POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION AND RESEARCH, CHANDIGARH

Medical Records Manual Policies, Processes And Standard Operating Procedures

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:-

  • Prepares hospital statistics
  • Dealing with receipt and disposal of summons
  • Carrying out the work related to Medical Disability Board.
  • Dealing with receipt and disposal of filling up of Insurance claim forms/Medico-legal cases.
  • Issue of files to doctors for research, study, medico-legal purposes.
  • Issuance of Medical Record under RTI Act.
  • Counter signature of Reimbursement of Medical Bills.
  • Deposing of Expert witness by the doctors of the Institute through Video conferencing(Tele-evidence w.e.f March 2014).
  • Issuance of Birth and Death Certificate occurred in the Institute.

 

LOCATION, CONTACT PERSON, PHONE NUMBER, TIMINGS

 

OBJECTIVES OF DEPARTMENT / SECTION

To provide prompt service to the doctors and patients / attendants by providing Medical Record in quick and efficient manner.

 

ORGANIZATIONAL STRUCTURE

Hierarchy of the Medical Record Department is as under:-

Medical Superintendent

 
Officer Incharge, Medical Record Department,

(Faculty from Hospital Administration)

 

Sr. Medical Record Officer

 

Medical Record Officer

 

Jr. Medical Record Officer

 

Medical Record Technician

 

SECTIONS / SUBSECTIONS AND THEIR TASKS

Outdoor

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.

Indoor

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

1. Tele-Evidence

In order to streamline the process of doctors complying to court 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 and other states.

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

  1. Application form
  2. Aadhar Card of parents
  3. Aadhar Card of Applicant(i.e Father/Mother/Grandparents)
  4. Copy of Discharge Summary in respect of Mother.

For Death Certificate

  1. Application form
  2. Aadhar Card of deceased.
  3. Aadhar Card of applicant (i.e Husband/Father/Mother.Son/Wife/Sister/Daughter/Brother)
  4. Copy of Death Notification form of PGI.

Application form 

  1. Birth Certificate
  2. Death Certificate 

 

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:-

  1. Copy of Treatment record (death notification form in case of death in PGI).
  2. Copy of Policy Stating nominee.
  3. Application form(Can be downloaded from the 'Download-Various forms"Menu)
  4. Rs.35/- to be deposited either in cash or through DD in favour of "Director, PGI. Chandigarh".
  5. Claim form of the Insurance Company-Blank.
  6. Copy of death certificate in case patient expired outside PGI.

 

4. Issue of files / record

This section issue files to doctors / patients / attendants for following purposes:

i)             Re-admission

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.

Timing of receiving of summon:

Monday to Friday :  9.00 am to 3.00 pm

Saturday: 9.00 am to 1.00 pm

 

6. Application and issuance of Disability Certificate: 

 

Application for Disability Certificate:

  • Person with Disabilities can register himself/herself for disability certificate and UDID Card on the website of the Department of Empowerment of Persons with Disabilities  i.e. www.swavlambancard.gov.in
  • Person with Disabilities can also apply for disability Certificate and UDID card in any nearest e-Sampark Centre in the U.T. Chandigarh.
  • Person with Disabilities can also apply for disability Certificate and UDID card in the Medical Records Department, PGIMER, Chandigarh.

 Process of assessment and issuance of disability certificate (For both multiple and single disability):

  • After Receiving of the application in the MRD, we send the patient to our assessment specialists for his/her disability assessment.
  • After assessment, Disability Certificate and UDID card generated online on the UDID portal and the Disability Certificate are given to the patients.

7. Correspondence

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.


10. Poor free information
As per the directions of the DPGI, the Medical Records Department is also compiling the poor free information of investigations and indoor patients received from the various departments of the Institute.

 

 

Related Committees


Medical Record Committee
Policies and any other decision for Medical Record of the Institute is taken by the Medical Record Committee.

 

Retention Policy

Sr.No.  Type of reccord   
 Retention Period    
 1. In-patient's Medical Records (i.e) case sheets etc.

 

3 years 

 
 2. OPD records (OPD Registers and Duplicate OPD record, if any      

3 years 

 
 3.

Medical Legal Registers and case sheets

 10 Years or  till the disposal of ongoing

cases in any of the courts related to these records  

 

 OUTDOOR SERVICES

Registration timings

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

Registration Fee

Outdoor: Rs. 10/-( Every January & July)

Emergency: Rs. 20/-

MEDICAL RECORDS MANUAL

Medical Records Manual Policies, Processes And Standard Operating Procedures