LILOY INTEGRATED HEALTH DISTRICT HOSPITAL

National Highway, Liloy, Zamboanga del Norte

MEDICAL RECORDS SECTION

Hospital Policies and Procedures

THE MEDICAL RECORDS SECTION

The general function of the Medical Records Section is to provide an organized system of
measuring quality patient care and to ensure that sufficient data is written in sequence of events
to justify the diagnosis, warrant the treatment and end results.
This department is responsible for the processing, analyzing, maintenance and
safekeeping of all medical records created/ maintained in the hospital in the course of giving
medical care to patients.

THE MEDICAL RECORD

A medical record is a compilation of pertinent facts of a patient’s life history including

past and present illness(es) and treatment(s) entered by health professionals contributing to the
patient’s care.

USES OF THE MEDICAL RECORD

THE PATIENT
 As a clinical history of the patient’s treatment at the hospital.
 As documentary support or evidence of confinement, diagnosis, and treatment
received as hospital patient.

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 an educational tool in the training of and feedback to the staff and for
assessment of clinical procedures.

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.
 1. THE MEDICAL RECORD
The patient’s medical record should contain complete and accurate set of
information and maintained to facilitate effective patient care and allow evaluation of the care
provided.

1. The record is detailed to enable:

a.) The patient to receive continuing care.
b.) Effective communication within the health team
c.) The Attending Physician to have available information required for the
consultation
d.) Other medical practitioners and health personnel to assume the patient care
e.) Concurrent or retrospective evaluation of patient care.

2. Entries into the records are made only by duly authorized persons of this hospital and
are dated and signed, containing designation.

3. All entries, including alterations, must be legible.

4. The medical record shall contain all original copies of examination results, operations
and other required forms.

5. The medical record of a patient must include the following forms, properly
accomplished, dated with the signatures of the medical, nursing and allied health
professionals affixed above their written names:

1. Admission and Discharge Record: Includes patient’s personal data like full name,
address, sex, civil status, birthday, age, birthplace, nationality, religion,
occupation, an “alert” notation for the condition such as allergic responses and
drug reactions, admitting and final diagnosis and operations or procedures
performed, patient number.

2. Informed consent slip to care.

3. History Sheet: contains chief complaint, personal and family history (past and
present).

4. Physical Examination Sheet: contains all pertinent positive and negative findings
and impressions.

5. Physician’s Order: contains all doctor’s orders.

6. Laboratory Report Sheet: contains results of all diagnostic, laboratory and x-ray
procedures.

7. Progress Notes: includes doctor’s positive and negative observations.

8. Discharge Summary: summarizes the significant findings and events occurring

during the patient’s hospitalization, final diagnosis, operation ( if performed,
complications, condition on discharge, recommendations and arrangements for
future care, and classification of injury ( if it is a medico-legal case ).

9. Anesthesia report sheet ( if performed ).

 10. Record of Operation: records and authenticates a pre-operative diagnosis before
surgery. The records should then contain a report of all findings, a description of
the technique used, a description of any “tissue” removed and a post-operative
diagnosis.

11. Nurses’ notes: contain all the notes of all the nurses who tended the patient.

12. Birth and Death Certificates, if either these events occurred.

13. Other Sheets: medication and treatment, vital signs sheet, graphic chart sheet, etc.

6. The front sheet is completed at the time of discharge as soon as relevant information
is available. It contains all relevant diagnoses and procedures using the terminology
of a current revision of the International Classification of Diseases (ICD).

7. A discharge summary for each patient should be completed within 48 hours of

patient’s discharge.

8. Abbreviations are not allowed in the writing the diagnosis.

9. All documentations must be written in ink legibly or typewritten.

10. Short forms like laboratory and other results should be securely fastened to the record
to prevent loss.

11. The medical record is a legal document, so no form must be detached once it is filed
with the chart. There should be no erasures of any sort. To correct an error:

 Draw one single line through the information to be corrected or changed.

 Write the word “ERROR” and affix initial and date; and lastly,
 Write the correct entry near the information to be corrected.

12. Doctor’s order received and written by a licensed nurse on the medical record must be
signed and dated by the nurse and countersigned by the doctor.

13. Every page of the medical record should contain the name and hospital number of the
patient.

14. The medical charts of discharged patients together with the Daily Census of the day
should be submitted to the ER for submission to the Medical Records Section at 8:00
in the morning the following day.

15. Only complete charts shall be coded, indexed and filed.

2. RECORD COMPLETION

1. The medical record should be completed within 48 hours after the discharge of the
patient.

2. History and PE should be completed within 24 hours after admission.

3. An incomplete chart, not completed within 15 days after the patient’s discharge, shall be
considered a delinquent chart
 4. The Attending Physician has the final and major responsibility for completeness and
accuracy of the data entry in the record.

