Hospital Medical Records Management Manual

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HOSPITAL MEDICAL RECORDS MANAGEMENT MANUAL

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DEPARTMENT OF HEALTH REPUBLIC OF THE PHILIPPINES

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. HOSPITAL MEDICAL RECORDS . ~ MANAGEMENf MANUAL .

Department of Health

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Second Edition

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Department of Health Republic of the Philippines

The second edition of the Hospital Medical Records Management Manual is a publication of the Health Finance Development Project of the Department of Health. This publication was made possible through support provided by the U.S. Agency for International Development (A.LD.), under the I erms of Contract No. 492-0446-GOQ-Zl14-00. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the U.S. Agency for International Development.

TABLE OF CONTENTS AUTHORIZATION MESSAGE FOREWORD PREFACE ACKNOWLEDGMENTS LIST OF FORMS LIST OF ABBREVIATIONS, INTRODUCTION Philosophy of the Medical Record Service Objectives of the Medical Record Service The Medical Record Service Functions of the Medical Record Service The Medical Record Uses of the Medical Record The Patient Health Care Provider Hospital Government and the DOH Organization and Administration Organizational Chart Chapter I.

II.

IlL IV.

Page No, MEDICAL RECORD POLICIES AND STANDARDS Standards 'Record Completion Release ofinformation Policies for. Doctors . on Release of Information Policies for Nurses on the Release ofinformation Other People Concerned Symbols and Abbreviations

1 1

3 3 5

6 6 8

PHYSICAL FACILITIES AND EQUIPMENT Filing Cabinets Arrangement and Distances of Cabinets Working Tables Proper Lighting Proper Ventilation Proper Temperature Aesthetic Consideration

20 20 20 20

MANPOWER/PERSONNEL

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THE NUMBERING SYSTEM The Unit Number Assignment of the Unit Number Assembly of the Medical Record

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17 18 19 19

30 30 31

Page No. Types of Formats 31 Source-oriented Medical Record 31 Problem-oriented Medical Record 31 Integrated Medical Record 33 Analysis of the Medical Record 33 General Documentation Guidelines 34 Quantitative and Qualitative Analysis Procedures 36 Coding and Indexing of Disease and Operation 38 Reporting and Coding Diagnosis, . Operations and Procedures 38 Simple Coding Procedures 39 Method of Reporting Final Diagnosis 39 Principal Diagnosis 39 Symptoms 40 Hospitalization for Investigation 41 Injuries/Poisonings 41 Abbreviations 41 Qualifying Expressions 41 Procedure and Operation Coding 41 Statistics 42 Needs for Statistics 42 Administrative Level 42 Clinical Level 42 Outside Agencies 43 Formulas Used in the Computation of Hospital Indicators 43 Measure of Hospital Utilization 43 Daily Census 43 Percentage of Occupancy 44 Average Length of Stay 44 Measure of Hospital Performance 44 Death Rate 44 Post OP Death Rate 45 Anesthesia Death Rate 45 Maternal Death Rate 45 Infection Rate 46 Consultation Rate ~ Autopsy Rate ~ Caesarean Rate 48 Perinatal Statistics 48 Fetal Death Rate 48 Neonatal Death 49 Filing of Medical Record 49 Terminal Digit Filing 50 Procedure in Filing Patient Index Card 51 New Admissions 51 Re-admissions 51 Rules in Alphabetical Filing 52 Loose Sheets 53 Sorting of Loose Sheets 53 Locating the Record 53 Filing Loose Sheet 54

Page No. Retrieval of Medical Record Indexes Master Patient Index Disease Index Operation Index Physician's Index Registers Admissions Discharge Birth D~

Out-patient Essential Requisites for Easy Retrieval . Retrieval Procedure Request for Medical Record for Studies and Research Retention and Disposal of Medical Record Procedure in the Disposal of Medical Record Disposal Schedule of Medical Record Service V

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60 60 61 61 62 63 64

MEDICAL RECORD OF DISCHARGE PATIENT 65 65 Processing Medical Record of New Patients Processing Medical Record of Re-admitted Patients 66

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MEDICO-LEGAL ASPECTS Ownership of the Medical Record Accessibility and Confidentiality Medical Information of Mental Patients Requests for Information from the Media Records Subpoenaed by Court Consent Handling Telephone Inquiries Dealing with People

VII.

QUALITY ASSURANCE FOR THE MEDICAL RECORD SERVICE The Medical Record Service and the Quality Assurance Program Steps in Developing a Quality Assurance Program for the MRS Expected Outcomes of the Quality Assurance Program

VIII.

54 54 55 56 57 57 58 58

MEDICAL RECORD FORMS Medical Record Forms Ten Basic Forms Supplemental Forms Concept of "SET" and "BLOCK"

APPENDICES Listing of Common Causes of Mortality and Morbidity with the Corresponding ICD Code Numbers Forms GLOSSARY REFERENCES

67 67 67 68 68 69 70 72 73 75 76 77

79 93

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Republic of the Philippines Department of Health OFFICE OF THE SECRETARY

SANLAZAROCOMPOUNO RIZAL AVENUE, STA CRUZ MANILA, PHIUPPINES TEL NO. 711-60-80

AUTHORIZATION January 6, 1994

In accordance with the authority vested on the Secretary of Health, I hereby declare the policies, regulations, and instructions in this HospitalMedicalRecords Management Manual shall govern the organization, management, and activities of th Medical Records Service in government hospitals until modified by order of the Department of Health or by law.

Republic: of the Philippine.

DEPARTMENT OFHEALTH

OFFICE FOR HEALTH FACILITIES, STANDARDS AND REGULATION Sen Lazaro Cmpd., Sta. Cruz Manila

Tel No. 711·95-72, FaxNo. 711-95-09

MESSAGE

January 6, 1994

The Hospital Operations and Management Service of the Department of Health has been tasked to develop operations manuals specifically for DOH hospitals that may be of use to other public and private hospitals. These manuals would serve as standard reference materials for DOH hospitals to aid administrators and practitioners in following standard operating procedures in the management and practice of the different hospital services or units. Likewise, it may also serve as a reference guide for other public and private hospitals. These manuals provide guidelines in the performance of duties and responsibilities of hospital personnel as well as outline steps necessary in the effective and efficient operation of each unit or service. The procedures in these manuals will assist them In the process necessary to operate an effective and efficient hospital. This is an attempt to develop standards and achieve uniformity of procedures in different hospitals. ~

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JUAN It 4NAGAS, M.D. Undersec tary on Health Facilities, Standards and Regulations

,' Republic of the Philippines Department of Health OFFICE OF THE SECRETARY

SAN LAZARO COMPOUND RlZAl AVENUE, STA. CAUZ MANIlA, PHIUPPINES

TEL NO. 711-60-80

FOREWORD Aware of the need to upgrade the Medical Records Service of Department of Health hospitals, the Bureau of Medical Services in coordination with the World Health Organization produced the first document on medical record management of the country, the "Manual of Medical Record Procedures" in 1980. The need to revise and update the manual in response to the everchanging thrust of the Department of Health, as a result of change in administration and the changes brought about by man's quest for more knowledge and information in the medical field and the very rapid changes in modern technology necessitate revision and updating of this manual. Appropriate and timely revision of the said manual is needed to guide health care facilities in its effective and efficient management operation and control. Effective management of the hospital system requires not only financial data but also quantitative and qualitative information on the scope of every activity the institution is engaged in. Patient care is the major activity in a hospital where a medical record needs to be created and maintained for each patient treated by the facility. Knowledge of, and competence in the effectiveand efficient management of the medical record is necessary in the attainment of quality patient care. Although the Medical Record's Service is not directly involved in patient care, information contained in the data base maintained by this vital service component serves the members of the medical and allied staff in effectively managing their patients. The extracted data from the medical record mainly helps health planners in assessing the effectiveness and adequacy of health care delivered. Furthermore, it is also used by the hospital management in planning, decision-making and management control.

, Successin the implementation of this manual rest heavily on the support of health managers/ administrators and the full cooperation of the people concerned. It is also believed that to best utilize the statistical data/information from the medical records, the medical record needs to be properly explained to those responsible for creating and maintaining the records. They are as follows:

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* Doctors

* Nurses * Medical Record Service Staff * Members of Allied Medical Staff I believe that as the user moves on to the manual itself he/she will want to look forward to finding and following the author's reasoning that this Medical Records Management Manual prepares us to better understand the need to standardize medical record policies, systems, and procedures. I am fully convinced that the outcome of the full implementation is worth an effort and believe that what will emerge will be a more effective and efficient Medical Record Service to enhance attainment of quality patient care, the ultimate objective of establishing a hospital.

MA.

MAR~ GALON, MD., MHA Director III Hospital Operations and Management Service

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PREFACE

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The patient's medical record is believed to be the primary repository of information concerning patient health care. This explains the fact why there is an increasing demand for its legitimate use by health professionals and policy makers. Nowadays, most people working in this line of profession are exerting more effort and spending more resources to ensure the creation and maintenance of quality medical records for quality statistical data. It is in this context that the Department of Health (DOH) through the initiative of the Hospital Operations and Management Service (HOMS), one of the four (4) offices under the Office for Hospitals and Facilities Services (OHFS), recognizes the need to upgrade the capability of the Medical Records Service (MRS) of government health care facilities, Coupled with the previously cited idea is the different ways of how medical records are handled and managed by the different hospitals. Although there is an internationally accepted medical record standard, the local medical record . practitioners seem not aware of its existence. Even with observed shortcomings, the medical record practitioners have been slow in recognizing the need to improve their profession because most of them lack the necessary theoretical background. In the formulation/development of standards and ideal systems and procedures, the inputs of the medical record practitioners who attended the seminar-workshops on medical record management conducted by HOMS served as invaluable data. This manual is designed for four purposes: first, to answer the need for a basic information-generating material in this field; second, to serve as a guide in the day-to-day operation of the MRS; third, for use as a "reference material in the health facility; and fourth, as a management aid for health managers/administrators. In short, this manual serves a wide range of users, namely: * doctors * nurses * allied health professionals * health managers/administrators * medical record staff * researchers The content of this manual is divided into chapters arranged according to the envisioned workflow of the MRS. As such, the medical record practitioners shall be reminded of the series of procedures to follow ill processing the medical record. Evident is the inconsistent use of disease and operation code numbers based on the International Classification of Diseases (lCD) and the International Classification of Procedures in Medicine (ICP~v1), the very reason why a listing of the commonly encountered diagnosis with the corresponding ICD code numbers was incorporated. Moreover, the problem of nonstandard forms as observed shall be properly addressed by the inclusion of the different suggested medical record forms, both the basic and the supplemental.

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This manual advocates the prompt development of standards and procedures in the MRS of government health care facilities, It is believed that there is a need to standardize policies, systems and procedures to improve the care of both individual patients and the entire population, and concurrently, to reduce resource wastage{cost-effectiveness} through the continuous improvement of quality care. Success in the implementation of this manual depends on the cooperation and coordination of the people involved in the creation, utilization, and maintenance of medical records, and perhaps some sacrifice and compromise as well. Finally, I am deeply indebted to all individuals and institutions for their support during the tedious preparation of this manual.

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EMMANUEL M. LAGUSTAN Medical Record Adviser Hospital Operations and Management Service

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ACKNOWLEDGMENTS r

Recognition and thanks aregiven to DR. MA MARGARITA M. GALON, Director III, Hospital Operations and Management Service, for the inspiration, support, and encouragement given throughout the preparation of this manual.

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To all the medical record practitioners who attended the SeminarWorkshop on Medical Record Management (1988-89), my utmost gratitude for unselfishly sharing their knowledge and experience which served as invaluable inputs in the formulation of policies, standards and ideal systems and procedures. Recognition is also given to those people who made possible my study grant in Sydney, Australia, whereI enhanced professional expertisein Medical Record Administration (Health Information Management) which greatly influenced the content of this comprehensive communication tool. Gratitude is extended to MS. ALMA Q SORRA for the clerical help done, MS. FENELlA MYLENE M. HAMO for some data entry suggestions, and to MR. CHITO NULOD for binding and reproduction assistance. Finally, I would like to extend special thanks to friends who in their own way, extended assistance in the preparation of the manuscript.

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LIST OF FORMS Hospital Daily Census Report Monthly Analysis of Hospital Service Consent Forms Consent to Involvement in ClinicalTrials (Therapeutic) Consent of Recipient to Operation, Transplantation, or Grafting of Tissue Informed Consent for Surgery, Anesthesia, or Other Procedures Discharge Against Medical Advise Consent to Release of Patient Medical Information Consent to Remove Organ for Transplant (Living Donor) Voluntary Sterilization Consent Form Therapeutic Abortion Refusal to Permit Blood Transfusion Consent to the Administration of Electro-convulsive Therapy Consent to Autopsy Refusal to Consent Autopsy Notification to Physician of Request for Access Request for Access to Medical Records Certificate of Confinement Medical Certificate Disposition of Cadaver Medical Record Forms (Basic) Admission-Discharge Record History Physical Examination Doctor's Order/Nurses Compliance Sheet Laboratory Report/Result Graphic Chart (Centigrade) Graphic Chart (Fahrenheit) Progress Notes Nurses Notes and Treatment Record Discharge Summary Other Supplemental Forms Medication Record Parenteral Fluid Sheet Progress Notes - Rehabilitation Medicine Diabetic Record Sheet Anti-coagulant Therapy Record Vital Signs Record Pulmonary Function Test Pulmonary Laboratory Blood Gas Analysis Intravenous Fluid Sheet Fluid Intake and Output Chart

Operation Block Pre-Anesthetic Assessment Operation and Anesthesia Record Anesthesia Record Operative Record Operating Room Record Recovery Room Record Surgical Recovery Room Record Tissue/Biopsy Report Delivery Block Prenatal Record Labor Record Summary of Parturation Newborn Record ECG/EKG Block Electrocardiogram Report Electrocardiogram Tracing

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UST OF ABBREVIATIONS AO AP COA COH

DAMA DO DOA DOS GSIS HOMS ICD ICPM MPI MRN MRP

MRS NBI OP PE PC PMCC P.N.P. POMR QAP RA RMAO SOAP

5.5.5. TPR WHO

Administrative Officer Attending Physician Commission on Audit Chief of Hospital Discharge Against Medical Advice Department Order Dead on Arrival Doctor's Order Sheet Government Service Insurance System Hospital Operations and Management Service International Classification of Diseases International Classification of Procedures in Medicine Master Patient Index Medical Record Number Medical Record Practitioner Medical Records Service National Bureau of Investigation Operation Physical Examination Philippine Constabulary Philippine Medical Care Commission Philippine National Police Problem Oriented Medical Record .Quality Assurance Program Republic Act Record Management and Archives Office Subjective, Objective, Assessment Plan Social Security System Temperature, Pulse and Respiratory World Health Organization

INTRODUCTION Medical records are important clinically for the immediate diagnosis, treatment, and welfare of the patient. Likewise, these are vital to the hospital for the evaluation of its services, and in the improvement of its effectiveness through lowered mortality, morbidity, and better patient care. The medical record is a written tool of communication used by the members of the medical and allied medical staff in the efficient and effective management of patients. It serves as source material for analysis, evaluation, education, research, and studies of the quality of medical care rendered. Most importantly, the medical record is also considered as the fundamental building block in the development of health information systems. In this regard, a good quality medical record needs to be created and maintained for each patient. To attain such, prompt recording of all findings and observations need to be done by those concerned. An old medical record management adage, "The quality of information that can be retrieved is totally dependent on the quality of records created/maintained," should always be in the mind of people involved in the creation/maintenance of medical records.

PHILOSOPHY OF 1HE MFDICAL RECDRDS SERVICE The MRS is tasked to enhance patient care through the use of data contained in the medical records; either individually or collectively.

OBJECTIVES: * To improve the accessibility of medical records;

* To create quality medical records; * To encourage greater utilization of hospital statistics generated in the MRS; * * *

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To implement staff development; To increase quality assurance programs not only in the MRS, but in the hospital where relevant; and To participate in research and studies which the facility, the members of the medical and allied staff, and other authorized researchers are engaged in.

1HE MEDICAL RECORDS SERVICE The general function of the MRS is to provide an organized system of measuring quality patient care and to ensure that sufficient data is written in sequence of events to justify ·the diagnosis, warrant the treatment and end results. This department is responsible for the processing, analyzing, maintenance, and safekeeping of all medical records created/maintained in the hospital in the course of giving medical care to patients. The medical record is a vital tool in the health team's provision of patient care. As the service component responsible for the custody and maintenance of these records, the MRS plays a key role in patient care through the generation of data from the record and other related sources. For the MRS to function as an indispensable support service in the delivery of quality patient care, it must perform the following functions: 1. Maintain all medical records in accordance with the principles and practices of efficient and effective medical record management. 2. Maintain comprehensive indexes (e.g., Master Patient Index, Disease and Operation Index, Physician's) and registers (e.g., Admission and Discharge, Operation, Delivery room (DR), Out-patient Department (OPD) and Emergency Room (ER), and Birth and Death Registers). These are important records for patient identification and also considered as indispensable retrieval tools. 3. Review records for completeness and accuracy, coding of diseases, operations, and special therapies according to approved nomenclature and classification. 4. Maintain a comprehensive and up-to-date record for hospital patients to ensure that all relevant information on each patient is collected, placed in the record, and filed accordingly. 5. Collate and compile data and produce statistical reports required by the DOH and respective hospital management. 6. Provide records of patient data for use in approved research programs. 7. Respond to all subpoenas and medico-legal cases directed to the hospital 8. Maintain and safeguard the confidentiality of the medical record. 9. Provide records, upon request, for patient's attendance to OPD and the wards. 10. Ensure that all reports and results are promptly and accurately filed in the corresponding patient record. 11. Participate in research activities and studies conducted by doctors and authorized researchers by providing needed data and other information. 12. Prepare periodic reports on morbidity, birth and death, utilization of hospital beds, rate of bed occupancy, out-patient service rendered, as well as compilation of statistical reports on type of surgery performed, types of diseases treated or cases receiving special form of therapy, and other related data. .

lHE MEDICAL RECORD A medical record is a compilation of pertinent facts of a patient's life history including past and present illness(es) and treatment(s) entered by health professionals contributing to that patient's care. The medical record has a variety of uses by a wide variety of personnel. Within guidelines of confidentiality and patient interest, the scope of the medical record as a resource material is limited only by the quality of the content and the needs of the prospective users.

