Post Graduate Diploma in Medical Records Science

Introduction:

Information is the life blood of health care delivery system. The medical record, in manual or
automated form, houses the medical information that describes all aspects of patient care.
Physicians, nurses, and other health care providers require medical information for treating a
patient. The medical record serves as a communication link among care-givers. Documentation
in the medical record also serves to protect the legal interests of the patient, health care provider,
and health care facility.

Objectives/aim of the course:

The aim of the recommended curriculum is to produce Medical Record professionals who
understand the:

Definition and characteristics of ‘Good’ Medical Record

Values of ‘Good’ Medical Record to various users
Required Characteristics of entries in medical Records
Responsibility for Medical Record Quality

They should be able to manage:

Analysis of Medical Record-Quantitative & Qualitative and Incomplete RecordControl

Source-oriented, Problem-oriented, and Integrated Health Information Management
Medical Record Forms and their Content
Standard Order of Arrangement of Medical Record forms

Objectives

To develop competent professionals who can:

Enable the health care organization to better manage patient information

Support health care administrators in routine activities
Apply the knowledge obtained on specialized areas effectively in the health care system
Work collaboratively with other health care professionals to achieve a quality service

Eligibility for admission:

Selection procedure

1. He/she has passed the bachelor of science degree or equivalent examination recognized
by any Indian University or a duly constituted Board with 50% pass marks
2. He/she has attained the age of 20 years as on - (current year) & maximum age limit is 30
years.
 Duration of the course

Duration of the course is of 2 years or 4 semesters (inclusive of internship) with 970 hours of
Theory &770 hours of Practical Classes

Medium of instruction:

English shall be the medium of instruction for all the subjects of study and for examination of
the course.

Attendance:

A candidate will be permitted to appear for the Examination for any semester if he / she secure
not less than 80% of attendance (separately in theoretical and Practical) during the calendar year,
failing which he / she should complete the number of days/hours and undergo the next
semester/final examination conducted by the Institute.

A candidate has to secure minimum 80% in Skills training (practical) for qualifying to appear for
the final examination. No relaxation, whatsoever, will be permissible to this rule under any
ground including indisposition etc.

Assessment:

The scheme of examination is as follows:

First Year

Internal Assessment Examination

Sl. No Subject Title
Max Min Max Min
1. Health Information Management – I 25 15 50 25
2. Medical Terminology 25 15 50 25

Second Year

Internal Assessment Examination

Sl. No Subject Title
Max Min Max Min
1. Health Information Management – II 25 15 50 25
International Classification of
2. Diseases(ICD-10) and Surgical 25 15 50 25
Procedures
Log Book/Project/Record work/Viva-
3. - - 50 25
voce

Internal Papers

Internal Assessment
Sl. No Course Titles
Max Min
1. Human Anatomy and Physiology 25 15
2. Biostatistics & Research Methodology 25 15
3. Communication and soft skills 25 15
 4. Biochemistry 25 15
5. Microbiology 25 15
6. Basic computers and information science 25 15
Marks for Internal papers will not be added along with the Final Examinations. Marks to be sent to
the Registrar.

Model Curriculum Outline

First Year

Hours
No Course Title
Theory Practical Total
1. Introduction to Healthcare Delivery System in India 10 0 10
2. Health Information Management - I 180 210 390
3. Human Anatomy and Physiology 40 0 40
4. Research Methodology and Biostatistics 40 20 60
5. Medical Terminology 150 120 270
6. Communication and soft skills 20 10 30
7. Clinical Visits 0 20 20
Total 440 380 820

Second Year

Hours
No Course Title
Theory Practical Total
International Classification of Diseases (ICD-10) and
1. 170 110 280
Surgical Procedures and SNOMED-CT
2. Health Information Management - II 180 70 250
3. Biochemistry & Microbiology 60 0 60
4. Pathology 30 0 30
5. Forensic Medicine 10 0 10
6. Basic computers and information science 80 150 230
7. Log Book/Project/Record work 0 60 60
Total 530 390 920

First Year

Introduction to National Healthcare System

The course provides the students a basic insight into the main features of Indian health care delivery
system and how it compares with the other systems of the world. Topics to be covered under the
subject are as follows:

1. Introduction to healthcare delivery system

2. National Health Programme
3. Demography & Vital Statistics
 3.1. Demography – its concept
3.2. Vital events of life & its impact on demography
3.3. Significance and recording of vital statistics
3.4. Census & its impact on health policy
4. Epidemiology
4.1. Principles of Epidemiology
4.2. Natural History of disease
4.3. Methods of Epidemiological studies
4.4. Epidemiology of communicable & non-communicable diseases, disease transmission, host
defense immunizing agents, cold chain, immunization, disease monitoring and surveillance.

