HEALTH RECORDS MANAGEMENT

CHAPTER ONE

INTRODUCTION

 Medical records are important documents meant basically for recording

the treatment procedure for a patient.
 The information contained in the medical record allows healthcare
providers to provide continuity of care to individual patients.
 The medical record also serves as a basis for planning patient care,
documenting communication between the health care provider and any
other health professional contributing to the patients care, assisting in
protecting the legal interest of the patient and the healthcare providers
responsible for the patients care, and documenting the care and services
provided to the patient.
 It is important for doctors to realize that medical records have become the
single, crucial and effective weapon in their hands to counter the false
claims of the consumers, when they file a case for compensation. Dosage
and the drugs used must be legibly written.
 It is crucial for medical record workers to make sure that the medical
record is available for healthcare personnel when the patient returns to the
healthcare facility.
 If the medical record is not available then the patient may suffer due to
lack of previous information, which could be vital for the continuing care.
 In addition, if the medical record cannot be produced when needed for
patient care the medical record system is not working properly and
confidence in the overall work of the medical record service is affected.
 Medical record documentation is required to record permanent facts,
findings and observation about individual’s health history including the
past and the present illnesses, examinations, tests, treatments and
outcome.
 The medical record chronologically documents the care of the patient and
is an important element contributing to high quality care.
 The medical record should be complete and legible.
 Health record
 Any written document containing information about a patient in a
professional relationship with a doctor or a single record of all data on an
individual’s health status- including immunizations record, reports of all
physical examinations as well as all illnesses and treatments given in any
healthcare setting.

Public records

 Records that exist by law for public use that is available to the general
public. Examples include birth and death records, criminal records and
marriage records.

Historical background of health records management

 The history of medical records can be traced back to old ages or early
civilization in Egypt and Greek where medical documentation were
inscribed on stone tablets.
 The first real physician of medical records in Egypt was Imhotep who
lived in pyramid age: he was the chief architect and royal advisor to
the pharaoh.
 He was credited with being the original author of Edwin Smith
Papyrus. The Papyrus is one of the most valuable ancient medial
documents.
 In about 460 Hippoeranus, Greek philosopher also known as the father
of medicine
 He was first Greek physician to cast superstition and practice medicine on
scientific principles. He was also interested in medical ethics and is the
author of Hippocratic Oath which pledged by physicians even today and
which state in part (whatsoever in my practice or not in my practice. I
shall see or hear amid the lives of men which ought not to be noised
abroad, and for this I will keep silence holding such things unfitted to
be spoken).
 The important principle which Hippocrates defined which directly affects
the medical codes of ethics is the secrecy of information concerning the
patient. Hippocrates kept detailed cases of reports in the 18th century.
 Benjamin Franklin established Pennsylvania hospital in Philadelphia
in 1752 and kept many records himself.
 In 1902, the American Hospital association discussed medical records
in a convention.
 In 1942, the Canadian association of Records was formed.
 In 1948, the Association of Records Officers of Britain was formed.
 In 1967, the department of medical records was established at Kenyatta
National Hospital in Kenya.
 In 1978, the Health Records and Information Technicians
programme was started at Kenya Medical Training Centre- Nairobi.
 In 1990 the Health Records and Information Officers Programme
was started at KMTC- Nairobi.
 In 2009, a Degree programme in Health Records and Information
Management was started at Kenyatta University.
ORGANIZATION OF HEALTH RECORDS SERVICES

 Since the department has a variety of functions, it is necessary to organize

the department into functions with employees assigned to each function. Or
in small facilities, several of the functions may be performed by one or two
employees.
 However, an organization chart for a medical record department may look
like this:

Medical Records Org Chart

Health Officer
Administrator

Supervisor –
Medical Records

Records Record Filing

Patient Registration
Management & Retrieval

 The person in charge of the department may be called a “director,”

“manager,” or “coordinator.”
 The number of staff or employees in each department will vary with the
size of the facility and the numbers of patients seen in the facility. Some
departments may have thirty (30) employees including managers and
supervisors and others may have ten (10) or even fifty (50).
 Some large hospitals in other countries have as many as 100 employees.
  The number of employees may also vary based on whether the facility has a
computer system or is using paper medical records. In a computerized
system, manual retrieval of records is not necessary.
 Organization charts will also look different in different facilities but it is
recommended that the director or manager of the department report to an
administrative official. It is also recommended that patient/client
registration function report to the Director of Medical Records.
 A complete health records department should have

a) Staff
b) Space
c) Medical records equipment’s i.e. movable racks, cupboards, staff
working tables with printers, notice boards, chairs, calculators, staplers, dustbin,
ICD 10th volume books, telephones
PROFFESIONAL ETHICS.