USES OF THE MEDICAL RECORD The major functions of the medical record are listed below according to the main user groups. THE PATIENT As a clinical history of the patient's treatment at the hospital. As documentary support or evidence of confinement, diagnosis, and . treatment received as a hospital patient. HEALTH CARE PROVIDERS As a reliable reference of the clinical history of the patient. As a tool/instrument to enable the various health care provider to assess their role in the patient's total care. As a record of the treatment ordered and given for the patient's continued care and treatment. As data source for research, both retrospective and concurrent. As an educational tool in the training of and feedback to the staff, and for assessment of clinical procedures. HOSPITALS As a basis for statistical data used in assessingquality and effectiveness of patient care; past performance; and workload for the projection of demands, and planning and allocation ofhospital resources. To form patient profiles to determine market demands for more effective provision of service. GOVERNMENT AND THE DEPARTMENT OF HEALTH For the provision of statistical data to aid resource allocation on an area, state and national basis. To provide morbidity data to project health trends within the population for the assessment within and against, national and international health patterns.

ORGANIZATION AND ADMINISTRATION The MRS is organized and administered to facilitate the provision of medical records which provide pertinent information on illness, diagnosis, and treatment being given in the health care facility and allow for more effective and efficient patient care. This service shall function under the direction, supervision, and control of a Medical Record Officer, who is directly responsible to the Administrative Officer (AO).

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CRITERIA FOR AN EFFECTNE MRS ORGANIZATION 1. Written objective reflecting the role of the facility and guiding the activities of the service are readily available. 2. The objectives are reviewed and revised as necessary. 3. An organizational chart shows clearly established lines of responsibility, authority and communication with the service and between other services. 4. Written and dated job descriptions are given to each staff member upon appointment which should at least specify the following: • Qualifications required for the position • Lines of authority • Accountability, functions and responsibilities • Frequency and type of appraisal • Terms and conditions of the service 5. The organizational chart and job descriptions are reviewed at least every five (5) years and revised wheneve~:, • Staffing patterns are altered • There is a restructuring of the MRS • The role of the facility changes • Services are added or deleted 6. A Medical Record Committee or its equivalent, at secondary and tertiary level hospitals, shall assist the Medical Record Supervisor in: a. Determining standards and policies for the service. b. Reviewing the different medical record forms and to come up with relevant ones when needed. c. Recommending action to be taken when problems arise in relation to medicalrecords and the MRS. d. Ensuring that the clinical information recorded is adequate to maintain quality medical records, this is done by regularly analyzing the content of the medical records.

MEDICAL RECORD SERVICE ORGANIZATIONAL CHART Fundamental to effective management is the development of an organizational chart which shows the lines of authority and responsibility. The organizational chart likewise indicates the channelof communication and protocol. In the formulation of the organizational chart, one should think of the institutional objective as well as the principles of effective organization. The following are suggested organizational charts for the different categories of government hospitals (primary, secondary and· tertiary). ORGANIZATIONAL CHART MEDICAL RECORD SERVICE CHIEF OF HOSPITAL ADMINISTRATIVE OFFICER MEDICALRECORD OFFICER I MEDICAL RECORD CLERK PRIMARY HOSPITAL (25 Beds)

ORGANIZATIONAL CHART . MEDICAL RECORD SERVICE CHIEF OF HOSPITAL ADMINISTRATIVE OFFICER MEDICAL RECORD OFFICER III

SECONDARY LEVEL (100 Beds)

ORGANIZATIONAL CHART MEDICAL RECORD SERVICE

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CHIEF OF HOSPITAL ADMINISTRATIVE.OFFICER MEDICAL RECORD OFFICER IV MEDICAL RECORD OFFICER II MEDICAL RECORD OFFICER I

MEDICAL RECORD OFFICER I

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STATISTIC CLERK

TRANSIcRIPTION CLERK I

MEDICOLEGAL CLERK

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MEDICAL RECORD COMMITTEE

MEDICAL RECORD, OFFICER II

MEDICAL RECORD OFFICER I I

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TERTIARY LEVEL (200 Beds) The Medical Record Committee should function as a separate committee or it could also function as the Forms Committee should management decide. But for a tertiary teaching, training, and research hospital, it would be ideal to create both committees for more effective control and supervision.

MEDICAL RECORD POllCIFS AND STANDARDS Policies and standards are important in medical record management to achieve a more-uniform practice for effective medical records management. Standards and policies suggest two things which are consensus and guides. Policies and standards are crucial, but their application may not fit every possible situation encountered, most especiallywhere material resource is lacking. Hence, modifications which may mean deviations from standards shall be warranted. Modification should not deviate from the standard to " the extent of adversely affecting the level of performance and quality of patient care. The patient's record should contain complete and accurate set of information to facilitate effective patient care and its evaluation.

1.

STANDARDS

An accurate record is maintained to facilitate optimal patient care and allow for evaluation of the care provided. 1.1 The record is sufficiently detailed to enable: a) The patient to receive continuing care b) Effective communication within the health team c) The Attending Physician to have available information required for the consultation d) Other medical practitioners and health personnel to assume the patient care e) Concurrent or retrospective evaluation of patient care 1.2 Entries into the records are made only by duly authorized persons of the facility and are dated and signed, containing designation.

1.3 All entries, including alterations, must be legible. 1.4 Only abbreviations and symbols approved by the Medical Record Committee are to be used. 1

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1.5 If possible, original copies of all reports made by medical, nursing, and allied health professionals are filed in the record. 1.6 Each record should at least contain the following data: a) A unique medical record number or reference b) Patient's full name c) Address d) Date of birth e) Sex f) Person to notify in case of an emergency 1.7 An "ALERr' notation, for the conditions such as allergic responses and drug reactions, is prominently displayed on the face sheet of the record. 1.8 The record contains a written admission diagnosis by the medical practitioner. 1.9 The record contains a patient's history, pertinent to the condition being treated, including relevant details of: a) Present and past medical history b) Family history c) Social considerations 11) A sufficiently detailed report of a relevant physical examination (PE), performed by a medical practitioner, should be included for the purpose of admission. 111 Evidence that the patient has given informed consent is available. 112 Drug orders are written in the record by the medical staff.

ill Therapeutic orders and orders for special diagnostic test are noted in the record. ill There is evidence in the medical record that patient care plans were made. 115 Progress notes, observations, and consultation reports are written by medical, nursing, and allied health staff to record all significant events such as alterations in the patient's condition and responses to treatment.

U, The front sheet is completed at the time of discharge or as soon as the relevant information is available. It contains all relevant diagnoses and procedures using the terminology of a current revision of the International Classification of Diseases (ICD). lI7 A discharge summary for each patient should be completed within 48 hours of patient's discharge, with a copy remaining- in the medical record. The discharge summary should at least include the following: a) Discharge diagnosis b) Procedures performed

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Hospital Medical Records Management Manual

c) d) e)

Follow-up arrangements Therapeutic orders Patient instructions (where necessary) When a patient is transferred to another facility, a discharge summary should accompany him/her. 118 When an autopsy is performed, a provisional diagnosis is noted in the medical record within 72 hours and the medical record is completed within 15 days following the death. A copy of the autopsy report is filed in the medical record.

2.

RECORD COMPLETION

2.1 The medical record should be completed within 48 hours after the discharge of the patient. 2.2 History and PE should be completedwithin 24 hours after admission. 2.3 An incomplete chart, not completed within 15 days after patient's discharge, shall be considered a delinquent chart. 2.4 The attending physician has the final and major responsibility for completeness and accuracy of the data entry in the record. He is also encouraged to raise the level of quality of the individual health record and sustain a high level of recording. 2.5 Residents and interns may be delegated the duty of recording medical information as history, PE, and discharge summaries. their entries have to be reviewed, corrected, and countersigned by the attending physician. 2.6 The Medical Record Practitioner assists the attending physician in reviewing records for completeness by checking for omissions and discrepancies and helps ensure that medical records comply with set policies and standards.

3.

REI EASE OF INFORMATION

Release of health information is a very sensitiveissue in several respects. The confidentiality of the medical record should always be the concern of people involved in the release of health information. 3.1 General Policies 3.1.1 The hospital shall safeguard all information contained in the health record against loss, destruction, or unauthorized use. 3.1.2 All information in the health record shall be treated as confidential and shall be disclosed only to authorized individuals. 3.1.3 It shall be the policy of all government hospitals not to use the medical record in any waywhich will jeopardize the interest of the patient. But the hospital may use the record to defend itself against any accusations.

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Hospital Medical Records Management Manual

3.1.4 The release of information is delegated to the supervisor of the MRS.. But in cases where the medical record practitioner encounters problems regarding the release of information, the matter should be referred first to the Administrative Officer (AO), or to the Chief-of Hospital (COH) for proper solution. 3.1.5 No release of information with clinical value shall be done without written consent from the patient himself. 3.1.6 The medical record is the physical property of the hospital. However, since the information written on the record is the patient's personal history, he/she also has a right to the said record. In cases where litigation is likely to happen and is intended against the hospital or any other personnel of the health care facility, the Medical Director/COH may refuse or deny access to the record even with the patient's written authorization, until the court declares otherwise. 3.1.7 Request for medical certificate or clinical information when the patient is still confined shall be referred to the attending physician. • Should the AP decide to release the certificate while the patient is still confined, a Certificate of Confinement shall be issued. • No certificate of confinement shall be issued where the patient concerned is already discharged, instead, a medical certificate shall be issued. • No medical certificate shall be released without the signature of the Chief of Professional Staff and the hospital seal. • On the other hand, no medico-legal certificate shall be released without the signature of the Director/COH and the hospital seal. 3.1.8 Information of no clinical value can be disclosed by the staff of the health care facility. However, hospital policy should first be consulted and utmost care taken into consideration before the release of non-clinical information. Such information includes the following: • Name • Address • Attending physician • Name of relative with patient during admission • Admission and discharge dates 3.1.9 Where the patient is a minor, consent of either one of the parents or the legal guardian shah be secured before any information of clinical significance is released. 3. LIO The medical record shall not be taken out of the hospital premises except on court orders. • Those authorized to do research and studies shall use the records inside the MRS.

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Hospital Medical Records Management Manual

3.1.11 Incomplete medical records shall be referred to the attending physician before entertaining any request to access and review the medical record. 3.1.12 In cases where the patient is in critical condition and does not have someone with him/her to give consent, the medical record practitioner shall release, information only after consultation with the Director/COH. 3.1.13Verbal request for clinical information shall be discouraged in favor of written requests. 3.1.14 The staff of the Medical Social Service (MSS) shall have access to the medical records for purposes of establishing patient classification. They may also reveal the social content of the record to organized and reputable social agencies who have a legitimate reason for inquiry. 3.1.15 Information may be released to other health care facilities, upon written request, that the patient is now under care. 3.1.16 Hospital management may, at its discretion, permit the use of medical records for research and studies, only stressing that no information which will directly identify the patient shall be published.

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POllCIES FOR DOCTOR'S RELEASE OF INFORMATION

4.1 Doctors and members of the allied health profession may reviewrecords of patients presently under their care. 4.2 Doctorswho aremembersofthe medicalstaff but not membersofthe team assigned to the patient shallbe armed with a written authorization signed by the patient before they aregiven access to the record. 4.3 The privilege against disclosure belongs to the patient and not the treating physician, therefore, the patient has the right to claim for it or waive it. In which case, the doctor's approval is technically not necessary. But it would be a good practice to notify the doctor prior to release of any information, as a sign of courtesy. 4.4 The hospital management may permit use of the medical record for research and studies, the medical record being the physical property of the hospital. The hospital may also withhold access to the medical record until a subpoena is issued. 4.5 Outside doctors intending to do some research/studies in a particular hospital shall seek the written approval of the management before they are given access to the medical record. 4.6 Insurance company doctors shall need proper written authorization from the patient, or a duly accomplished insurance waiver, before they are given access to medical record.

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4.7 Company physicians who are presently caring for a patient shall be given medical information only upon presentation of a formal request addressed to the MRS. ' 4.8 Consultants shall have access to records of patients referred to them. 5

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Hospital Medical Records Management Manual

4.9 Resident doctors and the rest of the medical staff may request the MRS for records 'needed for their research and studies. But in cases where there is suspicion that their wish to access will jeopardize the right of the patient, doctor-and the institution, access shall be denied by the medical record staff.

4.D It shall be the responsibility of the attending physician to inform his patient about his medical condition.

5.

POliCIES FOR NURSES ON RELEASE OF INFORMATION

5.1 Nurses may borrow/sign-out old records per doctors instruction for ward use. 5.2 In the ward, student nurses shall have access to the records of patients assigned to them. 5.3 Private nurses shall only be allowed to review records of those patients assigned to them. 5.4 All staff nurses may be given access to medical records not assigned to them for purposes of conferences and case presentations. After the conference, the record shall be returned to the MRS. 5.5 Ward nurses may review all records for purposes of compliance to requirements before forwarding said records to the MRS. 5.6 Ward nurses should always see to it that charts are in a secure place away from the patients or the patient's relative.

6. 'OTHER PEOPLE CONCERNED 6.1 The lawyer representing a patient shall only be given access after presenting a written authorization duly signed by the patient. 6.2 An insurance verifier shall be required a waiver before being given access to the record/information about a patient. The original copy of the waiver shall also be countersigned' and dated by the insurance verifier and shall be filed with the record.

*

Insurance verifiers representing the Social Security System (SSS) and the Government Service Insurance System (GSIS) shall review medical records for compensation purposes per Warranty No. 10 of the Philippine Medical Care Commission (PMCC).

6.3 Researchers from other medical institutions could gain access to medical records onlyaftercomplying withrequirements set by theinstitution concerned. 6.4 Patient's relative making inquiries about their patient shall be referred to the attending physician.

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HospitalMedical RecordsManagement Manual

6.5 Law enforcement agents (Philippine National Police (PNP), Philippine Constabulary (PC), National Bureau ofInvestigation (NBI) and others) shall need a written request duly signed by the Chief/Director of their respective agency before being given access to the record. Should it be possible however, to get the written consent of the patient, a written request from their agency is no longer necessary. 6.6 Patients also have a right to their record. But to prevent misinterpretation of medical information which may lead to litigation, patient may not be allowed access to his own record. However, his physical and mental condition shall be explained only by the attending physician. . '

6.7 The. health care facility may, in some situations, release health information even without the written authorization. Such situations are as follows: 6.7.1 Court Order A hospital or other health care facility must release health information in response to court orders. 6.7.2 Administrative Agency Order A provider must release health information when there is an adjudicative order from an administrative agency authorized byla~ . 6.7.3 Subpoena In a court proceeding, a party or an administrative agency may issue a subpoena, subpoena duces tecum, or notice to appear covering health information held by a health provider. Where the subpoena is valid, the hospital must disclose the health information. 6.7.4 Arbitration Order Either an arbitrator or an arbitration panel may issue an order authorizing the discovery of health information in an arbitration proceeding. 6.7.5 Search Warrant A government law enforcement agency which has been issued a search warrant is entitled to receive any health information covered by the warrant. 6.7.6 MedicalResearch Health information may be disclosed to public agencies, clinical investigators, health care research organizations or accredited education or health care institutions for purposes of bonafide research. But before the medical information is released, the medical record staff should take reasonable steps to ensure that theresearch is legitimate, and proper safeguards in the release of information are instituted.

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Hospital Medical Records Management Manual

SYMBOLS AND ABBREVIATIONS The following is a list of internationally accepted symbols and abbreviations used in the health record service/department Symbols and abbreviations not listed below but accepted for use by your respective institution shall be inserted here upon the recommendation of the hospital's Medical Record Committee.

A abd. a.e.

AF AFB AIDS AMA

abdomen before meals (p.e..- after meals) atrial fibrillation acid fast bacilli acquired immune deficiency syndrome

ambo

against medical advice; ambulatory; walking

AMI AODM

anterior myocardial infarction adult onset.diabetes mellitus

ARF

acute renal failure adult respiratory distress syndrome aortic stenosis

ARDS

AS ASHD AVR AP & Lateral

arteriosclerotic heart disease aortic valve replacement anterior posterior

A&P

auscultation and percussion (listening with stethoscope and tapping with fingers)

ax.

axillary (armpit)

!! BAM BBA BCC BID BKA BM BMR BNE BNS BOM BP BPH BRM 8

bilateral augmentation mammoplasty born before admission basal cell carcinoma twice daily; tid . three times daily; qid - four times daily below the knee amputation bowel movement basal metabolism rates bladder neck elevation bladder neck suspension bilateral otitis media blood pressure benign prostatic hypertrophy or benign prostatic hyperplasia bilateral reduction mammoplasty

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HospitalMedical RecordsManagement Manual

BRP BS

bathroom privileges bilateral salpingectomy

BSO BUN

bilateral salpingo-oophorectomy blood urea, nitrogen (kidney function test) biopsy

Bx.

C CA

carcinoma

CABG CAD

coronary artery bypass graft coronary artery disease

CAT CBC

computerized axial tomography complete blood count

CBD GD. CHF CI CMD

common bile duct communicable disease congestive heart failure coronary insufficiency chronic mental deficiency central nervous system

CNS COPD CRF CRHD CVA CVD

chronic obstructive pulmonary disease chronic renal failure

CXR

chronic rheumatic heart disease cerebro vascular accident (stroke) cerebrovascular disease cervix chest x-ray

C&S

culture and sensitivity

ex

D DAMA

discharge against medical advice

DC DIC

discontinue

dist. DJD DLE DM DNS Dr. DT DU DUB DVT

..

Dx.

disseminated intravascular coagulation (of newborn) distilled degenerative joint disease disseminated lupus erythematosus diabetes mellitus deviated nasal septum doctor delirium tremens duodenal ulcer . dysfunctionaFGterine bleeding /

. deep-vein-thrombosis

" diagnosis

9

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Hospital Medical Records Management Manual

EAC

ECE ECG orEKG ECT EEG EENT EPA ER ESR EST

ETA EUA

~ external auditory canal extra capsular extraction

electrocardiogram or electrocardiography electro-convulsive therapy electroencephalogram eye, ear, nose, and throat erect posterior anterior (chest x-ray) emergency room erythrocyte sedimentation rate electric shock therapy elongation of tendon achilles examination under anesthetic

E F

FB FBS FH

FI' FL

fahrenheit (temperature scale) foreign body fasting blood sugar family history for investigation false labor

PUO

fluid for observation frozen section full thickness graft full term fever of unknown origin

Fx.

fracture

fld. FO

FS FTGRAFT FT

G GA

general anesthetic

GE

gastroenteritis

GIT

gastro-intestinal tract .

GM GN GNC

grams glomerulonephritis general nursing care gun shot wound drops

GSW gtts,

10

GU GUT

gastric ulcer

GYN

gynecology

genito-urinary tract

Hospital Medical Records Management Manual

Hospital Medical Records Management Manual

LHF LIH

LLL LLQ. LMP LN LP LSCS LSO LSV

LUSCS LUQ LVF LVI

left heart failure left inguinal hernia left lower lobe left lower quadrant last menstrual period lymph node lumbar puncture lower segment cesarean section left salpingo-oophorectomy ligation and stripping of varicose veins lower uterine segment cesarean section left upper quadrant left ventricular failure left ventricular tachycardia

M M med. mg

MI mid. min.

