MADHYA PRADESH PARAMEDICAL COUNCIL

6th Floor, Satpura Bhawan, Bhopal

Syllabus & Guidelines

Schedule serial No. 22

Subject: Diploma in Hospital Medical Record Science

No. Of Admission: - 0-50 Admission Per Year

S.No

Duration/

Degree

/Diploma

/Certificate

Syllabus

Teaching faculty with minimum qualification & experience

Non-teaching state with qualification & experience

Library

Laboratory with Equipment

Buildings

Remarks

Teaching

Hostel

1.

1 years (12 months) course

Appendix 'A' enclosed

1. Medical Record officer postgraduate in Economics with statistics Trained in R.O. (Diploma in DMRSC) with 5 yrs experience. Or Postgraduate doctors in respective subject with 5 yrs experience of teaching.

1. Assistance statistical officer graduate in economics with 10 yrs working experience in MRD.

Eligibility criteria course is open to sponsored candidates only. Separate building is not required. Training course will be conducted in Medical College; Hospital where practical training facility is already available, classes can be taken in respective lecture hall of the Deptt. & One big room should be provided adjoining to medical record deptt. Lecture Hall 40'x40' one room 10'x15'

 

MEDICAL RECORD OFFICER

Introduction:

The working Group discussed in detail the duties and responsibilities of the Medical Record officer and after detailed deliberations, the following functions of Medical Record Officers were agreed to:

(i) Planning, organizing, budgeting, supervision of Medical Record Department.

(ii) Development of medical records and reports, their analysis and use.

(iii) Coding and indexing of hospital diagnosis.

(iv) Development and dissemination of statistical information necessary for hospital management and other uses. Qualitative and analysis of medical records for medical auditing and other purposes.

(v) Conduct of in-service and other training courses on Medical Records Science.

(vi) Preservation, safeguarding and maintaining confidentiality of information in medical records.

(vii) Preservation of records in medico-legal cases in safe custody and honoring court summons.

(viii) Preparation of policies and procedures for the development and maintenance of records.

(ix) Correspondence of the department.

(x) Issue of Medical Certificates for Impatient, Outpatient, Births and Death certificate, Insurance claims, and workmen's compensation certificates, Medico-legal reports/certificates. Scrutiny of attendance certificates.

(xi) Assistance in follow-up of patient as required by the physician.

(xii) Assistance in the research works in other studies.

(xiii) To act as a Member-Secretary in Medical audit and other Staff Committees.

Duration: The present duration of 12 months may continue. However, 2 semesters should be one from July to December and the second semester from January to June.

Commencement of the course: Ist July

Intake capacity: 10 to 15 candidates.

Medium of instruction: English at present.

Eligibility criteria: Course is open to sponsored candidates only.

Admission requirements: ESSENTIAL

(i) M.R.T. with minimum of 5 yrs experience in Medical Records Department. Or

(ii) M.R.T. and holding Graduate Degree with minimum of 2 yrs experience in Medical Records Department.

(iii) Candidates sponsored by other countries with similar qualification and experience at the discretion of the individual government having passed English Proficiency test.

(iv) As regards the center where the courses are affiliated and recognized by the Universities as Degree course such as B.M.R.Sc in JIPMER, Pondicheery, C.M.C., Vellore, etc, the essential qualification for admission will be Graduate Degree in discipline as recognized by the respective Universities concerned and their syllabus will also be governed as per the requirements of the Universities.

DESIRABLE:

(i) Pass in English lower grade typing examination or holding a certificate to indicate experience in typing with a speed of at least 40 words per minute.

6. Attendance: Each candidate should put in attendance of at least eighty percent in each semester.

7. Minimum requirement for passing:

A candidates should be declared to have passed if he obtain minimum of 40% of the marks in each paper and in the internal assessment separately but 50% marks in the aggregate in the final examination. Successful candidates who secure 75% of marks in aggregate in the first attempt shall be declared to have passed with distinction.

Discipline: Roles of discipline lay down by the training Institutes should be observed strictly. Any candidate violating the discipline will run the risk of termination of his/her candidature from the course.

Medical Fitness: The sponsoring Institute should ensure medical fitness of the candidate. In case of doubt, medical re-examination will be conducted by the Training Institute. In the event of finding any one medically unfit, the sponsorship will be terminated and to no TA will be admissible.

Stipend: A monthly stipend of Rs. 170/- will be given by the Government of India to the candidates duly sponsored. The rates approved from time to time will be enforced. The cost of traveling to the training center will be borne by the sponsoring authority. The above rate of stipend would be provided no free board and the Institution provides lodging where the training is held. No stipend will be admissible to the local candidates.

Deputation:

Sponsored candidates will be treated as on duty.

Selection Procedures:

Applications to the courses will be invited by the Dtc. General of Health Services. An ad-hoc selection Committee will select the candidates purely on merit with due regard to geographical representation. The candidates will be allotted to the training centies taking into view, inter-alia, and the choice of the candidates. Advance applications will not be entertained. If advance applications are sent, the original application should reach the Dtc. General of Health Services on or before 31st May.

EVALUATION:

Semester

Hours

Internal continuous Assessment Marks

Written/ University Exam Marks

FIRST SEMESTER:

Paper I

Pre and Para clinical subjects (Fundamentals of Anatomy, Physiology, Biochemistry, Pharmacology, Pathology, Microbiology)

Paper II

  1. Medical Terminology
  2. Introduction to fundamentals of clinical science.

SECOND SEMESTER

Paper III

Biostatistics (including General Statistics, Health Care Statistics and E.D.P.)

