Concepts, Principles and Methods of Hospital Health Information Management

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.

Thank you!