Introduction

A health record is the primary storage of data and information about the health of individuals and the
health care services they received. A good health record serves many different purposes that will
greatly benefit the performance of your duties and responsibilities as a barangay health worker.

For this reason, you must know how to determine a well-prepared health record as well as its lifecyle.

TOPIC 1: Characteristics of a Health Record

A health record is a document that contains the who, what, when, where, why and how of a patient's
health and health care. 

For this reason, a health record must be:

TOPIC 2: Lifecycle of a Health Record

The lifecycle of a health record involves the following phases:

 Creation of the record;

 Use and maintenance of the record;
 Safe-keeping of the record; and 
 Disposition of damaged health records.

Each phase includes a different set of activities that may vary per barangay health station. As a
BHW, you must be familiar with these activities in order for your to fulfill your roles as a record-
keeper.
TOPIC 2: Lifecycle of a Health Record

Creation of a Record
The first phase in the life cycle of a record is the creation of records. It refers to the process of
bringing records into existence. In this phase, we identify what type of record to create. It could be in
paper or digital form. 

Health record forms are recording tools used in the Barangay Health Centers. They contain data and
information that are collected and stored in relation to a particular healthcare program or service. 

The following are the most common types of health record forms:

TOPIC 2: Lifecycle of a Health Record

Use and Maintenance of Records

The second phase in the life of a record is the use and maintenance of records. During this phase, it is
necessary to:
TOPIC 2: Lifecycle of a Health Record

Sake Keeping of Records

The safekeeping of your records is a legislative requirement. It is also something which greatly aids
the effectiveness of your facility. The Public Records Act requires that you ensure the safekeeping of
all the public records which you hold at all times and at all stages of their time with you. 
 1. What constitutes good physical storage?

This is very important. You should ensure that all your records are stored in such a way as to be safe
from physical harm and physically secure from inappropriate access but still readily accessible to the
appropriate staff. Storage should at all times be in compliance with good health and safety practice.

1.1 Keeping your records safe from physical harm

This is a basic requirement of good record keeping wherever your records are stored. You should

ensure that all your records are:

 not in an environment that is too hot, cold, damp or dry or subject to fluctuating
 conditions
 not stored where damage from water is a high risk, for example at floor level in a basement
or below water pipes
 as secure as possible from fire
 secure from dirt, dust and infestation
 taken into account as part of routine good housekeeping (for example making sure taps
 are turned off before leaving) and also when any building maintenance is taking place
 given due consideration within your business continuity/disaster planning.

1.2 Keeping your records physically secure from inappropriate access

This is about ensuring the information in your records can only be physically accessed by appropriate
individuals. Aspects of this should be covered by your organisation’s information policy. You should
ensure that the following is in place and applied:

 lockable records storage whether a filing cabinet, a records store or a computer screen
 clear desk policies
 controlled access to records storage areas
 where relevant, the use of numbering rather than titles on folders and storage boxes with
 an index maintained and kept elsewhere. This makes illicit access to records harder.

1.3 Keeping your records accessible to the appropriate staff

This is an aid to business effectiveness. Considerations here are:

  ensuring keys, passwords and/or other security controls are available only to relevant staff
 the clear and consistent identification of records (see below: 3); staff accessing records
 also need to be familiar with systems used
 well-arranged storage (this applies to both electronic folders and boxed records).

1.4 Keeping your records in such a way as to promote good health and safety practice

Good records practice also makes good health and safety sense. This relates principally to paper
based records and considerations include ensuring that:

 record storage boxes are of appropriate specification and are not over-filled
 staff required to move boxes of records are both physically capable of doing so and are
trained in manual handling
 records are stored in such a way so as not to restrict thoroughfares, most especially
emergency exit routes
 records are never stored at the bottom of stairwells or on stairs
 boxed and unboxed records are not stacked in a dangerous manner
 suitable access equipment, such as kick stools or steps, is available if necessary and is
 used properly, checked regularly and maintained in good condition.

1. What about information security?

Many of the points above are also to be found in the information security policies. These are a central
pillar of record safekeeping for any organisation. 

1. What are order and integrity?

Safekeeping includes both establishing and, importantly, maintaining order and integrity in the
arrangement of your records.

Order is established through adopting a standard approach to file naming. This should extend across
all your paper and e-records. This file plan system should always be based on function. Order is
maintained through ensuring that staff consistently use this system once it is in place.
Integrity relates to maintaining the wholeness of an information system. It requires the creation and
maintenance of accurate and maintenance of accurate and complete records. It also requires that their
order and relationships are maintained.

Reference: https://upd.edu.ph/wp-content/uploads/2019/04/Records-Management-Notes.pdf

https://campus.ahima.org/campus/courses/CB/course_docs/HDCS/
HDCS_V3_C2_FunctionsHealthRecord.pdf

https://rcni.com/hosted-content/rcn/first-steps/principles-of-record-keeping

https://www.gov.im/media/1347230/factsheet-6-safekeeping-public-records.pd

TOPIC 2: Lifecycle of a Health Record

Disposition of Damaged Records

According to RA 9470 or the National Archives of the Philippines Act of 2007, disposal is the act of
selling, burning or any other way of discarding valueless records. Meanwhile, records disposal is the
removal of valueless records from existing agency files or storage areas and getting rid of them by
selling, landfill disposal, shredding or by any other way of destroying them.
LESSON 2: Health Records Management

Introduction

Health records management, also known as record-keeping,  this is a process that encompasses

records creation, use, maintenance, transmission, retention, and disposition activities. As a BHW, one
of your biggest roles is to make sure that the health records of your community clients are properly
maintained and organized. 

