HEALTH RECORDS

MANAGEMENT 1

BY Elizabeth

04/25/2025 1
MODULE 1: HEALTH RECORDS MANAGEMENT- I

• CODE: HRM 106

• MODULE COMPETENCE
• This module is designed to enable the learner organize and manage
health records.
• MODULE OUTCOMES
• By the end of this module, the learner should;
1. Explain an overview of the health records discipline, values, uses and
its organisation
2. Develop the procedures used in reception, registration, and initiation
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3. Organize and manage patients schedules, follow-ups, clinic
preparation procedures, admissions and discharges
4. Create and maintain health records indices
5. Establish and Maintain the system of storage, retrieval and control of
health records

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MODULE UNITS
NO UNITS NAME

1 Introduction to Health Records Management

2 Functions of a health records department

3 Qualities of a health records and information technician

4 Categorize types of health records and their sources

5 Organization and management of reception, registration and initiation of patient/client health

records

6 Organization and management of Health Records

7 Organization and management of patient/client schedules, follow-ups and clinic preparation

procedures

8 Organization and management of admission and discharges of patients

9 Management and Maintenance of health Records

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04/25/2025 5
Unit 1: Introduction to Health
Records Management
• Definition of terms
Records: Document that memorializes and provides objective evidence of activities
performed, events occurred, results achieved, or statements made.
Records are created/received by an organization in routine transaction of its
business or in pursuance of its legal obligations. A record may consist of two or
more documents.

All documented information, regardless of its characteristics, media, physical form,

and the manner it is recorded or stored. Records include accounts, agreements,
books, drawings, letters, magnetic/optical disks, memos, micrographics, etc.
Generally speaking, records function as evidence of activities, whereas documents
function as evidence of intentions.
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• Health records:- ​A health record is a confidential compilation of pertinent
facts of an individual's health history, including all past and
present health conditions, illnesses and treatments, with emphasis on the
specific events affecting the patient during the current episode of care

• Its any written information about a patient in a professional relationship

with a doctor.
• A health record is a confidential compilation of pertinent facts of an
individual'shealth history, including all past and present medical conditions,
illnesses and treatments, with emphasis on the specific events affecting
the patient during the current episode of care.
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• Public records:-are documents or pieces of information that are not
considered confidential and generally pertain to the conduct of government.
Eg
• Records of law court proceedings
• Marriage records
• Death records
• Voting rolls

Medical records: collection of facts about a patient health history including the
past and present illness and treatment given in an health care setting
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HISTORICAL BACKGROUND OF HEALTH RECORDS
DISCIPLINE

Learning Objectives
• The learner should be able to:-
• Define health records
• Give a historical background of health records discipline
• Define a health records department
• Enumerate the functions of a health records and information
department
• Explain the various functions of a health records and information
department
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historical background of health
records
The history of health records runs parallel with the history of medicine.
Records are as necessary for the practice of medicine as medications
are for effective treatment and they can be traced back to ancient
times. The earliest records were primitive in form and very different
from present health records, but they served to record health
achievements for later generations.
As time went on, health records became more detailed and in Egypt,
Greece and Rome physicians wrote important health and surgical
treatises.

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Egyptian period
• The first real physician of record in Egypt is Imhotep. He lived in the Pyramid Age
( around 3000 – 2500BC) and was a grand vizier, chief architect, and royal health
adviser to a pharaoh of the twenty-ninth century before Christ. He was IMHOTEP
• The ancient Egyptians were meticulous recorders of their history and they had
thousands of scribes to record it. Scribes were considered to be highly educated.
• Egyptian scribes were the forerunner to our modern day transcriptionists. health
information was transcribed on scrolls of papyrus, a material that was made
from a water plant. Egyptian records reveal that medicine was being practiced in
its many forms, from surgery to general medicine and even dentistry, more than
4000 years ago. And whilst x-ray reports are likely to be missing from these
records, the odd diagram might have been used. Like in Mesopotamia, much of
their medicine was still linked to magic, astrology and astronomy.

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• The hot Egyptian climate has been excellent in preserving these
health records. It’s almost like an ancient form of hard drive or cloud
storage. But unlike our health records, the Egyptians had to make
many duplicate copies by hand – can you imagine – no keyboard, no
typewriter and a Dictaphone would have been out of the question.

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Illustration of the ancient record

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• Imhotep has been credited with the authorship of Edwin Smith
papyrus, which is one of the most valuable ancient health documents
that has come down to us and appears to have been copied 1600BC
from an earlier original. It is a roll of over 15ft long and 13ft wide and
is made up of 12 sheets of the usual size. It is written on both sides
and consists of 48 cases of clinical surgery.

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Ancient Greek and Roman health Records

• Greek and Roman health records tend to overlap, with both

civilizations creating a systematic recording system more than 2000
years ago. The battle between Apple and IBM definitely has some
roots in industry.
• Greek and Roman records had a much more contemporary focus,
reducing the emphasis on magic and astrology. There is more of a
logical and scientific train of thought with descriptions of a patient’s
mental and physical history. However, the gods are still mentioned,
and we’re not talking about surgeons! Locals felt that the gods were
able to cause disease and that illness was viewed as a result of the
gods’ displeasure. Greek and Roman health records were transcribed
on parchment, which is prone to disintegrating, a problem our
modern electronic counterparts don’t have
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• Greek medicine was not purely Grecian, but was influenced by
contributions from older civilizations, especially those of Egypt,
Babylonia, and Assyria.
• This in no way reduces the credit to the Greeks for introducing the
scientific spirit into the art of healing, but merely indicates the various
sources from which they were able to draw information.

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• .in Greece Hippocrates, known as “father of modern medicine” was
born about 460 BC. He was the first to cast out superstitions and to
practice medicine in scientific principles.
• He was the author of Hippocratic oath which is pledged by physicians
and which states in part “ whatsoever in my practice or not in my
practice, I shall see or hear amid the lives of men which ought not to be
noised – as to this I shall keep silence, holding such things unfit to be
spoken.”
• Thus originated the privacy of all information given to the physician by
the patient, eventually the health records persee was also considered as
a privileged communication.
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• Hippocrates kept detailed case reports of his patients.
• In the 18th century, Benjamin Franklin established the first
incorporated hospital in united states. The institution is now known as
Pennsylvania hospital established in Philadelphia in 1752. Franklin
served as the secretary and many of its earliest records are in his
handwriting.
• In 19th century, -1821- the famous machachussets general hospital in
Boston opened. It has a distinction of having complete file of clinical
records with all cases catalogued from the day it opened.

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• In 20th century, this is the era when health records was received serious
consideration by other hospitals and the health association.
• In 1902, the American hospital associations discussed health records for the
first time at a convention
• In 1948 health records association was started in Britain
• In 1967, the department of health records was started in kenya- KNH in
Nairobi
• In 1978, the health records and information technician was started at health
training college – Nairobi
• in 1990, the health records and information officers was started at kenya
health training college – Nairobi
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Thereafter many campuses have so far been opened including –
• Mombasa,
• -Siaya, -Kuria, - etc
• -Lamu, -Chwele,
• -Lugari, -Webuye ,
• -Msambweni, Kaptumo,
• -Murang’a, – Isiolo,
• Mt kenya university
• -Othaya, -Kitui
• -Rachuonyo, -Bondo,

• -Rera, -Maanza,

Indicate the year they were established

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• Bachelors of science in health records and information management
was started at Kenyatta university in 2009, later other universities like
MKU, were started
• Currently health records and information officers can enroll in masters
in various institutions

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Summary
• The history of health records, from the earliest beginnings to the present time,
has continued unbroken, even though greater progress has been made in some
periods than in others. The mid-twentieth century brought in an era in which all
health professionals and hospital associations are united in the same primary
goal-to take proper care of the sick and injured.
• A health record must be maintained on every person who has been admitted to
the hospital as an in-patient, out-patient, or as an emergency patient. The health
record, documents the hospital experience of the patient. Other purposes are to
serve as a basis for continuity in the evaluation of the patient’s condition and
treatment, to assist in protecting the legal interests of the patient, the hospital,
and the doctors, and to provide data for use in research and education.
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 Key points to remember

• The earliest records were primitive in form and very different from the
present health records, but they served to record health achievements
for later generations
• A health record must be maintained on every person who has been
admitted to the hospital as an in-patient, out-patient, or as an
emergency patient.
• The content of the health record is developed as a result of the
interaction of the members of the healthcare “team” who use it as a
communication tool
• The purpose of health records is to serve as a basis for continuity in the
evaluation of the patient’s condition and treatment
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Health records ethics
• health Record Administration is concerned with the development,
use, and maintenance of health and health records for health care
and treatment, administrative, reference, professional education and
research purposes. health record practice is a trust delegated by the
health and health services.
• To protect and merit the trust placed in it, the health record
profession has the responsibility of defining basic principles governing
the professional conduct of its members.

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DEFINITION:
• The legal health record is the documentation of healthcare services provided to an
individual during any aspect of health care delivery in any type of healthcare
organization. It is consumer or patient-centric.
• The legal health record contains individually identifiable data, stored on any
medium and collected and directly used in documenting healthcare or health status
• Legal ethics is the minimum standards of appropriate conduct within the legal
profession.
- It is the behavioral norms and morals which govern judges and lawyers
- It involves duties that the members owe one another, their clients and the courts
- Ethics- moral principles that govern a persons behavior or the conducting of an
activity

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Health records ethics cont…
The following code of ethical conduct defines the tenets necessary for
carrying out the purposes of the health record profession, is binding
upon any member of the health Record Association, and upon any
person, certified, registered, or accredited by this Association. As a
member of one of the health professions, he shall:

1. Place service before material gain, the honor of the profession

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

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2. Preserve and protect the health records in his custody and hold inviolate the privileged
contents of the records and any other information of a confidential nature obtained in his
official capacity, taking due account of applicable statutes and of regulations and policies of his
employer
3. Serve his employer loyally, honorably discharging the duties and responsibilities entrusted
to him, and give due consideration to the nature of these responsibilities in giving his employer
notice of intent to resign his position.

4. Refuse to participate in or conceal unethical practices or procedures.

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

.
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6. Preserve the confidential nature of professional determinations made by the staff committees
which he serves.

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

8. Avoid encroachment on the professional responsibilities of the health and other health care
workers, and under no circumstances assume or give the appearance of assuming the right to make
determinations in professional areas outside the scope of his assigned responsibilities.

9. Strive to advance the knowledge and practice of health record administration, including continued
self-improvement, in order to contribute to the best possible health care.

10. Participate appropriately in developing and strengthening professional manpower and in

representing the profession to the public.

11. Discharge honorably the responsibilities of any Association post to which appointed or elected,
and preserve the confidentiality of any privileged information made known to him in his official
capacity.

12. State truthfully and accurately his credentials, professional education, and experience in any
official transaction with the health Record Association and with any employer or prospective
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employer
• Health ethics may be defined as a code of behaviour accepted
voluntarily, within the profession as, opposed to laws, regulations and
directives issued by official body or scientific study of morality, it
teaches us how to judge accurately the moral goodness or badness of
human action.
•
• Public Health Ethics - concerns the professionals, individuals and the
community at large. Focus on the mandate to assure and protect the
health of the public-which is inherently moral

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Basic Ethical Principles
(General)
There are five widely accepted ethical principles as put forward by Thiroux, 1995.

