DESUN

HOSPITAL

NAME :
SHUBHANKAR
SAHA
 COLLEGE NAME : INSPIRIA
KNOWLEDGE CAMPUS
COURSE :
BBA(HM)
SEMESTER :
5th
VENUE OF TRAINING : DESUN
HOSPITAL, SILIGURI DURATION : 60
DAYS
ROLL NO : 34403321007
 APPROVAL FORM

I hereby declare that this project is done

under the syllabus of BBA-HOSPITAL
MANAGEMENT under MAKAUT University of
& it has been under my guidance &
supervision.

Signature of Guide
Signature of HOD
 DECLARA
TION

I am SHUBHANKAR SAHA , student of BBA –

HOSPITAL MANAGEMENT at INSPIRIA KNOWLEDGE
CAMPUS , under MAKAUT UNIVERSITY , I hereby
inform that this project work entitled “A Project
Report on Study of Medical Record Department
conducted at DESUN Hospital, Siliguri.
The work has been undertaken as a requirement
toward partial fulfillment of BBA-HM degree under
MAKAUT.
NAME OF THE
STUDENT:
SHUBHANKAR
SAHA

ROLL NO:
34403321007

……………………………
….
Date:
Signature of the Student
 ACKNOWLEDGEMENT
It is an immense pleasure and satisfaction
to me that trainers helped me a lot to
bring out this project.
First of all, I acknowledge my indebtedness to the
HOD, Mr. Joy Mukherjee, and MRD Manager, Mr.
Joy Mukherjee for allowing me to pursue my
internship at Desun Hospital & Heart Institute,
SILIGURI with continuous support and guidance. I
am also obliged to all the employees of the MRD
department of the hospital. The constant Guidance
assistance and inspiration of the sir & ma’am
during the entire training period made me have a
fruitful internship as prescribed in our BBA-HM
syllabus and a special thanks to my mentor Ms.
Jayashree Barman for her sincere cooperation
and constant guidance.

I express my warm thanks to Mr. Jagdeep

Kumar (Hospital Administrator) and all the faculty
members who provided me the facilities needed for
my project. And last but not the least I extend my
heartfelt gratitude and thanks to all staffs of Desun
Siliguri.
Profile of the Hospital
 INTRODUC
TION:

Desun Hospital & Heart Institute is an NABH

accredited hospital and heart research institute of
SILIGURI, West Bengal, India. Desun hospital was
founded by Sajal Dutta in 2008, who pursued
Mechanical Engineering from Jadavpur University
and post-graduation degree in Business
Management from IIM Calcutta (Joka).

Within 3 years of opening, DESUN Hospital earned

the prestigious National Accreditation Board for
Hospitals (NABH) Accreditation from the
Government of India for its quality medical
treatment and hospital services. Since the setting
up of NABH in 2006, less than 100 hospitals have
been able to match the tough quality standards of
NABH and get the accreditation.
Desun is CGHS recognized NABH Multispecialty
Hospital since 2015 & also Class I
Multispecialty Hospital recommended by WBHS.

DESUN is also empanelled by

the Government of Tripura.

Awarded Healthcare Pioneers Of The East 2020 by

The Times Of India in Cardiac Care and
Orthop
edics.
MISS
ION:
Mission is to continuously improve the quality of
the entire range of hospital services and to
emerge as the most reputed hospital in the
country.

VISI
ON:
Vision is to deliver world class tertiary

healthcare services at an affordable cost.

SPECIALITIES:

The hospital is presently operating with:

300 BEDS

Largest ICU & ITU : 79 Beds

10 bed Burn unit, only one in North

Bengal.
Only hospital in SILIGURI having medical

grade steel OTs.

 MEDICAL RECORDS DEPARTMENT

INTRODUCTION:
The department is one of the most important
departments of the hospital Patient related all the
information’s are kept here; all the inpatient files
are kept here. After the patient is admitted in the
hospital each information related to him such as
name of the patients, age, sex, complication,
doctor who treated, diagnosis, condition after
treatment etc. are kept here with all importance.
Every patient has an individual file.

It builds up a bridge among the medical and

paramedical staffs, serves as a legal document
against litigation. Medical records form an
essential part of a patient’s present and future
health care. As a written collection of information
about a patient’s health and treatment, they are
used essentially for the present and continuing
care of the patient. In addition, medical records
are used in the management and planning of
health care facilities and services, for medical
research and the production of health care
statistics.

Department location: The location of the

department is in 2nd Floor.
 OBJECTIVES

Medical record can be defined as an orderly written

document encompassing the patient identification
data, health history, laboratory report, diagnosis,
treatment and hospital course.

• To provide a means of communication among

physicians nurses and other allied health care
professionals.
• To serve as an easy reference for
providing continuity in patient care.
• To furnish documentary evidence of care
provided in the health care facility.
• To serve as an information document to assist
in the quality review of patient care.
• To protect the patient, physician, as well as the health
care institution and its employees in the event of
litigation.
• To supply pertinent patient care information to
authorized organization and third party payers.
• Medical records are important- “people
forget and records remember.”
Role of Medical Records Department
in a corporate hospital:

The Medical Records Department staff under the

leadership of the medical record clerk in- charge is
responsible for the maintenance of medical records and
medical record services. The hospital administration
must provide security and sufficient storage space for
medical records and an adequate working area for
medical record staff. The MRD staff must safeguard the
medical records from tampering, loss and unauthorized
use. They are responsible for seeing that the patient's
right to privacy and the confidentiality of the
information stored within the medical record is
maintained at all times.

