Health Records Manual

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Health Records Manual
health records and information technology (Kenya Medical Training College)
Studocu is not sponsored or endorsed by any college or university

Downloaded by Charles Odhiambo ([email protected])
lOMoARcPSD|16934131
HEALTH RECORDS
MANAGEMENT STUDY
MANUAL.

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TABLE OF CONTENTS
CHAPTER 1: Introduction to Health Records Management………………………………………………………………………1
CHAPTER 2: Types and Uses of Health Records………………………………………………………………………………………..6
CHAPTER THREE: Qualities of Health Records and Information Officers…………………………………………………12
CHAPTER FOUR: The Medical Health Records Department……………………………………………………………………15
CHAPTER FIVE: The Unit Health Records System………………………………………….………………………………………..26
CHAPTER SIX: Effective Communication………………………………….…………………………………………………………….31
CHAPTER SEVEN: Health Records Indices……………………………….………………………………………………………………41
CHAPTER EIGHT: Appointment System and Scheduling………….……………………………………………………………..47
CHAPTER NINE: Filing System for Case Records and X-Ray Films………………………......................................52
CHAPTER TEN: Filing Methods……………………………………………………………………………………………………………….54
CHAPTER ELEVEN: Electronic Medical Records……………………………….……………………………………………………..70
CHAPTER TWELVE: Medical Records Committee.....................................……………………………………………….79
CHAPTER THIRTEEN: Medical Records Policies……………………………………………………………………………………….81
CHAPTER FOURTEEN: Medical Legal Issues and Procedures for Releasing Information…………………………89
CHAPTER FIFTEEN: Births and Deaths Notification, Certification and Registration……………………….………103
CHAPTER SIXTEEN: Medical Records Survey……………………………………………………………….……………………….108
CHAPTER SEVENTEEN: Medical Records Audit……………………………………………………………………………………..110
CHAPTER EIGHTEEN: Quality Assurance and Quality Improvement……………………………………………………..113
CHAPTER NINETEEN: Management of Special Health Records……………………………………………………………..117
CHAPTER TWENTY: Organizing of Medical Secretarial Service…………………………………………..…………………119
CHAPTER TWENTY ONE: Preservation and Conservation of Records……………………………………………………125
SAMPLE QUESTIONS…………………………………………………………………………………………………………………………….137

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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

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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

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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.
The Contents of The Health Records Folders

-These are medical records forms used in the hospital for the management of the patient
and kept in the patient’s folder, they vary from one health institution or country to another
in accordance with the medical policy in operation. The medical care history should be
comprehensive, its contents should be capable of including all the information likely to
be required by the state, hospital, medical and other professional staff, authorized
independent researchers and other stakeholders who may consult the health record.
-It should be remembered that it is the legal responsibility of the health record and
information technician to maintain confidentiality of the patient’s medical history and

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should take every administrative precaution to assure that the records or any of its
contents are not released to unauthorized persons.
The ideal case records should the following contents or forms.
1) Identification sheet /registration form front sheet:-This is the sheet where the patients
identification procedures are recorded, these include; name, gender, occupation, religion,
residence amongst other demographics.
-An ideal identification sheet should have the following characteristics.
-The doctor in charge of the patient must be able to remind himself at a glance of the
personal facts about the patient without going through the whole file.
-Persons seeking to compile the most commonly required statistics will easily find them
in the same place. The information should be complete and accurate so that anyone
writing to the patient can send the letter to the correct address.
2 )Clinical history sheet:-This is where the doctor writes his notes when clerking the
patient, this will include the doctors record of the patients immediate pre-history and his
present illness or injuries, the sheets forms a continuous history which the doctor writes
and this achieves a chronological statement about the patient clinical history. The result
of the physical examination carried out by the doctor can also be recorded here.
3) Continuation sheet:-This is similar to history sheet and has all clinicians seeing the
patient and subsequent episodes. The doctor should enter their findings on these sheets.
All entries should be dated by the attending doctor. These sheets give the progressive
clinical narrative.
4) Treatment sheet:-This is used for recording treatment instruction in the wards. It is

usually attached to the patient’s bed board while the medical records folder is kept at the
nursing stations. On discharge of the patients, the treatment sheet is incorporated in the
folder.
5) Anesthetic record:-This is a form where anesthetic techniques and other details by the
anesthetist are recorded.
6) Prescription chart:-This provides the doctors drugs prescription for both out and
inpatient. The form must be filed back in the case folder from the pharmacy so that the
doctor treating the patient can see what previous medications had been prescribed for the
patients.

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7) Diet sheet:-It is a special diet form which is required for the patient diet monitoring.
-The form should contain instruction for the principal diets prescribed.
8) Temperature, Pulse and Respiration Chart (TPR):-These charts are varied, designed
and are used four hourly, two hourly and four hourly they are held according to the
practice of particular hospitals and for seriously ill patients.
9) Clinical photography:-Photography is increasingly being used in hospitals for clinical

as well as teaching purposes. Clinical photographs will be taken when the patient is
automatically in an interesting condition where he or she may pass through several stages
of treatment e.g. in plastic surgery a photograph is often taken at intervals to record
progress. Special mounting sheet should be used for filing photographs.
10) Consent forms:-Consent certificates must be obtained for all operative procedures
and should be by either the patient’s next of kin or parents if patient is minor. For
operative interventions, anesthesia, post mortem examinations etc. and all the recordings
must be kept in the file.
11) Inpatient summary / discharge summary:-A summary should be completed for every
patient on discharge or upon death. A special form is provided for this purpose and
normally the summary should be dictated by the medical officer or the consultant. The
diagnostic coding in accordance with the international classification (ICD) is carried out
using this form e.g. Malaria=B54, SVD 080.0
12) Correspondence:-All correspondence which is of clinical importance to the patient

will be incorporated in the case record e.g. referral letters between hospitals/clinics. The
foregoing list of medical records contents is by no means exhaustive and will largely
depend on requirements of a particular health institution.
13) Report form:-All diagnostic investigations e.g. laboratory, radiology and other
departments’ results should be fastened to the patient file. Special mounting sheet are
used for this purpose.

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CHAPTER 2
TYPES AND USES OF HEALTH RECORDS
Types of Health Records

 There are various types of medical records generated by hospitals, labs, doctors’
offices etc. Each one will have a different type of content that require different
type of formatting standards.
 The most common types of medical records that a medical transcriptionist
transcribes and manage in hospital includes :Patient History and physical
examination report, consultation report, operative report, radiology report ,
pathology report, laboratory report, emergency report, progress note report,
therapy report, clinical notes, autopsy reports, biopsy reports, psychiatric
observations ,x- ray reports, scan reports, referral letters, Daily reports,
discharge summaries .
 There can be more types of medical records that come from a medical facility.
However these are the most widely used and transcribed medical records. These
records can be grouped into the following categories;
1.Case records/inpatient records

 An inpatient is a recipient of medical services who is admitted to a health facility
and receives health care services, room, board and continuous nursing service in a
unit or area of the hospital where patients generally stay overnight.
 Case records are records created for patients who get admitted into the hospitals or
who attend the various consultant clinics. The contents will constitute the contents
of a typical health record.
2.Out patient records

 Ambulatory services provided to patients in hospital- based clinics and
departments where the length of stay is less than 24 hours.
 This includes all the cards that are used in the outpatient department. Casualty
cards, child welfare cards and any other that may be used in the outpatient
department and in the health information system.

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3.Diagnostic records
 These includes the records of diagnostic investigations both in the outpatient and
inpatient department e.g. laboratory, radiology and cardiology reports.
Uses Of Health Records

-Patient’s medical records are very important in that they contain symptoms, examination
and test results, diagnoses, treatment and a plan for future care or treatment.
-They are a written collection of information about a patient’s health care and are
essential for his or her present and the future care, used for management and planning of
health care facilities and services, for medical research and the production of health care
statistics.
-Health professionals like doctors, nurses and others write in medical record so that they
can use the information again when the patient comes back to the hospital or health care
center. It is the job of medical record workers to make sure that the medical record is
available for health care personnel when the patient returns to the health care facility. If
the medical record is not available, then the patient may suffer due to lack of previous
information, which could be vital for their continuing care.
-This information is referred to as medical record, serve to accomplish the following

purposes.
(i) Planning patient care and treatment

-Medical records serve as a basis planning patient care and treatment. They are used to
show compliance in patient care. It is also a source of information for public health
officials who oversee the delivery of health care
(ii) Communication
-The means of communication among many health professionals who contribute to the
health of the patient care is a very crucial part of the treatment process and therefore
health care professionals must effectively communicate instructions for medication and
home treatment to the patient.
-A misunderstanding could result in an overdose or the worsening of the condition.

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(iii) Legal Documentation
-It provides legal documentation of the medical decision process, the health care rendered
and the results of care. This is very important in cases of malpractice, accusations or
negligence of patient due to professional misconduct.
(iv) Education
-Medical records act as a tool in educating health professionals ranging from medical
records technicians/officers to other healthcare workers. Students on their clinical
attachment use records to understand more about their field of study.
(v) Research
-Medical record plays a pivotal role in such organizations, which are especially involved
in research- work as well as imparting health education to the people. With the help of it
the standard and efficiency of the product there can be appraised.
- Besides this, one can easily ascertain the quality of service being delivered by the
expertise manpower and one can easily receive data pertaining to health of people in
order to conduct research work. It is a source of data for medical research.
(vi) Facility planning and marketing
-A source of data for facility planning and marketing:- The proportion of doctors to
patients, the nature of diseases, urgency of specialized service and the number of beds
available at certain place compared with its actual requirement and so on are some other
prominent facts as can be easily obtained through medical records.
(vii) Assessment of healthcare
-A tool with which can assess and continually work to improve the care we render and the
outcomes we achieve.
(viii) A source of information for accreditation
-Used to inform complex decisions ranging from how to improve patient care to how to
allocate resources and provides documentation for hospital accreditation.
(ix) Billing

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-Means by which client or a third- party player can verify if services billed were actually
provided.
The benefits of good medical records management
Systematic medical records management allows hospitals to:
 Know what medical records they have, and locate them easily
 Increase efficiency and effectiveness in patient management
 Make savings in administration costs, both in staff time and storage
 Support decision making
 Be accountable
 Achieve hospitals objectives and targets
 Provide continuity of patient care in the event of disaster
 Meet legislative and regularity requirements especially medical legal issues
 Protect the interests of employees, clients and stakeholders
 Medical records management offers tangible benefits to hospitals, from economic
to good practice in reducing storage costs of documents, enabling legislative
requirements to be met
An unmanaged medical record system results in the following:
 Makes the performance of patient care more difficult.

 Costs hospitals time, money and resources.
 Makes hospitals vulnerable to security branches, prosecution and embarrassment.
 Up to 10% of staff time is spent looking for information.
 Generally affects the credibility and reputation of the hospital or the institution.
-The dangers of corrupted records management have been illustrated in recent years
through scandals such as those at Enron in the USA, which involved the destruction of
vital records, poor records management, with an intentional loss of documents, has
caused embarrassment to organizations from government departments, hospitals to small
businesses.
-The importance of records can be put in context by events in South Africa where records
of the proceedings of the Truth and Reconciliation Commissions hearing against
President Botha about his actions during the period of apartheid have been destroyed, and
therefore details of this historically important event lost forever in their original form.
The principles of good medical records management
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-The guiding principle of medical records management is to ensure that information is

available when and where it is needed, in an organized and efficient manner, and in a well
maintained environment “Remember if it is not recorded it did not happen”
Hospitals must ensure that their records are:-
a) Authentic
-It must be possible to prove that medical records are what they purport to be and who
created them, by keeping a record of their management through time. Where information
is later added to an existing document within a record, the added information must be
signed and dated. With electronic medical records, changes and additions must be
identifiable through audit trails.
b) Accurate
-Medical records must accurately reflect the activities that they document for example,
procedures, operations, prescription, registrations amongst other businesses of the
hospital.
c) Accessible
-Medical records must be readily available when needed by users like doctors, nurses,
records managers, administrators amongst other authorized users.
d) Complete
-Medical records must be sufficient in content, context and structure to reconstruct the
relevant activities and transactions that they document.
e) Comprehensive
-Medical records must document the complete range of an organization’s business.

Clinical records should be sufficiently comprehensive for a colleague to have a clear
picture of a patient’s condition, treatment and wishes without a verbal handover. They are
a vital communication tool for high quality professional practice.
f) Compliant
-Medical records must comply with any recording keeping requirements resulting from
legislation, audit rules and other relevant regulations.
g) Effective
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-Medical records must be maintained for specific purposes and the information contained
in them must meet those purposes. Records will be identified and linked to the process to
which they are related, doing the right things at the correct time and doing the right things
correctly the first time.
h) Secure
-Medical records must be securely maintained to prevent unauthorized access, alteration,

damage or removal. They must be stored in a secure environment, degree of security
reflecting the sensitivity and importance of the contents. Where records are migrated
across changes in technology, the evidence preserved must remain authentic and accurate
i) Confidentiality
-The medical record is confidential and is protected from unauthorized disclosure by law.
Patient’s records should therefore be:

 Factual
 Consistent
 Accurate and identifiable
 Written visibly, legibly and clearly
 Be written as soon as possible after an event has occurred, providing current
information on the care and the condition of the service user ‘’Remember if it is
not recorded it did not happen’’
 Should not be erased
 Erasers, liquid paper, or any other obliterating agents should not be used to cancel
errors
 Correctly dated
 Evidence based
 Timed
 Signed
 The use of abbreviations should be kept to a minimum
 Be bound and stored so that loss of documentation is minimized
 Where actions relating to the patient have been agreed either with the patient’s
relatives or other professional they must document, actions to be taken, a time
frame for actions, who has been delegated or charged to undertake the action.
 Personal or objective statements should not be entered in the record.
 Documentation of value judgments and speculation should not be made
 Irrelevant documents should not be included
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 Any amendments to the record should be made transparent
CHAPTER THREE
QUALITY OF HEALTH RECORDS AND INFORMATION OFFICERS
Types Of Qualities
a) Efficient
-Plans with the staff, organizes, and conducts, direct, medical records activities according
to the needs of the hospital.
-Knowledge available about everything relevant to medical records practice, has the
necessary skills expected of him
b) Good listener
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-Here’s what is being said and what’s behind the words
-Always available for the participant to voice out their sentiments and needs pertaining to
medical records management
c) Keen observer
-Must keep an eye on the proceedings, process and procedures within the records
department and the activities that deals with the management of health records.
-Systematic knows how to put in sequence or logical order the activities and practices
within the hospital records department and produce the information when needed
d) Creative/Resourceful
-Uses available resources in making sure the records department runs effectively with no
hitch, always on the lookout on how best to improve the department for the better results.
e) Analytical/Critical thinker
-Decides on what has been analyzed and how best to use synthesized information.
f) Tactful
-Brings about issues in smooth subtle manner, does not embarrass but gives constructive
criticism on the best records management practices and staff commitment. Criticize
privately and praise publicly.
g) Knowledge
-Should be able to impart relevant, updated and sufficient input on medical records
functions. Understands every aspect of the medical records management and the overall
running of the hospital services.
h) Open
-Invites ideas, suggestions, criticisms, and involves people in decision making. Accepts
need for joint planning and decision relative to health care in a particular situation not
resistant to change.
i) Sense of humor
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-Knows how to place a touch of humor to keep audience alive especially during and
when on day to day discharge of duties.
j) Change agent
-Involves participant actively in assuming the responsibility for learning making in

changes for the benefit of the hospital whenever invited to make suggestions
improvement of the services within the hospital. Do not to management opinion.
k) Coordinator
-Brings into consonance of harmony the medical records department’s activities as

liaising with other departments in meeting organizational goals.
l) Objective
-Unbiased and fair in decision making without favoring any individual in the duty or
undermining performance of a unit within the health records department or departments.
m) Flexible
-Able to cope with different situations as they arise with minimal complaints and adjust
to issues and handling them tactfully.
General qualities
 Integrity.
 Adaptability.
 Discretion.
 Neat in appearance.
 Consistent efficiency.
Knowledge required by health records officers
-Medical records technicians must have knowledge of:
 Medical terminology and usages.

 Physical, major anatomical systems and related disease processes.
 Medical records forms and formats.
 Medical records classifications systems and references such as ICD, dictionaries
etc.
 Computerized data entry and information processing system.
 Data collection methods for basic health care and research information.
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 Medical psychology in order to understand human beings.
CHAPTER FOUR
THE MEDICAL HEALTH RECORDS DEPARTMENT
INTRODUCTION
-The medical Records Department is responsible for maintaining medical records in a
standardized and professional manner in order to protect confidentiality while allowing
adequate access to providers in order to promote quality patient care.
-Transcription, diagnosis coding, and release of information are some of the major duties
performed in the medical Records Department. Records are released in accordance with
state and federal laws.
-It is crucial for medical records 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 their continuing care.
Planning and Establishment of Health Records Department

-The major functioning of good quality Medical Records Department in the world is to be
the CUSTODIAN of patient’s health record and to provide prompt and efficient service to
users. The benefits would be to handle very large volume of medical data, improve
efficiency, easy storage of documents in minimal space, quick retrieval of records in
seconds at the press of button
-A study should be carried out to know what is required in the building of a new
department the staff required the equipment and the stationary that will be needed
Six phases observed when designing a new hospital health records department
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-The six phases determined by the architects whom they believe should be observed
when designing new hospital departments are as follows:
a) Definition phase-Is the definition of the precise need the design of the department is
to meet?
b) Brief phase-Is a detailed nomination of the estimated facilities to meet the defined
need?
c) Department phase-This deals with the integration of one specific area or department
into the greater complex of the total facility. In this phase the key people in the facility
along with the architect and planning co- coordinator establish ideal working
relationships with other departments.
d) Total facility phase-This phase involves wants, as compared to needs and the
available resources. A total hospital proposal is prepared to enable the election of the
most viable scheme for the department.
e) Process phase-At this stage attention is focused on the actual function of the
individual departments. This means that each proposed procedure to be performed in a
department is thoroughly analyzed and assessed. Diagrams illustrating the various
processes and procedure, most of which were completed in the definition phase, are
extremely useful as graphic expression of physical requirements and associated services.
It is at this phase that attention must be paid to the welfare, comfort and health of workers
in the proposed requirements for the department.
f) Department design phase-Is the stage where the architect prepares final proposals
enabling an optimum design to be prepared and selected? Detailed drawings of each
department are prepared, including a special requirement. There must be a systematic
means of assessing and comparing various schemes to enable the planning team to reach
a final decision.
-In this unit we will concentrate on the first two phases since these require the greatest
participation by the health information management / health record professional and also
have the greatest applicability in improving the layout of an existing department.
Consideration for Establishing the Records Department

-When preparing for this first phase in the planning of a health record department there
are five major points to be considered. These are:
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i. Locations of the department in regard to services and inter- relationship of service

areas.
ii. Space requirements for records, for personnel and for equipment.
iii. Functional design and logical placement of key work areas.
iv. System of communication within the health record department and between
department and other areas of the facility.
v. System to be used to transport health records with the department and to other
departments and wards.
i. Location
-When determining location consideration must be given to the need for the department
to be centrally located where it will provide
 Prompt service for all patients- inpatient, out patients and emergency.
 Ready accessibility for medical officers and other users, and
 Easy availability for administrative use.
 It should therefore be
 Adjacent to the Admission office the Emergency Department(ED) the Outpatient
Department (OPD).
 Close to medical staff office, entrance or lounge.
 Close to the administrative and business offices.
 Close to other service departments like x-ray, pathology, laboratories.
-While it is desirable to have the health record department centrally located, it is accepted
that this is not always possible. If this is the case and the department cannot be
logistically situated near all these areas, the first three should have top priority and, in
most situations, the proximity to the outpatient and accident and emergency departments
would have the highest priority, as these two areas usually have the greatest utilization of
records with speed of access often essential.
ii Space
Regardless of the type of facility, when planning for space requirements of records,
personnel and equipment, the health information manager/ health record administrator
must consider the following:
 Population of the district served by the hospital.

 Hospital services proposed.
 Number and types of beds.
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 Current and projected number of discharges\deaths and outpatient and emergency

registrations and visits.
 Major functions to be performed in the department.
 Number of personnel required to perform proposed functions.
 Equipment most suitable for the work to be done.
 Extent of computerization anticipated.
 Type of filling system to be used.
 The numbering system.
 Whether the record services are to be centralized or decentralized.
 Whether emergency/casualty records are to be are to be included in the main
record.
 Number of years of active storage.
 Length of time original records are to be retained and whether inactive records will
be selectively purged or microfilmed.
 Type of secondary storage required.
 Special services to be offered by the department.
a) Space for records
-Before calculating file space required, decide how many years of health records should
be kept in active filing and estimate the number of records generated per year.
-The retention schedules for health records recommended by the local health authority (or
national retention schedules where appropriate) should be considered when determining
record activity. These retention schedules usually take into consideration:
 The statute of limitations for legal protection, and

 State or national regulations.
-Retention for longer periods than determined by health authorities or national retention
schedules, however, could be influenced by:
 Available storage space.

