level I Hospital
on t 1 c e o i to )
Information Systems c"
. ( d ns no b no cm a net £ o.
inparients, bed status
entry cDEiiaunication and charge collection application and
enquiry application for charges for demand bill purposes.
Many also include a number of other applications to include
nursing notess care plans, medication profiles, laboratory
features etc. Level II system include the features in Level I
and have been designed from the start to capture and maintain
on-line the entire patient record.
Another trend is the development of disease data banks.
An example, National Institute of Neurological and Communi
cative
Disorders and Stroke have a data bank that
contains the clinical history of a large number of patients
described in a uniform manner from multiple centres. The
proliferation of microcomputers is another development.
Physician’s offices can create computerized systems with a
TRS 80 Radio Shack computers for $50000.
Developing countries Like India fere also experinecipg
the- impact of this ' emerging technology in Health Information r
Systems and Health c.are delivery. As medical record profess
ionals we* must be through with each step of advance, and how
it can be helpful to us. We must learn from the errors
committed by the automated systems. We must‘demand therequired
education, knowledge, and experience to actively participate
in the design, planning and implementation of the new
information systems., The system designers and the technology
should not overtake us. Automation will bring a lot of
benefits, It will improve organization, availability,
timliness, and decreased clerical activities and reduce
duplicative and unnecessary procedures. It can provide
information in all kinds of formants and combinations of
facts in alternate ways. Dut one important fact we should
bear in mind is ttet it will not solve the problems of a
totally disorganized system.
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If any Institution is experiencing record retrieval
problems, it must be analyzed properly. Most of it are
’People’ and ’control’ problems. Expensive automated
equipment and computerized tracking systems will not
solve ’people’ and ’control’ problems. We whould also
not think that what we are observing in advances countries
are their problems. This can be- ours tomorrow. Let us
be ready with a properly organized Health Information
System to face the challenge.
* * * * * * * * * * * *
References:
1.
Burda, Davicl. MUB-82 Arrives with work for Medical
Record Departments.” Journal of Amenican Medical
Record Association• Novenjber 1984.
2.
Kennedy, George Collingnon, Susan J., Protte, Denis.
"Impact of Medical Information Systems on Health Care
in U.S.A.” MED IUFO: Lind Berg and S.Kanihara.
North Holland Publishing Co., 1980.
3.
Murphy, Gretchen. ’’Computers in Medicate Demand
Commit tine n t”. Journal of American Medical Record
Associati on., April 1981.
4.
Thompson, Gene E. and Ira Handelman. Health Data and
Information Management. Boston: Butterworths, 1978.
FYI £
'’COMPUTERISATION OF MEDICAL RECORDSn
BY
MR S. PREMA. V.MALL YA,, .MEDICAL RECORDS OFFICER
KASTURBA MEDICAJ, COLLEGE HSOPITAL, MANIPAL, L.K:
’9
INTRODUCTION:
In all branches of Science and Technology, Computers have
Gained popularity like television and electrical appliances
in a household.
Therewere lot of problene faced-in Retrieving information from
various points and to link all these within a short tine. So
the nahagenent thought of introducing computers in Hospital
complex. Initialy the fear of retrenchment of staff was th^re
but the authorities declared that no one will be retrenched.
This assurance gained the popularity ,cf computerising the
various activities and motivated the staff to use computers*
To develops the computer Aided Manageneht Inofrnation System,
Zenith Computers were installed in September 1983 in the
Computer Department. Kasturba Medical Collage Hospital was
started in the year’ 1961'with 150 beds in Manipal, a rural
area to provide clinical facility to the Kasturba Medical
College Students. Today it has gr’&wn into a 1300 beded most
modern hospital well equipped with sophisticated machines*
It is a referral centre for various neighbouring districts,
eg. Uttara Kannada, Shimoga, Chikmagalure and also Kerala.
Some of the Public Sector industries like New Mangalore Pori;
Trust, VISE, KIOCL,. Myscre Paper Mills, Bhadravathi and
Various other private sector Industries refer cases to
this hospital.
CLINIOZL FACILITY:
CT Scan, Whole Body Scanner, Colour Dopier, Ultrasound, Limb
Fitting Micro Surgery equipment, Laser Therapy, Radiotherapy
etc. are some of the facilities available in the hospital.
Medical Health Insurance Scheme is extended to the staff and
economicaly backward clases. Vxxxx Various Camps are conducted
and there are about 7 Maternity and Child Welfare Centres.
Specialist outreach service is provided to the sick and
poor in the interior parts of rural areas.
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MEDIC AL RECORDS DEPARTMENT;
In the initial stages the various manual procedures of
collecting data of Admissions, Discharges, Outpatient, New
registration, Repeat registration, disease- wise, Operation
wise etc., was studied by the- Computer Departments Wherever
duplication of information data was there, it was noted and
final procedures were designed to be (utilised while entering
the data in the Computer. Fifty percent of ODD, Admission,
MED Staff were trained on h:,w to utilise- computers in their
daily work of patients data.
At the initial stage data entry work was started parallel
to the manual system. The results were faster and reliable,
after three months of trial, we stepped manual system of
writing registers and depended on Computers.
The Medical Records Department is the nucleus of collecting
information of all the activities carried out by the various
clinical, Paraclinical Departments regarding the patient from
his very first visit till1 his departure from the hospital.
Major work of Medical Records Department is to maintain 10
year’s Out-patient, Inpatient records with X-Rays. The
outpatient records for last 10 years has exceeded 5 lakhs.
To overcome the space shortage, we have introduced Canara/
N ikhil mobile racks on railings, which has helped to a
certain extent but we have plans to put discharge summaries
into computer to solve the problem of preservation of more
than 10 years records for research and publication. Records
are utilised fcr filling up of various forms such a LIC claims
Medicolegal treatment Certificates, Birth, Death Reports,
Workmen’s Compens-tion forms, disability certificates etc.
The Sttistics of communicable diseases, Heart operations and
any other disease required by the Government agencies has
been supplies within a short period. Thus Computers have
helped us to get results quickly linking the activities as
required by the Administrators, Government Departments,
clinicians, patients etc.
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COMPUTER DEP/JRTMENT:"
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The Computer Department has 8 cpLiputers at present and these
are used by various .departments such as Medical Records,
0.P.Registration and Admission Counter Staff. They feed the
different data from 1 to 4 on daily basis 5 and 6 once a week.
1) New" Regis trati on
2) Admission
3) Discharges
4) Diagnostic and Operation codes
5) Various Peripheral Centres.
6) Various Camps etc.
’
There are other various computer applications in this hospital.
Except pharmacy all others are done in Batch Process and
Pharmacy, application is on line. The present system.is. being
replaced by the Network of computers ( IBM PC Compatibles)
considered more versatile. The data is entered by.various
user departrent staff and the various programmes have been
developed by computer Department in consultation with the..
user departments. Data is preserved on diskettes. Programs
have been developed as per the need arised from time to tire.
1. OUTPATIENT 1TEW REGISTRATION; The sociological data,
Service/Unit of all the new patients is entered into Computer
which is preserved in the diskettes on an average 250 to 300
patients data is entered. Two printouts are obtained as
noted below:
i) Hospital Number wise printout to verify any missing
numbers on daily basis.
ii) Alphabetic name-wise list on monthly basis and yearly.
index. 2 x±1xk Both these are very important while compiling
the monthly statistics.
2ADMISSIONS: The adnissions to the various wards are ...
entered in the Computer.
1. Name, of the patient
2. Age/Sex
3. Hospital Number
4. Inpatient serial Number
. 5.. Bather’s Name/Husband’s Name
6. Service/Unit/Ward
7. 'Date and time of Admission
8.
Treatirg Doctor’s name.
...4
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Daily about 150 to 200 admissions are■ entered into computer.
A printout to that effect as per IP
— Serial Number is taken
monthly printout to incorporate in the monthly statistics
and a
is also availed, This is also utilised for studies and
research, eg . Sex wise and disease wise, Diseases and Surgers.
3. DAILY CENSUS;
The Daily midnight census of each ward comes to the Meuical
is entered in the computer. A
Records Department. This
1
against wards and the average occupancy
printout of service .u,
the ward is sent’to ■
of
*-• 1. Medical Director
2. Medical Superintendent.
4. WARD TRANSEERS: Prop higher Catqgorjr to lower category and
vise verse. The si ate"entered in computer by taking Inpatient
number as the control number. This helps in billing the proper
room charges.
5. DISCHARGES: The discharged records from various wards come
■ ' ■, number
' to Inpatient Billing Section only the discharge date
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of x-ray films are entered and a: list of discharges containing
Records Department
the following details is sent to Medical
.
along with the records since the admission data is already
there in the computer.
1.Inpatient Number
2. Hospital Number
3. Name of the patient
4. Ward
5. Service Unit
6. Date/time of admission
7. Date/time of discharge
8. Number of x-rays films.
6. DISCIkRGE ANALYSIS.; With the I.P.Number control i.e., by
typing I.P.Number, the Admission data is seen on the screen.
The result operation and diagnostic codes .are entered dai y
•^om the discharged records. Coding of Diseases and operations
is done manually before entering'the above data m cqgipu er.
A patient to verify the entiles and correct the errors i
anv is done without fail. The above computer operations are
carried out by Medical' Records Department, Patients Regis fc. ion
Counter and ^Admission Counter.
...5
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from Computer Department..
1. Monthly outpatient statistics related to New Registrtion
and. old or Repeat Registration. Departmental Refe-rals,
Medicine O.P.Visits., Valley View Health Cheko-up Programmes
G-eogrpahical distribution of New Registration.
2. Monthly Admissions, Discharges, Hospital days, Results,
Operations Referals, G-eographical distribution, Average
length of stay Average bed occupancy.
3. Monthly Diagnostic and operative procedure wise Index.
4. The various health statistics pertaining to maternity
centres. Camps School Health Check up. Specialist
outreach centres.
5. Daily Census: ward acainst service and Average occupancy
of each ward.
6. Patients A Lpha Indlx ic nanc wise and H.No. wise is taken
which helps in -searching the Hospital lTur.ibcr.
