Student Dissertation

Agency : Medical Records Department; Documentation Compliance; Information Management System; TAT (Turnaround Time)

Objective : • To study the existing system of documentation of the medical record department. • To identify the bottlenecks in the existing system of medical records. • To provide recommendations to overcome the bottlenecks and implement the changes required in the medical records department.

Methodology : • Study Design- The type of Research study was Descriptive Study. • Location of the study- The location of the study is Monilek Hospital and Research Center, Jaipur. • Duration of the study- The study started from February 2018 to April 2018 (3 months) • Study Subject- The subjects under study were Doctors, Nursing Staff, Medical Record Department Staff of the hospital. • Method of Data Collection- The data was collected through the Primary and Secondary sources- o Primary Data Source o Medical Record Audit Checklist, Self-Assessment Toolkit of NABH, Direct Observations o Secondary Data Source o Medical Records Issue Register, Medical Record Retrieval Register • Data Analysis- Data Entry and Analysis has been done in MS-Excel.

Findings : The observed findings of the study- 1. Out of 100 medical records or files that I have used for my study before implementing the changes in the MRD of the hospital, 27 files reach to MRD within 24 hours of discharge, 42 files reach to MRD within 48 hours and 31 files reach to MRD in more than 48 hours of the discharge of the patients. 2. The average time recorded for the retrieval of the file was found to be 32 MIN before changing the process flow and changes done in the MRD and after the changes, it reduces to 14 min. 3. Before implementing a new process in the MRD, no. of complete files by nurses are 53 whereas after implementation the number increased to 91 and before implementing new process incomplete files are 47 and after implementation, it reduces to 9. 4. This graph shows that before implementing a new process in the MRD, no, of complete files by doctors are 42 whereas after implementation the number increased to 84 and before implementing new process incomplete files by doctors are 58 and after implementation, it reduces to 16.

Recommendations : Medical Records are an essential part of a patient’s plan of care, therefore, it is very important to complete the medical record. After understanding and analyzing the whole process, the new process in the MRD was implemented which results in remarkable improvement in the working of the MRD of the Hospital. The number of files reached to MRD within same day increases after changing the process flow in the department. The documentation compliance in terms of completeness by nursing staff and the doctors also showed noticeable improvement and by the implementation of the Medical Record Tracer card and proper labeling of the racks in the MRD, it becomes easy to retrieve a file as and when required by the management, doctors or by the patient relatives.