MS MVA MVR

male medical (or medication) milligram myocardial infarction middle minute multiple sclerosis motor vehicle accident mitral valve replacement

N

NEe ned neg

NG NIDDM NOF NOS NPO NSA N&V

not elsewhere classified no evidence of disease negative naso-gastric non insulin dependent diabetes mellitus neck of femur not otherwise specified nothing by mouth (nothing per os) no significant abnormality nausea and vomiting

0

OA 00

OBS

osteoarthritis right eye organic brain syndrome

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HospitalMedical RecordsManagement Manual

OE OM OPD

OPS

OR OS OT OV

otitis externa otitis media out-patient department out-patient service operating room left eye occupational therapy both eyes

f P

PA PAT p.c.

PDA PE or PX Ped. or Pedia.

PGS PH

PI PID

PIE PMB PMD PMH PND PNP pre-op pm p.o. POP POP (OB) post-op PPH

PR p.r.n.

PROG pt.

PT

pulse .. . pernicious anemia paroxysmal atrial tachycardia after meals (a.c. before meals) patent ductus arteriosus physical examination pediatrics post gastrectomy syndrome past history, personal history present illness pelvic inflammatory disease pulmonary interstitial emphysema post menopausal bleeding progressive muscular dystrophy past medical history post nasal drip pneumoperitoneum (injection of air into the peritoneal cavity, used as TB treatment) pre operation as needed per os or by mouth plaster of paris persistent occipita presentation post operative post partum hemorrhage per rectum when necessary prognosis patient physical therapy

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HospitalMedicalRecords Management Manual

PUO PV PVD

pyrexia of unknown origin per vagina peripheral vascular disease

Q. q q.d. q.h. q.i.d. qod

every every day every hour four times daily every other day

R

R RA

RBBB RBC RDS reg

RF RH+ RHRHD RHF

RLL RLQ RML RMR ROS RPC RSO RTA RTI RUL RUQ RX

respiration rheumatoid arthritis right bundle branch block red blood cell respiratory distress syndrome regular rheumatic fever rhesus factor positive rhesus factor negative rheumatic heart disease right heart failure right lower lobe right lower quadrant right middle lobe right medial rectus (eye muscle) removal of sutures retained products of conception right salpingo-oophorectomy road traffic accident respiratory tract infection right upper lobe right upper quadrant prescription - treatment prescribed

S SBE SCC SH SID ) SIDS) SLE 14

sub-acute bacterial endocarditis squamous cell carcinoma social history sudden infant death syndrome systemic lupus erythematosus

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Hospital Medical Records Management Manual

SOB SOBE SOL SPP Spp & P

s.s. SS SSS SSG staph. stat STD STS SVD SVT

short of breath short of breath' on exertion space occupying lesion suprapubic prostatectomy smith-peterson pin and plate soapsuds one half sick sinus syndrome split skin graft staphylococcus (germ) at once sexually transmitted disease serologic test for syphilis spontaneous vaginal delivery supra-ventricular tachycardia

I T T4 TAH Tab.

TB tbsp. TBR TCI THR TIA tid 1's T's & Ns TMC TO TOP tsp. TSS TUR TURP

UA UD UDT UN

temperature thyroxin total abdominal hysterectomy tablet tuberculosis tablespoon tuberculin reactor transient cerebral ischaemia total hip replacement transient ischemic attack three times daily tonsillectomy tonsillectomy and adenoidectomy threatened miscarriage telephone order termination of pregnancy teaspoon toxic shock syndrome transurethral resection (usually bladder) transurethral resection of prostate

U urinalysis under-developed undescended testicle under-nourished

15

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Hospital Medical RecordsManagement Manual

URI URTI Un-

upper respiratory infection upper respiratory tract infection urinary tract infection

v VBI VDH VDRL

VEB VF VIa

VPS VSD VT

W

WEe WD 'WG

WN wt.

16

vertebro-basilar insufficiency valvular disease of heart slide test-venereal diagnostic research laboratory slide test (flocculation test for venereal disease) ventricular ectopic beats ventricular fibrillation by way of ventriculo-peritoneal shunt ventricular septal defect ventricular tachycardia . . vancose vems W white blood count well-developed wolfe graft well-nourished weight

PHYSICAL FACILITIES AND EQUIPMENT Ideally, the medical record room shall be big enough to accommodate active, inactive, and in-eoming medical records. The Medical Records Service (MRS) room should be properly ventilated not only for the protection of the records but also for health reasons on the part of the staff. Volatile and flammable liquids must not be placed inside the record room, and a "NO SMOKING" sign must be posted inside the MRS. In the event that the space allocated for the MRS is not enough to accommodate all records in the file, a plan to transfer inactive records to the inactive file should be considered. This will decongest the filing area, giving way to incoming records, and will make the retrieval process easier. Space requirement can be calculated by the use of the following formula: (Annual discharges) + (New OPD) x (Retention period) STORAGE SPACE REQUIRED; (Records per meter)

Example: Data Given: Annual discharges New Admissions Re-admissions . Annual New.OPD registration Retention period No. of records/meter ;

23,000 6,720 16,800 3,000 25 years (Phil. Law: R.A. 4226/ M.C. 77 s. 1981) 50 records

17

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Hospital Medical Records Management Manual

23,000 + 3,000 x 25 STORAGE SPACE REQUIRED = - - - - - 50 650,000

=

50 13,000 METERS OF SHELVING

Note:lO% of the computed required storage space should be added to the computed value to account for the projected increase in number of patient/year. .. 13,000 + 1,300

= 14,300 meters of shelving

To calculate for the number of meters of shelving for each terminal the formula is: Meters of shelving required

No. of meters required for each section

No. of sections in file 14,300

100

= 143 meters/primary section

FILING CABINETS FILING CABINETS FOR MEDICAL RECORDS There are two types of filing cabinets used in the medical record service: the open and the closed shelves filing cabinets. Of the two, the. open shelf type is more popularly used because of its advantages (e.g., space saving, ease of filing and retrieval). It also has its disadvantages (e.g., accumulation of dust, problem of security), but these are outweighed by its advantages. High stocking cabinets can be used to maximize the storage capacity of the filing area. However, provisionfor "kick stools" or "safety pulpit ladders" should be considered for the convenience and safety of the file and retrieval clerks. (Diagram)

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Hospital Medical Records Management Manual

CABINETS FOR INDEXES Cabinets for indexes come in standard sizes and these are often times made of steel. For the master patient index the cabinet must be able to accommodate 3" x 5" index cards. Whereas, for the disease.operation, and physician indexes a cabinet for 5" x 8" cards should be used. ARRANGEMENT AND DISTANCES OF CABINETS The physical arrangement of the cabinets has a direct effect on the efficiency of the filing and retrieval processes. The cabinets should be arranged for minimum walking. It is also important to remember that the direction of the expansion of the files should always be from left to right. A back to back arrangement of filing cabinets should, also be highly considered because this saves space. IMTtiICCf (Diagram) ,.---.......

t

•

1----.. t

; IDfAL ARRA_1I7 OF PIING rA8IItCTS (O"'n

.M1tIft>

WORKING TABLES The physical arrangement of employee's tables should be in accordance with workflow. Effonsshould be made to lessen travel time of paper within the department, to improve output and increase efficiency, by placing employeesIn their right places. The arrangement of employees should also be aimed at improving communication and coordination among etnployees. Employees in constant contact with patients/clients should be positioned near the main entrance. Employees doing technical jobs like coding and statisticians should be placed in an area free from distraction and noise, as much as possible near the Medical Rrecored Supervisor for better supervision and control. Transcriptionists/typists who produce noise in the performance of their tasks need to be placed a little further away from other employees. As much as possible their area should be acoustically treated to lessen distraction. The medical record administrator's (supervisor's) room should be situated strategically in a place where he can monitor his subordinates' for more effective supervision and control. Distances between tables of employees should be maintained at 1-1.5 meters to facilitate easy movement, a space of 5.57m per employee must be maintained.

. 19

Hospital MedicalRecordsManagement Manual PROPER LIGHTING Research shows that proper lighting directly affects employee performance to a certain degree. The level of lighting requirement (in foot candle) varies from activity to activity. A 100 foot candle light is required for the following activities: regular office work, reading or transcribing, handwriting, active filing, index referencing, and mail sorting. Age level has also direct influence on light requirement. Older people tend to work efficiently and effectively in welllighted working areas. Younger people, on the other hand, tend to prefer not too highly illuminated working areas. The light in the storage and filing area should be situated in between cabinets and should run parallel with the arrangement of the cabinets. It is to maximize the illuminating capacity of the light. (Diagram)

PROPER VENTILATION Another important thing to consider in planning for a good medical record layout is good ventilation. It is not only considered for health reasons but also for the protection of the records. Filing and storage areas with very humid conditions also have bad effectson the medical records. Papers absorb moisture to some extent and this could affect the quality of the record.

PROPER TEMPERATURE It is a fact that temperature affects the performance of a person. The temperature should not be too warm nor too cold. Temperature which is just right and conducive for working should be provided.

AESTHETIC CONSIDERATION Research shows that the color of the working area has some effect on employees' performance. So the medical record administrator/supervisor needs to consider light and color combinations to enhance the effectiveness of his subordinates.

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Hospital Medical Records Management Manual

The MRS should have enough working area for its staff. Likewise, a completion area, where doctors and researchers can do their work, should be provided. This shall include the following: * Tables * Chairs * Pigeon hole for incomplete charts Aside from a good record room facility, the MRS must also be provided with good and dependable office supplies for efficient performance. The basic equipment and supplies needed are the following: * Working tables and chairs * Typewriters * Coding tools * Telephone service * Dry seal * Numbering machine * Stapler * Index card sorter * Pencil sharpener * Sufficient filing cabinets for records, indexes, and registers. * Photocopying machine Ifit is within financial possibility, the MRS should try to acquire modern equipment because of the many benefits it offers. Some of these equipment are the following: * Computers * Dictating equipment * Transcribing machine * Micrographics

--- ----.--

--".~~._---_.

Department of ~e8lth

I I ~I I I ~

11111111III

D327

H108.45 H79m

-• .....=-=....=.----

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Hospital Medical Records Management Manual

22

/

MANPOWER/PERSONNEL The Medical Records Service (MRS) is considered as a storage area of patient information, or simply the information center of the hospital. For the service to be efficient and more responsive to the needs and demands of its clientele, it must have the necessary number of personnel/staff in relation to its bed capacity and the volume of work to be done. ' The number of staff required by the MRS is determined by the type of the hospital. A research hospital which needs a more comprehensive and sophisticated records-keeping system will naturally require a greater number of staff compared to an institution which is not engaged in research and teaching. Furthermore, one staffmember will be required for every 20 beds of the hospital. The classification of personnel in the MRS of a hospital will depend on any of the following: • The classification of the DirectorjCOH • Category and bed capacity of the hospital Listed here are the qualification requirements and job descriptions for the different classifications of personnel.

POSITION TITLE: MEDICAL RECORD OFFICER IY, MEDICAL RECORD SUPERVISOR. CHIEF MEDICAL RECORD SERVICE MINIMUM QUALIFICATION STANDARDS: I I

Must have a college degree with units in Anatomy and Physiology; , ,

,I

Must have first grade civil service eligibility;

II,

Must have thorough knowledge of medical terminologies; Must have attended a training course in medical record management; Must have at least five (5) years of ex~erience in the department of a reputable hospitalj institution; and ,

'

medic~l

record

Must have assumed supervisory or related posirion.. 23

Hospital Medical Records Management Manual

JOB DESCRIPTION: Shall act as the head of the service/department; Shall attend court proceedings and represent the hospital in court cases involving subpoena of medical/clinical records; . Shall represent the department to top management; Shall exercise direct administrative supervision and control over all subordinates in the department; Shall establish policies and procedures for the content, control, storage, and retrieval of records; Shall ensure the maintenance of the patient's right to privacy and confidentiality; Shall organize workflow throughout the service; Shall meet and dicuss with the administration of other departments within the hospital, issues related to the MRS; Shall supervise the evaluation and quality control of specified areas within the MRS; Shall serveon appropriate committees and attend meetings of relevance to the MRS; Shall answer by correspondence or by telephone, inquiries regarding information recorded in the patients' charts; Shall plan staff, space, and equipment of the department; Shall assist the medical staff in research projects; Shall keep abreast of current medical record practices; and Shall perform other related functions as may be assigned by the immediate supervisor

POSITION TITLE: MEDICAL RECORD OFFICER III MINIMUM QYALIFICATION STANDARDS: Must have a college degree with units in Anatomy and Physiology; Must have first grade civil service eligibility; Must have thorough knowledge of medical terminologies; Must have attended a training coursein medical record management; and Must have at least four (4) years of experience in the MRS of a reputable hospital one years of which must have been of supervisory capacity. JOB DESCRIPTION: Shall be a department head or assistant to the Chief of-the MRS; Shall, as the head of the MRS in a small hospital, plan, organize, and control all activities in the section; Shall, as an assistant to the head of the MRS in a large hospital, manage the section in the absence of the section chief; and Shall perform other related functions as may be required by the immediate supervisor. 24

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Hospital Medical Records Management Manual

POSITION TITLE MEDICAL RECORD OFFICER II MINIMUM,QUALIFICATION STANDARDS: Must have a college degree with units in Anatomy and Physiology; . Must have first grade civil service eligibility; Must have completed the medical record training; Must have at least three (3) years of medical record work in a reputable hospital; and Must have thorough knowledge of medical terminologies. lOB DESCRIPTION: Shall act as the department head in smaller hospitals oras an assistant Chief in a big hospital; . Shall, as head of the MRS in a small hospital, plan, organize, and control the activities Shall, as an assistant to the head of the MRS in a large hospital, act as the unit head in the absence of the section chief; and Shall perform other related functions as may be required by the immediate supervisor.

POSITION TITLE: MEDICAL RECORD OFFICER I MINIMUM OUALIFICATIONSTANDARDS: Must have a college degree with units in Anatomy and Physiology; Must have first grade civil service eligibility; Must have completed the medical record training; Must have at least two (2) years of medical record work in a reputable hospital; and Must have thorough knowledge of medical terminologies. lOB DESCRIPTION: Shall act as the department head in small hospitals (e.g. community hospitals) or as an assistant to the head/supervisor of the MRS in a bigger hospital; . Shall, as head of the MRS in a small hospital, plan, organize, and control the activities Shall, as an assistant to the head of the MRS in a large hospital, act as the unit head in the absence of the section chief; and '; Shall perform other related functions as may be required by the immediate supervisor.·. :.

.

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HospitalMedicalRecordsManagement Manual

POSITION TITLE: CODER MINIMUM OUALIFICATION STANDARDS: Must havecoUege level education with units in Anatomy and Physiology; Must have 'thorough knowledge of medical terminologies; Must have at least one (1) year of experience as disease and operation coder in a reputable hospital; , Must have second grade civil service eligibility; and Must be well acquainted with the different coding tools.

lOB DESCRIPTION: Shall work directly under the supervision of the chief of the MRS; Shall analyze specific portions of the medical record and assign code numbers to diseases and operations based on the accepted classification system; Shall update and maintain the disease and operation index file; Shall file disease and operation indexes numerically by disease and operation codes; and Shall perform' other related functions as may be assigned by the immediate supervisor.

POSITION TITLE: MEDICAL TRANSCRIPTIONIST MINIMUM QJ,JALIFICATION STANDARDS: Must have at least two (2) years of college education; Must have second grade civil service eligibility; Must have thorough knowledge of medical terminologies; and Must be proficient in operating the transcription machine/typewriter

lOB DESCRIPTION: Shall transcribe operating room reports and other dictated/recorded information; , Shall type/encode letters and reports, birth and death certificates; and Shall perform other related functions as may be assigned by the immediate supervisor

POSITION TITLE: MEDICAL RECORD CLERK MINIMUM OUALIFICATION STANDARDS: Must have at least two"(2) years of college education; Must have second grade civil service eligibility; Must have at least worked in the MRS of a hospitalor other related office; Must have thorough knowledge of medical terminologies; and Must be proficient in typing

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Hospital Medical Records Management Manual

lOB DESCRIPTION: Shall arrange and assemble the medical records of discharged patients of the hospital; Shall collect and compile data from medical records for statistical and other related reports; Shall review medical records to ensure that required reports and signatures' have been included (quantitative and qualitative analysis); Shall prepare the daily census report; Shall maintain surveillance of incomplete medical records and prepare reports of delinquent doctors; Shall process birth and death certificates; and Shall perform other related functions as may be assigned by the immediate supervisor.

POSITION TITLE: FILE/RETRIEVAL CLERK MINIMUM OUALIFICATION STANDARDS: Must have at least two (2) years of college education; Must have civil service eligibility; ·Must have a background in the process of filing and retrieval; and Must have attended a training course in medical record management. lOB DESCRIPTION: Shall file records and indexesaccording to the established and approved system; Shall incorporate loose reports/sheets to respective charts; Shall maintain a follow-up system for borrowed/needed charts; Shall maintain and update the patient master index; Shall retrieve requested records for follow up, research, and studies;

.1 .•

I .

Shall maintain the proper filing of the medical records and periodically ·check files for misfiled records; and · Shall perform other related functions. as may be assigned by the immediate supervisor.

.

\

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Hospital Medical Records Management Manual

TABLE ON MANPOWER REQUIREMENTS (Based on theresult of thevalidation workshop, RTIM, April 2fr27, 1991). BED CAPACITY

POSITION TITLE 10-15

25

50

100

200

300

MEDICAL RECORD OFFICER IV

-

-

-

-

-

1

MEDICAL RECORD OFFICER III

-

-

-

(1)

1

1

MEDICAL RECORD OFFICER II

-

-

(1)

1

1

2

MEDICAL RECORD OFFICER I

1

1

1

1

1

2

MEDICAL RECORD CLERK

-

1

2

3

5

5

TOTAL

1

2

3

5

8

11

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J

'lliE NUMBERING SYSTEM The numbering system employed has a direct influence on the filing system. Upon admission, the patient number should be assigned. The serial, unit, and the serial-unit numbering systems areusedin numbering medicalrecords.

SERIAL NUMBERING Under this method, the patient receives a new number on every in-patient admission or out-patient visit to the hospital or clinic. That is, the patient is treated as a new patient each time with a new number, new index card and new record, filed totally independent from the previous records. Serial numbering is not used extensively today and is only useful in small hospitals with a low rate of readmission.

UNIT NUMBERING Under this method, the patient is assigned a unique identification number on his first contact with the hospital, whether it is for an admission, emergency room attendance or out-patient clinic visit. The same number is kept and used on all subsequent visits, whether as an in-patient, out-patient, or emergency patient. Having one number assigned per patient and only one Master Patient Index (MPI) card makes for easier access to the patient's medical record. This number is normally related to one single record containing all the needed information on the patient. This data can originate from different clinics or wards, at different time periods: If no unit record is possible, the unit numbering system 'can be used to link medical records that are physically located in different places.