■}
There is a sanction of One Computer for Medical Records
Department, the work is in progress once wc get the computer.
V/e have plans for using computer for
Medical record
stationary, indents issue stock. Balance and also to use in
Medic'olegal History, wound certificates and the treatment
certificates.
At present we had put only the sociological and statistical
Data on the Computer, but we have plans to put Medical data
like history Discharge surxiary on the Computer.
THE UTILISATION OF TIiL IRIITTOUTS;
1. By Medical Director/Mcdical Superintendent.
$. Bed occupancy to increase the beds and the proper
utilisation of beds.
2. The provide best Medical care at reasonable cost to the
common nan.
3. Patients satisfaction rate to improve various supportiveservices.
5. Evaluation of Medical care rendered by different Clinical
experts.
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5. The patient consultant ratio to appoint additional staff
6. To plan, Organise and reorganise the structure of the
Hospital from time to time.
IILBY THE CLiniCIZiTSi. ■ l\
■-
Ex
1. Research with various combinations eg. Age - group, diseasewise Geographical distribution, Sex, Result-, Religion etc.
2. The evaluation of their service
3. Teaching prograiane
4-. Number of patients treated for any disease.
:
III r BY . THg
/J-+
rfjTryj f r.-’'
••mf'l'T-
• vq vswrip
1. Various Medical Certificates.
2. lischarce sjimary in-various clains.
I conclude that the computer aided management system ia an
aid for better patient care and a powerful tool to the
management in planning, organising and implementing better
methods.
w-
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rn
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*MICROFILIMING OF MEDICAL RECORDS.'*.
MRS. PREMA SATYAHARAYANAN, M.A*, D.M.R.Sc., FjM.R. Sc . (V/HO().
MEDICAL RECORDS OFFICER, GOVT. ROYAPETTAH HOSPITAL, MADRAS-14*
*#***.
>8 y
Before coming to the subject proper, I would Like to
touch on few important points relating to Medical Records in
general for a better appreciation and understanding of the
role of Microfilming in.Medical Records.
The objective of every department should be so tuned as
to achieve the ultimate goal of the Organisation. As such,
the primary responsibility and objective of a hospital is
"PROPER CARE OE THE SICK ARB THE INJITREB”. Medical Records
• Department plays d major role in achieving this objective.
UTILITY OF HELICAL. RECORDS?
The Medical Records, as you are alii -well aware of, being
a compilation of scientific data derived from many sources,
co-ordinated into document which are available for various
uses, personal and impersonal, to serve patients,, the physician,.
the institution in which the patient was treated, the science
of Medicine and the Society.as a whole, The Medical Records
therefore have to be necessarily maintained, in proper shape
for the benefit of:1. the patients for. better, care for the future illness.
2. the Medical Staff to evaluate their own work.
3. the Hospital Superintendent to assess the quality of care
rendered by the Medical Team.
4. the Health Authorities who are provided with correct
Medical Statistics for the prevention of diseases and
promotion of Health,. ,
5. the teachers in thelp-.teaching programme.
6. the .Research W- orkers for publication-of articles and
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dissertations.
7. the Hospital, the Datients and the Medical Staff in
Medico-legal cases.
.
8 thc^Mem^^rs for publication of articles and presentation
of papers at meetings and seminars.
9. the attending physician against unjust claim of malpractice
and for the protection of haspital against unjust
criticisms and claims for injuries and damages.
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RETENTION OF MEDICO RECORDS?
The Medical Records of a Hospital which play a very
useful and vital..role, as seen above, have to be necessarily
retained and preserved in tact for prompt retrieval whenever
required. How are these records to be retained and preserved?
'How long are they to be retained? Should all the records
be preserved? These are. the most important questions to be
answered for the retention of records.
During my visit to the United Kingdom for higher training
in Medical Records under -a W.H.O. Fellowship, I observed that
under the provisions of the Public Records Act of 1958 all
the Medical Records selected for preservation for more than
30 years, have to be transferred to the Public Records Office
or to any other place ©losen by the Lord Chancellor in Jsritaiu.
Thus those records from various hospitals in the U.K. that
are to be preserved for more than 30 years are kept and
preserved in.a centralised place approved by the Chancellor,
unlike our country, where in the absence of such an Act, all
the records are maintamned in the respective institution only..
STORAGE FACILITIES?.
Finding adequate space for storing the Medical Records,
has been a problem most of the Medical Records Officers are
facing'in their hospitals. I am happy to say, in this
respect, the Government of Tamilnadu had, issued an order
fixing the time limit of the preservation of Medical Records,
as thirty years, based on the recommendations of the Dean's
Conference. If the above orders of the Government are to be
implemented effectively there will be acute demand for more
space and additional funds for providing facilities like
provision of additional
kxk steel racks, cabinets etc • :5
Indidcntally, I would like
nxe to
w point
puxuu out
^u..,
in every hospital, Indidentally,
in this connection that in the Western Countries sufficient
space is allocated for records storage while drawing a plan
for new hospitals and provision is also made in the budget
for capital expenditure for the purchase of cabinets, racks
etc. In the absence of proper planning, Medical Records
Department is faced with serious problem 'of- storage,, This
solved oy
problem of storage of records can be
— successfully
-— - -
the introduction of,Microfiliming of records.
...3
I
- : 3 : WHATIS MICRO FILM?:The term ^Micro Film’ refers to‘the feduction of orginal
...... —■■
1
1 —■
11
documents on to photographic, film.
WY MICRO FILM FATIEITT RECORDS?!^The filing and retrieval of large quantities of patient
records presents a considerable problem to any hospital. Not
only do the records take up a large volume of space, but as
they increase in number there are difficulties in maintaining
a reasonable retrieval speed, in keeping them up to date in
^reserving them securcdly. Micro filming of patient’s records
A is a new technology to the developing countires but not
so to the western countires. In the western countries there
have been great advances in the method of keeping micro film
records complete, and updating them with new information.
Notes from several episodes relating to one patient Cc.n now
be filed in sequence, as with conventional paper system.
Every year, the influx of new files increases the problem,
of providing adequate and accessible storage capicity. A
microfilm patient record system provides the answer.
Let us examine our present filing system:
want it ?
1. Is the patient record -6.1 way's there when wo
.
,
If so, is the folder complete ?
documents remain in the correct sequence- within
2. Do all the
the file. even ..if it has been used several titres?
is time
3. Ar e we happy with the present ’Response Time’ or
wasted looking for lost files?
time?
4. Will our present filing area be-adequate in five years
” access?
5. Are our records conveniently stored for easy
6. Can the needs of research workers be met
i._. without the need
to release original case notes?
7. Is our present filing area safe? Are the racks too fully
leaded or stacked too high?
8. Are we satisfied with our present file security?
9. Do wc have a problem when one file is need simultaneously
in two different departments?
'
The.above questions highlights problem areas which can
be solved only by the use of micro film.
...4
i
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-:4s
Micro film is a very effective filing system with all
the advantages of conventional filing and none of the draw'backs such as space used up by vast rows of cabineis etc.
Infact micro film can save up to 98$ of the space used by
paper system. That is, records of hundred years can be
stored within the space required for two years-records by
micro filming. In addition to space saving, once a record
has been micro filmed it is safe.
SPEED AND CONVENIENCE OF RETRIEV/J.;
Only seconds are.involved in retrieving one of the
million fecords filed.
SECURITY:
Duplicate micro film files kept off premises xg protect
against destruction and loss of vital information.
LOWER OPERATING COSTS:
Valuable man-hours freed from.sorting filing and
re-filing paper records are either recovered or channelled
into more productive work.
FIXED FILE CONTINUITY:
Records filed on micro film are in fixed sequences,
gaurding against misfiling, mislaying,5> alteration or loss.
ADDITIONAL COPIES:
Additional copies of the patient record can be made for
research workiers or two copies can be made for a patient
who is attending two differ ent.clinics (e.g.) Casualty and
Dentistry.
DESTRUCTION POLICY:
Many hsopitals do not have destruction policy, and most
prefer to keep records for a considerable time before
destruction. In any km event, this is a time consuming
operation. But with the use of the micro film the additional
file area required for each year of files is so small that a
destruction policy becomes less important.
...5
: 5 :
WHEN TO MICRO FILM?
Documents can be micro filmed at any point between crea
tion and destruction of the file. This is an individual
choice for each hospital. In western countries their exper
ience suggests that filming at the point of discharge is
proving popular and practicable, but some hospitals prefer
to commit their records to micro film after 10 years from
the patients date of discharge.
WHICH DOUCMENTS TO BE MICRO FILMED?:
Not all documents within the patient record need necess
arily be filmed. But it must be agreed in advance which
douements can be destroyed.
WHAT ARE THE SEQUENCE OF EVENTS TO BE MICRO FILMED?:
From my experience with the Micro filming equipment, I
find that filming the patients records presents an opportunity
to organise a medical record department in a way which will
best suit medical staff for future reference by adhering to
the following order of sequence: 1) History, treatment,
Nurses Report, anaesthesis report, operation report, drug
sheets etc, 2) Pathology and X-ray reports 3) referral
letters etc. 4) Discharge summary.
In short, micro film is a recording medium - one that
results in high density information recording. It is a
medium which is self reproduceable - that is, micro film is
reproduced as micro film. When properly coupled with good fx
filing system, classification or indexing methods, micro
film is a medium for information storage and retrieval. To
Medical Records Officer,9 all this means that the medical
record micro filmed, is not only stored more compactly,
protectively and close at hand but it can be used to provide
information copies readily to authorised personnel as well.
I find from my experience that there are few problems,
of course minor in nsjot nature, have to be faced.
1. Medico Legal Cases:- The first one relates to the
admissibility of micro film copy as evidence in legal
proceedings as in the U.K. Unless it is permitted, the paper
medical record has also to be preserved defeating the very
purpose of the introduction of micro film, As ours is the
first hospital to introduce this system, we had taken up thi^
natter with higher authorities and
orders of Government
are awaited.