1. The Principle of Autonomy:

• This principle means that people, being individuals with individual differences must have a
freedom to choose their own ways and means of being moral with the framework of the other
four principles. Respect for autonomy involves respecting another person’s rights and dignity such
that a person reaches a maximum level of fulfillment as a human being. In the context of health
care this means that the relationship between clients is based on a respect for him or her as a
person and with individual rights.
•
Any notion of moral decision-making assumes that rational agents are involved in making
informed and voluntary decisions. In health care decisions, our respect for the autonomy of the
patient would, in common parlance, imply that the patient has the capacity to act intentionally,
with understanding, and without controlling influences that would mitigate against a free and
voluntary act. This principle is the basis for the practice of "informed consent" in the
physician/patient transaction regarding health care. (See also Informed Consent.)

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• Rights in relation to health care are usually taken to include:
• • The right to information
• • The right to privacy and confidentiality
• • The right to appropriate care and treatment

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2. Beneficence (doing good)
• Frankena (1963) suggests that beneficence means doing or promoting good as
well as preventing, removing and avoiding evil or harm.
• E.g. Giving clients clean needles, condoms and provide information about
emergency first aid to reduce the risks of HIV infection or accident. The ordinary
meaning of this principle is that health care providers have a duty to be of a
benefit to the patient, as well as to take positive steps to prevent and to remove
harm from the patient. These duties are viewed as rational and self-evident and
are widely accepted as the proper goals of medicine. Â This principle is at the
very heart of health care implying that a suffering supplicant (the patient) can
enter into a relationship with one whom society has licensed as competent to
provide medical care, trusting that the physician’s chief objective is to help. The
goal of providing benefit can be applied both to individual patients, and to the
good of society as a whole. For example, the good health of a particular patient
is an appropriate goal of medicine, and the prevention of disease through
research and the employment of vaccines is the same goal expanded to the
population at large
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3. Non-maleficence (doing no harm)
• Non-maleficence holds a central position in the tradition of medical
ethics and guards against avoidable harm to subjects.
• The principle of non-maleficence requires of us that we not
intentionally create a harm or injury to the patient, either through
acts of commission or omission. In common language, we consider it
negligent if one imposes a careless or unreasonable risk of harm upon
another. Providing a proper standard of care that avoids or minimizes
the risk of harm is supported not only by our commonly held moral
convictions, but by the laws of society as well (see Law and Medical
Ethics). This principle affirms the need for medical competence. It is
clear that medical mistakes may occur; however, this principle
articulates a fundamental commitment on the part of health care
professionals to protect their patients from harm.
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4. Justice (fairness)
• This principle states that human being should treat other human being fairly
and justly in distribution goodness and badness among them. In other words
justice should include:
• • Fair distribution of scarce resources
• • Respect for individual and group rights
• • Following morally acceptable laws
• Justice in health care is usually defined as a form of fairness, or as Aristotle
once said, "giving to each that which is his due." This implies the fair
distribution of goods in society and requires that we look at the role of
entitlement. The question of distributive justice also seems to hinge on the fact
that some goods and services are in short supply, there is not enough to go
around, thus some fair means of allocating scarce resources must be
determined
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In fact, our society uses a variety of factors as criteria for distributive
justice, including the following:
• To each person an equal share
• To each person according to need
• To each person according to effort
• To each person according to contribution
• To each person according to merit
• To each person according to free-market exchanges
(Beauchamp & Childress, 1994, p. 330)
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5. The principle of truth telling (honesty)
• At the heart of any moral relationship is communication. A necessary
component of any meaningful communication is telling the truth, being honest.

• Ethical rules
The ethical rules of health professional, like principles, are not absolute in that
one may override another although clearly this must be justified. These rules are
essential for the development of trust between health professional and patients.
Like the ethical principles on which the rules are based, there are four:
• Veracity
All patients in any health institution should always be told the truth. There is no
justification for lying, but this is not the same non-disclosure of information
should it.
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• Privacy
When patients enroll in a health institution, they grant access to themselves, but this is
not unlimited access. Access is a broad term and generally includes viewing, touch or
having information about them.

• Confidentiality
Although someone may grant limited access to him or herself, they may not relinquish
control over any information obtained. Certainly, no information obtained with the
patient’s permission from their medical records should be disclosed to any third person
without that individual’s consent. This applies to conversations too.

• Fidelity
Fidelity means keeping our promises and avoiding negligence with information. If we
agree for example, to send a summary of our research findings to participants in a study
we should do so.
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Current and future status of health records
(contemporary issues)
History and Evolution of Health Care Information Systems
• Definitions
• An Information System is an arrangement of information (data), processes,
people, and information technology that interact to collect, process, store,
and provide as output the information needed to support the organization

• Information Technology describes the combination of computer technology

(hardware and software) with data and telecommunications technology (data,
image, and voice networks).
• Electronic health Record: is the systemized collection of patient and
population electronically-stored health information in a digital format

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• eHealth is a broad term, and refers to the use of information and
communications technologies in healthcare. ...

• “...an emerging field in the intersection of medical informatics, public

health and business, referring to health services and information
delivered or enhanced through the Internet and related technologies

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Definition of terms

• Internet- a global computer network providing a variety of information and

communication facilities consisting of interconnected networks using
standardized communication protocols
• Intranet-local or restricted communication network especially a private network
created using a world wide web software
• Extranet- an intranet that can be partially accessed by authorized outside users ,
enabling businesses to exchange information over the internet in a secure way
• Ethernet- a system for connecting a number of computer systems to form a
local area network, with protocols to control the passing of information and to
avoid simultaneous transmission by two or more systems
• Firewall- is a system designed to prevent unauthorized access to or from a
private network. You can implement a firewall in either hardware or software
form, or a combination of both. Firewalls prevent unauthorized internet users
from accessing private networks connected to the internet, especially intranets
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Global Positioning System (GPS): An agricultural producer may use a
handheld GPS receiver to determine the latitude and longitude
coordinates of a water source next to a field or vineyard
geographic information system, GIS - a system for storing and
manipulating geographical information on computer.

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• Electronic patient record-EPR- it is essentially the same definition as
the electronic medical record. It is an electronic record of periodic
health care of a given individual, provided mainly by one institution.
The term is more patient centric than is the EMR
• Electronic health record-EHR/EMR is the systematized collection of
patient and population electronically-stored health information in a
digital format. These records can be shared across different health
care settings
• Computer based patient record –CBPR-it is an interpreted electronic
system that contains patient information. (also known as CPR). It is an
electronic patient record that resides in a system specifically designed
to support users by providing accessibility to complete and accurate
data, alerts, reminders, clinical decisions support systems, links to
medical knowledge, and other aids.
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• Automated medical records system – AMS- these are records that
have been operational for two years maintaining the medical records
for 20,000 people who have made a total visits of 80,000. the
principal data source is a structured encounter form that is filled out
by the care provider at the time of each visit
- These terms have been used interchangeably but some specific
differences have been identified eg EPR has been defined as electronic
health care of periodically health care of a single individual provided
mainly by one institution. The term is patient centric than EMR

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• Telemedicine- the remote diagnosis and treatment of patients by
means of telecommunications technology
• Telehealth- the provision of health care remotely by means of
telecommunications technology
- It’s the remote exchange of data between a patient at home and their
clinicians to assist in diagnosis and monitoring typically used to
support patients with long term conditions
Difference between telehealth and telemedicine – telehealth refers to
non clinical services , such as provider training, administrative
meetings, and continuing medical education in addition to clinical
services. Telemedicine is a subset of telehealth that refers solely to the
clinical health care services
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• M-health- mobile health – is a general term for the use of mobile phones and
other wireless technology in medical care. The most common use of mhealth is
the use of mobile devices to educate consumers about preventive health care
services
• E-prescribing- or electronic prescribing is a technology framework that allows
physicians and other medical practitioners to write and send prescriptions to a
participating pharmacy electronically instead of using handwritten or faxed
notes or calling in prescriptions
• Electronic health records- or electronic medical record, is a sytemised collection
of patient and population electronically-stored health information in a digital
format. These records can be shared across different health care settings
• Health care information systems- eg Master Patient Index, medical billing
software, patient portals; also health information system:- refers to a system
designed to manage health care data. This includes systems that collect, store,
manage ,and transmit a patients electronic medical record (EMR) in a hospitals
operational management or a system supporting health care policy decisions 45
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Types of Health Care Information
Systems
• Administrative Information System
• Primarily administrative or financial information
• Used to support management functions and general operations
• Human Resource Management, Materials Management, Patient Accounting or Billing,
Staff Scheduling
• Clinical Information System
• Contains clinical or health-related information used by providers in
diagnosing, treating, and monitoring
• Department: radiology, pharmacy, laboratory systems
• Clinical decision support: medication admin, CPOE, EMR

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Types of health care information systems
Healthcare information systems capture, store, manage, or transmit
information related to the health of individuals or the activities of an
organization that work within the health sector. There are many different
types of healthcare information systems, including:
1. Operational and tactical systems for easy classification of information.
2. Clinical and administrative systems for managing patient details on an
administrative level.
3. Subject and task based systems such as Electronic Medical Records
(EMRs) or Electronic Health Records (EHRs).
4. Financial systems for tracking revenue and managing billing submissions.
These systems are designed to assist healthcare providers with managing
daily tasks and patient information. Often, these types of systems are broken
up into different software solutions, but what if you could have all of these
systems
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packaged into one convenient software solution? 47
History and Evolution
• Policy and market innovations and correlations with IT was the first to
Demand for IT driven largely by the market (follow the money). The dollar seems to
be a better motivator than “doing the right thing”
• In 1991 IOM (institute of medicine) report presented a report on – The
Computer-Based Patient Record: an Essential Technology for Health Care;
it was Called on the adoption of computer-based records by the year
2001
• HIPAA in 1996 adapted integration of IT in health care
• IOM (institute of medicine): instituted the slogan ‘To Err is Human’ in the
year (2000)
• IOM Patient Safety: introduced Achieving a New Standard for Care (2004)
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 The key challenges
(adapted from Coiera p 104)

• How do we apply knowledge to achieve a particular

clinical objective?

• How do we decide how to achieve a particular

clinical objective?

• How do we improve our ability to deliver clinical

services?