Paper IV

Medical Records Science (including Hospital Organization, management and Medical Jurisprudence)

Oral

3

 

 

3

 

 

 

 

3

 

3

40

 

 

40

 

 

 

 

40

 

40

60

 

 

60

 

 

 

 

60

 

60

 

 

50

 

 

 

 

 

 

 

1. TEACHING HOURS

Experience Distribution of subjects

Hours

Semester I

General Introduction to Hospital Organization

Paper I: Fundamentals of Pre and Para clinical subjects

    1. Anatomy
    2. Physiology
    3. Biochemistry and Biophysics
    4. Pharmacology
    5. General Pathology and Clinical Pathology
    6. Microbiology

Paper II: (1) Medical Terminology

(2) Introduction to Fundamentals of Clinical Science

Semester II

Paper III: Biostatistics (including Health statistics & Electronic Data Processing)

10

30

30

10

10

30

10

120

(a) General Statistics

(b) Health Care statistics

(c) EDP (Theory & Practical)

Paper IV: Medical Records Science

(Including legal aspects and medical care evaluation Medical audit, medical jurisprudence, Hospital Organization and Management)

II. Directed Practice

III. Seminars

40

20

20

210

 

800


60

1400 hrs

General introduction to Hospitals- (10 hrs.)

(i) History and Evolution of Hospitals

(ii) New trends in Hospitals.

2. Definition of Hospital

- Objectives of Hospital.

- Parameters of Good Medical Care/Patterns of Patient Care.

- Functions of Hospital.

3. Role of a Hospital in Health is Delivery Systems (HCDS)

4. Classification of Hospitals.

5. Hospitals Organization and its analysis

– Chart of Organization.

– Board and committees

– Duties and responsibilities thereof.

6. Departmental Administration

– Delegation

– Decentralization

  1. Patient Care Appraisal (PCA)

– History of Medical Audit

– Tools and Techniques

– Various Phases of Medical Audit.

8. Introduction to various departments of Hospital

(i) Clinical Departments

(ii) Diagnostic and therapeutic services (including clinical Laboratories, Radiology, Physical Medicine and Rehabilitation and Pharmacy services)

(iii) Nursing Department

(iv) Dietary Department

(v) Outpatient Department

(vi) Accident and emergency services Department

(vii) Medical Social Service Department

(viii) General and Medical stores

(ix) Blood Bank

(x) Medical Library services.

9. Service unit: Laundry, Housekeeping, CSSD.

10. Miscellaneous Services: Engineering, Mortuary and Transport services.

11. Tumour Registry Maintenance and other Registry system in India NB:

The above syllabus will be covered for theory examination under Medical Records Science (Paper IV)

Paper- I FUNDAMENTALS OF Pre AND PARA CLINICAL SUBJECTS:

A. Anatomy

1. General Introduction

– Definition of Anatomy & Physiology.

– Types of Anatomy (including systemic)

– Definition of topographic term/term used to describe the body.

– Description of Various regions of the body.

2. Cells and tissues of body and general histology.

3. Anatomical description of the following:

- Skin and breast – Ontology

– Joints – Ligaments

– Fasciae and Bursae – Musculoskeletal system

– Cardiovascular system – Respiratory system

– Lymphatic system – Blood and blood forming organs

– congenital system – Endocrine system

– Organs of special senses (ear, eye, etc.) – Digestive system – Embryology

Reference books:

1. Janet S.Ross, Kathleen, J.W. Wilson, Foundation of Anatomy- Physiology, 4th Ed. E&S, Livingstone Ltd. London.

2. Thompson Haydan, Anatomy for the Medical Record Librarians Physician's Record Co.

3. Francis, C.Cerl, Introduction to Human Anatomy, 6th Ed., C.V. Menbey Co., St. Louis.

B. PHYSIOLOGY

1. Introductory Lectures or specialization of tissues.

2. Homeostasis and its importance in mammals.

3. Blood and lymphatic system

4. Cardiovascular system

5. Excretory system, skin and temperature regulation

6. Respiratory system

7. Digestive system and metabolism

8. Endocrinology

9. Reproductive system

10. Nervous system

11. Special senses

12. Muscles

References books:

1. 1. Janet S.Ross, Kathleen, J.W. Wilson, Foundation of Anatomy- Physiology, 4th Ed. E&S, Livingstone Ltd. London.

2. Miller and Heavall Kimber- Gary- Stackpole's Anatomy and Physiology 18th Ed. Amerind Publishing Co., New Delhi.

C. BIOCHEMISTRY & BIOPHYSICS

– Chemistry in Health

– Chemistry of the body in Health and diseases C and F.

– Clotting mechanisms of the blood.

Anaemias

– G.I. system

– Diuretics

– Endocrinology

– Sex hormones

–Chemotherapy

Books - Sears Golden, '' Material Medical for Nurses, Edward Arnold Gordon. Trounce J.R. Pharmacology for Nurses ELBS. Edinburgh. Alstead Thompson '' Clinical Pharmacology'' Bailliera Tidal and Chassell, London. Nird, Musser '' Modern pharmacology and Therapeutics Macmillan Co. New York, A concise Text Book of Pharmacology by Dr. N. Murugesh, Sathya Publication, Tamil Nadu.