.6
:6s —
2* ^rop^er Conditions:- 2 As the photographic equipment is
ve±y sensitive to the variations in atmosphere,- humicTity, .
etc., the equipments have to be kept in an air conditioned
places and sufficient space.
■
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i
Of course, the>e are only minor problems which can be
easily solved, with the co-operation of authorities 9 when
once the above system is introduced in hospitals.
CONCLUSION:
Considering the very many advantages of the system, the
problems arc very few and minor in nature which could be very
easily solved. ‘
An/-
S':
|3
LEGAL ASPECTS OP MEDICAL RECORDS
by
Dr^T.R.Nagaraj
Professor of Orthopaedics
Bangalore Medical College, Bangalore.
Allow me at the outset to profusely thank the
organisers of this seminar who have given me this
opportunity to be with you today and to share a few
thoughts about Legal Aspects of Medical Records.
History of Medidal Records run parallel with the
history of Medicine, Records are as necessary for the
practice of Medicine as the Medication itself. Polychrome
nurals were found in the caves of old stonage and
silhouttes of amputation of fingers appeared on the walls
of caves in spain. All these dates back to about 25,OOOB. c.
Of course initially records were maintained to
record the treatment and for follow ups. B .ut the
importance of these records with respect to legal impli
cations came to light as late as 1882. This was specially
noticed in the Western Countries where Medical Records
were given absolute importance in respect of legal
implications. And today it has reached such status that
it could decide the fate of a practitioner or fortune of
a disabled patient. The way the records are maintained
in those countries are a treat to be seen, watched and
followed.
But, alasl I an pained to state that in our
country the medical records are treated with, such scant
respect that it hardly deserves to be called Medical
Records, and not to speak of the legal implications.
Right from the time it gets initiated to the
point it rea ches records section, it hardly gets its
due respect and credence. I an sorry to state that
our own colleagues have not understood the real serious
ness of maintaining proper records especially if its
not a Medico Legal Case. Lately, there has been a slight
awareness amongst ourselves with regard to legal impli
cations of medical records.
.. .2
: 2 :
But, I feel whether it involves legal implication or not,
records must be maintained systematically right from the
start i.e., initiation point to coding point. By this
we can achieve many things specially academic aspects and
to produce papers and to malce certain conclusions and
decisions. So it is apparent that medical records must
be maintained even if no statute er regulation is imposed
on the requirement. Certainly we need them to provide
best medical care and of high quality.
So, Medical.Records is the focal point of claims
of a growing number different groups such as Attorneys
and patientss, physicians and insurance people, Government
and finally the hospital itself are
and Police personnel
;
interested in the contents of record, Each of these
groups, many times competing between themselves havelegitimate interest in the contents of tne recoru*
Requirements of a. Medical Record particularly frori the
Legal view point
Legal Aspects;- Medical Record should be initiated at
the time of initiating treatment for every patient as
an out-patient ticket or a chit. Routine cases will
contact the respective Doctors of their ailment and
obtain treatment which must be clearly written on the
O.P.Chit. If the examining Doctor or even at the chit
counter, feel that the case is not a routine one but
has a Medical Legal implication then he or she directs
the patient to Gasuality Medical Officer for making
necessary entries in the Accident Register and
ixifornation to the police is given* Subsequently he
Doctor for the
directs the patient to the concerned
---treatment. On quite a few occassions a Medico Legal
Case nay be treated on merely Out Patient basis and .
it is imperative here that Out Patient Chit must be
maintained and retained obsolately well. It must also
have entries of X-Ray number, details of treatment
report, followup notes etc., Additional
given, X-Ray
A-Kay rep^xu,
Out Patient Chit and a regular case sheet will "be
initiated at the- admission counter.
3
: 3 :
Tt will have a Summary (Pilot) Sheet in which all entries
with regard to. patients personal particulars are entered
very clearly, especially name, address, sex, age, income
ere,. If the patient is un-concious the attendent who
brought the patient will give the particulars. On many
occacsions .this may be incorrect and might require
corrections by making an affidavit on a stamp pajer. In
addition to Summary Sheet, case- records -will have a
Doctors sheet. Nurses notes, Tenparature chart, Diet
sheet* Scon'
Scon after adirission,
admission, the- Doctor concerned must
exan'ine the patient in detail and make entries about
his findings before any treatment is started except in
absolute emergencies. He must be clearly write the
following in a Medico Segal Case:-
•e
1* Type, Size, Side of any wound.
2. Side 8: type of Fractures .if any
J. Type of complications if any.
This is in addition^ to,, the routine entries about the other
systems-. Doctor will also make entries immediately of the
investigations ordered.such as X-Ray etc., and also of the
treatment. The ward nurse in turn will also make entires
of the treatment instituted in addition to the maintaining
the routine investigations like Pulse, Temparature Chart,
Dialcbio Chart’etc* All investigation reports as and when
available must be entered into the case sheet at the
appropriate sites including the X-Ray number. Surgery
when done Emergency or otherwise^ must have a pre-requisite
caonsent obtained from the- patient or the attendant/
G-aurdi&n in case of minor or unconsicious patient.
All surgical procedures including post operative
instructions must be meticularly entered in the operation
chart. This will necessarily contain the Anaesthetist
pro-operative assessment and operative findings. Any
‘specific post-operative Anaesthetic instruction must be
entered also. If.an emergency treatment is given even
before the records are initiated it must be brought to the
notice of the CeM.O., otherwise he will miss the orginal
injury. It is advisable to bring it to the notice of the
C.M.O., of the emergency before any treatment is given
eg. reduction of a dislocation C.M.O., might refuse to
a ccept that there was a dislocation if you reduce it
without an X-Ray or of his knowledge.
• ..4
4
Regular followup of the patient including doctors
in structions9 findings, nurses notes, nust be HEentered
every day, till he is discharged. However, if the patient
wants a discharge against medical advise necessary
formalaties must be followed in informing police before
the patient is permitted to go out of the hospital. Even
then the case sheet must be entered fully till the time
the patient staysin the hospital.
summing up the case sheet/opd chit must be
complete at all costs, before it is sent to record section
whether it is a Medico Legal case or otherwise. Now, the
Medical Records form part of the hospital property and it
has its absolute and complete rights.
So,
Naturally it cannot be over emphasisted have the
importance of two vital points with regard to maintanance
and upkeep of the records. They are security and relia
bility. Need I say or stress the importance of these
two vital points in maintaining the records particularly
from the view point of legal aspects. I don’t have to
eloborate on.these %% aspects as.it is out of my
jurisdiction.
The importance of the record from the legal point
lies when the court calls for an evidence from the
Doctor while deciding on the compensation for the victim
in a Motor Vechile Addident case or in a Homicidal case
to determine the extent of injury caused to the agrieved
person and to decide the punishment to the accused. It
is here that a correct medical records plays an important
role. Medical record can be issued to the concerned
doctor on production of vouchers signed by him. On the
basis of the information which lies in the record the
Doctor can safely state the injuries and fractures
sustained by the patient, and the treatment given to him.
Hence it is important that correct entries are made in
the case records and O.P.D., chits with respect to all
injuries sustained bybthe patient and treatment given.
At the- end of the oral evidence of the Doctor inveriably
the records are kept by the court as an exhibit and
hence any discrepancy in the statement will haul up the
doctor severely.
• .•5
: 5 :
Invariably it is about 3 to 4 years later that a Motor
Vechile Accident clain cones up for the evidence. So
it nay require re-examination of the patient once again
to assess the present condition to decide bn the
percentage disability. Hence, Accurate record of the
re-exanination including .X-ray Examination must be
recorded in an OPD chit and produced in the court.
Any treatment given between the time of discharge and
the evidence must be maintained throughly, for all
documents kept by the court as exhibits, a receipt must
be obtained from the court clerk and filed in the
records section. Case sheets are narked serially at
every pa;e and total number of pages is noted on the top
of Summary sheet.
In the same light, injuries and disabilities
sustained by the. individuals, specially labourers must be
a ccurately and precisely recorded to be produced in the
court of law to decide on the compensation to be paid
to the sufferer, lately labour courts are organised to
deal with the extent of damage caused to the labourer and
the compensation he is entitled to. In addition, Public
Sectors have organised health insurance for their workers
and if they are injured while at work they are entitled
for compensation to the extent of damage suffered by them.
For all these procedures accurate Medical Records to
assess the percentage disability is absolutely necessary.
NEGLIGENCE: What is negligence - it is carelessness!
Records negligently prepared may be instrumental in
causing harm to the patient-either medically or legally.
Medical record gives the information about what actually
occurred and the testimony of expert witness gives the
information to the Judge to decide on the case as it
merits. Hence any direliction and negligence on the
part of the Doctor/Nurse in preparing the record or in
giving evidence will directly reflect on the prospects
of the patient eg. 1. Paediatric case 2. Left to Right
(wrong entries) 5. No entries or Missing entries. Loss
of record, alteration of record have bearing on the
legal aspect.
...6
I 6 :
It is the duty of the nurse to keep it safe while patient
is in the wards and report to R.MO., if it is missing.
Necessary action in informing police and initiating a
duplicate is left to R.M.O. After discharge of the
patient, the record must reach the record department xtx
within 24 to 48 hours - and subsequent custody lies with
the record department.
I
It is needless to .inpress here that the all
infornation of the record is essentially confidential
and there is no room for the access of infornation
expecially in Medico Legal Cases to anybody except:(a.) Police for the sake of Wound Certificate (2) Leath.
Certificate (?) Notary of the Public for Insurance.
In such cases it is preferable to nake a photostat copy
and retain the original. Infornation can also be
divulged in cases of Scientific and research projects.
Here it is essential to mention that all infornation
divulged by the patient to the Loctor is strictly
confidential and Loctor is on oath tokeep these informa
tion a secret except in Medico Legal Cases. Patient can
sue a doctor for divulging infornation known to him
through the patient, such as diseases mentally or otherwise. He can't testify and re-veal secrets of the patient
but only in criminal cases he can divulge such infornation
which may be useful to the prosecution, However patient
has a right for any information from the records at all
times and it can be given after obtaining the written
permission from the patient,
H
long should the record be retained
How long do you retain thesS records? It varies from
state to state and country to country. It is about 25
years in the U.S.A. and length of tine a. record to be
maintained can be decided by Hospital Authorities in
consultation with the Health Lepartment. If space is
available it can be kept for any length of tine or the
records nay be converted into microfilm and then stored.
