Management of Medical Records

Session Objectives Explain the purpose of medical records management Discuss the function of a medical records unit Describe the uses of a medical record Describe the organization of a medical record unit Discuss the rationale and the application of the numbering system of medical records Describe the common policies related to the management of medical records Describe the essential standards of information inherent to patients’ medical records Describe commonly used hospital record forms Describe the use of index cards, log books and reporting forms

Purpose of Medical Records Management To improve the accessibility of medical records; To create quality medical records; To encourage greater utilization of hospital statistics generated in the Medical Records Unit (MRU); To increase quality assurance programs not only in the Medical Records Unit, but in the hospital as well; To participate in research and studies

Functions of a Medical Records Service / Unit Maintain all medical records in accordance with the principles and practices of efficient and effective medical record management; Protection from deterioration and safe keeping Ensure storage arrangement for easy retrieval Ensure the integrity of data in the records are maintained Maintain comprehensive indexes Review records for completeness and accuracy, coding of diseases, operations, and special therapies according to approved nomenclature and classification

Functions of... Maintain a comprehensive and up-to-date record for hospital patients to ensure that all relevant information on each patient is collected, placed in the record, filed accordingly; Collate and compile data and produce statistical reports required by the Ministry of Health, the Bureau of Hospitals and other agencies; Provide records of patient data for use in approved research programs; Respond to all subpoenas and medico-legal cases directed to the hospital;

Functions of ... Maintain and safeguard the confidentiality of the medical record; Provide records, upon request, for patient’s attendance to OPD and the wards; Ensure that all reports and results are promptly and accurately filed in the corresponding patient record; Participate in research activities and studies conducted by doctors and authorized researchers by providing needed data and other information; Prepare periodic reports on morbidity, birth and death, etc.

Uses of Medical Records For the patient As a clinical history of the patient’s treatment at the hospital; As a documentary support or evidence of confinement, diagnosis, and treatment received as a hospital patient.

Uses of ... For the Health Care Providers As a reliable reference of the clinical history of the patient. As a tool/instrument to enable the various health care provider to assess their role in the patient’s total care. As a record of the treatment ordered and given for the patient’s continued care and treatment As data source for research, both retrospective and concurrent. As an educational tool in the training of and feedback to the staff, and for assessment of clinical procedures.

Uses of ... For the Hospitals As a basis for statistical data used in assessing quality and effectiveness of patient care; past performance; and workload for the projection of demands, and planning and allocation of hospital resources; To form patient profiles to determine market demands for more effective provision of service.

Uses of ... For the Government and the Department of Health For the provision of statistical data to aid resource allocation on an area, state and national basis To provide morbidity data to project health trends within the population for the assessment within and against, national and international health patterns

Organization of MRU Secondary Hospital Primary Hospital

Organization of ... Tertiary Hospital

The Numbering System Serial numbering Unit numbering Under this method, the patient receives a new number on every in-patient admission or outpatient visit to the hospital. Unit numbering Under this method, the patient is assigned a unique identification number on his first contact with the hospital Serial unit numbering A tracer is left where the previous records were pulled out to indicate where the records are now filed.

Features of an Effective Numbering System Use of unique patient numbering system Specific ordering arrangement for a collection of medical records Indexing of vital patient information

Illustration of the Features

System of Filing Record Arrangement and distances of cabinets

System of ... Terminal numbering system: How-to First, the medical records are assigned six digits. The last two digits are called primary digits. The middle two are called secondary digits and the the first two are called tertiary digits Second, if the medical record library has five record cabinets, each has four rows of shelves from top to bottom, then there are a total of 20 shelves. Each shelf is now assigned equal number of consecutive primary digits

Common Policies and Standards Policies in the use of medical records Completeness of medical records Release of information contained in the medical records

Standards on Minimum Essential Patient Information Needs Vital information and Patient’s Identification Purpose : Establish the identification of the patient the record pertains to. Types of Information: Patient’s full name, date of birth, sex, name of mother - establish unique identity of the patient Address (home and work), telephone number (if any) - establish the location the patient lives. Names of close relatives - in anticipation of future information requirements (eg. Person to give consent, birth / death certificates, etc) Other information depending on the needs

Standards ... Consent Purpose: Provide legal basis of authorizing future medical treatment and other actions that have potential harmful effects, thus, releasing the health provider from legal liabilities. Types of Information: Consent for confinement, medical and diagnostic treatment. Consent for surgical operation and giving of anesthesia Consent for autopsy Others

