Medical Records Manual
9
A Guide for Developing Countries
QUALITY ISSUES FOR MEDICAL RECORDS SERVICES
Over recent years, the quality of documentation in the medical record has become an important issue, not only with the need to promote better health care, but also, the need by governments to reduce health care costs. In some countries, when funding began to be based on medical record data, it was found that more attention should be paid to the quality of the medical record and documentation of the original health care data. In many countries, some problems facing administrators and government authorities include: • poor medical record documentation; • large backlogs of medical records waiting to be coded; • poor coding quality; and • poor access to, and utilization of, morbidity data. To address these problems and improve the quality of data collected, and the information generated from that data, quality control measures need to be implemented.
An MRO checks the information on records with a doctor.
The Medical Record Department is often the first department in a hospital to introduce quality assurance. As the Medical Record Department has connections with most other departments within the facility, the medical record is the best place to check the medical care and treatment of the patient. It should be noted that quality checking of the medical record often results in action being required by staff outside the Medical Record Department. One approach to quality checking is for the MRO to ask staff from other departments to check the services of the Medical Record Department using a check-list. The results of these quality checks (or audits) are kept on a chart (or graph) in the Medical Record Department. They should also be presented to the Medical Record Committee for review. As the results improve, the figures on the chart are a source of pride for the Medical Record Department staff. This process is often the beginning of a reciprocal quality-checking program with other departments, which could result in an improvement in the quality of procedures throughout the health care facility.
Areas in Which the MRO can Evaluate Medical Record Procedures There are a number of procedures in the Medical Record Department that can and should be evaluated. Some study questions that could be used to evaluate the work of the Medical Record Department staff could include: • Are medical records filed promptly? • Is the file room clean and tidy? • Are Master Patient Index cards filed promptly?
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