Sunning up a Medical Record a property of the
Hospital, containing confidential communication of the
patient and it is compiled, preserved and protected foJ
the benefit of patient, hospital and physician as
required by law and also for administration purposes.
**-**********
i
/ ;»•
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INTERACT JDN BETWEEN THE MKD AND OTHER DEPART WTS
OF THE HOSPITAL
DR. MARIO C. DE SOUZA
Deputy HoApj^tal Administrator
St. John’s Medical College Hospital
Bangalore.
DISCUSSION OUTLINE
?
MRD in.the Hospital Setting
Role of Hospital Executive
MRD Data for Hospital Committees
Interactions with Medical and Nursing Services
Interactions with Ancillary Service Departments
Interac-bions with Supporting Service Departments .
Medic al Sup er int en dent
Medical Records Committee
Quality Assur.Comnittee
Infection Control Committee
Hospital Administrator
Administrative & Planning
Co mraittee
Medical Records Department
Enquiry
Admitting offic-e
Medical Staff
Nursing Staff
Out-patient
Account s and Billing
Casualty/
Erpergency ..
Latoratorie s
Ward
Operation Theatre
Oomputer
Stores & Purchase
Maintenance
House-keeping
Security
personnel.
MRD AND TIE MEDICAL SUPERINTENDENT (MS)
1.
The MS is ultimately responsible for the overall functioning
the 'MRD in relation to patient care activities:
i. Compilation? storage, rettrieval of medical records
ii. Availability of records at all times
iii. proper indexing: diseases, operations, physicians, patients
iv. Periodical reports:
- registration of births and deaths
- communication of notifiable diseases
- statistical reports on patient load, length of stay,
discharge analysis, morbidity, mortality•
v< Medico-legal issues:
- reporting to police
- issue of certificates
- pre nervation of evidence for product ion-at court •
vi. Retention policy ard disposal of records
2. MS*’should effectively liaise with doctors to ensure:
i. proper documentation of patient data:
* legible
- accurate and factual
- timely completion
i. ..*2^
: 2 i
ii< Roturn. of record on tine j
— f r om OPD , ward , doctor's office
~ when oaken for res earc h pur po s es
MKD AND THE
- JD SP IP AL APMlNI gPRAIOR ( (EQ).
GEO is responsible to the Governing Board fo'r implementing.
1.
i<
decisions of
for out-patient
sp ec if io dir ec f i0
reC°fds
^e maintained
processed and stored"
ii.
iii.
2*
standards of
OEO bears ultimate :
records against If) ssV^fac ementy
safeguarding medical ss
fire and water daimge.
’ tamPerinS, unauthorized use,
3
of0tospitll^niSdtogrjySfaEi2^ the ^““istrative functionin'
if
UnVjSS 304
iii.
o^SSlnaSs®’ delines‘tin4S
iv.
v•
vi.
Implementation of personnel policies
-Disciplinary action
vii<
viii.
«
clarifying accountability
”Ork“‘e °f “D ”tth otte
Providing equipment, space, facilities
Wmmistrative and financial nanagement
MRP AND HDSPIf AL Go MIvUTTEES
1.
Medical .Records Committe e:
SUSI
,“de
tes of meetings, follow-up Zctionf
ii.
t0
h”
minu.
MR! apprises members on
- pending records
- non-conformance to established
clinical
pertiaenc e; ^deluac^for
(timely completion^ c"
’
care, research, medico-.legal; availability).
•
- r^luests.for new forms.
MRl seeks guidelines from clinicians on
-retention policy for records
- specific requirements regarding- nrocpeaiv.
•
storage of patient data;
“S Pressing, indexing &
2.
Quality Assuranc e Committee;
i. ' MRD to compile data on
incidence on hospital acquired infections
post-operative infection rate
risk management incident reports
re\iew> length of stay
a::?1 ij;
chart deficiencies
ii.
MRD to provide patient records
for retrospective (medical)
audit.
3.
’<r '
1).
Infection Control
•
:
3 ;
co mmittee:
i.
MhD to compile data on
ii.
incidence of nosocomial infection
incidence of postoperative infection
- •
deaths resulting fr0H hospital acquired infection.
Analysis of cross-infection statistics
■
-
4.
ward-wise
correlated with primary disease condition
Administrative and Planning -Committee.
i.
MRS provides data on:
•
™r"^nices
’
f°r
in a defined psrxod,
“d
needs of
cost accounting according to average patient load
-
in
hospital semises
existing resources, need for additional
facilit ies
- patient profile
practicioner prof iie
ii. Committee must approve;
retention policy of regiwteres, ca^e records
mamer of storage, summarizat hn, disposal of patient
MHD Atffi THE 1OICAL STAFE
patient data.
—
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. -•
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'Medical
ii.
iii.
iv.
v•
•vi.
vii.
Staff require patient records fors
Documenting the patient’s condition
out aid his response to treatment
’ procedures carried
Review of the patient’s present status (in the
f past medical history, earlier finding
°f x
so as to plan patient care.
d investiSati°ns)
f acilitating- review and continuity of treatment
by
inuluipie practic ionerg in the hospital
Quality assurance, medic al aud it, c linic0-r at ho in
reviews, evaluation of patient c^re
pathological
Medico-legal documents for production at cnort o -p
ding interests of practic io ners and cbXr.
*f e^arwritten consent for procedures issno ->■(=■
’ °^aininS
Medical education and research’
ertn icate,Stc.
Statistical analysis of .medical data.
5
To fulfil the above objectives, medical staff should ensure that;
3.
i. Patient records are legible, complete the factual
ii. They
+ r - accurate
o n . summarize the patient Ts condition at the
ne of admission ( or Shen
when see at the OPP/Ca^ualtv
OPD/Casualty)),
,treatnent, major patient-provider^’intera^
ctions, and c3nditon on
r.^^hpatienl3“Provider intera----------- 1 on discharge.
JCHA guidelines on Medical
Staff:’s responsiblities for patlept
-----------records:
Approving symbols and abbreviations that nay be used
and disseminating this list to ..all its meSers
specific categories of hospital and
medical personnel who are qualified to
transsilte vertex h, tetean orfe. 3
wSen^ouSt
ergeature on traneorlbed verbal orders
SlXa
• ...4
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+• of
i lo^xut; admission of the patient
of -b-irrp
tine to
following
^3fcal ^"‘toatiDn
t’a
iii •
documented
,
rlcS fTi^Sg^iS^li^ge0^16*3011 °
?
■
■v •
4r
Comrron problems encountered:
i.
ii.
iii.
iv.
v i.
vii •
inadequate and do not
Entries in r ecord are perf unct o xy ,
and treatmant given
reflect patient !s condition
<--------Inappropriate abbreviations
contain patient identification
pages in record do not
details? liable
1 ... .... for misplacement
traceable to the respective doctor,
Entries in record not
not signed, not dated
complications not factually documented,
iatrogenic
nosocomial infections not reported
Timing/date of discharge differ from nurses notes
" r admission record) and
Records incomplete (particularly
indexed and stored
viii»
MRD AND
SERVICE .
staff require patient records for:
1. Nursing
Carrying out phy sic-oa orders which should he unambiguous
i.
D?cu2m ing '■ p rt lent ' s co ndi tio n , critic al inc id ent s,
ii.
response to treatment
Documenting medication gi^en, procedures carried out
iii.
Documenting compliance with hospital policies, ward
iv.
transfers, billing formMities
Census information required for planning patient care,
•v •
staff ing, attending to ward routines
Nursing audit, critical incident review, enquiries into
vi*
negligence.
To fulfill these objectives? nursing staff should ensure that
2.
enteries are:
i. Legible? complete , factual
"by same individual
ii. Made promptly on carrying out procedure,
3.
4.
iii. Bated, tin^d, s igned».
■
portion of TP record* Need, iiot be preseNurses notes occupy major
^eFexcept ’for m^ico-iegal purpo ses.
Common, problems encountered•
pages in record do not contain patient indentifi|cation
i.
det ails•
numbers
ii. Bradam not used, wrong I.P.
5 not returned following discharge
iii. Charts held up in wards
especially transfers
iv. Census incorrect ,
*;s not filed correctly, especially far
Investigation report
v •
patients transferred out.
WHD AND THE ANCILLARY SERVER WARTNENTS
5
:
1.
5
0
0 ut-p at ie nt D apart u& nt;
i.
2.
3.
prolonged patient waiting time for registration and record
retrieval.
n. Referral to correct department based on presenting complaint
iii. Wmer of. despatching records to doctors
iv. Non-return of records
v. Wrong filing-by doctor, by MED
vi. MED invariably hardies the appointments system;
Casualty / Emergency £
i. Delay in opening new cards/retriev al of old records wh en
emergencies report especially at night;
night.'
ii. Admission fornalities of. patients admitted through Casualty
,to be streamlined
iii. Documentation to be complete as every case is a potentially
medico-leg al one
iv. Follow up on medico-legal formalities
- preservation of records, X-ray, material for examination
police formalities
maintenance of medico-legal register
- issue of certificates; wound, medical examination, death.
laboratories and Diagnostic Services?
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i.
r ■■I’ I I-W
It ■
MtaWM —WW
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- -|MI. . |
,|
I, r—-
Investigative reports to "be filed
- promptly
- correctly - wrong IP number , wrong patient folder.
Summarization of reports essential to prevent bulky OP
records.
LED to despatch reports to in-patient folders when
laboratory unable to locate patients
iv.
4.
Reports, including ECG, EEG, X-ray,-may be preserved by
MRI) in respect of medico-legal cases'.
Wards;
Census data dependant on ward admission - discharge
registers.
ii. Ward to clearly interact with KRD for;
- effectiveness of centralized admission jroces.s (communication of vacant bed status)
- inter-ward and inter-unit transfer of patients
- despatch of IP records ( and investigation reports) to
MID following disch Tge of patient
5.