Standards … Clinical History and Physical Examination Findings Purpose: To establish the clinical conditions at the time of arrival to the health facility by the patient. This serves as basis to determine the progress of the patient while under treatment. Types of Information: Clinical History Chief Complaint History of Present Illness History of Past Illnesses History of Family Illnesses Obstetric History (for pregnant mothers) Personal and Social History Review of Symptoms by Systems Physical Examination Findings PE findings by organ system Admitting Diagnosis

Standards … Diagnostic Examination Results Purpose: Provide additional vital information in aid to the diagnosis and treatment of a patient Type of Information Laboratory Radiology Special Procedures

Standards ... Operative or Delivery Procedure and Anesthesia Record Purpose: To record the details of a high risk but, life saving procedure Type of Information Operative record - Names of the operating team, indication for operation, operative procedure performed, operative findings Delivery record - Names of the delivery team involved, essential characteristics of labor (duration of stages of labor, time of full dilatation, etc), manner of delivery, outcome of delivery Anesthesia record - Type and dose of anesthesia, vital signs during anesthesia, time of induction, name of anesthesia team

Standards ... Course in the Wards / Nurses’ Notes Doctors’ Orders Purpose: To record periodically the status of the patient in the course of treatment including detection and monitoring of complications. Type of Information: Subjective (symptomatic) complaints, Objective (physical signs) findings, Analysis (diagnosis), and Plan (nursing management) Doctors’ Orders Purpose: To record all instructions (written or verbal) of the attending physician related to the treatment of the patient Type of Information: Instructions on medical / surgical treatment, request for diagnostic procedures, nursing and diet instructions, etc.

Standards ... Temperature, Pulse Rate, Respiratory Rate and Intake/Output Purpose: Monitor indicators of life’s vital functions Type of Information: Quantitative measurements taken periodically as ordered by the attending physician. Medication Record Purpose: To serve as evidence of medications given to the patient and guide to succeeding drug dosages Type of Information: Schedule of drug medications and their corresponding dosages; Acknowledgment entries of medications given to the patient

Standards ... Discharge Summary Purpose: To serve as documentary summary of hospitalization containing all vital information that may be relevant for future reference. Type of Information: Summary information including names of the patient and the doctor, dates of admission and discharge, final diagnosis, condition upon discharge, medical management provided and course in the wards.

Common Regular Report Requirements Index: Indices may be considered as intermediate reports which contains commonly required and logically arranged information and derived from specific sets of medical records. They serve as one of the main sources of information used for analysis and report generation. The other sources are the registers Registers: Registers are official recording of selected information considered vital, commonly required and are derived from the patient’s medical records. They represent summaries of service or transactions provided by the hospital.

End of Part 1

MRD WORKFLOW START Charts from Unit NEEDED LOANED RECORD RECORDS Med. Record Request Accomplished Release to Borrower Returned Record Recording/ Indexing Pre-sort Search: Forwarded Records Un-filed MPI Record of Adm. Etc… Assembly Accomplish Trucking System Remove from Trucking System In MPI File? NO Analysis Disease Coding/Indexing YES In File? YES Complete? NO Operation Coding Routing Process YES NO Physician’s Index Search at: Incomplete Processing Etc… Final Disposal Data Collection Statistics Re-check Complete? Permanent File Retrieval system

CREATION AND COMPILATION OF THE MEDICAL RECORDS

CREATION OF THE MEDICAL RECORD Registration Counter/Admitting Unit/Emergency Room Collection of essential & accurate identification information Reason for admission to the healthcare facility Provisional diagnosis Admitting impression Working diagnosis Symptom

LINKAGES OF THE ADMITTING UNIT Medical Records Billing Admitting Unit Ward/ Unit Ambulatory Services

RECORD CREATION Ward Past medical history Family history History of present illness Physical examination Plan of treatment Request for diagnostics Physicians continues to record, on daily basis, writing notes on the patient’s progress, medical findings, treatment, test results, and the general condition of the patient.

RECORD CREATION Nurses record all observations, medications, treatment and other services rendered by them to the patient. Other health professionals record their findings and treatment as required during the patient’s hospitalization. At discharge, the physician write the condition at the end of the progress notes, the prognosis, treatment and whether the patient has to attend for follow-up. In addition the physician accomplish the following: * Discharge Summary * Discharge Diagnosis * Operation performed .

