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Chapter 4 Medical Records Management

Revised EHIS

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93 views15 pages

Chapter 4 Medical Records Management

Revised EHIS

Uploaded by

Ibsa Abdo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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Training on EHSTG Chapters

Medical Records Management


Outline

• Introduction
• Objective
• Operational standards
• Implementation guidance
• Summary
Objective
 After completion of this presentation; participants
will be able to -
• Describe about what medical records management is?
• Emphasize the operational standards
• Elaborate the implementation guiding principles of MRs
• Know the composition and staffing issues in MRU
• Describe basic considerations related with EMR
• Specify resources to deploy ICT infrastructures
1-Introduction

• A well-managed medical records system is crucial for


improving quality healthcare services.
• It also aids in making informed decisions for medico-legal
issues and researchers.
• Also essential for clinical decision-making, continuity of
care, scientific research, quality assurance, and promoting
equity.
• However, challenges in a hospital's medical record
management system include incomplete recording practices,
lack of information technology, and failure to audit records.
2-Operational standards

1.The hospital has functional medical record management


unit.
2.The hospital has standard MR room.
3.The hospital has created a system to register and retrieve
medical records.
4.The hospital avails and utilizes a standard set of formats
for medical record registration.
2-Operational standards…1
5.The hospital complies with national guidelines to manage
access to patients’ medical records.
6.The hospital has a system for proper handling and
confidentiality of medico legal patients’ medical records.
7.The hospital performs medical record auditing and takes
corrective actions on a regular basis.
8.The Hospital ensures patients’ medical record tracing
system.
9.The hospital implements fully automated medical recording
system
2-Implementation guidance…2
 Implementation Guidance

• The hospital need to establish a functional medical


record management unit.
• The unit should develop annual, quarterly and
monthly plan align with the hospital’s strategic plan
• The unit is led by MR unit coordinator, preferably HIT
professional
• The hospital should hire professionals as per
respective health tire level
2-implementation…3
• All MR personnel should undergo MR orientation and
subsequent annual training on all departmental policies.

• The Hospital should have single and unified medical record


room with adequate service delivery windows.

• There should also have adequate amounts of the necessary


equipment as per standard.

• Each patient should have one MRN for all visits to the health
facility used for all other visits.
2-implementation …5
• Both computer and manual systems should be used to
ensure optimal patient care.
 If duplication of MRN is identified it should not be
canceled rather cross-referring should be linking the
duplicated number.
• Hospitals are expected to offer paperless medical
recording systems /EMR/
• However, it is also advisable to have a paper-based card
file in case of computer malfunction or downtime.
2-implementation…8
Retrieving existing Medical Record .

 The MR is filed numerically in the MR room and hence


can be easily retrieved from the shelf.

1.Use the MRN to find the MR.

2.Retrieving a MR by phone number

3.Retrieving a MR by name
2-implementation…11
 Standardized documentation and forms.

• Only approved and standard clinical forms (approved by


government agencies or hospital management) should be used
in the MR.
• A standardized format should be used all over the hospital to
facilitate the entry, review, and retrieval of information.
• The following criteria can be applied to ensure standardization.

1-All forms should be of the same size, usually A4.


2-Key identifiers such as the name of the form, patient’s name and
medical record number should be located in the same place on all
medical record and clinical documentation forms.
2-implementation…12
Key components of clinical documentation and Medical Record
forms
• Demographic sheet • Nursing Process Forms
• Summary sheet of all visit • Routine Observation Chart
dates • Medication Administration
• History and physical Record
examination assessment • IV Fluid and Additive
• Progress notes Administration Record
• Consultation request sheet • Fluid Balance Chart
• Consent forms • Discharge summary
• Physician order sheet • Death summary sheet (if
• Laboratory order and report relevant)
result forms • Triage form
• Radiology order and report • Critical Care flow sheet
form
• Referral and Feedback Form
• Pathology order and report (if relevant)
form
2-Implemntatio…13
Handling of Medical Records
Tracking the location of Medical Records .

• MR location tracking system should be established.

• On a daily basis, assigned MR staff should refer to the


logbook and ensure that all MRs are returned to the MRU.

• When a MR is removed, one should put in its place, a


tracer card
Summary

• Medical records management refers to a system of


medical records policy and procedures responsible for
governing patient information throughout the entirety of
the data lifecycle.
• From the moment a patient record is created, it must be
appropriately stored, secured, and maintained.
• After it has been retained for the necessary amount of
time (its retention period), the record must be properly
destroyed.
• There’s a complex set of rules and regulations regarding
medical records management and for good reason.
• When health records are mismanaged, patients and their
private health information are put at risk.
Thank You!

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