E. Pathology – 30 Hours General Pathology:

- Definitions and Classification of diseases,

Inflammatory diseases – viral and fungal,

Inflammatory diseases –Parasitic,

- Degenerative diseases – Fatty degeneration, Amyloid etc.

– Tumors – Definition, etiology& classification,

-Disturbances in blood flow,

- pigment disorders,

Hereditary diseases, C.V.S. Blood vessels,

-V.S. Heart, Respiratory system,

- G.I. tract, Liver Lymphatic system,

- Genitourinary system, Skeletal system,

- Blood, Central Nervous system,

- Endocrine system

Clinical Pathology – Normal composition of blood; diseases of RBCs.,WBCs., Plate less. – Coagulation factors and disorders – Blood groups and cross – matching, - Blood transfusion, - Urine composition: variation in common diseases, - CSF and body fluids, - Gastris & Duodenal contents, - Fasces – parasites,

- Examination.

Reference Books (Page 500 backside misprint, not written)

  1. MICROBIOLOGY: 10 Hours

    • Introduction and historical background,

    • Classification special,

    • Characteristics of organisms

    • bacterias, - Asepsis, - Disinfection

    • Antiseptics- Sanitation,

    • Infection,

    • Immunity,

    • Allergy study of pathologenic organisms, Non-pathology organisms,

    • Virus and fungus,

    • Parasitic diseases- their stance in India with lab

    • Diagnosis.

Reference Books: Frobisher, Sommerneyer and Good ate, Microbiology and Pathology for Nurses, W.B. Saunders and Co, Philadelphia, Frabisher Martin ' Fundamental of Microbiology'' – W.G. Saunders and Co, Philadelphia.

PAPER –II

Medical Terminology (including Fundamentals of Clinical Science) - 120 Hours

– Medical Terminology – 100 hrs. – Fundamentals of Clinical Science – 20hrs

i. Objective ii. Basic iii.. Elements of Medical Terms

(a) Roots (b) Prefixes

(c) Suffixes (d) Colours

(e) Numerals (f) Symbols(g)Abbreviationn (page501)

(iv) Terms pertaining to Body as a whole.

II. Terms relate to _______________,

____________, Investigations, and operation, treatment of conditions, disorders of: -

1.Skin and Breast (integumentary system)

2. Musculoskeletal

3. Neurological and psychiatric

4. Cardio- vascular

5. Blood and blood forming organs

6. Respiratory

7. Digestive

8. Uro – genital

9. Gynacological

10. Maternal, Antenatal and Neonatal conditions

11. Endocrine and Metabolic

12. Sense organs of: (i) Vision (ii) Hearing

13. Systemic: (i) Infectious diseases. (ii) Immunological diseases. (iii) Diseases of the Connective Tissues. b

14. Geriatrics and Psycho geriatrics.

III. Supplementary terms: Selected terms relating:

1. Oncology

2. Anesthesiology

3. Physical Medicine and Rehabilitation

4. Nuclear Medicine

5. Plastic Surgery of Burns and Maxillofacial

6. Radio- Diagnosis

7. Radiotherapy

BIOSTATICS

PAPER – III

General statistics (40Hours) (Theory & Practical Assignments)

(i) Introduction to Statistics.

(ii) Methods of collection of data.

(iii) Measures of central tendency (simple average, G.M., H.M. Mode and Median).

(iv) Measures of dispersion (Standard deviation, range, variance, average deviation)

(v) Sampling; Definition, Methods of sampling (randoin systematic, stratified, cluster).

(iv) Correlation and regression: Significance, linear correlation, correlation coefficient, linear regression.

(vii) Time series analysis – concept and its utility, component of time series.

(viii) Test of significance.

(ix) Graphical presentation of data.

(x) Probability- concept and definition.

(xi) Uses of statistics.

Health Care Statistics (Theory & practical Assignments) (20 Hours 1. Orientation to Medical Terms

-1. Sources of hospital statistics (In-Patient census, Out – Patient Deptt, and Special Clinics).

2. Definitions (live, birth, foctal death, immaturity, cause of death, underlying cause of death inpatient bed etc)

3. Analysis of hospital services and discharges.

4. Indices (Bed occupancy, average length of stay, bed turn – over interval, death rate, birth rate etc.)

5. Vital statistics.

6. Uses and Limitations of hospital data.

7. Method of compilation of various Health Returns/ Statistical Returns.

Electronic Data processing(8 hrs. Theory & 12 hours practical) 20 Hours

(A) 1. Introduction to Computer.

2. Creation of Data Files using dBase.

3. Programming using BASIC. (Page502)

(4) Word processing.

(B) Introduction to computers

(a) Capabilities of computer.

(b) Characteristics of a computer. '' Speed. '' Monitor '' Plotter ''OPU " output devices ' Printer ' Dise-drives ' Communication.

(c) Types of use ages: '' Independent PC '' Networks '' Batch processing '' on-lines '' Packages

(d) Computer & Principle

(e) Types of usages

(f) Software

2. Creation of Data files using dBase

(a) File structure and it's planning.

(b) Creation of files, Data entry.

(c) Multiple copies with specific individual comments.

PAPER IV: Medical Records Science.

Section A: Hospital Organisation and Management. (40hrs.)

