Highlights of the Department

Objectives of the department:

6 Medical Records System:

Medical records are permanent form of information preserved about a patient or client. It is the account compiled by physicians and other health care professionals of a variety of patient health information such as patient's assessment findings, treatment details etc. This information is preserved to make accessible to users for health planning, research and education. Good record and information management system are essential to effective and better clinical and hospital management.

Medical records are vital means of communications between patient care providers and valuable teaching tool for house staff. The good medical records form the basis of many places of administrative efficiency. It provides the management with information necessary for decision making and taking action in regard to utilization of resources, planning for administrative control. It also furnishes documentary evidence of adequacy and quality of patient care.

Objectives: To keep patients' details with aims

• to conduct prospective, qualitative and operational research
• to ensure high quality patients care
• to provide referral care
• to help administrative and financial management
• to facilitate training of the institute
• to provide necessary information for medico-legal purposes

Strategies:

• Computer assisted clinical data base
• Computer network will be used for patient data entry
• Relevant information regarding patient's care will be printed in prescribed forms
• ICD 10 will be used subsequently in Medical Record System
• The Medical records of the patient will only be read by those directly involved in his/her care.

The department has the potential to achieve departmental objectives in terms of training, research and community activities. In addition to community research, the department will organize and conduct clinical research on child and mother health and nutrition in collaboration with the clinical departments-Pediatrics and Obstetrics and Gynecology. Thus the department of Epidemiology and Biostatistics will contribute much in improving the health and nutritional status of children and mothers of the country.

Central record section:

It initiates documentation of patients, maintains records of patient admission and discharges and also collects documentation after discharge. It keeps an updated information of bed state of the hospital wards.

• Assembling : Arranging the medical records in a strict chronological order.
• Quantitative Analysis : Checking the component parts of the records and analysis the contents for completeness accuracy and adequacy with the help of a "deficiency check list."
• Completion of Incomplete records : This will be done by the concerned physician/Nurse/ unit/department
• Coding : According to the International classification of diseases.
• Indexing
• Analysis and statistics : Preparation of monthly hospital abstracts and annual statistics.
• Reporting : Reporting of the communicable disease, births and deaths furnished to the hospital administration, municipalities, and health authorities.
• Numbering and Filing.
• Storage : Protection and secrecy of medical records.
• Release information and documentation of the sanction of the authority.
• Improved services to users with facilities for prompt retrieval.
• Establish user and scientific oriented documentation of the records, photographs,
  negatives etc.