 The clinical and/ or research value of the records.
b) Secondary storage
-If a secondary storage area is considered it should ideally be located within the
department or immediately adjacent to it, or directly underneath with its own stairway.
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-There are a number of advantages for keeping non-active health records readily
accessible and available, two of which are that:
 It is time saving for staff, and

 Offers easy access for refilling.
-If storage space is a problem and microfilming if in active records is being considered a
special room for microfilming will need to be planned.
c) Master patient index (MPI)
-Consideration must be given to the space the patients’ master index will occupy. When
all or part of the MPI is on cards, the space requirements can be considerable. The steps
to be followed in calculating the space needed to file the index cards and guides are the
same as those for the health record files?
d) Planning space for personnel and equipment
-When planning for personnel and equipment requirements, consideration must be given
to the functions to be performed within the department and the services offered by the
department to other areas.
iii Staff required
Once the functions of the department have been determined, consideration should be
given to the number of staff required.
(a) Forecasting
-Once the health information management/health record professional has:
 Determined the predicted number of discharges/deaths, and OP/ED visits and

predicted specialized work e.g. research, quality assurance, etc.
 Determined the functions of the department services to other departments.
 Determined the hours of service like 24 hours X 7 days per week or less.
 Defined each function and determined the tasks to be performed.
 Defined how each task is to be divided into manageable work units or jobs.
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(b) Ergonomically sound work areas. If the entire department is not air conditioned,
provision should be made to protect the computers from excessive heat and dust.
(c) Dictation/transcription
-Appropriate space for dictation and transcription services needs to be carefully planned
to allow for ergonomically sound facilities and work areas. The use of dictating a service
with a central receiving unit encourages doctors to dictate reports and discharge
summaries promptly.
-Computers for word processing are now widely used in health care facilities and
appropriate space must be allocated to ensure efficiency and also the health and well-
being of the staff.
(d)General
-The number and therefore, space requirements, of desks, chairs, type writer, telephones,
filling cabinets and other office equipment will be based on the jobs to be performed and
the number of personnel required. Staff working different shifts can occupy the same
work and a toilet facility is needed.
(e)Special space
-Space requirements for a photocopier, storage cabinet (for supplies and folders etc.),
bookshelves and any other special equipment should also be defined at this stage.
Microfilming is planned, space for the necessary equipment e.g. microfilm camera, reader
printer, jacket filler, filling cabinets and work area must be considered in the planning
stage.
-The predetermined departmental functions, job description and number of proposed staff
however will enable the health information management/health record professional to
determine the equipment and furniture needed and the approximate space required for the
work area.
(f) Functional design and logistical placement of work areas
-When considering functional design and layout, a key consideration is workflow. At this
stage of definition, the health information management/health record professional should
prepare workflow from procedure or desk to desk. Keeping in mind that:
 Desks should be prepared so that paper moves in a straight line and only a short
distance at a time.
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 Desks should be next to each other for procedures performed in sequential steps.
 Amount of floor space required will depend largely on record activity and whether
or not data processing or microfilm programs are established.
 Equipment should be chosen for reasons of both efficiency and appropriateness.
 Analyzed each job to determine the content, skills, knowledge and responsibilities.
 Prepared a job description and job specification for each job.
-The next step is to forecast the number and type of staff required to perform each job
(g) Health information management/health record professional’s office space
Since privacy is desirable for the health information management/health record

professional (for talks with personnel, doctors, lawyers, administrators); a private office
may be necessary. However, in smaller hospitals the director may prefer to be with the
staff in the main department area.
(h)Other specific areas
 A section of the health department should be provided away from the flow of
traffic for the medical staff so that they can complete their records or review
records for research in reasonable quiet and comfort.
 A special area often required for transcription. Medical transcription should be
confined to one area because of noise- sound proof booths or partitions help
reduce the noise of computer equipment and printers.
(iv)Equipment
-The number of staff and the functions of the department will determine the equipment
required.
-As well as planning space requirements for records and personnel, consideration must
also be given to the allocation of sufficient space for the equipment required to cover the
defined functions of the department
The major areas for consideration are:

(a)Filing
-Type of shelving to be used is important and it is generally accepted that open shelving
is the most practical. It utilizes less floor space than other forms of filing equipment,
allows for faster filing and retrieval and lends itself to any type of filing system used.
Once the amount of shelving required is calculated, the amount of floor space required
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for the shelving can also be calculated using the width and length measurements of each
bay of shelving.
-The space should also be allocated for aisles and it is generally accepted that main aisles
should be 150-155cm wide and secondary aisles 90-95cm wide.
(b) Computer facilities
-The level of initial computerization would have be defined in the determination of

functions and job analysis and sufficient space must be planned for terminals and:
 To keep flow in the medical record department to minimum, it may be desirable in

many hospitals to have a reception and/ or waiting area where employee may
attend to requests
 Employees handling enquiries should be placed near the main entrance
 Equipment should be near users and the doors wide enough for record carts
 Desks should face the same direction with 1 to1 1/2meters between desks
 Supervisors should be at the back of the people she/he is supervising – should not
be placed near the main entrance (for safe keeping)
 Sufficient space for workers to stretch and move around.
-The use of a layout diagram or flowchart sometimes called (La Tour 2002), which is a
diagram of the flow of work through the layout, can assist with determining the furniture
and equipment are placed effectively
-When preparing a layout for the architect, the health information management health
record should be able to use appropriate terminology and blueprint symbols to illustrate
the essential features such as columns, lifts, doors, windows, furniture and equipment etc.
This will give everyone including the health information management/health records
professional, a visual image of the proposed department.
(v) System of communication
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-During the definition stage, consideration must be given to the communication system to
be used within the department and between the health record department (HDR) and
other departments or areas.
-Most health record departments require numerous telephones placed at strategic points
within the department. In addition, some hospitals may use intercom systems between the
Emergency Department /A&E and the HDR, or the OPD and the HDR.
-If computer terminals are to be used, both as communication devices between the HDR
and other areas and for the input and output of data, the cabling for such devices are an
important part of the planning process. If the entire department is not air conditioned,
consideration must be given to air conditioning the area where the terminals are located
not only to prevent them from overheating but also to protect them from excessive dust.
(vi) Transport
Consideration must be given to how the health records are to be transported both within
the HDR and to other areas. If carts are to be used within the department they have to be
able to be pushed freely between desks and files. If a dumb waiter or pneutic tube or
other automated device is to be used, special space provision in the appropriate place
must be made. Some hospitals use motorized trolleys, which need to be stored in the
HRD when not in use. Provision for all these needs must be considered in the definition
phase of planning.
(vii) Layout
In determining the physical layout the following points should also be considered:
 It is important that full use be made of available space. Desks and files must be
arranged to provide maximum efficiency, light and air.
 To eliminate the hazard of electrical cords, attention should be given to the most
convenient placing of electrical outlets for the use of any electrical equipment
 Temperature control and circulation of air, i.e. adequate ventilation, fans, windows
 Adequate lighting – i.e. well positioned lighting (experts should be consulted as to
levels required and correct placement). Workers should not face glaring lights
 Use of color- walls, floors, furniture and equipment (light colors for walls bright
for accents and trims). This is controlling the movement of documents.
Duties and Responsibilities of Health Records and Information Officers
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-The duties and responsibilities of Health Records and Information Technicians/Officer

include the following:
1) Convert a patient’s diagnostic and intervention information to a standardized form

using an International Classification System-ICD (Classify, code and internal
diseases).
2) Ensure that every patient’s record is complete, accurate and secure as well as be
readily accessible for appropriate release.
3) Safeguard and release patient information under the provisions of the hospital
management or under any acceptable act laid down.
4) Use computer applications to compile, sort, group, retrieve, analyze and preserve
health data in ways that are useful for planning, research and education.
Transparent information from paper documents to electronic records.
5) Plan, supervise, coordinate and manage health records service in a health facility.
6) Maintain good public relations at all levels with the public, patient and other
health workers.
7) Plan, organize and design health stationery needed by the health institution in line
with the national standardization.
8) Maintain legal aspects and security of the health records in the health facility.
9) Administer quality assurance in coordination with other relevant members of
health records department.
10)Institute and maintain health records indices.
11) Edit, store and retrieve health records including x-ray films and other diagnosis
records.
12)Manage and control reception, registration, appointment, and admission and
discharge procedures.
13)Maintain disaster and special records.
14)Participate in basic operational research study.
15)Participate in teaching Health Records and Information students and other health
personnel.
16)Collect tabulate and analyze, interpret and store in information.
17)Provide or disseminate health information to health management terms of planning
and management of health services.
18)Clinical preparation: This is a method of preparing for the patient in advance
usually conducted 2 or 3 days before the patient attend clinic. Files are made
available with all the necessary documents e.g. investigation reports.
19)Follow up: Mechanism for patient who requires follow up after discharge should
be put in place.
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20)Coding & Indexing: Disease, surgical operation and other procedures in the
hospital need to be coded indexed as per International Classification of Disease
(ICD) and procedures medicine (ICPM).
21)Collection, tabulation, analysis, interpretation and dissemination of data:
Collection of health facility statistics relating to discharges/deaths, length of state
occupancy rates for administrative and health department use. Data collected from
health records are put in table, analyzed interpreted and forwarded to the users.
22)Maintenance of health record equipment: All the equipment used in the health
records department must be maintained and put in good order.
23)Manage special health records: There are special health records that are indicated
and handled differently from other health records e.g. psychiatric records,
tuberculosis records, maternity records Genito-urinary/HIV records e.g. P3 form.
24)Maintain confidentiality: All the information in Health Records is confidential and
it should be handled authorized person.
25)Design medical forms.
26)Plan, budget and control health equipment, supplies and medical stationery.
27)Assist the coordination of civil registration i.e. registration of births and deaths.
28)Controls finances allocated for the health records and information services.
29)Participate in surveillance activities.
30)Provides first Aid.
31)Advise on medical-legal policies as regard to medical health and information in a
facility.
32)Maintain proper mechanism for patients who need follow up.
33)Collect additional information about patients who need follow up.
34)Collect additional information about patients and their hospital stays to generate
data about patient population.
35)Providing information and guidance to patients, attendants and visitors.
Functions of the Health Records and Information Department

-The following are the functions of Health Records and Information Department
1) Reception-This is the area where the patient received and welcomed to the health
facility.
2) Registration-This is the recording of patient social detail like names, age, gender,
residence and other identification information.
3) Admission-This is the procedure carried out when the patient is being admitted to
the ward. In patient number and word detail together with the registration are
added on the admission form.
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4) Discharge-This is the procedure carried out when the patient is supposed to leave
the hospital after treatment.
5) Appointment-This is a way of giving a specific date, time and venue of the
individual patient.
6) Filing, storage and retrieval-This is a systematic way of arranging documents to
enable the documents filed to be maintained in good order. Filing and retrieval of
all inpatient health records with an inbuilt record control system.
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CHAPTER 5
THE UNIT HEALTH RECORD SYSTEM

Definition
-This is the health record system where one patient is given one number for the rest of the
stay or attendance in one hospital
Initiation of the Unit System

-It is necessary to assign a unit to a patient attending for the first day or time. The unit is
the patient and each patient is given one number for subsequent stay or attendance in one
hospital.
-A six digit number is normally used ranging from 1-999999. Some health records
officers or technicians prefer to insert the zeros from the beginning .i.e. 000001. This
depends on policy of the institution.
-When an old patient attends the hospital, the old notes are supposed to be retrieved as
the unit number. A tracer card should be inserted where the old records were indicting old
unit number.
Prevention of duplication
-Duplication in the use of unit number can be prevented by:
o Not giving the same number to two patients.

o Not giving the same patient more than one number.
o Observing legibility.
-When a patient attends the hospital he should be asked whether he had attended the
hospital before. If a patient says yes or no, across check can be done through the patient’s
master index or through checking from the Electronic Patient Registration System
ascertain this.
The unit number register

-It is important to maintain the unit number register which includes the following:
 Full names of the patient.

 Address.
 Date of birth.
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 Registration number.
 Specialty to which patients have been referred.
 Next of kin etc.
-The quality of the health records will reflect on the type of health care being rendered to
the patient or client
Feedback
-It should be provided from the health facility and other departments that need them
Coordination with other departments

-The Health Record and information officer in a health facility is expected to coordinate
the day to day administrative function with other departments in the hospital. No
department is important than the other. They should work together as a team for the
achievement of quality medical care rendered to the patient.
Transcription
Transcription services covering discharge summaries, operation reports, outpatient letters
and medical- legal correspondence (using word processing facilities).
1. Outpatient
-Start with the Reception Desk as soon as patients walk in the door, the reception should
be their focal point of attention to promote easy check-in. In order to ensure that
registration process is efficient for both the receptionist and the patient, the reception of
the desk must be chosen with care.
-The clinic list will be the basis for collection of all outpatient attendances. It is obvious
that great care must be taken in the collection of these figures.
-All patients who attend outpatients’ clinics or departments must be captured.
2. Admission office receptionist

-The inpatient receptionist should be aware of the patients who have come or called to
come for admission. She should be well informed about visitors hours, hospitals,
wards/facility well prepared for the for the patient such that she can afford a few
moments with each one make each individual feel a sense of welcome.
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3. Accident and emergency receptionist

-Some accidents and emergency departments in most cases will have two entrances, one
walking and wounded patients and one more seriously ill patients who have been brought
in by ambulance. The receptionist should be able to convey a sense of calm patients who
may be extremely sick and anxious.
-She must never neglect her duties to obtain full and accurate identification details.
4. Treatment and investigation department receptionist

-The areas attended by these patients include,
 Physiotherapy.
 Radiotherapy.
 Occupational therapy, etc.
-Receptionist in radiology department has a duty of explaining to the patients

preparations necessary before such examinations are done, e.g. barium meal, barium
enamel treatment all clients with courtesy, respecting and directing them accordingly.
Registration of patients
Definition-The completion of documentation of personal and health data before patient

is treated.
Patient Registration Process

 The healthcare team receives the patient information from the clients.
 The details are entered into the patient information sheet in order to process patient
demographics.
 The information sheet contains fields for personal details as well as insurance.
Reception of Patients in the Hospital/Health Unit

Definition: Reception is an act of greeting and welcoming patients, clients to the facility
-The right person should always do the work of reception.
-It requires cool efficiency, ability to convey the right message, maintain confidentiality
and being compassionate.
-He should have ease of assurance of manner and pleasant appearance
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-Should convey to the anxious patients that are there is nothing to worry about while in
the hospital premise since there is better care to be provided
Receptionist
-Receptionist should always anticipate patient’s problems and not wait until she is
presented with a question.
-She must be fully aware of the clerical duties, put attractive flowers which can do much
to improve the appearance of any reception areas as well as candy shops from where the
patient can buy certain requirements while they are waiting or should they find out that
they were required to have something but probably forgot to bring them along, they can
buy.
-The receptionist functions are of such enormous to the hospital. A good receptionist
should:
 Be smart in appearance.
 Be able to speak and express herself clearly.
 Be well informed and be able to give information quickly and accurately.
 Be polite and sure of what one is doing at all time.
 He should be pleasant and good mannered.
 Have strong interpersonal and communication skills.
 Be friendly and confident and enjoy meeting and dealing with a variety of people.
 Have good organizational skills and able to priorities workload.
 Be able to cope in a busy environment.
The common physical requirement for any reception area

 Comfortable chairs.
 Good lighting system.
 Decorations clear sign posting.
 Adequate privacy.
Reception Procedures
-Health records technician will be responsible for reception of patients in the following
main areas.
 Outpatients.
 Admission.
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 Accident and emergency department.

 Treatment investigation department.
 The patient information is processed, verified and validated.
 Once this process is complete the patient is registered at the healthcare providers’
facility.
 Records technicians/receptionists handle the appointments/scheduling after
registration of the patient.
-Patients can be registered as outpatients or inpatients Patient full names.
Environment should be conducive and patients should be interviewed individually and in

privacy.
-Patients should be given one unit number and ensure patients are not registered twice.
-Ask the patients whether he or she had attended the hospital before.
-Cross-checking of patients details with the patients master index or Electronic patient
Registration system is necessary.
Initiation of patients file

-The identification details that are taken during the registration time are used to create the
patients file. These are:
o Patient full names (preferable three names).

o Date of birth.
o Hospital number.
o Address.
o Occupation.
o Marital status.
o Religion.
o Name of the next of kin and address.
-The patients master index card should also be created during the time that the record is
being created and filed immediately. This will help to answer inquiries incase the patient
happens to lose the attendance card.
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CHAPTER 6
EFFECTIVE COMMUNICATIONS
Definition
-The term ‘communication’ has been derived from the Latin word ‘communis’ that
‘common’. Thus ‘to communicate’ means ‘to make common’ or ‘to make known’. But
communication is sharing information, whether in written or orally.
-It is a means of sending messages, orders, etc., including telephone, telegraph or

television.
-Communication is vital in a health care and social care setting. The patient health
professional need to understand each other clearly in order for the patient to receive the
best possible care. Providing care to a patient is next to impossible patients’ needs cannot
be clearly stated. Communication eases anxiety and eliminates more possibilities for
mistakes, and lets each party know what is expected of them.
Objectives of communication
1) Conveying the right message: The main object of communication is to convey the
right message to the right person that is to the person for whom it is meant.
2) To get others to think or act the way we want to think or act.
3) To inform others for example patients, clients.
4) To ask and answer questions from patients, clients and colleagues.
5) To listen to others.
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Principles of effective communication
a) Know your audience

-The first and most important step in communication planning is to gain as much
information as possible into the target audience, understand your clients/patients and their
needs.
b) Focus on the right objective
-The strategies and tactics of a communication intervention will differ depending on

stated objective (like informed decision-making, persuasion, policy change, and
advocacy.
c) Determine what information is of greatest value
-A critical step in communication planning is to determine what information has the value
in helping to achieve the stated objective of the campaign. Be limited in the greatest value
of information you can successfully convey.
d) Non-verbal communication
-Non-verbal communication involves things such as body language and pasture, your
arms, having your hands in your pockets, crossing your legs, gestures or expression and
eye contact, object communication such as clothing, hairstyles etc.
e) Communication process
-The communication process consists of a message being sent and received message may
be verbal or non-verbal.
-Effective communication involves a message being sent and received. Addition to this
however, is the element of feedback to ensure that the message is sent and received
exactly as intended.
f) Process and components of communication
-The following are the components on which communication rely in any organization.
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1) Context-It is a theme that a message must have.

2) Sender-Sender acts as encoder from where the message is sourced.
3) Message-The purpose of context and detail information is provided in this
component.
4) Medium-It is the channel from where the message is bypassed and information
flows towards the receiver.
5) Receiver-It acts as an encoder that understands the message, sent by the sender
and whether the information sinks.
6) Feedback-The final phase where the sender gets its audience and readers response
in form of criticism or appreciation.
-Also effective communication is based upon the knowledge of the 5 W’s as when,
where, why, what? This makes it more complete.
-Convey simple, clear messages many times, through many sources.
-One must determine how to convey information simply and clearly often and by many
trusted sources. Message repetition is an important element of program success.
-When the message is stated simply and clearly. When it is repeated often enough and
when it is stated by many trusted sources, audience/patients are more likely to learn and
embrace the message.
Characteristics of effective communication

-Effective communication should possess the following fundamental characteristics:
a) Accuracy: Content should be valid and error free, distorted message automatically
affects patients treatment especially during drugs dispensing, nutrition advice
amongst others.
b) Availability: The content should be delivered or placed where the patients can
access it.
c) Consistent: The message should remain consistent over time especially during
treatment and drug prescription.
d) Evidence based: Should be piece of information that supports a conclusion or an
action. Medical records creation serves as evidence between what the patient said
and what the doctor documented.
e) Reliable: The source of the content should be credible and up to date, let the right
person give advice concerning treatment and any other medication.
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f) Timeless: The content should be available or be provided when the patient is in

need of it, it should be specific.
g) Reach: The content should get to or should be available to the targeted patient
population.
h) Understandability: The message should be appropriate for specific
patients/clients.
Types of communication
1. Verbal communication
-Incudes sounds, words, language and speaking.
-In communication self- confidence plays a vital role which when clubbed with fluent
communication skills can lead to success.
2. Written communication
-Written communication is practiced in many different languages. E-mails, reports,
articles and memos are some of the ways of using written communication in business.
Methods of and media of communication

-There are several ways of communicating and receiving messages
Speech-An obvious method of communication that one thinks of first
Sight-Most effective because the mind thinks in pictures
-An average person is able to remember a mental picture of up to 80% of what he has
seen. What he has heard, that is why visual aids e.g. picture, diagrams, charts, films are
such valuable to teaching and it is why practiced demonstration are essential.
Sound-Sound is a good mode of communication
-A whistle, a car horn, wailing, bomb blast play a great part in communicating a message.
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Actions-An old adage states that actions speak louder than words: It’s often how one
reacts physically and this conveys a clear message both in communicating and receiving
messages.
-Covers facial expression and other behavioral signals like small, nodding, to show
understanding
-A frown face or head scratch will show lack of understanding or concentration.

Mannerism is important when communication is not verbal
Taste-For example, there is no salt in our food today. This conveys a message to the
receiver.
Touch-A pat on the back to congratulate somebody amongst other positive or negative
touch, a touch can send a positive or negative message
Smell-There is a bad smell coming from the dustbin
Silence-This can show deep understanding of the speaker’s words and unwillingness to
him or can show rudeness for failure to response to a question
Successful communication
-To make our communication successful get the clue about the audience interest. The
following methods should be noted:
1) Get the rough idea of the strength of the listeners.

2) Think over the age, sex, background and interest of the listeners.
3) See whether the audience is patient enough to handle you for hours they are
friendly or hostile.
4) Choose the approach that suits the audience.
5) Create a feeling such that each individual feels that the speaker is trying him and
sharing the joy and the sorrow of events with him.
6) Let the audience know the depth your knowledge regarding the subject.
7) Show you sincerity and whole heartedness for the subject.
8) To keep the communication healthy to keep cracking jokes in between, the jokes
should not appear to be deliberately told.
9) Concentrate on your ideas and do not get distracted by the activities, the audience
e.g. smiling, whispering.
Importance of effective communication in healthcare
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-Good medical care depends upon effective communication between patients. Ineffective
communication can lead to improper diagnosis and delayed medical treatment. Effective
communication in healthcare is significant, diagnosis correct care, effective treatment,
legal processes and medial program
Correct Diagnosis
-Effective communication in the healthcare industry is incredibly important in correct

diagnosis of an individual’s condition. It is very important that both the providers and the
patient are very clear in what they say to one another. If there is unclear, inconsistent or
limited in the information he provides his systematic past experiences, the diagnosis the
healthcare providers comes up with may be leading to mistreatment of the condition.
History
-It is very important that the patient is very clear in communicating her healthcare
professionals. Drug allergies, medical conditions, previous such illnesses can provide
critical information to doctors and nurses while the patient is in hospital. Failure to
effectively communicate these parts of a medical history patient’s life at risk. For
example, failure to mention an allergy to penicillin patient to go into anaphylactic shock.
Treatment
-Communication is a very crucial part of the treatment process. Healthcare professionals

must effectively communicate instructions for medication and home treatment to the
patient. A misunderstanding could result in an overdose or the worsening of the
condition. Patients must ask questions about their treatment if they are unclear on the
instructions.
Legal processes
-Effective communication is important for legal issues pertaining to treatment. A

thorough understanding of diagnosis and treatments must be established before a
healthcare professional can proceed. Documentation of all communications can become
important should something go wrong. Documentation of the communication that has
taken place can provide a defense for the hospital or ammunition for the plaintiff.
Medical progress
-Communication is critical for advancing medical progress. Information gathered at a

hospital or doctor’s office can help track things like outbreaks of the flu or other
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communicable diseases. Information can inform healthcare providers on the need to

stockpile certain medications, ultimately saving lives.
Barriers to effective communication

-There are barriers in the communication system that prevents the message from reaching
the receiver; these barriers are as follows;
(i) Language Barrier
-Different languages, vocabulary, accent, dialect represents a national/regional barriers.

Semantic gaps are words having similar pronunciation but multiple meanings like round;
badly expressed message, wrong interpretation and unqualified assumptions.
- The use of difficult or inappropriate words/ poorly explained or misunderstood

messages can result in confusion thus affecting patient management.
(ii) Cultural Barriers
-Age, education, gender, social status, economic position, cultural background,

temperament, health, beauty, popularity, religion, political belief, ethics, values, motives,
assumptions, aspirations, rules/regulations, standards, priorities can separate one person
from another and create a barrier.
(iii) Individual Barrier
-It may be a result of an individual’s perceptual and personal discomfort. Even when two
persons have experienced the same event their mental perception may/may not be
identical which acts as a barrier. Style, selective perception, poor attention and retention,
defensiveness, close mindedness, insufficient filtration are the individual or psychological
barrier.
(iv) Organizational Barrier
-It includes poor organizations culture, climate, stringent rules, regulations, relationship,
complexity, inadequate facilities/opportunities of growth and improvement. Whereas; the
nature of the internal and external environment like large working physically separated
from others, poor lighting, staff shortage, outdated equipment background, noise.
(v) Interpersonal Barrier
-Barriers from employer are; Lack of trust in employees; Lack of knowledge, verbal clues
like facial expression, body language, gestures, postures, eye contact ; experiences
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shortage of time for employees; no consideration for employee needs ; capture authority ;
fear of losing power of control; bypassing and information overloading, while barriers
from employees includes lack of motivation, lack of operation, trust, fear of penalty and
poor relationship with the employer.
(vi) Attitudinal Barrier
-It comes about as a result of problems with staff in the organization. Limitation in patient
and mental ability, intelligence, understanding, pre- conceived notions, and dischargeable
source divides the attention and create a mechanical barrier which affects the attitudes
opinion.
(vii) Channel barrier
-If the length of the communication is long, or the medium selected is inappropriate,
communication might break up; it can also be a result of the interpersonal between the
sender and the receiver; lack of interest to communicate; information should access
problems which can hamper the channel and affect the clarity, accurate effectiveness.
How to Overcome the Barriers

-The following are some of the ways communication barriers can be overcome;
 Allow employees access to resources, self- expression and idea generation.