1. Introduction to Principles of Management and Administration - scope and importance of management. –Principles of Management. – Functions of a Manger (POSDCORB-E). Management Techniques. –Material Management – Personal Administration. –Financial Administration.

2. Public Health Structure in India. – Directive Principles of

-With relation to Public Health & medical Care. – Constitutional lists. – Various five years plans and priorities.

3. Role of Voluntary Health Organisation.

4.Basic facts of Health in India.

5. Current Objectives and strategies. – Population Dynamics. – Community Health Worker schemes.

6. National Health Programmes of Medicine and Homeopathy.

8. Other programmes of relevance to Health Sector. – Family Welfare. – Medical Termination of Pregnancy. – National Population Policy. – Maternity and Child Health.

Section B: Medical Record Science. (170hours)

I. Introduction to Medical Record Science.

II. - 1.Development, Analysis and Uses of Medical Record.

2. (i) Development of Medical Record Forms, basic and special. (ii) Order of Arrangements:

(a) Ward

(b) Medical Record Department.

(c) Source oriented medical record.

(d) Problem oriented medical record.

(e) Integrated Medical Record.

3. Analysis of Medical record: (i) Quantitative. (ii) Qualitative.

4. Uses of Medical Records:

(a) as a personal document.

(b) as impersonal document.

5. Values of the Medical Record. (Page503)

III. Responsibility for the Medical Record.

1. Governing Body.

2. Administrator.

3. Medical Staff.

4. Nursing Staff.

5. Medical Record Officer.

6. Medical record committee

7. Medical care review committee

IV. 1. Functions of medical record department:

a) Importance

b) Function

2. a) Organisation of admitting services

b) In patient services

c) Out patient services

d) Accident and emergency services

V. Numbering, filling, retention of medical records:

1. Numbering system

2. Filling system

a) Physical facilities

b) Storage methods

c) Record control

3. Retention and destruction of medical records

i) Retention procedures

ii) Disposal procedure

VI. Indexes (Indexing of patient care data)

1. Patient

2. Diseases

3. Operative procedure

4. Physician

VII. Classification of diseases as per I.C.D. (published by W.H.O.) Classification of diseases as per I.C.D.- C.M. (S.N.D.P.) (published by U.S. public health department) Classification of oncology- I.C.D- O (published by W.H.O.)

VIII. Design, maintain, updating of information system

1. Manual

2. Mechanical

3. Electronic

IX. Legal aspects of medical records:

a) 1. (miss printing)

2. Medical as a legal document

3. Release of information from medical records

4. Legal action requiring evidence from medical records

5. Privileged communication

6. Consentient and authorization

7. Owner ship

b) Medical jury prudence

1. Introduction

2. Legal procedure, Medical law and ethics

3. Identification, Medic logical autopsy

4. Death and post- mortem changes

5. External causes of injuries and medico legal aspects (case study) (Reddy, K.S. Narayan, Second edition " essential of forensic medicine and toxicology)

(Krishnan- Text book of medical juries prudence and toxicology).

X. Organisation and management of medical record.

XI. Uses of medical records in medical care evaluation

XII. Health records in various types of health care institutions

XIII. Interdisciplinary relationship.

1. Intra departmental

2. Inter department

XIV. Introduction of public relationship,

PRACTICAL TRAINING

Directed practice in number of hours- 800 hrs.

OUT- PATIENT AREA: Hours

1. Registration of new cases- 30

2. Registration of old cases- 20

3. Patient guide- 30

4. Lab. X-Ray report and record filling- 40

5. Alpha index, typing and filling- 24

6. O.P. record coding (diseases and indexing)- 72

7. O.P. records retrieval- 30

8.O.P. statistics- 30

9. Test on O.P. procedure- 14

290

IN-PATENT AREA

1. Admitting office - 40

2. Inpatient records, removal and forwarding – 20

3.Census -24

4. Assembling and deficiency check 36

5. Inpatient record coding and indexing – 70

6. Discharge analysis (Manual, Electronic & Mechanical) –70

7. Incomplete record control – 15

8. Complete record control (Group study) - 25

9. Medico –legal procedure & issue of Med. certificates -20

10.medical Statistics and Research -30

11.Record retention and destruction of OP & IP record -10

12. Test on I.P.Procedure - -10

--370

MISCELLANEOUS SECTIONS:

1. Orientation: Introduction to all sections of the hospital - 10

2.Hospital Reception 10

3. Record system in other department of the hospital (Radiology, Pathology, Clinical, Pharmacy, Engineering, Printing Press and Photography etc.)- 32

4. Secretarial work – 10

5. Review of Random problematic cases in Quantities Analysis Point of view –15

6. Visiting other health intuitions 20

7. Special Projects 13

8. Training in rural and urban health centers 30

–140

REVISION OF THE SYLLABUS FOR MEDICAL RECORD TECHICIANS

The workshop reviewed the duties and responsibilities entrusted to the Medical record Technicians and after detailed discussions finalized the following functions for the Medical Record Technician. Medical Record Technicians will however work under the overall guidenance and supervision of medical record officers of officer incharge of medical records deptt.

1. OPD REGISTRATION:

(i) Registration of new and old out patient cases.

(ii) Guidenance to patients to direct them to concerned doctors room.

(iii) Retrieval, dispatch, collection and filling of respective records and supervision there of.

(iv) Collection and linkage of various reports.

(v) Out patient number control.