Health Information Management – I:

Health Information Management serves the healthcare industry and the public by managing,
analyzing, and utilizing the data vital for patient care and making the data accessible to healthcare
providers. Enhancing individual patient care through timely and relevant information is one of the
primary goals for the Health Information Management Technology

I. Characteristics of quality Health Information Management:

a. Definition, Characteristics of Medical Record
b. Values of Medical Record to various users
c. Required Characteristics of entries in medical Records
d. Source-oriented, Problem-oriented, and Integrated medical records
e. Medical Record Forms and their Content
f. Standard Order of Arrangement of Medical Record forms
g. Analysis of Medical Record-Quantitative & Qualitative
h. Incomplete Record Control
i. Practical: Actual handling of medical records
II. Medical Records for different patient encounters with health care facility
a. Ambulatory Care Records {Emergency & Outpatient Records]
b. Clinical Records in Long Term Care and Rehabilitation Facilities
III. Filing Methods, Storage, and Retention
a. Numbering and Filing Systems
b. Filing
c. Storage- Microfilming and Disk Storage
d. Retention
e. Registers & Indexes
f. Record movement control & Tracking system
IV. Organizational Aspects of the Centralized Admitting Services
a. Principles of Identification of a Patient
b. Methods of Collection of Identification Data
c. Types of Central Admitting Services
d. Admitting Policies
e. Procedure Outlines for Admissions
f. Flow of Records following Admissions
g. Advantages of good Admitting Policies and Procedures
V. Medical Record Department Management
a. Planning, Organizing, Directing and Controlling
 b. Personnel Management
c. Principal Responsibilities and Duties of the Medical Record Administrator
d. Tools of Management in the Hands of the Medical Record Administrator
VI. Intradepartmental and Interdepartmental Relationships
a. Developing Intradepartmental Relationship
b. Developing Interdepartmental Relationships with various Departments of the
Hospital
VII. Medico-Legal Aspects of Health Information Management
a. Medical Ethics, Hippocratic Oath, and Code of Ethics for the HIM Professionals
b. Ownership of the Medical Record
c. Privileged Communication and confidentiality of Medical Records
d. Release of Information: To the Patient, To Authorized Persons /Agencies Legal
Implications of release of Information to unauthorized, Persons/Agencies.
e. Consents: Different types and their validity, invalidity blanket, and improper
consents.
f. Corrections in identification data medical documentations
g. Rights and responsibilities of patients
h. Medical Record in a Court of Law
i. Legal requirements in Retention of Medical Records

Human Anatomy & Physiology

Understand the technical functions of various organs and systems of the body
Acquire knowledge about various body fluids, hormones and enzymes

Topics Covered:

o Integumentary system,
o Musculoskeletal system,
o Respiratory system,
o Cardiovascular system,
o Blood and lymphatic system,
o Digestive system,
o Urogenital systems
o Nervous system,
o Organs of special sense.

Research Methodology and Biostatistics

The objective of this is to help the students understand the basic principles of research and
methods applied to draw inferences from the research findings.

1. Introduction to research methods

2. Identifying research problem
3. Research design
4. Basic Concepts of Biostatistics
5. Types of Data
6. Research tools and Data collection methods
7. Developing a research proposal
 8. Frequency Distribution: Measures of Central Tendency – Arithmetic Mean, Median and
Mode for un-grouped and grouped data
9. Presentation of data: Bar diagram, Pie Diagram, Histogram, Frequency polygon, Frequency
curve, and Line diagram.
10. Measures of Variation: Range, Inter Quartiles, Mean Deviation, Standard Deviation
Coefficient of Variation
11. Probability: Definitions of Classical Probability (Priori) and Frequency, Addition and
Multiplicative Theorems of Probability
12. Probability Distribution: Binomial distribution, Poisson distribution and Normal distribution
13. Sampling- Definition: Population and simple Sampling, Simple Random Sampling, Stratified
Random Sampling, Systematic Random Sampling and Cluster Sampling
14. Correlation and Regression: Scatter Diagram, Linear Correlation and Linear Regression
Equation Test of Significance – Procedure Test of Significance for large samples and for
small samples Chi-square Test – Testing for association Misuse of Chi-square Test

Communication and soft skills

Major topics to be covered under Communication course

1. Business Communication Skills. With focus on speaking - Conversations, discussions,

dialogues, short presentations.
2. Teaching the different methods of writing like letters, E-mails, report, case study, collecting
the patient data etc. Basic compositions, journals, with a focus on paragraph form and
organization.
3. Basic concepts & principles of good communication.
4. Ability to create agendas, lead meetings, maintain documentation, and follow up
5. Effective communication and negotiation skills.