5. Residents and interns may be delegated the duty of recording medical information as
history, PE, and discharge summaries. Their entries must be reviewed, corrected and
countersigned by the Attending Physician.

3. RELEASE OF INFORMATION

1. The hospital shall safeguard all information contained in the health record against loss,
destruction, or unauthorized use.

2. All information in the health records shall be treated as confidential and shall be
disclosed only to authorized individuals.

3. The hospital must not use the medical record in any way which will jeopardise the
interest of the patient. The hospital may use the record to defend itself against any
accusations.

4. The release of information is delegated to the supervisor of the Medical Records

Section. In cases where the medical record supervisor encounters problems regarding the
release of information, the matter should be referred first to the Administrative Officer
or the Chief of Hospital.

5. A written consent from the patient himself must be obtained before the release of
information with clinical value.

6. A patient has the right to the medical record since the information written therein is the
patient’s personal history even if the said records is the physical property of the hospital.

7. Request for medical certificate or clinical information when the patient is still confined
shall be referred to the attending physician.

 A Certificate of Confinement shall be issued to the patient should the Ap decide

to release the certificate while the patient is confined.
 A medical certificate released must be signed by the AP, Chief of Hospital duly
sealed.
 A medico-legal certificate released must be signed by the AP, Chief of Hospital
bearing the hospital seal

8. A staff of the hospital can release information of no clinical value after a thorough
consultation of the hospital policy and utmost care taken into consideration. Such
information includes:

 Name
 Address
 Attending Physician
 Name of patient during admission
 Admission and discharge dates
 9. The consent of either one of the parents or guardian must be secured before any
information of clinical significance will be released concerning a patient who is a minor.

10. The medical record shall not be taken out of the hospital premises except on Court
orders. Those authorized to do the research and studies shall use the record inside the
MRS.

11. Incomplete medical records shall be referred to the AP before any request to access and
review will be entertained.

12. In the absence of a watcher for a patient in critical condition to give consent, the MRS
shall release information only after consultation with the COH.

13. The staff of the Medical Record Service shall have access to the medical records for the
patient classification. The social content of the record may also be revealed to organized
and reputable social agencies who have a legitimate reason for inquiry.

14. Information may be released to other health facilities upon written request, that the
patient is now under care.

15. The use of medical records may also be permitted upon the discretion of the hospital
management for research and studies, only stressing that no information shall be
published which will directly identify the patient.

4. DOCTOR’S RELEASE OF INFORMATION

1. The medical record may be reviewed by the doctors and members of the allied health
professional.

2. A written authorization signed by the patient must be obtained from the doctors who are
members of the medical staff but not members of the team assigned to the patient before
they are given access to the record.

3. The privilege against disclosure belongs to the patient and not the treating physician,
thus, the patient has the right to claim it or waive it. The doctor’s approval is technically
not necessary but as a sign of courtesy the doctor must be notified prior to any release of
information.

4. Insurance company doctors shall need written authorization from the patient, or duly
accomplished insurance waiver, before they are given access to the medical record.

5. Company physicians who are presently caring for a patient shall be given medical
information only upon presentation of a formal request addressed to the MRS.

6. The attending physician is responsible in informing his patient about his medical
condition.

5. NURSES ON RELEASE OF INFORMATION

1. Nurses may borrow/sign-out old records per doctor’s instruction for ward use.
2. All staff nurses may be given access to the medical records not assigned to them during
the conferences and case presentations. After the conference, the record shall be returned
to the MRS.

3. For purposes of compliance to requirements ward nurses may review all records before
forwarding them to the MRS.

4. Ward nurses should always see to it that the charts are in a secure place away from the
patient or patient’s relatives.

5. OTHER PEOPLE CONCERNED

1. A written authorization duly signed by the patient must be presented by a Lawyer

before he will be given access to the record of the patient he represents.

2. A waiver is required before an insurance verifier will be given access to the record of
a patient. The original copy of the waiver shall be countersigned and dated by the
insurance verifier and shall be filed with the record.

 Insurance verifiers representing the SSS and the GSIS shall review medical
records for compensation purposes per Warranty No. 10 of the PMCC.

3. Inquiries concerning a patient made by relatives shall be referred to the attending

physician.

4. Law enforcing agencies like PNP, 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.

5. Patients also have the right to their record but to prevent misinterpretation of medical
information which may lead to 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.

6. The hospital may release information even without a written authorization in

situation such as:

 COURT ORDER
In response to court order the hospital must release health information.

 ADMINISTRATIVE AGENCY ORDER

Health information must be released by the hospital when there is an
Adjudicative order from an administrative agency authorized by law.