Ope rat ion Theatre
i.
ii •
Indexing: Operation index s Surgeon’s in des
Compiling incidence of:
- post-operative infections
- surgical complications / deaths
- anaesthetic complications / deaths
MRD AND THE SUPPORTING SERVES DEPARTKIENTS
|r> II
■■■I—I1
>1 ■ Win in
IIWWMW—WM— ■■*■■111 —
I
I
HIM
■■■■ — I ■
1. Enluir y / Rec ept io n:
111 ■ ■! 1 11 mi
i
if
.
r—i
6
:
6
:
•
Census inf'o rm at ion to be up-to-date
ii* Information on dangerously ill patients
iiie Information onV.I.Ps'i'
iv'< Assisting registration formalities.
Admitting Office:
• KJ
Often an integral part of MRD
ii • Should not delay commencement of tratment
iii.
should comply with hospitalization formalities:
- admission to a specific facilit y / department
- docunentation of patient identification data
- assignment of IP-number.
- advise WEB to’ trace earlier Ip fillers if necessary
- obtain consent for treatment
- preparation of bradaia platee
Accounts and Billing:
!•
3.
i." Billing Department to be intimated at time of adnission
(without delay).
ii. Billing to be kept informed of ward transfers, change
in fac ility , discharge, etc.
iii. Certain charges get automatically up-datedwith c ensus
datak: bed rent
rent, tratment charge, professional fee.
Computer Department:
4.
i.
5.
Well-established applications:
- 'registration
- appointments system
- booking admissions, scheduling procedures at
serv ic e
departments
- census
- discharge analysis
- indexing; alpha, disease, operations, surgeons
- generating statistics on work turnover, length of stay,
mortality, risk management.
or
- storing data on set fornats for research*
ii. Recent advacenents:
- data base system for patient case records
- on-line real-time access of patient informratian
- security provisions to prevent unauthorised ac-cess of and
modification of patient data.
Stores and Purch/se:
i.
Indents generally include;
- registrat fin and case record proformae, index cards,
registers,
case folder-s
;
- stationery and other office materials and appliances
- books: ICD codes, medical dictionary, MRD nanagement
*• storage racks, furniture.
................. 7
:
7
ii. Safe-gnards:
- volume of indents can te correlated with patient turnover
- annual requirements must be estimated in advance and co mnunicated to Stores
- stock-outs can seriously disrupt flow of work
- MRD should make conscious attempts to cut down on station
ery in view df its high unit cost
- MRD should endeavour to cut down on multiplicity of forms
6.
Ifaint enance;
i. Maintenance of:
- typewriters
- brad ma embossing and printing equipment
- kardveyor, filing cabinets
- calculator'
- vacuum cleaner
- computer, terminals
ii. Preventive maintenance v ersus breakdown maintenance
- can be scheduled during non-busy periods
- preventive maintenance decreases frequency of"bre.lkdowns , less
expensive, does not disrupt functioning,avoids wastage
(duplicative work).
7.
Hou sc-ke eping;
Daily cleanliness
Periodical spring-cleaning, dust removal
Orderliness of recoi'ds, correct filing
Disposal of old records as per retention policy guidelines'.
iii.
iv.
8.
Security:
i.
ii.
iii.
iv.
9.
Unauthorized entry of outisders
Theft of hospital property
Internal securit y of patient data: unauthorized access,
manipulation, destruction of medico-legal evidence
Security to staff working at night, holidays, etc.
personnel:
!•
ii.
ill.
vi.
v.
Manpower planning, appropriate number of filled posts
Selection of qualified and competent staff, orientation
training
performance appraisal, conf irmat ion, promotion
leave
Disciplinary action.
BRADMA SYSTEM FOR MEDICAL RECORDS
/
A recent study in a few Hospitals in India revealed that:
'INTRODUCTION:
On an average/a patient waits for 85 minutes in order to
get 2 minutes of Doctor’s time.
- 25% of the patients get less than 1 minute of the Doctor’s time.
-
-
The cost of an inpatient per day in the Govt.Hospitals was
Rs. 55/- whereas the charges were free or negligible.
T1 e cost of an outpatient (calling a few times a year) was
Rs.419/- whereas the charges were free or negligible.
A new patient - or old patient without records - spends 2
days on observation before the treatment is commenced/
OBJECTIVES(ADVANTAGES)OF THE BRADMA MEDICAL RECORDS SYSTEM:
Hundreds of Hospitals the world over have introduced Bradrna System for
Inpatient and Outpatient Records,with a view to achieve the following
objectives:
* to provide a means of reproducing patient-data speedily,legibly and
accurately on all documents.
* to eliminate writing work of Doctors and Nurses,and thereby maximise
utilisation of their professional skills.
★ to reduce Hospital clerical work in this respect to a minimum.
★ to eliminate checking of repetitive transcription of patient-data.
* to ensure that the Patient's Hospital Number appears correctly on
forms so that:
assimilation of case-data is ensured for future use in case of
patient’s re-admission or for vital case-studies in medicaeducation and research.
all vouchers are properly accounted and charged for/ and 'writingoff because of illegibility of patient-data is eliminated.
* to provide properly assimilated case-data needed for reference by:
-
Teaching & Research Staff
Insurance Companies
Investigation Departments in respect of Medico-legal cases.
BRADMA METAL PLATE SYSTEM FOR MEDICAL RECORDS
Bradma System for Medical Records has been installed by Hospitals through
out the world#for neat/accurate & speedy preparation of following forms
ADMISSION OFFICE:
Patient’s Folder
1.
2. Admission Record & Lists
Index Cards for Medical Records
3.
4. Advice to Enquiry Desk.
WARD:
5. Consultation Record
6. History & Physical Examination Sheet
7. X-ray Requisition and Record
8. Electro-Cardiogram Record
9. Neurological Examination Record
10. Diabetic Chart
../2
: 2 :
Laboratory Reports for:
- Clinical Pathology
- Microbiology
- Biochemistry Laboratories etc.
12. Operation Authorisation
13. Operation Record
14. Request for Blood & Blood derivatives
15. Anaesthesia Record
16. Oxygen Consumption Record
17. Doctor’s Orders
18. Temperature and Pulse Rate Chart
19. Nurses’ Daily Report
20. Physiotherapy Record
21. Midnight Census Sheet
22. Discharge Slip & Certificate
RECORD OFFICE
23. Daily Discharge List
24. Statistical Analysis Sheet
11.
The basis of the Bradma System is a simple one-piece recording unit on
which facts and figures can be embossed for complete or partial reproduc
tion as required. One piece plate is prepared for each patient and on
it is embossed with the following data:
1. Hospital Number
2. Name of Patient
3. Age,Sex & Marital Status
4. Occupation & Civil Status
5. Medical Records Code
6. Address of Patient
7.
Father1s/Husband’s Name &
8. Name of Attending Physician
:
Occupation
9. Date of Admission
10. Deptt.and Ward to which
admitted
12. Income of Patient £tc.
11. Bed & Diet Rate
After printing the first set of Forms 1 to 4 at the Admission Office,the
plate along with the Patient*s folder is sent to theWard. In the Wards,
the plates are filed in Wooden Trays with compartments indexed with the
Bed Numbers. These plates are used on the Bradma Small Hand Printing
machines in the Wards to print the documents 5 to 22.
In due course/when the patient is discharged/the plate is sent to the
Medical Records Office/where Daily Discharge Lists and Statistical
Lists are prepared on the Bradma Printing and Listing Machine.
Finally/ when the plates have served their purpose/ they are blanked out
and re-used for new patients. This can be done 3 or 4 times.
The following are the advantages which will be gained with the introduction of the Bradma Medical Records System.
1.
Records will be prepared at least 5 times faster than by manual
methods.
2.
Records printed from the Bradma Plate will be 100% accurate.
Records will be typewritten and as such perfectly legible.
Valuable time of Doctors and Nurses will not be wasted in band
writing details(at a recent study in one of the hospitals in
Bombay/it was found that a patient gets an average of only 2
minutes of the Doctor's time).
3.
4.
: 3:
5.
Cross Indexing will facilitate tracing of previous records in the
shortest possible time. This will be very helpful for referring
to the previous medical history of the patient and treating him
more objectively.
6.
Installation of Bradma Automatic Selector Machine will enable
compilation of Medical Statistics.
7•
Bradma Medical Record System will prove invaluable for Medical
Research.
8.
Correct coding will facilitate correct assimilation of all
chargeable records and therefore maximum billing and minimum write
off because of illegibility.
EQUIPMENT CONFIGURATION;
Admission Office; One or Two-Model—1620(Depending upon the number of
admission per day) One Model-1210 and One Printing
and Listing Machine.
Wards:
One Model-1210 each.
PARTIAL LIST OF BRADMA USERS
i)
CMC Hospital/ Vellore
ii)
CMC Hospital/ Ludhiana
iii)
iv)
Jaslok Hospital/ Bombay
v)
vi)
vii)
viii)
Jawaharlal Nehru Institute of PG Medicine/ Pondicherry
Institute of PG Medicine & Research, Chandigarh
Holy Family Hospital/ Delhi
Safdarjung Hospital/ New Delhi
Calcutta Hospital & Medical Research Institute/
Calcutta.Eastern Railway B.R.Singh Hospital/Calcutta
ix)
x)
Shree Chitra Tirunal Medical Centre/Trivandrum
xi)
Wanless Hospital/ Miraj
xii)
Tribhuvan University Medical College/ Kathmandu/Nepal
etc. etc.
~ raSTEBpAY, TO-DAY & TOWRROW
Sri. 0. Keshava Rao By Former Medical Record Officer, BMC & St. John’s
Medical Hospital College, Ban^lore,
We know that the History of Medical Records run parallel w ith
tie .History of Medicine. We also know that Records are as necessary
for the practice of Medicine as Medications are for the effective
treatment. The History of Medical Records from tie earliest beginings
to the present time, has continued unbroken even though greater prog
ress has been made in some periods than others.