CREATION OF THE MEDICAL RECORD ADMITTING UNIT NURSING UNIT PATHOLOGY/ LABORATORY RECOVERY RADIOLOGY/ X-RAY OPERATING ROOM MEDICAL RECORD DEPARTMENT ECG

FLOW OF DATA COLLECTION SIMPLISTIC FLOW MODEL DATA DATA REPOSITORY PATIENT ENTERS HEALTHCARE PATIENT MEDICAL RECORD PATIENT CONDITION ASSESSED/ EVALUATED Patient History Physical Examination DIAGNOSTIC ACTIVITIES Transaction & Results

MEDICAL RECORD PROCESSING (Interdepartmental Systems Flow) ADMITTING OFFICE PATIENT UNIT/ WARD MEDICAL RECORD DEPARTMENT Reservation Reception Information Identification Social Data Assignment Notification History Examination Diagnosis Treatment Progress Education Evaluation Completion Coding Indexing Analysis Reports Filing Retrieval

DOCUMENTATION AND RECORDING

DOCUMENTATION: Objectives; THE MEDICAL RECORD SERVICE  DOCUMENTATION: Objectives; 1. To serve as database containing all information regarding a patient; 2. To communicate such information to individuals authorized to access it; 3. To be authentic; 4. To be comprehensive; 5. To be available when needed; 6. To be originator-friendly, and 7. To be economical. Methods: 1. Traditional 2. Mechanical 1.1 Handwriting 2.1 Encode into the system 1.2 Oral 1.3 Typing directly onto typewriter

DOCUMENTATION GUIDELINES THE MEDICAL RECORD SERVICE  DOCUMENTATION GUIDELINES Documentation should be complete; Documentation should be objective and non- judgmental; Documentation must be legible and written in ink; Entries must be dated and signed; Documentation of volunteers must be reviewed and initiated by a regular hospital staff prior to the filling of the medical records;

Documentation should be completed shortly after the service was provided; No form may be removed or destroyed once it is filed in the Medical Records Office; Errors should be corrected in the proper manner.

GOOD RECORDING AND DOCUMENTATION PRACTICES THE MEDICAL RECORD SERVICE GOOD RECORDING AND DOCUMENTATION PRACTICES Evidence of timely recording of entries Legibility Authentication of all entries Use of approved abbreviation Avoidance of extraneous remarks Medical Record should contain no unexplained time gaps. e.g. E.R. record Record Skipped spaces (consecutive lines) Correct spelling Ethical

GUIDELINES FOR GOOD REPORTING AND DOCUMENTATION FACTUAL = OBJECTIVE ENTRY = WHAT YOU SEE, WHAT YOU WRITE ACCURATE CONFIDENTIAL COMPLETE CURRENT ORGANIZED ETHICAL LEGIBLE CORRECT SPELLING CONSECUTIVE LINES SIGNATURE WHERE AND WHEN TO CHART NEVER DOCUMENT FOR SOMEBODY ELSE CHART AN OMMISSION AS A NEW ENTRY

STEPS TO EFFECTIVE MEDICAL RECORD DOCUMENTATION THE MEDICAL RECORD SERVICE  STEPS TO EFFECTIVE MEDICAL RECORD DOCUMENTATION 1. A complete history and physical exam including baseline lab values, pap smear,breast examination and rectal examination are required. Provisional diagnosis must be documented. 2. Daily progress notes must reflect findings, assessment and plan of care. Avoid use of such phrases as “status quo”.Progress notes should reflect the acute condition of the patient. 3. Physician orders must reflect treatment of the condition for which the patient was admitted or which develops subsequently. If ancillary tests or medical therapies are ordered which are not consistent with the current diagnosis or condition, they should be justified in the progress notes. 4. Note all abnormal test findings in the progress notes, along with an assessment of the findings’ impact on the patient’s current condition. A[ plan for treatment or follow-up must be included. 5. If antibiotic ordered do not conform with sensitivity results, document the reason for the choice.

THE MEDICAL RECORD SERVICE 6. If the patient must undergo unplanned surgery,document indications clearly. 7. Nosocomial infections, transfusion reactions or errors, or trauma suffered in the hospital should be completely assessed in the progress notes. 8 Document early efforts to arrange an adequate discharge plan for the patient. 9. The final note should reflect the medical stability of the patient on discharge. Blood pressure and temperature within normal limits, wound status if surgery was performed, and any abnormal ancillary findings should be addressed with a plan for follow-up after discharge. 10 The final summary should be a meaningful recapitulation of the patient’s course of illness, hospital management, discharge plan/instruction and include a plan for follow-up care. At discharge, final diagnosis which relate to the current hospitalization should be included.