Transcript GOVERNMENT OF INDIA OFICE OF THE MEDICAL …

GOVERNMENT OF INDIA
OFICE OF THE MEDICAL SUPERINTENDENT
SAFDARJANG HOSPTIAL, NEW DELHI-110029
MEDICAL RECORD DEPARTMENT AND
TRAINING CENTRE FOR MEDICAL RECORDS
SAFDARJANG HOSPITAL, NEW DELHI-110029
WORKSHOP OF
ICD – 10
FROM CITIES OF
DELHI AND ROHTAK
(21-23 JULY, 2004)
SUBJECT: CBHI – WORKSHOP OF KEY TRAINERS ON ICD – 10
FROM CITIES OF DELHI & ROHTAK
PRESENT ACTION PLAN FOR IMPLEMENTING ICD – 10 IN THIS
HOSPITAL
A.
PRESENT STATUS OF MEDICAL CODING IN MRD&TC OF S.J.
HOSPITAL
B.
DIAGNOSTIC INDEXING
C.
TRAINING IN MEDICAL CODING IN ICD-10 IN THE TRAINING
CENTRE FOR MEDICAL RECORDS OF THIS HOSPITAL
BY
VIJAY KUMAR HARNAL,
MEDICAL RCORD OFFICER,
(MRD&TC),
MEDICAL RECORD DEPARTMENT AND
TRAINING CENTRE FOR MEDICAL RECORDS,
SAFDARJUNG HOSPITAL,
NEW DELHI-110029.
A. PRESENT STATUS OF MEDICAL CODING
IN MRD&TC OF S.J. HOSPITAL
1.
2.
3.
4.
5.
6.
THE MEDICAL CODING OF DISEASES IS DONE ON THE CASE SHEET, AS
AND WHEN DISCHARGED CASE SHEETS ARE RECEIVED FROM THE
WRDS.
IT IS DONE BY CODING BOOKS OF WHO I.E. ICD – 10TH REVISIONS SINCE
1996, BEFORE IT, IT WAS DONE BY THE ICD-9TH REVISION
IT IS DONE BY THE TRAINED MEDICAL RECORD TECHNICIANS OF THIS
HOSPITAL
MULTIPLE CODING IS DONE I.E. CODE NUMBERS TO ALL THE PRIMARY
AND SECONDARY DISEASES ARE GIVEN ON THE CASE SHEETS.
OPERATIONS OR SURGICAL PROCEDURES CODING IS ALSO DONE ON
THE CASE SHEET WITH RED INK
AS YOU MAY BE AWARE CODE NUMBERS FOR OPERATION ARE NOT
PUBLISHED IN ICD – 10TH REVISION. THE CODE NUMBER FOR OPRATION
ARE GIVEN AS PER INCD-9TH REVISION
B. DIAGNOSTIC INDEXING
1.
PREVIOUSLY WE HAVE BEEN DOING DIAGNOSTIC INDEXING MANUALLY
ON THE DIAGNOSTIC INDEX CARDS FOR RETRIEVAL OF MORBIDITY
AND MORTALITY DATA.
2.
SAMPLE OF DIAGNOSTIC INDEX CARD IS AS UNDER
FOR CODING: G 04.9
(G 04 IS FOR ENCEPHALITIS, MYELITIS AND ENCEPHALOMYELITIS.
.9 IS FOR UNSPEC9IFIED FOR ITS FURTHER DETAILS)
CODE NO. G 04
-----------------------------------------------------------------------------------------------------------------------------MRD NO AGE RESULT MONTH OF DAYS OF ASSOCIUNIT
OTHER
SEX M F
DISCHARGE STAY
ATED DISEASE
DISEASES
--------------------------------------------------------------------------------------------------------------------------635686 38
Exp.
6
12
.9
NEAURO.1
24.9 (IHD)
-----------------------------------------------------------------------------------------------------------------------------3.
AT PRESENT WE ARE DOING DIANOSITC INDEXING IN THE COMPUTERS
C. TRAINING OF MEDICAL CODING ON ICD – 10TH
REVISION
1.
2.
3.
4.
THE MEDICAL RECORD DEPARMENT OF THIS HOSPITAL IS DOING CODING OF
DISEASE AS PER ICD-10TH REVISION SINCE 1996.
BEING A TRAINING CENTRE FOR MEDICAL RECORDS THE MRO/MRT TRAINEES
ARE ALSO TRAINED N THE MRD&TC,
ABOUT 19 MRO & 87 MRT TRAINEES OF VARIOUS STATES OF INDIA, VIZ DELHI, U.P.,
HARYANA, RAJASTHAN, MANIPUR, ASSAM, J7K HAVE BEEN TRAINED IN THIS
MRTC SO FAR IN USE OF INCD-10 CODING.
THE RESPONSE FO RMRTC TRAINING IS VERY LOW DUE TO VARIOUS REASONS
VIZ:
- LACK OF MRO/MRT POSTS IN MEDICAL RECORD DEPAREMENTS IN HOSPTIALS.
- LACK OF WELL ORGANISED MEDICAL RECORD DEPARTMENTS IN IN THE
HOSPTIALS
- IT SHOULD BE MADE MENDATORY TO HAVE A TRAINED MRO/MRT IN HOSPITALS
BY THE DGHS IN ALL OVER INDIA
SOME HOSPITALS ARE MANNED WITH STATISTICIANS/MINISTERIAL STAFF IN
PLACE OF MRO/MRT
LACK OF RECOGNITION TO MEDICAL RECORD DEPARTMENTS AND TRAINED
MEDICAL RECORD PERSONNEL
5. THE ICD-10 MEDICAL CODING CAN BE
IMPROVED IN INDIA BY DEVELOPING MEDICAL
RECORDS OF HOSPITALS OF INDIA BY -
-
-
- A STUDY SHOULD BE MADE TO IDENTIFY THE STATUS OF MEDICAL RECORDS
OF VARIOUS HOSPITALS OF ALL THE STATES OF INDIA.
- EXISTENCE OF MEDICAL RECORD DEPARTMENT.
- SUGGEST SUFFICIENT NUMBER OF TRAINED MRO/MRT STAFF.
-TO MAKE IT ESSENTIAL TO HAVE A TRAINED MEDICAL RECORD STAFF.
- FOR TRAINED MEDICAL RECORD STAFF
FOR TRAINING LIN MEDICAL CODING OF INC-10 IN VARIOUS HOSPITALS IN
INDIA THE HOSPITALS SHOULD GET THEIR STAFF TRAINED IN MRTC OF
SAFDARJANG 7 PONDICHERY IN MRO/MRT TRAINING, BEING CONDUCTED IN
THESE TRAINING CENTRES THROUGH THE OFFICE OF DIRECTOR, CBHI (DGHS),
ROOM NO. 401, A WING, NIRMAN BHAVAN, NEW DELHI.
MEDICAL CODING IS ONE OF THE ULTIMATE SUBJECT IN BOTH THE ABOVE
COURSES.
MEDICAL CODING CAN NOT BE DONE WITHOUT THE TRAINED MRO/MRT
PERSONNELS.
THANK YOU