Ethics are moral principles that govern a person’s behaviour or the conducting
of an activity. The health Record department is concerned with the
development, use, and maintenance of health records for

 Medical care and treatment,

 administrative,
 reference,
 professional education
 And research purposes.

Medical record practice is a trust delegated to the medical and health services
personnel. To protect and merit the trust placed in it, the medical record
profession has the responsibility of defining basic principles governing the
professional conduct of its members. The American Medical Record
Association (AMRA) therefore came up with Code of Ethics that govern the
health records department. The medical records association in Kenya is referred
to as the AMRO (Association of Medical Records Officer)

The following code of ethical conduct defines the actions necessary for carrying
out the purposes of the health record profession and is binding upon any
member of the American Medical Record Association, or Association of
Medical Records Officers and upon any person, certified, registered, or
accredited by this Association. As a member of one of the paramedical
professions, he shall:

1. Place service before material/monetary gain, the honour of the profession

before personal advantage, the health and welfare of patients above all personal
and financial interests, and conduct himself in the practice of this profession so
as to bring honour to himself, his associates, and to the medical record
profession.

2. Preserve and protect the health records in his custody and hold inviolate
(without violating) the privileged contents of the records and any other
information of a confidential nature obtained in his official capacity, taking due
account of applicable statutes and of regulations and policies of his employer.

3. Serve his employer loyally, honourably discharging the duties and

responsibilities entrusted to him, and give due consideration to the nature of
these responsibilities in giving his employer notice of intent to resign his
position.
4. Refuse to participate in or conceal unethical practices or procedures.

5. Report to the proper authorities but disclose to no one else any evidence of
conduct or practice revealed in the health records in his custody that indicates
possible violation of established rules and regulations of the employer or of
professional practice.

6. Preserve the confidential nature of professional determinations made by the

staff committees which he serves.

7. Accept only those fees that are customary and lawful in the area for services
rendered in his official capacity.

8. Avoid encroachment on the professional responsibilities of the medical and

other Para medical professions, and under no circumstances assume or give the
appearance of assuming the right to make determinations in professional areas
outside the scope of his assigned responsibilities.

9. Strive to advance the knowledge and practice of medical record

administration, including continued self-improvement, in order to contribute to
the best possible medical care.

10. Participate appropriately in developing and strengthening professional

manpower and in representing the profession to the public.

11. Discharge honourably the responsibilities of any Association post to which

appointed or elected, and preserve the confidentiality of any privileged
information made known to him in his official capacity.

12. State truthfully and accurately his credentials, professional education, and
experience in any official transaction with the American Medical Record
Association/the Association of Medical Records Officers and with any
employer or prospective employer
CURRENT AND FUTURE DEVELOPMENT/CONTEMPORARY ISSUES
IN HEALTH RECORDS MANAGEMENT.

Contemporary issues in health information management are events that are

ongoing currently in the health sector. These are the current trends or
happenings in the health information management field. With the widespread
computerization of health records, papers based are being replaced with
electronic health records.

As the field of health information grows, it is increasingly being used to develop

new applications to improve the patient experience and increase the efficiency
and efficacy of healthcare organizations.

To succeed in a position in this constantly evolving industry, it is important for

new Health records and Information graduates to stay up-to-date on the changes
that are occurring in the field, including the latest developments and priorities

The following are some of the contemporary issues in health information

management

a) Healthcare future going Mobile

With vendors such as Apple, Microsoft, Nokia and android bringing
technologies to the market, industry analysts are predicting explosive growth for
those devices over the next few years and not just with the consumer.
Physicians are seeing the device as a way to better patient care. Wearable
sensors have the capability to serve as medical dashboard-helping physician
track patient’s vital signs and overall health conditions, using that data to see
patterns and warning signs of illness.

