1. Concepts, Principles and Methods of Hospital Health Information Management

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. Thank you!