POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION AND RESEARCH, CHANDIGARH
Medical Records Department (MRD)
The Medical Record Department preiously known as Central Registration Department of PGIMER, Chandigarh during the year 1962. This Department is responsible for registration and keeping of outdoor / indoor and special clinic records of the Institute including round the clock emergency registration at Nehru Hospital, Advanced Pediatric Centre, Advanced Eye Centre, Advanced Cardiac Centre and Advanced Trauma Centre.
The department undertakes the following work:-
OBJECTIVES OF DEPARTMENT / SECTION
To provide prompt service to the doctors and patients / attendants by providing Medical Record in quick and efficient manner.
Hierarchy of the Medical Record Department is as under:-
(Faculty from Hospital Administration)
Sr. Medical Record Officer
Medical Record Officer
Jr. Medical Record Officer
Medical Record Technician
SECTIONS / SUBSECTIONS AND THEIR TASKS
Main function of this section is to register a patient as an outdoor in the general OPD and special clinics. After registration, outdoor files of the patients are serialled and filed accordingly. Reimbursement of Medical bills is also being carried out by this section. Apart from this, issuance of Investigation Reports, correction of demographic details of patient, change in the category of patients like Poor free, Leprosy free, prisoners ,etc. is also being dealt by this section.
I. Incomplete area
Receiving of inpatient files: This area is responsible for receiving indoor treatment files of the patients discharged from the Institute as per midnight census prepared by the Nursing staff in the respective ward.
Assembling: Files received from the various ward of the Institute are arranged in the prescribed order and are punched accordingly.
Coding: These files are coded according to International Classification of Diseases prescribed by the WHO.
Indexing: Thereafter the same are indexed as per diagnostic code for making disease-wise information of indoor patients. Thereafter files are forwarded to the complete area for filling.
II. Complete Area
This area is responsible for serialling and filing of inpatient record as per admission number and for retrieval of the same as and when required.
III. Miscellaneous work
In order tostreamline the process of doctors complying tocourt summons and save their previous time for patient care, PGIMER has initiated Tele-Evidence facility which utilizes video-conference technology for attending the court evidences since March,2014.
Exclusive Tele-evidence Lounge, with facility for testimonies of three doctors simultaneously with different courts of Punjab and Haryana has been started and shall facilitate extension of the facility to the courts of Hemachal pradesh as well as to the courts of the Tri-City.
2.Birth and Death
Department has been delegated wiht powers of Sub-registrar Birth and Death since September 2015. Department issues one free birth certificate(with/without name) and death certificate of vital events i.e Birth and Death occurring in the Institute. Procedure/documents required for obtaining said Certificate are as under:-
For Birth Certificate
For Death Certificate
Addition of Baby's Name Rs. 50/-
Penalty after one year Rs.500/-
Correction of any particulars Rs.100/-
Fee Structure can be downloaded from the "Download>Various forms" menu
Timing of Issue Birth & Death Certificate:
Receipt of Birth/Death application form : 9.00 AM to 01.00 PM( MONDAY TO fRIDAY)
: 9.00 AM to 11.00 AM ( SATURDAY)
Isssue of Birth/Death certificate : 2.00 PM to 04.00 PM (MONDAY TO FRIDAY)
: 12.00 NOON to 1.00PM (SATURDAY)
3. Filling up of MLC / LIC forms / Duplicate discharge summary
On receipt of request from the concerned police station / investigating officer for providing Medico-legal case summary, the treatment file is forwarded to the concerned department for making the same and on receipt back after needful, the same is issued to the concerned Polic Station / Investigating Officer.
Accordingly, on receipt of request from the patient / nominee for filling up the insurance claim form / making duplicate discharge summary, the same is forwarded to the concerned department alongwith the treatment file of the patient and on receipt back after needful, the same is issued to the quarter concerned.
Document required for applying for Insurance Claim forms are as under:-
4. Issue of files / record
This section issue files to doctors / patients / attendants for following purposes:
ii) Clinical presentation
iii) Paper presentation
iv) Thesis purpose
v) Court evidence
vi) Death certificate
vii) Birth certificate
viii) Copy of card
ix) Copy of refer slip
x) Copy of bill
xi) Refund of security
5. Receipt and disposal of summons
This section is responsible for receipt and disposal of doctor’s summons of the Institute. Summons is received from various courts of the neighbouring states and the same are forwarded to the concerned department to depute doctor concerned to attend the Hon’ble court.
6. Medical Disability
This section is responsible for receipt and disposal of Medical disability certificate and sending the same for date of assessment to the concerned member of the Medical Disability Board. After receiving date of assessment, letters are issued to the patients to attend OPD of the doctor concerned (member) as per the date given by them.
After assessment by the Doctor, cases come back for final board meeting. Again patients are informed about the date of meeting through letters and as per assessment; final certificates are typed in the standard format for the same.
Notice of board meeting is prepared and issued to all members of the Medical Disability Board. On the date of meeting, signatures / thumb impressions of the patients are taken on the certificates. After the said meeting, the same are issued to them accordingly.
Correspondence related to court reply, reply to patient’s query, insurance claim, RTI cases, preparation of agendas and other work regarding noting and drafting of various types of work are being dealt.
8. Stationery Store
This section is responsible for stationeries like OPD Cards, OPD files, Special Clinic files, Indoor files, and other stationery items of day to day requirements. Maintenance of stock registers and issues the material to the staff of the department.
9. Hospital Statistics
This section is responsible for preparation of indoor / outdoor hospital statistics monthly / yearly (financial as well as calendar year). Supply of information is provided and when required.
Medical Disability Board
Retention policy of the treatment record recommeded by the Hospital Coucile Meeting held on 24.08.1994 and Medical Record Committee in its meeting held on 20.01.2004 duly approved by Director,PGIMER,Chandigarh on 28.05.2004 us as under:-
Outdoor: 08.00 AM to 11.00 AM ( Monday to Friday)
08.00 AM to 10.30 AM (Saturday and Gazetted holiday).
Advanced Pediatric Centre
08.00 AM to 12.00 AM-(Monday to Friday).
Emergency & Indoor: 24 hours
Outdoor: Rs. 10/-( Every January & July)
Emergency: Rs. 20/-
Application form to apply for Medical Disability Certificate
MEDICAL RECORDS MANUAL