Medical Terminology :

This course introduces the elements of medical terminology. Emphasis is placed on building
familiarity with medical words through knowledge of roots, prefixes, and suffixes. Topics
include: origin, word building, abbreviations and symbols, terminology related to the human
anatomy, reading medical orders and reports, and terminology specific to the student’s field of
study.Spelling is critical and will be counted when grading tests.

On the completion of this course, the students will be able:

To know the elements of medical words.

To develop sense of correctness of medical terms.
To gain an understanding of standard medical abbreviations.
To understand the relationship between medical terms and their synonyms in common
usage.
To spell correctly the medical terms, to detect the meaning of unfamiliar medical terms, by
analysis into their elements, and to follow directions given in medical phraseology
To appreciate the logical order of medical terms, the exactness of concepts in medical terms,
and the importance of medical terminology consciousness and continuous study.

All the above characteristics will enable the students in:

 Developing an ability to read and understand medical records and the medical literature;
Writing terms correctly when abstracting medical records
Establishing accuracy in International Classification of Diseases, Surgical procedures which
will be useful in statistics, medical billing, and auditing medical insurance claims.

Topics to be covered under the subject are as follows:

I. Introduction to Medical Terminology

a. Definition and Origin of Medical Terms.
b. Define word roots, prefixes, and suffixes
c. Basic medical terms
d. Components of Medical Terms
e. Prefixes
f. Suffixes
g. Roots and Combining forms
h. External Anatomy and Internal Anatomy
i. Additional Lists and their combining forms grouped as: Verbs, Adjectives, Body
Fluids, Body Substances, Chemicals, Colours and Phobias
II. Terms Relating to the Body as a Whole
a. Study of the Body
b. Basic Structures
c. Cells
d. Tissues
e. Organs
f. Systems
g. Directions
h. Anatomic Planes and Position
III. Basic medical abbreviations/symbols
a. Diagnostic, surgical, and procedural terms and abbreviations related to the
integumentary system, musculoskeletal system, respiratory system, cardiovascular
system, nervous system, and endocrine system.
b. Interpret medical orders/reports (Practical training to be included)

Community orientation and clinical visit

The objective of this particular section is to sensitize potential learners with essential knowledge;
this will lay a sound foundation for their learning across the post graduate program and across
their career. Innovative teaching methods should be used to ensure the attention of a student
and make them more receptive such as group activities, interactive fora, role plays, and clinical
bed-side demonstrations.

The clinical visit will include visit to their respective professional department within anyof the
healthcare delivery system -Sub centre, PHC, CHC, SDH, DH and Medical college, private
hospitals, dispensaries and clinics.

Second Year

International Classification of Diseases (ICD-10) and Surgical Procedures and SNOMED-CT:

Introduction and usage of International Classification of Disease

 Coding of final diagnosis and secondary diagnosis.
Disease and operation nomenclatures, International Classification of Disease 10,
International Classification of Disease – 9CM, indexing of patient care data.
ICD-10 CM- Alpha-numeric coding Guidelines
International Classification of Diseases
o Volume 1 – Tabular list
o Volume 2 – Instruction manual
o Volume 3 – Alphabetical Index
Morbidity and Mortality Reporting
CPT – Current Procedural Terminology (Introduction)
HCPCS – Healthcare Common Procedure Coding System (Introduction)
ICD- Oncology (ICD - O)
ICP (Procedure) coding system - Practical
International Classification of Diseases - Practical
SNOMED-CT