 Use less of absolute words such as “never’’, ‘’always’’, ‘’forever’’, etc.
 Be a good, attentive and active listener.
 Filter the information correctly before passing on to someone else.
 Try to establish one communication channel and eliminate the intermediaries.
 Use specific and accurate words which audiences can easily understand.
 Try and view the situations through the eyes of the speaker.
 The ‘’you’’ attitude must be used on all occasions.
 Maintain eye contact with the speaker and make him comfortable.
 Write the instructions if the information is very detailed or complicated.
 Oral communication must be clear and not heavily accented.
 Avoid miscommunication of words and semantic noise.
 Ask for clarifications; repetition where necessary.
 Make the organizational structure more flexible, dynamic and transparent.
 Foster congenial relationship, this strengthens coordination between superior and
subordinate.
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 Focus on purposeful and well-focused communication.

 The message communication should be clear and practical.
 Get proper feedback.
Some typical characteristics which good communicators posses

1) Good communicators pay attention to everything the other person is
communicating
2) Good communicators constantly think about the nature of their messages; they
always think about when, where, and how they will deliver their messages;
3) Good communicators always try to find the right combination of words, body
language, dress, and tone of voice before sending a message;
4) Good communicators try to avoid using the same words when sending their
message to different persons because no one person is identical. Good
communicators try to find out what is important for the other person.
5) Good communicators are always ready to be flexible or try to move on after
delivering their message by reaching a decision, solving a problem, negotiating a
compromise, etc.
6) Good communicators are fully aware of the reciprocal nature of communication
which is a process of giving and receiving a message. Good communication is like
a dance which entails leading and following.
Other characteristics of great communicators

 Knowledgeable.
 Sincerity.
 Humorous.
What to observe for effective communication

1) Always try to give feedback based on facts and not on opinions and/ or emotions
which might upset or offend the other person.
2) Always try to empathize or to see a situation from the other’s point view. Try to
accept the other person’s views without preaching and / or moralizing.
3) Criticize using neutral language and tone of voice.
4) Say what you mean without becoming sarcastic.
5) If you want something from others, ask don’t command.
6) Give the other person a chance to speak, don’t slip into continuous talking.
7) Explain why something needs to happen don’t threaten.
8) Don’t give advice or opinions if people don’t ask for it.
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9) Be to the point, avoid vagueness at all cost.

10)Don’t talk down or up to others; avoid diverting the conversation to trivial manner.
What should be the body language during conversation?

-Body language is very important part of our communication. Most of the communication
done by our body languages. If one body language is good we can be good
communicators.
Good body pasture involves

 Keeping good individual space.
 Making eye contact.
 Sitting or standing up straight.
 Looking concerned.
Bad body language

 Staring at the floor.
 Turning body to one side, scowl.
 Fidgeting.
 Rocking back and forth.
 Crossing arms.
 Playing with airs or clothes.
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CHAPTER 7
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HEALTH RECORDS INDICES

Definition of Indices: A more or less detailed alphabetical listing of names, places, and
topics along with the numbers of the page on which they are mentioned or discussed.
-There are different types of health records indices used and maintained in a health record
department, these include:
 The patient master index.

 The diagnostic index (Disease index)
 The operation index.
 The waiting list index.
1. The patient master index

-This is an alphabetical key to numerically filed case records. It is an index referencing
all patients known to an area, enterprise or organization.
-The master patient index contains identification information of all patients admitted to a
healthcare facility and is the key to locating a patient’s medical record.
Importance-An important index in case a patient has lost his attendance card.
-The following must appear in an index card;
 Surname.
 Name.
 Date of birth.
 Sex.
 Hospital number.
 Address.
 Space left for change of address.
Creation of the master patient index-It is created when the patient is being
registered.
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Filing techniques used in filing patient master index

(i) Sorting-This means putting the cards into groups before they are filled. There are two
methods of sorting most appropriate to master index e.g. pigeon, holes and sort files
(ii) Filing-Putting card in order as per the system of filing laid down
(iii) Checking cards order-Confirming if cards are filed in order or if all the cards are
present in the equipment.
(iv) Diagnostic index-It lists diseases, conditions and injuries by the specific code
number for each condition or injury based on a clinical classification system to allow for
retrieval of records for research by each specific code.
-Health record personnel willing to carry out a study on any particular disease from the
index can obtain the case folder. The diseases index will provide the number of the
relevant case records and provide some minimal data about the patient’s age and outcome
of episode treatment.
2. Operation index
-Besides the diagnostic index, operation index needs to be coded just as do diagnosis.
-Its list operations and procedures by a specific code number based on an operation
procedural classification system. The index enables the retrieval of medical record
patients who have undergone a specific operation or procedure while in hospital.
3. Waiting list index

Definition: This is an index for all patients awaiting admission or treatment on a day case
basis.
-A waiting list admission occurs when a patient whose name was on an inpatient or day
waiting list for the specialty is admitted to that specialty as planned. Waiting admission
therefore cover all patients whose names were on a true waiting list, admission waiting
list or a planned repeat admission waiting list for the specialty are admitted as planned.
Function of waiting list index
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 Enquiries can be answered from individual patients.

 Easy for consultants to know how many patients are awaiting his care.
 Assist in understanding utilization of available beds in a health institution.
Types of waiting lists
-They are: 1. Centralized.
2. Decentralized.
The centralized waiting list

-The waiting list is held in one office and contains the names of all patients awaiting
admission under all consultants.
Advantages
 Gives a fair representation of all the demand being made on the inpatient facilities.
 All enquiries are referred to one place.
 Staff dealing with the waiting list develops skills in dealing with enquiries and
maintenance of the waiting list.
 Updating procedures such as change of address and name can be carried out very
easily.
 Checking of admissions and discharge is easy
 When one staff falls sick or goes on leave another staff can carry on with the work
Disadvantages
 Consultants need to walk or telephone to the central office or select their patients
from the waiting list.
 The list becomes so big and long that some patients can be left out of the waiting
list.
Decentralized waiting list

-This is maintained in several places, possibly by each consultant’s secretary or by
individual wards.
Advantages
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 The list is short and become easy to maintain.

 Consultants need not to go to central office to select their patients from the waiting
list.
 The records staffs get familiar with the patients and can call them by their names.
Disadvantages
 Several staff will be deployed in the maintenance of the waiting of the waiting list
in different areas.
 Expensive since each department will need to use its equipment.
 Record staff will have to walk to the central waiting list department to check on
the discharges from the daily bed return.
Creation of waiting list
-Most of the waiting list records are initiated in the outpatient clinic.
-There are five ways in which information can be conveyed to the waiting list.
1. Card-The card is created to every patient who is to be admitted. The card will be filled
and form part of the waiting list.
2. A list-The nurse or doctor may send a list of patients to be included in the waiting to
the records department.
3. Letter-A consultant in one hospital may wish to include his patient’s name in his
waiting list.
-The information to be included is;
 Patient’s name.
 Address.
 Telephone.
 Holidays.
 Diagnosis.
 Operation to be carried out.
Procedures of selecting the patient on the waiting list
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 The patient is selected from the waiting list by the consultant.

 The record staff writes to the patient or telephones him inviting him.
 The records are got out from the file and sent to the documentation.
 The waiting list card is sent to the admission so that the day the patient comes in,
the admission office checks the record, when he/she comes the details are checked
and confirmed.
 The patient is admitted and sent to the ward.
 When the patient has been discharged his name is removed from the waiting list.
 Certain checks are made on the waiting list to remove the names of patients that
may have been admitted through accident and emergency department that have
died.
Checks to be made on the waiting list

 Checking for completeness.
 Checking for accuracy.
 Checking for deaths.
 Checking for duplication.
(i) Checking for completeness
-Ensure that the patients name is in the waiting list to avoid inconveniencies. The list
should be checked against the alphabetical index file, if there is any in the patients listed,
the matter may be investigated and the patient put on the waiting list.
(ii) Checking for duplications
-The admission form in the routine and emergency should be checked in the files.
Patient’s files for specific operation should be retrieved at the time the patient is ready to
avoid a situation where by a patient is called to the hospital and yet the patient is already
in the ward.
(iii) Checking for deaths
-It is always important to check death notification procedure and the ward to confirm the
status of the patient if alive or dead.
(iv) Checking for accuracy
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-Where a hospital has a large waiting list for more than a thousand people for admissions,
some of those patients will be forced to wait for a long time
-It is important to write to these patients to confirm if they are still coming to the hospital
for treatment or operation, they can be informed to write back to confirm if they are still
ready for admissions.
-This check of accuracy means that patients who no longer need admission are
recognized and statistics are not inflated.
Statistics
-Regular returns will be needed for the number of patients on the waiting list. These
returns are in the form of the number of patients waiting for admissions under consultant
e.g. number of males, females or children may be shown separately with specific clinics.
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CHAPTER 8
APPOINTMENT SYSTEMS AND SCHEDULING

Definition: This is the giving of day, date, time and clinic of attendance to individual
patient or client.
Concepts of scheduling
1) Patients should be distributed evenly to various clinics depending on the

information that the consultant should be able to see
2) The staff manning or running the clinics should ensure that the patients are not
kept waiting for long before they are seen
3) Overloading of clinics should be avoided
4) There should be a laid down policy on how to schedule agent cases
5) Staff working in the appointment area should be familiar with the hospital so that
they give proper direction to the patients or clients
Purposes of appointments/scheduling
1) To reduce patients waiting time.

2) To provide an even spread of work over the whole clinic session.
3) To allow the hospital to prepare in advance for each and every patient for
registration at the time of the clinic can be reduced.
4) To provide for special clinic arrangement e.g. recording of social history of
patients, removal of plaster.
5) To cater for issues of transport and distance difficulties from their house to the
hospital and back.
6) To provide for teaching arrangements. A consultant may wish to issue an
interesting case to the medical students.
Types of appointment systems
-There are two types of appointments, they include:
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1. Centralized
2. Decentralized
Centralized appointment system

-This means that all the appointments for the various clinics are made in one central place
Advantages
1) The master index will be near the area for quick reference.
2) Control of staff, stationery and equipment by the health record information officer
is easy.
3) Each of the appointments record staff becomes familiar with the working system
for various consultants.
4) All enquiries concerning appointments are referred to one area/ place.
5) Urgent cases can be channeled quickly for respective clinics.
6) When one record staff is sick or goes on leave other clerks continue with the work.
Disadvantages
1) It creates congestion of patients.

2) Increases the patients waiting time.
Decentralized appointment system

-It is an appointment system carried out in different clinics
Advantages
1) The records staff dealing with the appointment becomes familiar with the patients
and knows them by name.
2) The consultant in charge of the clinic will know the number of patients on his list
without having to walk or ring the central area.
3) It eases congestion of patients.
4) Reduces the patients waiting time.
Disadvantages
1) The master index is far from the appointment area.

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2) Control of the available resources is difficult.

3) When the records staffs who man the clinics is sick or on leave, the work may be
interrupted.
4) Enquiries concerning appointment are directed to different place.
Sources of requests for the appointments in hospitals
1) Patients telephoning personally to make appointments.

2) Physicians or private practitioners wanting to book appointments for their patients
through telephone or writing.
3) Letters from other health institution given to come and book their appointments.
4) Patients already discharged from the hospital making a return appointment.
5) Patients referred from one clinic to another.
6) Patients can come from outpatient clinics.
Clinic preparation
-Two days prior to the clinic list should be sent to the appropriate sections, one to the
filing area and the other to the consultant in charge of the clinic area.
-All the records and documents should be pulled out, all the pathological results should
be inserted in the correct files and kept in the pigeon holes for the clinical methods to
come and collect.
-The clinic receptionist should make sure all the documents are such as x-rays are
recorded each and every patient attending the clinic.
-The clinics are prepared two days in advance to reduce the patients’ time before he is
seen by the physician. At the end of the clinic the receptionist should ensure that all
records are returned to the central library ready for filling.
Follow up procedure
Definition-The process of keeping in touch with the patients so that certain objectives
can be met.
Purpose of follow up
1) To make or not changes that have occurred in terms of relieve/ improve treatment
given.
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2) To be able to provide immediate treatment as soon as need arises.
Follow up procedures/ policy
-The basic rules for follow up procedures include:
1. Full registration of the patients.
2. Recording against all dates of attendances.
3. Specific instructions as regards the methods of procedures or methods.
4. Limitations of time in respect of the various patients to be followed up.
What is an outpatient appointment?

-An outpatient is when a doctor refers a patient to a hospital for a medical problem. The
hospital will send a letter to a patient confirming the name of the consultant, the location
of the clinic and time of the appointment.
Regulatory viewpoint
-Outpatient Did Not Attend (DNA) rates vary between hospitals, regions and area of
specialty. Current opinion is that DNA rates can be reduced by reviewing appointments
and other procedures from the point of view of outpatients.
-The care quality commission (CQC) assesses individual hospitals, trusts on their DNA
rates and has stated that large numbers of missed appointments may bring poor provision
of community services. High DNA rates may also be an indication of inappropriate
referrals and reflect the quality of the interface between primary care surgeries, clinics,
primary care trusts and secondary care in hospitals.
Why do patients miss their appointments?
-Studies investigate why people do not attend their outpatient appointments have revealed
a number of possible reasons, the following are four common types of issues related to
missing appointments without notifying the clinic staff:
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1. Emotions- fear and anxiety about both procedures and bad news.
2. Perceived disrespect by the healthcare system.
3. Not understanding the scheduling system.
4. Distance and finances may force patients to miss appointments.
5. Inconvenience caused by friends, relatives on the alternatives of treatments.
Return appointment
-There are obvious advantages to such appointment made in the clinic for example;
1) If a clinic for which a doctor has requested a future appointment is ready fully
booked the receptionist will be in good position to speak to him direct and find out
if he wishes to see an extra patient on that day.
2) Or whether he wishes the appointment to vary by bringing the patients sooner or
later than originally intended.
3) The receptionist will also be aware of the test that are being ordered at the current
attendance and will be able to make a note against the result of these tests if it will
be needed.
4) Also the patient will have to talk to one receptionist instead of a receptionist and to
an appointment clerk.
5) This will save the patient a lot of walking and time.
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CHAPTER 9
FILING SYSTEMS FOR CASE RECORDS AND X-RAY FILMS

Definition-Filing is a systematic way of arranging documents to enable those documents
files maintained in good order.
-The library from which notes are not really available is a threat to the patients’ treatment.
Importance of filing medical records
1) Waste less employee time with faster record retrieval and use.
2) Enables access of documents that demonstrate regulatory and legislative
compliance (administrative use, court cases).
3) Helps perform daily records activities more efficiently.
4) Protect against accidental or premature record destruction.
5) Prevent costly paper accumulation with systematic weeding and record disposure.
6) Reclaim office space used for inefficient storage.
7) Secure vital records and information in case of business disruption or disaster.
Selecting a filing system
-Media records management is intended to control recorded information from delivery

until its disposition. The ability to file and retrieve information easily and effectively is
central to this process. Choosing the correct filing system can be difficult, therefore are
the basis for making that choice; records come in all formats- paper, microfilm, visual
and electronic media.
Which is the right system for your department?
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-To determine which system is right for a medical records department, four questions
must be answered:
1. How are the records used or retrieved
-Types of records and the usual method of retrieval may determine the filing system,
example a numeric system would work well for small library where records are kept by
number, an alphabetical system would make more sense for licensing files are retrieved
by license name and terminal digit filing system will work well for a larger medical
library.
2. How many records do you have?
-Departments or libraries with limited records volume can often use an alphabetical
system; large volumes of records usually require numeric filing systems.
3. How big is the hospital or agency?
-Large agencies, especially those with multiple branch offices may use an alphanumeric
central filing system to insure consistent filing practices throughout the agency. Larger
agencies have more people filing and retrieving records.
4. Who uses the records?
-The needs of the people filing and retrieving records must be considered when choosing
a filing system.
Evaluating a filing system
-Here are some questions you need to ask about any system you are considering to put in
place.
-These same questions can also be used to evaluate an existing filing system.
1. Is the systematic logical?
Logic speeds learning, so staff members do not have to rely on memory alone. The
method behind the system should be clear and reasonable.
2. Is the systematic practical?
-Does it do what you want it to do? Avoid academic and overly complex classifications.
The system should be designed to use common terms known to all users of the system.
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3. Is the system simple?
-Simple here means easy to learn. The system should be as straight – forward as possible,
with little (or preferably no) room for interpretation.
4. Is the system functional?
-Does it relate to the function of the records it addresses? Classification terms should
reflect the function of the records regardless of their operational location.
5. Is the system retention- conscious?
-Your filing system should be linked to your records retention schedule in a way that
allows you to move records to inactive storage, and to move files with expired retention
periods. These activities should be done according to your agency’s approved records
retention schedule.
-The efficiency and practicality of a filing system should not be sacrificed to retention
considerations, however.
6. Is the system flexible?
-You should be able to expand it when needed. Additional or different classification will
be needed in the future, or your office may experience unforeseen growth or change.
Filing system should be able to accommodate growth and change.
7. Is the system standardized?
-Filing system terms should be standardized, because using because using different terms
to describe same record or subject will cause confusion. You should also have a written
set of rules that all staff to follow, to avoid lost files, misfiles, and planned duplication of
the records filing locations.
Filing methods
-There are three major filing methods used in an organized health records department.
 Alphabetical filing (this has little place in any discussion of the case records.
 Chronological filing.
 Numerical filing.
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a) Chronological filing system
-This is where records are filed using dates when the record was created or the date of the
patient. It cannot be used to file case records except that it can be used for the records
inside the case folder. It is not recommended for filing in a big library
b) Numbering filing system
-In this case the ways of filing can be adopted;
 Straight numerical.
 Terminal digital filing system.
(i) Straight numerical filing system
-Straight numeric filing is putting the folders in order of lowest number to highest. It’s
probably the filing system that comes automatically into most people’s mind 4.5 and it’s
probably the most suitable method of filing for a small records library there is no
necessity to go into facing elaborate detail needed to install a terminal.
Advantages
1. This works well with smaller filing systems. Because pretty much everyone knows
how to count from lowest number to highest number.
2. Training is minimal.
3. Purging/ weeding are easier.
Disadvantages
1. Growth of the case record is confined at one of the filing area because there is the
busiest section of the library i.e. at the end of the filing area.
2. Gaps are usually left after weeding.
3. Transposition of the figures occur wherever one is dealing on big numbers like
record 567424 can be misfiled as 564724.
4. In most current records, it is not visible to fix responsibility for a section of the
filing to one clerk
.
(ii) Terminal digit filing
Definition-This is a state of organizing files under the last two digits of an identifying
number, and then sequentially by any preceding numbers.
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-A system of filing using a six digit number or higher that is divided into three parts,
whereby the last two digits are considered primary.
Primary digits- The last two digits to the right in the number.
Secondary digit- The middle two digits in the number.
Tertiary digits- Any remaining digits.
-This method is not recommended in countries where the number of records is small and
also not recommended when clerks are not trained in its implementation and use.
-Before one starts terminal digit filing system, one should make sure that there is enough;
 Space
 Man power trained.
 Shelves constructed.
 Medical forms.
 Pre-printed folders.
-Incorrect implementation could cause problems and confidence in the staff of the
Medical Records Department will be affected.
-The terminal digit filing is a simple and accurate filing method that makes it easier for
clerks to file. They may also file faster and sometimes more accurately. This method of
filing is signed for large acute care facilities, and is not appropriate for medical record
systems in small developing countries where the volume of medical records to be filed is
low.
-Terminal digit filing is used to spread medical records evenly throughout the filing room.
It is used in facilities where the volume of medical records is large and enables the
distribution of work between a numbers of cleric staff.
-This system was first used in the United States hospitals and has been the standard of
filing in the country. Anyone starting a new records department could be well placed to
start off from the beginning; the main difficulties experienced with the straight filing
system are overcome by the terminal system
Its main principles are as follows:
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-In this method, numbers are allocated in the same way as for straight numeric filing and
difference is HOW they are filed. A six digit number is generally used and divided into
three parts e.g. the number 345678 is divided as 34-56-78 with each part containing
numbers.
-The last two numbers on the right hand side (78) are called the primary numbers (that is
the first two considered when filing), the middle two digits (56) are called the secondary
Digits (the second sets of digits considered when filing); and the two digits on the left
hand (34) are the territorial digit third and last set of digits to be considered when filing.
Tertiary secondary and primary digits
-With this method the filing area can be divided into 100 sections for the primary digits
e.g. 99. This then allows the filing to be distributed among a number of clerical staff.
-Within each primary section medical records are grouped by the secondary digits and
this ranges from 00-99.
-To file a medical record, after locating the primary and then the secondary section the
files the medical records by the tertiary digits. For example to file the number 34-56-78.
‘’78’’ primary section needs to be located then the ‘’56’’ secondary section. The records
56-78 are then filed before 35-56-78. The series of the numbers would be as follows;
32-56-78
33-56-78
34-56-78
35-56-78
-Some hospitals also use a color code on the folder to assist with identifying the method
of record quickly and to improve the efficiency of the filing clerks.
A sorter or pre-file system
-Each file room should have a set of shelves for records waiting to be filed, this is usually
called a ‘’sorter’’
-Medical records which are returned from outpatient clinics (if the medical records are
combined, that is if a centralized system is used or completed after discharge of an
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inpatient and ready to be filed, should be sorted in a manner, which will be enable them
to be found, if required while waiting to be filed.
-The shelves should be numbered, perhaps in sections of 10’s or 20’s and the records
placed on the correct numbered shelf while waiting to be filed. This makes it easier to
find a record which is waiting to be filed.
Terminal digit
-The shelf is divided into 100 pigeon holes, beginning with 00 and ending with 99 as
shown below:
00 01 02 03 04 05 06 07 08 09
10 11 12 13 14 15 16 17 18 19
20 21 22 23 24 25 26 27 28 29
30 31 32 33 34 35 36 37 38 39
40 41 42 43 44 45 46 47 48 49
50 51 52 53 54 55 56 57 58 59
60 61 62 63 64 65 66 67 68 69
70 71 72 73 74 75 76 77 78 79
80 81 82 83 84 85 86 87 88 89
90 91 92 93 94 95 96 97 98 99
Advantages
1) Old and new files are evenly spread through the system.
2) Work amongst filing clerks can be equally distributed.
3) Individual clerks can be responsible for certain sections.
4) There is no annual shift-back or closing up of notes after-weeding to make room
for new records.
5) Sorting of notes is simple.
6) The system is simple for both filing and retrieving.
7) New staff finds the system very much faster to learn than straight section
numerous filing. Because of the library being more static and the zeros are always
in the same place.
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8) Fewer misfiles occur, this is because the filing clerk concentrating on only two
digits at a time.
9) The congestion that results when several clerks file active records in the same are
filing area is eliminated.
Disadvantages
1) Needs bigger filing space.

