Medical records department (MRD)
Every file complete, findable and released only on record.
When a patient is discharged, the file goes to medical records as a checklist the system has already filled in from the stay. What is missing is listed against the doctor who owes it. Requests for copies from patients, insurers and courts are logged, approved and released with a name and a date, and the paper that still exists is scanned into the same patient record.
| File | Discharged | Doctor | Deficiency | Since |
|---|---|---|---|---|
| IP-0884 | 12 Nov | Dr. A. Mehra | Complete | 6 h |
| IP-0879 | 11 Nov | Dr. V. Sethi | Operative note unsigned | 31 h |
| IP-0871 | 10 Nov | Dr. R. Bose | Consent form not on file | 52 h |
| IP-0866 | 10 Nov | Dr. S. Rao | Complete | 22 h |
- Patient copy IP-0841Released 11 Nov
- Insurer · Payer B IP-0852Approved, to release
- Court order IP-0790 · MLCAwaiting approval
What changes on the floor
Lab links, records and oversight. Included in: Hospitals, Hospital groups.
Files reach the record room incomplete and stay that way
Each discharged file is checked against a completeness list. Deficiencies go to the responsible doctor's worklist and stay there until closed.
Finding an old file takes a morning
Every visit and admission is on the patient's record by hospital number, with the scanned case sheet beside it. A file is found by searching, not by walking the racks.
Nobody can say who was given a copy of a record, or when
Each request is logged with who asked, why, who approved it and what was released. Medico-legal files are marked and released only with approval.
Accreditation asks for indicators the hospital compiles by hand
Admissions, discharges, deaths, length of stay and chart completion within 48 hours come from the records themselves.
Rules the software enforces
These are checks in the product, with the reason shown to the person at the screen.
- LockedA signed record
Notes, surgery records and discharge summaries cannot be edited once signed. A correction is a new entry that refers to the old one.
- RecordedEvery release of a record
A copy leaves the hospital only against a logged request, with the approver's name and the date of release.
- CheckedA file is complete or it has an owner
Every deficiency names the document that is missing and the doctor or department responsible for it.
What is in it
Chart completion
- Completeness checklist filled from the stay
- Discharge summary, consents, operative notes and medication chart checked
- Deficiency worklist per doctor and department
- Files completed within 48 hours of discharge, as a measure
The file
- Every visit, admission, order, result and bill by hospital number
- Scanned case sheets and outside documents on the same record
- Diagnoses coded in ICD-10
- Medico-legal files marked
Requests and release
- Requests from patients, insurers, courts and other hospitals
- Approval before release
- What was released, to whom and when
- Retention period by type of record
Statistics
- Admissions, discharges and deaths
- Average length of stay and bed occupancy
- Discharges by diagnosis and department
- Medico-legal case register
Questions hospitals ask
Do we still need a physical record room?+
Paper that the law or your policy requires you to keep still needs a home. What changes is that the working copy is on the patient's record, so the racks are opened far less often.
Can old paper files be brought in?+
Yes. Old files are scanned and attached to the patient's hospital number, so past admissions sit beside new ones.
Does it help with NABH documentation?+
The indicators that come from records, such as chart completion and length of stay, are reported from the system. The hospital's quality team remains responsible for the accreditation itself.
See medical records on your own setup.
A demo is set up with your departments, bed types and tariffs, so you see your hospital and not a sample one.