In this lesson, you will learn about health record systems, as well as the purposes and principles of
record-keeping.

TOPIC 1: Benefits of Health Records Management

Health records management or record-keeping facilitates proper handling of documents to ensure

that:

 Health records are quick and easy to be found when needed. 

 Health records are stored in proper places to avoid damage.

Furthermore, record-keeping is conducted for the following purposes:

Other than these, health record management is also beneficial for educational/ research purposes as
well as in policy-making and in planning, implementing and evaluating programs and projects.

TOPIC 2: Principles of Record-keeping

In order to ensure that record-keeping will serve its true purpose, you as a BHW must perform this
task properly. 

Here are important reminders you can observe while conducting record-keeping.

LESSON 1: Gathering Health Information

Introduction

Health Information is knowledge obtained from an investigation, instruction or study. Health

information is used by “policymakers, planners, managers, healthcare providers, communities, and
individuals” to improve their professional and personal health outcomes (WHO, 2, 2008). 

In this lesson, we will discuss the different sources and methods of gathering health information.

TOPIC 1: Common Sources of Health Information

A valid and reliable source of information is the essential foundation of health strategies, plans,
policies, programs, treatment, and services. For this reason, as a BHW, you must be able to
determine whether a piece of health information is valid and reliable. 
Here are common sources of valid and reliable sources of health information:

International Level:

o World Health Organization (WHO)

National: 

o Department of Health (DOH)

Local: 

o Provincial Government
o Municipal/City Government
o Municipal/ City Health Center
o Barangay Health Center

Individual:

o Individual Patient’s Health Record

TOPIC 2: Methods of Gathering Health Information

Gathering health information refers to the organized and systematic collection of client’s
information. This is done to obtain an accurate assessment of a client’s health status. This enables
health service providers to guide, assist, and treat clients for the attainment of their optimal health.

As a BHW, you can gather health information through:

TOPIC 2: Methods of Gathering Health Information

Tama, Sigurado, Sapat, Makabuluhang Information System (TSiSMIS)

This is an information and communication system implemented to enable BHWs and other
community health team members (CHT) to gather and verify information from community clients to
provide primary health care services to clients. 

TOPIC 3: Storing Health Information

Information that has been collected and assessed is usually stored for future use, or passed on to
another person for use within the organization. Records are often stored for many years; thus, the
storage system needs to keep records in good condition, secure and accessible. 
As Barangay Health Workers, you are responsible for the safe and secure storage and handling of
documents and records. It must be supported by the policies and procedures for documentation,
methods of filing and retrieval, the release of information and maintenance of confidentiality.

Examples of relevant policies include:

 Record keeping policy

 Policy for access to confidential information
 Record disposal policy
 Confidentiality policy
 Privacy policy

The storage of most operational documents, and particularly personal and case-related documents, is
prescribed by legislation or organizational protocol.

TOPIC 3: Storing Health Information

Using Databases
A database refers to any structured collection of data, for example, sets of client records saved on a
computer, or kept in files or folders in a cabinet, or contact details or records kept on an index card
system. Protocols for naming files and storing them in appropriate folders will enable other staff to
locate and access the documents they require.

Regardless of its physical format, you still need to rely on information being up-to-date and accurate.
When access to the database is open to many users, maintenance of the data can be more difficult and
critical.

Strategies for ensuring the accuracy of data need to be formalized in a system. This system should be
time-efficient, simple to use and effective. All users need to be educated regarding their
responsibilities to ensure ongoing maintenance.
LESSON 2: Preparing Reports
Introduction

A report is a document that contains an organized presentation of information regarding a specific

plan, program, activity, etc. As a BHW, you may be required to prepare and submit a report weekly,
every other week or monthly. 

In this lesson, we will discuss the purpose of reports and the reporting tools that can be used by
Barangay Health Workers. 

TOPIC 2: Characteristics of a Good Report

Reports serve as your reference for program planning, monitoring and evaluation because they:

 Present the kind, quantity and quality of health program or service delivered in a specified
period of time.
 Show the progress in reaching the set goals for a specified period of time.
 Serve as a basis in understanding or studying the health condition in a given community for a
specified period of time.
 Serve as the basis in planning for the delivery of health programs and services.
 Interpret the status of the health programs and services to the general public and interested
groups. 

For this reason, the reports that you prepare must be:

 Accurate
 Complete
 Evidenced-based
 Timely

TOPIC 3: Discussing and Submitting Reports

In writing reports, always discuss specific cases with your supervisor. Have your supervisor verify
the contents. In cases when you are not sure or you do not know what to put in the report, ask for
their input. 

After making the report and discussing the contents with the supervisor, make sure to submit it to the
Rural Health Midwife and concerned officials in the Barangay.