Medical Records

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HEALTH INFORMATION SYSTEM DEVELOPMENT (Medical Records)

HEALTH INFORMATION SYSTEM DEVELOPMENT (MEDICAL RECORDS)

Organizational Chart Policy on Health Information System Development y y y y y Objectives Standards Record Completion Release of Information Policies for:  Doctors Release Of Information  Nurses On Release Of Information  Other People Concerned

Policy on Medical Records of DIDH y y y y y y y Objectives General Policies Patients Record Fill Retrieval of Patient Chart Death Certificate Reports Hospital Records

Duties and Responsibilities y y y Appendix Hospital Daily Census Section Head Recording and Analysis Clerk Receiving, Filing, And Retrieval

ORGANIZATIONAL CHART
(Medical Records)

PRESIDENT/ CHIEF EXECUTIVE OFFICER

CHIEF OPERATING OFFICER

SECTION HEAD

y y

ADMISSION & DISCHARGE RECORDING CLERK

RECEIVING CLERK

ANALYSIS CLERK

FILING, RETRIEVAL & BORROWING CLERK

STATISTICIAN

PATIENT INDEXING CLERK

ICD 10 ENCODER

BIRTH / DEATH / MED CERTIFICATE CLERK

POLICY ON HEALTH INFORMATION SYSTEM DEVELOPMENT (MEDICAL RECORDS)

OBJECTIVES: y y y y y y To formulate effective policies and to guide the operation and management of the medical records. To strictly implement approved policies for the good of the service. To make available to the concerned staff the approved policies for their information and guidance. To use the approved policies in monitoring staff performed and the operation of the department. To ensure systematic approach in filling the records. To maintain the accuracy, completeness & confidentially of data.

STANDARDS: y y y y y y RECORDS: 1. Prepares the patients index based on the list of admission and check the patient·s assigned number. All applicable policies and procedures in an effective medical records management form record creation for disposal. All departments must be aware of the existence of medical records section (MRS) policies and procedures. Presence of copy of the policy of the manual in strategic location of the medical records section (MRS). Policy manual must be updated every 5 years Availability of needed resources. At least the services which will be affected shall be consulted.

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Rearranges the record according to the Standard Format (Contents of Medical Chart) Namely:  Identification Data                 Chief Complaint History of Present Illness Physical Examination Diagnosis/ Admitting Diagnosis Admitting/ Attending Physician Doctor·s Order Sheet Progress Notes Clinical Laboratory Report X-ray Reports Consultation/ Referral Notes Medication/ Treatment Final Diagnosis Nursing Record Discharge Summary Obstetrical Record (If applicable) Consent

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Records is sufficiently detailed to enable; y y y y The patient to receive continuing care; Effective communication within the health team; Attending Physician to have available information required for the consultation; Other medical practitioners and health personnel to assume the patient care.

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Entries into the records are made only by duly authorized persons of the facility and are dated and signed, containing designation. All entries, including alterations, must be legible. Only abbreviations and symbols approved by the Medical Record Committee are to be used.

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If possible, original copies of all reports made by medical, nursing and allied health professionals are filed in the record. Each record should at least contain the following data: a. b. c. d. e. f. A unique medical record number or reference Patient·s Full Name Address Date and Birth Sex Person to notify in case of emergency & contact number.

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An ´ALERTµ notation, for the conditions such as allergic responses and drug reactions is prominently displayed on the face sheet of the record. The record contains a written admission diagnosis by the medical practitioner. The record contains a patient·s history, pertinent to the condition being treated, including relevant details of: a. b. c. Present and past medical history Family history Social considerations

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A sufficiently detailed report of a relevant physical examination (PE), performed by a medical practitioner, should be included for the purpose of admission. Evidence that the patient has given informed consent is available. Drug orders are written in the record by the medical staff. Therapeutic orders and orders for special diagnostic test are noted in the record. There is evidence in the medical record that patient care plans were made. Progress notes, observations and consultation reports are written by medical, nursing and allied health staff to record all significant events such as alterations in the patient·s condition and responses to treatment. The front sheet is completed at the time of discharge of as soon as the relevant information is available. It contains all

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relevant diagnoses and procedures using the terminology of a current revision of the International Classification of Disease (ICD). 19. A discharge summary for each patient should be completed within 48 hours of patient·s discharge, with a copy remaining in the medical record. The discharge summary should at least include the following: a. b. c. d. e. Discharge diagnosis Procedures performed Follow-up arrangements Therapeutic orders Patient instructions (where necessary)  A copy of discharge summary shall be given to the patient when transferred to another health care facility..

