Medical Record Department
Medical Record Department is an integral part of patient care, which houses the medical records of all the patients who have utilized the services of the hospital. A medical record is a systematic documentation of the patient’s medical history and care provided in the hospital. The information thus collected are stored in an orderly manner is useful for patients , their relatives, healthcare team members, hospital management, Government Agencies, Public Health Agencies, Research organizations etc.
Its purpose is to ensure seamless integration of medical information across the hospital by maintaining timely accurate and complete health records and ensuring safety and confidentiality of the information. Apart from Medical record keeping the department also collects the information from departments and prepares statistics which is useful for planning and organizing the hospital services
Functions of MRD
- Outpatient Record Management
- Inpatient Record Management
- Storage and Retrieval of Hospital Records and Registers
- Coding and Indexing
- Hospital Statistics Preparation
- Death and Birth Certificate intimation to local Authority
- Issue of Medico legal certificates
- Management of Medical Board (MACT, Special Board & Disability Board)
- Medical Audit
CERTIFICATE ISSUED FROM MRD TO POLICE
Sl No. | Name of Certificates | Who can Issue | Format | Procedure/Requirements |
1 | Wound Certificate | Casualty MO | As per Kerala Medico Legal Code | Written requisition from investigating officer |
2 | Post Mortem certificate | Police Surgeon/Assistant Police Surgeon | As per Kerala Medico Legal Code | Written requisition from investigating officer |
3 | OP treatment certificate | Concerned Medical officer | As per Kerala Medico Legal Code | Written requisition from investigating officer, OP treatment record of patient and other reports. |
4 | IP treatment certificate for Police cases | Concerned Medical officer | As per Kerala Medico Legal Code | Written requisition from investigating officer, Discharge Summary |
CERTIFICATE ISSUED FROM MRD TO PUBLIC | |||
SL.No | Services | Procedure/Conditions | Time Schedule |
1 | Correction of entries in Medical Record | 1.Written request to Superintendent | Same Day |
2.Copy of Aadhaar card/Election ID | |||
2 | Correction of entries in Birth Register | 1.Written request to Superintendent | 3-5 working days |
2.One & same Certificate | |||
3.Copy of school Certificate of the person whose name need to be corrected | |||
4.Copy of Aadhaar card/Election ID of parents | |||
5.Copy of Ration Card | |||
3 | Correction of entries in Death Register | 1.Written request by relative of the deceased person to Superintendent | 3-5 working days
|
2.Copy of Aadhaar card/Election ID of applicant& deceased | |||
3.Ration Card of the deceased person | |||
4.One & same certificate | |||
4 | Birth Time | 1.Written request to Superintendent | Same Day |
2.ID proof of parents | |||
5 | Copy of Accident cum wound Certificate | 1.Written request to Superintendent | Same Day |
2.Patient should come in person | |||
3.In case of bedridden patient, relative should submit authorization | |||
4.Letter with self attested ID proof of both bill receipt | |||
6 | Copy of PM | 1.Fill the prescribed Application form | Same Day |
2.Copy of ID proof of the applicant | |||
3.Bill receipt | |||
7 | Treatment Certificate | 1.Written request to Superintendent | 5-7 working day |
2.OP/Casuality ticket, other reports(X-ray,MRI,CT Scan etc) | |||
8 | Other Medico-legal Certificate | 1.Written request to Superintendent | Same Day |
2.ID card of patient | |||
3.Patient should come in person | |||
9 | Medical record related document | 1.Written request to Superintendent | Same Day |
2.ID card of patient | |||
3.Applicant should come in person | |||
4.In case of bedridden patient, relative should submit authorization | |||