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Challenges to eHealth
1. Ensuring data security and data protection was highlighted as the biggest
challenge. Patients and healthcare professionals alike need to feel one
hundred per cent confident about the confidentiality of digital health
systems.
2. Healthy investment. It was revealed that EU Governments and private
healthcare providers are forecasted to invest a staggering €12.7 billion by
the year 2018 into eHealth systems. The returns are predicted to be even
greater.
3. Engaging and training doctors, nurses and other healthcare professionals, in
the new technologies are essential. As well as creating a digitally savvy
workforce, patient populations have to be educated to ensure that the
potential of efficient healthcare systems are maximized.
4. Apps for healthcare, of which there are more than 100,000 now available,
need to be better absorbed into healthcare systems. They also need to be
rationalized, s standardized and simplified to aid value and usability.
5.
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Looking for and recruiting new IT talent. 50
• 6. Together! By pooling knowledge and resources across surgeries,
hospitals and countries integrated eHealth systems can be developed
faster and for the good of all. Tweets revealed that delegates at the
EU eHealth Week were keen advocates of ‘sharing best practice.’
• 7. Healthcare professionals and a patient-centric imperative have to
be at the center of all digital innovation

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 Medical research, clinical
practice
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and and
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Health
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04/25/2025 52
First …
• Capture your data,
accurately, completely
• Make the data readily
accessible

Health
Records
04/25/2025 53
The paper record, pros
• Portable
• Familiar and easy to use
– Exploits everyday skills of visual search, browsing etc
• Natural: “direct” access to clinical data
– Handwriting
– Charts, graphs
– Drawings, images…

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The paper record: cons
• Can only be used for one task at a time
– If 2 people need notes one must wait
– Can lead to long waits (unavailable up to 30% of time in some studies)
• Records can get lost
• Consume space
• Large individual records are hard to use
• Fragile and susceptible to damage
• Environmental cost

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Reality: The Case of Betsy A.
Lehman
“How long, Oh Lord, must this continue? …
That’s 21 years ago…Isn’t it time that basic
computerization be part of the expected, and
required, care at medical facilities?”

That humans make 0.1 percent errors on

prescriptions may be forgivable; that hospitals don’t
take obvious actions to protect themselves and
patients, well within state-of-the-art, is not”
(Millenson, 1997).
56
04/25/2025
 Electronic health records
• An electronic health record is a
repository of information about a
single person in a medical setting,
including clinical, demographic and
other data.
• The repository resides in a system
specifically designed to support users
by
– providing accessibility to complete
and accurate data
– may include services to provide alerts,
reminders, links to medical knowledge
and other aids to clinical practice.
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• It is a record in a digital format that is capable of being shared within
and across a health setting by being embedded in network that is
connected enterprise that is wide system
• Is a digital version of a patient paper chart
• E.H.R are real time patient centred records that make a patient
information available instantly and secure authorized access and use
• there is increased retrieval of information
• Can be used for Research and teaching statistics

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• Among other types of data, E.H.R typically includes:
- Contact information
- Information about visits to health professionals
- Allergies
- Insurance information
- Family history
- Immunisation status
- Conditions of disease
- List of medications
- Records of hospitalization
- Surgeries or procedures performed
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Conditions for consideration for computerization
of patient related health records
• Hardware and software support is readily available
• All health records staff should have been trained use of computers
• Computerized terminal made easily available among medical staff
• Authorized staff should be issued with passwords which are changed
regularly to prevent unauthorized access

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Medical records procedures commonly computerized in any hospital facility
include the following:
Master patient index: all papers are assigned a patient number
admissions., transfers and discharges
Disease and procedure index
In addition to the applications listed above, the following procedures should
be considered when system is running smoothly:
Records tracking/location system
Medical records completion system
Discharge summary
outpatient appointment scheduling sytem
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Functions of the EHR (1)
1. Supports structured data collection using a defined vocabulary.
2. Accessible at any or all times by authorized individuals.
3. Contains a problem list - patient’s clinical problems and current
status
4. Supports systematic measurement and recording of data to promote
precise and routine assessment of the outcomes of patient care
5. States the logical basis for all diagnoses or conclusions as a means of
documenting the clinical rationale for decisions about the
management of the patient’s care.

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 Functions of the EHR (2)
1. Can be linked with other clinical records of a patient—from various settings and time periods—
to provide a longitudinal (i.e. lifelong) record of events that may have influenced a person’s
health.
2. Can assist the process of clinical problem solving by providing clinicians with decision analysis
tools, clinical reminders, prognostic risk assessment and other clinical aids.
3. Can be linked to both local and remote databases of knowledge, literature and bibliography or
administrative databases and systems so that such information is readily available to assist
practitioners in decision making.
4. Addresses patient data confidentiality.
5. Can help practitioners and health care institutions manage the quality and costs of care.

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Key capabilities of electronic health
record
There are eight core care delivery functions that an E.H.R should be capable
of performing in order to promote greater safety, quality and efficiency
1. Health information and data: having immediate access to key information
such as patients diagnosis, lab tests results medications etc. This will help
improve care givers ability to make sound decisions in a timely manner
2. Results management: ability for all poviders to participating in the care of
a patient in multiple settings to quickly access to new and past results.
This will increase patient safety and effectiveness of care.
3. Order management: ability to enter and store order for prescription tests
and services in a computerized system which should enhance , legibility,
reduced duplication and improve speed with which orders are executed

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4. Decision support: using reminders, prompts and alerts, computerized
support system will help improve compliance with best clinical practices,
ensure regular screening and other preventive practices and facilitate diagnosis
and treatment
5. Electronic communication and connecting: efficient, secure and readily
accessible communication among providers will improve continuity of care ,
increase timeliness of diagnosis and treatment, reduce frequency of adverse
effects
6. Patients support: where tools that give patient access their health record,
provide interactive patient education and help them carry out home
monitoring and self testing and improve control of chronic conditions eg
diabetes
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7. Administrative processes: computerized administrative tools eg
scheduling tools will greatly improve hospital efficiency and provide
more time service to the patient
8. reporting: collecting data storage that employs uniform data
standards will enable health care organization to respond more quickly
to government reporting requirements including those that improve
patient quality and disease surveillance

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Benefits of electronic health record
I. Replace paper based medical records which can be incomplete, fragmented in
different parts, in different locations, hard to read and sometimes to find
II. Provides a single, sharable and up to date accurate rapidly removable source of
information potentially available anywhere at anytime, require less space and
administrative resource
III. Potential for automating, structuring and streamlining clinical workflow
IV. Provides integrated support for a wide range of discrete care activities like
monitoring, e-prescribing, e-referrals, lab orders and results display,
V. Maintain data and information trail that can be readilty analyzed for medical audit,
research and quality assurance, epidemiological monitoring and disease
surveillance
VI. Support for continuing medical education
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vii. Ability to automatically share and update information among
different offices or clinical organisations
ix. Ability to share multimedia information eg medical imaging results
among locations
x. Ability to link records to sources of relevance and current research of
already solved cases
xi. Provision of decision support system for helath care professionals
xii. Less redundancy of efforts as well as lower cases after
implementation

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Barriers of EHR
• Incompatibility:
• Results issues: Needs training, resistance by potential users, implied
changes in working practices etc
• Technical problem: functionality, ease of use, lack of integration with
other applications
• Financial constraint: initial costs for installing software, maintenance,
upgrading, and replacement is high
• Interoperability: merging old and new notes becomes a problem
• Certification: security ethical matters, privacy and confidential are
doubts on clinical usefulness
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Issues in electronic health system
• Integrated systems require consisted use of standards eg medical
terminologies and high quality data to support information sharing
across wide networks
• Ethical, legal and technical issues link to accuracy, security,
confidentiality and access are set to increase as medical electronic
ahealth system come online
• common record architect and structures
• Clinical information standards and communication protocols
• Security and confidentiality of information
• Patient data quality, data sets and data dictionaries
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 Electronic health records:
pros
• Compact
• Simultaneous use
• Easily copied/archived
• Portable (handheld and wireless devices)
• Secure
• Supports many other services
– Decision support
– Workflow management
– Performance audits
– Research
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 Electronic health records:
cons
• High capital investment
– Hardware, software, operational costs
– Transition from paper to computer
• Training requirements
• Power outs – the whole system goes down!
• Continuing security debate
– Stealing one paper record is easy, 20 is harder, 10,000 effectively impossible –
the security risks are very different for electronic data

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Fully Operational Electronic Health
Record
• Core functionality
• Storage & retrieval
• Result management
• Order entry & support
• Decision support
• Other functionality
• Electronic communication
• Patient access
• Administrative support
• Population reporting

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Characteristics of e-health (10 e’s)
• Efficiency- avoids duplication of diagnostics or interventions through enhanced
communication between health care establishment and patient involvement
• Enhancing quality of care- allows comparison between health care providers ,
directing patient streams to best quality providers
• Evidence based- its effectiveness is not assumed but provided by rigorous
scientific evaluations
• empowerment of consumers and patients- by making knowledge of medicine and
personal electronic records available , accessible to consumers over the internet,
e-health opens new avenues patient centered medicine and enables evidence
patient choice
• Encouragement of new relationships-between patients and health professionals
turns into a true partnerships where decisions are made in shared manner
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• Education of physicians-through online sources (continuing medical education) and
consumers health education (health education tailored)preventive information for
consumers
• Enabling information exchange and communication in a standardized way between
health care establishment
• Extending the scope of health care beyond its conventional boundaries- e-health
enables consumers easily obtain health services online from global providers; from
simple advice to more complex interventions or products such as pharmaceuticals
• Ethics- e-health involves new forms of patient physician interractions and posses
new challenges and threats to ethical issues such as online professional practice,
informed consent, privacy, and equity issues
• Equity- to make health care more equitable , considerate threat thet e-health may
deepen the gaps between the haves and the have nots people who do not have
enough money, skills and access to computer and networks and not use computers
effectively. The digital divide is an urban pop. – rich vs poor, male vs female, neglect
vs common disease
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Personal Health Record (PHR)
• Owned by a patient
• Maintained by a patient
• A personal health record (PHR) is a collection of information about your health. It is
different from an Electronic Medical Record (EMR) or Electronic Health Record (EHR),
which are owned and stored by your healthcare provider. A PHR is a document that
you are in charge of-one that you compile, update, and keep
• the Personal Health Record (PHR) is an Internet-based set of tools that allows people
to access and coordinate their lifelong health information and make appropriate parts
of it available to those who need it. PHRs offer an integrated and comprehensive view
of health information, including information people generate themselves such as
symptoms and medication use, information from doctors such as diagnoses and test
results, and information from their pharmacies and insurance companies

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 Benefits of PHR
• PHRs grant patients access to a wide range of health information sources, best
medical practices, and health knowledge. All of an individual’s medical records
are stored in one place instead of paper-based files in various doctors’ offices.
Upon encountering a medical condition, a patient can better access test results,
communicate with their doctors, and share information with others suffering
similarly
• Moreover, PHRs can benefit clinicians. PHRs offer patients the opportunity to
submit their data to their clinicians' EHRs. This may help clinicians make better
treatment decisions by providing more continuous data, resulting in improved
efficiency in care.
• However, some physicians may have concerns about patient-entered information
and its accuracy, as well as whether the added patient engagement creates more
unreimbursable work.
• PHRs have the potential to help analyze an individual’s health profile and identify
health threats and improvement opportunities based on an analysis of drug
interaction,
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• Patient illnesses can be tracked in conjunction with healthcare providers, and
early interventions can be promoted upon encountering deviation of health
status.
• PHRs also make it easier for clinicians to care for their patients by facilitating
continuous communication as opposed to episodic.
• Eliminating communication barriers and allowing documentation flow
between patients and clinicians in a timely fashion can save time consumed
by face-to-face meetings and telephone communication. Improved
communication can also ease the process for patients and caregivers to ask
questions, to set up appointments, to request refills and referrals, and to
report problems. Additionally, in the case of an emergency a PHR can quickly
provide critical information to proper diagnosis or treatment.
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Architecture

Like other health information technology, PHR architecture can be roughly

organized into three main components:
1.Data
The information collected, stored, analyzed, and exchanged by the PHR.
Examples: medical history, laboratory results, imaging studies, medications
2. Infrastructure
The platform that handles data storage, processing, and exchange.
Examples: stand-alone software programs or websites, provider- or payer-
connected (tethered) websites
3. Applications
The information exchange, data analysis, and content delivery capabilities of
the system.
Examples: scheduling appointments, medication refill or renewal, decision aids,
and patient education materials
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Barriers to adoption
• Since the National Academy of Medicine (previously the Institute of
Medicine) called for greater adoption of PHRs in 1999,the software has
faced many barriers to adoption, including:
- economic,
- technological,
- regulatory, behavioral,
- and organizational issues at both the environmental and individual levels
- most people did not keep record of minute details of their healthcare
experiences and therefore made it difficult to get full value from web-based
PHRs.
- The PHRs selected for evaluation offered limited functionality to the general
public,
- limitations in data entry, validation, and information display methods. [
- limited access to computers and the internet access,
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- as well as low computer literacy levels, known as the digital divide,
- "that both usability concerns and socio-cultural influences are barriers
to PHR adoption and use.“
- other issues such as privacy and confidentiality concerns,
- lack of motivation,
- low health literacy,
- health- and disease-related disabilities,
- and even administrative burdens.

