MEDICAL RECORDS

The Department of Medical Record at Sri Sathya Sai Institute of Higher Medical Sciences, a 300 bed hospital, commenced functioning from the inception of the hospital on 22nd November 1991. For the past twenty-six years under the Divine Guidance of Bhagawan Baba, the “Medical Records team” has been carrying out its responsibilities towards patient care with love dedication and commitment.

The department admits on an average 45 to 50 patients / day. We have an admission counter where patients are counseled and admitted to the various specialties. The outpatient files are maintained at the outpatient departments only. Only admitted patient files are maintained at the MRD.

Electronic Health Records (EHR) was started in our Hospital on November 23, 1991 in a small way using the help of IT Department. In the year 2007, Enterprise hospital information System was introduced. Enterprise Manager a totally web based software from DXC Technology India Pvt. Ltd (DXC) was introduced. It has the entire standard operating procedures of any HIS built in. We use this software to maintain an EMR, with personal & all the clinical details of the patients.

Patient search and retrieval is based on various parameters like name, patient ID, age, gender, district, city, state, country and now even aadhar number. We can also search the database on various clinical parameters like Diagnosis based on ICD codes, procedure codes, anesthesia type etc. EHR searches the given combination of parameters, retrieves the relevant data and displays it.

All the details right from patient registration at the OPDs to the final discharge in the wards is totally computerized. It includes, at the outpatient consultation reports, internal department’s references, Lab & radiology test & procedure ordering, result reporting of the orders/tests, appointment scheduling, OT scheduling and inpatient management. It also includes many features / modules like Nursing management, pharmacy, dietary management, medical records and care plans.

Right patient right procedure/treatment: In SSSIHMS doctors will first screen the patients who require workup and treatment. Only those patients who are treatable in our hospital will be selected by the doctor. The rest of the Registration process applies to only these selected patients. The photo of the patient is captured during registration. During consultation, when the doctor sees the patient and places order or writes consultation notes, he will verify identity of the patient with the photograph in the ehis system, thereby ensuring right patient right treatment. Similarly in the procedure unit or labs/radiology the staff verifies the identity of the patient before doing any test/procedure on the patient by matching the patient with the photo in the system.

Inpatient: At the inpatient level, Admission record, initial assessment of doctors & nurses, Ward Management, Operation record and even nursing care plans. The ehis covers all the activities right from admission to discharge of the patient after treatment. It includes, Ward management, Diet management, History and physical Examination (Initial Assessment by Doctor & nurse). On day to day basis all the medications prescribed, Nursing Care plans based on doctor’s orders and nurse assessment will be done on system. OT scheduling, Surgery / procedure details will be entered as and when required. Finally the discharge summary is also recorded on the system.

We have made 80% of our Health Records from paper to Paperless with the help of IT department using electronic hospital information system. Only those that are required by law are maintained on paper. We also scan and update these hand written forms to complete the patient record on the system.

Standards & Procedures: We maintain standards in all our procedures and protocols in MRD, being an NABH accredited institution. The whole accreditation is monitored using 75 indicators which span clinical and managerial aspects of health care. They are fully maintained on the system by software which is developed in house.

We also have a fully computerized deficiency check & closed file auditing program. For each form deficiency details are captured on system. The details entered are whether the form is Non-Compliant or partially compliant or fully compliant. We also capture which doctor & nurse are responsible for the deficiency. We scan all the pages of the patient file once it is received from the wards. The deficiency program is linked to the scanned images of the file to display the deficiencies. Remarks also can be captured in this program for each form, describing the deficiency. Then the MRD staff processes the deficiencies and gives the following information:

• No. of Noncompliance, Partial Compliance, full compliance by Specialty, within specialty by Doctors & nurses
• Compliance trend analysis for the past 3 months can also be done.

Statistics: We generate demographic and social statistics like, Age wise, Gender wise, District wise, State wise, Distribution of surgeries, admissions and procedures. We can also generate statistics for Doctors & Nurses which can be Diagnosis wise or surgery wise. Online Reports stipulated by government are also submitted by us monthly on a regular basis.

Digitization of physical Records: We have scanned all the medical record files from Day 1, 21-November 1991 till date. Around 240000 files have been scanned and it constitutes 6 TB of images.

The medical records of all discharged patients are now scanned as files arrive in MRD using the high speed duplex roller scanner (80 pages/ min) and archived into NAS storage. We are also storing these data on cloud storage as a backup.

These scanned files can be seen online by doctors at the opds for reference when operated/treated patients visit opd and also for study purposes. They need not physically borrow files at all from MRD. This minimized the chance of damage or loss of physical patient file.

At the medical records department in SSSIHMS, we ensure:

• As much as possible all MR forms are computerized and are entered in system as on date.
• All the papers of each admission in the patient file is digitized soon after discharge. All files are available in digital format for use, on permission, by the authorized users.
• All discharge files are fully processed for deficiencies, captured in system and analyzed for tracking quality of care and documentation.
• All statistical analysis are provided by the department to the various committees like Medical Audit committee, Quality assurance committee etc. We also provide statistics and analysis of outpatient visits, admissions, surgeries, procedures and any other report required by the Administration.
• Total confidentiality of records is maintained by digitization. A safe backup of digital records is also kept on the cloud.