2) Weeding/ purging of notes.
3) Hard to determine the number of files created over time in the library because
terminal digits are used and not straight numerical.
4) Costly in implementation.
Fundamental requirements of a filing system
-For a filing system to be effective it should put into account the following requirements:
1. Accessibility-Any filing system should be easily accessible; it should allow speedy

location and identification of document/ records contained in it.
2. Simplicity of operation-It should be easily understood by those working in the library

and those who might have occasional access e.g. new staff.
3. Compactness-It should be one that takes into account the value and cost storage space
and also to reduce physical effort in the working system for example every space should
be maximally used.
4. Economy-Finances and other requirements should be basically be considered in any

filing system, good filing system should be affordable or economical both installation or
in operation.
5. Elasticity/flexibility-It should be easy to adjust when need arises. It should be able to

expand to accommodate future requirements and also to ensure retention and disposal of
documents without much disturbances.
6. Tracing system-It should adopt tracer systems which will enable the keeping track of
the document/ record circulation from one place to another.
7. Methods of classification of documents-A filing system, which is well planned,

should explain clearly how the document records are to be grouped in the filing.
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8. Good lighting system-There should be enough lighting to allow users good visibility
of records and comfort for staff working in the library. Adequate lighting, well positioned
lighting (experts should be consulted as to levels required and correct placement).
Workers should not face glaring lights.
9. Sufficient ventilation-Filing area should be well ventilated to avoid accumulation of

dust that may affect staff and records in the library. Temperature control and circulation
of air that is adequate ventilation, fans, windows.
10. Enough working space-The filing area should be spacious enough to accommodate
staff movement as well as working freely during clinic preparation and sorting of files.
Filing equipment used in filing case records and x-ray films
1. Shelve filing
-It is the most used filing equipment probably more suitable for filing large quantities of
notes or x-rays films than anything else. Metal is more suitable than wood. There are
some advantage and disadvantage of shelve filing.
Advantages
 Records can easily be filed and pulled quickly since the shelve are open.
 More records can be filed on the shelves than in the cabinets.
Disadvantages
 If shelves are constructed high, light cannot penetrate to the lowest shelve.
 If shelves are constructed high, the shortest clerk has to climb the ladder stools.
 Shelves are not dust proof.
 Shelves are not fire proof.
 Shelves are not water proof.
2. Filing cabinets
-These are recommended for smaller libraries and provide ideal filing conditions.
Advantages
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 Good access.
 Dust proof.
 Convenient height.
 They provide attractive appearance.
Disadvantages
 They take up more space.

 More expensive than the shelves.
 It provides safely.
3. Suspended filing
-It is not suitable for a large number of case records and x-ray films on the ground and
amount of manila pockets hanging for the metal bars and providing a V- sharp into which
notes can be filed.
-The metal hanging bars have flat tops to indicate the unit number filed in each
suspended filing can be stored in the filing cabinets and addition of special frame which
to hang the pockets or it can take place of the shelves in horizontal unit.
Advantages
 It is ideal for filing administrative records where file are slim.
Disadvantages
 It takes a lot of space.
4. Mobile racking
-This is the most economical filing method/Equipment as far as space is concerned of
shelves of shelves is contained in a rigid frame and racking run on races. One set shelves
and then there may be 3 mobile sets. It will immediately be obvious from this the five
sets of racks were static; far more room would be taken up by the gangways to gain
access to both sides of the rack.
Advantage
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 It saves space.
Disadvantages
 The pushing of the rack would be a difficult task.
Two other major items of filing equipment which should be mentioned are
i) Dividers
-Documents as heavy and the same time flexible as a case folders and x-rays film need
plenty of support.
-Dividers for any sort of shelves filing provide this. Ideally the dividers are metal and
reach from the bottom of one shelves to the top surface of the shelve below being firmly
attached to both shelves.
-They thus provide support not only for the actual shelve unit by adding rigidity. The
metal dividers can be supplied and rolled edge similar to that used for the shelve unit.
Notes should be divided heavy in inches and x-ray films divided after 6 inches.
Otherwise they soon ‘’droop’’ and become permanently misshaped.
ii) Color coding
-Color coding can be applied to both notes and x-ray films for a variety of purposes. It is
traditional that the ten colors should be used for the ten main divisions of terminal digit
filing. Thus each number 1-9 has a different color. Color can be used to identify a
particular number except that a few individuals suffer from color blindness. Color-coding
can also be used to indicate the year when the record was created. This can be affected by
use of colored collotype or colored adhesive labels.
Auxiliary Equipment
-The efficiency of a well laid out and carefully filed records or x-rays films library can be
significantly increased if certain basic items are provided in addition to the most suitable
type of shelving.
a) Filing trolleys
-If clerks are to walk round the filing area and with armfuls of notes putting them down
each time they have to withdraw or file a record they will be very tired at the end of the
day. Trawlers should be strong and large enough to be able to carry heavy loads of case
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records and x-rays films hence saving the clerks the duty of moving around carrying
armfuls of notes and x-ray films.
b) Kik stools/ladders
-These are necessary for the shortest clerk to climb on to reach the shelves as high as 7
feet. Any ladder or Kik stool should be light, strong and easily moved.
c) Sorting equipment
-Sorting equipment for case records and x-rays films will certainly be in pigeon holes. It
is usually very important that this vital task is not attempted and is equipped. Where
terminal digit filing system is used, it is desirable to have one pigeon holes one for each
terminal digit. This should be clearly numbered as from the back to the library from
clinics, secretaries, wards etc. They can be straight appropriate pigeon holes of the
sorting unit. The filing clerk responsible for each of the library will thus take the files on
the pigeon number sort them out and file them.
d) Preparation tables
-These tables can be used for sorting the notes for filing or for preparing the clinics
should be enough.
Tracing systems of case records and x-rays films
Tracing
-It is a system used to keep track of records when moving from one place to another
normally from the main library.
-It’s the act of keeping track of movement of records, X-rays films from one place to
another mainly from the main library.
Types of tracing system

-There are three commonly used tracing systems in a records library to trace health
records:
1. The common tracer card
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-It’s a card used to replace a record when it’s removed from the filing area. When the
record is returned to the filing area, the tracer card is removed and the record filed back.
The tracer card is cancelled and re-used; the card should be strong enough.
The information written on it is
i) Patients full name.
ii) Date of appointment.
iii) Destination i.e. ward/clinic (specify the type of clinic etc.).
iv) Reason for extraction.
v) Patient’s number (unit number/hospital number).
Advantages
 It can be used as many times as possible (80 times) hence economical

 A clerk can prepare a whole clinic record while seated.
2. Library tracer system

-Each case record has a small pocket inside the cover with a small card written the
patients name and the hospital number at the top. When the notes are withdrawn, from the
filing area, the card is marked and the date and the name of the borrowed and then filed
in a small tracer index. When the notes are returned the card is removed from the index
the entry cancelled and the card filed into the pocket in the folder. Then the folder itself is
refilled.
Advantages
 Since the card is created permanently when the folder is created then the facts are
always right.
Disadvantages
 It is recommended only for small libraries.

 There is no object in place of the file to show where the record was before
extraction/retrieval.
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 Misfiling is likely to occur.
3. Personal tracer card

-It is a card created together with the case folder and it identified with the patients name
and unit number. It is filed inside the folder and removed out of the file when the notes
are taken out of the filing. The same details as in the common tracer card are entered on.
Advantages
 Since the card is created permanently when the folder is created then the facts are
always right.
Disadvantages
 It is recommended only for small libraries.

 There is no object in place of the file to show where the record was before
extraction/retrieval.
 Misfiling is likely to occur.
Advantages
 No transposition of numbers since the number created permanently on the card

 When the record cannot be traced the details of the previous destination may give
glue as to the destination of the record.
4. Computer tracing system

-A patient record system is a type of clinical information system, which is dedicated to
collecting, storing, manipulating and making available clinical information important to
the delivery of patient care. Computer tracing system makes it easy to track records
within a given setting by the touch of a button.
Accident and Emergency Records Procedures

-After a patient has been seen at the health center he may be having someone who needs
immediate and urgent attention. Definitely the doctor will refer him to a hospital for
immediate attention. He will find himself in an accident and emergency department. Also
patients with any type of accident will be brought to this department directly.
1. Records to be kept
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-First a register must be maintained at the accident and emergency department following
information should be included in the register:
 Name of the patient.

 Address.
 Age.
 Time of arrival.
 Brief description of the living.
 Brief details of treatment.
 The mode of disposal.
 The particulars of the person who has brought these patients to the accident
emergency department must also be taken as well as the police officers number
which should be recorded in the register.
-The register may be in loose- leaf form or in bound volumes.
-From the register, statistic of attendance will be combined.
2. Clinical record
-Single card measuring 8 inches 5 inches or 6’’ by 4’’ on which the identification should
be maintained. For RTA (Road traffic accident) patients the time and the particular
accident must be given as well as space left for the clinician to write on.
-Two part card with carbonized part made of good material should be maintained. This is
made up in an envelope form so that x-ray reports and any other correspondence filed in
it.
-A thick paper envelope is maintained. The envelope will serve as a card and reports.
Appointments in casualty before disposal

-Most patients attending this department rarely come back for return appoint those
patients that need return appointments, this can be carried out in two ways.
 Referred to out-patient consultant clinic.

 Referred to a consultant clinic in another hospital.
 Admitted to the wards for further treatment (here full documentation for admission
will be carried out before the patient goes to the wards).
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 Transferred to another hospital for further treatment. In case of a patient who has
been brought in death (B.I.D) just certifies the death and the body is conveyed
straight to the mortuary.
Legal requirements
-It is important to note that the same legal requirements that are applicable to other health
records as far as retaining is concerned still applies in accident and emergency records.
They may be retained for a minimum period of 6 years after the last attendance. The
records may be filed numerically or alphabetically depending on number of records
created annually at the beginning of the year that is for 1st January, a new file is started.
The records should be kept in lock and key because most of these records are required in
court and as much details as possible should be recorded. Most of the patients who have
been involved in traffic accidents claims in future. Therefore statistics for the patients be
sent to the finance department so as to issue the necessary claims.
Bed Bureau
Definition-The bed bureau section of the medical records department is the section that is
admission for emergency patients.
The functions of the bed bureau
 To pass messages to the medical records library for the initiation of the case or the
retrieval of the old ones.
 To locate a bed to which the patient may be admitted.
 To receive telephone calls from general practitioner who which to have patient
admitted on emergency and to whichever department which receives emergency.
 To answer patients relatives enquiries.
-It is important to note that the bed bureau staff must have an exact and up knowledge of
bed state of every ward in the hospital.
-The bed bureau may consist of a series of hooks; slotted racks, peg boards, planning etc.
divided into as many section as they are wards.
-A bed bureau can save lot of medical and nursing time in locating empty bed emergency
admissions.
What information to gather about the bureau
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-The ward clerks or nursing staff gather information about bed state with information
concerning:
i) Patients unlikely to live in the next 24 hours.
ii) Patients who have been discharged or died and have left a vacant bed.
iii) Patients likely to be discharged on the next visit by the consultant.
iv) Delayed discharges.
What to do with gathered information about bed bureau
-The information is processed by the ward staff in their assessment of the situation ward.
-The information may be stored informally or on statement sheets.
-The information is passed (distributed) to the bed manager who gathers an overall view
the hospital/medical directorate situation by ‘’processing’’ the information received in
each ward. This may be via face-to- face contact, over telephone or in a few cases direct
network link.
-Information on emergency admissions is gathered from vacancy and emergency unit.

Doctors amongst other professionals by the bed manager casually on a piecemeal basis
except when the bed manager comes on shift in the morning. The information is
processed by a matching of new need and current bed stands one minute by minute
(matching of supply to demand).The key factor here is that the situation is rarely stable.
-Information on elective work is processed as a delivered sheet of potential booked in

according to consultant.
-Further information on potential influx is gathered informally.
What record staffs should know in maintaining filing system for bed bureau
 Have a wide knowledge of departments, hospital sites, procedures and medical

terminology.
 Provide routine enquiries, advice and assistance to service users.
 Completion of paper record and then computer record for all General Practitioners
referrals.
 Record number of emergency bed bureau referrals on data base (entering total
types of referrals on a daily basis for use in statistical information production).
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 Recording admissions totals for all sites for use in statistical information
production.
Communications and relationships within bed bureau users
1) Liaison with General Practitioners who require patient admission and/ or advice on
patient referral i.e. which site for a particular specialty.
2) Liaison with various members of staff within hospital to maintain the service of
the bed bureau i.e. patient flow managers for updating bed availability on
particular sites.
3) Speaking to specialty clinicians for advice on Patient admissions.
4) Liaison with ambulance service operation room assistants to ensure patient
transport is arranged as required.
5) Dealing with delays and contacting General Practitioners and patients advising of
delays or problems.
6) Liaison with hospital health emergency planning officer during major incidents or
national emergencies.
7) Liaise regularly with the capacity management team to ensure that Emergency Bed
Bureau services are being maintained effectively and appropriately.
Major challenges about bed bureau
 Collation of high volume of information requiring accurate documentation.

 Advising General Practitioners of alternatives to admission in a culture of change
and new initiative.
 Negotiating changes to wards (zone) due to capacity demand with conflict from
the General Practitioners.
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CHAPTER 11
ELECTRONIC MEDICAL RECORDS

-This is a longitudinal electronic record of patient health information generated by one or
more encounters in any care delivery setting.
-It is a record in digital format that is capable of being shared within across different
health care setting, by being embedded in network-connected enterprise-wide information
system.
-A patient record system is a type of clinical information system which is dedicated to

collecting, storing, manipulating and making available clinical information important to
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the delivery of patient care. The central focus of such systems is clinical data and not
financial or billing information.
-The aim of many hospital authorities is for the development of an automated patient
information service that will increase the efficient retrieval of information for patient
care, statistics research and teaching. An important point to remember, however is that the
use of computerization system may improve the effectiveness and efficiency of a Medical
Record Department, but ONLY where the basis manual procedures are already in place
and well organized.
-Computerized information systems have not achieved the same degree of penetration in
healthcare as that seen in other sectors such as finance, transport and the manufacturing
and retail industries. Further deployment has varied greatly from country to country and
from specialty and in many cases has revolved around local systems designed for local
use.
-Electronic medical record systems lie at the center of any computerized health
information system. Without them other modern technologies such as decision support
systems cannot be effectively integrated into routine clinical workflow.
-Terms used in the field include electronic medical record (EMR), electronic patient
record (EPR), electronic health record (EHR), computer based patient record (CPR),
automated medical records system (AMRS) amongst others.
-These terms can be used interchangeably or generically but some specific differences
have been identified, for example an Electronic Patient Record has been defined as
encapsulating a record of care provided by a single site in contrast to an Electronic Health
Record which provides a longitudinal record of patients care carried out across different
institutions and sectors. But such differentiations are not consistently observed.
Consideration for the computerization of patient related medical records
-Before computerization of patient medical records is instituted, it is the responsibility of

the administration to ensure that:
 Hardware and software support is readily available.

 All clerks have keyboard and mouse training and are also trained in the use of
relevant software.
 A computer terminal is made easily available to the clerical staff and should be
locked away in the manager’s office.
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 Appropriate furniture is made available (power points, electrical cables, chair

desks) furniture provided for computers in Medical Records Department are taken
away by managers for other offices. This should not be permitted.
 Security procedures should be implemented to avoid the use of the computer
games and other non- medical record functions and to protect the computer
viruses.
 Authorized staff should be issued with passwords, which are changed regularly to
prevent an authorized access.
-Medical record procedures commonly computerized in many countries include the:
 The master patient index.

 Admission, transfer and discharge/ death system.
 Disease and procedure index.
-In addition to the applications listed above the following procedures could be common
when the above systems are running smoothly:
 Record location/tracking system.

 Medical record completion system.
 Discharge summary abstracting system.
 Outpatient appointment scheduling system.
Key capabilities of an Electronic Health Record System
-The following are a set of eight core care delivery functions that electronic health record
systems should be capable of performing in order to promote greater safety, quality
efficiency in health care delivery.
The eight core capabilities that Electronic Medical Records should Posses are:
1) Health information and Data-Having immediate access to key information as
patients’ diagnosis, allergies, laboratory test results and medication will improve
caregivers’ ability to make sound clinical decisions in timely manner.
2) Result management-The ability for all providers participating in the clinical
patient in multiple settings to quickly access new and past tense result would
increase patient safety and the effectiveness of care.
3) Order management-The ability to enter and store orders for prescriptions tests
and other services in a computer- based system should enhance legibility, reduce
duplication and improve the speed with which orders are executed.
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4) Decision support-Using reminders prompts, prompts and alerts, computerized

decision support system would help improve compliance with best clinical
practices, ensure regular screenings and other preventive practices, identify
possible drug interactions and facilitate diagnoses and treatments.
5) Electronic communication and connectivity-Efficient, secure and readily
accessible communication among providers and patients would improve the
continuity of care, increase the timeliness of diagnoses and treatments and reduce
the frequency of adverse events.
6) Patient support-Tools that give patients access to their health records provides
interactive patient education and help them carry out home monitoring and self-
testing can improve control of chronic conditions such as diabetes.
7) Administrative processes-Computerized administrative tools, such as scheduling
systems would greatly improve hospitals and clinics efficiency and provide more
timely service to patients.
8) Reporting-Electronic data storage that employs uniform data standards will
enable health care organizations to respond more quickly to federal state and
private reporting requirements including those that support patient safety and
disease surveillance.
Other key capabilities of an Electronic Health Record System include
 To capture data at the point of care.

 To integrate data from multiple internal and external sources.
 To support caregiver decision making.
Benefits of Electronic Medical Records
 Replace paper based medical records which can be incomplete, fragmented

(different parts in different locations) hard to find.
 Provide a single shareable up to date, accurate, rapidly retrievable source of
information, potentially available anywhere at any time. Require less space and
administrative resources.
 Potential for automating, structuring and streaming clinical work-flow.
 Provide integrated support for a wide range of discrete care activities including
monitoring, electronic prescribing, electronic referrals, radiology, laboratory
ordering and results display.
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 Maintain a data and information trait that can be readily analyzed for medical audit
research and quality assurance, epidemiology monitoring disease surveillance.
 Support for continuing medical education.
 The ability to automatically share and update information among different
organizations.
 More efficient storage and retrieval.
 The ability to share multimedia information such as medical image among
locations.
 The ability to link records to sources of relevant and current research.
 Easier standardization of services and patient care.
 Provision of decision support systems (DSS) for healthcare professionals.
 Less redundancy of effort as well as lower cost after implementation.
Barriers
-Wide spread implementation of Electronic Records has hampered perceived barriers
including:
 Technical matters (uncertain quality, functionality of integration with other

applications.
 Financial matters – Particularly applicable to non- public health service systems
(initial costs for.
 Certification, security, ethical matters; privacy and concerned issues
 Doubts on clinical usefulness.
 Incompatibility between systems (user interface, system and functionality can
vary significantly between suppliers production.
Issues to note in Electronic Medical Records Systems
 Integrated systems require consistent use of standards in e.g. medical terms and
high quality data to support information sharing across wide network.
 Ethical, legal and technical issues linked to accuracy, security confidential access
rights are set to increase as national Electronic Medical Records come online.
 Common record architectures, structures.
 Clinical information standards and communications protocols.
 Security and confidentiality of information.
 Patient data quality, data sets, data dictionaries.
Comparisons between Electronic Medical Records and Medical Paper Records.
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-The electronic medical record (EMR) is slowly replacing the paper chat for doctor
patient details. As the adoption curve for EMRs rapidly increases, so will the clinical
terminologies. Currently, administrative classifications such as ICD-9-C and HCPCS
serve not only billing and reporting purposes, but also are used by the providers for
documentation and capturing patient procedures and problem lists.
-Paper based records require a significant amount of storage space compared to digital
records in the US; most states require physical records held for a minimum of seven
years. The costs of storage media, such as paper and film per unit of information differ
dramatically from that of electronic storage media.
-When paper records are stored in different locations, collecting them to a single location
for review by a healthcare provider time consuming and complicated, whereas the
process can be simplified with electronic record. This is particularly true in the case of
person- center records, which are impractical to maintain if not electronic (thus difficult
to centralize or federate). When paper based records are required in multiple locations,
copying, faxing and transporting costs are significant compared to duplication and
transfer of digital records.
-Electronic records help with the standardization of forms, terminology and abbreviations
and data input. Digitalization of forms facilitates the collection of data for epidemiology
and clinical studies.
-In contrast, EMRs can be continuously updated. The ability to exchange records between
different EMR systems (interoperability would facilitate the coordination of healthcare
delivery in non- affiliated healthcare facilities. In addition, data from an electronic system
can be used anonymously for statistical reporting in matters such as quality improvement
resource management and public health communicable disease surveillance.
-Electronic medical records like medical records must be kept in unaltered form and
authenticated by creator. Under data protection legislation, responsibility for patient
records (irrespective of the form they are kept in) is always on the creator and custodian
of the record, usually a health care practice or facility. The physical medical records are
the property of the medical provider (or facility) that prepares them.
Areas of Concern in Electronic Medical Records

Electronic signature
-Most national and international standards accept electronic signature. According to the
American Bar Association, ‘’ A signature authenticates writing by identifying the signer
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with the signed document. When the signer makes a mark in a distinctive manner, the
writing becomes attributable to the signer.
Technical Features
-Using on EMR to read and write a patients record is not only possible through a
workstation but depending on the type of system and healthcare settings may also be
possible through mobile devices that are handwriting capable.
-Electronic Medical Records may include access to Personal Health Records (PHR)
which makes individual notes from EMR readily visible and accessible for consumers.
Event monitoring
-Some EMR systems automatically monitor clinical events by analyzing patient data and
Electronic Health Record to predict, detect and potentially prevent adverse events can
include discharge/transfer orders, radiology results laboratory and other data from
ancillary services or provider notes.
General Practitioner to General Practitioner
-General practitioner to General Practitioner is Health Service Connecting for Health in

The United Kingdom. It enables GP to transfer a patient’s electronic medical record
another practice when the patient moves onto the list of other practice.
Privacy concerns
-A major concern is adequate confidentiality of the individual records being

electronically, doctors and nurses to technicians and billing clerks have access to part of
patients’ records during a hospitalization.
Characteristics of e-health (the 10 e’s in ‘’e-health)