The earliest records were primitive in form and very different
from the present Medical Recordsthat is, like outline figures found
in the caves of Old Stone Age etc* These date back to about 2,5qO B.CT.
But these served to record the Medical achievements for later generations,
s. As the time went on, Medical Records became more detailed
and improved also. The Physicians of Greece, Rome & Egypt etc. itvrote
more treatises on Medicine ^nd Surgery. The most valuable ancient
Medical document that has come down to us are EDWIN SffiTH BAPYRllt)
(Surgical treatise) aid GEORGE EBERS PAPYRUS (Medical treatise) .
appears to have been written about 1 600 B.C* and 155O'B.C. respecti
vely. These are now in possession of the NEW Y)RK ACADEMY OP MJDICINE.
In the 19th Century, a new hospital at Massachusetts, Bo ston, was
opened in 1821, a Medical Record Librarian was appointed for the first
time and the hospital kept records in Polio Volumes of size 18" : c 12"x
2^” the...weight of which is approximately 5 Kgs- still stated to be in
good condition. Notable attempts were made to uplift the Medical’
record maintennaree during 2oth Century i.e.. starting of Medical
Record Deptg.in teaching and non-teaching hospitals, uniformity of
keeping records and person to be incharge of the records, stadanrdization of hospital, training to Medical Record Personnel.
i:u
It was thought that World-wide participation of Medical Record
Personnel would bring about greater and .more rapid advance s in the
establishment of International standards, the compilation of statistics
that could be used for International comparisons, as well as disease
classifications that could,.be adopted on the International bases* The
first International Congress ine Medical Records was held in Lpdon.
in 1952 and thereafter in various other countries.
In UNITED MNGD3M by beginning of 2oth Century, there appears
to have been a more vigorous and wider acceptance that the purpose and
uses of accurate and complete ’LCASE PAPERS” were manifold. If good
and accurate records existed, it was due to insistance of individual
doctors, or group of doctors, or the entire medical staff of an
institution, who wished to make use of them for a specific personal or
collective interest of their o^n. At that tine, the doctor was not
obliged to write up his findings ard intentions inrespect of each and
every patiert. There was gradual change in the first years of
Century.. An ever increasing population meant ever increasing
:
2
:
demands on Medical Laboratory, Nursing and Technical services.
Clerical assistance was given - but they were not trained - therefore
not always with good results. •
Another problem was reluctance on all sides to provide space.
It meant to the ordinary mind - the record^ had fulfilled their purpose
and therefore could be dispensed with. But a.few hospitals, in U.K.
preserved their records in some formj practice being to hind them
annually, either alphabetically by patients' name, Chronologically
by date of admission or under the name of treating doctor. Bor many
years, the Suaff of affairs was that the clerical staff provided were
untrained, inadequate space, unsuitable equipment etc*
After Igi 4- I9I8 -war, need for ad minist rativ e and clerical assist
ance was felt by doctors as they Wanted to study their new techniques
in fields calling for long term followup, such as, Orthopaedics, T.B, ,
Cancer etc*-' This was probably overlooked.- At the end of find.. World-,
War 1939-1945, the demand was again m'de the Medical '!taff. As a
result a new profession "MEDICAL RECORDS" cane into, being and steps
taken for proper and methodical maintenance of Records*
In INDIA, Christian Medical College Hosjpitai, Vellore was first
XVI
*"
•
hospital to start the Medical. Rec ord Dept in 1900 in an organized
system. Training of Medidal Record Officer^and Technicians was
started in C.M.C. hospital in 1 962 *
A number of Committee were
appointed by Govt.of India frontime to time, to go through the need
for maintaining t he Medical Records. The Jain Committee specially
brought out the importarpe of keeping good records in a teaching
hospital under the guidance of the MediCal Records Officer.
In KARNAJAKA - patients records used to be maintained in short
form-in single or double follscap. sheet forms called Medical Case
she t/Surgical case sheet* .These were bound in heavy volumes Surgery and Medicine, and were preserved. The Medical Records in an
organized pattern was started in the Combined hospitals attached to
the Bangalore Medical College, Bangalore in January 1972, as an
exp a? im eat ah measure, although a begning has been made earlier in the
yeax^1_965 ~
without much results. Medical Records Technician
training was started at Ban^lore Medical College in June 1977.
Also, a vocational course - P.U.C. Diploma . M.R._T. was started by
the Directorate of Vocational Educat ion in Karnataka, Bangalore;
the course being conducted by a Junior College -. ith the hospital
assistance, at three training centres viz., Manipal, Gadag and
_Davangere. The private hospital had the Medical Record Depts prior
to this*
• -X...
:
3
.j
TO -DAY
In many of the private hospitals, the system of maintenance of
Medical Records is on scientific line and are used freely by the Decut ors
Administrators etc, for various purposes. As regards the Govt •Mod ical
Institutions in the State and some of the private Institutions, fedic a j,
records are not maintained in Scientific way. Computerization ana
I
Microfilming of Medical Records have been introduced in very few
institutions. Most of the Govt.Medical Institutions do not maintain
Medical Records for the Out-Patients. An Out-patient ticket is is <3.1 ed
to patient, wherein the history, investigations and treatment given is
recorded briefly. The usual tendency of people is that they keep 1 h.
O.P. Chit trill they get well and then throw it. Some times, even., for
a Second visit, the O.P. Chit is not found with the patient. This not
only increases the number of Ne^ patients, the work of the Doctai? in
In
re-examinat ion of patient, re-invest! gat ion etc. but also delays proper
treatment to the patient.
The plight of the patient win be nore in
the case of Medical legal cases. Each Institution hasits own farms
different - sizes etc* Proper collect ion of case-records, drawal 01'
statistics and proper filing is rot there. The statistics furnished
these institutions may not also be very accurate. Since there is no ~
^^i^PtatJDo£to_rs-axd—other staff make entires in the cape records
in their own way-.-----
I remember that the D. Q.H. S. New Delhi and arranged for a
Seminar on introduction of Common set of forms in the Medical liistitutions of diff i ent level through out the Country and some off jo ia is
from the Karnataka State and Other .“bates has participatou. later,
these forms were introduced in certain institutions in Karnataka on
trial basis. The results are not known — The scheme doesnot appear
to be continuing'.
From the above, the following draw backs could be noticed;1. Want o f trained personnel to maintain and Man the Medical
Records Dept. Even if trained staff are posted, they
withdrawn and utilised for work other than M.R.D.
2. Want of Proper Equipment, forms ard Stationery.
3. Ifent of sufficient space for the Dept.
4. lack of proper planning of the dept. Uniform Rules and
Regulatio ns.
5. lack of strict insistance on the Medical, para-medical
and other staff connected with the treatment of patient s
to record their findings etc, in the Medical Records
pro mpt ly . ..
6. lack of inspection regarding the proper working of thfe
Depts and a Co-ordinator to Supervise andGuitfe.
. ».C4
.....4.
:
4
:
We all know that a good Medical Record is not the product of
the Medical Record Department alone, but it is the combined efforts
of all those who are concerned in the treatment of the patient from
admission bo discharge viz., Doctor, Nurse,'Radiolo gist, para-Medical
personnel and others.
. TOMORROW
Medical Record Depts, need be established inteaching and Major
hospital in the first instance and. then extended to District Hospitals,
TaluQ hospitals, Primary Health Centres etc.
Trained staff sufficient to ten the work load of the department
should be made available to work in:the deparmtnet in scientific way.
Withdrawl of the staff sanctioned and posted t? the M.R.Dept. OR
Utilization of their services in other dept^. should be stopped,
X
this deprive the Medical Records D$pt. from turning out its legitimate
work. AU these thirigs happen because the work turned out by the
Medical Records Dept , is'not known to nany of the personnel in other
depts. Therefore, it'is necessary that the personnel .working in a
hospital should be aware of the existence of a Medical Record Dept
and its functions. It would be better if a Orientation Programme
for every new c ommer ( i.e. Medical Personnel, Nurses and Para Medical personnel etc ) to the hospital is there, so that he/she
could understand DOs and DON’ts of Medical Records in that hospital.
There need be latent eluipmaits and also furniture, at least
Calculators, Index cabinets, steel racks heavy duty staplers, steel
almirahs, typewriters,5 duplicating machine,’ Zerox photo copying machine,
a^Vacoum cleaner., wooden or steel tables and chairs, side racks,
sorting table etc. in the dept. Provision of Computers and Micro
filming equipment will be to the advanbage.
’
1
’
,
.
—
*
’
______________________________________________________ ____________
____________ __________________________________________________________ _
Medical Record forms are used as an essential tool in the
care of apt lents . They 'Will assist in prividing and transmitting the
aggregate information on the individual patient in a .stardard pattern
to any member of the hospital staff concerned with^the welfare, of the
p atient. printing and supply of forms should be properly regulated
Wastage of forms by using them for the
and the ..forms standardized.
purposes other than t ley are meant for, should be prevented.
Stationery also should be na&e available to the Medical Record
Dept in sufficient Quantity.
STAGE for tie storage of Old and current records faces
Many do not realise importance of filing O^d
grave problem,
records
■
a
a
: 5 i
and their retrival and also their safety. Records, as wen all know,
are usually preserved for three purposes: viz.
1. To meet the needs of patients
2. For Medico-legal purposes
3; For use of Doctors for writing scientific papers^ for
writ irg dissetation and for Research#
Proper palling made at the time of starting the dept and fixing the
retention period for various types of records, Co mputerizat jon dnd
Microfilming win reduce the burden of storage to a great extent
Fixation of retention period for Medico-legal cases and orders
regarding acceptance of Microfilmed records in Courts would go a
long way in solving space problem.
Training of personnel as Medical Record Technicians, and
Medical Record Officer ( B.M.R. Sc) need to be introduced to meet the
demand fi>r the trained personnel to Man the Medical Record Dept
sanct ioned.
Rules and regulations regarding functioning of the dept,
writing of case records by doctors, nurses etc, and sending the case
records of patients after discharge to the Medical Ibcords, tie Method
of filing them so as to retrive them at a moments notice, drawing aid _
maintenance of statistics out the Medical records for various purposes
need be there, and be strictly adhered to. There need be a Medical
Record Committee andfitedical Audit Committee to enrishthe value of
records which will deal with matters of Medical Record maintenance
and their duality.