(vi) Alpha index of outpatient records.

2. INPATIENT REGISTRATION:

(i) Inpatient number control.

(ii) Admission of patient.

(iii) Admission and discharge analysis.

(iv) Assembling deficiency checks and completed record control.

(v) Completion of hospital statistics.

(vi) Coding of diseases and operations (outpatient and inpatient).

(vii) Maintenance of Diagnostic index and operation index.

(viii) Alpha index of inpatient records.

(ix) Scrutiny and maintenance of birth and death registers.

(x) Reporting of communicable diseases etc.

(xi) Supervision of inventory, storage and supply of forms.

(xii) Assistance to the medical record officer in training of new employees and medical record personnel.

(xiii) Supervision of work of personnel under him.

(xiv) Preparation of medical-legal report pertaining to medical record.

(xv) Scrutiny of daily ward census reports and completion of census report.

(xvi) Any other duties assigned by MRO/officer-in-charge of medical record deptt.

MEDICAL RECORD TECHNICIANS COURSE RULES AND REGULATION AND COURSE CONTENT THEREOF

Duration: The course of 6 months duration starting from 1st January and 1st July each year.

Qualification for admission: The candidate should posses the following qualifications. Essential:(i) 10 +2 =12 years schooling recognized by a University/ Board with English as one of the subjects of study.

(ii) Experience in English typewriting with a speed of not less than 30 words per minutes.

Desirable: Experience in medical records of not less than 3 years duration.

Relaxation may be given to the essential qualifications given above in case of matriculate (10) years schooling having in a medical record department of not less than 5 years duration at the discretion of the selection committee. The decision of the committee will be final.

Selection Procedure:

Applications to the course will be invited by the Directorate General of Health services. An ad hoc selection committee will select the candidate purely on merit. The officer's incharge may be associated as members with the selection committee. The student will be different training centers taking into view inter-alia the choice of the candidates. The last date for receipt of applications will be 30th November and 31st May.

Intake Capacity:

Ten to fifteen candidates per course will be admitted.

Stipend:

A monthly stipend of Rs. 500/- will be given by the government of India to candidates duly sponsored. The payment of stipend is admissible subject to fulfillment of the following conditions: -

1. The stipend would be given to in service trainees.

2. The candidate shall not draw any daily allowance from their employer.

3. No free board and loading is provided to the candidate by the institution where the training is held.

4. The cost of traveling to the training center should be borne by the organization to whom the employee belongs.

Course Content:

The following subjects will be taught:

(i) Anatomy and Physiology.

(ii) Pathology, Microbiology and Biochemistry.

(iii) Medical Terminology.

(iv) Medical Records Science.

(v) Hospital organization.

(vi) General and Health care statistics & E.D.P.

(vii) Directed Practices:

The detail of the course contents for each subject are given below:

Anatomy and Physiology – (30 Hours)

More emphasis may be laid on Anatomy.

(i) General Introduction:

(a) Definitions of Anatomy and Physiology.

(b) Types of Anatomy (including systemic).

(c) Definition of Topographic term/ terms used to describe the body.

(d) Description of various regions of the body.

(ii) Cells and Tissues of Body

(iii) Anatomical & Physiological Description of:

(a) Skin and Breast.

(b) Osteology.

(c) Joints, Ligaments, Fasciae and Bursac.

(d) Musculoskeletal system.

(e) Cardiovascular system.

(f) Respiratory system.

(g) Lymphatic system.

(h) Blood and Blood forming organs.

(i) Digestive system.

(j) Urogenital system.

(k) Endocrine system.

(l) Organs of special senses (Eye and Ear).

Pathology – (5 Hours)

(i) Introduction to Clinical Pathology.

(ii) Definitions and classification of diseases.

(iii) Broad outline and classification various types of clinical lesions/tumours and malignant.

Microbiology – (5 hours)

(i) Introduction and Orientation to subject of Microbiology.

(ii) Modes of transmission of diseases and general principle of Immunodiagnosis.

(iii) Principle of lab, diagnosis of Bacterial infections.

(iv) Principle of lab, diagnosis of parasitic infection.

(v) Principle of lab, diagnosis of Viral and Fungal infection.

Biochemistry – (5 Hours)

(i) Definition of Biochemistry.

(ii) Elementary ideas/overview of the following:

(a) Sugars, Proteins and lipids and their metabolism.

(b) Different types of constituents in blood including enzymes and their variation in diseases.

(c) Composition of CSF in Health and diseases.

(d) Composition of ascetic fluid and pleural fluid in diseases.

(e) Functional test like LFT, GTT, AHT and clearance test for Kidney functions.

(f) Special investigations like radio-active iodine uptake, radio-immune assay, protein bound iodine and PH, PO2 and PCO2.

(g) Elementary ideas on nutrition.

(h) Basic knowledge of Vitamins, hormones and Vitamin deficiency diseases and endocrine diseases.

(i) Water and electrolyte balance.

(j) Acid base balance.

(k) Normal and abnormal constituents of urine.

Medical Coding – (30 Hours)

(i) Definition of coding and classification of diseases.

(ii) Introduction to Vol. I & II of the ICD (latest revision of WHO).

(iii) Rules for classification of Morbidity and Morality.

(iv) Tabulation list of Morbidity and Morality.

(v) Introduction to classification of Oncology – ICD – O.