SERIAL UNIT NUMBERING Under this method, a number is given for every admission but all previous records brought forward to the patient's latest admission. A tracer is left where the previous records were pulled out to indicate where the records are now filed.

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Hospital Medical Records Management Manual

1 lHE UNIT NUMBER A patient who is admitted to or attends an out-patient clinic is issued a six-digit identifying number. This is called the patient's unit number, hospital number, or Medical Record Number (MRN). The same number is used no matter what ward or clinic the patient visits, or how often; and regardless of the time lapses between visits. It is handy to think of the MRN as three sets of two- digits. These are referred to as the primary, secondary, and tertiary numbers. Example ofa Unit Number:

20

76

Tertiary

. Secondary

95 Primary

ASSIGNMENT OF TIlE UNIT NUMBER The collection of patient data and the assignment of a medical record number should be the first step in every admission or visit to a hospital or health center and it is usually done at the admitting office. This facilitates the retrieval of properly identified documents. Two ways where numbers can be assigned are:

(a) CENTRALIZED The responsibility for number allocation is retained or assigned in one place only, usually the admitting office or the Medical Record Service.. If a patient arrives at the registration area, the area concerned is contacted for the unit number.

(b) DECENTRALIZED Predetermined blocks of numbers are often issued to the patient' admitting area. This is usually done by the hundreds, depending on the projected number of patients for the day. In this process, care should be taken as chances of duplication are greater, compared to when only one area is in charge of assigning patient numbers. Six-digit numbers are used ranging from 00-00-00 to 99-99~99. The very first record received by the MRS shall be numbered, '~OO-OO-OO"; the second record, "00-00'01"; and so on, until the first hundredth record, which shall be numbered "00-00-99", is reached. The record after this shall be numbered "OO-OI~O"; the next, "OO-OI~I"; then followed by !'00-01~2"; and so on, until it reaches ."00-01-99". Number the records seriallyand add the necessarydigit to complete the required six digits: An MRS maintaining a centralized recordskeeping system must keep numbering patients regardless of whether . the record is for in-patient or for out-patient. Whereas, the MRS with a decentralized records-keeping system should maintain a separate number for the in-patient and the out-patient record. . The last record that you receive in any given day plus one (I) shall represent the total number ofpatients the hospital has served. Meaning if the last number assigned is 00-20-99, then the hospital has served as total of 2,100 patients. .

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Hospital Medical Records Management Manual

ASSEMBLY OF lHE MEDICAL RECORD After the patient is discharged from the facility, the medical record is , forwarded to the MRS by the members of the Nursing Service. . After receiving the medical records, the MRS performs some procedures essential to the' filing and storage. process. There are three types of format used, in assembling the medical record. ' These are as follows: 1. Source-oriented medical record 2. Problem-oriented medical record

3. Integrated medical record The format which best fits the institution's need and that which is approved by management should be adapted by the MRS. 1. SOURCE-ORIENTED MEDICAL RECORD

This is the conventional format of arranging the medical record. The patient record is organized in sections according to the patient care department which provides care and data. The record is arranged in reverse chronological order for the convenience of the doctors in the ward. Upon the patient's discharge, the MRS re-arranges the record based on the approved sequence. ADVANTAGES:

*

It is easy to determine the assessment, treatment and observations a particular department has provided.

* Most health professionals are familiar with this conventional or traditional way of arranging the medical record. DISADVANTAGES:

*

Prompt determination of all the patient's problems is riot possible.

* Determining all the treatments provided to the patient would be difficult 2. PROBLEM-ORIENTED MEDICAL RE~ORD (POMR) This is the most logical format of arranging the medical record and it is computer-based. The four basic components of this format.are as follows: a. The data base, which includes the following information:

* *

* * * *

Chief complaints Present illness ' Patient's profile 'Past history and review of the system Physical examinations Base-line laboratory plan

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Hospital Medical Records Management Manual

b. The problem list is a mere listing of all the problems which need medical management. Problems are numbered and tided from the most to the least severe complaint of the patient. The list may include anything that requires management from past and present social, economic, and demographic problems. It may also contain a statement of a symptom, an abnormal finding, a physiological finding, or a specific diagnosis. Addition or changes are made in the list as new problems are identified and active problems resolved. c. The initial plan describes the steps to be taken in order to learn more about the patient's condition, the treatment to be applied, and ways to educate the patient about his physical condition. Specificplans for each problem are delineated and fall under three categories: • More information for diagnosis and management • Therapy • Patient education . Plans are numbered corresponding to the problems which they address. d. The progress notes are follow-ups for each problem. Each note is preceded by the number and title of the appropriate problem and may include all of the following elements: • Subjective (symptomatic) • Objective (measurable, observable) ASsessment (interpretation or impression of the current condition) • • Plan statements The acronym for this process is SOAP, and the writing of progress notes in the POMR format is often referred to as "SOAPING". Emphasis is on unresolved problems. A slightly different way to describe the patient's progress, other than the narrative method mentioned, is through the use of flow sheets. Flow sheets are recommended in situations where several factors are being monitored or when the patient's condition is changing rapidly. The discharge summary and transfer note are also included in the progress note category. These should address all the numbered problems on the patient's list. It may be necessary for the physician to write an overall summary and use flow sheets to clarify the patient's progress. It is recommended that certain forms (e.g., physician's orders, consultant reports, and nurses' notes) be in the problem-oriented style, with reference to titled and numbered problems. Other data in .the record maybe in the conventional format, suchaslaboratory and operative reports. ADVANTAGES: -

• •

• • 32

Physician is required to consider the patient's problems in itstotal context. The record clearly indicates the goals and methods of the physician in treating the patient. Medical education is facilitated by the documentation of logical and thorough processes done by the attending physician. Quality assurance process is easier because the data is logically arranged.

Hospital Medical Records Management Manual

DISADVANTAGES: • The format usually requires additional training for the medical and professional staff. • To be effective in a facility, a significant number of physicians must be convinced of the system's worth or at least must be willing to try it. 3. INTEGRATED MEDICAL RECORD In the integrated format, the information is organized in strict reverse chronological order, with the most current entries at the beginning of the record. The forms from various sources are intermingled, thus, history and physical examination may be followed by a progress note, a nurse's note, an x-ray report, a consultation, and so on. The forms for each episode of care are organized in separate sections of the record. ADVANTAGES: • All information on a particular episode of care is in a single file, thus, providing a clear picture of the patient's illness and response to treatment. • A patient's progress can be determined promptly because the current notes of all disciplines are together in one file. • The number of specialized forms is reduced. • The team concept of health care is encouraged. DISADVANTAGES: • It is difficult to compare similar information over a series of admissions because the reports are not in the same section as that of the record. • Only one person can document at a time. • It may be difficult to identify the professions/ position of the individuals making the entries unless notes are always followed by the title of the recorder. • Physicians often feel their documentation requires some manner of indication (e.g., highlighting) to differentiate it from that of other professionals caring for the patient.

ANALYSis OF TIlE MEDICAL RECORD Since chart analysis ensures maintenance of quality medical records through proper documentation, it is one of the most important functions of the MRS. The medical record reflects the quality of care rendered to patients. As such, at any point in time during admission, the record should accurately and clearly document the care provided. Since the major concern of most doctors and nurses is the care of the patient and not the documentation of data, most medical records forwarded to the MRS are lacking in some important requirements.

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The MRS is responsible in helping the members of the medical and paramedical staff in spotting deficiencies to correct errors and omissions. Analysis is the process of evaluating and/or checking medical records to ensure completeness, accuracy, and adequacy of documentation. Both quantitative and qualitative analysis should be performed on the medical record. The general documentation guidelines used to ensure quality documentation and hence, produce quality medical records are as follows:

I. There must be a medical record for each patient confined/treated in the health care facility. 2. Documentation in the medical record should reflect the patient's physical condition, and the orders and care provided from admission to discharge.

3. Documentation should reflect observation and should be objective and non-judgmental. 4. There should be a standard format for medical record documentation which should include demographic and assessment data. 5. A unit record should be maintained for;each patient. This shall include all admissions to the facility, discharge summaries and quality documentation by the physician and other inter-disciplinary team . members who participated in the care of the patient. 6. All documentations must be legible and written in ink or typewritten. Z Any person making an entry on the record must date and sign his entry or properly authenticate the entry made. 8. Documentation of the medical record should be completed within 48 hours upon patient discharge. History and Physical Examination (PE) should be completed within 24 hours upon admission of the patient. 9. Every institution should develop an ongoing reviewof medical records to assure quality documentation. This could be one of the major duties of the Medical Record Committee. 10. It should be the policy of every health care facility not to allow the use of abbreviations in writing the diagnosis. But for symbols which might be written by the authorized person, an explanatory legend shall be approved by the said institution. 11. Short forms like laboratory and other results should be securelyfastened to the record to prevent loss. 12. The medical record is a legal document, so no form may be detached once it is filed with the chart. Furthermore, there should be no erasures of any sort. To correct an error:

* Draw one single line through the information to be corrected or change. * Write th word "ERROR" and affix initial and date; and lastly,

* Write the correct entry near the information to be corrected.

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13. In cases where the patient wants some data corrected especiallyon the sociological data, it shall not be done in the original entry, but should .appear as an amendment only. 14. The medical record shall contain all original copies of examination results, operations and other required forms. For the medical record of a patient to be complete, it must include the following forms, properly accomplished, signed, and dated: I. Patient's Data Sheet: Includes patient's personal data like name, address, patient number, and other social data. 2. Admitting and final diagnosis, as wellas a description ofany operation and procedures performed. 3. History sheet: contains chief complaint, personal and family history (past and present). * Past history records the previous operations and illness of the patient, and particularly those that might be related to the present illness. * Social history presents fum about the patient's life and habits that might affect his condition. If, for example, he has an allergic condition, it may be important to know his diet, the pets he own, the plants thar grow around his house, and the materials he comes in contact with at work and at home. Family history records the diseases which members of the * patient's immediate family have or have had..Most important are those that might directly affect the patient either through heredity or contact. . . 4. Physical examination sheet: contains all pertinent (positive and negative) findings and impressions. 5. Physician's order: contains all of the doctor's order. 6. Laboratory Report sheet: contains results of all diagnostic, laboratory, and x-ray procedures.

7. Consultation reports: adequately record the consultant's findings on physical examination of the patient, as well as his opinion and recommendations. 8. Progress notes sheet: includes doctors' positive and negative observations and comments. It gives a chronological picture of the clinical condition of a patient. 9. Discharge summary: summarizes the significant findings and events occurring during the patient's hospitalization, final diagnosis, operation (if performed), complications (if any), condition on discharge, recommendations and arrangements for future care (OPD follow-up treatment), and classification of injury (if it is a medicolegal case). 10. Anesthesia report sheet (if performed)

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11. Record of operation: records and authenticates a pre-operative diagnosis before surgery. The-record should then contain a report of all findings, a description of the technique used, a description of any "tissue" removed, and a post-operative diagnosis. 12. Nurses' notes (recorded in a brief narrative style): contain the notes of all the nurses who tended the patient. These include their observations of the patient, the treatment given, the response to treatment, and any unusual occurrences. The first page shall always contain a record of checking the patient in the unit, recording his physical condition at the time, and the listing of personal belongings he has brought . with him. The admission portion is completed when the patient is first admitted to a particular nursing unit; while the discharge portion is completed when the patient is discharged from the unit. The discharge notes should include basic information such as the time of discharge, the condition upon discharge, and person with the patient. This also includes the medication/ instructions and the advice for follow-up consultations. 13. Birth and death certificates, if either of these events occurred. 14. Other sheets: medication and treatment, vital sign sheets. graphic chart sheet, etc.

QUAUTATIVEAND QUANIITATIVE

ANALYSIS PRcx:::EDURFS After recording and assembly, the chart undergoes the process of analysis. The analysis clerk should perform the following: I. Check basic forms required by the case: a. Check all forms explicitly ordered. b. The analysis clerk needs to read the doctor's order and countercheck it with the nurses' notes to confirm whether or not the order was carried out. c. When the nurses' notes say so, the analysis clerk should see to it that the result of such an order is attached d. The analysis clerk also checks on the explicitly ordered forms. (Forms included in a block) 2. The analysis clerk should check all information required by the case; a. Every page should contain the name and hospital number of the patient. b. Every form should be properly filled. c. Accounts of all tests, treatments, and observations should be reflected in the record. 3. The analysis ~lerk should check all necessary authentications; a. Check whether or not all reports of treatment, medication, examination or evaluation of the patient are dated and signed by the person who made the report. b. Similarly, check if all orders were dated and signed. 36

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c.. Doctor's orders received and written by a licensed nurse on the medical record must be signed and dated by the nurse and countersigned by the doctor. 4. Analysisclerkshould check if an necessary authorizations are attached to the chart. Check if authorization is dated, signed by the patient, and signed by a witness (these are needed in order for the authorization to be considered valid). \ b. Check if special procedures performed have corresponding authorization. c. If there is surgical intervention, check if there is surgical consent. 5. Analysis clerk should check for errors or unexplained inconsistencies. a. Check spelling of names and correct hospital number, b. Check if there is a disagreement between one part of the record and another (e.g., if the pre-operative diagnosis does not agree with the post-operative diagnosis), the discrepancy should be . noted and!or referred to the attending physician. c. When the clerk analyzing the medical records finds one which is incomplete, he should attach a "Deficiency Slip" and then check an those items which require completion. The chart should then be placed in a preset area so that the doctor concerned will know that it is awaiting his attention. d. Deficiency slip shan be attached at the upper left hand side of the record, and a tracer slip is filed for easy retrieval. e. Analysis clerk sorts out analyzed charts Into complete and incomplete charts. f. Analysis clerk forwards the complete charts to the disease and operation coder. g. Filesthe incomplete charts in the pigeon hole, by the doctor's name. h. Ifthe Standard Operational Procedure (SOP) requiresthe MRS to re-route incomplete charts to the areas concerned, then, the analysis clerk must do so. I. Upon receipt of completed charts, the analysis clerk should review charts for specific areas completed as shown in the deficiency slip. J. Reviewed charts are forwarded to the disease and operation coder. a.

Simultaneously done with analysis. is the preparation and accomplishment of the service discharge slip which is forwarded to the statistician for entry into the Daily Cumulative Statistical Form.

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CODING AND INDEXING OF DISEASES AND OPERATION REPORTING AND CODING DIAGNOSIS. OPERATIONS AND PROCEDURES Coding of diagnosis or problem is the process of assigning numbers to represent diagnosis or problems. This is done to allow for a systematic sorting of medical records by diagnosis and operations for easy retrieval. Coding is performed to meet internal and external demands for information. Internally, coding, when done correctly, helps achieve accurate, precise, and meaningful statistics which may be used by the management to plan and evaluate program implementation. Likewise, this acts as an aid to assess the quality of care rendered and to make decisions about staff, facility, and resource allocation. Externally, other agencies and third party payers use this information to forecast health care needs, evaluate the utilization of health care facilities and the appropriateness of health care cost, and conduct epidemiologic studies.

Disease Index is a numerical listing of patients' records by code number assigned to diseases and/or condition for which the patient is treated.

Diagnosis is a statement by the physician of the patient's health problem. Final Diagnosis includes the admitting diagnosis, interim diagnosis and discharge diagnosis. a. Admitting diagnosis is the condition stated on entry (prior to entry) to the facility as the reason for hospitalization. b. Interim diagnosis is an additional diagnosis that describes a condition arising after admission that modifies the course and treatment of the patient's illness or the health care required. c. Discharge diagnosis is the condition stated at the time of discharge. In cases ofdeath, the discharge diagnosis will usually be the immediate cause of death and any underlying cause. Principal diagnosis is the diagnosis chiefly responsible for the admission of a patient. All diagnosis, operations and procedures performed shall be coded using the International Classification of Diseases (ICD), and the International Classification of Procedures in Medicine 9th edition per Department Order 104-D s. 1991, dated 4 April 1991. Coding can be performed with the use of the ICD books or any of the available coding tools approved by the DOH. Each book is a cross index to the other, so that from the diagnosis, one learns the code or from the code, one will know the diagnosis. Every final diagnosis and complications or name of operation performed is listed on the face sheet, by the relative code. These codes should be entered in the correct order in the marked area. The coding clerk must be able to detect poorly-defined diagnosis. In cases where the diagnosis is not clear, the coding clerk should refer it to the attending physician for clarification. When the code numbers have been entered on the face sheet they should also be recorded on the cards making up the "Disease and Operation Index". These cards should be of good quality to withstand considerable handling. A 5" x 8" card printed on both sides shall be used.

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The disease and operation index should be kept in file drawers, and when any particular card is filled up, a new one should be added to be filed in front of the old one. For clarity, only one diagnosis should be recorded in one card. The year in which the entries are made should be written in the box provided.-Should that year end while a card is still unfilled, a line should be drawn under the last entry to show the cut-off date. Since doctors often require charts from a certain year when studying the treatment of a particular diagnosis, the recording of "other diseases" by their codes would enable doctors to clearly define the particular charts they wish to stu dy.

SIMPLE CODING PROCEDURE: 1. 2. 3. 4.

Locate the main term in the alphabetical index. Refer to any notes under the main terms. Refer to any sub-terms indented under the main term. Follow cross-referencing instruction, if the needed code is not located under the first main entry consulted.

5. Verify the code number in the tabular list. 6. Read and be guided by any instructional terms.

MEfHOD OF REPORTING FINAL DIAGNOSIS (Morbidity Code) The attending physicians are requested to carefully specify all diagnoses, operations and procedures, external causes of injuries and poisoning and places of occurrence. (If no firm diagnosis has been made, the manifestation which best accounts for the period of in-patient care shall be written by the attending physician, in which case shall be coded by the Medical Record Practitioner (MRP). This condition may be a complication or a recurrence of an earlier condition of the patient which required care on its own. PRINCIPAL-DIAGNOSIS The cause of death should be listed as the principal diagnosis only if it was chiefly responsible for the admission to the health care facility. For patients with cancer, the primary site should be coded first except when; •

The primary site is unknown, add 199.1 for unknown primary.

•

The primary site has been operated and removed, code secondary site and appropriate V code for "History of malignant neoplasms of site."

•

The reason for hospital admission is related specifically to a secondary site rather than the primary site, V codes are usually supplementary codes but occasionally may be listed as the principal diagnosis.

Adenoma is known to be benign neoplasm, but when the word benign is preceded by the word malignant, the resulting final diagnosis shall be coded under malignant.

