Mr. Shihab Hamed Ali Al Subhi, Dip in Medical Records (On study leave)
Mr. Sultan Saif Bader Al Rubaiey, Dip Medical Records, Actg Head
Mr. C.R. Bhat, BSc, DMRSc, Dip in Personnel Management, Medical Records Officer
Mr. Ayoob Al Balushi, Dip Medical Records, Supervisor, Registration, Admissions & Appointments
, Supervisor, Records Processing
Mrs. Azza Al Rawahi, Dip Medical Secretary, Supervisor, Medical Coordinators’ Section
Mr. Ravi Gnanakumar, Statistical Officer
Medical Records Clerks: 32
Medical Coordinator: 29
GENERAL NATURE OF WORK CARRIED OUT
The Hospital has established a paperless environment for clinical documentation. The patient’s electronic medical record, stored permanently on the computer, contains the patient’s demographic particulars, administrative and clinical details of all episodes of outpatient, inpatient and emergency care, procedures, investigations, and reports.
To render efficient services, the MRD is organized into 4 sections: Registration, Admissions and Appointments; Medical Records Archive; Records Processing and Statistics; and Release of Information. The MRD is responsible for deployment of medical secretaries to all the clinical departments.
Eight Registration counters have been set up at different locations (MRD, OPD, Adult A&E, Ped A&E, Delivery Suite, OBGY Clinics, Oncology Centre and Radiology Department). Each patient, treated on an outpatient or inpatient basis, is registered and assigned a unique hospital number following the unit record system (one record, one patient, one number). Further outpatient visits are registered clinic-wise in order to get on-line information of outpatient attendance. All booked and direct inpatient admissions are registered and referred to respective wards. Inter-ward/inter-service transfers and discharge of patients are updated by the nursing staff promptly in the computer system. On an average, About 75 patients are admitted per day. Daily mid-night census is taken to verify and ensure the accuracy of information about the ward-wise as well as service-wise occupancy.
The computerized appointment system provides efficient outpatient services for referred patients from other hospitals. Requests for appointment are received centrally from MoH Hospitals/Health centers linked through e-referral system and through fax referrals from all other referring institutions. All such referrals are forwarded to the respective clinics to vet the urgency and justification of the request. The appointment confirmation particulars are communicated online system and for others are faxed back.
In the medical record archive, files are stored following terminal digit filing system. Presently, around 3,50,000 records are maintained in the primary filing area and around 8000 death case records are stored in the secondary filing area. Computerized track-out/in system is followed to achieve control over the movement of records. Efforts are being made to computerize all aspects of clinical documentation to achieve total paperless environment. Forms which are yet to be computerized are scanned and archived separately.
The Records processing section reviews all patient records for completion. Thereafter the diagnostic conditions and operations/procedures pertaining all IP, OP & A&E encounters are coded and indexed by the qualified coders as per the WHO International Classification of Diseases (ICD-10).
Release of information deals with issue of birth certificates, death certificates, and medical reports. This section, after scrutinizing the requests for its authenticity, refers the file to the concerned doctor for preparing the medical report. Certificates/reports are issued on payment of prescribed fees wherever applicable.
Statistical reports are reviewed for their accuracy and important reports are made available in the computerized Management Information System module. Data on deaths are submitted to the Ministry on a monthly basis. Infectious diseases like HIV etc. are reported to the concerned authorities in the Ministry.
To improve qualitative aspects of documentation the Medical Records Department has taken the following initiatives in the recent past:
- Liaison with clinicians and the computer department to develop and streamline the various modules of the computerized clinical information, including development of a paperless medical records system.
- In coordination with Internal Medicine Team A, a study was carried out to demonstrate the inadequacies in writing death notification, following which sessions were held to train junior doctors in improving the quality of such documentation.
- Several audits were carried out jointly with clinical departments such as 'Documentation of Cause of Death' statements, 'Death Notification', and 'Documentation of Diagnostic Statements on Admission - Discharge Record', etc.
In order to streamline the type, methodology and quality of data generated by various MoH healthcare facilities and thereby ensure proper reliability and validity of statistical information, the Health Information Department at the Directorate General of Planning, MoH-HQ has overseen the appointment of Statistical Officers in various Regions.
The Statistical Officer compiles data in the format prescribed by MoH-HQ and submits the same on a monthly basis. Beyond responding to other data queries requested by MoH on a random basis, he also fulfils the Hospital's own requirements for data for audit of on-going activities and special studies.
EDUCATION AND RESEARCH ACTIVITIES
- The MRD holds periodical orientation lectures on Medical Records Systems for newly joined doctors, nurses and all other staffs.
- The MRD regularly conducts lectures on Documentation Requirements for OMSB resident clinicians.
- The MRD has been collaborating with the MoH-HQ in imparting didactic and practical training to Medical Record technicians and Asst. Medical Record technicians.
- The MRD also provides assistance to clinicians in conducting research/study projects by providing information as well as medical records.