(vi) Introduction to coding SNOD, SNOP, ICD-CM of Vol. I & II of ICD (latest revision of WHO).

Medical Terminology – (75 Hours)

(i) Definition, Objectives, Values of Medical Terminology.

(ii) Colours, Symbols, Numerals etc.

(iii) prefixes

Microbiology – (5 hours)

(i) Introduction and Orientation to subject of Microbiology.

(ii) Modes of transmission of diseases and general principle of Immunodiagnosis.

(iii) Principle of lab, diagnosis of Bacterial infections.

(iv) Principle of lab, diagnosis of parasitic infection.

(v) Principle of lab, diagnosis of Viral and Fungal infection.

Biochemistry – (5 Hours)

(i) Definition of Biochemistry.

(ii) Elementary ideas/overview of the following:

(a) Sugars, Proteins and lipids and their metabolism.

(b) Different types of constituents in blood including enzymes and their variation in diseases.

(c) Composition of CSF in Health and diseases.

(d) Composition of ascetic fluid and pleural fluid in diseases.

(e) Functional test like LFT, GTT, AHT and clearance test for Kidney functions.

(f) Special investigations like radio-active iodine uptake, radio-immune assay, protein bound iodine and PH, PO2 and PCO2.

(g) Elementary ideas on nutrition.

(h) Basic knowledge of Vitamins, hormones and Vitamin deficiency diseases and endocrine diseases.

(i) Water and electrolyte balance.

(j) Acid base balance.

(k) Normal and abnormal constituents of urine.

Medical Coding – (30 Hours)

(i) Definition of coding and classification of diseases.

(ii) Introduction to Vol. I & II of the ICD (latest revision of WHO).

(iii) Rules for classification of Morbidity and Morality.

(iv) Tabulation list of Morbidity and Morality.

(v) Introduction to classification of Oncology – ICD – O.

(vi) Introduction to coding SNOD, SNOP, ICD-CM of Vol. I & II of ICD (latest revision of WHO).

Medical Terminology – (75 Hours)

(i) Definition, Objectives, Values of Medical Terminology.

(ii) Colours, Symbols, Numerals etc.

(iii) prefixes.

(iv) Suffixes (Diagnostic operative & symptomatic).

(v) Roots.

(vi) Origin of term anatomical,

(misprint page 507)

. Radiology and Clinical terms and abbreviation in respect of the following: (i) Musculoskeletal system.

(ii) Integumentary system.

(iii) Circulatory and lymphatic system.

(iv) Respiratory system.

(v) Digestive system.

(vi) Genito-urinary system.

(vii) Endocrine system.

(viii) Neurological and Psychiatric disorders.

(ix) Obstetrics and Gynecology.

(x) Special senses (Eye and Ear).

(xi) Body a as whole, diseases of.

(A) Medical Records Science (80 Hours):

1. Brief history of Medical Record.

2. Definition of Medical Record.

3. Characteristics of Medical Record.

4. Values of Medical Record.

5. Contents and components of Medical Record (not written).

5. Need for the Medical Record Department and its functions.

7. Responsibility for Medical Record, hospital administrator doctors, nurses, Para-medicals.

8. Organisation and management of medical record department, medical record committees, medical audit committees etc.

9. Origin and development of medical record including organisations of admission office.

10. Control and quantitative and qualitative analysis of discharged inpatient records.

11. Numbering, filling retrieval and storing of records.

12. Indexes and indexing control.

13. Legal aspects of Medical Records.

14. Retention, preservation and destruction of medical records.

15. Organisation of outpatient medical record services.

(B) Medical Jurisprudence (5 Hours):

1. Introduction.

2. Legal procedures, medical law and ethics.

3. Identification, medical autopsy.

4. Death and Post-mortem change.

5. External causes of injuries and medico-legal aspect (case studies).

BIOSTATISTICS (80 Hours):

(a) General Statistics: (30 hours: Theory 25 hours, Practical: 5hours).

(i) Definition.

(ii) Types of Data.

(iii) Methods of collection of data.

(iv) Classification and tabulation of data.

(v) Measures of Central Tendency (Simple average, mode & median)

(vi) Measures of Dispersion (Mean deviation, standard deviation, range).

(vii) Graphical presentation of data (Line graph, Bar graph, Component chart, Pie chart).

(viii) Vital Rates and Ratios.

(ix) Use of statistics.

(x) Use of calculators.

(xi) Practical Assignments.

(b) Health Care Statistics: (20 Hours:

Theory-15 hours, Practical-5 hours)

(i) Definition.

(ii) Important terms (Inpatient/Outpatient, Bed, Admission, Discharge, Length of stay, live birth, still birth, cause of death etc.)

(iii) Sources of hospital statistics.

(iv) Calculation of derivatives (percentage, bed occupancy, death rate, birth rate, turnover interval etc.).

(v) Uses and limitations of hospital statistics.

(vi) Practical Assignments.

(c) Hospital Organisation: (10 Hours)

1. Introduction to Hospital.

2. Definition of Hospital.

3. Functions of Hospital.

4. Classification of the Hospital.

5. Hospital Organisation.

6. General Principles of Management (POSCORDE):

(i) Planning

(ii) Organizing.

(iii) Staffing.

(iv) Directing.

(v) Coordinating.

(vi) Evaluation.

7. Introduction to the various departments of Hospitals namely: -

(i) Nursing

(ii) Dietary.