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When an autopsy is performed, a provisional diagnosis is noted in the medical record within 72 hours and the medical record is completed within 15 days following the death. A copy of the autopsy report is filed in the medical record.

RECORD COMPLETION: 1. 2. 3. 4. The medical records should be completed within 48 hours after the discharge of the patient. History & PE should be completed within 24 hours after admission. An incomplete chart, not completed within 15 days after patient·s discharge, shall be considered a delinquent chart. The attending physician has the final and major responsibility for completeness and accuracy of the data entry in the record. The medical record in-charge is also encouraged to raise the level of quality of the individual health record and sustain a high level of recording. Residents and interns may be delegated the duty of recording medical information as history, PE and discharge summaries, their entries have to viewed, corrected, and countersigned by the attending physician.

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Maintain the completeness of the medical record by checking the omissions and discrepancies and helps ensure that medical records comply with set policies and standards.

RELEASE OF INFORMATIONS: Release of health information is a very sensitive issue in several respects. The CONFIDENTIALITY of the medical records should always be the concern of people involved in the release of health information. GENERAL POLICIES: 1. 2. The hospital shall safeguard all information contained in the health record. All information in the health record shall be treated as confidential and shall be disclosed only to authorized individuals. It shall be the policy of all hospitals not to use the medical record in any way which will jeopardize the interest of the patient, but the hospital may use the record to defend itself against any accusations. The release of information is delegated to the supervisor of medical record section (MRS), but in case where the medical record in charge encounters problems regarding the release of information, the matter should be referred first to the Administrator or Medical Director for proper solution. No release of information with clinical value shall be done without written consent from the patient himself. The medical record is the physical property of the hospital. However, since the information written on the record is patient·s personal history, he/she also has a right to the said record. In case where litigation is likely to happen and is intended against the hospital or any other personnel of the health care facility, the medical director/ chief of hospital may refuse or deny access. Request for medical certificate or clinical information when the patient is still confined shall be referred to the attending physician. a. No certificate of confinement shall be released without the approval of the attending physician.

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No medical certificate shall be released without the approval of the attending physician. On the other hand, no medico-legal certificate shall be released without the signature of the Medical Director/ COH and the hospital seal.

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Information of no clinical value can be disclosed by the staff of the hospital with utmost care.      Name Address Attending physician Name of relative with patient during admission Admission and discharge dates

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Where the patient is a minor, consent of either one of the parents o the legal guardian shall be secured before any information of clinical significance is released. The medical record neither/nor shall be taken out of the hospital.  Those authorized to do research and studies shall use the records inside the Medical Records Section (MRS)

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Incomplete Medical Records shall be transferred to the attending physician before entertaining any request to access and review the medical record. In cases where the patient is in critical condition and does not have someone with him/ her to give consent. The medical record in charge shall release information only after consultation with the Medical Director/ Chief of Hospital. Verbal request for clinical information shall be discouraged in favor of written requests. The staff of the Medical school Services (MSS) shall have access to the medical records for purpose of establishing patient classification. They may also reveal the social content of the record to organize and reputable social agencies who have a legitimate reason for inquiry. Information may be released to other health care facilities upon written request that the patient is now under care. Hospital management may at its discretion permits the use of medical records for research and studies only stressing that no information which will directly identify the patient shall be published.