1. Efficiency – One of the promises of e-health is to increase efficiency in
healthcare, thereby decreasing costs. One possible way of decreasing costs would
be by avoiding duplicative or unnecessary diagnostic or therapeutic interventions,
through enhanced communication possibilities between health care establishment
and through patient involvement.
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2. Enhancing quality of care- increasing efficiency involves not only reducing costs
but at the same time improving quality. E-health may enhance the quality of health
care for example by allowing comparisons between different providers, involving
consumers as addition power for quality assurance and directing patient streams to
the best quality providers.
3. Evidence based- e-health interventions should be evidence – based in a sense that
their effectiveness and efficiency should not be assumed but proven by rigorous
scientific evaluation much work still has to be done in this area.
4. Empowerment of consumers and patients- by making the knowledge bases of
medicine and personal electronic records accessible to consumers over the
internet, e- health opens new avenues for patient- centered medicine, and enables
evidence based patient choice.
5. Encouragement of a new relationship between the patient and health
professional, towards a true partnership where decisions are made in a shared
manner.
6. Education of physicians through online sources (continuing medical education)
and consumers (health education, tailored preventive information for consumers)
7. Enabling information exchange and communication in a standardized way
between health care establishments.
8. Extending the scope of healthcare beyond its conventional boundaries. This is
meant in both a geographical sense as well as in a conceptual sense. e- health
enables consumers to easily obtain health services online from global providers.
These services can range from simple advice to more complex interventions or
products such as pharmaceuticals.
9. Ethics e-health involves new forms of patient-physician interaction and poses new
challenges and threats to ethical issues such as online professional practice,
informed consent, privacy and equity issues.
10. Equity – to make healthcare more equitable is one of the promises of e-health but
at the same time there is considerable threat that e-health may deepen the gap
between the ‘’haves’’ and ‘’have nots’’. People who do not have the money, skills
and access to computers effectively. As a result these patient populations (which
would actually benefit the most from health information ) are those who are the
least likely to benefit from advances in information technology, unless political
Tele-health helps patients reduce healthcare costs and increases effectiveness
through improved disease management, less travel time and fewer hospital stays
caused by otherwise delaying early or preventive care.
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Telemedicine
-Is a rapidly developing application of clinical medicine where medical information is
transferred through the phone or the internet and sometimes other networks for the
purpose of consulting and sometimes remote medical procedures or examinations? They
improve, maintain or assist patients’ health status or provide clinical services when
participants are at different locations. It is practiced on the basis of two concepts: Real
time (synchronous) and store and forward and home health (asynchronous).
-Telemedicine may be as simple as two health professionals discussing a case over the
telephone or as complex as using satellite technology and video- conferencing equipment
to conduct a real time consultation between medical specialists in two different countries.
Telemedicine generally refers to the use of communications and information technologies
for the delivery of clinical care.
Importance of Telemedicine
 Benefits to the patients living in isolated communities and remote regions who can
receive care from doctors or specialists far away without the patient having to
travel to visit them.
 Allow healthcare professionals in multiple locations to share information and
discuss patient issues as if they were in the same place.
 Remote patient monitoring through mobile technology can reduce the need for
outpatient visits.
 Facilitates medical education by allowing workers to observe experts in their fields
and share best practices more easily.
-The drawbacks of telemedicine include the cost of telecommunication and data

management equipment and technical training for medical personnel who will employ it.
-Virtual medical treatment also entails potentially decreased human interaction between
medical professionals and patients, an increased risk of error when medical services are
delivered in the absence of a registered professional and increased risk that protected
health information may be compromised through electronic storage and transmission.
-Decrease time efficiency due to the difficulties of assessing and treating patients through
virtual interactions; for example it has been estimated that a teledermatology consultation
can take up to thirty minutes whereas fifteen minutes is typical for a traditional
consultation. Additionally potentially poor quality of transmitted records such as images
or patient progress reports and decreased access to relevant clinical information are
quality assurance risks that can compromise the quality and continuity of patient care for
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the reporting doctor. Other obstacles to the implementation of telemedicine include

unclear legal regulation for some telemedical practices and difficulty claiming
reimbursement from insurers or government programs in some fields.
CHAPTER 12
MEDICAL RECORDS COMMITTEE

Introduction
-Hospitals with aim of improving their services should have a Medical Record
Committee; This Committee makes decisions on medical record policy, medical record
procedures, medical record forms and procedures in other departments/ wards relevant to
the management of medical records and patient information.
-Medical Record Committee appointed by hospital staff from among its members should
act as a liaison between the MRO and hospital staff. Such a committee should support the
MRO support and assist with the implementation of regulations regarding the completion
of medical records. Members should be representatives of the various clinical services of
the hospital, rotating on a yearly basis so that all services will eventually be represented.
Terms of reference
-The medical record committee is responsible for all matters relating to the content of
medical records and the provision of medical record services in the hospital. The Medical
Record Committee in large hospitals meets every month and less frequently in smaller
hospitals. It should meet at least four times per year.
-The committee should be made up of people who are interested in good medical records
and who are prepared by their own example to provide an incentive to others, particularly
junior doctors. The committee should consist of not less than 3 members and not more
than 6 members.
Membership
-Membership of the Medical Record Committee should consist of:
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 The representative of the doctors from both medicine and surgery.

 The representative of the nursing administration.
 The representative of hospital administration (management).
 The representative of allied health staff –physiotherapy, social work amongst
others in this allied health staff care and,
 The medical Record Officer.
-Other members may be invited onto the committee, if their input is required such
In a larger health care facility representatives from nurses on the ward are also included.
Responsibilities
-A Medical Record Committee is responsible for
 Ensuring that accurate complete medical records are kept and for every patient
treated in the hospital.
 Helping to ensure that medical staffs complete all the medical record under their
care by recording a discharge diagnosis and with summary (where required) for
each discharged patient.
 Determining the standards and policies for the medical record section care facility
 Recommending action when problems arise in relation to medical record service
 Controlling new and existing medical record forms used in the basis of all forms
should be cleared by the MRC before being put into use.
 Assisting the medical record officer in liaison with other staff/healthcare facility.
-It is important that rules and regulations for the completion of medical developed and
approved by medical staff.
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CHAPTER 13
MEDICAL RECORDS POLICIES

Introduction-Many procedures in the Medical Record Department are based on medical
records policy. “Policies are plans within which objectives may be set and decisions
made” Medical records officers may develop policies specific to their department but the
policies must be limited to the activities of the department and not conflict with hospital
organizational policies.
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-It is usually the responsibility of the senior hospital management in conjunction with the
Medical Record Committee to approve the policies relating to the medical record services
each country should have national policies for medical records.
-The Ministry of Health in most countries is often responsible for developing many
hospital and Health center policies which will be different for each country depending on
legal and cultural issues. Once the policies are determined then procedures must be
written to ensure that the policies are followed.
Important medical record policies include
 Patient access to their medical record.

 Privacy, confidentiality and the release of patient information.
 The retention of medical records and,
 The destruction of inactive medical records.
Patient access to their medical record
-Patient access to the information in their medical record will vary from country to
country and hospital to hospital if there is no national policy on this issue. You need to
find out if your hospital and country has a current policy. If patients are allowed access to
their medical record in your hospital you should make sure that a policy based on the
regulations has been prepared and a procedure for patient access is available and is
followed by the clerical staff in your department.
Some issues you need to know about access
o If patients are allowed to see their medical record.

o If yes what procedures are to be followed when patients view their medical
record?
o What medical information may be released to patients?
Privacy confidentiality and the release of patient information

-The medical record is a confidential document and the patients’ right to privacy
considered all times.
-The information contained in the medical record belongs to the patient and is a
communication between the doctor or other health professional and the patient. Records
should be safe guarded against unauthorized use. They should be stored in an area and
there should be detailed policies regarding confidentiality of the patient information
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Release of patient information
-The medical record officer should develop a policy for approval by the medical
Committee for the release of patient information. It is important to ensure that only in the
Medical Record Department but also in all other sections of the aware of the policy that it
is followed.
There are four methods of releasing information
 Direct access to the medical record.

 Supply of abstract giving details requested.
 Verbal release and.
 Photocopying.
‘’No unauthorized person can take any or part of a medical record out of read, copy,
or otherwise tamper with’’
-If a request is made for the release of information the request should contain the
following
 Full name of patient, address and date birth.

 Name of person/persons or institution requesting information;
 Purpose and need of the information.
 Extent and nature of information to be released, including dates.
 A recently dated authorization signed by the patient or authorized (like parent of a
child).
-When developing a policy of patient privacy and the release of information know the
following:
 Consider if there is consent form for the patient to sign to permit personal
information.
 If there is anyone outside the hospital/health center allowed access records.
 Special provisions for the police and law enforcement agencies to view records.
 The rules for the secure locking of the Medical Records Department working
hours.
 Name of attending doctor.
 Diseases treatment and operations performed.
 A discharge summary for each admission if more than one.
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-In addition to leave a permanent record of the patient on file, a note should be included
with the retained documents stating that the records have been destroyed according to
retention policy.
-The following issues on destruction should be noted:
 If it is the policy of the hospital to destroy inactive medical records, they should be
destroyed by burning.
 If medical records are to be completely destroyed the medical record officer
should supervise their destructions.
 What special rules apply to the release of patient information to other people,
relatives, friends, insurance companies, lawyers’ etc.?
 Consider if patient information may be released to other people for research.
 Confirm if there are separate rules for children information release.
 If there are separate rules for patients who have died.
 The forms and registers used to record requests for personal information from the
medical record.
 What penalties are provided for breaking the rules?
-In general it is best to have written policies relating to the release of patient information
and all staff must be familiar with these policies
Policy on retention of medical records
-Medical records should be kept by the hospital as long as required under the country’s
record retention regulation.
-Before determining a retention policy the hospital administrator should review the
record usage after discharge.
Some questions that need to be answered include
 How long records should is kept after the last visit of the patient?
 Are there separate rules for children’s records?
 If medical records are not kept how are records to be destroyed?
 Are there specific diseases for which the medical record must be kept for the life
of the patient?
 What penalties are provided for breaking the rules?
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 Who approves the destruction of medical records?
In general, the retention of medical records in an active file depends on:
 The amount of filing space available.

 The yearly expansion rate of current files.
When considering a retention policy the hospital must consider
o The readmission rate of inpatients.

o The volume of medical research undertaken by hospital staff.
o The statute of limitation (legal requirement).
o Cost involved in finding inactive filing space and,
o Cost of destruction of medical records.
-In many countries when medical records are destroyed after the required retention
period, basic information is retained permanently. This information includes:
 Patient’s full name and date of birth.

 Admission and discharge date’s private patients’ record is made the sole
responsibility of the practitioner in change of case.
Confidentiality
-There is no doubt that a medical record is a confidential document. The position of

hospital in this respect is the possession of confidential information. There is no doubt the
court would jealously guard or protect the right to secrecy in medical records secondly
the records officer and his staff must be continuously aware of that professional tradition
which has resulted in no case being brought to decide circumstances in which case
records may be disclosed.
-The courts have no need to consider whether the act of disclosure has resulted in the
damages to the patient’s interest and if so, whether there was any legal justification.
-Barring anything coming within the terms of the official secrets act there cannot be from
nor has imprisonment for disclosure adversely affected the patients’ interest.
Disclosure
-The circumstances in which the contents of a medical record may be disclosed fall into
five main categories.
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(a) Disclosure with patient’s.
(b) If there is an order of court.
(c) If the interest of the doctor or hospital cannot otherwise be safeguarded.
(d) In transference between hospital, clinics or doctors in the interest of patient health.
(e) I f there exist a higher duty than the private duty.
a) Disclosure With Patient’s Interest
-A patient can give his consent for disclosure either expressly or implicitly.
Implied consent- arises only in certain limited circumstances i.e. when records disclosed
to another medical agency for the purpose of continued treatment.
Express Consent- is obtained when the patient signs a document authorizing the hospital
to disclose his medical history for some specific purpose. In general, the consent form
should always indicate the reason for disclosure and no disclosure should be made except
for reason and If the reason on purpose changes, specific consent should again be
obtained.
-Where a consent form reaches a hospital, merely giving unconditional authority to

disclose the hospital is quite at liberty to disclose as indicated and the patient would have
no reason or ground for complaint, if in fact, the disclosure was wider than the indented.
b) Disclosure by an Order of Court
-A court in the pursuit of justice may make an order that a case record must be obeyed.
Generally the appropriate person to attend court and produce the appropriate record
would be the records officer, in court proceedings it is permissible for witness to refresh
his memory from the notes made at the time of occurrence about which he is being
questioned, but not only on notes made later. Copies or original notes used in court where
it is not reasonably practical to obtain the originals might be called and if documentary
evidence is important, it is prudent to have the copies certified as the copies by a solicitor
or other legal overcoming position to have the copies compared under the originals
-A court may order production document in court and failure to produce it will constitutes
a contempt of court
-Court decision during the past few years have accepted photographic facsimile of a
medical record which has been reduced to film or otherwise unavailable in its original
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form. The submission of such a photographic copy has usually to be accompanied by a

written certification that the photographic print is in fact a true copy of the patient’s
records. If there are omissions such as in the case of temperature charts destroyed prior to
reduction to film, this omission might well be stated to the precise clinical issue before
the court.
-On the other hand irrelevant disclosure ever in court would not be privileged and
therefore care should be taken not to volunteer clinical information when the court does
not want. In case of doubt perhaps when the question is put rather loosely a direct appeal
to the persons sitting in judgment should result in definite directions as to what the court
desires to know.
c) Disclosure to Safeguard the Interest of the Doctor or Hospital.
-If an action is brought against a hospital or doctor then disclosure of a patient may be
necessary before justice can be done, of equal importance is the fact that disclosure is
permissible if the hospital is to work effectively.
-If cases of litigation arise, alleging cases of neglect or any form of mal-practice, contest
of the case record can be disclosed to safeguard the interest of the doctor or the hospital
as a whole.
d) Disclosure in Transfer of Information between Authorized Medical

Agencies
-A doctor dealing on a patient has full rights of access to any clinical data made at the
hospital (except where patient has been referred for treatment to a doctor who is acting
for party)
-When a patient is seen subsequently by another doctor, strictly speaking that doctor has
legal right of access to the notes made by the previous doctor. The patient has a moral
right and probably a legal right to insist that the notes made by the first doctor made
available to the second doctor. In addition the first doctor is under a strong environment.
-In case where requests for information are received from solicitors claiming to be acting
on behalf of the patient’s care should be taken to ascertain that the solicitors really are
acting on behalf of the patient and not in fact against them.
-Where a patient is concerned in litigation, it is by no means unknown for solicitors

representing the other side to write to the hospital claiming to be acting in connection
with the patient’s claim.
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-Solicitors and banisters acting for a patient are truly legal representatives of the patient,
having had the conduct of the patients affairs placed in their hands by the patient himself.
-Not only in full disclosure to them about the particular patient in order but they
themselves acting for the patients can authorize disclosure to the parties.
-Request from insurance companies and similar bodies should only be acceding to, with
the patient’s written consent.
-There are many circumstances in which the legal position is not clear and the line always
taken by hospital is to regard the patient’s own interest as paramount in dealing with
request for clinical information.
-Unless there is higher duty of the hospital to the public however it is advocated that
when a hospital receives any request for information it should refer the request to the
patient for decision.
e) Disclosure as A ‘’Higher Duty’’
-The existence of the ‘’higher duty’’ may be said to apply when the interest or need of the
public are to be served especially if there is a clear legal duty to give information which
supersedes the doctrines of confidentiality. More common instances are in the following
circumstances:
i. Notification of infectious disease by medical practitioners to local medical officer

of health under the public Health act 1936.
ii. Notification of the cause of death under the births and death registration Act,
1836-1926.
iii. Notification of industrial poisoning under the factory and workshops Act 1901.
-The above three (3) are ‘’statutory obligation and must be compiled with the other 3
below are ‘’good causes’’ Here, there would be no breach of law if there is no disclosure
 Claims for sickness benefits

 Exchange of records between doctors for research purpose
 Disclosure to a central body for collective statistical purpose
-In the foregoing instances it is plain that the disclosure is in the public interest
There are justification which occasions for the disclosure of confidential clinical data
being legally required (except for the last three) and being made to a recipient on proper
accession. You treat the information as confidential
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CHAPTER 14
MEDICAL LEGAL ISSUES AND PROCEDURE FOR RELEASING
INFORMATION
Introduction-It is important to bear in mind that medical records are important legal
documents. It is essential that they are complete, accurate and available when needed.
Notes of the patient’s condition on admission and complete findings upon physical
examination should be recorded along with the progress of the patient while in hospital.
Ownership of medical records
-When a hospital admits a patient, it enters into an explicit contract to render services
necessary in the care and treatment of that patient. This necessitates keeping a
chronological record of the care and treatment rendered by hospital personnel so that the
results may be available for continuing care.
-In addition to being kept for patient care medical records are also kept as a guide for
doctors and for education of nurses and other health care personnel. Legally they are used
to support the patient’s claim in case of injury, for the protection of the attending doctor
against claims of malpractice and for the protection of the hospital against criticism and
claims for injuries and damages.
-Medical records are considered the property of the hospital and are compiled and kept
primarily for the benefit of the patient.
-The personal data contained in the medical record is considered a confidential

communication and the property of the patient.
-The recorded information is a privileged communication. A privileged communication is

one, which contains certain confidential information given by a patient to his or her
doctor. Unless the patient has given written consent to release information from his or her
medical record, the information contained in it can only be released to court by subpoena
or a court order.
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-The case notes patients treated privately outside the hospital are the property of the
general practitioner concerned.
-Where the records are created on hospital stationery and are contributed to by staff
employed by the hospital/ government, the production of the medical records could be
said to be part of the expenses incurred by the hospital in maintaining the patient in the
hospital.
-Where hospitals take the responsibility for custody of private patients records, they
usually take the safest cause of treating these records as though they had legal ownership
of them, applying the same rules and measures for their security and in relation to
disclosure of information as for the general record except that release of clinical
information relating to information as for the general record except that release of clinical
information relating to the police seek clinical date in the cases. First and more
commonly they are accident cases in which the police are expected to report on the
injuries sustained usually seek a medical pronouncement as to the nature and extend of
injury, information should be given with the consent of the patient and all consciousness
should be asked. In the case of unconscious patients, it is customary to give address and
diagnosis only.
-This involves a slight risk but it is most improbable that the patient will be affected by
tracking the minimal information suggested.
-The police on the other hand, however are often interested in the original of particularly
where illegal offence is suspected.
-It would not be right for a doctor to aid and abet crime by deliberate concealer, is a
detective in connection with those patients he treated. More suspicion would lead to
disclosure.
-Any statement made to the police in connection with an offence is liable to verbatim at
any subsequent legal proceedings and the utmost censure should be wording of any such
statement made.
-A court can always call medical witness and any disclosure made in court as a result is
privileged. A patient suing in connection of a foot injury could secure damages
unnecessarily mention that had suffered a venereal disease?
General medical legal principles
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 As a general rule no information concerning a patient should be released to the

person without the written consent of the patient or the patients’ legal guardian.
 If a patient is under the age of 14 years or otherwise subject to a guardian any
consent for access to information should be given in writing by the parents or legal
guardian.
 In the case of a patient who has died, the written consent to access information the
patient’s medical records or by the administrator of the patient’s estate.
 If the patient lacks the capacity to provide genuine consent then the writing must
be obtained from the person’s legal guardian.
 Medical records should be kept under adequate security and only remove hospital
or health care center upon receipt of a subpoena, statutory authority warrantor
court order.
 In many countries when an original medical record leaves the hospital purposes, a
photocopy of the medical records is made before and the hospital until the original
is returned. The copy is subsequently destroyed.
 As a general rule a doctor or other health professional should supervise a patient’s
medical record by non-medical persons.
 As discussed later, in many countries a patient has the right to see what intention is
held about him or her by a health care facility.
Instances in which medical records are used as evidence

-Medical records are generally used in court for the following:
a. Insurance Cases
-Used by the patient for proof of injury and/ or disability in personal accidents cases
insurance company to disclaim responsibility.
b. Worker’s compensation
-In most countries a person injured in the course of his or her duties and while acting
scope of his or her employment is entitled to compensation for bodily injury and other
-The medical record is used as evidence to show the date of injury, the type and see injury
and the patient’s expected recovery obligation to make his notes available to subsequent
doctor in the general interest of the patient
-Records department should therefore make available promptly and freely such data to
other department or doctors at their request except of course where the cosign is not
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serving a patient medically but in the interest of a third party. There is no question of
improper disclosure when one doctor calls another into consultation over a case.
-The circulation of clinical data amongst medical authorities is guaranteed so long as

these medical authorities are acting in the medical interest of the patient, this does not
require the patients consent as it is being done for his benefit and without detriment to his
medical interest.
-Caution should be shown in those cases where for example a factory data or general
practitioner writes in the interest of the patient’s employer to whether on medical grounds
patient should be retained in his employment.
-The patient should be informed of the nature of such request and asked for his consent to
disclosure of such a request. As previously stated disclosure in the interest of the patient
does not need the patient consent and transferable of information or records between
hospital/doctors in the interest of a patient is an everyday occurrence.
-A patient may be legally aggrieved if his treatment was prejudiced by his records not
being so transferable and in good time. A successful action for damages might
conceivably be brought for instance by a patient who undergoes an operation which could
have been unnecessary if the notes of the previous treatment in another hospital had been
available.
-Patient sends a letter to the hospital requesting the information. The lawyer must include
the patient’s written authority, giving the hospital permission for the release of the
requested information. The hospital is NOT legally bound however to release information
if it affects the hospital or the attending doctor or other staff.
The procedure to be followed when handling this request is as follows
1) Request from lawyers are usually registered and date of receipt of request recorded
by the hospital administration and forwarded to the MRO for processing.
2) The medical record is located and the patient’s signature checked against the
signature on the consent form in the medical record.
3) In some countries a charge is made for the production of medico-legal reports. The
amount charged varies from hospital to hospital and country to country and the
MRO must be familiar with the charges and regulations in his or her hospital. If a
cost is charged an account should be made out by the MRO (or hospital
administration) and included with the report. In some countries lawyers already
know this cost and in many cases a cheque is included with the letter of request.
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4) The information requested is identified and the attending doctor asked to write a
report. In many health care facilities a pre-designed form may be used (see
example below) or if a discharge summary is already in the medical record, it is
checked and if it includes all the requested information a copy is made. This will
save the doctor from having to write a new report.
5) The medical record officer may write a brief letter acknowledging the request and
enclosing the doctor’s report. In some hospitals a ‘’with compliments’’ slip is used
instead of a letter from the MRO.
6) The letter (or ‘’with compliments’’ slip), report and account (if required) is sent to
the lawyer and a copy of each documents is filed in the correspondence section of
the medical record.
7) The MRO notifies the hospital administration that the report has been sent.
8) In most cases the report is all that is required. If the actual medical record is
needed the lawyer must produce a court order of subpoena to enable the release of
the medical record.
Subpoena or court order

