Medical Records Management is the systematic control of records throughout their lifecycle – from creation and maintenance to safe disposal or archiving, ensuring accuracy, confidentiality, and easy retrieval for patient care, legal, administrative, and research purposes.
2. Objectives
- To maintain accurate, complete, legible, and timely records.
- To ensure confidentiality and security.
- To support continuity of care.
- To comply with legal, accreditation (e.g. NABH), and regulatory requirements.
- To aid in medical audits, research, and statistics.
3. Key Components
✅ Patient Identification System
✅ Standardised Forms & Formats
✅ Filing and Retrieval System (e.g. terminal digit filing)
✅ Coding and Indexing (ICD, CPT)
✅ Record Completion & Deficiency Check
✅ Confidentiality & Access Control
✅ Retention and Disposal Policy
✅ Electronic Medical Records (EMR/EHR) Management
4. Types of Medical Records
- Inpatient Records (IPD files)
- Outpatient Records (OPD cards/files)
- Emergency Records
- Diagnostic Records (Lab, Radiology, etc.)
- Consent Forms and Legal Documents
- Registers (Birth, Death, Notifiable diseases)
5. NABH Requirements (Brief)
- Records must be legible, complete, and authenticated.
- Entries with date, time, and signature/name of person documenting.
- Retention policies defined and implemented.
- Privacy and security (physical & electronic).
- Regular audits for completeness and quality indicators.
6. Challenges in MRM
- Illegible handwriting in manual records.
- Incomplete documentation by clinicians.
- Misfiling and retrieval delays.
- Data privacy breaches.
- Transition from paper to EMR.
7. Recent Trends
- EMR/EHR implementation
- Digital scanning and archiving
- AI-based coding assistance
- Data analytics for hospital performance and research
Photographs of Training Session of Medical Record Management
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