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POLICIES: POLICIES FOR DOCTOR·S RELEASE OF INFORMATION 1. 2. Doctors and members of the allied health profession may review records of patients presently under their care. Doctors who are members of the medical staff but not members of the team assigned to the patient shall be armed with a written authorization signed by the patient before they are given access to the record. The privilege against disclosure belongs to the patient and not the treating physician, therefore the patient has the right to claim or waive it. In which case, the doctor·s approval is technically not necessary, but it would be a good practice to notify the doctor prior to release of any information as a sign of courtesy. The hospital management may permit the use of the medical record being the physical property of the hospital for research and studies. The hospital may also withhold access to the medical record unit if a subpoena is issued. Outside doctors intending to do some research/ studies in a particular hospital shall seek the written approval of the management before they are given access to the medical record. Insurance company doctors shall need proper written authorization from the patient, or a duly accomplished insurance waiver before they are given access to medical record. The company physicians who are presently caring for a patient shall be given medical information only upon presentation of a formal request addressed to the Medical Record Section(MRS) Consultants shall have access to records of patients referred to them. Resident doctors and the rest of the medical staff may request the medical record of a patient needed for their research and studies from the medical record section, but in cases where there is suspicion that their wish to access will jeopardize the right of the patient, doctor and the institution, access shall be denied by the medical record staff. It shall be the responsibility of the attending physician to inform his patient about his/her medical condition.

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POLICIES FOR NURSES ON RELEASE OF INFORMATION 1. 2. 3. 4. Nurses may borrow/ sign-out medical records per doctor·s instruction for ward use. In the ward, student nurses shall have access to the records of patients assigned to them. Private nurse shall only be allowed to review records of patients assigned to them. All staff nurses may be given access to medical records not assigned to them for purposes of conferences and case presentations. After the conference, the record shall be returned to the Medical Records Section. Ward nurses should always see to it that charts are in a secured place away from the patients or the patient·s relative.

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OTHER PEOPLE CONCERNED: 1. The lawyer representing a patient shall only be given access to medical record after presenting a written authorization duly signed by the patient. An insurance verifier shall be required a waiver before being given access to the record/ information about the patient.  Insurance verifier representing the SSS and GSIS shall review medical records for compensation purposes embodied by the existing laws of the Philippines Medical Care Commission. 3. Researchers from other medical institutions could gain access to medical records only after complying with requirements set by the institution concerned. Patient·s relative making inquiries about their patient shall be referred to the attending physician. Law enforcement agents (PNP, PC, NBI and others) shall need a written request duly signed by the Chief/Director of their respective agency before being given access to the record. Should it be possible however, to get the written consent of the patient, a written request from their agency is no longer necessary. Patient also has the right to their record, but to prevent misrepresentation of medical information which may lead to

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litigation, patient may not be allowed access to his own record. However, his physical and mental condition shall be explained only by the attending physician. 7. The health care facility may, in some situations, release health information even without the written authorization. Such situations are as follows: 1.) COURT ORDER  A hospital or other health care facility must release health information in response to court orders. 2.) ADMINISTRATIVE AGENCY ORDER  A provider must release health information when there is an adjudicative order from the administrative agency authorized by law. 3.) Subpoena

POLICY ON MEDICAL RECORDS OF DIDH
OBJECTIVES: 1. 2. 3. To ensure systematic approach in filling the records. To maintain the accuracy, completeness & confidentiality of data. Confidentiality of patient information is maintained at all times.

GENERAL POLICY: 1. Medical records contain patient information that is uniquely identifiable, accurately recorded. Confidential and accessible when required. Medical diagnoses, procedures and or operations performed on patients are recorded using ICD-10. ICD-10 reference books are available. The medical record officer is trained regarding ICD-10. Patient logbooks are properly filled up in the following areas: a. b. c. d. e. 6. Admitting Section Emergency Room Out-patient Department Operating Room Delivery Room

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Patient charts are properly and completely filled up and contains up to date information on the following: a. b. c. d. e. f. Identification Data Diagnosis/ Admitting Diagnosis Chief Complaint History of Present Illness Physical Examination Admitting/ Attending Physician

g. h. i. j. k. l. m. n. o. p. q. 7.