-A subpoena duces tecum is the term used in most English speaking countries for a legal
order to produce records to a court. It is usually addressed to ‘’the custodian of medical
records’’ directing that person to appear in a given court, on a date and at a time
specialized on the subpoena, and to bring on that date the records designed for the patient
named in the subpoena.
-After accepting the subpoena all medical records specifically mentioned in it must be
produced in court at the time and place designated or the person subpoena is liable in
contempt of court.
Procedure for preparing a medical record for court
-If a subpoena or court order is served it must be obeyed
c. Personal injury claims
-A person may claim to have been injured through the fault or neglect of another and sues
recover damages for injuries sustained. The medical record would be used to show how
the injury happened as recorded in the patient’s words on admission to the hospital. The
medical record would also be used to show the extent of the injuries, treatment given
duration of care and expected recovery or disability. Medical records are used more
frequently in this type of cases than in all cases combined.
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d. Malpractice claims
-In this type of case the plaintiff (person suing) claims damages from a doctor, a hospital,
nurse or other health professional for negligence in rendering care or giving improper
treatment. The medical record would be used to show the mental state of the patient at the
time of making the will
f. Criminal cases
-Medical records have been used in many criminal cases the most frequent use includes
g. Assault cases
-To prove the assault and extent of injuries
h. Violent or unexplained death
To prove death resulted from natural causes, accident, misadventure or murder
i. Sexual assault cases
-To prove the condition of a patient on admission or attendance at a hospital and the
history of the assault related by the patient
j. Mental competency
-Hospital medical records may also be used as evidence in proving the mental condition
of a patient
Procedure for the release of medical information in a legal case
-The hospital may permit a patient’s lawyer to view the medical record, in the presence of
a doctor, upon the written authorization of the patient. It is rare for this to happen
however and in most medico-legal cases a lawyer requesting specific information about a
particular adequate security should involve hand delivery of the medical record from the
hospital health center direct to the clerk of the court by an employee of the hospital or
health or by courier services.
-In some countries the MRO is required to take the medical record to court or prescribed
day and time. He or She may be required to testify that the medical record has been kept
in the normal business of the hospital and to the best of his or her knowledge not been
tampered with by unauthorized persons.
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-If the medical record has not been returned to the hospital by the specified date the MRO
must check with the court to find out if the court case is over and if it is request the pro-
return of the medical record. If not ask for the probable date of completion.
-On return from court the medical record is checked to ensure that all pages (forms)
present. The removed correspondence is returned to the medical record and the record
returned to the file and the tracer removed. As mentioned previously if a photocopy has
been made it must be checked as for the original and then destroyed.
Other important medico-legal issues
-Remember that the laws in each country vary and you must be familiar with your
country laws for dealing with medico-legal request. In the absence of specific statutes are
regulations certain practices should be determined by the hospital administration and
MUST be followed by the medical record staff.
-Requests for information by the police or a government department where the patient
has NOT authorized access to information from his or her medical records should be
dealt with by the attending doctor or senior health care professional. Except in
circumstances which the police can confirm that they seek information essential to the
execution of the police officer’s duty, the information supplied should be limited to
confirmation of identity and address. Any other information may only be divulged on
production of a search warrant.
-The attending doctor or other health care professional should be responsible for checking
legal requests and release of information to ensure that only information relevant to the
request is released.
-Except for the purpose of providing ongoing care and treatment for the patient, all
photocopying of the patient’s medical records requested by the patient or the patient’s
authorized nominee, should be at the expense of the patient and not the hospital
-As a general rule access to medical records should be restricted to health professionals
currently involved in the continuing care of the patient. Remember that no information
may be released without the patient’s consent, including the fact that the person is a
patient. Where a patient requests that NO information be released at all, or information be
released in limited circumstances, his or her wishes must be respected.
-Medical records may be used for research and statistics without the patient’s consent as
long as the patient is NOT identified. Medico-legal issues bring out the necessity for
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accurate and adequate medical records. That is medical records that will clearly show the
treatment given the patient, by whom it is given, and when given, for the protection of the
Receipt of a subpoena the MRO records the date and the time the subpoena was received
and records in a diary the date and time the medical record is due in court.
-The MRO should notify the attending doctor and hospital administration that a subpoena
has been received for the release of the medical record to court.
-In many countries if the patient is NOT involved in the court case he or she is also
notified by the health care facility that the subpoena has been received. They are also
advised of the place, date and time of the court hearing in sufficient time allow the patient
to arrange to attend the court if he or she so wishes.
-The MRO should locate the medical record. If the medical record is not on file the MRO
should find it and keep it in a safe place awaiting preparation for court. A tracer is made
out showing that the medical record is with the MRO for medico-legal purposes.
-The MRO should check that all necessary information, as specified in the subpoena, is in
the medical record and that it is complete.
-All correspondence not written at the time the patient was in hospital should be removed
as it is considered ‘’hearsay’’ and not permissible as evidence. The correspondence is
placed in a temporary folder made out with the patient’s name and MRN and kept in the
medico- legal file.
-All pages (forms) should be numbered in ink and the total number of pages recorded on
the folder and a record of the number of pages (forms) kept with the removed
correspondence.
-In some countries the original record is not sent to court, if a photocopy is permissible as
evidence in court all forms are photocopied and numbered and the photocopy sent in
place of the original. If a copy is made note needs to be recorded in the medical record
indicating that a copy exists and will need to be destroyed on return from court. Some
hospitals send the original and keep a photocopy on file. When the original medial record
is returned to file the copy is removed from file and destroyed. To protect the privacy of
the patient it is important that if a medical record is copied the copy MUST be destroyed
on return from court. The following steps apply to both original and photocopied medical
records.
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-A form of receipt should be prepared for signature of the receiving officer of the court.
This may have a limited amount of information such as the number of the subpoena, date
received, name of the lawyer requesting the medical record, name and MRN of the
patient, number of pages (forms) and date the medical record is sent to court. The hospital
may wish to use more structured form as shown in the following example:
-The medical record is placed in a large envelope addressed to the clerk of the court (or
specified person) with the receipt attached to the front. The tracer on file is changed to
indicate that the medical record was sent to the court and the date it was sent.
-The medical record should be forwarded under adequate security to the clerk of the court
named in the subpoena and the signed receipt obtained from the person accepting
delivery.
-The need for the hospital rule will thus be seen as there is a very serious danger of
clinical data being disclosed in this way without the patients consent.
Confidentiality of medical records declaration

I understand that it is most important that I should be aware of the confidential nature of
all medical records and that I have had the need for confidentiality explained to me
I also understand that no information from medical records should be divulged to

patients’ relatives or to any other unauthorized person and that in no circumstances must I
ever give medical information over the telephone no matter who makes the request
I am also aware that the procedures for dealing with request for information from official
bodies are detailed in the booklet ‘’MEDICAL RECORDS DEPARTMENT
PROCEDURES’’ to which I can refer when necessary
I have read the above statement I am fully aware of my obligation in this respect and
understand that my employment might be at risk if should I fail to respect this obligation
(Signed)……………………………………… (Date)…………………………
(Witness)………………….
a) Consent to Operations
-It is necessary as a safeguard in hospital to obtain the consent of a patient or in the case
of an infant the consent of the parent or guardian to physical interference for medical
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reasons i.e. operation or administration of an anesthetic. This procedure has become

routine in all hospitals difficulty arises in the case of children and unconscious patients, in
case of the latter’s absence, consent should not delay necessary procedures.
-It has been customary to obtain the consent of a patient or guardian for operations or any
other procedure involving anesthesia in respect of any person under 16 years of age.
-There has been no case in which the question of the consent to operation upon an infant
has actually been litigated and there is no low laid down especially on the matter.
-In view of the importance of this question of the age at which consent may be given by a
person who is an infant at law (i.e. under 18 years of age) and the confusion which
existed between 18 age point and ‘’the age of discretion (16) an authoritative legal
opinions on the matter has been given;
a) Where operation is urgently required time should not be wasted in seeking the
consent of the father if the delay is likely to increase the risk.
b) If the infant is living away from home and the operation is clearly necessary the
surgeon would probably be safe in carrying out operation although he would be
wise if possible to obtain the consent of the father.
c) In many proceedings based on lack of parental consent the question whether the
infant had reached the age of discretion would probably be taken into account, as
would also probably the general standard of intelligence and worldly experience of
the infant.
(b) Instruction to staff
-An obvious source of leakage is among the medical records staff themselves, registration
of staff, filing clerk, medical stenographers, coding clerks, receptionist all gain a great
deal information of clinical nature in the course of their duties and they should all be
instructed at the outset of their appointment regarding the confidentiality of clinical
records.
-They should be discouraged from discussing patients among themselves and certainly
outside hospital. The most junior members of staff in the records department know that
the contents of a case folder are confidential.
-Staff should be reminded that is not simply the medical records file which is confidential
but many other documents created or maintained in ancillary departments e.g. registers,
outpatient registers, departmental reports in physiotherapy, speech therapy, radiology,
pathological etc.
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(c) Signing a declaration
-Lay staff of a medical records office must be made to realize that unauthorized
disclosure of medical records will not be tolerated and any such occurrence will be
regarded break of confidence involving disciplinary action.Each member of staff should
be required to sign declaration of secrecy
(d) Responsibility of the medical staff
-Medical staff has a legal interest in medical records to which they have contributed such
records may be required as evidence of having exercised the reasonable degree and skill,
having regard to qualification and experience which is legally expected.
-It is clear therefore that a doctor has a legal right of access to the medical record course
of his work and will be him or her successor that responsibility results to questions of
disclosure arises in connection with the clinical part of the record.
-It is inadvisable in any circumstance for a medical officer in the hospital to edit
information without first consulting with a medical member of the firm which last treated
the patient.
-This is not only as a matter of courtesy but for the practical reasons that the medical
officer might prefer to edit a record before it goes to some recipient outside the hospital.
-The medical staff is well aware of the canons of professional secrecy but it is
nevertheless be made a rule of the hospital that the medical officer are the responsible
once the records are in their hands or possession.
-An example of the need for this rule is respect of a specialist required to give the nature
of express evidence for the purpose of litigation. In this instance the staff has no
automatic right of access to the record but should make his request officially to the
hospital and the patients express consent must be obtained.
(d) If the father was not readily accessible in any case in which parental permission might
seem desirable any delay would increase the risk of the operation or be fraught would be
danger to the child the surgeon would probably be safe in proceedings and the operation.
(e) The father is the proper person to give the consent, if there is no father or if he is
accessible the mother’s consent would serve. Failing parental consent that of the legal
guardian would have to be obtained in any case in which the consent of the father would
otherwise have to be obtained.
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-Although there is no minimum age specified by law below which consent is

automatically invalid in relation to medical interference it is held that irrespective of the
age whether or not under 18 years. For consent to be effective the person giving it must
fully appreciate the nature of that which he or she is consenting. The legal value of
consent therefore would always be a matter of fact depending on the circumstances of the
case. No legally needed to be written, although signed consent has obvious safeguarding
value, verbal and implying consents not by their manner of granting of any less legal
worth.
-Even if the hospital is satisfied that a person fully understands the nature of a consent
which he or she is asked one should refrain from seeking consents from anyone under
(16) years of age and between that age and 21 years.
-While accepting the parts consent the wise course should be taken of informing before
the parents or guardian of any major procedures not already contemplated by them.
-Their consent can therefore be obtained as well as that of the patient where any main
procedure might lead to death or permanent disability.
-Manual women enjoy the same right as single women and may give or refuse consent
the husbands consent particularly where sterility may follow an operation.
-For mentally disordered patients, the consent of the patient and or the nearest release
should normally be obtained. Even where a patient although mentally disordered is
capable of giving consent it is prudent to obtain the consent of the nearest relative
additional emergency the responsible medical officer may act without consent.
-Last point is that it is essential if admitted to hospital for operative treatment the
operative proposed will not necessarily be performed by a particular surgeon who have
seen the patient previously or under whose name he is admitted
Professional Secrecy
-All medical staff should know that the illness of their patients should not be discussed
with anyone. They may have to withhold information from senior officers and even court
law, if individual patients do not give their permission for details to be given
(In court you may say I do not wish to tell medical details about a patient but if the justice
magistrate directly orders you to tell then you must do). Obviously in health center few
things will be secret but all medical staff should try not to talk about patient more than
necessary
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-The need for the hospital rule will thus be seen as there is a very serious danger of
clinical data being disclosed in this way without the patients consent.
-The power are intended to facilitate the negotiation of settlements between the patients
before trials and in the event of this is not being achieved to enable them to proceed not
the past in the dark about the facts contained in the relevant documents.
Civil Evidence
-Another important development arises from a provision of the civil evidence Act which
gives the courts power to direct that either party in any action must disclose the other
party involved the medical evidence that is proposed to adduce in evidence on trial.
-This also is considerable change from the situation under the long established subpoena
rules, as far as the use of medical records as evidence is concerned.
-Unnecessary talk can embarrass patients and make difficulties for them. The medical
records officer will be called to court by being issued with subpoena or (summons), this
will be presented by the police officer and will give the date and time to attend. He has to
sign it and the police officer then will take the duplicate.
-Once you have signed this subpoena it is an offence not to attend the court when
required.
-In fact if friendly and co-operative atmosphere is maintained between the medical
records officer, the medical assistant, magistrate and the police it is usually possible to
arrange things so that the medical assistant and records officer do not waste hours waiting
court.
-After all you are for the community and many parties may have to wait if you are away
from the health center for long time
The Administration of Justice Act 1970 and Personal Injuries Actions

-This act introduced new and extended powers to courts to order disclosure of documents
in and before actions and claims in respect of personal injuries or death. The provisions in
questions are as follows:
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a) SECTION 31: This section gives the courts power to order a person who appears to
the court likely to be a party in the proceedings to disclose documents BEFORE the
commencement of the proceedings
b) SECTION 32: This section gives the court a similar power to order disclosure by a
person who is NOT A PARTY TO THE PROCEEDINGS
c) SECTION 33(3): Defines personal injuries include any disease and any impairment of
a person’s physical or mental condition’ the order of the courts must specify the
documents and must show that they are relevant to the case and can only be made in
actions and claims injuries
The provisions are set out in full in S.I 1971 NO. 1269 which took effect from August
1971 and which quotes medical & hospital records as examples of relevant documents
quoted
Those provisions represent an important development in the law affecting confidentiality

of medical records. They go beyond and differ the ‘’subpoena duces tecum’’ powers
which only require production in court of specified documents by one or either of the
parties involved for disclosure when the court calls for such disclosure during the hearing
These new provisions give the courts power to order the disclosure of the documents
concerned to the person who applies to the court for such an order. The will usually be
legal representative of the plaintiff or defendant but may also be legal representative of a
NON-PARTY to the case.
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CHAPTER 15
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BIRTHS AND DEATHS NOTIFICATION, CERTIFICATIION AND

REGISTRATION
Births
a) Notification Under the notification of births Act 190, 1915, 1965, notification of every
birth (including a still birth after the 28th week of pregnancy) must be completed at the
place of birth and sent to the medical officer of health of the area in which the birth
occurs within 36hrs.
-It is primarily the duty of the father if he resides on the premises but otherwise devolves
on the person in attendance on the mother.
Where a birth takes place in hospital the hospital is responsible for notifying the medical
officer of health. For the purpose of notifying births that take place in the home, the local
health authority supplies special forms which are normally completed by the mid-wife.
b) Registration-Notice must be given within 42 days to the local register of births and
deaths. In the case of a still birth, the information must also deliver to the registrar a
written certificate that the child was not born alive (signed by the doctor or mid-wife in
attendance, who has examined the body) or make a declaration that no doctor or mid-wife
was present and that the child was not born alive.
-If registration is not affected within 3months a declaration is made before the
registration. If the child has reached the age of 12months the consent of the registrar
general is required before registration can take place. Because the vast majority of births
now take place in hospital, it is normal for the hospital to provide an office where
registration may take place.
-The medical records department is not likely to be closely concerned with registration
but may be responsible for seeing that notifications are made promptly to the medical
officer of health.
-Records of birth that have taken place in hospital should be carefully maintained and the
method of gaining access to such records must be known to the medical records
department.
-It is quite possible that in adult life a person whose parents omitted to register the birth
may need to have information corroborated by an entry in the records of a hospital to
assist in obtaining some official document (e.g. a passport for which the production of a
birth certificate is required.
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Deaths
a) Notification
-The nearest known relatives or friend must be formally notified by the hospital, this has
occurred and asked whether he will arrange for disposal of the body (it should be that a
common law, spouse may be the nearest relative).
-At common law a residuary duty (i.e. a duty when all high duties have failed) lies person
under whose roof the death occurred to provide for burial and it is the first deceased’s
executors.
-It may be that in frequent instances the hospital may be responsible for arrangement
paying for the burial of a patient who has died.
b) Certification
-A medical certificate of death must be completed for every natural death. This certificate
must be signed by the medical practitioner in attendance during the last illness and sent or
taken to the local registrar of births and deaths. In the case of still births and certificate
must be competed. If the deceased person is to be cremated, a special certificate which
has to be signed by two medical practitioners has to be made out.
-If the medical practitioner in attendance is not able to sign a certificate until post
examination has been carried out, he must report the case to the coroner (SURGEON).
-It is illegal to carry a hospital postmortem (i.e. one not ordered by the coroner) in and
find out the primary cause of death.
c) Registration
-Registration is affected by a relative who has been given an information note, medical
practitioner completing the death certificate.
-The death certificate book is composed of pages of certificate with perforations in the
left hand side of the page forms a counterfoil on which duplicated details about time
patient’s identification and cause and time of death are entered.
-These counterfoils are always retained by the hospital. The middle portion of the forms
the official death certificate.
-This is completed by the doctor certifying death and put into a special envelope
addressed to the registrar of death.
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-The right hand side of the page forms the information note
-Registration should take place within five days of death occurring.
The order of informers is:
 The nearest relative present at death.

 A relative in the district.
 A person present at the death.
 The occupation or the person responsible for burial.
-The registrar may refer to the corner but ordinarily issues of a disposal of the certificate
which authorizes disposal of the body and which is handed by the undertaker to the
officiating religious minister. Without this certificate the undertaker may not arrange
disposal of the body. It is the registrar’s duty to enquire into the matter if he does not
receive notice of disposal of the body within 14 days.
d) Inquests
Cases report by the medical practitioner to the coroner includes:
 Violent death.
 Unnatural death.
 Sudden death from cause unknown and,
 Death in circumstances in which no practitioner is able to give a certificate.
-In all cases reported to him the coroner decides whether an inquest shall be held. If he is
satisfied that no inquest is necessary he authorizes registration
-If an inquest is held the coroner issues a certificate authorizing disposal of the body. He
may adjourn an inquest pending a postmortem examination or analysis
-Where an inquest is held in case of death following a factory accident the inquest must
be adjourned if inspector of industries is not present.
Importance of Registration of Births and Deaths

-There are numerous benefits from the registration of births and deaths. They can be
realized at the personal level with an individual enjoying certain rights and privileges,
otherwise unattainable without the registration. They include the following:
 Mobilizing resources and making key decisions/planning.

 Proof of age.
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 Ownership of property.
 Issuance of identity cards, driving licenses, registration as voter, entry into
employment.
 Proof of place of birth.
 Admissions to educational institutions, military.
 Issuance of bursaries.
 Determining citizenship.
 Proof of parents.
 Determining claims and inheritance/wills.
 Proof of nationality, illegitimate children.
 Pension gratuity, compensations/claims
 Identifying needy cases like widows, orphans.
 Planning for adequate provision of schools, teachers’ educational materials.
 Knowing population size.
 Easy to determine deployment of government employees.
 Helps to assess the effectiveness of family planning and other development
programs.
 Help to monitor illegal immigrants.
 Helps to detect demographic changes.
 Improvement in immunization and health services in general.
 Improvement in nutrition and general hygiene.
 Improvement in combating epidemics.
 Enables acquisition of birth and death certificates cheaply.
Preparation for a physical survey
-It is always a good idea to inform all affected managers and other staff of what had
happen to prior to the commencement of the survey. You will need to tell them the survey,
what is being conducted for, any possible impact it may have on and also when you
intend to begin.
 Depending on the size of the area surveyed, it may be a good idea awareness
session for affected staff.
 It will help you to study relevant maps and plans of buildings, and available
inventory of records storage equipment (including certain organization charts too,
will assist you in understanding the flow within your hospital as will procedure
manuals, any existing file list and evidence of previous surveys that may have
taken place.
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 In preparing for survey you are trying to gain an overall picture of the ownership
of the medical records, the amount of records and the environment within records
are maintained.
How to conduct a physical survey
 In respect of a physical survey, you need to visit all areas and look into the records
of storage equipment; you will also need to complete a survey form for each
record series identified.
 There is no need when conducting a records survey, to examine every record you
should be interested in is the identification of the records at the record level.
 The physical survey needs to be carefully planned to ensure the disruption to the
work of the hospital.
 There are ways that are central to discovering the information requirement,
physical survey, you will need to: discover every storage place for records and
identify all medical records that are discovered, ensure that the information has
been gained from the survey is adequately documented for future analysis.
CHAPTER 16
MEDICAL RECORDS SURVEY

Definition
-Medical records survey is the exercise that is undertaken to locate and identify all
medical records that are held by a particular hospital or institution
-A medical records survey is a way of gathering information about records and papers.
The key to a medical records survey is that it is performed in a systematic and logical
manner that will provide sufficient information
Importance of medical records survey
 Medical records survey helps establish control over existing medical records and
enable them to be brought into a controlled records environment.
 Helps in creating a logical plan for identifying which medical records should be
discarded and creating a schedule for when these records should be retained, how
long a period they should be kept and how they can best be safely stored.
 To improve access to medical records.
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 Helps ensure that these medical records are preserved. Historical records can be
very fragile, and once lost can be impossible to replace. An archival records survey
can help those in possession of such records become more aware of preservation
issues, provide a means for obtaining advice and consultation.
Conducting survey
-It is the responsibility of each hospital or institution to manage the records that it creates
and maintains and this includes carrying out a records survey if it is required. The survey
can be undertaken by those responsible for carrying out the functions and activities that
are covered by the information map- or by Medical Records Officers charged with
responsibility for medical records management within particular hospitals
Methods of survey are
There are two methods of collecting data for the purpose of a records survey:
 Physical observation
 Questionnaire
-The physical survey is the most reliable method and needs to be used when it is
important to obtain detailed and accurate information as to the records held.
 -A survey by questionnaire is a very effective way of covering a wide area quickly,

but- you need to bear in mind that the method relies on other people to complete
the questionnaire and if not all the questionnaires are returned the results may be
unreliable (even misleading) and which may well make necessary in the end
undertake the survey anyway.
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CHAPTER 17
MEDICAL RECORDS AUDIT

Definition-Auditing refers to the quantitative and qualitative analysis of medical records.
-Quantitative analysis is a view of prescribed areas of the medical record for identifying
specific deficiencies in recording.
-Qualitative analysis is a review of the content of medical record entries for

inconsistencies and omission which may signify that the medical record is inaccurate or
incomplete.
-Amid demands to contain costs and improve efficiency, hospitals are looking for ways to
reduce their exposure to potential liability suits through proper internal controls.
-One of the most important phases of a hospital’s administrative operation is its medical
records department. Carelessness in the operation of this department may result in
medical and financial liability. An operational audit of a hospital’s medical records
department can go a long way toward ensuring an orderly, efficient and potentially
liability- free operation.
Step one: Preliminary survey
-It is important that an internal auditor first must determine how the department under
review should work. An auditor should consult objectives, goals and standards
established by administrators for the department and the policies and procedures enacted
to meet those aims.
-Objectives and goals for a medical records department will vary among organizations
but they usually focus on achieving economy and effectiveness.
-Because a medical records department serves and interacts with most other hospital
departments, communication with other areas is a necessary component of a medical
records audit. While a medical records manager would be the major contributor to an
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audit questionnaire, other department heads also should be questioned to detect

interdepartmental problems.
-During an interview, an auditor can pinpoint areas requiring further examination as well
as those that seem to be operating economically and effectively.
-Flow charts can be drawn up for selected departmental activities. By using symbols to
replace words, flow charts can describe activities much more clearly than narratives
-Normally an auditor would choose not to audit areas that seem to be operating
economically and effectively or those for which auditing costs outweigh expected
benefits of further examination.
 Design, development and implementation of programs for effective and active.