Example: Adenoma of the Colon Malignant adenoma of the colon

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Hospital MedicalRecords Management Manual

A neoplasm diagnosis which does not specify whether a malignant neoplasm is a primary or secondary site, it should be presumed primary, unless,the malignant neoplasm is of lymph nodes or glands. Neoplasm of the lymph glands are presumed to be secondary unless the diagnosis specifies they are primary. A separate code 155.2' is -provided for malignant neoplasms of the liver whose behavior is not specified as primary or secondary. Terminology referring to metastatic cancer is often not very clear. Diagnosis stating cancer "metastatic from" a site shall be interpreted as primary to that site and neoplasms described as "metastatic to" a site shall be interpreted as secondary to that site.

Example: Carcinoma of the cervical lymph nodes metastatic from prostate, shall be coded prostate as the primary site 185, and cervical lymph nodes as secondary ~. Morphology coding, or simply called the M codes, is of special interest in tumor registry and in planning for radiation, surgery, and chemotherapy in the pathology department. When the diagnosis has more than one qualifying adjective, choose the M code with the higher number.

Example: Undifferentiated scirrhous carcinoma involving the hard palate and lateral wall of the oropharynx. (8020/3) Undifferentiated Scirrhous (8141/3) Hard palate 145.2 Lateral wall oropharynx _ _ 149.8 Therefore, the complete code for this diagnosis should be: M Code used: (8141/3) 145.2, 149.8. Where the attending physician uses non-standard medical terms which coders could not find in the rCD books, the coder should likewise refer the case to the attending physician for alternate terms used in the classification system. SYMPTOMS A symptom or ill-defined condition should not be reported as the final diagnosis if a more defined diagnosis or cause of the symptom or condition ' is known.

Example: Hyponatremia _____ 276.1 - the underlying cause of this condition has not been established Fever of unknown origin 780.6 (pyrexia) Suspected CA of the larynx _' 235.6 (ruled out)

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HOSPITAl TZATION FOR INVESTIGATION Where a patient is admitted just for investigation, the condition after' the said investigation shall be stated as the final diagnosis.

INJURIES/POISONINGS For injuries, the nature of the injury should be specified (e.g., fracture, bum, open wound), the bone, organ,or part ofthe body affected should be mentioned. For poisonings, the poisoning agent must always be mentioned.

.ABBREVIATIONS Final diagnosis should not be abbreviated as they may be ambiguous.

QUALIFYING ExPREsSIONS

.

Qualifying expressions indicatingsomedoubts to the accuracy ofthe diagnosis should be ignored (e.g., apparently, presumably, possibly, probably, etc.).

PROCEDURES AND OPERATION CODING An operation or procedure is defined as one which:

*

is performed in any operating room;

* carries an operative or therapeutic risk; and *

requires highly specialized equipment or facilities

Principal Operation or Major Procedure is the main procedure performed during an individual hospitalization episode.

.

Where there is more than one procedure or operation performed, all procedures aside from the major operation shall be coded. Some procedures are classified in more than one chapter or code number, of the International Classification of Procedures in Medicine (ICPM), depending on the reason for the procedure being undertaken..

Example: Appendectomy Prophylactic Appendicectomy Cervical Smear Routine Cervical Smear Circumcision, Male Female (ritual) circumcision Cystoscopy for removal of foreign body Ureteric cystoscopy Diagnostic Dilatation and Curettage Dilatation & Curettage for termil~ation of pregnancy' Episiotomy Routine Episiotomy Esophagoscopy Esophagoscopy for dilatation

5-470 .5-982 1-472 4-251 5-640 5-988 8-114 1~652 ,;.

",

5-690 . 5-752 5~738

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Hospital Medical Records Management Manual

Terms which indicate the surgeon's access route are not coded if details regarding the procedure carried out are available.

Example: If a laparotomy and appendicectomy are performed at the same time, then the laparotomy is not coded. Laparotomy will only be coded when no further procedure is performed.

STATISTICS Statistics are numerical facts which break down data into concise, useful form. It involves the process of collection, analysis, interpretation and presentation of facts as numbers. Accurate and comprehensive data collection is vital in statistical preparation and the effectiveness of statistical reports depends upon the terminology used. There must be a mutual/common understanding of its meaning between the person who preparesthe statistical report and its users. It would also be essential to know what data to collect and how to collect them.

NEEDS FOR STATISTICS: 1. To provide data for management activities: a. Planning b. Controlling c. Evaluating 2. Comparison of past and present performance of the facility 3. Appraisal of patient care by medical, nursing and allied health professionals 4. Provide information in the preparation of reports of outside agencies 5. Meet legal requirements 6. Funding (if it is a government hospital)

7.

Research and education

ADMINISTRATIVE LEVEL: 1. 2. 3. 4.

Decision making and evaluation Cost accounting Budgeting and resource allocation Organizing staffing levels

CLINICAL LEVEL: 1. Assessment of the quality of care rendered 2. Appraisal of health personnel performance 3. Teaching and tabulating instrument

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Hospital Medical Records Management Manual

OUTSIDE AGENCIES:

1. Data for accreditation purposes 2. Licensure of approved hospital and their services 3. Disbursement of funds The importance of accurate statistics as a tool of management cannot be overemphasized. It is the responsibility of the Medical Record Officer to ensure that the medical statistics produced for his hospital are accurate and available. The basis for many medical statistics is the hospital Census Report Forms. Computation should be done as soon as possible after work starts each morning. The aim is to monitor the movement of in-patients in and out of the hospital over the previous 24 hours, cut-off time is 12:01 to 12:00 midnight. . The foUowing form layout is recommended for aU government hospitals. Its use will ensure that the Medical Record Officer will be able to accumulate the figures required. The floor census may be accomplished by the nurses, the admitting office, or by the MRS, a copy of which shall be distributed to the designated services of the hospital. The first form layout is accomplished daily, whereas, the second form is accomplished monthly. Data are derived from the accomplished daily census reports.

FORMULAS USED IN lHE COMPUTATION OF HOSPITAL INDICATORS I.

MEASURE OF HOSPITAL UTILIZATION DAILY CENSUS: (In-patients {Admissions up (Discharges/deaths CENSUS = remaining + to the next - between census taking hours) census hour) at midnight) AVERAGE DAILY CENSUS: This is the average number of in-patients per day. This figure is derivedfrom the daily census plus the patients admitted and discharged . on the same day. (Total service days for aperiod)

Average daily census = (Total days in the same period) Total days of care/service days is compiled on the Daily Census Report and the grand total for the month is listed on the last day of that month.. Newborn census must be reported separately. Average daily census. can also be figured by the wards or specialty departments using the same formula. 43

Hospital Medical Records Management Manual

PERCENTAGE OF OCCUPANCY This is the percentage of in-patient beds occupied over a' given period of time. (Total in-patient service x (100) days for a period)

OCCUPANCYRATE =----'-------, , (Total Number of authorized beds)

x (Total days in the same period)

Newborns must not be included in the computation for these are made separately. Beds in the Labor Room (LR), ER, Clinics, Examination rooms, Recovery Room .(RR) or temporary set-ups for, temporary overflow (cots, beds in hall, etc.) or beds in the ward set-up but with no staff or patients using them (vacant or closed off area or wards, stored beds) are not to be counted. To be counted, a bed must be permanently in use and capable of being staff just as any other bed (700/0 is the minimum required to stay "even" or support the hospital's existence at no profit whatsoever). (Total length of stay for discharged patients for a period)

AVE. LENGTH OF S T A Y = - - - - - - - - - (Total discharges and deaths .in the same period) Total length of stay of patients discharged during the month (regardless of the date of admission) is taken from the Daily Analysis of Discharges compiled in the MRS. Actual days of confinement is taken from each patient's chart and totalled for the month. The figure arrived at is used as the numerator in computing for the average length of stay. ., A patient admitted and discharged that same day is considered as . having stayed one day. In computing for the length of stay, the-date of admission is counted but not the day of discharge. Newborns must not be included in computing for this indicator.

II.

MEASURE OF HOSPITAL PERFORMANCE GROSS DEATH RATE: This is a comparison of all in-patient deaths to all discharges for a given period. {Total deaths (incl. newborn) ,(100) for a given period} x

DEATH RATE = - - " - - - - - - ' - - - - - ' - - - - ' - - - (Total discharges and death for the saDle period) Do not includeDead on Arrival (DOA),stillbirth,and ER deaths. Include newborn in computing for this indicator. Below 3% is acceptable.

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NET DEATH RATE The net death rate produces a lower figure than the gross death rate. This is also known as institutional death rate. [{Deaths (incl. newborn)} {those under 48 for the period}]

x

(100)

Net Death Rate =

--------------~--

(Institutional Death Rate)

[l Total no. of discharges (incl. deaths & newborn)} - {deathunder 48 hours for the period}]

Death occurring at the ER is not counted if the patient is not yet considered admitted. 0.5- 2.5% rate is acceptable by western standards.

POST-OPERATNE DEATH RATE A post-operative death is one occurring within 10 days of the operation and was due to, or connected with, the surgery performed. (Total post-operative deaths for a period) x (100)

Post-operative Death Rate

=

(Total patients operated for the same period)

Up to one percent (1%) is considered normal.

ANESTHESIA DEATH RATE: An anesthesia death is a death that occurs while the patient is under anesthesia or caused by anesthetics or agent used by an anesthetist in the practice of his profession. (Total no. of death caused by anesthetic agent for a period)

x (100)

Anesthesia = (Total no. of anesthetics administered Death Kate for the same period)

MATERNAL DEATH RATE: These are deaths resulting from obstetric complications of the pregnancy state (pregnancy, labor, and puerperium) from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above.. {(Total no. of direct maternal x (100)} deaths for a period)

Maternal Death Rate

{Total no. of maternal (obstetrical) discharges (including) deaths for the period}

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Hospital MedicalRecords Management Manual

To be counted, death must occur between conception and puerperium. Up to twenty-five percent (25%) is considered normal. Count only those patients whose death was a result of an obstetric complication of the pregnancy, labor or the puerperium or from interventions, omissions of treatment or chain of events resulting from any of these. A woman who dies following an abortion is a maternal death, as in an obstetrical patient who dies before the delivery of a cause due to pregnancy. Non-maternal death rate is an obstetrical death resulting from accidental or incidental cause and not related to pregnancy or its management.

A.

MORBIDITY

GROSS INFECTION RATE: Those infection which have occurred following dean wound operations or births, or have developed in medical cases after admission to the hospital. {Total no. of infections in hospital x (100) (or ward) for a period} Infection = - - - - - - - - - - - - - - - {Total discharges & deaths from hospital Rate (ward) for the same period} The infection to be included must be hospital acquired and must be so determined by a committee or a physician. Up to two percent (2%) is considered normal. NET INFECTION RATE: (Total number of infections debited against the hospital for a period)

x

(100)

Net Infection = - - - - - - - - - - - - - - - Rate (Total number of discharges in the same period) POST-OPERATNE INFECTION RATE: These are infections occurring after a clean surgical operation (O.P.) or procedure. (No. of infections occurring after clean surgical O.P.) x (100) Post-o.P. = -------------Infection Rate (Total no. of clean surgical O.P'; procedure for the period)

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B.

MEDICAL

CONSULTATION RATE: This is the ratio ofconsultation following an attending physician's request, to a consultant, to examine a patient and give a second opinion. {Total consultations (all Depts.) for a period} x (100) Consultation = - - - - - - - - - - - - Rate (Total discharges and deaths) Include newborn in computing for this indicator. Twenty percent (20%) is considered normal for teaching hospitals. A ten to fifteen percent (10-15%) rate is acceptable by western standards. AUTOPSY RATE: It is the ratio of all autopsies performed in the hospital to all inpatient deaths. . (Total autopsies performed (100) for a period) x Autopsy Rate (Total number of deaths of patients whose bodies are available for autopsy) In computing for this indicator, do riot include DOA,stillbirth, and fetal deaths. A seventy percent (70%) rate is considerednormal for teaching hospitals. A twenty to twenty-five percent (20-25%) is the minimum rate acceptable by western standards. NET AUTOPSY RATE: (Number of autopsies performed on in-patients deaths) x (100)

Net Autopsy = - - - - - - - - - - - - - (Total number of deaths minus unautopsied cases) The following are four exclusions in computing the net autopsy rate: * Stillbirth * Dead on Arrival * Death at E.R. when patient is not admitted * Medico legal cases, given to the proper authority

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C.

OBSIEIRICS

CAESAREAN RATE: It is a comparison of the number of caesarean sections performed against the total number of deliveries. (Total caesarean sections (100) in a given period) x Caesarean Rate = - - - - - - - - - - - - - (Total deliveries for same period) A three to four percent (34%) rate or loweris acceptable by Western Standards. Note: Regardless of whether the delivery produces one child, twins, etc. and whether a dead or live newborn is delivered, the mother is considered to have delivered only once.

D.

PERINATAL STATISTICS

Perinatal period is that which extends from the gestational age at which the fetus attains the weight of 1000gm. (equivalent to 28 weeks gestation) to the end of the seventh completed day (168 hours) of life. LNEBIRTH: This is defined as the complete expulsion or extraction from the mother of the product of conception, irrespective of the duration of the pregnancy, which, after separation, breathes or shows any other evidence oflife, such as beating of the heart, pulsation of the umbilical cord or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is still attached. Each product of such a birth is considered live born. FETAL DEATH: (STILLBIRTH RATE) This is death prior to the complete expulsion or extraction of a product of conception from its mother irrespective of the duration of pregnancy. The death is indicated by the fact that after such separation, the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord or definite movement of voluntary muscles. (Total no. of intermediate and!or late fetal deaths for the period) x (100) Fetal Death = - - - - - - - - - - - - - - Rate {Total no. of birth (incl. intermediate and late fetal deaths) for the period} Below two percent (2%) is considered normal.

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Hospital-Medical Records Management Manual

Fetal deaths are classified as: a. Early Fetal Death = less than 20 weeks gestation (500 gm. or less) b. Intermediate Fetal Death = 20 weeks of gestation but less than 28 (501-1,000 gm) c. Late fetal death = 20 or more weeks Ofgestation (1,001 gm - stillbirths)

NEONATAL DFAlH RATE QNFANT NEWBORN MORTAUIY RArE): ,This is the death of a child whose heart beat after complete expulsion or extraction from the mother, and died within 28 days of birth. (Total number of newborn deaths for the period) x (100) Neonatal death = - - - - - - - - - - - - Rate {Total no. of Newborn infant discharges (incl. deaths) for the same period} Fetal deaths of less than 20 weeks should not be included as well as those who were admitted after their deliveries/births outside the hospital. For Infant Death Rate, below 2% is acceptable' in western standards. . Neonatal Death could be divided into: a. Neonatal period I - from the hour of birth through . 23 hours and 'JJ minutes b. Neonatal Period II - from the beginning of the 24th hour of life through 6 days, 23 hours, and 'JJ minutes c. Neonatal Period III - from the .beginning of the 7th day of life through 27.days, 23 hours, and 59 minutes.

FILING OF MEDICAL RECORD An efficient filing system is a vital requirement in an efficient and effective MRS. All records should be filed in one established sequence. A filing area which will ensure the rapid location and retrieval of records must be maintained. There are several systems of filing medical records, among these are: ALPHABETICAL - all records of discharged patients are filed in strict alphabetical order from A to Z. This is otherwise known as the dictionary arrangement of filing. NUMEll.ICAL" all records are- filed by their ad~ission number.

BY YEAR - charts may be filed either alphabetically or numerically by year of discharge.

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Hospital Medical Records Management Manual

TERMINAL DIGIT FILING For terminal digit filing, a six digit number is used and divided into three (3) parts. 1. Part I - The PRIMARY digits which are the last two (2) digits on the right hand side of the number. 2. Part 2 - The SECONDARY digits which are the two (2) middle numbers.

3. Part 3 - The TERTIARY digits which are the first two (2) digits on the left of the assigned number. For example, the unit number 19-30-90, is divided as follows: 19 20 90 Tertiary Secondary Primary The record of those who have been in-patients of the hospitals are filed and stored in terminal digit order. This means that they are filed in order of primary digits (that is, last two digits of the medical record number and then the secondary digits and finally the tertiary digits). When filing charts under the terminal digit system, the unit number is first considered. This should be divided into three parts - in pairs of digits. Taking chart 509326, this divides as follows 50-93-26 and the process of filing commences by considering the right hand or "terminal" pair of digits which, in this example, is "26". A terminal digit filing area should have 100primary sections starting from 00, 01, 02, 03, 04, 05,...99. When filing , the clerk will take the chart to the primary section corresponding to the terminal pair of digits. Once in the right terminal, the row of records is located by considering the secondary and the middle number which, in the above example, is "93". Within each secondary section, charts are filed in order of their tertiary (left hand) pair of digits. The advantages of terminal digit filing are numerous. As records are added to the filing area, they are equally distributed throughout the 100 primary sections. Thus, congestion of one particular area of the file room is eliminated. This system makes quality control possible since it gives clerks the fixed responsibility for certain sections of the file. This also prevents the backshifting of records which usually happens in other types offiling systems. If you are looking for a record, it should be in the order shown below or a tracer should be in its place. An example of sequence is: 46-52-02 47-52-02 48-52-02 49-52-02

98-05-26 99-05-26 00-05-26 01-06-26

98-99-30 99-99-30 00-00-31 01 - 00 - 31

Note: A misfiled record may take hours to locate or could be lost forever. File all records correctly.

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Hospital Medical Records Management Manual

07 06. 77 05 77 50 04 77 50 03 77 50 02 77 50 01 77 50 00 77 50

l

77 50 50

The lllustration above shows how charts are filed in terminal "50".

PROCEDURE IN FILING PATIENT INDEX CARD NEW ADMISSIONS: 1. Check alI new admissions from the daily census report. 2. Check the Master Patient Index (MPI) to make sure the patient has not been previously admitted to the hospital, otherwise, the patient may already have one.

3. Prepare an MPI for each new patient admitted in the hospital. 4. Pre-sort alI finished MPIs. 5. File the MPI's in the in-house box alphabeticalIy according to the patients' last name (surname). 6. After the patient's discharge, pulI out the MPI from the in-house box. 7. Pre-sort pulIed-out MPI cards. 8. File in the MPI card cabinet folIowing the rules in alphabetical filing. (Refer to rules on alphabetical filing, p. 52) RE-ADMISSIONS: 1. Check re-admissions from the daily census report. 2. Check the MPI to make sure whether the patient has been previously admitted to the hospital, otherwise, he may already have one.

3. PulI out the MPI from the index card cabinet.

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4. Pre-sort the pulled-out MPIs alphabetically.

5. File the MPI's in the in-house box alphabetically according to the patients' last names.

6. After the patient's discharge from the hospital, pull out the index 7.

card from the in-house box. Pre-sort the alphabetically pulled-out MPIs.