(iii) Clinical Laboratories.

(iv) Radiology.

(v) Pharmacy.

(vi) Outpatient services.

(vii) Accident and Emergency services.

(viii) Medical Social Services.

(ix) Medical library.

8. Other Department:

(i) Personnel administration.

(ii) Financial administration.

(iii) Engineering and Maintenance.

(iv) House Keeping.

(v) General Stores.

(d) Electronic Data Processing (20 hours: Theory-8 hrs. Practical- 12 hrs.)

1. Introduction to Computers:

(a) Capabilities of a Computer.

(b) Characteristics of a Computer/Speed/Accuracy/Memory.

(c) Types of Computer and their areas of usage.

(d) Components & peripherals (Input devices/Output devices/Monitor/Printer/Plotter/Disk drives/CPU/Communication.)

(e) Types of Usages (Independent PC, Batch processing, misprint, On-line.).

    1. Software Languages/Utilities/Packages/Programmes.

2. Creation of Data Files using dBase:

(a) File structure and its planning.

(b) Creation of files, Data entry.

(c) Simple operations of files.

3. Word Processing:

(a) Preparation of letters.

(b) Creation of tables.

(c) Multiple copies with specific individual comments.

PRACTICAL TRAINING:

Directed Practice (425 hours)

Outpatient Area:

1. Registration of New cases (15hrs).

2. Registration of old cases (10hrs)

3. Record guide (15hrs)

4. Lab-ray reports and record filing (15hrs)

5. Alpha Index typing and filing (15hrs)

6. Out- patient Records coding (Diseases) & indexing (40hrs)

7. Outpatient record Retrieval (15hrs)

8.Out-patient statistics (20)

9. Test on –patient procedure (5hrs) - 150

6. General Principles of Management (POSCORDE)

–Planning,

- Organizing,

- Staffing,

-Directing,

- Coordinating,

- Evaluation,

7. Introduction to the various departments of Hospital namely:

- Nursing,

- Dietary,

- Clinical Laboratories,

-Radiology, - Pharmacy,

- Out-patient Services,

- Accident and Emergency services,

- Medical social service,

- Medical Library.

8. Other Department:

- Personal administration,

- Financial administrating,

- Engineering and Maintenance,

- House keeping,

- General stores.

(d)Electronic Data Processing – 20hours (Theory – 8hrs. Practical 12hrs.)

1. Introduction to computers; -

(a) Capabilities of a computer.

(b) Characteristics of a computer. '' Speed,''Accuracy, –'' Memory,

(c) Types of Computers and their areas of usage.

(d) Components & peripherals: -'' Input devices –''Monitor, -'' Plotter –'' OPU –'' Output devices –'' Printer –'' disk drivers – ''Communication.

9. Inpatient Area: -

1. Administrative. (20hrs)

2. Inpatient records removal and forwarding –(10hrs)

3. Census (15hrs)

4. Assembling and deficiency check. (20hrs)

5. Inpatient record coding and indexing. (30hrs)

6. Discharge Analysis (Mantral, Mechanical and Electronic)(30hrs)

7. Incomplete record Control

8. Complete record control(Group study) (25)

9. Medico – legal procedure and issue of Medical certificates etc. (15hrs)

10. Research in Medical & hospital & Statistics (20hrs)

11. Record Retention and destruction of Out-patient & In-patient Record (15hrs)

12. Test on In-Patient Procedures (5hrs) 225

10. Miscellaneous section: -

1. Orientation: Introduction to all section of the hospital (5hrs)

2. Hospital Reception (10hrs)

3. Record system in other departments of the hospital (rediology, pathology, Clinical, path lab, Pharmacy, Engineering, Printing Press and Photography etc.) (10)

4. Secretarial Work (5hrs)

5. Visiting to other Hospital/ Health Institutions (10hrs)

6. Training to rural and urban health centers (10hrs) 50 (page511)

 

 

 

 

 

 

 

ANNEXURE-V

ELEVALUATION OF TRAINING PROGRAMMES

The group discussed in detail the utility of elevalution of training programmes as a tool fact further improvements in the training programmes meant for Medical record Officers. Medical Record – technicians. To apply Corrective Measures from time to time, the misprint flet that there should be periodical evaluation in a semester for training programmes misprint for Medical Record Officers and Medical Record Technicians. The group was of the misprint that the following schedule may be adopted for evaluating the training programmes

MRO/MRT.MRO Trainees:

- Pre-term –Second week of staring of the course,

-Mid-term – At the end of three months,

-Final – 10 to 15 days before final examination of the semester

MRT Trainees:

- pre-term – second week of starting of the course,

Mid- term – At the end of the three months,

-Final – 10 to 15 days before final examination of the semester,

As regards the sample questionnaire circulated by the CBHI,the groups observed that questionnaire with suitable modification, as may be necessary, in the light of the course content may modified by the Officer- in –charge of the Training Centers and adopted for periodical evaluation of the training programmes. The group also pointed out that order to have an objective evaluation of the training programmes an Official from the CBHI should also be associated with such evaluation of the training programmes.