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Example of PHR in taiwan

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Health Information Exchange (HIE)
• Move clinical information across organizations
• Maintain the meaning of the information
• Health information exchange is the mobilization of health care
information electronically across organizations within a region,
community or hospital system. In practice the term HIE may also refer to
the organization that facilitates the exchange
• Electronic exchange of clinical information is vital to improving
health care quality, safety, and patient outcomes. Health information
exchange (HIE) can help your organization: Improve Health Care Quality:
Improve health care quality and patient outcomes by reducing
medication and medical errors
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• Health information exchange is defined as the mobilization of
healthcare information digitally across organizations within a region
or community. HIE provides the capability to move clinical information
between separate health care information systems while maintaining
the meaning of the information being exchanged.

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• Electronic health information exchange (HIE) is improving the quality
and efficiency of healthcare by allowing healthcare providers to
access and share patient medical information via computer. ... The
provider can then determine which patients need immediate care due
to symptoms such as consistently high blood sugar.
• What is HIE? Electronic health information exchange (HIE) allows
doctors, nurses, pharmacists, other health care providers and patients
to appropriately access and securely share a patient's vital medical
information electronically—improving the speed, quality, safety and
cost of patient care.

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Regional Health Information
Network (RHION)
• Multi-stakeholder organization
• Operating in a specific geographical area
• Enables the exchange of health information
• The Regional Health Information Organization (RHIO), which
organizes and oversees facilities participating in information
exchange within a geographical area.

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• A RHIO is a multi-stakeholder organization, operating in a specific
geographical area, that enables the exchange and use of health
information, in a secure manner, for the purpose of promoting the
improvement of health quality, safety and efficiency. Officials from the
U.S. Department of Health and Human Services see RHIOs as the
building blocks for the National Health Information Network (NHIN).
When complete the NHIN will provide universal access to electronic
health records.

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National Health Information Network
(NHIN)
• The technologies, standards, laws, policies, programs and practices
that enable health information to be shared among health decision
makers, including consumers and patients, to promote improvements
in health and health care. The vision for the National Health
Information Network begun in 1991 with the publication of an
Institute of Medicine report, "The Computer-Based Patient Record."
A National Health Information Network is a collection of regional
health information organizations.

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• The Nationwide Health Information Network (NHIN) is being developed to
provide a secure, nationwide, interoperable health information
infrastructure that will connect providers, consumers, and others involved
in supporting health and healthcare. This critical part of the national health
IT agenda will enable health information to follow the consumer, be
available for clinical decision making, and support appropriate use of
healthcare information beyond direct patient care so as to improve health.
The NHIN seeks to achieve these goals by:
• Developing capabilities for standards-based, secure data exchange
nationwide
• Improving the coordination of care information among hospitals,
laboratories, physicians offices, pharmacies, and other providers
• Ensuring appropriate information is available at the time and place of care
• Ensuring that consumers’ health information is secure and confidential
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• Giving consumers new capabilities for managing and controlling their
personal health records as well as providing access to their health
information from electronic health records (EHRs) and other sources
• Reducing risks from medical errors and supporting the delivery of
appropriate, evidence-based medical care
• Lowering healthcare costs resulting from inefficiencies, medical
errors, and incomplete patient information
• To promote a more effective marketplace, greater competition, and
increased choice through accessibility to accurate information on
healthcare costs, quality, and outcomes,.
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Computerized Physician Order Entry
(CPOE)
• Computerized system
• Physicians to enter their own orders
• Computerized physician order entry (CPOE), sometimes referred to as
computerized provider order entry or computerized provider order
management (CPOM), is a process of electronic entry of medical
practitioner instructions for the treatment of patients (particularly
hospitalized patients) under his or her care.

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• A computerized system that allows physicians to enter their own
orders for services such as medications, laboratory tests and other
tests. Orders are no longer entered in sheets or prescription pads.
Computerized entry allows for the order to be compared against
standards for dosing and to be checked for any patient allergies or
interactions with other medications, or other potential problems if
the order is filled.

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04/25/2025 94
• mHealth (also written as m-health) is an abbreviation for mobile health, a
term used for the practice of medicine and public health supported by mobile
devices. The term is most commonly used in reference to using mobile
communication devices, such as mobile phones, tablet computers and PDAs,
and wearable devices such as smart watches, for health services, information,
and data collection.
• The mHealth field has emerged as a sub-segment of eHealth, the use of
information and communication technology (ICT), such as computers, mobile
phones, communications satellite, patient monitors, etc., for health services
and information.
• mHealth applications include the use of mobile devices in collecting
community and clinical health data, delivery of healthcare information to
practitioners, researchers and patients, real-time monitoring of patient
vital signs, the direct provision of care (via mobile telemedicine) as well as
training and collaboration of health workers.
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 Advantages
The emergence of mHealth enables speedier and faster spread of information.
In situations where information needs to be provided to a large section of the
population like in case of natural calamities, this shall be a rescuer and redeemer.
The awareness about mHealth doesn’t mean that each and every person is
accessible and one can easily reach out to everyone, this is definitely not the
case. But it can very efficaciously be spread the word about health concerns
when it matters most to a large number of people.
MHealth is a very useful, convenient and an educative app which schools us
about the drugs, dosage, purpose and a lot more. It also helps in identifying the
medical condition just by listing down the symptoms and also prescribes us the
suitable medicines. Such mobile apps also have educative and detailed blogs and
medical newsletters which are very useful and informative.

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The mHealth also keeps a track record of our day to day health
condition. One can easily track his or her medical condition on a daily
routine basis. This therefore, helps us to be more conscious and
mindful of our dietary habits, exercise and health. These apps work
very effectively and make the patients fully responsible and
accountable of their own health condition as it keeps warning and
notifying them about their well-being. Thus, these apps encourage
and foster a healthy behaviour and even a healthy life.

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These apps have undoubtedly eased out our lives. Irrespective of
vacations, business trip or a normal day, the app keeps a track of our
health very meticulously and even at minimal cost. These apps are also
available free of cost and allow the users to access their health records
in real time. These also set a track record of the appointments, visits to
the doctor and even the time of your medicine.
These apps substantially reduce the expenditure of the patients and
their families as it communicate the health condition of the patient to
the doctor. This has reduced the burning holes in their pockets as the
visit to the doctor are minimized and it is not always necessary for the
patient to be admitted in the hospital.
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Disadvantages
In a country like India where poverty and illiteracy prevails, the access to
mHealth apps is denied to a large section of the population because of their
incapacity to afford it and the knowledge and skill to use it. This is a major
drawback and setback the country is still facing in this 21st century as there still a
large section of the society who is still technologically challenged.
These apps can never be too accurate to replace the human mind and
judgements. These have been made to ease out the health structure but not to
substitute it by mankind. Even the most well designed and technologically best
developed apps also can never be 100 per cent correct. Apps which do not have
a strong support system, their information can be unapproved, unverified and
potentially unreliable as well.
These mHealth apps also make us dependent completely on the technology
which might be a bane in the longer run. If one loses his or her mobile phones,
often all the information is lost and can be misused too.

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There might be several privacy and encryption issues when it comes to
mHealth. In such cases where there is the security and data privacy is not
strengthened, the personal information can be leaked and shared to third
parties.

Conclusion
As with developing knowledge and technology, mHealth has its own pros and
cons to reflect and contemplate. The mHealth apps shall definitely ease out
the hassle of the patients and the doctors by clearing out the communication
mechanism. It shall save time but also has several threads of its own threats
attached to it. Therefore, one must be very cautious about the breachment
of the safety and security of the information and medical conditions.
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The Benefits of mHealth

By using mobile devices in the healthcare setting, practices have the potential to
enhance productivity, lower failure-to-respond rates, increase information access and
communication. There are several specific ways that this technology has become
popular over the last few years. These include:
1. Medication/treatment compliance - One of the hardest things for medical
professionals to control is how patients handle their medication once they have
headed home. There is no guarantee that a patient is going to follow the guidelines laid
out by a physicians or tell false information when they have follow-up appointments.
For patients that have chronic or critical conditions, keeping to a strict medication
regimen can not only help patient’s health, but also lower a hospital’s costs by reducing
readmissions.
This is done through reminder messages set to patients about when and how to take
medication, notifications of when prescriptions should be refilled and daily messages
that ask if certain medications have been taken, which acts as a reminder but also
transmits that information back to physicians, who can use it to ensure medications are
taken correctly.
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This type of feedback and reminding can also be used for post treatment, as it is not
uncommon for post surgery paperwork to be lengthy. However, with digital
information and the ability to quickly message a doctor’s office, it is much easier to
get clarifications and follow instructions.

2. Improved information access - There are numerous ways that consumer

technology is helping people stay healthy through sensors and tracking. However,
the ability to access their medical records has not been included.
That has changed in recent years as the use of patient online portals and mobile
applications has changed the ability to access patient records. This helps patients
and hospitals better coordinate care and ensure that important information is
shared with the individuals that need it.
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3. Aggregated data/population health - By pulling patient and healthcare
information together into a single location, providers with have access to the
newest and greatest evidence-based medical practices. This helps ensure that
the best possible health outcome is achieved.
This also helps physicians stay on top of the latest health trends in real time.
Doctors, federal agencies and healthcare organizations are able to access
baselines of trends and have the best idea of how to proceed next.