Health Information Management II

I. Organizational Aspects of Medical Record Department/Services

a. Policy development
b. Functions
c. Location, Space and Layout
d. Equipments
e. Forms Designing and Control
f. Medical Records Flow and processing
II. Heath Care Statistics, Quality control of Data Collection & Presentation
a. Heath Care Statistics
b. Inpatient census and rates computed from it.
c. Processing and reporting of Vital Health Statistics
d. Reporting of Notifiable Diseases to Public Health Authorities
III. Quality Management
a. Quality Assurance and Quality Improvement
b. Utilization management & Utilization review processing
c. Accreditation requirements, licensing regulations, and certification requirements
relevant to department/organization.
d. International Standards Organization [ISO], Quality Council of India, Joint
Commission International [JCI] & National Accreditation Board of Hospitals
[NABH]
IV. Fundamentals of Health Informatics
a. Hospital Information System (HIS) with Electronic Medical Records (EMR) or
Electronic Health Information Management System
b. EHR – definitions – contents and examples of EHR practices
c. Preliminary steps in implementation of EHR
d. Issues and challenges in implementation of EHR
e. Planning for the introduction of EHR
f. Factors to be considered when developing EHR & implementation plan
V. Health Insurance and Billing Design:
a. Definition and history of Health Insurance
 b. Concepts in Health Insurance
c. Types of health insurance
i. Social health insurance
ii. Private health insurance
iii. Community health insurance (CHI)
iv. Government-initiated health insurance schemes (GHI)
d. Denial of claims
e. Role of MRD in Health Insurance and Billing
VI. Medical Transcription:
a. Basics of Medical Transcription
b. Objectives of Medical Transcription
c. Rules of Medical Transcription
d. Advantages of Medical Transcription
VII. Telemedicine:
a. Objectives of Telemedicine
b. Technology of Telemedicine
c. Rules of Telemedicine
d. Future Telemedicine plans

Biochemistry

Topics covered:

a) Chemistry of the human body fluids in health and diseases

b) Cerebrospinal fluid
c) Clotting mechanism of the blood,
d) Enzymes produced in the G.I.Tract,
e) Vitamins, Hormones, Proteins and Non-proteins,
f) Nitrogenous substances, lipids, carbohydrates,
g) Electrolytes
h) Metabolism, acid-base balance,
i) Normal values and ranges of biochemistry investigations

Microbiology

Topics covered:

a) Introduction to Microbiology,
b) Classification and characteristics of organisms,
c) Cultivation and identification of organisms, Viral, fungal, bacterial etc
d) Disinfection,antiseptics,sanitation,
e) Immunity,
f) Allergy
g) Pathogenic organisms,non-pathogenic organisms,virus and fungus.

Clinical and General Pathology

Topics covered:

a) Introduction to Pathology
 b) Inflammation and Repair
c) Infection, Degeneration, Neoplasia
d) Blood groups, cross-matching, transfusions
e) Tests done on various body fluids and tissues
f) Infectious Disease
g) Disease of red blood cells
h) Disease of white cells and lymph nodes

Forensic Medicine

Topics covered:

a) Introduction to Forensic Medicine

b) Medico-legal aspects of wounds
c) Wound certificate
d) Toxicology
e) Traffic Accidents
f) Drowning
g) Food poisoning
h) Medico-legal autopsy

Basic computers and information science

The students will be able to appreciate the role of computer technology. The course has focus
on computer organization, computer operating system and software, and MS windows, Word
processing, Excel data worksheet and PowerPoint presentation. Topics to be covered under the
subject are as follows:

1. Learning to use MS office: MS word, MS PowerPoint, MS Excel.

2. Basic Data Processing
3. Database and Spreadsheet Operations
4. Basic Computer Concepts and Applications
5. Miscellaneous: Scanning of documents (of various sizes) and in different conditions (for e.g.,
mutilated), file naming, saving, uploading, etc. Copying of original medical document, back
up of old data/ records.

Log Book/Project/Record work

As a part of this, the students will choose a relevant subject and prepare an in-depth project
report of not less than 1000 words which will be handed over to the Registrar or HOD. The
report can include objective, scope of the project and an in-depth report.
 Skills-based outcomes and monitorable indicators for Medical Records Assistants

Knowledge / Applications / synthesis /

Sl No: Learning outcomes
comprehension evaluation
Basic health record forms Is able to verify the accuracy
Verify the documentation in
Completeness of health of data collected and
1 the health record is timely,
records Assembling and assemble into a complete
complete, and accurate
deficiency checking health record
Basic data generated from Is able to liaise with patients
Collect and maintain health
2 medical records and its and their families to collect
record data
purpose and uses the necessary data
Apply mortality and
Is able to use the ICD system
3 morbidity codes as per the ICD classification system
effectively
guidelines
Identification of the legal use Legal requirements of Demonstrates the ability to
4 of health records and managing and maintaining identify legal implications of
relevant documents health records documents
Identification of
Minimum entry Demonstrates the ability to
discrepancies between
5 requirements in the health identify discrepancies in
documentation and disease
records documentation
coding
Demonstrates the ability to
Comply with ethical aspects
Confidentiality and privacy uphold the confidentiality
6 of health records and the
aspects of health records and privacy of patient
information it contains
records
Utilize basic descriptive, Basic hospital statistics Is able to perform basic
7 institutional healthcare calculation and data statistical calculations and
statistics requirements document results