MEDICAL RECORDS DIVISION

The Medical Records Division is the backbone of a healthcare organization’s information infrastructure. It is a specialized administrative and clinical service unit responsible for managing patient health information from creation through final disposition. Far from being just a “storage room for files,” the modern MRD is a dynamic, technology-driven department that ensures data accuracy, accessibility, security, and compliance. It bridges clinical care, administrative operations, legal requirements, and research.

 Functions of the Medical Records DIVISION.

1. Record Creation, Analysis, and Curation

Registration & Indexing:  Creating the Master Patient Index (MPI) – the central database of every patient seen by the facility. This ensures unique patient identification to avoid duplicate records.

Record Assembly & Analysis: Reviewing each record for completeness, accuracy, and compliance. Analysts check for missing signatures, timed entries, discharge summaries, operative reports, and other critical components.

Abstracting & Coding:  Extracting key clinical data (diagnoses, procedures) from the record and translating it into standardized codes (ICD-10/ICD 11). This is critical for billing, reimbursement, and statistical reporting.

Deficiency Management:  Identifying and tracking incomplete or delinquent records. The MRD works closely with physicians and other clinicians to ensure all documentation is completed within a specific time line.

2. Release of Information (ROI)

 Processing authorized requests for patient health information from patients themselves, insurers, attorneys, government agencies, and other healthcare providers.

Ensuring strict adherence to NDPA 2023 (Nigeria Data Protection ACT 2023) privacy and security rules, including proper authorization and verification.

3. Coding and Reimbursement Support

Diagnosis & Procedure Coding:  Using ICD-10/ICD11 codes to capture a patient’s condition and their services.

Query Process:  Coders send queries to physicians if documentation is unclear, insufficient, or contradictory. This ensures accurate coding and reflects the clinical picture.

4. Data Management, Analytics, and Reporting

 Maintaining and securing the electronic health record (EHR) system.

Generating internal reports for quality improvement (e.g., infection rates, readmission rates), operational efficiency (length of stay), and clinical research.

 Providing data to external agencies (e.g., state health departments, Public health department and Regulatory Councils for accreditation purposes.

Supporting cancer registries, trauma registries, and other disease-specific databases.

5. Legal and Regulatory Compliance

Ensuring that health information releases adheres to local, state, and federal laws (e.g., NDPA Act).

Managing subpoenas, court orders, and legal requests for records.

Participating in risk management, audits, and accreditation surveys

Maintaining records retention and archives

Banbole Julianah Aderonke.
HND, MHIM (ABU Zaria)
Head Medical Records Services