4. Many Agencies are Onboard

Mobile technology is not just being pushed by tech companies and vendors. A
number of medical organizations have expressed support.
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Why mhealth promises to be a
winning solution
• Low network coverage
• Remote monitoring
• Low cost
• Phone are always available
• Carrying a phone is part of lifestyle
• Convenient, economical, practical and personal

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Barriers to mhealth
• Knowledge on use
• Policy
• Cost
• Legality
• Technical expertise
• demand

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Explain how mhealth technologies
can be used to improve health care
delivery
• Patient monitoring and compliance
• Remote diagnosis
• Remote data access
• Information on disease prevention
• Public wellness apps
• Health surveillance

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summary
• Consumers can maintain a personal health network
• Clinicians maintain an electronic health record, which maintain
information from multiple sources within the organization about the
patient.
• Health Information exchanges allow the transfer of information
among various clinicians and patients.
• The exchange of information across clinicians within a region creates
the Regional Health Information Network.
• Several Regional Health Information Network make up elements of
the National Health Information Network
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 ca n
ers
ns um a
Co tain alth
in e
ma onal h
s
per rd
o
rec

04/25/2025 108
From Blumenthal and Glaser, New England Journal of Medicine Vol. 356: 24, June 2007
 t ain
m ain
ians
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Cl lectr ord
E
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Hea

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 at ion
f orm
lt h In
Hea anges
xc h
E

04/25/2025 110
 es a
t
ea ealth
c r
This ional H
Reg mation
f or
I n ork
w
net

04/25/2025 111
 Several RHIOs
make up elements
of the National
Health Information
Network

04/25/2025 112
High Hopes for HIT
• Hospitals want to reduce medical errors
• Providers hope to work easily
• Governments and businesses hope to save money
• Save $77 billion per year after a 15-year adoption period
• There is high hopes for health information technology, or health IT. Hospitals
hope to reduce medical errors, such as ordering and administering the wrong
dose of a medication. Providers hope to access and share patient information
more easily, thereby improving care. Governments and businesses hope to
save money by improving efficiency. According to RAND Corporation
researchers, full implementation of health IT systems could produce efficiency
savings as great as $77 billion per year after a 15-year adoption period.
04/25/2025 113
Current and Emerging Use of
Clinical Information Systems
• The systems
• The electronic medical record
• CPR EMR
• Core Functions
• Health information and data (diagnoses, medications, allergies, demographics,
narratives)
• Results management (test and procedure results)
• Order entry and support
• Decision support (computerized decision support capabilities such as reminders,
alerts and diagnosing)

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Comparisons between Electronic
Medical Records and Medical
Paper Records
• -The electronic medical record (EMR) is slowly replacing the paper chat for
doctor patient details. As the adoption curve for EMRs rapidly increases, so
will the clinical terminologies. Currently, administrative classifications such as
ICD-9-C and HCPCS serve not only billing and reporting purposes, but also are
used by the providers for documentation and capturing patient procedures
and problem lists.
• -Paper based records require a significant amount of storage space compared
to digital records in the US; most states require physical records held for a
minimum of seven years. The costs of storage media, such as paper and film
per unit of information differ dramatically from that of electronic storage
media.
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Electronic medical records
• This is a longitudinal electronic record of patient health information
generated by one or more encounters in any care delivery setting.
• -It is a record in digital format that is capable of being shared within
across different health care setting, by being embedded in network-
connected enterprise-wide information system.
• -A patient record system is a type of clinical information system which
is dedicated to collecting, storing, manipulating and making available
clinical information important to the delivery of patient care. The
central focus of such systems is clinical data and not financial or billing
information.

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• The aim of many hospital authorities is for the development of an
automated patient information service that will increase the efficient
retrieval of information for patient care, statistics research and teaching. An
important point to remember, however is that the use of computerization
system may improve the effectiveness and efficiency of a Medical Record
Department, but ONLY where the basis manual procedures are already in
place and well organized.
• -Computerized information systems have not achieved the same degree of
penetration in healthcare as that seen in other sectors such as finance,
transport and the manufacturing and retail industries. Further deployment
has varied greatly from country to country and from specialty and in many
cases has revolved around local systems designed for local use.
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• Electronic medical record systems lie at the center of any computerized health
information system. Without them other modern technologies such as decision
support systems cannot be effectively integrated into routine clinical workflow.
• -Terms used in the field include electronic medical record (EMR), electronic
patient record (EPR), electronic health record (EHR), computer based patient
record (CPR), automated medical records system (AMRS) amongst others.
• -These terms can be used interchangeably or generically but some specific
differences have been identified, for example an Electronic Patient Record has
been defined as encapsulating a record of care provided by a single site in
contrast to an Electronic Health Record which provides a longitudinal record of
patients care carried out across different institutions and sectors. But such
differentiations are not consistently observed
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Consideration for the computerization of
patient related medical records
• Before computerization of patient medical records is instituted, it is the responsibility
of the administration to ensure that:
• Hardware and software support is readily available.
• All clerks have keyboard and mouse training and are also trained in the use of relevant
software.
• A computer terminal is made easily available to the clerical staff and should be locked
away in the manager’s office.
• Appropriate furniture is made available (power points, electrical cables, chair desks)
furniture provided for computers in Medical Records Department are taken away by
managers for other offices. This should not be permitted.
• Security procedures should be implemented to avoid the use of the computer games
and other non- medical record functions and to protect the computer viruses.
• Authorized staff should be issued with passwords, which are changed regularly to
prevent an authorized access.
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Medical record procedures commonly computerized in many countries
include the:
• The master patient index.
• Admission, transfer and discharge/ death system.
• Disease and procedure index.

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• In addition to the applications listed above the following procedures
could be common when the above systems are running smoothly:
• Record location/tracking system.
• Medical record completion system.
• Discharge summary abstracting system.
• Outpatient appointment scheduling system

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Key capabilities of an Electronic Health Record System
• -The following are a set of eight core care delivery functions that
electronic health record systems should be capable of performing in
order to promote greater safety, quality efficiency in health care
delivery

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• In contrast, EMRs can be continuously updated. The ability to exchange
records between different EMR systems (interoperability would facilitate the
coordination of healthcare delivery in non- affiliated healthcare facilities. In
addition, data from an electronic system can be used anonymously for
statistical reporting in matters such as quality improvement resource
management and public health communicable disease surveillance.
• -Electronic medical records like medical records must be kept in unaltered
form and authenticated by creator. Under data protection legislation,
responsibility for patient records (irrespective of the form they are kept in) is
always on the creator and custodian of the record, usually a health care
practice or facility. The physical medical records are the property of the
medical provider (or facility) that prepares them.
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Areas of Concern in Electronic Medical Records

• Electronic signature
• -Most national and international standards accept electronic signature.
According to the American Bar Association, ‘’ A signature authenticates
writing by identifying the signer with the signed document. When the
signer makes a mark in a distinctive manner, the writing becomes
attributable to the signer.
• Technical Features
• -Using on EMR to read and write a patients record is not only possible
through a workstation but depending on the type of system and healthcare
settings may also be possible through mobile devices that are handwriting
capable.
• -Electronic Medical Records may include access to Personal Health Records
(PHR) which makes individual notes from EMR readily visible and accessible
for consumers.
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Event monitoring
• -Some EMR systems automatically monitor clinical events by analyzing patient data and
Electronic Health Record to predict, detect and potentially prevent adverse events can
include discharge/transfer orders, radiology results laboratory and other data from
ancillary services or provider notes.
General Practitioner to General Practitioner
• -General practitioner to General Practitioner is Health Service Connecting for Health in
The United Kingdom. It enables GP to transfer a patient’s electronic medical record
another practice when the patient moves onto the list of other practice.
Privacy concerns
• -A major concern is adequate confidentiality of the individual records being
electronically, doctors and nurses to technicians and billing clerks have access to part of
patients’ records during a hospitalization.
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Characteristics of e-health (the 10 e’s in ‘’e-health)
1. Efficiency – One of the promises of e-health is to increase efficiency in
healthcare, thereby decreasing costs. One possible way of decreasing costs
would be by avoiding duplicative or unnecessary diagnostic or therapeutic
interventions, through enhanced communication possibilities between health
care establishment and through patient involvement.
2. Enhancing quality of care- increasing efficiency involves not only reducing costs
but at the same time improving quality. E-health may enhance the quality of
health care for example by allowing comparisons between different providers,
involving consumers as addition power for quality assurance and directing
patient streams to the best quality providers.
3. Evidence based- e-health interventions should be evidence – based in a sense
that their effectiveness and efficiency should not be assumed but proven by
rigorous scientific evaluation much work still has to be done in this area.
4. Empowerment of consumers and patients- by making the knowledge bases of
medicine and personal electronic records accessible to consumers over the
internet, e- health opens new avenues for patient- centered medicine, and
enables evidence based patient choice.
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5. Encouragement of a new relationship between the patient and health professional,
towards a true partnership where decisions are made in a shared manner.
6. Education of physicians through online sources (continuing medical education) and
consumers (health education, tailored preventive information for consumers)
7. Enabling information exchange and communication in a standardized way between
health care establishments.
8. Extending the scope of healthcare beyond its conventional boundaries. This is meant in
both a geographical sense as well as in a conceptual sense. e- health enables consumers
to easily obtain health services online from global providers. These services can range
from simple advice to more complex interventions or products such as pharmaceuticals.
9. Ethics e-health involves new forms of patient-physician interaction and poses new
challenges and threats to ethical issues such as online professional practice, informed
consent, privacy and equity issues.
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10. Equity – to make healthcare more equitable is one of the promises
of e-health but at the same time there is considerable threat that e-
health may deepen the gap between the ‘’haves’’ and ‘’have nots’’.
People who do not have the money, skills and access to computers
effectively. As a result these patient populations (which would actually
benefit the most from health information ) are those who are the least
likely to benefit from advances in information technology, unless
political

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• Tele-health helps patients reduce healthcare costs and increases
effectiveness through improved disease management, less travel time
and fewer hospital stays caused by otherwise delaying early or
preventive care.

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Telemedicine
• -Is a rapidly developing application of clinical medicine where medical
information is transferred through the phone or the internet and
sometimes other networks for the purpose of consulting and sometimes
remote medical procedures or examinations. They improve, maintain or
assist patients’ health status or provide clinical services when
participants are at different locations. It is practiced on the basis of two
concepts: Real time (synchronous) and store and forward and home
health (asynchronous).
• -Telemedicine may be as simple as two health professionals discussing a
case over the telephone or as complex as using satellite technology and
video- conferencing equipment to conduct a real time consultation
between medical specialists in two different countries. Telemedicine
generally refers to the use of communications and information
technologies for the delivery of clinical care.
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Importance of Telemedicine
• Benefits to the patients living in isolated communities and remote
regions who can receive care from doctors or specialists far away
without the patient having to travel to visit them.
• Allow healthcare professionals in multiple locations to share
information and discuss patient issues as if they were in the same
place.
• Remote patient monitoring through mobile technology can reduce
the need for outpatient visits.
• Facilitates medical education by allowing workers to observe experts
in their fields and share best practices more easily.

