EMR 6

Electronic Medical Records: Overview

Introduction

  • Speaker: Dr. Omar Nakshabandi, Computer Engineer and PhD in Management Information Systems.

  • Focus of Lecture: Managing medical records in healthcare settings.

Filing Systems for Medical Records

Current Practices

  • Medical records are primarily filed numerically using patients' medical record numbers.

  • Past practices included filing by names, discharge numbers, or diagnostic codes, but these methods have significant complications.

Reasons for Numerical Filing

  • Errors: Alphabetical filing by names is prone to errors.

  • Connection: Other important records in the facility often relate specifically to medical record numbers.

Types of Medical Record Numbering Systems

1. Serial Numbering

  • Each visit results in a new medical record number.

Example: Patient Ravi receives numbers 13650, 14020, and 19560 over different visits.

2. Unit Numbering

  • One number assigned for all treatments, promoting consolidated records.

Example: Patient Ravi keeps the number 13650 for all subsequent visits.

3. Serial Unit Numbering

  • Combines elements of serial and unit systems; new numbers assigned upon each registration but previous records are consolidated under the latest number.

  • Example: New patients receive a number like 14020 but retain the history under 13650.

4. Annual Numbering

  • Introduces a two-digit year indicator alongside the serial number to assist in record management.

5. Family Numbering

  • Structure: Family members assigned numbers prefixed by digits indicating family structure (01 for the head of family, 02 for spouse, etc.).

  • Families can be grouped under one number for filing, enhancing record management.

Managing Bulky Medical Records

  • Records that exceed storage capacity should be clearly labeled as multi-volume.

Example: Use labels like "Volume 1 of 2" to indicate complete records across folders.

Medical Records Filing Systems

1. Straight Numeric Filing

  • Records filed in ascending order based on medical record numbers.

  • Advantages: Simple and easy training for personnel.

  • Disadvantages: High risk of misfiling due to the need to recall all digits.

2. Terminal Digit Filing

  • Uses a six or seven-digit number divided into three parts, filing primarily by the last two digits.

  • Advantages: Reduced misfiling and easier number management for staff; quicker access to records.

3. Middle Digit Filing

  • Primary digits are in the middle of the number, while secondary and tertiary digits are on either side.

  • Advantages: Simple retrieval of 100 records, easier conversion from numerical systems, and even distribution of records.

Centralization vs. Decentralization

Centralized Filing

  • All outpatient, inpatient, and emergency patient records stored in one location for efficiency, particularly effective for continuous care.

Decentralized Filing

  • Separation of outpatient records in the medical records department while inpatient and emergency records are filed in their respective areas.

  • Necessary for large medical complexes to ensure quick access and retrieval of records while maintaining departmental control.