 Creating confident and committed staff with new competencies.
 Managing and maintaining the technical infrastructure.
 Evaluating for continuous improvement.
 Provision of effective and efficient administrative services.
 Supporting the needs of learners.
Step two: Audit program
-It is critical to note that as plan of action, an audit program guides an internal auditor
initiating an audit, keeping an audit on track and letting the auditor know when an audit is
complete and has adequately assessed an entire department.
-Program worksheet should be constructed for each segment of a department to be

audited. Each worksheet should list the segments objective and the projected time needed
complete that part of the audit.
-It should identify segments potential problems, controls to guard those problems and
audit tests to verify the effectiveness of controls. Potential problems should be ranked by
order of severity to ensure that the most damaging are assessed within the budgeted time
for each phase of the audit. Worksheets should include space for working paper reference
and comments.
Step three: Field work
-It is noted that once an audit program is developed, an auditor turns to field work,
implementation of an audit program. During field work, an auditor collects and evaluates
information used to support an audit opinion recommendation.
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-Field work may include direct observation, questioning, analyzing procedures, verify
adherence used to standards, investigating improper activities, and conducting a final
evaluation.
Step four: Deficiency findings
-An auditor must carefully evaluate deficiencies uncovered during field work to
determine significant problems that require administrator’s attention. Those selected
should be backed up by audit evidence that is sufficient, competent and relevant.
-Reported deficiencies should be developed objectively, lead to reasonable and logical

conclusions about a department and be capable of influencing administrators to
correction. Unreported deficiencies should be brought to the attention of the individual
responsible and recorded in the audit working papers, along with the corrective action.
Step five: Audit report
-An audit report should communicate findings to hospital administrators and persuade
them to pursue solutions. An effective audit report is organized to help readers easily find
information they need without having to read the entire report.
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CHAPTER 18
QUALITY ASSURANCE AND QUALITY IMPROVEMENT
DEFINITION OF TERMS
Quality-Compliance with standards, the degree of grade of excellence of something or
Conforming to the requirements. It entails the following:
 Knowing what you want to do and how you want to do it.

 Learning from what you do.
 Using what you learn to develop your organization and its services.
 Seeking to achieve continuous improvement.
 Satisfying your stake holders- those different people and groups with an interest in
your organization.
Dimensions of quality
 Effectiveness
 Efficiency
Benchmarking-Benchmarking involves comparing a set of products or services against

the best that can be found within the relevant industry sector
Quality assurance
-Quality assurance is a process oriented to guaranteeing that the quality of product or a

service meets some predetermined standard. The process of quality assurance therefore
compares the quality of a product or service with a minimum standard set either by the
producer or provider or by some external government or industry standards authority.
Concept of Quality Assurance
-This is the process through which the level of desired quality is defined, pursued and
maintained through the institutional hospital facility for detecting and collecting which
prevents the achievement of desired quality. It is also the term that describes the overall
efforts of the facility to achieve effectiveness without compromising quality.
-Patients care quality is defined as the degree to which patients care services in ability of
desired patient’s outcome and reduce the probability of undesired outcome the correct
state of knowledge.
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Quality assurance objectives are designed to:
 Reduce the avoidable deaths, missing files.

 Reduce the avoidable complications, duplication of numbers (records).
 Reduce the unnecessary surgeries, opening of temporary files or other procedures.
 Identify omission of unnecessary services, make full completeness of records.
 Reduce unnecessary readmission.
The quality assurance structure has three components
 Various committee department and service engaged in review assessment.

 Medical staff leadership and facility managers are accountable to demonstrate
finding is acted upon and action brings needed change.
 Staff supports structure responsible for facilitating and coordinating the work of
those engaged in assessment and assurance functions.
Procedure for ensuring quality assurance
-The process of monitoring, evaluation and problem solving should be used to review
quality and appropriateness of patient care in all its aspects by medical records officer.
Steps followed in ensuring quality assurance
 Assign responsibilities for the monitoring and evaluation of activities.

 Identify scope of care provided by the organization or department/clinical services.
 Identify the most important aspects of care that the organization provides.
 Identify indicators (well defined, measurable variables related to that structure
process of outcome of care) that can be used to monitor these important aspects of
care.
 Establish the threshold for the indication at which further evaluation of care is
triggered.
 Collect and organize data for each indicator.
 Evaluate the care in order to identify problems or to improve care.
 Take actions to correct identified problems or to improve patient care.
 Assess the effectiveness of the actions and document the improvement of patients
care.
 Communicate relevant information to other medical officer’s in charge,
departments and to the facilities wide QA team.
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Quality improvement
-The process of identifying and addressing problems within a service, a project or

program to meet or exceed the set standards.
-It is concerned with raising the quality of a product or service. It is also concerned with
comparing the quality of what is about to be produced with the quality of what has been
produced in the past.
-The quality improvement framework is organized around Ten key principles. These
principles are meant to encompass the range of functions involved in supporting online
delivery:
 Informed planning and management of resources.

 Sustained committed leadership.
 Improving access for all clients, incorporating equity and promoting cultural
diversity.
 Understanding the requirements of the learner and reflecting stakeholder
requirements.
 Technical competence.
 Safety.
 Accessibility.
 Good interpersonal relationships.
 Continuity of service.
 Amenities.
Importance of quality assurance and quality improvement

 Improve quality in information service delivery (records).
 Low cost in managing information (records).
 Reputation in the service of the clients towards the hospitals.
 Reduce execution time in serving clients.
 Compliance to standards set by the institution and the authorized bodies.
 It ensures that the organizations meet all the standards and guidelines required
quality management systems like ISO and other quality certifications awards.
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Common causes of problems affecting quality in Health care Delivery
People –Physicians, records staff, nurses.
Machines –Database, breakages in computers.
Materials – supplies, information, quality of files.
Methods –Procedures, protocols.
Measurements – inaccuracy of data, calibration of machines.
Environment – Management, biases, hostility.
-Short to meet customer requirements effectively and consistently. It is very important for
every service provider to have QA department. This will ensure that the effective
processes are involving in right direction so that the end product not only meets but also
the customer expectations.
Quality assessment
-It refers to a system designed to monitor and evaluate quality issues within a care facility
these are:
o Clinical service monitoring and evaluation like nursing, emergency amongst

others
o Medical staff monitoring and evaluation like departmental review and surgical
review
o Organization wide quality assurance like infection control.
Quality control
-Quality control (QC) is a system of routine technical activities, to measure and quality of
the inventory as it is being developed. The QC system is is designed to
° Provide routine and consistent checks to ensure data integrity, correct completeness
° Identify and address errors and omissions within records services
° Document and archive inventory material and record all QC activities
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CHAPTER 19
MANAGEMENT OF SPECIAL HEALTH RECORDS
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TYPES OF SPECIAL HEALTH RECORDS

-The following are some of the special health records managed in hospitals
 Psychiatric.
 Tuberculosis records.
 Radiotherapy records.
 Maternity records.
 Genito-urinary records.
 Casualty records.
Psychiatric records
-The way psychiatric records are maintained is different from the way other general
records are maintained
-There are two types of admission for psychiatric cases:
 Informal admission.
 Formal admission.
Informal psychiatric records
-It means a patient is admitted without legal or other formalities and the hospital has no
right to detain him in the hospital against his will, unless he or she is a threat to public
himself.
Formal admission
-Patient is admitted voluntarily he or she is aware he has mental illness. Admission is

carried out in reference to mental health Act. Discharge procedures are also carried out
under the same Act.
Tuberculosis records
-Tuberculosis is one disease for which an attempt is made at complete registration to

identify that population. Since it is an infectious disease notification copies of the
notification of new cases is sent to the chest clinic, a unit records for this patient and the
information contained unit should be very comprehensive.
-The records belonging to these patients are supposed to be kept for long time and
therefore the case folder must be made of a sturdy material to resist wear and tear. The
records can be used to calculate disease prevalence rates and incidence rates.
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Radiotherapy records
-All radiotherapy cases are supposed to be registered nationally for continuous or

perpetual follow up.
Maternity records
-Maternity records are confidential and necessitate proper care and security. They are
supposed to be kept for a period of 25 years before being destroyed in order to safeguard
legal matter that may arise.
Genito- urinary records
-These records are sometimes considered super confidential; patient may use fake names
concealment, thus making linkage with other hospital records impossible.
-AIDS cases are supposed to be kept under Genito-urinary records because of

confidentiality.
Casualty/Accident
-These records are basically kept in form of cards in accident and emergency department
usually relates to accidents which have no bearing on hospital episode. When more cases
result in admission on referral to consultant clinics, case notes would be created in
accident and emergency records embodied into these notes.
Security and control of special health records
-Special health records should be if possible locked in cabinets and the keys kept in the
Health Records and Information Department.
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CHAPTER 20
ORGANIZING OF MEDICAL SECRETARIAL SERVICE
Introduction
-Medical secretaries support doctors and other health care professionals by performing a
wide variety of clerical and administrative tasks. These duties range from scheduling
appointments to word processing to filing. Since their work is highly specialized, their
job requires them to have knowledge of medical terminology and procedures, such as
insurance rules, billing practices and hospital or laboratory procedures.
-The management and organization of medical secretarial services is important part of the
medical records officer since part of the duties of this service directly affects the medical
staff of the hospital. The good relationship between the medical records officer and the
medical staff therefore will depend very much on the efficiency with which medical
secretarial services are run.
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-The well trained medical secretary is considerable asset to the medical organization of
the hospital. It is logical to include the secretarial services in the medical records
organization since the medical secretary on behalf of the consultant produces and
maintains much of the clinic data record in the medical records.
-There are a number of ways in which medical secretarial services may be organized. The
main such ways are the pool system, the unit system, a combination of the pool and the
unit system and the personal medical secretarial.
Duties of a medical secretary

-The following are some of the duties of medical records secretaries in hospitals:
1) Schedule and confirm patient diagnostic appointments, surgeries and medical

consultations.
2) Compile and record medical charts, reports, and correspondence using type writer
or personal computer.
3) Answer telephones, and direct calls to appropriate staff.
4) Receive and route messages and documents, case histories and forms such as
intake and insurance forms.
5) Greet visitors, ascertain purpose of visit and direct them to appropriate staff
6) Interview patients in order to complete documents, case histories and forms such
as intake and insurance forms.
7) Maintain medical records, technical library and correspondence files.
8) Operate office equipment such as voice mail, messaging system and use word
processing, spreadsheet, and other software applications to prepare reports,
invoices, financial statements, letters, case histories and medical records.
9) Transmit correspondence and medical records by mail, e- mail or fax.
10)Perform various clerical and administrative functions such as ordering and
maintaining an inventory of supplies.
11)Arrange hospital admissions of patients.
12)Transcribe recorded messages and practitioners’ diagnoses and recommendations
into patients’ medical records.
13)To perform book- keeping duties such as credits and collection and preparation
and financial statements and bills and keeping financial records.
14)Complete insurance and other claim forms.
15)Prepare correspondence and assist physicians or medical scientists with
preparation reports, speeches, articles and conference proceedings.
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Training of medical secretaries

-Even when medical secretaries’ staff have attended medical secretarial courses, the
training is still essential. The MRO and the senior medical secretary will be responsible
for planning and maintaining training of trainees’ medical secretaries
The programme will include the following:
 For staffs that have been recruited from medical secretary college, introduce
medical terminology with provision of appropriate book on terminology prefixes,
suffixes and root wards is essential.
 Instruction on the complex organization of the hospital management of the
services and the training of new recruits.
 Typing dummy trial letter to give her confidence.
 Inpatient system.
 Request for investigation procedures.
 Using dictation equipment.
 Taking dictation in the company of a qualified medical secretary.
 Medical records system- this involves short rational attachments in order of
various functions of the department.
 Attachment to unit secretaries or personal secretaries in order to acquit themselves
the varieties in procedures.
 After this type of training the new recruits should with a fair degree of confidence
able to act as relief secretary during sickness and a rural leave.
Secretarial Systems
A Pool System (Centralized)
a. What is the pool system?
-The principle of the pool system is that the medical secretarial and stenographs are
together in one area. The system can be used in either of the two ways:
 The medical staff can go to the dictating booths adjacent to the pool dictation to
any available short hand typist
 The medical staff contents the pool and short-hand typist goes to the ward the
outpatient department to take dictation
b. What are the advantages of the pool system?
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 The typist can be supervised more effectively.

 New entrants (ascertained/recruits) can be helped and trained easily.
 The question of organizing relieves or such offs during absence doubts normally
arise.
 Work-load can be more even and easily spread out.
 Medical records not in file but can be more easily obtained.
 Files can easily be traced wherever needed.
c. Disadvantages of the pool system
 Provides a less comprehensive service to the medical staff.

 Possible lack of job satisfaction and commitment or the part of the medical
secretary and her duties are more limited than as the unit secretary.
 Not easy to measure somebody (secretary) capabilities.
Unit Secretarial System

-It is useful to allocate medical secretaries to medical specialties or firms where there is a
large outpatient services in addition to the formal routine inpatient work.
-The advantage of the method is the personal services which the head of the specialty will
receive and the satisfaction the medical secretary will receive when taking in her unit,
anticipating the need of her doctor and even important getting to know the patient and
ensuring that their case notes follow up and investigation are all up to date.
The other advantages are
a) Medical staff working together in the unit have a focal point to which enquires
may be directed. The medical secretary fulfills this function.
b) The secretary in the unit is more involved with organization of the various clinical
activities of the medical staff this involvement promotes interest and commitment
and tend to produce a more loyal and devoted secretary.
Combined Unit and Pool System
-The unit and pool system of medical secretarial services can be combined in order to get
the best out of the system. This means in addition to allocating secretaries to special or
firms, a small typing pool is also provided
 In the pool some of the secretaries may be new recruits in training and others
working on part-time basis or normally.
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 The typing pool staff would be able to assist with work from firms during periods
when pool secretarial are under pressure, the pool secretaries would also be
available to cover for the unit secretaries during sickness and holidays.
 The pool will provide a base for instructing and training new medical secretaries.
 To boast the efficiency unit secretaries belong to the departmental unit e.g.
orthopedic.
Personal Secretaries
-A person medical secretary would be permanently attached to an individual consultant
the duties of a personal secretary will entail the following:
a. Duties relating to outpatient
i. A typical hospital procedure provide recent folders of all return patients due to
attend a particular clinic to be forwarded to the person secretary by records
department two days before clinic it will then be the responsibility of the personal
medical secretary to ensure that all diagnostic reports and other essential
documents are included in the folder in their assigned places in readiness along
with x-rays on the day of the clinic.
ii. At the end of the clinic session the secretary return all record folder to the central
records filing library through the clinic receptionist except those files which need
secretarial action and which she retains for later insertion of the copy, the letter to
the doctor or report before returning to the central record filing room.
b. Duties relating to inpatient
-The secretary will be required to receive dictation for letter reports and summaries in
respect to inpatients under the care of the consultant whom she is attached to.
-In hospitals where the waiting list is decentralized the secretary is responsible for
maintaining the waiting a list and arranging admission.
c. Liaison duties
-A personal medical secretary has many other duties to perform from her own office she
will be required to deal on behalf of her client with many telephone enquiries from other
hospitals and outside doctors as well as from patients. She will imitate through the
medical social worker medico-social action and perform other administrative duties in the
interest of the patient or relative and in perspective of the work of the department.
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-There is a great deal of liaison work with pother hospitals and an experienced medical
secretary will find that the consultant to whom she is attached relies upon her more and
more in patient is in fait take indeed the modern secretary is becoming a liaison officer
the consultant and all his constants within the hospital.
-A surgeon secretary may be required to attend for dictation in the theatre or other special
departments but this will depend upon local practice.
Supervisor of Medical Secretaries
-The day organization and supervision of medical secretaries and the planning and
provision of training procedures for news records will be normally the responsibility of
the senior medical secretary. Her duties will vary according to the size of the secretaries’
organization and the type of services provided. In a small hospital, her time will be taken
up with the management of the secretarial service and the training of new recruits
-The overall function of a senior medical secretary may therefore be summarized as

follows:
 Job assessment.
 Maintenance of staff level required for any task in the area.
 Ensuring that changes resulting from new policy decisions directed by medical
records officers are properly initiated.
 Advice the Medical Secretarial Records Officer for placing training when
vacancies occur.
 Organizing of work flow in the given area of responsibility.
 Testing and accessing to hired skills of all secretarial candidates post.
 Organizing of leave including placing of any relied staff.
 Supervision to ensure maintenance of any out-put of new recruits.
 Training of new recruits.
 Supervision of equipment used by her secretaries.
CHAPTER 21
PRESERVATION AND CONSERVATION OF RECORDS

Introduction
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-Medical records preservation is a crucial element in the whole operation of a record

programme. The aim of archival preservation is to prolong the usable life of the research
information in two ways. First, preventive preservation seeks to reduce risk damage and
slow down the rate of deterioration. This aim is usually accomplished selecting good
quality materials and by providing suitable storage environments and selecting good
quality materials and by providing suitable storage environments and handling
procedures. Secondly prescriptive preservation is a means of identifying treating or
copying damaged materials to restore useful access to the information.
-Conservation is a field of knowledge concerned with the coordination and planning

practical application of the techniques of binding, restoration, paper chemistry and
material technology as well as other knowledge pertinent to the preservation of archival
resources. Conservation can be further characterized as both preventive and renewed.
Preventive conservation consists of indirect action to retard deterioration and damage by
creating conditions optimal for the preservation of materials. On the other is remedial
conservation which consists mainly of direct action carried out on doctor in order to
retard further deterioration. In order to protect to protect records and archives, no matter
where in the life cycle they are record keeper must.
o Understand how records and archives deteriorate and the environmental and phase
causes of their deterioration.
o Know how to develop a well-planned preservation programme.
o Know how to care for materials in all media, from paper to photographic to
electronic.
o Understand the value of reproduction as a preservation tool.
o Understand the importance of security.
o Know where to go for more information.
Preservation Digital Information

Definition
-Digital preservation are among the activities necessary for the long term maintenance
byte stream (including metadata) sufficient to reproduce a suitable facsimile of the order
document and for the continued accessibility of the document contents through time
changing technology. Digital technology holds great promise for the world’s archives and
records, for it revolutionize how we capture, store, preserve and access information.
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-From the preservation perspective, digital technology offers important reform

advantages over photocopy and microfilm, including its capability to create a higher
quality reproduction of a deteriorating original the ability to reproduce digital images
over and over again with no loss of image quality, greater flexibility in terms of
outpatient distribution and potential cost savings associated with storage and most
important digital technology offers unprecedented opportunities for access and use since
it facilitate the expansion of scholarship by providing sources from a variety of locations.
Problems affecting preservation and conservation of information materials in

African institutions managing records and archives
 Absence of organizational plans for managing records.

 Low awareness of the role of records management in support of organizational
efficiency and accountability.
 Lack of stewardship and coordination in handling records.
 Absence of legislation, policies and procedures to guide the management of
records; absence of core competence in records and archives management.
 Absence of budgets dedicated for records management.
 Poor security and confidentiality controls.
 Lack of records retention and disposal policies.
 Absence of migration strategies for records.
Causes of deterioration of information
 Acidity.
 Temperature and relative humidity.
 Light.
 Air pollution.
 Water.
 Moulds.
 Insects.
 Rodents.
Preservation and Conservation Techniques of Print & Non-print materials
-There are a number of widely used processes or techniques for repairing or extending the
life of paper- based archival materials. Prominent among them are:
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Acid- free storage materials -Most paper, including that used in file folders and storage
containers contains acids which eventually lead to its disintegration; thus acidic storage
materials should he discarded and replaced with acid-free folders and storage containers.
Boxing storage -of archive in standard archival containers or other study enclosures
provides protection from the harmful effects of light and dust. Archival boxes also
provide considerable protection to their contents in the event of flooding or fire.
De- acidification -alkaline baths or sprays will neutralize acids and substantially prolong
the life of paper; the process will remain expensive until some means of mass de-
acidification can be perfected.
Lamination-The application of thin, transparent sheets of acetate foil to both sides of a

document, which are then bonded to the paper with heat and pressure usually after de-
acidification of the paper; this process has been used extensively in many archives but
currently seems to be losing favor because of evidence that the high temperature may
damage paper fibers.
Encapsulation Placement of a document within sheets of transport Mylar and all edges,
usually after De- acidification of the paper, the use of this process is gaining at the
expense of lamination as it requires substantially less in the way of equipment readily
reversible and does not require the application of heat to the document itself.
Rebinding-Records contained in bound volumes may be rebound using acid free

materials.
Microfilm reproduction -Records may be microfilmed and users required to use copies
in lieu of the originals; this will prevent wear and tear through frequent handles well as
additional harm to already damaged or fragile materials; although microphotography of
archives is not an inexpensive process, it is the least costly preserving the informational
content of records.
Other means of copying-Xerography and similar means of producing facsimiles durable

acid-free paper can serve essentially the same ends as microphotography; costs are
slightly higher and the bulk of the newly created reference materials is much larger;
however special reading devices are not needed.
Others
 Cleaning and dusting of library materials.

 Photocopying.
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 Shelving library materials to allow for free flow of air.

 Installing air-conditioners in your library.
 Provision of adequate security to prevent theft, mutilation and defacing of based
materials.
 Use of insecticide and insect repellant.
Microfilming Records
Definition-Microfilming refers to the process of photographing records and reproducing
the photographic film. The records that are created by this process are called Microform.
Most common types of microforms are:
 Roll microfilm, where the film is stored on a continuous roll, in either a record
cassettes.
 Microfilm jackets, where the film is sliced into sections and put into a 4 by
polyester sleeve.
 Microfiche a sheet of film usually 4 by 6 inches which can contain hundreds of
exposure.
 Aperture cards, a card that has rectangular openings in which a strip or frame
film is mounted.
Benefits of microfilm records
-Microforms are mainly used to store records that are in the cycle. Microforms offer a
number of advantages.
Substitution- In some cases it is useful and cost- effective to microfilm records in order
to replace paper originals. Substitution is best used for large series of semi- active records
that have high retrieval rates. It is also used for records that will be kept for more than 20
years.
Security- Microforms can be used as a back-up copy of vital records and records that
will be kept permanently.
Planned duplication- portions of records series may be filmed in order to give two or
more agencies access to the same information. This is useful when a program is
transferred from one department to another.
Publication- In some cases microforms are used to distribute records to people or

organization. This can be less expensive than printing paper copies
Types of records to be microfilmed

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-Almost any paper record can be microfilmed. The condition of the records will affect the
price of the project and the quality of the microform. Well organized and uniform records
are easier to film.
1. A rotary camera is used to film records that are of uniform size and contrast. The
cameras use a feeder to automatically move records in front of the lens. They can
photograph thousands of records in an hour.
-You can only use this type of camera for records that are in stable condition and do not
have attachments.
2. Stationery or planetary cameras are used for records that cannot be fed into a rotary
camera. They are used for large records, such as maps and engineering drawings, Records
management advice prepared for GNWT employees by Records Management.
Medical Records Appraisal and Disposal

-Most health care and medical professionals understand that it is vital to properly destroy
medical records in order to protect the privacy of patients. Doctors and healthcare
practitioners are entrusted with individuals most sensitive and confidential information
which must be handled with care and professionalism, thus when medical records are
being discarded, it is vital that the record destruction process also be managed with
utmost care and professionalism. Retention periods for patient case notes and other
clinical records will be determined by a combination of legal, clinical, administrative
audit and research requirements.
Appraisal
Definition-Records appraisal is the process of determining the archival value and
ultimate disposition of records. Appraisal decisions are informed by a number of factors
including the historical, legal, clinical, operational and financial value of the records
-When deciding on the retention and disposition of medical records the following
questions
 Is the record needed and referred to on a day to day basis?