8. Re-file in the MPI cabinet following the rules on alphabetical filing. RULES ON ALPHABETICAL FILING: 1. Place the surname first, then the given name, followed by the middle name or initial, and file in strict alphabetical sequence. 2. Arrange index cards in alphabetical order. 1 When a patient requires more than one card to accommodate all of his admissions, the cards should be arranged in chronological order, with the earliest date first, working from front to back in the drawer. 4. If there is more than one person with the same surname and given name, the cards should be arranged alphabetically by middle initiaL If no middle initial is given, the cards should be arranged according to birth date, filing the oldest card first. 5. Names with prefixes of D, dela, De, Des, Di, Du La, Me, Mac, Ma, Van, \bn, etc. are filed alphabetically as De-l-a-Cr-u-z; De-l-a-F-u-e-n-t-e. 6. Names beginning with Sta. and St..are filed as S-a-n-t-a, and S-a-i-n-t, as in S-a-n-t-a-M-a-r-i-a and Sa-i-n-t,

7.

COmpound or hyphenated names are filed as one word; thus, NavarreteClemente would be filed under N-a-v-a-r-r-e-t-e- Cd-e-m-e-n-r-e.

8. Names with religious titles such as Reverend, Mother, Father, Brother, and Sister are filed under the surname, the titles disregarded, followed by the given name. Father Jose Romero is filed as Romero, Jose or Romero, Jose (Father). 9. If an initial is given instead of a person's first name or middle name, the rule is "file nothing before something." Thus, J. Romero would precede M. Jose Romero and Miquel Jose Romero.

10. It is customary for people of Spanish descent to combine the name of the mother with the name of the father, For instance, with the name Soto Ramirez, Soto is the surname of the father, and Ramirez is the surname of the mother. They are filed in alphabetical sequence, the father's name first, followed by the mother's name. Thus, the name Maria Dolores Soto Ramirez would be filed in the section of the file in the following order; So-t-o-Ra-m-i-r-e-z, Maria Dolores. 11. If the patient's name has changed since a previous admission, a crossreference should be made to the former name. For instance: if Dayrit, Josefina is admitted, a cross-reference should be made to her previous admission as Manalastas, Josefina.

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12. When looking for a given person's name card, one must keep in mind that there may be many spellings of the same name. A thorough search must be made under every possible spelling of the name before stating that there is no card for that name. 13. The MPI should contain sufficient alphabetical guides for speedy reference. As a rule, no more than 20 cards should be filed behind a guide. 14. To maintain uniformity in the patient index when a personnel change is made, filing directions should be explicit. Whenever possible, only one person should be responsible for filing the index cards. 15. Card files should be audited regularly for misfiled records. 16. Additional training of MPI clerks should be provided as necessary.

LOOSE SHEETS Vast quantities of unattached laboratory, E.C.G., and other test results (loose sheets) are produced daily and make their way to the MRS. These reports contain vital patient information and it is essential that they are filed promptly and accurately to maintain complete, comprehensive and effective medical records. SORTING OF LOOSE SHEETS: Loose sheets are delivered to the MRS from the different services of the hospital. The in-patient sheets should be separated from the out-patient loose sheets in a decentralized medical record keeping system. Then they are pre-sorted terminally in preparation for the actual filing process. The procedure is as follows: 1. Separate loose sheets that have been stapled together. 2. Date stam~ all loose sheets received. 3. Check names and numbers on the loose sheets. Note: For loose sheets forwarded to the MRS without corresponding numbers, the MPI should be consulted. LOCATING THE RECORD

1. Refer to the in-house box to determine whether or not the patient has already been discharged. 2. For patients whose names are not in the in-house box, consult the MPI for the MRN, then retrieve the record from the permanent file area. 3. Medical records shall be filed by the terminal digit filing system. (See Terminal Digit Filing, p. 50) 4. Records which are not in the permanent filing area.should be recalled from respective borrowers to incorporate loose sheets. 5. Retain any loose sheets that were not filed the first time for a future attempt.

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FILING LOOSE SHEETS I. Check and re-check patient number and date on the report if they correspond to the number and date indicated on the medical record.

2. File the loose sheets using the "Assembly of Records".list as a guide to correct filing order. 3. First admission is filed at the bottom with subsequent admission on top. 4. Reports from each department are filed chronologically within each admission. 5. Maintain statistics of loose sheets received by the MRS for any administrative use.

RETRIEVAL SYSTEM FOR THE UTILIZATION OF MEDICAL RECORDS All medical records not in the processing stage and those not in use are expected to be in the file/storage room. Inherent to documents and records is the property to be retrieved from the permanent file for further use - one of the main reasons why they were maintained. A good retrieval system directly affects the total efficiency of the MRS. It would be a good practice for small hospitals with a small filing! storage area to transfer inactive records to the inactive file to give way to incoming records, to decongest the area, and to make retrieval easy. It shall be the policy of the facility to maintain a filing system that shall facilitate accessibility and prompt retrieval of the records. The system must be consistent (i.e., it must not vary from' one record to another), and it must be maintained in a definite sequence at all times. A retrieval processwill not be efficient and effective if there is no provision for adequate finding aids, captions, locator aids, and retrieval tools. Retrieval tools in the medical record are classified into three, namely: (1) indexes, (2) registers, and (3) tracers. The following indexes shall be maintained by the MRS:

MASTER PATIENT INDEX (MPI) - The MPI is one of the most important tools in the MRS. * It is the key in locating medical records maintained in the file. * It servesto identify the patient and helps in the retrieval process of medical records. * The patient index is maintained as a permanent file. MPI is maintained manually in a 12cm x 7cm or 3"x 5" card. * * It is filed in strict alphabetical order by the patient's name. The minimum data requirements for the Patient Index card are as follows: the patient's name, address, date of birth, hospitsl/record number, date ofadmission, and the name ofthe attending physician.

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Hospital Medical Records Management Manual

Sample of a Patient Index: f

NAME OF HOSPITAL

PATIENT INDEX

NAME: FAMILY AGE

FIRST

DATE OF BIRTH

MIDDLE

SEX

HOSPITAL NO. STATUS

ADDRESS:

-r-r-'

ADMISSION DISCHAJl{;E ATIENDING ADMISSION DISCHAJl{;E ATIENDING ~HYSICIAN PHYSICIAN

DISEASE INDEX - is a listing on a card for specific disease based on standard classification/nomenclature, arranged according to code numbers. Sample of a Disease Index:

NAME OF HOSPITAL

DISEASE INDEX DISEASE: YEAR CODE NO. Attending Hospital Patient Age Other Result O.P. . Date Name M F Disease Adm. D Physician No.

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Hospital Medical Records Management Manual

A disease index is a numerical listing ofthe code numbers assigned

by the medical record practitioners to represent each patient's diagnosis. These code numbers are taken from the coding tools approved by the DOH. The disease index serves as a valuable resource to retrieve records with specific disease or problem, hence, very useful for research and studies. An entry on an index card should be made for each code number. (Example: If the final diagnosis of the patient is Pulmonary Tuberculosis [code no. 011.9) with bronchial asthma [493.9)), an entry would be made on one card for code 011.9 and another card for code number 493.9 Code No. 011.9 Hospital Patient Age Number Name M F

Other Diagnosis 493.9

Card No. I

Code No. 493.9 Hospital Patient Age Number Name M F

Other Diagnosis OIL 9

Card No.2

OPERATION INDEX - is a listing on a card for a specific operation according to standard classification/nomenclature, arranged according to code numbers. Sample of an Operation Index: NAME OF HOSPITAL OPERATION INDEX Code No.

Operation:

Year

Hospital Patient Age Other Result Diagnosis Date Attending No. Name MF O.P. Adm. Physician

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Hospital Medical Records Management Manual

PHYSICIAN'S INDEX - is a record of the work done and end results of , treatment rendered by the' physician practicing in the hospital or an index containing a list of all the patients a doctor has. These cards are filed alphabetically according to the doctor's name. 'Sample of a Physician's I~dex: NAME OF HOSPITAL

PHYSICIAN'S INDEX Code No

Physician's Name'

Year

Date Hospital Patient Age Discharge Days. Service Cons. Result Name M F Date No.

NUMBER INDEX - is the patient identification number control. In cases where only the number of the patient is known, the name can be traced from the number index. This is maintained in a 3" x 5" index card... Sample of a Number Index: I

I:

NAME OF HOSPITAL

NUMBER INDEX PAGE Hospital No.

YEAR Patient's Name

Date Admitted'

REGISTERS Registers are official recording of items, names, or actions entered in a book or a logbook. The register.is.a vital document in the MRS. Very often, statistical data is required and the only record available will be this register. It is very useful as a cross reference because ,it can identify all patients by name and by number.

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Hospital Medical Records Management Manual

ADMISSIONREGISTER - This is a list of all patients admitted in a particular hospital. The minimum data requirements for admission register are as follows: patient's name, date of birth, patient/hospital number, admission date, name of attending physician, and the section! area where the patient was admitted from. This register shall be done daily as patients are admitted and/or discharged. Each section of this register shall be maintained in chronological order. This register is a permanent record, and as such, all entries shall be made in ink. Sample of an Admission Register:

ADMISSION REGISTER Patient Adm. Patient's Numbe Date Name

Page No. Rm. ~~ Birth iNtending Admitted From No. M F Date Physician

DISCHARGE REGISTER - The minimum data requirement for a discharge register are as follows: patient's name, patient/hospital number, discharge date, name of the attending physician, and disposition. Sample of a Discharge Register:

DISCHARGE REGISTER Discharge Patient Patient's Date Number Name

Physician

Page -No .. Adm. Diagnosis Result Date

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Hospital Medical Records Management Manual

,

"'.

BIRTIf REGISTER - this is a chronological listing of all the names of the children delivered in a particular hospital, Sample of a Birth Register: Page No.

_

BIRTH REGISTER Hospital Patient Child Delivered Day/lime HI Wt No. of Attending Del. Physician Delivery No. Name Name By:

DEATIf REGISTER This is a record of all the deaths occurring within the hospitaL This is a log of all the names of the patients who died in a particular hospitaL This is arranged according to the date of death. Sample of a Death Register: Page No.

_

DEATH REGISTER· ervice Attending Patient Patient's ~ ~ Adm. Date of limeof Number Name M F Date Death Death Phvsician ..

OTIfER REGISTERS - Other required registers that government hospitals need to maintain are. as follows: Out-patient register, Emergency Room Register, Delivery Room Register, and Operating Room register.

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OUT-PATIENT REGISTER - Every out-patient who comes in for consultation must be listed in the OUT-PATIENT REGISTER.

Page No,

_

OPD REGISTER Date Hosp. Re-Adm. Name Jj:.- Diagnosis Service Attending No. Adm. (Surname, [}.-iF hysician First,MI)

If a logbook is utilized for this purpose, at the end of the year, it should be forwarded to the MRS for safekeeping, as it is classified as a permanent file/record. If, however, this register is maintained on a loose sheet or loose leaf, at the end of every month it must be forwarded to the MRS for thepreparation ofNotifiable or Reportable Diseases which isprepared monthly. This is also necessary for the compilation and collation process.

ESSENTIAL REQUISITES FOR EASY RETRIEVAL EFFICIENT AND EFFECTIVE FILING SYSTEM This is an important factor that makes retrieval easy because it is adaptableto the type of records maintained. Proven to be very effective in managing voluminous health records is the terminal digit filing system. However, to be truly effective, it needs to adapt the corresponding unit numbering system. 2. TIME Time element is very crucial in medical record management. Retrieval time of medical records should be as short as possible because the information that may be retrieved from the chart might .be the deciding factor between the patient's life or death. 3. MONITORING OF CHART MOVEMENT Another important factor to consider in the efficient and effective management of medical records is the full knowledge of the movement of the records. This is the reason why the MRS should' maintain an .effective tracking or follow-up system. The use of such a system coupled with the full knowledge of the workflow will help the medical record staff control the records more effectively. 4. GOOD PHYSICAL LAYOUT For a good physical layout, the MRS should consider flexibility and functionality. The arrangementof the employees should (1) follow the workflow, (2) facilitate smooth flow of paperwork, and (3) improve coordination between employees. The physical location of the MRS should be near the OPD and ER as the activity rate of medical records is considered high in these services. 1.

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Hospital Medical Records Management Manual

RETIUEVALPROCEDURE 1. Authorized requesting party fills up borrower's slip form. 2. Requesting party/authorized representative brings the request to the MRS and hands it to the medical record personnel.

3. Medical record personnel receives and verifies whether the borrower is authorized to borrow. He also checks the MRN on the request form. 4. Those requests without the corresponding MRNs shall be checked against the MPIs. Records of requests with MRN/patient numbers shall be pulled out from the permanent file. 5. After retrieving the record, charge-out needed/borrowed charts to the authorized borrower.

*

Record the borrowed chart in the tracking system employed.

*

Insert the tracer card in the place where the record was pulled out.

6. The borrower/authorized representative acknowledges' receipt of the record.

REQUEST FOR MEDICAL RECORD FOR STUDIES AND RESEARCH Authorized physicians/researchers shall accomplish the borrowers' slip forms and forward them to the MRS (at least.a 24-hour notice should be given for the preparation of the charts). The medical record personnel receives the request and checks its authenticity. The requesting party is then asked the variables and limitations of the study. The medical record personnel checks the code number of the disease/ operation for research and retrieves the corresponding index card. (See Filing and Arrangement of Disease and Operation Index, pp. 55-56 ) . The medical record personnel (Retrieval clerk) reviews the disease and operation index to determine which' charts 'to retrieve, considering the variables specified by the researcher. The retrieval clerk then retrieves the records from the file and performs the charge-out procedure, The retrieval clerk then notifies the authorized borrower when the charts are ready for pick-up. The authorized borrower/representative acknowledges receipt of the medical records requested.

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Hospital Medical Records Management Manual

RETENTION AND DISPOSAL A.

RETENTION

Retention period is the period of time established and approved by authority after which records are deemed ready for inactive storage or destruction. Medical records should be keprby the facility for the duration of time required by the statuteoflimitations or by the'DOH record retention regulation. This is the HospitIl licensure Act otherwise known asRepublic Act 4226, which requires hospitals to maintain medical records for 10 to 25years. Aside from this legislation, DOH came up with Ministry Circular 77, series 1981 which further qualifies the 25year retention period for all hospitals under the DOH regardless of its category/classification. The medical record is also influenced by the following factors:

1. ACTMTY/USAGE OF DATA: This can be assessed by determining the number of requests for information from the records as well as the type of information requested. This reflects the clinical value of the medical record. 2. SIZE AND TYPE OF SPECIALIZATION OF THE HEALTH CARE FACILITY Teaching-training and research hospitals maintain their medical records longer than hospitals not connected with medical schools or not engaged in research and studies.

3. AVAILABLE SPACE AND ALTERNATIVES Because ofiegal considerations, the MRS with a small filing area must maintain a secondary filing space for inactive records. Active records are usually maintained for five (5) years after which they are transferred to the inactive file until they reach the required retention period. 4. ATTITUDE The people involved in medical records influence record retention (in terms of its use for patient care, clinical research, and education).

B.

DISPOSAL OF RECORDS

Disposal of medical records in government hospitals/institutions is governed by DO NO. 13-A and 13-B. Department Order 13-A, Article III, Rule 2.2, specifically states that, "Agencies shall not dispose of their records earlier than the period indicated for each record series. However, records may be retained for longer periods ,if there is a need to do so". The disposal of records must be done in close coordination with the Records Management and Archives Office (RMAO), the government agency in charge of record disposal.

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" (

PROCEDURE IN THE DISPOSAL OF MEDICAL RECORDS

1. Check the Record Disposition Schedule for records which has reached the required retention period (MC 77 s.1981). 2. Pull out medical records from the file. * Check the year when the record was last activated. (This appears on the upper right hand side comer of the folder.) DIZON, EDWARD 1987 1988 1989 1990

02 98 - - year of activity 78 78

Note: In this example, the patient was first admitted in 1987, re-admitted in 1988, and was last admitted in 1990.

3. Prepare a list of records for disposal.

\ ~.

4. Communicate with the RMAO regarding a request to. dispose of medical records addressed to tile Chief, Current Records Division, Records Management and Archives Office, through the Director, Hospital Operations and Management Service, Department of Health, Manila. HOMS will endorse the request to the said office. 5. Upon receipt of the request, the RMAO will assign a record management analyst to appraise and examine the records for disposal. Finally, the record analyst will also recommend the manner or method to be used in the disposal of the record. 6. The director ofRMAO will issue the authority to dispose of the records and the manner of disposal. 7.

Actual disposal shall be directed by the Director of RMAO or the Head of the agency. 8. A certificate of disposal shall be prepared in triplicate by the agency, witnessed by representatives of the Commission on Audit (COA), RMAO, and a representative from the agency. The certificate shall include the following information: * Nature of the record * Manner of disposal * Place of disposal * Date of disposal * Approximate volume in cubic meters * Weight of the records The original certificate of disposal goes to the agency, one copy to COA, and one copy to RMAO.

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DISPOSAL SCHEDULE FOR MEDICAL RECORDS SERVICE Disposal Schedule Retain permanently Retain permanently Seven (7) years after the date of the last entry. One (1) year after Retain permanently Retain permanently Retain permanently Retain permanently

Document type Admission and Discharge Register Birth Register Correspondence Log Book for MRS Daily census Report Death Certificate (file copy) Death Register Disease and Operation Index ER Blotter/ER Register In-patient Records Adults • Teaching-training and research, and Provincial Hospitals

25 years

• District/Community Hospitals Minor (all)

25 years Until the child reaches the age of maturity (18 yrs.) plus an additional five (5) yrs. Retain permanently If filed in the in-patient, retain as for in-patient record Retain permanently Retain permanently Retain as in-patient records Retain permanently Retain permanently

• Psychiatric Hospital Laboratory Report Copies Labor Room Register Number Register Out-patient Records Operating Room (OR) Register Master Patient Index! Patient Master Index Research Requests Subpoenas If no record X-ray Result/Report - If filed with the chart - If no record

10 years Retain as for in-patient Retain as for correspondence Retain as' for in-patient record Retain for 10 years

-;

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MEDICAL RECORDS OF DISCHARGED PATIENTS Medical records of discharged patients are delivered/ forwarded to the MRS every morning from the different wards of the hospital. The records are then sorted alphabetically. The medical record clerk processes the new admissions and re-admissions according to the following procedure: 1. Pull the corresponding cards from the in-house box. 2. Sort and divide the records into new and re-admission

3.

Process chart following procedure in filing patient indexcard (see p. 55) and terminal digit filing (see p. 50).

NEW ADMISSIONS 1.

Check the Master Patient Index (MPI), to make sure the patient was not previously admitted to the hospital and therefore mayalready have an existing medical record.

2. Prepare a folder for the record.

3. Assemble the admission into the folder following the assembly of record order (see p. 31 ). 4. Stamp the current year on the upper right hand corner of the folder. indicating the year of admission.

5.

