Professional Documents
Culture Documents
DEPARTMENT
INSURANCE CASES
Life insurance policy (LIC) for death cases
Medi claim policy
Any other insurance claim
· A form has to be filled by the concerned for requesting for the inpatient health record chart(s).
· In case the no. of charts are more than 20 , then at least 24 hrs. to be provided to complete the
retrieval process and placing the tracer card in place of the retrieved health record chart.
· In all MLC and death cases the Medical Superintendent’s written permission is a must to access
them.
· The completed form should be submitted to the MRD. The following details should be provided to
access the chart:
i. IPD#
ii. PNT#
iii. Patients’ name
iv. DOA and DOD
v. Consultant’s name
vi. Reason for borrowing that can be readmission, study/ review, court evidence, research or any
other.
· The chart will be borrowed for 07 (seven) days excluding the borrowing day.
· The borrower with date and time should duly sign the completed form.
· The required health record chart is then provided to the concerned person.
· After the chart is retuned back in MRD and returned date and time is written on the form with the
signature.
STANDARD OPERATIVE PROCEDURES
ISSSUE OF THE MEDICAL CERTIFICATE
The patient / attendant can directly request the treating doctor for issue of the Medical Certificate.
PROCEDURE:
· The concerned treating consultant will issue the required medical certificate on his/her letterhead
and send it to the Medical records Department.
· All the Medical Certificate should be routed through the MRD for the verification of the following
data:
i. PNT# and IPD#.
ii. Patients’ name
iii. Age and sex
iv. DOA and DOD
v. Diagnosis
vi. Operation/procedure
· After the necessary verification of the patient data, the MRD will forward the Medical Certificate to
the Medical Superintendent for the counter signature. It is a mandatory requirement.
· Every effort will be made to provide the completed medical Certificate to the patients / relatives as
soon as possible.
· The Hospital will not take the responsibility of authenticity of a certificate issued without the
verification and counter signature of the Medical Superintendent.
STANDARD OPERATIVE PROCEDURES
DEPOSITING OF THE DAILY DISCHARGE INPATIENT HEALTH RECORD CHART (S)
TO THE MEDICAL RECORDS DEPARTMENT
Patients who are discharged previous night (till 12 ‘O Clock midnight), their health record charts
must be deposited in the Medical Records within 48 hrs.
All discharged health record charts should be borrowed from the MRD and not from the Nursing
Station.
The Nursing Station sister in charge should maintain a register with the following data:
Date of sending the health record charts.
IPD#
PNT#
Patient’s name
DOA
DOD
Consultants name
No. of CCFS.
Remarks if any
· These health record charts are dispatched to the MRD through a Ward Aide.
· The receiving person in the Medical Records Department should sign these details.
· Any reports / documents that come after the deposition of the health record charts should be sent
as soon as possible by the shift in charge to the MRD within 24 hrs. of their receipt.
DEPOSITING OF THE EXPIRED PATIENTS’ HEALTH RECRD CHARTS:
Dispatch of the expired Health Record Charts along with the death notification form both in English
and Hindi should be made within 24 hrs. of the death.
These charts should be placed under the lock and key. And a paper sheet tracer card to be placed
on the IPD# of the chart for future reference.
The MRD should ensure the following particulars:
The death notification form in English and Hindi is complete in all respects.
The concerned doctor has documented death events including the time of declaring the death in the
Doctors’ Progress Note.
· It is mandatory for the MRD to maintain a Death Register which includes the following details:
i. S.no.
ii. PNT/IPD no.
iii. Name of the diseased
iv. Name of the doctor
v. Age
vi. Sex
vii. Address
viii. DOA
ix. DOD
x. Time of death
xi. Name of the procedure
xii. Date of the procedure
xiii. No. of days from the procedure till death Only in computer
xiv. No. of days stayed in the Hospital
xv. Place of death
xvi. Cause of death
xvii. Name of the informer
xviii. Address of the informer
· The original Hindi death notification form must be delivered to the Panchayat Authorities, Jolly
Crant, Dehradun and obtain date and the signature of the receiving concerned official of Birth and
Death registration Office.
· The death details are then passed over to Medical Superintendent’s office.
The arrangement of the documents are to be done from Top to Bottom according to the following
heads:
(Place documented sheets behind the guides)
CLINICAL NOTES
· Face Sheet or final summary sheet
Discharge / expired summary
General Case Notes
Doctors’ Progress Notes in chronological order – admission to discharge
Operation / Procedure Notes
Anesthesiology Record & Anesthetic Sequence
Doctor’s Order Sheet – Post Procedure Orders
Standing Physician Orders
Previous Discharge Summary of HOSPITAL
Transfer Notes.
DIAGNOSTIC STUDIES
Reports (in chronological order)
Invasive
Non Invasive
X-Ray
CT Scan
Ultrasound
Laboratory Medicine
Other HOSPITAL and multispeciality reports.
MISCELLANEOUS
Informed Consent
Consent for Cardiac Procedure
Admission Checklist (Package)
Case Sheet – Patient’s Demographic data
Various other notes, letters/ correspondence etc
Clearance for surgery/procedure
Clearance for discharge
Death Notification Form
Before acknowledging the file, tallying the details written on the register and the file is done. Then
acknowledging is done. Then the details are being entered in the computer to have updated record.
The details are:
· PNT
· IPD
· Name
· Mothers name
· DOA
· DOD
· Address
The color-coding is being done for the readmitted and death patients:
Blue – two times admission
Red – three times admission
Green – four times admission
Brown – five times admission
Light green - six times admission
Pink – Fourteen-time admission
Black - death
The re - assembling of these files are being done in the chronological order according to the
following criteria:
1. Clinical
2. Diagnostic study
3. Nursing
4. Miscellaneous
Then it is being entered in the daily discharge /death register being maintained by the Medical
records Department. This register is being maintained to monitor, follow N’ control that all the
discharge and death files are being received in the MRD. Then the name of the patient and the IPD
no. is written on the file with blue and with black for the death cases. The health record charts
which are not received from the respective Nursing Stations , a Email reminder is sent for it and a
copy to Asst. Nursing Superintendent (Ms. Thankham Gomes).
A deficiency check list (Quantitative Analysis) is being prepared and a summary of
incomplete/complete files data is prepared consultant wise. Filing is done according to the IPD no. A
daily report is made and is submitted to the Medical Director.
If ever any Doctor wants any file for review then a form is being signed by the concerned person
and that file is being given to him/her.
Linkages for the re – admission patients are being done side by side. Death register is also
maintained separately for notification to the Municipal Council Dehradun, which includes the
following details :
· S.no.
· PNT/IPD no.
· Name of the diseased
· Name of the doctor
· Age
· Sex
· Address
· DOA
· DOD
· Time of death
· Name of the procedure
· Date of the procedure
· No. of days from the procedure till death Only in computer
· No. of days stayed in the Hospital
· Place of death
· Cause of death
· Name of the informer
· Address of the informer
And this is maintained in the computer also.