 Is the record required for legal purposes e.g. for medico-legal mismanagement?
 Is there any legislation which affects how long the record should be kept?
 Is the record likely to be enduring public interest?
 Is there guidance or precedent available on retention of this type or elsewhere in
the sector?
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-The answers to these questions will inform how long records will be kept.
Selecting Records for Permanent Retention
Records are likely to be designated as archival and selected for permanent where:
 They are essential to the continued functioning of the hospital or agency and it to
assert its legal position and rights.
 They provide evidence and accountability of the hospital or agencies provide
activities and decisions.
 In most cases this will mean retaining records which provide evidence of: high
level decision making for the hospital management or patient care
 The structure, organization and remit of the agency (including any changes)
 Policy formulation within the institution.
 Significant interactions between the hospital, agency it’s stakeholders, bodies and
the wider community.
Who Is an Appraiser?
-An appraiser is one who is typically engaged in valuation.
What are the qualities of an appraiser?
 Should be licensed or certified.

 Should have a clear sense of judgment so as to separate record with continued
value from the absolute ones.
 Must be detailed oriented, methodical, organized and open minded.
 Should have vision- he should be able to look forward in advance, see the file so
that he can know when records will be appraised man power and finance to
accomplish the job.
 Must be flexible and versatile with regard to applying appraisal and assets
principles to a multitude of styles, size, amenities and other unique characteristics.
 Should have inner motivation drive-he/she should have an inner urge to
accomplish his/her job.
 Should be well trained and comfortable with building codes, construction method
and materials.
 Proper relation attitude should have proper interpersonal skills and input as the
appraiser will be liaising with the management of the hospital and national
archives pertaining to records which will be permanently preserved.
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 Adaptability, he/she must be ready to adopt to new ideas and views of others as
may be demanded by the situation for example policies concerning record may
change as new information became available so he/she should be able to adopt
this.
Records Transfer Procedures

Records transfer- This is physical movement of records from office floor space to
archives centers. Before records transfer procedure starts, the appraiser;
 Has to identify important / vital records and advice on their proper preservation.
 Must identify records that are not being used for daily operations but are
frequently referred to and have them maintained in a records center.
 Should determine how each series of records should be maintained at the archieves
before complete destruction to create space for movement of records.
-In order to transfer records to the archives and records office you need the following
 Instructions- on how to transfer records to archives and records.

 Records transmittal and check list forms used to describe the records being
transferred to the archive and records office and to provide quality assurance.
 Transfer standards- This must be followed when transferring records to the
archives and records office.
Preparation of Disposal List

-Doctors and healthcare practitioners are entrusted with individuals most sensitive and
confidential information, which must be handled with care and professionalism. Thus
when medical records are being discarded, it is vital that the records destruction process
also be managed with utmost care and professionalism.
-Health information management professionals traditionally perform data and

information warehousing functions (e.g. purging) utilizing all media including paper,
images, optical disk, computer disk, microfilm and CD- ROM. These warehouses or
resources from which to retrieve store and maintain data and information include, but are
not limited to, application-specific databases, diagnostic biomedical devices, master
patient indexes and patient medical records and health information.
-One data integrity characteristic of warehousing is relevancy of data or information. To

ensure the availability of relevant data and information, appropriate retention schedules
must be established. Disposal list is a list with the records to be destroyed. The appraise
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prepares a list of all records evaluated and determined to have containing value and those
that need to be maintained for a specialty period of time. A list of all records to be
destroyed will be made available to departmental heads that will go through them and
raise any concern they may be having about them.
Preparation of Records Disposal Schedules

-Disposal schedules apply to information not the media containing the information. If
records contained on electronic media (for example, magnetic tape disk or optical data
storage systems) are printed out in an eye readable format (paper or immediately in their
case a permission letter would not be needed to be sent to the supervisor records. If the
electronic record is the sole source of the information it must be the same member as its
hard copy center parts for the purposes of disposal schedule.
Disposal- The process of destroying records. Carrying out any process that makes it
impossible to produce the information in a transferring or delivery ownership of a record
-The disposal process for official records also determines whether the record is
permanent value or terminal value.
 Collect old registers and index cards of the medical records department and
department of the hospital.
 Classify them according to sections.
 Allocating an old record register number.
 File all old records in a place design for the purpose of a prescribed period.
 Destroy the records as per the regulations establish for retention records.
 Enter in the destruction register the record destroyed.
 Keep a role of the records destroyed for with microfilm copies are available.
Destruction Procedures
-Records destruction functions, most effectively is a routine procedure of office

management and is carried out at regular intervals. Certain events offer opportunities for
an organized destruction of obsolete and outdated records.
 The release of an audit report.

 When there is a policy stating a specific period of time of destruction e.g. ten years
after the last contact with the patient.
 In the case of a school system the end of academic year.
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Records may be kept longer, however maintain short term records longer than new ‘’just
in case ‘’ will lead to overcrowding of value storage space
When records are not to be destroyed
-A record regardless of its format should never be destroyed prior to the end of its legal
retention periods have expired, however should not be destroyed under the following
circumstances.
o When the agency is undergoing an audit or an investigation.

o When there are claims against the agency or a particular program of agency.
o When litigation is either pending or in progress.
Who should destroy records?
-The records officer co-ordinates destruction of records by designating the time which it
occurs, selecting the records to be destroyed, coordinating the completion of the
destroyed notices with the records liaison , securing the signature of the authorizing
officials setting the notices to the department of archives.
-The Medical Records Officer develops a plan for destruction process of inactive medical
records; this should be with an agreed retention period for records.
Recommended retention Standards for medical records
Health Information Recommended Retention Period

Diagnostic images (such as x-ray film) 5years
Disease index 10 years

Fetal heart monitor records 10 years after the infant reaches the age of
maturity
Mater patient/person index permanently
Operative index 10 years
Patient health/medical records(adults) 10 years after the most recent encounter
Patient health/medical records (minors) Age of majority plus statute of limitations
Physician index, maternity records 10 years, 25 years respectively
Register of births Permanently
Register of deaths Permanently
Register of surgical procedures Permanently
-The plan for destruction process for medical records should comprise the following ways
of destruction;
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1) Shredding- This is destroying records in papers by cutting into small pieces
2) Degaussing- This destruction procedure applies to electronic records for example flash
disks, CDs disks. They are destroyed by exposing them to magnetic conditions which
prevent function
3) Incineration- Records are enclosed in a furnace or enclosed container with very high
temperatures and they are burned to ashes
4) Burning-Records are exposed to fire
5) Recycling
Recommendations
 Each healthcare provider should ensure that patient health information is available
to meet the needs of continued patient care, legal requirements, research,
education, and other legitimate uses.
 Each healthcare provider should develop a retention schedule for patient health
information that meets the needs of its patients, physicians, researchers and other
legitimate users and complies with legal regulatory and accreditation
requirements.
 The retention schedule should include guidelines that specify what information
should be kept, the time period for which it should be kept and the storage medium
(paper, microfilm, optical disk, magnetic tape or other).
 Compliance documentation.
 Compliance programs should establish written policies to address the retention of
all types of documentation. This documentation includes clinical and medical
records, health records, claims documentation and compliance documentation.
Compliance documentation includes all records necessary to protect the integrity
of the compliance process and confirm the effectiveness of the program, including
employee training documentation reports from hot lines, results of internal
investigations results of auditing and monitoring, modifications to the compliance
program and self- disclosure.
 The documentation should be retained according to applicable federal and state
law and regulations and must be maintained for a sufficient length of time to
ensure their availability to prove compliance with laws and regulations.
 The organization’s legal counsel should be consulted regarding the retention of
compliance documentation.
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 The majority of states have specific retention requirements that should be used to
establish a facilities retention policy. In the absence of specific state requirements
for record retention, providers should keep health information for at least the
period specified by the states statutes of limitations or for a sufficient length of
time to prove compliance with laws and regulations. If the patient was a minor the
provider should retain health information until the patient reaches the age of
maturity (as defined by the state law) plus the period of the statute of limitations
unless otherwise provided by the state.
-Unless longer periods of time are required by state or federal law, the American Health
Information Management Association recommends that specific patient health
information be retained for established minimum time periods.
Records Management in the Libraries

Definition-Records management is a process of ensuring the proper creation,
maintenance use and disposal of records to archive efficient transparent and accountable
governance.
-Sound records management implies that records are managed in terms of an

organizational records management program governed by an organizational records
management.
-Records or information management is simply the strategy developed and implemented

to manage your offsite records and data. It can be as simple as boxing up and labeling
your overflow file or as intricate as scanning all your existing hardcopy records, online
anytime. If you simply have old obsolete files that you seldom access, but that need to be
retained as a safeguard by law, then probably a simple hardcopy storage and retrieval
system can be developed. If you have large volumes of files and documents that you need
to access regularly then perhaps a digital database is the answer.
Records storage
-When records are stored in professional records center, the action there includes;
 Barcode label and index all files and cartons.

 Create on online inventory detailing your entire list of files and cartons.
 Stock cartons on custom build shelving units.
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 Records preservation.
 Indexing.
Records indexing
-A reliable indexing is the key to any efficiency retrieval system. It is used to both
identify the information you need and to pinpoint the exact location of the requested file
or documentation.
-A complete inventory report is delivered when needed in both hard copy and on excel, or
view the complete records inventory online using web access software, just real time
view of your inventory also allows you to order filed records or boxes directly while on
line.
Records retention
-Once all your record have each been entered into system software each item is assigned
a retention code that will remind you when, if ever records are to be destroyed. Once
reminded you can authorize the destruction saves space, money on storage fees and may
be an important way to shelter you agency/ hospital from unnecessary liability.
SAMPLE QUESTIONS
SECTION ONE (Multiple choice question)(10marks)
Indicate the most appropriate response in the examination booklet
1. Which one of the following documents in the patient file is used to carry out diagnostic
coding?
A. Nursing Cardex
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B. Medical History form
C. Continuation Sheet
D. Discharge Summery
2. Clinic preparation entails the following activities except
A. Sorting
B. Retrieval
C. Editing
D. Tracing
3. The following are permanent records, which one is not?
A. Maternity records
B. Registers of births
C. Registers of deaths
D. Registers of surgical procedures
4. All listed below are health records indices, which is the odd one out?
A. Waiting list index
B. Bed bureau index
C. Operation index
D. Diagnostic index
5. One of the following information is not included in an index card, which one is it?
A. Name of the patient
B. Diagnosis of the patient
C. Patient hospital number
D. Space left for change of address
6. These are the checks made on the waiting list except?
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A. completeness
B. Eligibility
C. Accuracy
D. Deaths
7. A unit number register contains the following information except?
A. Address
B. Date of birth
C. Full names of patient
D. None of the above
8. Which one of the following is not a special health record?
A. Radiotherapy records
B. Casualty records
C. Out-patient records
D. Genito-urinary records
9. The following equipment is used to record appointment which one is not?
A. Loose leaf binder
B. Bound volumes
C. Diaries
D. Visible edge cards
10. When selecting a folder the following points should be noted except?
A. Strength of manila
B. Cost of the folder
C. Clarity of numbering on the inside cover
D. Method of fastening documents
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11. The following persons contributed towards the development of medical records
system, except?
A. Abraham Lincoln
B. Grace Whiting Myers
C. Imhotep
D. Hippocrates
12. Which one of the following is not a quality of Health Records and Information
Officer?
A. Integrity
B. Generosity
C. Humility
D. Adaptability
13. Which Country is famed with keeping of early records?
A. Germany
B. Britain
C. Canada
D. Egypt
14. The following are the content of a case folder, exept?
A. Consent Form
B. Prescription chart
C. Tally sheet
D. Surgical Operation sheet
15. In the Unit medical Records, the unit is the?
A. Master Index
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B. Patient
C. Record
D. Folder
16. The following are qualities required in a receptionist, except?
A. Appear neat
B. Be proud
C. Be Empathetic
D. Be Competent
17. The following are used to file the waiting list, except?
A. Card wheel
B. Strip wheel
C. Visible edge card
D. Bound Volumes
18. All listed below are ways of conveying information to the waiting list, except?
A. Cards created for every patient
B. Nurse or Physician sending list of patients to be added to waiting list
C. Letters from a consultant
D. Letters from in patient department
19. Putting records in order before filing is sometimes referred to as?
A. Tracing
B. Filing
C. Sorting
D. Follow-up
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SECTION TWO (Write TRUE or FALSE in the examination booklet)

1. For a file already outside the filing area, a common tracer card will show its where
about when you check it in its usual place in the filing area.
2. In a centralized appointment system, all enquiries regarding clinic appointment
would be directed at different places.
3. Terminal digit filing system is where is a health record system where the middle
two (2) numbers are considered when filing the documents.
4. Mobile raking is the most economical filing method as far as space is concerned.
5. It is not necessary to include the reason for extraction and the borrower’s signature
on a trace card.
6. One advantage of straight numerical filing system is that the growth of files in the
filing area is evenly distributed.
7. A unit number in Health Records is the same as primary key in Electronic Medical
Records.
8. Misfiling is normally reduced when straight numerical filing system is put in
place.
9. A tracer card that can be used more than Eighty (80) times is termed as personal
tracer card
10. The relationship between Health records department and other department in
healthcare provision is the patient / client.
11. The diagnostic index is the alphabetical key to numerically filed case records.
12. Filing Trolleys, Kik stools/ ladders, sorting equipment are also referred to as
Auxiliary Equipment
13. The bed bureau is not a section in medical records department dealing with
admission of emergency patients.
14. Canadian association of Health Records was formed in the year 1948 whereas the
Association of Records Officers in Britain was formed in 1942.
15. Editing is an objective method of applying a yardstick to the quality of
professional performance.
16. In case of a minor the consent form should be signed by a parent or guardian
before an operation is carried out.
17. Registration is the completion of documents of personal and social data after a
patient is treated.
18. Taking down the identification details of patient through telephone and writing of
a letter before a patient attends the hospital is also known as pre-registration.
19. Auditing is the arrangement of all forms inside a case folder in a prescribed
manner.
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20. In Egypt Hippocrates, known as “father of medicine” was born about 460 BC.
SECTION THREE (fill in the blank spaces)(20 marks)

1. The term used to describe a variety of processes through which information is
reproduced mechanically is known as…………………………………………
2. …………………………is the objective method of applying a yardstick to the
quality of professional performance.
3. …………………………..is a method used to find out the where about of all
records at any given time
4. Health Records and Information officers program was started at Kenya Medical
Training, Nairobi in the year…………………………
5. A health Records system in which all health records notes relating to one patient
are contained in one case folder is………………………………
6. …………………is a case where a patient authorizes release of his/her health
information but does not involve signing of any document.
7. ………………………is a type of filing that entails a normal sequential order such
as 1, 2, and 3.
8. ………………………..is defined as customer satisfaction process.
9. ………………………..is a record in digital that is capable of being shared within
a cross different healthcare settings .
10. The act of removing files that are not currently in use to give space for new ones in
the library is known as…………………………………………..
SECTION FOUR. Essay Questions

1. (a) Briefly talk about the term subpoena. (5marks).
(b) List Ten (10) instances under which medical records can be used as
evidence. (10 marks)
2. State and explain Five (5) importances of Health Records. (15 marks)
3. Describe Five (5) purposes and Five (5) Concepts of scheduling appointment.
(20 marks)
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GLOSSARY AND TERMINOLOGY

Admission register-A register of all inpatients admitted to the hospital.
Coding-A procedure that assigns a numeric code to diagnostic and procedural data based
on a clinical classification system.
Culling-Culling is the removal of medical records from the medical record file room
when they are no longer active. Records may then be either destroyed or filed in active or
secondary storage. Records in secondary storage may be culled for destruction.
Discharge summary-A summary of a patients stay in hospital written by the attending

doctor.
Disease index-Lists diseases, conditions and injuries by the specific code number for
each disease condition or injury based on a clinical classification system to allow for
retrieval of medical records for research by each specific code.
Emergency patient-Attends a hospital or health care facility needing immediate

attention for a disease or injury.
Electronic Health Records (EHR)-It is a record in digital format that is capable of being
shared within across different health care settings by being embedded in network
connected enterprise wide information system
Front sheet -The first form in the medical record also called identification sheet
General outpatient-In developing countries a general outpatients department of the

healthcare facility without an appointment. These patients do not include accident and
emergency patients.
Health care facility- Hospital, health center aid post etc.
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Health record-Any written document containing information about a patient in a

professional relationship with a doctor or health worker or a single record of all data on
any individual’s health status – including birth records immunizations reports of all
physical examinations as well as all illnesses and treatments given in any health care
setting. Often used interchangeable with medical record but is a broader concept.
-The health record must be complied in a timely manner and contain sufficient data to
identify the patient support the diagnosis justify the treatment and accurately document
the results.
Health records management-The planning controlling directing organizing training

promoting and other managerial activities related to the creation maintenance and use and
care organizations policies and transactions.
Health information manager-The person who manages the health information service.
Hospital information system-A collection of data relating to patients and their care.
ICD-9-International statistical classification of Disease (9th revision) published by World

Health Organization ( WHO).
ICD-10-International statistical classification of disease and related health
Problems; 10th revision published by World Health Organization.
ICPM-International Classification of Procedures in Medicine published by WHO.
IFHRO-International federation of health records organization.
Inactive medical record-A medical record belonging to a patient who has not attended
the hospital for a specified number of years.
Inpatient-An inpatient is a patient who has been admitted to the health care facility.
Inpatients usually occupy a bed in a health care facility usually overnight.
Master patient index-The master patient index contains identification information of all
patients admitted to a health care facility to health care facility and is the key to locating a
patient’s medical record.
Medical record-A collection of facts about a patient’s health history including past and
present illness and documents written by the health care professional treating the patient
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Medical record number-The number used to identify the patient’s medical record and
used to file the medical record. Also referred to as hospital number, identification number
or unit record number.
Medical Record Officer- Person responsible for the medical record service.
Medical record room-Usually a small medical record department in a developing

country.
Numbers register-Is a book of numbers in strict numerical order and is the origin of the
patient identification numbering system.
Operation index-Lists operations and procedures by a specific code number based on an

operation or procedural classification system. The index enables the retrieval of medical
records of all small patients who have undergone a specific operation or procedure while
in hospital.
Outpatient-An outpatient is a patient who is not admitted to a health care facility and
who does not occupy a bed for any length of time.
Patient management Generating planning organizing and administering medical and

nursing care and services for patients.
Principal diagnosis-The condition established after study to be chiefly responsible for

occasioning the admission of the patient to hospital for care (USA definition)
The diagnosis established after study to be chiefly responsible for occasioning the
patient’s episode of care in hospital (or attendance at the health care facility).
Research-A systematic investigation of a subject designed to expand the knowledge and

generate new ideas.
Record-A record can be either a tangible object or digital information for example birth
certificates medical x-rays office documents database application data and e-mail. Or
anything such as a document or a photograph record providing permanent evidence of or
information about past events.
Service analysis-An analysis of the type of service under which the patient was treated
while in hospital e.g. medical surgical orthopedics ophthalmology e.t.c
The analysis is used to determine the number of patients treated under each service for
statistical purposes.
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Straight numerical filing-Medical records filed in strict numerical sequence.
Specialist outpatient-An outpatient who attends a specialist clinician in the outpatient

department. A specialist outpatient is usually a patient with a chronic problem
(hypertension, diabetes etc.) a pediatrics patient or a recent inpatient.
Tracers card-Usually the same size or slightly larger than the medical record which
replaces the medical record in the file when the record is removed for use elsewhere in
the hospital.
Unique patients’ characteristic-Something about a patient that does not change such as
national identification number or social security number
Quote
The greatest gift is a passion for reading. It is cheap, it consoles, it distracts, it excites,
and it gives you the knowledge of the world and experience of a wide kind. It is a moral
illumination; a book lying idle on a shelf is wasted ammunition. Elizabeth Hardwick
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REFERENCES
1. Abdelhak, M. Grostick, S.Hanken, M.A Jacobs,E.1996 Health information
management of a strategic resource W.B. saunders; P.584-585
2. Huffman E.K (1990) Medical records management ninth revision physicians
record company P.33-35
3. Bitpipe.com (2010) Medical records management available and
http//www.bitpipe.com/tlist/medical- records management html
4. Nancy stimpfel (2007) importance of proper medical record documentation
available :http//www.transformed.com/working papers/quality medical charts pdf
5. Norah Okello 1996 Health records science
6. [FHRO (1996) Learning package for medical record practice unit 6 : Hospital
medical record
7. IFHRO (2006) computer applications: International Federation of Health Records

Organization (IFHRO)
8. WHO The international statistical classification of diseases and related health
problems 10th revision (ICD-10) Vol.1, p.1235-1237
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health records and information technology (Kenya Medical Training College)

Studocu is not sponsored or endorsed by any college or university

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CHAPTER 1: Introduction to Health Records Management………………………………………………………………………1

CHAPTER 2: Types and Uses of Health Records………………………………………………………………………………………..6

CHAPTER THREE: Qualities of Health Records and Information Officers…………………………………………………12

CHAPTER FOUR: The Medical Health Records Department……………………………………………………………………15

CHAPTER FIVE: The Unit Health Records System………………………………………….………………………………………..26

CHAPTER SIX: Effective Communication………………………………….…………………………………………………………….31

CHAPTER SEVEN: Health Records Indices……………………………….………………………………………………………………41

CHAPTER EIGHT: Appointment System and Scheduling………….……………………………………………………………..47

CHAPTER TEN: Filing Methods……………………………………………………………………………………………………………….54

CHAPTER ELEVEN: Electronic Medical Records……………………………….……………………………………………………..70

CHAPTER TWELVE: Medical Records Committee.....................................……………………………………………….79

CHAPTER THIRTEEN: Medical Records Policies……………………………………………………………………………………….81

CHAPTER FIFTEEN: Births and Deaths Notification, Certification and Registration……………………….………103

CHAPTER SIXTEEN: Medical Records Survey……………………………………………………………….……………………….108

CHAPTER SEVENTEEN: Medical Records Audit……………………………………………………………………………………..110

CHAPTER EIGHTEEN: Quality Assurance and Quality Improvement……………………………………………………..113

CHAPTER NINETEEN: Management of Special Health Records……………………………………………………………..117

CHAPTER TWENTY: Organizing of Medical Secretarial Service…………………………………………..…………………119

CHAPTER TWENTY ONE: Preservation and Conservation of Records……………………………………………………125

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HEALTH RECORDS MANAGEMENT

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Historical background of health records management

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Benjamin Franklin established Pennsylvania hospital in Philadelphia in 1752 and

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

In 2009, a Degree programme in Health Records and Information Management was

The Contents of The Health Records Folders

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The ideal case records should the following contents or forms.

-An ideal identification sheet should have the following characteristics.

4) Treatment sheet:-This is used for recording treatment instruction in the wards. It is

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9) Clinical photography:-Photography is increasingly being used in hospitals for clinical

12) Correspondence:-All correspondence which is of clinical importance to the patient

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TYPES AND USES OF HEALTH RECORDS

Types of Health Records

1.Case records/inpatient records

2.Out patient records

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Uses Of Health Records

-This information is referred to as medical record, serve to accomplish the following

(i) Planning patient care and treatment

-A misunderstanding could result in an overdose or the worsening of the condition.

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(iii) Legal Documentation

(vi) Facility planning and marketing

(vii) Assessment of healthcare

(viii) A source of information for accreditation

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