Records of dead patients could be marked accordingly, placed in separate file and entered in the death register.

6. Allocate/forward incomplete records, according to the attending physician(s), to the proper units for completion.

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HospitalMedical RecordsManagement Manual

RE-ADMISSIONS 1 Locate the old record. 2. Assemble the new medical records and incorporate them with the old . records. ensuring that a divider is placed after the first by placing the new medical records on top of the previous records. 1 Stamp the latest admission year on the upper right hand comer of the folder. 4. Mark the records of dead patients accordingly and enter in the death register. 5. Allocate/forward incomplete records. according to the attending physician(s). to the proper units for completion.

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MEDICO-LEGAL ASPECTS OWNERSHIP OF THE MEDICAL RECORD The medical record is the physical property of the health care facility and is maintained for the benefit of the patient, the physician, the health care facility and the community. As a general rule, ownership carries with it the right and power to control the utilization of the said property. For medical records, ownership is not absolute because the patient also has a right to the information written on the record, that being his health history.

ACCESSIBILITY AND CONFIDENTIALITY As a general rule, all the people who are directly involved in the treatment of a patient shall have access to the record. The medical record is a legal document, as such, all records shall be stored in areas where only authorized staff are allowed access and appropriate security measures are instituted. No information concerning a patient or client shall be released to another person without the consent of the patient. * Where the patient is a minor, a person below 18 years of age, authorization of the parent or legal guardian should be obtained.

*

If the patient has died, the consent must be signed by the identified next of kin, or by the administrator or executor of the decedent's estate. In the event the patient is unable to sign the authorization by reason of physical or mental disability, the authorization should be signed by the next of kin or the legally appointed guardian. If possible. verification of such disability should be obtained from a physician. A person who is a minor but is married or self- supporting and living apart from his/her parents may sign his own authorization. In general, because the medical record is the physical property of the health care facility, they should not be taken out of the hospital except on court orders.

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REQUEST FORINFORMATION FROM DOCTORS ORHEALlH INSTITUTION REQUIRED FOR CONTINUING PATIENT CARE Advances in health care delivery gave rise to what is known as the "team care approach" to health care delivery. This requires a wider range of health professionals who might have a legitimate need for access to information from the medical record. In this sense, institutions should formulate guidelines to restrict access to records to those who are only actually involved in the care of a particular patient.

REQUEST FOR INFORMATION FROM THE MEDICAL RECORD FOR RESEARCH AND STUDIES Health care facilities are said to own the medical records, but legally, the "privilege against disclosure belongs to the patient and nobody else." In a hospital setting, proper notification of the attending physician, prior to the release of information is ideal, in order to protect the legal interest of the doctor and the hospital as well. In cases of research and studies, the hospital management may decide on who can and who shall not be given access to the medical record, the record being the hospital's physical property. While thehospital may give access to a patient's medical . record for research, study, and publication, the courtof law emphasizes the need to protect theidentity of thepatient,which explains why thenameof thepatient isnot mentioned in these published reports. A research proposal to be presented for approval should be accompanied by a comprehensive protocol detailing the objectives methods and reasons for the study. Records for research purposes should not be removed from the health facility.

MEDICAL INFORMATION OF MENTAL PATIENTS Any medical information on patients with mental problems may be released only upon presentation of a written authorization from the patient's nearest kin or by a person appointed by the court as the legal guardian. Where the request is from a mental hospital where the patient is presently confined, the release of information shall be acted upon without hesitation since the use of the information is for the patient's benefit.

REQUESTFORINFORMATIONFROMlHE MEDIA The DOH recommends that the following procedures be observed in giving information to the press: 1. Request shall be referred by the MRS to the COHo 2. Noinformation idemifying thepatient shall be released without proper consent 3. Where the patient concerned is conscious, his/her consent or the legal guardian's (in case of a minor) shall be obtained regarding the release of his/her information to the press.

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4. Where media requests the privilege of photographing a patient in the health facility, the following conditions shall be followed: * The patient or legal guardian (in case of a minor) shall give consent for any picture to be taken: and * The opinion of the doctor declares that the patient's condition will not be jeopardized.

RECORDS SUBPOENAED BYCOURT Subpoena is a process directed to a person requiring him to attend and to testify in any investigation being conducted under Philippine law. He may also be required to bring with him books, documents, or other materials under his control in which case, it is called a subpoena duces tecum. Oftentimes, the MRS receives a subpoena duces tecum, which only requires the medical record supervisor to bring a particular record(s) to court. A subpoena is legally binding on the person who receives it. The MRS should not accept any subpoena not directly addressed to it. If a subpoena is addressed to a particular doctor, it must be served to him personally. .' Upon receipt of a subpoena, always indicate the TIME and DJU"E of receipt Where the patient, whose record is subpoenaed, is not a party to the proceeding before the court, the hospital should properly notify the patient of the place, date, and time of the court hearing.

PROCEDURE TO FOLLOW WHEN TIlE MEDICAL RECORD SERVICF/DEPARTMENf RECEIVES A SUBPOENA DUCES TECUM 1. Check the Master Patient Index (MPI) if the person mentioned in the subpoena was admitted/treated in the health care facility, 2. Check the file and retrieve the record. 3. Verify with the court if the case is on-calendar. 4. Re-check the chart/record for complete data entries. 5. Notify management and the attending physician about the subpoena. 6. Have the attending physician review the record for completeness of clinical data. 7. Number all the pages consecutively.

8. Transfer the record in a secure place preferably under lock and key. 9. Access to the record shall be limited to the attending physician and to authorized personnel. 10. Photocopy the record and, if possible, never leave the original copy in court. 11. Always solicit a written request from the judge or the fiscal's office before leaving the record in court for litigation purposes.

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CONSENT It must be taken into account that there are other legal aspects to medical record documentation in addition to the medico-legal certificate. As a general rule, no treatment or procedure may be performed without the patient's consent. There are instances where consent could not be obtained (ex, when the patient is comatose or without a legal guardian), this leaves the doctor and the hospital open to court litigations due to negligence (for not properly informing and advising the patient as required). To be considered valid, a consent should be signed by the patient and a witness and should also be dated. Aside from these requirements, the person giving the consent should be legaIly and mentaIly competent. The consent must be freely given to the authorized person and the patient must be weIlinformed for him to reach a reasonable decision. The foIlowing documents require specific signatures and must have their legal requirements completed before they can be included in the record.

1. CONSENT TO INVOLVEMENT IN CLINICAL TRIALS (THERAPEUTIC) (See Appendix) 2. CONSENT OF RECIPIENT TO OPERATION, lRANSPLANfATION OR GRAFTING OF TISSUE (See Appendix)

3. INFORMED CONSENT FOR SURGERY, ANESTHESIA, OR OTHER PROCEDURES (See Appendix) This consent must be signed and witnessed after a doctor has explained to the patient the nature of the operation or the procedure to be performed. This consent must be completed before the patient is given pre-operative medication. (See Appendix) 4. DISCHARGE AGAINST MEDICAL ADVICE (DAMA) This consent has two parts. The first section, whenever possible, should be completed before the patient leaves the ward (in some cases, this requirement may cause him to change his mind). If the patient leaves without signing, then the second part of this form should be completed, signed by a nurse and witnessed by someone who is not a member of the hospital staff. 5. CONSENT TO RELEASE OF PATIENT MEDICAL INFORMATION This consent should be obtained and notarized before any confidential information is released. Should a law enforcement agent request confidential information, he must present an authorization signed by his Head of Office.. This authority should always be confirmed by caIling the said office before releasing the information. (See Appendix) 6. CONSENT TO REMOVE ORGAN FOR lRANSPLANf (I1VING DONOR) This consent has two parts. The first part is signed by the patient (donor), and the second part is the confirmation which is to be accomplished by the doctor. (See Appendix) 7. VOLUNTARY STERILIZATION CONSENT FORM This consent requires that both parties, husband and wife, sign the consent for it to be considered valid. (See Appendix) 70

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8. THERAPEUTIC ABORTION FORM This form is to be accomplished by both the husband and the wife before the procedure is performed by the physician. This also requires the signatures of at least two witnesses. (See Appendix) 9. REFUSAL TO PERMIT'BLOOD TRANSFUSION The patient has the right to refuse medication or treatment (e.g., blood transfusion) which might be against his/her religious belief. In which case, this consent form should be properly accomplished. (See Appendix) 10. CONSENT TO THE ADMINISTRATION OF ELECTROCONVULSIVE THERAPY This form must be accomplished in mental hospitals before the administration of electroconvulsive therapy. (See Appendix) II. CONSENT TO AUTOPSY The consent to autopsy must be properly signed, by whoever is the next of kin or executor of the deceased, before doing the procedure. (See Appendix) 12. REFUSAL TO CONSENT TO AUTOPSY This form should be accomplished in cases where it is applicable, by the next of kin of the deceased. (See Appendix)

13. REQUEST FOR ACCESS TO MEDICAL RECORDS This form must be accomplished by the patient and other authorized parties before any information, of clinical nature, can be released by the hospital or health facility. (See Appendix) 14. NOTIFICATION TO PHYSICIAN OF REQUEST FOR ACCESS For the information of the attending physician, a notification form must be accomplished, every time a request for medical information is received by the Medical Record Service. (See Appendix) 15. CERTIFICATE OF CONFINEMENT This certificate should be accomplished and signed by the medical record supervisor and should bear the hospital seal. It should also have a control number for authentication purposes. (See Appendix) 16. MEDICAL CERTIFICATE This certificate should have a control number. It must be signed by the attending physician and must bear the hospital seal. (See Appendix) 17. DISPOSITION OF CADAVER This form shows all the steps to be taken following the death of a patient. If each item is accomplished correctly, then the hospital and its staff will be free from any legal liability. (See Appendix)

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HANDIlNGlELEPHONEINQUIRIFS The MRS receives numerous telephone calls which involve requests for information. Great care should be taken before giving any form of information. These inquiries may come from the following: A. A doctor asking information about a person who has been a patient in the hospital B. A patient presently confined at the hospital C. A former patient of the hospital who wants information about himself/ herself D. A friend or relative of a patient E. A police officer F. A government agency (e.g., GSIS, SSS, NBI, etc.) The following are the procedures for handling such inquiries. A. . FROM A DOCTOR 1. Ensure that the doctor identifies himself clearly. 2. Find out the name of the patient; date of birth, if possible, or other identifying information; and the approximate date of admission. 3. Locate the patient number from the MPI in order to find the record from the file. 4. The record shall be forwarded to the supervisor of the MRS for him to answer the inquiry. 5. The supervisor shall take the name and address of the doctor for reference purposes. B. FROM A PATIENT I Ask the patient for identifying information and find out what he/she wishes to know. 2. Only the following data can be given directly to the patient without the approval of the attending physician: admission and discharge dates, name of the attending physician, and other sociological data except any clinical information. 3. If an approval has been obtained from the attending physician, the patient may have the right to access. all the clinical information needed. C. FROM FRIENDS AND RELATIVES Any information about a patient shall not be given to the patient's friends or relatives without a written consent. D. FROM THE POUCE Any information regarding patients are not to be released to the police except when there is a written request signed by the head of the police department. The police should be reminded that the said information can only be used for legal purposes.

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E. FROM GOVERNMENT AGENCIES The only information that may be released to government agencies over the telephone are the admission and discharge dates and the name of the attending physician. The patient's written consent shall be required should any additional information be needed.

DEAliNG WfIH PEOPLE WHO COME TO TIlE MEDICAL RECORDS SERVICE A variety of people approach the MRS to make inquiries or to borrow records. The procedures for handling such inquiries are as follows: I. Ascertain who the person is. 2. If the person wants to borrow any record, refer to "Handling Request for Records" (see p. 3).

3. If the person is requesting information about a patient, follow the guidelines in "Handling Telephone Inquiries" (see p. 72) and in the "Release ofInformationPolicy" (see p. 5). . 4. Refer any problem to the medical record supervisor.

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QUAllTY ASSURANCE PROGRAM FOR TIlE MEDICAL RECORD QualityAssurance Program (QAP) is a planned and systematic approach to monitoring and assessing the patient care provided or the service being delivered. Quality Assurance identifies opportunities for improvement and provides a mechanism through which action is taken to make and maintain these improvements. Quality assurance should encompass the evaluation of structure, process, and outcome. Structure factors include components such as staffing, funding, and risk factors. Process, on the other hand, includes the care process and its components like diagnostic, therapeutic, and after effects of care. Outcome factors involve health status components such as physical functioning, patient . or physician satisfaction and wellness level. The essential elements of Quality Assurance activities are as follows:

1.

Planned and Systematic Approach - a quality assurance plan should exist and address the following: a. Scope of the program b. Objective c. Methods to be used d. The individuals to be involved in the program

2. Monitoring - there should be a systematic ongoing process of collecting information on clinical and non-elinical performance.

3. Assessment - the periodic analysis and interpretation ofthe information collected in order to identify problems in patient care.

4. Action - at this stage important problems in patient care or opportunities to improve care are identified, action/ studies are undertaken. 5.

Evaluation - the effectiveness of actions taken is evaluated to ensure long-term improvement.

6. Feedback - to be effective, results of the activities should be regularly relayed to the staff or people involved in the program. 75

Hospital Medical Records Management Manual

I

I

Follow-up

Monitoring

1_ _----. _ _--11 Ir Feedback

.------'1

L . I_ _- - - ,

1

Action

IL-

--.J

Cycle of an Effective Quality Assurance

Benefits that Can Be Derived from the Ouality Assurance Program (OAP); 1. Highest level of care is achieved by assuring the quality and appropriateness of care.

2. The institution can save money by increasing efficiency and/or by reducing risks or simply for cost-containment purposes.

3. The program will result in an effeetive utilization of resources. 4. Adverse effects will be prevented.

The MRS and Quality Assurance Program The Q\P of the MRS shall be an ongoing program. It must look into the effectiveness of the services offered and resource utilization. Some activities in Quality Assurance Programs in the health services are peer review, medical and nursing audit, medical record review, utilization review, morbidity and mortality review, and risk management. The main concern ofQuality Assurance is to subject the structure, process and outcome of health delivery to an objective, professional scrutiny. The objective of the QAP of the MRS should reflect the overall objectives of the organization/ institution.

Objectives: 1. To achieve good health care data/informarion processing and to facilitate the delivery of quality patient care;

2. To attain cost-effective medical record management;

3. To see to it that all the procedures and practices of the MRS conform with acceptable standards; 4.· To assess and determine the quality of service delivered and to identify the areas which need improvement to attain the excellent service delivery; 5. To further improve the services contributed by the MRS in the attainment of the institutional goals and objectives; and 6. To provide feedback to facilitate necessary corrective actions, identify staff in-service training needs, provide an objective basis for disciplinary actions, encourage each employee to achieve the optimum level, and recognize excellence in employee performance in order to institute staff development. 76

Hospital Medical Records Management M~nual STEPS INVOLVED IN DEVELOPING A QUALITY ASSURANCE PROGRAM FOR THE MRS The procedures/steps in the development of a QAP in the MRS are as follows:

1. The identification of problems inherent in specific process or activities involved in medical record management. a. The main activities involved in the Medical Record Management are: recording, assembly, analysis (Qualitative and Quantitative), coding, data collection, statistical preparation, filing ofcharts and indexes, retrieval process, release of medical information, and other legal matters. b. An ongoing QAP shall also be done to study other identified problems. 2. Establishment of the Objective The general objective of Quality Assurance should be to improve the status of service delivery in order to contribute to the improvement of the quality of patient care. . This step should specify what is to be achieved and how to attain the set objective. In stating the objective, use phrases such as "to ascertain", "to . "" n" to determme, . " an d'" to investigate. . " examme , to assess, Example: * To determine the accuracy of documentation through qualitative and quantitative analysis.

*

To assess the effectiveness of the follow-up system employed.

3. Choose the Assessment Method and select the sampler At this stage, the sample size is to be decided on (whether it should be document-based, questionnaire, or direct observation assessment), and the time frame of the program is to be set. Example: * What percentage of the dailyadmission record is to be assessed ? * Until what month should the assessment be done? 4. Develop Criteria and Set Standards Identify the established standards, regulations and performance criteria that have an impact on the MRS. The standards for each criteria may be set individually according to what can realistically be expected or what the goal is (e.g., 80-90%) rather than always being set at the optimum (i.e., 100%). There should be instructions as to the acceptable deviations from the standards. This standard may be reset after the initial survey if circumstances warrant.

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Hospital Medical Records Management Manual

In developing the criteria, select thosewhichcould be compared to the set standards. Criteria should be measurable rather than descriptive.

Example: Element

Standard

Consent forms should be; a. Signed by the patient b. Dated c. Signed by a witness

Yes/No) Yes/No) 100% Yes/No)

5. Assessment of the Actual Procedure The actual procedure undertaken is assessed against the criteria set and the differences are noted. Assessment could be done through: observation, statistical data, random sampling, and reports. 6. Analyze Results Results should be properly analyzed and differences in procedure compared with the criteria set. Determine whether the variation is justifiable. Since individuals absorb information in different ways, it is helpful to summarize results by using more than one method. 7.

Institute Appropriate Action Appropriate action on identified problems must be directed to institute some changes. These changes are as follows: a. Changes in systems and procedures b. Changes in policies, rules, and regulations c. Changes in format of forms d. Better and effective lines of communication

8. Re-evaluation of the corrective actions taken should be done to document its effects and benefits. It is necessary to conduct a follow up study on the same topic to determine whether the problem' has been corrected or. not. When setting priorities in Quality Assurance Projects, the following must be considered: a. Severity of problem b. Potential impact on the service provided and on patient care c. Anticipated benefits (including cost benefits) d. Staff and money resources required for the study, time required to analyze data, and the identified problems e. The potential for correction of the problem

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EXPECTED OUTCOMES OF THE QUALITY ,ASSURANCE PROGRAM L Demonstrable and higher standards of clinical and non- clinical care and service, 2. Identification of barriers in the achievement of higher quality patient care;

3. Motivation for the staff to be more aware of and interested in standards of patient care and service. 4. Delivery of safe and efficient care and service. 5. Efficient and effective allocation and use of resources. 6, Commitment from staffwhich will ensure that the program is ongoing, and improved standards are long lasting. 7.

Construction input, from all staff levels, into the continuing education program of the complex.

8. Communication at all levels about problems related to standards of quality care and service. 9. Cooperative problem-solving, where a service involves more than one area in the complex. The following are examples of medical record qyalitr assurance evaluation forms:

CRITERIA SET ON PHYSICAL FACILITIES AND EQUIPMENT Objectives: L To determine whether there is a separate MRS; 2, To determine if available space is sufficient to accommodate incoming, active, and inactive records;

3. To determine if there is an allocated area to the Medical Record Staff and doctors for the completion of medical records/charts; and 4. To look into the security of the storage/filing area to protect the confidentiality of the Medical Record. Criteria

Sample Standard

Standard

Size

Achieved

L Is there an established MRS/Unit?