• The major role of a Medical Records

Department includes:
• Development and maintenance of the master patient
index for patient identification
• Retrieval of medical records for patient care and
other authorized use
• Discharge procedure and completion of medical
records after an inpatient has been discharged or
died
• Coding diseases and operations of patients
discharged or died
• Filing medical
records
• Evaluation of the medical
record service
• Completion of monthly and
annual statistics

• Medico-legal issues relating to the release of patient

information and other legal issues. Associated with
these functions there are an essential group of basic
medical record procedures that should be performed
by the staff of a Medical Records Department. Failure
to undertake any of these procedures could result in a
poor medical record service. These essential medical
record procedures are explained as you progress
through this Manual.
RETENTION POLICY OF MEDICAL RECORDS:

The following represents the minimum retention policy

for all records, data and information.

TYPES OF MINIMUM
RETENTION POLICY
RECORDS / DATA
/ INFORMATION
OPD RECORDS

• Duplicate OPD
prescription
• All undelivered 5
reports Year
s
• All manuscripts
/ hand written
 IPD
RECORDS

• Regular discharge 10 Years

records
• Dialysis chart
• Gastro
bronchoscopy
records and consent
Lifeti
• All invasive me
procedural records
• Death case records
Till the resolution of
• Medico legal case the case at the highest
records court

TPA 1
Yea
RECORD r

REGIST

ER 5
Year
s
• Birth
• Death lifetime
1
 COLOUR CODE OF
FILES:

FLOOR BED COLOUR

3rd ICU- 3 ( 32- 45) Gree

Floor n

4th ICU- 1 ( 1-14 ) Pink

Floor
ICU- 2 ( 16-29 ) Yellow

5th General Ward ( 1- Gree

Floor 71 ) n

6th S1- Yellow

Floor S2

23-
44

Single Bed (
1-6 )

7th S-3, Pink

Floor S-4

23-
38

Single Bed (
1-7 )
 8th Level- 1 ( 1- Blue
Floor
16 ) Level- 2

( 44-51 ) D1 - Pink

D5 Gree
n
Burn
Unit

38, 39, 41, 42, Yellow

43

ICU-
 METHODOLOGY

• Observational Method:-

In observational method only present behaviour

can be studied, present problem which exist in that
time those problem come under observational
method .With the help of these method all area
examine carefully and find out problems from
this .It is a less expensive method.

• Questioner Methods:-

Questioner methods is a method of research where

some questions are set previously according to the
study subject .To continue the research ,this
method helps a lot.

• Interactive Method: - This method helps to

finish the research work interaction with patients,
their relatives and staffs helps to complete the
research. Interactive method helps to know many
unknown information about the study topic.
 NATUR
E OF
DATA

PRIMARY DATA:- The primary data has been

collected through personal observation and as
well as through both open and closed ended
questionnaires prepared for questions asked to
the patient/patient party and to the staff &
employees of the hospital.

SECONDARY DATA: - The secondary data has

been collected from the hospital information
system.
 WORKFLOW
First the file auditing
done in ward

Discrepancies found
are completed

Files sent to MRD within 48

hours of discharge

Files are received in MRD

(receiving area)

Files are being sorted according to discharge date and

normal discharge death
MLC & serial no

is placed Files

are assembled

Index

Conte
nt

Checkli
st

ICD coding are done of final

Diagnosis
 Files are
stored

Hard copy files are then sent to an out-source agency

after 3 months

Department activities of
flowchart:

Receiver

Checklist

Registrati

on

Checklist

Filing

Inde
xing
Arrange
ment

Deficiency
Checklist

Stora

ge

Retrie

val

Re-

stora

ge
 OBSERVA
TION

• How the MRD department works.

• MRD files that is the patients’ discharge files
are coming from wards, ICU, emergency.
• Files are checked and assembled like the
admissions notes, treatment sheets, doctors’ or
‘consultations’ signatures, medicine cards, and
other documents.
• Files are coded through ICD.
• Then the files are enveloped and segregated
through MLC, death and normal discharge.
• Provisional death and birth certificates are
done.
RECOMMENDATION:

• The files might be arranged properly.

• The files might be racking properly
• Communication might be better in the
department.
• The department might be more
conscious about the distributing of filling
system
• The staffs might be cooperate with
each other in the department
• Other departments might be
communicating properly with the
department.
• The nurses might be completed the
paper works properly.
• The file might be stored properly also.
 CONCLU
SION
Medical records are technically valid health
records which must provide an overall
correct description of each patient’s details of
care or contact with hospital personnel
Medical records form a very important and
critical document in hospital. These records
are vital for legal purposes and for future
planning of the hospital medical care. All
possible steps should be taken to ensure that
all hospital medical records are maintained in
systemic and orderly manner. The importance
of the medical records should also be
communicated to all staff. Periodic audits of
the medical records will help to determine the
possible deficiency in keeping records, which
can be improved and worked upon by the
hospital.
THANK
YOU