1. Management of Medical Records

2. 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

3. 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

4. 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

5. 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;

6. 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.

7. 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.

8. 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.

9. 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.

10. 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

11. Organization of MRU
Secondary Hospital
Primary Hospital

12. Organization of ...
Tertiary Hospital

13. 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.

14. 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

15. Illustration of the Features

16. System of Filing Record
Arrangement and distances of cabinets

17. 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

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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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.

25. 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

26. 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.

27. 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.

28. End of Part 1

29. 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

30. CREATION AND COMPILATION
OF THE
MEDICAL RECORDS

31. 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

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

33. 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.

34. 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 .

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

36. 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

37. 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

38. DOCUMENTATION
AND
RECORDING

39. 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 Mechanical
1.1 Handwriting Encode into the system
1.2 Oral
1.3 Typing directly onto typewriter

40. 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;

41. 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.

42. 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

43. 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

44. 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.

45. 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.