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

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What are the advantages of telemedicine?
How can telemedicine benefit me? Telehealth has been shown to overcome
barriers to health services caused by distance between patient and provider,
access to reliable transportation, fragmentation of care due to gaps in time
between appointments, and lack of available providers.
• Telemedicine increases access to care - Distance and travel time between
patients and care providers can limit access to care. Fortunately, telemedicine
can overcome geographic barriers to healthcare, especially for specialized
providers. Telemedicine can be particularly beneficial for patients in medically
underserved communities and those in rural geographical locations where
clinician shortages exist.
• Telemedicine improves quality of care delivery-Telemedicine can improve the
quality of care for patients with both medical and mental health conditions.
• Telemedicine reduces healthcare costs-Telemedicine can increase efficiency of
care delivery, reduce expenses of caring for patients or transporting to another
location, and can even keep patients out of the hospital.
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• Telemedicine enhances traditional face-to-face medicine -A strong doctor-patient
relationship is the foundation for high-quality patient care and reducing health
care costs. Telemedicine should support, not replace, traditional care delivery.
With telemedicine care providers can continue to care for patients in-person care
while still providing the flexibility and convenience of seeing patients remotely
for follow up visits, check-ups, and education when appropriate or necessary.
• Telemedicine improves patient engagement and satisfaction- Telemedicine makes
it easier and more convenient for patients to stay healthy and engaged in their
health care. Patients love the convenience, flexibility and real-time care with
their providers.
• Telemedicine improves provider satisfaction- Being a healthcare provider today
can be challenging and stressful at times. Telemedicine can improve job
satisfaction by making it easier to meet with patients. Providers can use
telemedicine to make it easier to balance their work and family life.
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E-health, telehealth and
telemedicine
E-health – health services delivered through the internet
• It’s a networked, global thinking to improve health care locally,
regionally and world wide by use of ICT
• The term encompasses a range of services or systems that are the age
of medicine, health care and technology
• They include
- EHR- communication of patients data between different health
professionals, doctors, specialists etc

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E-prescribing- access to prescribing options, printing prescriptions to
patients, at times electronic transmission of doctor to pharmacist
Telemedicine- physical and psychological treatment at a distance including
tele monitoring of patients functions
M-health- use of mobile devices in collecting aggregate and patient level
health data providing health information to practitioners researchers and
patients, real time monitoring of patients’ vitals and direct provision of
care via mobile
Tele-health-involves the use of telecommunications and virtual technology
to deliver health care outside of traditional health care facilities
Live video conferencing, mobile health apps, “store and forward”
electronic transmission, and remote patient monitoring (RPM)
are examples of technologies used in telehealth
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• Telehealth is the use of digital information and communication
technologies, such as computers and mobile devices, to access health care
services remotely and manage your health care. These may be
technologies you use from home or that your doctor uses to improve or
support health care services

• Telehealth is different from telemedicine because it refers to a broader

scope of remote healthcare services than telemedicine. While telemedicine
refers specifically to remote clinical services, telehealth can refer to remote
non-clinical services, such as provider training, administrative meetings,
and continuing medical education, in addition to clinical services.
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Example of tele-health

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 example of EMR system

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Top barriers to implementation
10. Usability – products hard to use
9. Politics/naysayers-key position to use
8. Fear of lost productivity
7. Computer illiteracy
6. Interoperability- exchange data with other systems
5. Privacy – easy to hack
4. Infrastructure/IT reliability
3. Vendor product selection/suitability
2. Cost
1. People- trained/champions to help roll out
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Development of health records

• The skills of many health and allied health specialists are required to
provide complete care to the patient. The team consists of physicians,
nurses and numerous allied health personnel.
• They inform and advise each other through their entries in the records
about their findings, observations, opinions and treatment of the patient.
• Good health care generally means a good health record, while an
inadequate health record may reflect poor health care.
• health records store information concerning the patient and his care. To be
complete, the health record must contain all relevant details to clearly
identify the patient, to support the diagnosis, to justify the treatment, and
to record the results accurately.
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• A written health record must be maintained on every person who has been admitted to
hospital or other health care facility. This may be an out- patient, in-patient or
emergency patient.
• The health record usually begins in the patient registration area with the patient’s
registration. It is there that the essential identification data and other necessary
information are obtained.
• This new record usually accompanies the patient to the vision room. The attending
physician and his co-workers add their notes. These include the patient’s complaints
regarding the onset and course of present illness, his personal/family history, a complete
report of the physical examination, and a plan for study and treatment in the hospital.
• Additional reports are added as they are made. These include laboratory, X-ray reports,
in-patient reports when a patient gets admitted, reports of operation as written or
dictated by the surgeon, and reports of the parahealth services .
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• The nurses record all observations, medications, treatments and other
services rendered.
• The attending surgeon records the progress of the patient in the
progress notes as often as necessary for an adequate report until
discharge of the patient.
• When the patient is discharged, the patient’s care is summarized by
the attending surgeon or his designee in the discharge summary,
which includes the patient’s condition upon discharge and pertinent
instructions for care following hospitalization

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Uses of health records

• The health record contains information acquired in a doctor - patient

relationship, which is generally considered to be confidential. The
hospital is responsible for preventing access to patient’s health record
by non-authorised persons from the time the health record is
initiated, during hospitalisation, as well as after discharge.
• Identification data unrelated to treatment are generally considered
non-confidential and may be released without the consent of the
patient. Release of this information, however, should be carefully
screened and given out only in response to proper enquiry.

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health records are used
• To record the patient’s problem, history, and treatment given either as out-
patient or in-patient
• To form a bridge between the doctors and other health professionals
contributing to patient care
• To give continuity in treating the patient during subsequent visits or admission
• To assist in protecting the legal interests of the patient, the hospital, and the
doctors
• To provide data for any research, study or education
• To review the quality of treatment given by doctors, nurses and other health
professionals
• To provide data for any third party agencies connected with the patient, doctor
and hospital
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Value of the health records
• The content of records may not only aid in diagnosis of a specific case,
but may aid in the treatment of another case, and it is also of legal
value. The health record is an orderly written report of the patient’s
complaints, the diagnostic findings, treatment, and end results. In
total they form a clinical picture and, when completed, contain
sufficient information to clearly identify the patient, to justify the
diagnosis and treatment, and to record results because, “Patient
forgets and records remember”.
• “The record is of value to the patients, the hospital, the physician, and
for research and teaching” (Fig.1.1 next slide). Can you explain each
of the five values?

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04/25/2025 147
For patient
• A complete report of an illness results in the accumulation of a large
amount of information about the patient
• Physicians cannot be expected to remember the details of each patient’s
illness. Therefore, health records serve as a reference
• When a patient requires subsequent hospitalisations with the same or
another illness, and with or without a change of physician, the health record
of the previous hospitalisations will enable the physician to review and
analyse the previous illness and treatment and make judgements as to the
course of treatment to be followed.
• With this knowledge of the patient’s previous hospitalisation the physician
may be able to initiate treatment without waiting for results of diagnostic
tests
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For the physician
• health record will be useful to a physician when he needs to gather
information during subsequent hospitalisation
• In addition a physician may wish to know how many times he has
been called in consultation during a given period
• The hospital as well as the physician may need the record for medico
legal purposes

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For scientific research and teaching
• In scientific research the health record is indispensable. Case studies
supply a practical and reliable source of material for the advancement
of health science.
• In addition, the health record is valuable in all teaching programs. It is
a source document for health facts related to disease, treatment, care
and results.
• Without the documentation of patient care found in the health
record, payment for services could not be justified.

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

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

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

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Benefits of a good health records
management
- Records can be allocated easily
- Increases efficiency and effectiveness in patient management
- Makes savings in administrative costs both staff time and storage
- Supports decision making
- Be accountable- records are evidence of transactions
- Achieve hospital objectives
- Provide continuity of patient care
- Meets legislative and regulatory requirement
- Protects interest of employees, clients, and stakeholders
- Offers tangible benefits to hospital from economic-good practice
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Poor health records leads to
• Patient care management too difficult
• Costs hospital money and resources
• Wastes a lot of time looking for records
• Makes hospital vulnerable to embarrassment, security, bridges,
persecutions
• Upto 10% of staff time is spent in looking for information
• Affects credibility of the hospital - reputation

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The principles of good medical records
management

• The guiding principle of medical records management is to ensure

that information is available when and where it is needed, in an
organized and efficient manner, and in a well maintained environment
“Remember if it is not recorded it did not happen”
• Hospitals must ensure that their records are:-

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a) Authentic
• It must be possible to prove that medical records are what they purport to be and who
created them, by keeping a record of their management through time. Where
information is later added to an existing document within a record, the added
information must be signed and dated. With electronic medical records, changes and
additions must be identifiable through audit trails.
b) Accurate
• Medical records must accurately reflect the activities that they document for example,
procedures, operations, prescription, registrations amongst other businesses of the
hospital.
c) Accessible
• Medical records must be readily available when needed by users like doctors, nurses,
records managers, administrators amongst other authorized users.
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d) Complete
• Medical records must be sufficient in content, context and structure to reconstruct
the relevant activities and transactions that they document.
e) Comprehensive
• Medical records must document the complete range of an organization’s business.
Clinical records should be sufficiently comprehensive for a colleague to have a clear
picture of a patient’s condition, treatment and wishes without a verbal handover.
They are a vital communication tool for high quality professional practice.
f) Compliant
• Medical records must comply with any recording keeping requirements resulting
from legislation, audit rules and other relevant regulations.

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g) Effective
• Medical records must be maintained for specific purposes and the information contained
in them must meet those purposes. Records will be identified and linked to the process to
which they are related, doing the right things at the correct time and doing the right
things correctly the first time.
h) Secure
• Medical records must be securely maintained to prevent unauthorized access, alteration,
damage or removal. They must be stored in a secure environment, degree of security
reflecting the sensitivity and importance of the contents. Where records are migrated
across changes in technology, the evidence preserved must remain authentic and accurate
i) Confidentiality
• The medical record is confidential and is protected from unauthorized disclosure by law.

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 Patient’s records should therefore be:

• Factual
• Consistent
• Accurate and identifiable
• Written visibly, legibly and clearly
• Be written as soon as possible after an event has occurred, providing current information
on the care and the condition of the service user ‘’Remember if it is not recorded it did not
happen’’
• Should not be erased
• Erasers, liquid paper, or any other obliterating agents should not be used to cancel errors
• Correctly dated
• Evidence based
• Timed
• Signed
The use of abbreviations should be kept to a minimum
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• Where actions relating to the patient have been agreed either with
the patient’s relatives or other professional they must document,
actions to be taken, a time frame for actions, who has been delegated
or charged to undertake the action.
• Personal or objective statements should not be entered in the record.
• Documentation of value judgments and speculation should not be
made
• Irrelevant documents should not be included
• Any amendments to the record should be made transparent

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Who is a health records and
information technician
• Every day, people make thousands of visits to doctors and hospitals, and each
one of these visits involves a person’s medical record. A health records
technician is someone who is responsible for accurately transcribing and
organizing patients' medical histories, symptoms and diagnoses, as well as
categorizing treatments and procedures for insurance billing.
• Medical records technicians play a very important role in ensuring that
physicians' offices, outpatient clinics and hospitals are organized and maintain
detailed records of patients' visits, including symptoms, test results and medical
histories.
• The medical records technician position provides an excellent opportunity for
detail-oriented individuals who enjoy the responsibility of ensuring top-quality
care without the patient contact that most healthcare positions require.
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What does a HRIT do
• A doctor reviews a patient’s history as described in the medical record before and during
a patient's visit and then conveys either in written or spoken notes the nature and
content of the current visit. The notes the doctor makes details the symptoms, possible
diagnoses and follow-up actions, such as medications that are prescribed, or any further
testing that may be required.
• A medical records technician takes the data from a doctor's notes and transcribes them
into a patient’s permanent medical record. The accuracy and timeliness of this data is
very important for appropriate patient treatment.
• By using computer programs and filing systems, a medical records technician will input
and update information for doctors' and insurance companies' reference. Some
technicians specialize in standard coding systems used to categorize conditions,
treatments and diagnoses for insurance processing, while other medical records
technicians pursue further education and training to enter the medical information
management field.
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What is the workplace of a health Records
Technician like?