Chemical Laboratory Report X-ray Report Consultation Referral Notes Doctors· Order Medication / Treatment Progress Notes Final Diagnosis Nurses Notes Consent for Admission Obstetrical Record (If Applicable) Discharge Summary

Records of the following are properly and completely filled up. a. b. c. d. Records of Newborns Medico-Legal Birth Certificates Death Certificates

PATIENT·S RECORD FILE: 1. 2. 3. 4. 5. 6. Patient·s chart from ER & nurse station upon discharged, must be forwarded to the medical record section for recording. Check all charts received against the list of discharges as reflected in the Daily Census Report. Records all chart received to the logbook. Prepares the patients index based on the list of admission and check the patient·s assigned number. Rearranges the record according to the standard format. Analyze data on patient·s chart. a. If the data are incomplete (from ER & ward), fill up the deficiency sheet, attach it to the chart and return it to the ward or unit concerned; Upon receipt of incomplete chart and deficiency sheet, fill up the required data and sign it.

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Return completed chart and deficiency sheet to the Medical Record Section. Once the data are already completed the medical record in-charge will sort our according to filling system and prepare folder with corresponding terminal digits.

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File the patient·s record (folder) in terminal digit filing.

RETRIEVAL OF PATIENT CHART: 1. 2. 3. The requesting party must submit duly accomplished request form to the medical record in-charge. The medical record in-charge verifies patient·s name, number from the patient index card. The medical record in-charge will retrieve the chart from the file and record the said chart in the logbook, indicating the patient·s name, the requesting party, the date when borrowed and the name of the recipient of the patient·s chart. The medical record in-charge will release patient chart to the requesting party and the latter will sign the logbook.

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DEATH CERTIFICATE: 1. If the patient dies the medical record in-charge will prepare four (4) copies of death certificate and let the attending physician signed the certificate. The attending physician will check, completes and signs death certificate and return it to the medical record section. The medical record in-charge will check the accuracy and completeness of data and forwards it to the releasing/ information clerk. The information clerk will record the death certificate in the official logbook and releases four (4) copies of the death certificate to the patient·s relative. The patient·s relative acknowledges acceptance of the death certificate and sign the logbook. Medical record in-charge files the annotated Death Certificate copy from the Local Civil Registrar.

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BIRTH CERTIFICATE: 1. 2. 3. 4. 5. The medical record in-charge will provide a birth certificate draft form to the parent. The parent fills-up the draft form. The medical record on duty will interview the parent and verifies data. The medical record in charge advises the parent to sign a preliminary blank official certificate form. The medical record will advise the parent to submit the following documents that requires in the submission of the birth certificate to the Local Civil Registrar (LCR). FOR MARRIED a. b. c. Marriage contract (Xerox copy) Two (2) valid ID namely: SSS, Passport, company ID, Voter·s ID & etc. (Xerox copy). c. Latest Residence Certificate (Xerox copy)

UNMARRIED a. d. e. f. Affidavit of paternity signed & notarized by lawyer Two (2) valid ID namely: SSS, Passport, company ID, Voter·s ID & etc. (Xerox copy). Birth Certificate of the parents (Xerox copy) Latest Residence Certificate (Xerox copy)

REPORTS: 1. 2. 3. 4. Mandatory Monthly Hospital Report required by Philhealth and to be submitted within 10 days to the ensuing month. Daily Census Report Quarterly Hospital Statistical Report. Annual Hospital Statistical Report.

DUTIES AND RESPONSIBILITIES
Section Head
Reports to Unit/ Department RESPONSIBILITIES: 1. Provides adequate training of Medical Records personnel and supervise daily activities. Prepares and arrange proper scheduling of Medical Records personnel. Gathers and receives medical records problems and reports to medical records consultant for immediate action and solution. Represents the Medical Records Section in meetings, seminars and other related activities. Re-echo the said activity to the personnel of the Medical Record Section. Monitors accuracy of daily summary. patient·s census and monthly : : Director of Administrative Services Medical Records

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Codes diagnosis of patients according the Classification of Diseases (ICD-10) as required.

International

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Compile data and produce statistical reports required by Department of Health and PHIC. Maintain and safeguard the confidentiality of the Medical Records. Digital clinical documentation and archiving.

