Medical Record Department & Its Quality Indicators

Are you pursuing a Diploma or Degree course in Medical Record Technology

If yes, then this information is for you.

The Quality Indicators are the guidelines which are used to improve the quality and the performance of the hospital towards patient care. Medical Record Technicians (MRT) are advised to follow the indicators laid down by the National Accreditation Board for Hospitals & Healthcare Providers (NABH) and other national bodies involved in hospital quality improvement in India. NABH is the constituent body of Quality Council of India (QCI) which provides a quality accreditation to the hospitals / diagnostic centres on certain parameters. NABH was established in 2005 to run an accreditation programme for healthcare organisations in India; the NABH-certified hospitals are well recognised at national and international levels for providing quality patient care.

A Medical Record Department (MRD) is built within the hospital premises to maintain patients’ medical records as per the indicators laid down by NABH. These indicators help to improve patient care and enhance the process of documentation. While the Quality Indicators help maintain the discrepancies’ checklist through which the hospital staff such as doctors, nurses & the paramedics can improve their performances, elevating and maintaining the quality standards, simultaneously.

These are the quality indicators followed by hospitals:

  1. The percentage of medical records in which the Patient Care Plan is documented – It is the calculation of ‘patient care plan’ in which the treating doctor explains his/her condition to the patient or attendant/s. All the treatment details should be documented and countersigned by the treating doctor, which is required to create the deficiency list as to improve the quality of care and settle the record. It further acts as a supporting document in legal cases, if any.
  2. The percentage of medical records maintaining a Nursing Care Plan – It is the percentage of a Nursing Care Plan and it varies from patient to patient going by the diagnosis made by the treating doctor. This document is referred as the ‘nursing efficiency’ to find the diagnosis according to doctors.  If the medical records file has a nursing note without a plan of care, then, there occurs a discrepancy which becomes mandatory to report to the quality team for improvisation; and it should be signed by the assigned nursing staff.
  3. The percentage of medical records having incomplete / improper consent – Every Inpatient file has an informed consent form which establishes that the patient knows about their illness, disease prognosis and hospital’s policies explained by the treating doctor, which should be duly signed by the patient as well as by the treating doctor. This consent is signed and attached at the time of hospitalisation. If the form lacks signature, it will be considered incomplete as per the amended laws (HIPAA 1996). This document will be helpful to prove the innocence of a doctor, in case a patient raises his healthcare related concerns by lawful means.
  4. The percentage of medical records not having ICD codesInternational Classification of Disease (ICD) are the alphanumeric codes given to the diagnosis to recognise diseases and bring them for international recognition. When a patient arrives in the hospital with some signs and symptoms of the illness, the treating doctor advises investigation after examination. The investigation report helps into the analysis stage, after which the doctor recommends to diagnose. The Medical Records Technician has to give the code to the diagnosis prepared adhering to the instructions given in the ICD10 book recommended by WHO. According to the codes, WHO gathers information on the morbidity and mortality data of a particular region.
  5. The percentage of medical records not having discharge / death summary – When a patient gets discharged or declared dead in the hospital, they themselves / their attendants receive a document that includes the discharge summary / death summary so that the Medical Records Technician can easily do coding, indexing and other  requirements in the MRD. A major discrepancy can erupt if the inpatient file has no discharge or death summary attached. It is monitored by the quality team of the hospital.
  6. The percentage of missing records / information – A MRT needs to maintain the healthcare records for future use. The MRT also provides the inpatient records on loan for multiple reasons like verification, insurance, treatment, Subpoena etc. There are numerous reasons for missing the records and if the MRT notices that a file is missing, then he / she should check with all the departments wherever are chances of the file to be found. Then, the MRT needs to file a complaint at the police station mentioning about the missing medical record/s. If a situation requires a duplicate copy, then the MRTs can generate a copy with the help of Electronic Medical Records.
  7. Percentage of medication chart with error prone abbreviations – A MRT needs to check the medication chart referring to the abbreviation list given by the quality team. If the physician has mentioned improper abbreviations, then the MRT needs to find the discrepancies and make the correction with the help of doctor’s team. 

It is always recommended to fulfil all the quality indicators which are shared above; whether you are applying for NABH accreditation or improving the quality of patient care. These indicators are regularly used in the MRD for yearly audits, internal as well as external. These indicators are useful to uphold the medical ethics and policies drafted for the consumers benefit (for patients) laid down by the law of the land.

Hence, it becomes essential for all Medical Record Technicians to have deep knowledge of these indicators before they step into the healthcare industry.

We, at Tech Mahindra SMART Academies for Healthcare, have incorporated these quality indicators as well as medical coding in the curriculum of Diploma in Medical Record Technology, with a focus on practical demonstration by our qualified trainers at our SMART IT (Information Technology) labs.

Hope the information above is helpful!

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Rekha Kumari

Author

Rekha Kumari, Associate Faculty – MRT, Tech Mahindra SMART Academy for Healthcare, Delhi, has over 10 years of clinical experience. She holds a degree in B.Sc in Medical Records and Health Information Technology. Connect with her on LinkedIn

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Rekha Kumari

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Rekha Kumari, Associate Faculty – MRT, Tech Mahindra SMART Academy for Healthcare, Delhi, has over 10 years of clinical experience. She holds a degree in B.Sc in Medical Records and Health Information Technology. Connect with her on LinkedIn

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