• The medical records technician is typically a full-time position in an

office environment. He or she can work in medical settings such as:
hospitals, medical practices, clinics, and state or local health
departments.

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Qualities of a medical records Staff

• Personal appearance: It is essential that every enquiry personnel should have a proper
personal appearance. The Medical records staff must be particularly careful that their
mouths are free from bad odors.
• A high sense of personal grooming: Uniforms must be clean and neatly pressed. Hair should
be groomed well and nails should be manicured. Jewellery should be restricted to one ring
and a chain for ladies that denote wedded status. In short, the medical records staff must be
seen at their best at all times.
• Physical fitness: Enquiry operations require the staff to stand for long hours at a time. The
staff must be sturdy, agile and active. Self-confidence: Self-confidence is necessary as enquiry
personnel meet patients and visitors of different countries, status and cultures. They should
be comfortable and feel at ease in dealing with these people.
• Communication must be correct and clear: It is preferable that medical records staff knows
more than one language. It helps in communicating with patients who cannot speak English
or the local language. The manner of speaking is also important. Discourteous language can
provoke patients. Since senior citizens may have visual impairment or loss of hearing, the
voice should be clear, polite and courteous, like
“Good Morning/Afternoon/Evening”
“May I help you, Sir / Madam?”
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• Remain calm in all situations: Being the nerve center of the hospital, the enquiry is
constantly in touch with patients and therefore invariably encountering tremendous
pressure. The patients always expect personalized priority treatment and the pressure of
demand never ceases. Coupled with this are difficult patients who can be very unnerving.
The enquiry staff should thus have a high degree of tolerance to pressure of work and be
calm and composed at all times.
• Ability to remember names and faces of regular patients: This attribute distinguishes
the good from the average amongst the medical record staff. Every individual has an ego
and his/her name is precious and personal to him. If the Medical records staff can call
patients by their names, this immediately flatters them and personalises the patient
experience. The patient begins to feel welcome as people recognise him by name.
• Personal appearance: It is essential that every enquiry personnel should have a proper
personal appearance. The Medical records staff must be particularly careful that their
mouths are free from bad odors.
• A high sense of personal grooming: Uniforms must be clean and neatly pressed. Hair
should be groomed well and nails should be manicured. Jewellery should be restricted to
one ring and a chain for ladies that denote wedded status. In short, the medical records
staff must be seen at their best at all times.
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• Quick decision making ability: Patients often approach the enquiry desk
with problems and requests. Patients like to be handled by a cheerful
staff at the desk. Their smile exudes cheer to the patients and puts them
at ease. Medical record reception staff must be able to quickly decide a
course of action that satisfies both the patient and the interests of the
organisation.

• Efficient-Plans with the staff, organizes, and conducts, direct, medical

records activities according to the needs of the hospital.
Knowledge available about everything relevant to medical records
practice, has the necessary skills expected of him
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 Good listener-Here’s what is being said and what’s behind the words
Always available for the participant to voice out their sentiments and
needs pertaining to medical records management
Keen observer-Must keep an eye on the proceedings, process and
procedures within the records department and the activities that deals
with the management of health records.
Systematic knows how to put in sequence or logical order the activities
and practices within the hospital records department and produce the
information when needed

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Creative/Resourceful-Uses available resources in making sure the
records department runs effectively with no hitch, always on the
lookout on how best to improve the department for the better results.
Analytical/Critical thinker-Decides on what has been analyzed and how
best to use synthesized information.
Tactful-Brings about issues in smooth subtle manner, does not
embarrass but gives constructive criticism on the best records
management practices and staff commitment. Criticize privately and
praise publicly.

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Knowledge-Should be able to impart relevant, updated and sufficient
input on medical records functions. Understands every aspect of the
medical records management and the overall running of the hospital
services.
Open-Invites ideas, suggestions, criticisms, and involves people in
decision making. Accepts need for joint planning and decision relative
to health care in a particular situation not resistant to change.
Sense of humor-Knows how to place a touch of humor to keep
audience alive especially during and when on day to day discharge of
duties

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Change agent-Involves participant actively in assuming the
responsibility for learning making in changes for the benefit of the
hospital whenever invited to make suggestions improvement of the
services within the hospital. Do not to management opinion.
Coordinator-Brings into consonance of harmony the medical records
department’s activities as liaising with other departments in meeting
organizational goals.
Objective-Unbiased and fair in decision making without favoring any
individual in the duty or undermining performance of a unit within the
health records department or departments.

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• Flexible-Able to cope with different situations as they arise with
minimal complaints and adjust to issues and handling them tactfully.
General qualities include
• Integrity.
• Adaptability.
• Discretion.
• Neat in appearance.
• Consistent efficiency.

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Unit 3. General Qualities of a health
records technician
Most of these qualities apply to most of the employees in a health care delivery
services. A trained health records technician should have the following plus the
previously discussed qualities:
1. Integrity – quality of being honest and morally upright
2. Adaptability – should be flexible to new circumstances in an environment
3. Discretion – ability to use his own knowledge to make decisions
4. Politeness – humility
5. Calmness – a stake of not being emotional in an emergency situation
6. Neat appearance – smart and acceptable appearance in his work
7. Consistent – efficiency – effective and exceptional performance in his work
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summary
Health records technicians have distinct personalities. They tend to be
conventional individuals, which means they’re conscientious and
conservative. They are logical, efficient, orderly, and organized. Some of
them are also enterprising, meaning they’re adventurous, ambitious,
assertive, extroverted, energetic, enthusiastic, confident, and
optimistic.

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Knowledge required by health records
technicians

• Medical terminology and usages.

• Physical, major anatomical systems and related disease processes.
• Medical records forms and formats.
• Medical records classifications systems and references such as ICD,
dictionaries etc.
• Computerized data entry and information processing system.
• Data collection methods for basic health care and research
information.
• Medical psychology in order to understand human beings.
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Duties and responsibilities of a
health records technician
1. Manage and organize health records and health information services
( these are activities that support current and continuing patient care,
health services, research, patient accounting, case management, legal
affairs, administration affairs, and various patient services…assuring that
patient services are complete
2. Manage and maintain health records and information system
( health information systems refers to any system that captures , stores,
manages or transmits information related to the health of the individuals
or the activities of the organizations that work within the health sector)

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• Convert a patient’s diagnostic and intervention information to a
standardized form using an International Classification System-ICD
(Classify, code and internal diseases).
• Ensure that every patient’s record is complete, accurate and secure as
well as be readily accessible for appropriate release.
• Safeguard and release patient information under the provisions of the
hospital management or under any acceptable act laid down.
• Use computer applications to compile, sort, group, retrieve, analyze
and preserve health data in ways that are useful for planning, research
and education. Transparent information from paper documents to
electronic records.
• Plan, supervise, coordinate and manage health records service in a
health facility.
Maintain good public relations at all levels with the public, patient and 180
•04/25/2025
• Plan, organize and design health stationery needed by the health
institution in line with the national standardization.
• Maintain legal aspects and security of the health records in the health
facility.
• Administer quality assurance in coordination with other relevant
members of health records department.
• Institute and maintain health records indices.
• Edit, store and retrieve health records including x-ray films and other
diagnosis records.
• Manage and control reception, registration, appointment, and
admission and discharge procedures.

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• Maintain disaster and special records.
• Participate in basic operational research study.
• Participate in teaching Health Records and Information students and
other health personnel.
• Collect tabulate and analyze, interpret and store in information.
• Provide or disseminate health information to health management
terms of planning and management of health services.

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• Coding & Indexing: Disease, surgical operation and other procedures in
the hospital need to be coded indexed as per International Classification
of Disease (ICD) and procedures medicine (ICPM).
• Collection, tabulation, analysis, interpretation and dissemination of
data: Collection of health facility statistics relating to discharges/deaths,
length of state occupancy rates for administrative and health
department use. Data collected from health records are put in table,
analyzed interpreted and forwarded to the users.
• Maintenance of health record equipment: All the equipment used in
the health records department must be maintained and put in good
order
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• Manage special health records: There are special health records that are
indicated and handled differently from other health records e.g. psychiatric
records, tuberculosis records, maternity records Genito-urinary/HIV
records e.g. P3 form.
• Maintain confidentiality: All the information in Health Records is
confidential and it should be handled authorized person.
• Design medical forms.
• Plan, budget and control health equipment, supplies and medical
stationery.
• Assist the coordination of civil registration i.e. registration of births and
deaths.
• Controls finances allocated for the health records and information services.
• Participate in surveillance activities.
• Provides
04/25/2025 first Aid. 184
• Advise on medical-legal policies as regard to medical health and
information in a facility.
• Maintain proper mechanism for patients who need follow up.
• Collect additional information about patients who need follow up.
• Collect additional information about patients and their hospital stays
to generate data about patient population.
• Providing information and guidance to patients, attendants and
visitors

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Responsibilities of a health records
technician
• Compiling patients' health information
• Communicating with doctors to explain diagnoses
• Ensuring patients' medical records are complete
• Entering information into a computer system
• Improving patient care and managing costs with computers and
information technology

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DUTIES AND RESPONSIBILITY OF HEALTH RECORDS
OFFICER

The health records officer should be able to:-

1. Manage and organize health records and health information services.
2. Manage and maintain health records and information systems:
a) Initiate, collect, store and retrieve health records
b) Collect, tabulate analyse, interpret and store health information.
c) Disseminate health information and provide feedback
d) Establish good public relations
e) Plan, supervise, co-ordinate work in health records services
f) Maintain legal aspects and security of health records
g) Maintain health records equipment
h) Maintain health records indices
i) Classify, code and index diseases
j) Schedule patients appointments
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 k) Edit records and provide quality assurance
l) Provide first aid
m) Receive, register and admit and discharge patients
n) Establish mechanism for patients’ follow-up
o) Handle disaster and special records conduct/ participate in basic operational
research.

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 p) Participate in teaching health records and information students and other
health workers and community on health records.
q) Design various health/ clients forms
r) Control client forms and finance
s) Budget and control health records equipments, supplies and medical
stationery.