ORGANISATION OF REFERESHER COURSES

The group examined in depth the proposal for introduction of refresher courses for Medical Record Officers who have completed 5 years service. They considered various courses highlighted by the CBHI in this context and suggested that one week refresher course may be organized for Medical Record Officer who have completed at least 5 years of service and such course may be organized at appropriate medical colleges/ institutions which well established and where the facilities of medical records exit. During the refresher courses, the Trainees may be exposed to various modern management techniques for better organization of medical records; case studies of some well established hospitals to provide insight into the management techniques and practical exposure to the latest equipments personal computers, mini- computers or micro-computers for better records management. Misprint refresher courses may be organized through lectures, seminars/workshops.

4. Suffixes (Diagnostic, operative & symptomatic)

5. Roots

6. Origin of terms anatomical, diagnostic operative, Radiology and Clinical terms and abbreviations in respect of the following:

(i) musculoskeletal system.

(ii) Integumentary system.

(iii) Circulatory and lymphatic system.

(iv) Respiration system.

(v) Digestive system.

(vi) Genito- urinary system.

(vii) Endocrine system.

(viii) Neurological and Psychiatric disorders.

(ix) Obstetrics and Gynecology.

(x) Special senses (Eye and ear).

(xi) Body as a whole, disease of.

(A) Medical Records Science (80hours)

1. Brief history of Medical Record.

2. Definition of Medical Record.

3. Characteristics of Medical Record.

4. Values of Medical Record.

5. Concents and components of Medical Record.

6. Needs\ for the Medical Record,Department and its functions

7.Responsibilty for medical record, hospital administration doctors, nurses, Para- medicals.

8. Organization and Management of medical record Department, Medical Record Committees, and Medical Audit Committee etc.

9. Origin and development of medical record including organisations of admission office.

10. Control and quantitative and qualitative analysis of discharged inpatient records.

11. Numbering, filling retrieval and storing of records.

12. Indexes and indexing control.

13. Legal aspects of Medical Records.

14. Retention, preservation and destruction of medical records.

15. Organisation of outpatient medical record services.

(B) Medical Jurisprudence (5 Hours):

1. Introduction.

2. Legal procedures, medical law and ethics.

3. Identification, medical autopsy.

4. Death and Post-mortem change.

5. External causes of injuries and medico-legal aspect (case studies).

BIOSTATISTICS (80 Hours):

(a) General Statistics: (30 hours: Theory 25 hours, Practical: 5hours).

(i) Definition.

(ii) Types of Data.

(iii) Methods of collection of data.

(iv) Classification and tabulation of data.

(v) Measures of Central Tendency (Simple average, mode & median)

(vi) Measures of Dispersion (Mean deviation, standard deviation, range).

(vii) Graphical presentation of data (Line graph, Bar graph, Component chart, Pie chart).

(viii) Vital Rates and Ratios.

(ix) Use of statistics.

(x) Use of calculators.

(xi) Practical Assignments.

(b) Health Care Statistics: (20 Hours: Theory-15 hours, Practical-5 hours)

(i) Definition.

(ii) Important terms (Inpatient/Outpatient, Bed, Admission, Discharge, Length of stay, live birth, still birth, cause of death etc.)

(iii) Sources of hospital statistics.

(iv) Calculation of derivatives (percentage, bed occupancy, death rate, birth rate, turnover interval etc.).

(v) Uses and limitations of hospital statistics.

(vi) Practical Assignments.

(c) Hospital Organisation: (10 Hours)

1. Introduction to Hospital.

2. Definition of Hospital.

3. Functions of Hospital.

4. Classification of the Hospital.

5. Hospital Organisation.

 

 

(e) Types of Usages (Independent PC, Batch processing, misprint, On-line.).

(f) Software Languages/Utilities/Packages/Programmes.

2. Creation of Data Files using dBase:

(a) File structure and its planning.

(b) Creation of files, Data entry.

(c) Simple operations of files.

3. Word Processing:

(a) Preparation of letters.

(b) Creation of tables.

(c) Multiple copies with specific individual comments.

PRACTICAL TRAINING:

Directed Practice (425 hours)

Outpatient Area:

1. Registration of New cases (15hrs).

2. Registration of old cases (10hrs)

3. Record guide (15hrs)

4. Lab-ray reports and record filing (15hrs)

5. Alpha Index typing and filing (15hrs)

6. Out- patient Records coding (Diseases) & indexing (40hrs)

7. Outpatient record Retrieval (15hrs)

8.Out-patient statistics (20)

9. Test on –patient procedure (5hrs) - 150

Inpatient Area: -

1. Administrative. (20hrs)

2. Inpatient records removal and forwarding –(10hrs)

3. Census (15hrs)

4. Assembling and deficiency check. (20hrs)

5. Inpatient record coding and indexing. (30hrs)

6. Discharge Analysis (Mantral, Mechanical and Electronic)(30hrs)

7. Incomplete record Control (Group study) (25)

8. Complete record control

9. Medico – legal procedure and issue of Medical certificates etc. (15hrs)

10. Research in Medical & hospital & Statistics (20hrs)

11. Record Retention and destruction of Out-patient & In-patient Record (15hrs)

12. Test on In-Patient Procedures (5hrs) 225

Miscellaneous section: -

1. Orientation: Introduction to all section of the hospital (5hrs)

2. Hospital Reception (10hrs)

3. Record system in other departments of the hospital (radiology, pathology, Clinical, path lab, Pharmacy, Engineering, Printing Press and Photography etc.) (10)

4. Secretarial Work (5hrs)

5. Visiting to other Hospital/ Health Institutions (10hrs)

6. Training to rural and urban health centers (10hrs) 50.