?
The Inspection Committee of the Indian Medical Council and
the Universities need make it a point to inspect the Medical.
Record Depts# When they inspect, the Medical College hospitals to
see the quality of records and see whether ..they meet the need of
Medical education and Research; if necessary by enlistirg a senior
Medical Record Officer in the team of inspectors.
To ensure that all these are followed, there need be a representation in the State Directorate, a post of Deputy Director
(Medical Records) to assist the Director and Government Pto pl^n,
develop ad Co-ordinate the Medical Record Services at the Stat e
Thispost need filled in by promotion of Senior Medical Records
Offic er.
Lastly, there need be Medical Record Council for tie 'Country,
wherein all the Medical Record Personnel should get registered
before they practice the piogession, just as on the lines of the
Indian Medical Council and Nursing Council*
Thanking you.
Medical Audit
.bR- s ev kAKrefl
Medical audit is a method of objective evaluation of the
quality of medicare^ by physicians, to detect deficiencies in the
services provided, and to improve attitude. skill and knowledge
of the health care providers, to ensure collective accountability
for quality care.
Objective evaluation is data and information based.
The three sets of data viz. the patient data, the clinical
data and the financial data,
are selected to be desirable,
feasible and affordable. The data collected are analysed and
converted into information. A simple and effective dat.< base
management system or management information system is therefore a
basic requirement of medical audit.
For evaluation of quality, the efficacy, the efficiency and
the acceptability of the services
rendered are evaluated.
The three components of a medicare facility viz.
its
structure, function and outcome are audited.
The audit is conducted by the service providers themselves
i. e. by the treating physicians and the medical administrator,
supervised by a peer group.
The emphasis is on detecting deficiencies in services with a
view to improve attitude, skill and knowledge of the service
providers.
1
Medical audit is to ensure shared responsibility and
collective accountability for quality care.
It
is not
a
fault
finding exercise.
BASIC OR VITAL PATIENT DATA
(INCLUDING SOME CLINICAL AND
FINANCIAL DATA) AND THEIR RELEVANCE
(Conscious and purposeful selection of the data to be recorded)
Name of patient- It is recorded as the personal identifier.
IPD and OPD Nos.- The serial IPD and OPD number constitute the
hospital identifier. Name,
the personal identifier may be common
to more than one patient,
but the hospital identifiers will be
distinctive
to each patient.
Besides,
the hospital
identifiers
are chronological and gives the idea about the patients arrival
in the hospital.
Age of patient-
It
is
recorded to group the patients
clinically relevant age groups such as neonates,
geriatric etc.
into
pediatric,
Age distribution in morbidity and mortality
pattern may provide vital information if distinctive.
Date of admission. date of operation and date of discharge/death-
These provides information about the duration for which a patient
stayed in the hospital.
Average stay of patient in a hospital is used as an indicator of
efficacy of hospital services and also of patient turn over.
Decrease in average pre-operative stay of patients
reflects
efficient pre-operative workup and decrease in average post
operative stay reflects lesser complication and infection rate.
Number of one day surgeries performed can also be calculated from
it. Average number of patients discharged per day gives the
2
7-
patient turnover or the patient load.
Percent bed occupancy is calculated by the following Number of beds occupied (at midnight) X 100
Number of beds in the hospital
It can be calculated for individual ward or discipline.
Percent of bed days utilized is an alternative evaluation parame
ter that can be calculated as follows
Sum of days for which each patient stayed in the hospital X 100
Total number of beds in the hospital X 365
Name of treating doctor/ unit
performance
This is recorded to evaluate
of individual doctor or a unit.
Final diagnosis - This should be entered and codified as per the
ICD Code to render the patient data into valuable and easily
retrievable clinical data. Diagnosis of the underlying (primary)
and antecedent and associated
(secondary)
diseases/ conditions/
disorders should be entered as Diagnosis 1, Diagnosis 2, Diagno
sis 3 and Diagnosis 4. Upto 4 diagnosis should be permitted.
From the aforesaid morbidity and mortality pattern of the hospit al is
easily worked out. The two provide vital primary information for
performance evaluation of a hospital.
Expenditure incurred on the patient-
An entry about
expenditure incurred on a particular patient or the
amount
the
of
hospital bill in the data base, enables cost analysis in term of
various treatment groups of patients.
3
CODIFICATION OF PATIENT DATA TO MAKE
IT RETRIEVABLE,
USABLE AND
COMPREHENSIBLE
The patient data when coupled with codified clinical data about
the primary cause of disease or death and
associated or
antecedent secondary causes, renders the data set into a readily
usable information base for effective management.
International Classification of Diseases (ICD) code is a readily
available low priced WHO publication that provides ready to use,
simple but comprehensive, method of codifying diseases, disorders
and conditions.
The classification is dual axis
classification
using the site and the etiology as the two axes of the disease.
It is thus possible to classify a disease in term of the organ or
part involved and the condition(s)
earlier was purely numeric,
is
causing it. The code,
which
now alpha numeric using an
alphabet followed by 3 digits. The 3 digit core classification is
sufficient for vast majority of purposes. For those who wish to
use a very detailed and comprehensive classification, an extended
3 digit code with a decimal and
further 2 digits is provided.
The ICD code is available in low priced book form. The diseases
can be very easily codified using these books and the index
provided in them. As a matter of fact the core classification can
be easily extracted for use in the wards if desired. Otherwise,
all records of the patient discharged on a particular day should
come to a central palace before become sent to the record room. A
medical officer scrutinises them and puts the codes against the
diagnoses. With approximately 30 discharges every day in a 250
4
•f'
bedded hospital,
the codification does not take more than 30
minutes. And the value of codification is immense
it makes the
data set a valuable base for understandable and reliable obj ec
tive information to be used for decision making.
This provides for periodic mortality and morbidity audit of the
hospital
the basic minimum information needed for monitoring
the performance of a hospital.
From the data set available, the following audit (evaluation)
information can be generated :I. Performance parameters
Patient turnover
- Bed occupancy
- Average bed stay
- Pre-operative stay
- Post-operative stay
- Percent mortality
- Percent morbidity
Unwanted outcomes
* post-operative
* nosocomial
infection
infection
* bed sores
* adverse drug
reactions
* Transfusion reactions
II.
Morbidity pattern
III. Mortality pattern
5
IV.
Specific audits e.g.
* Infection audit
* Tissue audit (negative histopathological reports as
indicator of unnecessary surgeries)
I
* Caesarean audit
To ma,ke the audit exercise complete to the aforementioned data
set, two more data sets are added :-
1. Store
consumption
data. Using
modern
the
method
of
inventory management (store management) consumption cost
of each unit is calculated as part of operative cost.
2. Accounting data.
The above two sets are used in conjunction with the patient data
set for the following :-
- Resource prioritisation and resource allocation.
- Cost audit e.g.
- Hospital overheads or administrative overheads.
- Cost of bed per day (hospital/ward).
- Cost of operation theatre per day.
Cost
of
operations
by
their
types
viz .
major,
intermediate , minor.
- Cost of ICU bed per day.
Cost containment exercise
- By monitoring and preventing post-operative infection
- By shortening preoperative stay
By
monitoring
and
preventing
post-operative
complications
- By monitoring and preventing bedsores.
6
AUDIT
EQUIPMENT
By adopting simple methods of maintaining
(1) a History Sheet
and '(2) a Log Book of each equipment and allocating 10%
the
equipment
department,
a
cost
for
continuous
its
of
user
maintenance
to
the:
and
cost
effective
fault free
functioning of equipment can be achieved.
REVIEW
PEER
the
Periodic
review by a committee of senior
audited
activities
is a desirable
audit.
7
professionals
ingredient
of
of
medical
THE MORBIDITY AND MORTALITY STATISTICS 1991
Diseases
(ICD Code)
Primary
Assoc
Combined
Patients
admitted
(percent)
Patients Mortality
died
as (%) of
(percent) morbidity
I.
Infectious and
parasitic
diseases (001-139)
P
A
C
.1537 (14.5%)
162 ( 1.5%)
1699 (16.0%)
78 (20.4%)
28 ( 7.3%
106 (27.7%
( 5.1%)
II.
Neoplasms
(140-239)
P
A
C
588 ( 5.5%)
35 ( 0.3%)
623 ( 5.8%)
31 ( 8.1%)
3 ( 0.8%)
34 ( 8.9%)
( 5.3%)
P
A
C
263 ( 2.5%)
236 ( 2.2%)
499 ( 4.7%)
7 ( 1.8%)
31 ( 8.1%)
38 ( 9.9%)
( 2.7%)
2
0.5%)
(
11 ( 2.9%)
13 ( 3.4%)
III. Endocrine,Nutritional
& Metabolic diseases
& Immunity disorders
(240-279)
IV.
Diseases of blood &
blood forming
organs (280-289)
P
A
C
105 ( 1.0%)
21 ( 0.2%)
126 ( 1.2%)
V.
Mental disorders
(290-319)
P
A
C
179 ( 1.7%)
42 ( 0.4%)
221 ( 2.1%)
VI .
Diseases of the
nervous system
& sense organs
(320-389)
P
A
C
503 ( 4.7%)
24 ( 0.2%)
527 ( 4.9%)
14 ( 3.7%)
3 ( 0.8%)
17 ( 4.5%)
( 7.8%)
VII. Diseases of the
circulatory
system (390-459)
P
A
C
986 ( 9.3%)
475 ( 4.5%)
1461 (13.8%)
108 (28.3%)
72 (18.8%)
180 (47.1%)
(11.0%)
VIII.Diseases of the
respiratory
system (460-519)
P
A
C
615 ( 5.8%)
125 ( 1.2%)
740 ( 7.0%)
24 ( 6.3%)
21 ( 5.5%)
45 (11.8%)
( 3.9%)
IX.
