Medical Record Numbering in Healthcare

Medical Record Numbering

• Medical record numbering is a key procedure in healthcare
• This allows for identifying a patients medical record
• The first step in every admission is collecting patient identification data
• This allows for assigning a new or verifying an existing medical record number

Assigning one medical record

• In facilities where a patient has one medical record and all admissions are filed in one folder, a medical record number is assigned at the time of the patient's first visit.
• This ensures future identification of the patient and their medical record during both current and future admissions.
• This number may be called different names, such as hospital number, patient identification number, unit record number, or medical record number.
• The Medical Record Number or MRN is the permanent identification number assigned in a straight numerical sequence.
• Admission staff assign this number and record it on all medical record forms pertaining to that specific patient.
• This number is used to file the medical record, confirming the importance of correct assignment and recording on all forms.
• Some hospitals start a new file and new number for every visit which is not recommended
• For good patient care, a patient should only have one medical record with all admissions in the same place

Issuing numbers

• MRNs should be issued in straight numerical order starting with the number 1 from the number register.
• For instance, if the previous patient was assigned number 342, the next patient gets 343, and so on.
• For previous inpatients, the admission clerk must use the Master Patient Index to find the old number and allocate to them
• It is vital patients keep the same number, even after they are discharged or if they die
• If an error leads to a patient having two numbers, the duplicate number should be cancelled and not reused

Components of a Medical Record

• When a patient is admitted, they become an inpatient
• At this point the front sheet is the records starting point
• Inpatients occupy a bed in a health care facility for at least four hours and overnight
• As a patient receives care, their medical record grows with new forms

Physical Components

• Medical record forms
• A clip or fastener to hold the papers together
• Dividers between each admission and outpatient notes
• A medical record folder.

Medical Record Forms

• Medical records are made up of many forms that all have a purpose to fulfill
• The basic set of forms for inpatients includes the front or identification and summary sheet
• These sheets cover identification, final diagnoses, disease and operation codes, and the attending doctors signature.
• Consent for treatment is typically on the back of the Front Sheet and MUST be signed upon admission
• The first half of the form is general consent for treatment, and the second half is consent to release information.

Other Key Forms

• Correspondence and legal documents
• Referral letters and requests for information
• Discharge summary if required by the hospital/health authority
• Admission notes covering medical history, presenting symptoms, physical examination results, provisional diagnosis, proposed tests, and care
• Clinical progress notes which involves daily treatment notes written by health care professionals
• Other reports include X-ray, etc.

Treatment and Nursing

• Orders for treatment and medication forms includes daily medications with signatures from prescribers and nurses.
• Nurses' process notes, covering daily nursing care data
• Operation reports with pathology, hematology, histology, or microbiology
• Special nursing forms for observation of head injuries

Form Consistency

• All forms should be the same size (A4)
• Patient details such as name and medical record number should be in same place on every form
• In addition, the name of the form should always be in the same place on every form
• Only include official forms approved by administration or the Medical Record Committee in the record

Order of Forms

• All forms should have an order once a patient leaves
• The hospital administration or Medical Record Committee determines this order for the list to be available to those who work with the record
• It makes it easy for medical staff to assemble the record and locate necessary information.
• Once the patient is discharged the clinical progress notes and nursing notes are up front for general access

Ward Staff Protocols

• In many countries, it's the ward staff's job to sort forms before sending them to the Medical Records Department
• Medical record staff responsible for discharges must sort forms as apart of the discharge procedure

Fasteners

• Forms should be held by clips of fasteners within the record
• Due to rust, staples should not be used
• Some countries go with 1 fastener secured top left
• 2-Pronged clips get threaded through the folder and attach to adhesive backing
• Plastic clips are recommended over metal options as they don't cut or rust

Medical Record Folders

• All medical records should be stored in folders
• They should be manila or stronger cardboard which are stored on end so the medical number is visible
• Hospitals should budget medical record stationery annually
• Key things to be written on the folder include the patients name, medical record number and year of last attendance
• No medical information should be contained on the folder itself

Responsibilities

• The core function of medical facilities is to supply all patients with consistent, quality care
• The accuracy and comprehensiveness falls to those who record the data
• The hospital administration is responsible for care quality overall.
• The MRO (Medical Record Officer) is responsible for managing the department
• They oversee management of the patient data
• The MRO sees the record is needed for continuing care plus ensure all related forms are in the record
• Making sure that diseases and operations are coded accurately with information produced for statistics being available when required