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Recording and Analysis Clerk
Reports to Unit/ Department RESPONSIBILITIES: 1. 2. Maintains the patient·s master file. Records all completed patient·s chart in the computerized logbook. Codes diagnosis of patient according to International Classification of Diseases (ICD-10) as required by PHIC & DOH. Checks clinical case records for completeness and deficiencies. Entertains statistical inquiries related to hospital services. Retrieves and pull out patient·s record requested for the use of a. Medicare or PHIC b. Insurance c. ECC d. SSS e. Study purpose of Doctors, Students and health personnel. Checks patient·s records return from Medicare or PHIC. Monitors borrowed patient·s record. Monitors daily census and prepares monthly summary. Makes Mandatory Monthly Hospital Report and submit to PHIC. Prepares medical statistics report for licensure purposes. Files complete patient·s records to permanent shelves. : : Director of Administrative Services Medical Records

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Receiving, Filing & Retrieval Clerk
Reports to Unit/ Department : : Director of Administrative Services Medical Records

RESPONSIBILITIES:
1. 2. 3. Collects daily census reports and discharged patient·s charts from the nurse·s station. Records admission in the computerized logbook. Checks discharged patient·s records on logbook and summary of discharges. Arrange charts to proper sequence and detached blank pages. Segregates complete and incomplete patient·s chart. Makes a list of incomplete patient·s chart for completion and place into the pigeon holes provided. Checks return patient·s chart and classify for coding. Retrieves and pull out charts requested for the use of PHIC claims. Processing, ECC, Study purpose of students, doctors and other health personnel. Attends & prepares client request, this is the birth certificate, death certificate, medical certificate & insurance. Files complete patient·s chart to permanent shelves following the terminal digit filing.

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Section Head
Reports to Unit/ Department RESPONSIBILITIES: 11. Provides adequate training of Medical Records personnel and supervise daily activities. Prepares and arrange proper scheduling of Medical Records personnel. Gathers and receives medical records problems and reports to medical records consultant for immediate action and solution. Represents the Medical Records Section in meetings, seminars and other related activities. Re-echo the said activity to the personnel of the Medical Record Section. Monitors accuracy of daily patient·s census and monthly summary. Codes diagnosis of patients according the Classification of Diseases (ICD-10) as required. International : : Director of Administrative Services Medical Records

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Compile data and produce statistical reports required by Department of Health and PHIC. Maintain and safeguard the confidentiality of the Medical Records. Digital clinical documentation and archiving.

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Recording and Analysis Clerk
Reports to Unit/ Department RESPONSIBILITIES: 13. 14. Maintains the patient·s master file. Records all completed patient·s chart in the computerized logbook. Codes diagnosis of patient according to International Classification of Diseases (ICD-10) as required by PHIC & DOH. Checks clinical case records for completeness and deficiencies. Entertains statistical inquiries related to hospital services. Retrieves and pull out patient·s record requested for the use of a. Medicare or PHIC b. Insurance c. ECC d. SSS e. Study purpose of Doctors, Students and health personnel. Checks patient·s records return from Medicare or PHIC. Monitors borrowed patient·s record. Monitors daily census and prepares monthly summary. Makes Mandatory Monthly Hospital Report and submit to PHIC. Prepares medical statistics report for licensure purposes. Files complete patient·s records to permanent shelves. : : Director of Administrative Services Medical Records

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Receiving, Filing & Retrieval Clerk
Reports to Unit/ Department : : Director of Administrative Services Medical Records

RESPONSIBILITIES:
11. 12. 13. Collects daily census reports and discharged patient·s charts from the nurse·s station. Records admission in the computerized logbook. Checks discharged patient·s records on logbook and summary of discharges. Arrange charts to proper sequence and detached blank pages. Segregates complete and incomplete patient·s chart. Makes a list of incomplete patient·s chart for completion and place into the pigeon holes provided. Checks return patient·s chart and classify for coding. Retrieves and pull out charts requested for the use of PHIC claims. Processing, ECC, Study purpose of students, doctors and other health personnel. Attends & prepares client request, this is the birth certificate, death certificate, medical certificate & insurance. Files complete patient·s chart to permanent shelves following the terminal digit filing.

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