Diseases of the
digestive system
(520-579)
P
A
C
887 ( 8.4%)
202 ( 1.9%)
1089 (10.3%)
34 ( 8.9%)
19 ( 5.0%)
53 (13.9%)
( 3.8%)
X.
Diseases of the
genitourinary
system (580-629)
P
A
C
1225 (11.5%)
262 ( 2.5%)
1487 (14.0%)
9 ( 2.4%)
14 ( 3.7%)
23 ( 6.1%)
( 0.7%)
XI.
Complications of
pregnancy
childbirth &
puerperium (630-676)
P
A
C
1333 (12.6%)
22 ( 0.2%)
1355 (12.8%)
5 ( 1.3%)
2 ( 0.5%)
7 ( 1.8%)
( 0.4%)
(1.9%)
I
I
XII. Diseases of the skin
& subcutaneous
tissue (680-709)
P
A
C
363 ( 3.4%)
53 ( 0.5%)
416 ( 3.9%)
1 ( 0.3%)
3 ( 0.8%)
4 ( 1.1%)
( 0.3%)
XIV. Congenital
anomalies
(740-759)
P
A
C
193 ( 1.8%)
11 ( 0.1%)
204 ( 1.9%)
5 ( 1.3%)
2 ( 0.5%)
7 ( 1.8%)
( 2.6%)
XV.
P
A
C
277 ( 2.6%)
56 ( 0.5%)
333 ( 3.1%)
37 ( 9.7%)
18 ( 4.7%)
55 (14.4%)
(13.4%)
XVI. Symptoms, signs
& ill-defined
conditions (780-799)
P
A
C
273 ( 2.6%)
40 ( 0.4%)
313 ( 3.0%)
9 ( 2.4%)
15 ( 3.9%)
24 ( 6.3%)
( 3.3%)
XVII.Injury and
poisoning
(800-999)
P
A
C
665 ( 6.3%)
114 ( 1.1%)
779 ( 7.4%)
18 ( 4.7%)
24 ( 6.3%)
42 (11.0%)
( 2.7%)
Not coded
P
625 ( 5.8%)
nil
&
XIII. Diseases of the
musculoskeletal
system & connective
tissue (710-739)
Certain conditions
originating in the
perinatal period
(760-779)
Total Number of discharges
Total Number of deaths
10617 (100%)
382 (100%)
S'
ESSENTIAL INGREDIENTS OF A MEDICAL RECORD
Medial record should contain sufficient information to
I
1.
Identify the patient
2.
Support the diagnosis
3.
Justify the treatment
4.
Document the curse and the result accurately
5.
Facilitate continuity of care among health care oroviders
THE DANGEROUS MACHINES (REGULATIONS) ACT
This is a welfare law to provide protection to farm hands against injuries from farm
implements by mandator.- safety' provisions in manufacture, distribution and use of such
implements. It also provides for no-fault compensation for any injury that may result
from farm implements.
The Act is a Central Act. The State Governments are required to create the stipulated
implementing agency. It has not been done.
As a result hundreds of poor farm hands loose their limbs, scalps and body parts every'
year without even receiving compensation which is their right under the Act.
Medical professionals must insist that the provisions of the Act are enforced to prevent
injuries to their patients and to see that when injured the farm hands receive tneir due
compensation.
f
I
CONSENT FORM FOR MTP
I, the undersigned, Mrs./Miss
of _____ _________
_____
Years
Wife of / Daughter
Aged
Residing at
__ L_
4
Request
Agmittea unJer IPD No.------------------------ ^rrnmatemy^eg^V7
*
(To Sign at a to c whichever is applicable and strike out others)
a.
3
as the pregnancy has occurred as result of failure of the contraceptive techniqu'p of
lUD/oralpills/condom/coitus interrupts/periodic abstinence/tubectomy/vasectoHy/
employed by us.
5
(any other)
(Signature of patient)
in view of the substantial risk that if the child were born it wouid suffer from si|ich
b.
s*
I
(Signature)
c.
as this pregnancy has resulted from my being raped--------(Signature)
in order to prevent a risk of injury to my physical or mental health by reason of rjny
J
d.
actual / reasonably foreseeable environment.
i
T-
physical of mental abnormalities as to be seriously handicapped.
(Signature)
J
s ■
1.
a 1
2.
*
The procedures proposed to be employed for termination of pregnancy and of
anesthesia have been explained to me and I have understood the same.
The risks and possible complications of anesthesia and operation, including the
remote possibility of pregnancy continuing inspite of the MTP proceoure . have been
explained to me.
3.
I also understand that procedures other than the proposed ones or :n addition to tnem
for termination the pregnancy and/ or anesthetizing mav be founo necs^s_ar\°^
desirable and I consent to them/ if the surgeon and /or ithe anesthetist think them
essential and beneficial to me.
&
’
*
(Signature of patient.)
IN CASE OF A
MINOR OR A MENTALLY RETARTED GIRL THE FOLLOWING CONSENT SHOULD BESIGNED)
J
I,
>
7
the undersigned,
Mr.
_residing
/Miss/Mrs.
at
(Full name)
am the nusband/ father/ mother/ legal guardian of------------------------------<narne °f Padent) w o
IS a minor/mentallv retarded and I consent for the operation of Medical Termination of Pregnancy
to be performed on her after understanding the procedure and the risks as stated above.
1
*
(Signature of parent/guardian)
Signed in my presence
(Signature of witness)
S'
Dated :
(Name and address of the witness)
9
S
7-3
I
. Ur..
. ■'jBA
TO RESIGNED BY THE REGISTERED .MEDICAL PRACTITIONER/S
B> one medical practitioner if the pregnancy is 12 wks or less
rwo practitioners if the pregnancy is between 12 to 20 weeks.
I. the undersigned Dr.
after examining Miss/Mrs.
>
(Name of patient)
am of opinion, tormed in good faith, that it is necessary to terminate her pregnancy for the following
reason:a.
I *
I
I
b.
c.
d.
e.
I >
I 4
I
I
>
>
i
i >
4
i
>
ii
J
The pregnancy is the result of failure of contraceptive technique used.
The pregnancy is the result of rape.
Tie continuation of the pregnancy will be a threat to her life.
To prevent grave injury to her physical and mental health.
Tiere is substantial risk that the pregnancy would result in the birth of a child with serious
mental and /or physical defonnities/handicaps.
(Signature with date)
the undersigned Dr
(Med. Cou. Reg. No.)
_
fier examining Miss. Mrs.
(Name of patient)
am or opinion, termed in good faith, that it is necessary to terminate her pregnancy for the following
reason:-
>
i f>
a.
b.
>
I
I
d.
e.
Tlie rregnancy is the result of failure of contaceptive teciuiique used.
The pregnancy is the result of rape.
The continuation of the pregnancy will be threat ot her life.
To prevent grave injur to her physical and mental health.
There is substantial risk that the pregnancy would result in the birth of a child with serious
menta; and/or physical deformities/ handicaps.
>
>
1
J
(Signature v>»itli date)
(Med. Cou. Reg. No.)
a
*
9
I
/
THE INDIAN MEDICAL COUNCIL ACT
Registration provisions, right to practice or licence to practice.
Regulation and control over standard of practice
Medical ethics - what are they ?
Professional misconduct - what constimtes professional miscondut ? How
it is alleged and how is it adjudged ? The Ethics Committee and
procedure.
r
THE MEDICAL TERMINATION OF PREGNANCY ACT
The law perraining to abortion was liberalised by this Act.
The law provides for liberalised conditions for women to seek abortion and doctors to do
it.
Medical termination of pregnancy is now permitted under the conditions stipulated in the
Act.
The stipulated conditions are
a.
approved indications viz. contraceptive failure, congenital anomalies, threat
to mothers life and rape.
b.
approved centre viz. government hospitals and centers specifically approved
by health authorities for MTP after veriricarion of necessary surgical
facilities.
c.
approved doctor viz trained in MTP or a post-graduate in gynaecology and
obstetrics.
d.
approved and certified duration of pregnancy viz. on certifcation by one
doctor when oregnancy is below 12 weeks and by two doctors when it is
upto 20 weeks. NO TERMINATION BEYOND 20 WEEKS
e.
approved form of consent of the lady/girl or guardian when the girl is a
minor.
/
DRUGS AND MAGIC REMEDIES (OBJECTIONABLE) ADVERTISEMENT ACT
4
The law provides for prevention of advertisements in lay press 'and
popular media concerning drugs, remedies and treatment as the same
in tthe
' 'hands
' of" commercial
...
. . unscrupulous persons may prove
minded
.
inducing
to be faudulent, exploitative,dangerous and harmful by
people to self medication.
The definition of 'drug* under the Act is comprehensive and
includes any thing used for diagnosis, mitigation, treatment or
maintenance of body functions or condition.
Advertisements
about
sex
tonics,
menstruation
regulators,
abortions and incurable or intractable diseases (as per the liin)
are prohibited by any one.
The offence is cognizable and advertiser, publisher, printer and
editor are all individually liable.
/
i
Any one who has read or seen or heard such an advertisement chn
lodge a complaint with the police or the court at the place where
he encountered such an advertisement.
.sail
M
THE ATOMIC ENERGY ACT
rcaes framed under the Act, provided for Atomic Energy Regulation Board (AERB)
■escribe safety code and regulation of diagnostic X-ray units in the country.
aarmfui potential of unnecessary' and excessive X-ray radiation far outweighs the
of diagnostic X-rays. X-rays with their potential of causing cancers, genetic
sons and congenital malformations, have to be used judiciously and with utmost
; precautions to prevent harm to patients and others who may receive radiation
:z 2. diagnostic procedure.
for installation and functioning of
sue X-ray units. The state governments/ state health authorities are required to
: recommended regulatory' authority to enforce, supervise and monitor the
need safety' provisions. It has. however, not been done.
aERE has prescribed detailed safety norms
As result, patients, doctors and members of public, and their progeny, pay dearly with
her .r es in form to radiation induced cancers, congenital malformation and other
:er.e’_c defects and disorders.
is ne iuty of medical profession to see that the prescribed safety norms for diagnostic
s are strictly enforced
- Media
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