Yet the question remains will the use of technology on a greater scale result
in improved health outcome especially on people with chronic conditions
such as diabetes and heart disease.

b) Privacy and security

With advances in healthcare technology, an increasing amount of information is

being stored online. While this offers a number of benefits for patient care, it
also makes the data vulnerable to attack from online threats, such as hackers
who want to steal and sell the personal information found in electronic health
records. In fact, according to TrapX Security, cyber-attacks against healthcare
institutions increased by 63 percent in 2016 as compared to 2015. The
organization expects the trend to continue.

Lack of new technology and associated best practices make it very difficult for
hospitals to detect and remediate ransom ware attacks. These incidences are
expected to increase in 2017.

To answer this growing threat, strategies and technologies that ensure the
privacy and security of health data are a growing focus of professionals in the
field. In addition to the ultimate goal of protecting sensitive information,
healthcare organizations also need to be able to build trust with their patients.
Patients will not accept storing their health information online if they feel that
their provider is unable to keep it safe and secure.

c) Information governance

Information governance is one of the most significant challenges in health

information management. This function involves implementing policies,
structures, controls and other procedures to ensure an organization’s data assets
are handled appropriately.

Technology advances are enabling the creation, capture and retention of more
data and information, from more sources every minute of the day. Beyond the
need to harness, analyze and turn data and information into intelligence, there is
also a need to control it.

Information governance is an important addition to the more traditional

approaches taken by professionals in HIM. Information Governance optimizes
health data extraction abilities, while also mitigating risk and ensuring that
compliance guidelines are met. Healthcare organizations that have these
systems in place will likely see improvements in the areas of population health,
quality and safety of care, efficiency and efficacy of operational efforts and cost
savings.

d) Interoperability

One of the major benefits of modern health information technology is the ease
with which data can be transported and shared between stakeholders. However,
this is only manageable if the systems used by different departments and
healthcare organizations are interoperable.

Interoperability is the ability for computer software or systems to communicate

and exchange information in a way that the data is understandable to the user.
This enables test results, medical histories, images and other important data to
be sent from one provider to another, whether the patient is seeing a specialist,
changing doctors or being treated by multiple professionals at a given time.

The common factor in any interoperability use case is the patient. She is the one
moving between specialists, being admitted to the hospital and attempting to
engage in her care. As such, true interoperability will not be achieved until her
clinical data follows her effortlessly. This is patient-centred interoperability and
it’s sadly missing from the typical discussion in our industry.

Identifying HIM practice needs and a means to address them in standards is the
first step in achieving the shared goal of the interoperability and overall
governance of health information.

The three main stages for achieving nationwide interoperability by 2024

include:

 “Send, receive, find and use priority data elements to improve health and
healthcare quality.” (2015-2017)
 “Expand interoperable health IT and users to improve health and lower
cost.” (2018-2020)
 “Achieve nationwide interoperability to enable a learning health system.”
(2021-2024)

These steps are in aligned with the ultimate goal of creating a strong foundation
in healthcare IT to equip patients with digital pictures of their health over a
lifetime.

e) Data analytics

The rate at which data is being produced, collected and analyzed is greater than
ever before.

Healthcare is no exception to this trend of increased collection. But raw data

does very little to impact patient care on its own. The numbers must first be
analyzed to ensure that the information is used properly. As such, data analytics
is playing an increasingly important role in health information management.

HIM professionals are playing an increasingly active role in determining what

types of data are needed to address and resolve challenges in health care leading
to providing the highest quality care to patients.
HIM professionals are increasingly getting involved wherever healthcare data is
being collected, stored, or retrieved. All of this wealth of information requires
analysis for decision-making purposes, and HIM professionals have the critical
thinking skills to effectively analyze health data and information of all types.
In its most basic form, data analytics refers to the processes and techniques that
are used to examine large amounts of data to find trends that can benefit a
business in some way. These strategies can be qualitative or quantitative in
nature and the specific approaches vary by organization.

There are five major ways that hospitals can benefit from the use of data
analytics. Using analytics can help to:

1. Cut down on administrative costs.

2. Support clinical decision-making.
3. Reduce abuse and fraud.
4. Improve care coordination.
5. Increase patient wellness.

Because healthcare organizations can experience benefits such as these when

their collected information is properly utilised, increased use of data analytics is
likely to continue throughout 2017 and beyond in the field.