N/A

2. Is there a 6Iling area for Active and Inactive In-

N/A

Set Space sufficient to maintain MRD for 25 years based on prospected number of patients. S-yrs. storage space for active file; 2a-years storage for inactive file

j:omments

coming records ?

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Hospital Medical Records Management Manual

Criteria

Sample Standard Set Size

Standard Achieved

3. Is the filing/ storage area secured to ensure the confidentiality of the medical record? 4. Is the area allocated for completing the charts/records, in relation to the number of doctors and staff, enough? 5. Are there enough filing cabinets to accommodate . . . mcommg, active, and inactive records?

N/A

Filing/Storage area secured to prevent unauthorized entry

N/A

There must be a sufficient area where the staff could work and the doctors could complete the charts/ records.

~ommenlS

There must be enough space to accomodate the systematic filing of medical records

Evaluation Criteria (Physical Facility and Equipment) Administrative Function of the Medical Record Service y Criteria I. Is there a manual of procedure prepared bythe Medical Record Supervisor ? 2. Is there a Record disposition schedule approved by management and the govenunent agency concerned ? 3. Is there a policy on release of clinical information? 4. Isthere a program of continuing education/orientation conducted by the MRS?

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N N/A Comments

Hospital Medical Records Management Manual

Policies y

Criteria

N

N/A

Comments

1. Is there a policy formulated for the release of clinical information? 2. Is the policy for the release of information enforced?

3. Are policies written for the information of all concerned? 4. Is the objective of the MRS clearly stated in the policy? 5. Is the policy formulated by the MRS consistent with the hospital-wide policies? 6. Are policies circulated for the information and guidance of all concerned ? 7. Does the policy state the person authorized to enforce it ? 8. Was the policy formulated in consultation with all people affected? 9. Is the policy updated to reflect the latest trends in Medical Record Management ?

CRITERIA SET ON PROCESS Medical Record Management Objective: To determine the qualitative and quantitative aspects of medical records forwarded to the MRS Criteria

Sample Standard

Standard

Size .

Set

Achieved

100 100

-100% 100%

Comments

1. Do all the pages of the record. bear the; - Patient's name - Record No.

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Hospital Medical Records Management Manual

Policies TOPIC: Medical Record Forms

Criteria

Date: y

N N/A Comments

1. Do all forms have space for; a. Nameb. Patient Number 2. Do all forms have space for physician's signature? 3. Do all forms have space where the date could be written by the doctor? 4. Do all forms have the name of the hospital? 5. Do all forms have a control number?

PROCESS TOPIC: Medical Record Content Criteria

y

Date:

_

N N/A Comments

1. Is the sociological data of the

patient complete? 2. Does thehistory of thepatient , contain the following: a. Present history b. Past history c. Family history d. Social history 3. Are theentries signed and dated by the people concerned ? 4. Does the consent form bear the signature of the patient? 5. Isthe consent form dated and signed by a witness? 6. Are all pages of the charts correctly identified? 7. Are all results of the requested examinations properly attached to the chart ?

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Hospital MedicalRecords Management Manual

Criteria

y

N

N/A Comments

8,'Does the discharge note of the nurse state the following: a. The condition of the patient b. The mode of discharge c. The person who was with the patient d. The medication instruction

PROCESS TOPIC: Loose Sheets Criteria

Date: y

N N/A Comments

L Are all loose sheets forwarded to the MRS stamp dated? 2, Are all loose sheets filed as soon as they reach the MRS ? 3. Are loose sheets sorted upon receipt? 4. Are all loose sheets filed in their correct charts ? 5. Do all the loose sheets bear the name and the number of the patient? 6. Does the MRS maintain a record ofloose sheets?

,

PROCESS TOPIC: Disease and Operation Coding Criteria

Y N

,

Date: N/A Comments

L Are all procedures properly coded ? 2. Are all diagnoses coded ? 3. Does the disease index card contain only one diagnosis? 4. Does the operation index card contain only one procedure'?

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Hospital MedicalRecordsManagement Manual

Criteria

y

N

N/A Comments

5. Are the disease and operation index cards arranged according to disease and operation numbers ? 6. Isthe morphology code (M code) used in coding neoplasms? 7. Are the disease and operation indexes updated daily? 8. Are abbreviated final diagnosis coded? 9. Are all diagnosis written on the chart located on the coding tools used?

PROCESS TOPIC: Filing and Retrieval Criteria

Date: y

N

N/A Comments

I. Is the terminal digit filing

system employed? 2. Are records sorted prior to filing? 3. Is the unit numbering system used? 4. Does the MRS maintain active as well as inactive files ? 5. Does the MRS maintain a centralized records keeping system? 6. Are there captions to guide the filing and retrieval process? 7. Isthe file area secured to prevent unauthorized entry? 8. Are the cabinets arranged for a minimum of walking? 9. Does the MRS maintain the following indexes; a. MPI b: Disease index c. Operation index d. Physician's index 84

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Criteria

o'

y N

N/A Comments

10. Are the following registers maintained by the MRS: a. Admission and discharge b. OPDand ER c. Birth and Death d. ORand DR

PROCESS TOPIC: Unlocated Records Criteria

Date:

Y N

N/A Comments

1. Are all requested records located ? 2. Are all requested records entered intot:he ~systm1emp~? 3. Is the in-house box updated daily ? 4. Are all therecords in their proper filing places? 5. Are incomplete records filed in their respective pigeon holes? 6. Are all the records lent emproperly acknowledged by the authorized borrower? 7. Does the SOP clearly state the time element in borrowing charts?

CRITERIA SET ON OUTCOME TOPIC: .Retrieval.and Completion Times Date: Objective: 1. Todetermine whether incomplete records of in-patients are completed within 48 hours after discharge . . 2. To assess if a research list can be promptly obtained from the disease and operation indexes 3. Toassess if a research "Jist can be promptly obtained from the diseases and operation indexes 4. To be able to determine whether records are available any time they are requested

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CRITERIA ESTABLISHED Criteria

Sample Standard Set Size

90% 1. Are records 50 completed within requests 48 hours after ,patient's discharge? 50 2. Cana research list furnished by reqoess researchers, promptly be obtained from the disease or operation indexes? 3. Are all requested 50 records made requests available to borrowers?

RECOMMENDATIONS:

FOLLOW-UP:

EVALUATION:

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100% except records not yet forwarded to the MRS

100% except for charts not yet forwarded to the MRS and records under process

Standard Achieved

Comments

Hospital MedicalRecords Management Manual OUTCOME TOPIC: Assessment of Q!lalityAssurance Program Objectives: 1. To know the extent of the implementation of the recommendations as a result of the Quality Assurance P-rogram 2. To determine whether there is an improvement in communication with services/departments concerned as a result of the Quality Assurance Program . 3. To determine whether there is a need to change or revise systems and procedures as a direct result of the Quality Assurance Program 4. To be able to know whether there is a need for staff training after analysis and evaluation of the result of Quality Assurance datagathering 5. To know if results and recommendations have reached the people concerned

CRITERIA ESTABLISHED Criteria

Standard Set

Standard Achieved

Comments

1. What is the percentage of 75.:s00f0 implementation of recommendations and suggestions made? 2. Hascommunication improved between departments concerned as a result of the Quality Assurance Program ? 3. As a result of the Quality Assurance Program, is there a need to revise or change some systems and procedures? 4. Is there a need to re-train the medical record staff?

RECOMMENDATIONS:

FOLLOW-UP:

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· QUALITY ASSURANCE ACTMTY SUMMARY SHEET

TOPIC:

Problems Identified:

Action:

Follow-up:

Review Date:

_

QA. Coordinator Date signed:

-

,

_ _

.

"QUALITY ASSURANCE STIJDY

Name of Hospital

FORM A . CRITERIA TOPIC:

_

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1

·a ··,N· o.

_

S

· 1

e. r

Dale

Criteria ..

t a n d a r d

Exceptions .'

Instructions for retrieval of data

0I0-

1

2 3

-4

5 6 7 8

9 10

.

QUALITY ASSURANCE STUDY

NAME OF HOSPITAL

FORM B -WORK DOCUMENT

.TOPIC

Page Date

_

I

_ _

I

CRITERIA

';.~

Document Number

,

.

.

•

QUALITY ASSURANCE STUDY

NAME OF HOSPITAL FORM C -SUMMARY

TOPIC

_

. Study Objectives

No.

Criteria Results

Date

Source Document(s) No. in study Tune period mstudy _LJ- to ----l----l_ Assessment method Original study? _~ Date oforiginal study ----l----l_ Overall Total No.

Rate in °/0

CONCLUSION/PROBLEMS/ RECOMMENDATIONS/ACTION/FOLLOW-UP

..

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.

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....

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MEDICAL RECORD FORMS A form is an intelligence document, an advisor, an instruction, and a record. It is also an instrument to collect, record, transmit, request, report, evaluate, store, and retrieve data. A well-thought and properly-designed form facilitates the collection of only the needed and relevant data and thus prevents the excessive use of resources. Research shows that a hospital spends at least 1% to 2% of their entire expenditure on the printing and supply of medical record forms. With the present escalating hospitalization cost beyond the reach of an ordinary Filipino citizen, coupled with general economic recession, there is an urgent need to cut down on health care expenditures. However, cost control measures must be achieved by the standardization of forms used in the MRS and not by sacrificing overall quality care. In 1969, a study group from the World Health Organization (WHO), recommended that "consideration should be given to standardizing the medical record at the national level, to include the size of the folder, the size of the record form, and the content of the case summary. This should be within an individual hospital or with all hospitals of a system." Effectiveforms management should be an integral part of medical record management. A Forms Committee shall be established to help the Medical Record Supervisor in determining forms needed by the hospital as well as in the proper design of the forms. The function of the Forms Committee can also be performed by a Medical Record Committee, if this committee is already in existence and should management decide. Medical record forms consist of standard/basic and supplemental/special forms. Standard forms are those that are commonly found on all patient charts. Supplemental forms are forms added to selected patient's chart during their hospitalization. The addition of supplemental forms depends upon the patient's care and treatment. Some hospitals usually include other forms which the MRS and the Forms Committee has approved. These forms could also be considered "standard forms" for their own hospital only.

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Hospital Medical Records Management Manual

All hospitals have forms that correspond to the ten "BASIC" or "STANDARD FORMS" only they may be called differently. Some of the common names of the basic forms are as follows: 1. Admission-Discharge Record, Summary Sheet, In-patient Summary, Patient Information Sheet, Patient's Identification, Clinical Cover Sheet, Face Sheet 2. Conditions of Admission and Authorization for treatment 3. Personal History Record 4. Physical Examination Record 5. Physician's Order and Doctor's Order Sheet 6. Laboratory Record, Laboratory Report, Laboratory Results 7. Clinical and Graphic Record - Graphic Chart and Temperature, Pulse, and Respiration (TPR) Chart 8. Progress Record, Progress Notes, Progress Doctors's Notes 9. Nurses' Notes - Nursing Record and Bedside Record 10. Discharge Summary

SUMMARY OR FACE SHEET The summary or face sheet is used to summarize the patient's hospital stay. The attending physician usually accomplishes this form at the patient's dischargedate. Other information about the patient (e.g., admission diagnosis, relatives ofthe patient, health insurance policy, etc.) may be included.

LABORATORY REPORT The laboratory report sheet is used for filing reports of laboratory findings. This sheet must allow the results of the laboratory tests to be pasted systematically.

GRAPHIC SHEET OR CLINICAL RECORD The graphic sheet is a graphic representation of the patient's vital signs (e.g., TPR and blood pressure) for the period of hospitalization. Vital signs are normally taken at least twice a day or depending on the doctor's order. Information on other treatments and measurements (e.g., enemas, bowel movements, height, weight, intake and output) may also be recorded on the Clinical Record Sheet.

MEDICATION RECORD This form contains all the medications given by the nursing staff. As new medications are ordered by the attending physician, the name of the drug, dosage, administration route, and frequency of administration are all written on this form.

PROGRESS NOTES This form should provide a summary of the condition of the patient upon admission and the chronological record of the patient's progress. This form should record consultations, complications, condition of surgical wounds, development of infection, removal of sutures and drains, use of casts and splints, and any other pertinent data. Progress Notes should conclude with a summary of the case with condition on discharge.

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APPENDICES

HospitalMedical RecordsManagement Manual

SUPPLEMENTAL CHARTFORMS

to

Supplemental forms are added the basic chart forms to make it complete as required by the case.Some supplemental forms may be considered basic forms by a certain type of health care booty, but other hospitals may not This classification of the different kinds of forms in the medical record is influenced by the type of health care facility. For example, a maternity hospital may consider pre-natal form as a basic form, but a pediatric hospital may regard this as a supplemental or special form. Some of the common supplemental forms are as follows: 1.

OPERATING ROOM RECORD Operating room record is a part of the "Operation Block." Other forms that goes with the operation block are the consent for surgery, anesthesia record. and the recovery room record. When a tissue is removed, there shall be a tissue report or biopsy report. TISSUE/BIOPSY REPORT - Where a tissue is removed during operation a tissue/biopsy report should be forwarded to the pathology section together with a corresponding request. The original copy of this report shall become part of the medical record.

2. CONSULTATION FORM A doctor may wish to obtain the opinion of another doctor or specialist. in which case, a consultation form is accomplished. This is also the same form where the consultant writes his findings.

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3. DIABETIC RECORD This form is placed in the charts of patients who are receiving medication for diabetes. The form also contains the results of blood test and urine studies done to monitor the effects of diabetic medication.

4. ANTI-COAGULANT THERAPY RECORD 5. VITAL SIGNS RECORD 6. PULMONARY LABORATORY BLOOD GAS ANALYSIS. t.

7.

PULMONARY FUNCTION TEST

8. FLUID INTAKE AND OUTPUT CHART 9.

PARENTERAL FLUID SHEET

10. INTRAVENOUS FLUID SHEET

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HospitalMedical RecordsManagement Manual

TI-lE CONCEPr OF "SET"AND "BLOCK" FORMS The concept of" set" and" block" forms in the medical record helps to determine the completeness of the medical record. . . A "set" is a collection of forms of the same type treated as a unit. A good example of this are the progress notes, nurses' notes, 'ere, A "block" is a collection of different types of forms' treated as a unit. Examples of blocks .. are Operation block, Delivery block, and Electrocardiogram (ECG/EKG) block. Thorough knowledge of the different components of a block facilitates faster quantitative analysis of the medical record. A procedure considered to le one of the major functions of the Medical Records Service.

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I1STING OF COMMON MORTAlITY; MORBIDITY: AND CONSULTATION DIAGNOSIS IN GOVERNMENf HOSPITAlS This listing includes the most common diagnosis, operation, and procedures reported by government hospitals. The following data weretaken from statistical and other reports prepared by the different hospitals. The disease and operation index of some assessed and evaluated hospitals were likewise used as a source material for this listing.

DISEASES/CONDITIONS OPERATIONS/PROCEDURES

ICD 9 CODE NO.

ABORTION Complete abortion Incomplete abortion Spontaneous abortion Threatened abortion

6J1.9 6J1.8 6J1.9 634.9 640.0

ACCIDENTS· Dislocations Food poisoning (NOS) Fractures Physical Injury Trauma and other current injuries

E928.9 830-839 005.9 800-829 830-839 959.9

ACCIDENT. CEREBROVASCULAR (CVA) With paralysis Old or healed with paralysis

436 436 & 344.9 344.9 & 438

ACQUIRED IMMUNEDEFICIENCY SYNDROME (AIDS) (NOS) With specified infection Causing other specified infections With specified malignant neoplasms

044.9 042.0 042.1 042.2

ADMISSION FOR Chemotherapy Radiotherapy (solely)

V58.1 . V58.0

ADVERSE EFFECTS. DRUGS (NOS)

995.2

AMOEBIASIS Amoebiasis colitis Amoebiasis, Instestinal Amoebic Dysentery

006.0 006.9 006.1. 006.0

ANEMIA Anemia with hypotension Chronic blood loss anemia Iron-deficiency anemia Pernicious anemia Posthemorrhagic anemia Severe anemia

285;9 285.9, 458.9 280 280 281.0 , 285.1 289.8

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DISEASES/CONDITIONS .OPERATIONS/pROCEDURES

ICD 9 CODE NO.

ANGINA PECTORIS

413

ANOPLASTY

5-4%

ANOREXIA(loss of appetite) ANXIETYSTATE APPENDICITIS (NOS) Appendicitis; acute Appendectomy Rupture Inflamed appendix

783.0

AKfHRITIS. RHEUMATOID. CHRONIC ASPHYXIA NEONATURUM

300.0 541 540.9 5-470 540.0 714.0 768.9

ARREST Cardiac Cardiorespiratory Respiratory

427.5 799.1 799.1

ARl"ERIOSCLEROSIS. ARl"ERIOSCLEROTIC Cardiovascular disease ASCVD Cerebrovascular disease Extremities (peripheral) Generalized Heart (disease) ASHD

429.2 437.0 440.2 440.9 414.0

ARTHRALGIA (pain in joint)

719.4

ARTIFICIAL OPENING STATUS Colostomy Cystostomy Gastrostomy Ileostomy Other artificial opening, Gastrointestinal tract Other artificial opening, Urinary tract Other specified site (NOS)

V44.3 V44.5 V44.1 V44.2 V44.4 V44.6 V44.8

ASCITES. ABDOMINAL

789.5

ATELECTASIS. PULMONARY

518.0

BELL'S PALSY

351.0

BIOPSY OF CERVICAL LYMPH NODE

1-586

BLEEDING. POST MENOPAUSAL (PMB)

627.1

BLOCK. LEFT BUNDLE BRANCH BRONCHITIS (NOS) Acute Bronchitis Asthmatic Emphysematous

426.3 490 466.0 491.2 491.2

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DISEASES/CONDmONS OPERATIONS/pROCEDURES . . . .

ICD 9 CODE NO.

BRONCHOSCOPY WITH BIOPSY

1432

BURNS erythema (first degree) blisters, epidermal loss (second degree) full-thickness skinloss(third degree, NOS) deep necrosis of.underlying tissues (deep third degree)

949.0 .1

CESAREANSECTION low segment (low transverse) classical cervical extraperitoncal ceasarean section

5-74 5-741 5-740 5-741 5-742

.2

.3 .4

CARCINOMA (See Neoplasm, Malignant) CATARACT mature (senile) presenile

366.1 366.0

PHYSICAL CHECK-UP

V70.0

CHEILOPLASTY

5-898

CHOLECYSTECTOMY WITH INTRAOPERATIVECHOLLANGIOGRAM

5-511

CHOLERA

001.9

CIRRHOSIS. LIVER

571.5

CLEFT LIP & PALATE

749.2

COLD. COMMON. COLITIS