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Medical Records

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This module is required, to be fully, integrated with, inpatient management and patient accounting. This module should support the operational needs of a modern medical records department including transcription, case indexing, abstracting, statistical reporting, charge location, with complete integration with patient billing function.

The following has been extracted from a recent RFP. I've included it here for your reference. It may prove useful for anyone preparing such a document.
Please feel free to comment on this list, and propose any items that you think should have been included in this list. 

Medical Records

This module is required, to be fully, integrated with, inpatient management and patient accounting. This module should support the operational needs of a modern medical records department including transcription, case indexing, abstracting, statistical reporting, charge location, with complete integration with patient billing function.

>>> General
1   Automatic and manual assignment of medical record numbers to patients not found in Master Patient Index
2   Allow for error correction and merging of duplicate patient records
3   Support on-line maintenance and access to medical records for inpatients, outpatients, and emergency patients.
4   Provide a Master Patient Index ( MPI ) containing patient demographic, insurance and diagnosis data for all hospital visits.
5   Automatically update MPI based upon entry and update of patient data in admissions or registration
6   Provide storage capacity to retain MPI data permanently
7   Allow authorized medical records staff to merge to medical records for same patient
8   Allow reuse of medical record number if used in error
9   Support medical records abstracting
10   Retrieve patient demographic data from admissions system and/or MPI into abstracting functions
11   Retain all diagnoses during patient stay for abstracting purposes
12   Support user-defined fields for hospital’s unique abstracting needs
13   Provide on-line help screens to assist in abstracting process
14   Generate abstracting productivity statistics on amount of work completed and time spent per chart
15   Support ICD-10 coding and online maintenance
16   Support Current Procedural Terminology – Fourth Generation ( CPT-4 )
17   Provide updates of ICD-10 and CPT-4 code files required by regulation changes
18   Maintain and provide ability to display hospital-specific coding procedures and guidelines
19   Automatically edit coding entries to insure valid order of codes ( e.g. principal diagnosis as 1st and specific complication as 2nd )
20   Include context-sensitive coding prompts and instructions to ensure complete coding
21   Provide “quick entry” feature that replaces long medical terminology after short abbreviation is keyed
22   Support “reasonableness” edit checks to insure proper coding ( e.g. patient sex correlate with procedure )
23   Support current and past DRG groupers for previous two years on the system for use at the same time
24   Provide option for DRG optimizing to assess alternative coding and expected reimbursement
25   Provide an automated birth log
26   Provide an automated death log and bereavement form
27   Provide automated tumor registry functions
28   Bar code capabilities to facilitate record reading and data entry

>>> Medical Record Data
29   Patient data :- Demographic patient data
30   Patient data :- Outpatient data
31   Patient data :- Current administrative data
32   Patient data :- Confidential records
33   Clinical data :- Test results
34   Clinical data :- Medications
35   Clinical data :- Vital signs, allergies
36   Clinical data :- Orders
37   Clinical data :- Nursing documentation
38   Clinical data :- Graphical display of data , automatic plotting of results

>>> Query
39   On-line search of MPI by patient name
40   On-line search of MPI by patient name with soundex ( phonetic ) search capability
41   On-line search of MPI by Social Security Number
42   On-line search of MPI by Medical record number
43   On-line search of MPI by alternate name ( e.g. maiden name , father’s , mother’s)
44   On-line search of MPI by patient birth date

>>> Medical Record Tracking
45   Track status of all required data to complete patient’s medical record folder at discharge
46   Allow for reserve of Medical Charts by authorized Staff
47   Allow to change location of Medical Records
48   Provide chart control functions that track chart location by physician or other members
49   Produce an automated ‘picking list’ of charts to be sent by bulk ( i.e. to the clinics ) , based upon the appointments system
50   Generate chart out-guides and chart routing slips to assist in chart control
51   Track incomplete charts and missing data required for completion
52   On-line inquiry for all not found in / returned to the Medical Records department
53   Print reminder letters and reports monitoring location of the records checked out
54   Enable users to view any record and display the record’s current location
55   Support merging and deletion of Medical Records
56   Generate an audit trail and recipient inquiry
57   Warn for duplicate or incomplete records
58   Incomplete Medical Records check

>>> Reporting and Print Options
59   Print daily chart retrieval lists for all patients with scheduled visits
60   Print chart request notice in Medical Records for unscheduled admissions and registrations
61   Production of bar-coded labels
62   Print incomplete medical record delinquency reports by physician showing deficiencies
63   Print deficiency, suspension and reinstatement letters for physicians
64   Provide ability to report abstract data on magnetic media and other interfaces medias ( e.g. tape or disk ) for reports to outside agencies )
65   Print aging report of all checked out charts by location in hospital
66   Produce deficiency report for physicians and specialties
67   Produce deficiency report for diagnosis and procedures
68   Print incomplete coding reports
69   Print ICD-10 attestation statements for physician signing
70   Print statistical report of admissions
71   Print statistical report of discharges
72   Print statistical report of deaths
73   Print Statistical report of occupancy percentage
74   Print statistical report of patient days
75   Print report of physician activity by medical service
76   Print list of physicians with suspended admission privileges
77   Pint list of physicians with suspended clinical privileges
78   Maintain user activity log
79   Maintain monthly log of new medical records

>>> Statistical Reports
80   Statistical Report of admission by service and admitting diagnosis
81   Statistical report of discharge by service by discharge diagnosis
82   Statistics by discharge diagnosis to include: Frequency, age groups, percent of deaths, gender , actual length of stay
83   Statistics by primary discharge diagnosis and secondary diagnosis to include: Frequency, age groups, percent of deaths by age group, gender, actual length of stay

>>> Archiving
84   Maintain abstracting data on-line for three years
85   Maintain sensitive archiving facilities
86   Maintain discharge summary of inpatients in various formats
87   Perpetually maintain the patient index as per set criteria

>>> Clinical History
88   A visit history which lists visits, providers visited, and when
89   A history of the patient’s encounters
90   A list of all patients’ visits, along with the diagnosis associated with each visit.
91   Medical history and test results

>>> Integration
92   Registration Module
93   Inpatient and Outpatient modules
94   Labs
95   Order entry and results reporting
96   Radiology
97   Pharmacy

Last Updated ( Tuesday, 28 October 2008 01:43 )  

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