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***Relationship of health records
department with other departments
• The HRIT in a health facility is expected to coordinate the day administrative functions with
other departments in a hospital. Some of the departments in a health facility include:
1. Laboratory
2. Radioghraphy
3. Othopaedic
4. Dental
5. Physiotheraphy
6. Occupational therapy
7. Nursing
8. Supplies
9. ENT

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10. Accounts
11.Transport
12. Maintanance
13. Nutrition
14. Pharmacy
15. Community oral health
16. VCT
17 Youth friendly centres

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• Physician/doctors-provide patient discharges-home/farewell homes
• Nurses- provides nursing notes/ procedures, vital events, daily
admissions, available beds, patient movement within/out of the wards,
• X-ray – provide radiology records
• Laboratory – provide results of test done and number of tests done
• Mortuary- provides records of bodies embalmed, postmortems,
disposals
• pharmacy- prescription done
• Nutrition- provide number of under five children seen for regular check
up, weight, nutritional status, and no follow ups seen
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• Central bureau of statistics – projected population and distribution of
resources
• Registration of persons- births and deaths
• Regulatory bodies – provisions of guidelines and procedures
• Biomedical engineering – purchase and maintenance of equipment

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• A written health record must be maintained on every person who has been
admitted to hospital or other health care facility. This may be an out- patient, in-
patient or emergency patient.
• The health record usually begins in the patient registration area with the
patient’s registration. It is there that the essential identification data and other
necessary information are obtained.
• This new record usually accompanies the patient to the vision room. The
attending physician and his co-workers add their notes. These include the
patient’s complaints regarding the onset and course of present illness, his
personal/family history, a complete report of the physical examination, and a
plan for study and treatment in the hospital.
• Additional reports are added as they are made. These include laboratory, X-ray
reports, in-patient reports when a patient gets admitted, reports of operation as
written or dictated by the surgeon, and reports of the health services . .
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• The nurses record all observations, medications, treatments and other
services rendered.
• The attending surgeon records the progress of the patient in the
progress notes as often as necessary for an adequate report until
discharge of the patient.
• When the patient is discharged, the patient’s care is summarized by
the attending surgeon or his designee in the discharge summary,
which includes the patient’s condition upon discharge and pertinent
instructions for care following hospitalization

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Health records an information
department
Definition: a department where health records/information is kept
Functions of the department
- Reception- This is the reception of patients when they come to a health facility,
greet and welcome client to the facility
- Registration-Recording of identification details, mostly social on the
identification details
- Admission-Add ward number to identification details on the admission form
- Discharge-Procedure carried out when a patient is supposed to leave the
hospital after treatment
- Appointments-Patients are asked to report to the various clinics on certain
times and dates ready to be seen
- Filing-Is a way of arranging the documents in a prescribed order in a systematic
order
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Unit 2: Functions of the health
records and information department
The following are the functions of Health Records and Information Department
• Reception-This is the area where the patient received and welcomed to the health
facility.
• Registration-This is the recording of patient social detail like names, age, gender,
residence and other identification information.
• Admission-This is the procedure carried out when the patient is being admitted to the
ward. In patient number and word detail together with the registration are added on the
admission form.
• Discharge-This is the procedure carried out when the patient is supposed to leave the
hospital after treatment.
• Appointment-This is a way of giving a specific date, time and venue of the individual
patient.
• Filing, storage and retrieval-This is a systematic way of arranging documents to enable
the documents filed to be maintained in good order. Filing and retrieval of all inpatient
health records with an inbuilt record control system.
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• Tracing- tracing the movements of all the documents and their whereabouts
• Clinic preparations- getting ready all the documents 48 hours in advance before a
patient attends a clinic
• Follow up of patients-patients who require follow up after they have been
discharged from the hospital eg those with terminal conditions like HIV/AIDs, cancer
etc
• Coding and indexing- all diseases and operations and other procedures in medicine
need to be coded using ICD-10- international classification of diseases and the
international classification of procedures in medicine
• Collection, tabulation, analysis and dissemination of data- raw data collection from
the health records are put in tables, analyzed, interpreted and forwarded to users
• Maintenance of health records equipment- all equipment used in health records
must be maintained by heath records and information technician
• Maintenance of confidentiality of health records- all information in health records
are confidential and should not be handled by unauthorized persons
Manage special health records- there are special health records that are initiated 198
•04/25/2025
and handled differently from other records namely:
i. Psychiatric records
ii. Tuberculosis records
iii. Maternity records
iv. Casualty records-medical legal aspect
v. Genito-urinary records – super confidential

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• Design medical forms- all medical forms are supposed to be designed
by the health records and information technician in consultation with
the users
• Ensure quality assurance of health records (quality assurance is
maintenance of a desired level of quality in service or product,
especially by means of attention to every stage of the process of
delivery or production)- the quality and quantity of the record will
reflect the type of health care being rendered to the patient /client

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relationship between a health records department
and other departments in a facility

• The health records technician is expected to coordinate the day to

Day administrative functions with departments in a hospital. Eg
- Laboratory - nursing
- X-ray - oral health
- Orthopaedics - supplies
- Dental - accounts
- Physiotherapy - transport
- Occupation therapy

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• All these coordination is done to enhance the treatment of patients.
Therefore the patient stands in the middle and these activities revolve
around the patient. No one department is more important than the
other they should work together as a team for the achievement of
this common goal

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• Ensure Medico-legal issues relating to release of patient information
and other legal matters
• Retrieval of patient records
• To meet the training requirements of the new health records staff and
students
• To prepare monthly, quarterly and yearly service statistical reports

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NB:

Quality assurance-the maintenance of a desired level of quality in a

service or product, especially by means of attention to every stage of
the process of delivery or production

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• health records are useful in protecting the legal interests of the
patient, the hospital, and the doctors, and to provide data for use in
research and education.

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Organization of health records
services
• The health records department must be organised and managed upon the
concept that it exists for the benefit of the patients. The health record
department benefits the patient by being responsible for the completeness,
accuracy and availability of the health records at all times. Organising the
work of the health record department in order to attain the planned
objectives should be done on the basis of the departments functions.
• The functions of the department are the processing of outpatient and
inpatient records, retrieval, record storage, disease and procedure wise
coding & indexing.
• In a smaller department which may have only a few workers, it is better for all
the staff to be familiar with all aspects of the health record department, so
that the department functions smoothly
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Organization of health records
services
• The medical records department (MRD) must be organised and managed upon the
concept that it exists for the benefit of the patients.
• The medical record department benefits the patient by being responsible for the
completeness, accuracy and availability of the medical records at all times.
• Organising the work of the medical record department in order to attain the
planned objectives should be done on the basis of the departments functions.
• The functions of the department are
1. the processing of outpatient and inpatient records,
2. retrieval,
3.record storage,
4. disease and procedure wise coding & indexing.
In a smaller department which may have only a few workers, it is better for all the
staff to be familiar with all aspects of the medical record department, so that the
department
04/25/2025 functions smoothly 207
• Organization of a Medical Record:. Each hospital has its own
procedures for organizing a medical record. ... After the patient is
discharged from the hospital, a summary of the patient's diagnoses
and treatments may be prepared by the attending physician and
inserted at the front of the medical record

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The health records and information
department
Introduction
• The health Records Department is responsible for maintaining medical records in
a standardized and professional manner in order to protect confidentiality while
allowing adequate access to providers in order to promote quality patient care.
• Transcription,(conversion of speech into a written or electronic text document)
diagnosis coding, and release of information are some of the major duties
performed in the medical Records Department. Records are released in
accordance with state and federal laws.
• It is crucial for medical records workers to make sure that the medical record is
available for healthcare personnel when the patient returns to the healthcare
facility. If the medical record is not available then the patient may suffer, due to
lack of previous information, which could be vital for their continuing care.
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Organisation structure of a health
records and information department
Since the department has variety of functions, it is necessary to
organize the department into functions with employees assigned to
each function or in small facilities, several of the functions may be
performed by one or more employees. However an organization chart
for a records department may look like this:

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Health records and information
department organization chart

Medical
superintendent/administraor

Health records
supervisor

Registration of patients Records Records filing and

management retrieval

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• The person in charge of the department may be called a “director,
manager or coordinator. The number of staff or employees in each
department will vary by the size of the facility and the numbers of
patients seen in the facility. Some departments may have
thirty (30) employees including managers and supervisors and others
may have ten (10) or even fifty (50). Some large hospitals in other
countries have as many as 100 employees. The number of employees
may also vary based on whether the facility has a computer system or is
using paper medical records. In a computerized system, manual
retrieval of records is not necessary.

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• Organization charts will also look different in different facilities but it
is recommended that the director or manager of the department
report to an administrative official. It is also recommended that
patient/client registration function report to the Director of Medical
Records.

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Organization and management of reception,
registration and initiation of patient/client
health record
definitions:
Reception: the main reception is the first point of call of all patients ,
visitors, carers, and members of the public visiting the hospital.
Members of staff are happy to help with any enquiry that you have
about the hospital and its services.

Patient flow: is the movement of patients through a healthcare facility.

It involves the medical care, physical resources, and internal systems
needed to get patients from the point of admission to the point of
discharge while maintaining quality and patient/provider satisfaction.
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Flow of patients illustrated

04/25/2025 215
- Patient documentation: The purpose of complete and
accurate patient record documentation is to foster quality and
continuity of care. It creates a means of communication between
providers and between providers and members about health status,
preventive health services, treatment, planning, and delivery of care.
- File Storage & Retrieval – Healthcare Records. Healthcare practices
generate and maintain many different types of records,
including patient health records and business records. To
protect records, healthcare practices should develop and implement
formal file storage, retention policies, and procedures.

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Flow of Health records
HR department

PHERIPHERAL UNIT CENTRAL UNIT

M. RECORDS DEPT
OPD
EMERGENCY
REGISTRATIO ASSEMBLY
REGISTRATION
N &DEFICIENCY CHECK
INCOMPLET
ADMISSION/DISCHARGE E RECORDS
ANALYSIS DESK
ENQUIRY &CENTRAL
ADM. OFFICE

CODING &INDEXING
Admission check DESK

WAR FILING
WARD
D
MR
04/25/2025 CENSUS DESK 217
LIBRARY
1. Reception of patients
• Reception is an act of greeting and welcoming patients, clients to the
facility
-The right person should always do the work of reception.
-It requires cool efficiency, ability to convey the right message, maintain
confidentiality and being compassionate.
-He should have ease of assurance of manner and pleasant appearance
-Should convey to the anxious patients that are there is nothing to
worry about while in the hospital premise since there is better care to
be provided

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Areas of reception

a) Outpatient
-Start with the Reception Desk as soon as patients walk in the door, the
reception should be their focal point of attention to promote easy check-
in. In order to ensure that registration process is efficient for both the
receptionist and the patient, the reception of the desk must be chosen
with care.
-The clinic list will be the basis for collection of all outpatient attendances.
It is obvious that great care must be taken in the collection of these
figures.
-All patients who attend outpatients’ clinics or departments must be
captured
04/25/2025 219
b)Admission office receptionist
-The inpatient receptionist should be aware of the patients who have
come or called to come for admission. She should be well informed
about visitors hours, hospitals, wards/facility well prepared for the for
the patient such that she can afford a few moments with each one
make each individual feel a sense of welcome

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

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d) Treatment and investigation department receptionist
The areas attended by these patients include,
• Physiotherapy.
• Radiotherapy.
• Occupational therapy, etc.
• -Receptionist in radiology department has a duty of explaining to the
patients preparations necessary before such examinations are done,
e.g. barium meal, barium enamel treatment all clients with courtesy,
respecting and directing them accordingly.

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Receptionist

-Receptionist should always anticipate patient’s problems and not wait

until she is presented with a question.
-She must be fully aware of the clerical duties, put attractive flowers
which can do much to improve the appearance of any reception areas
as well as candy shops from where the patient can buy certain
requirements while they are waiting or should they find out that they
were required to have something but probably forgot to bring them
along, they can buy.
-The receptionist functions are of such enormous to the hospital. A
good receptionist should:

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• Be smart in appearance.
• Be able to speak and express herself clearly.
• Be well informed and be able to give information quickly and accurately.
• Be polite and sure of what one is doing at all time.
• He should be pleasant and good mannered.
• Have strong interpersonal and communication skills.
• Be friendly and confident and enjoy meeting and dealing with a variety of
people.
• Have good organizational skills and able to priorities workload.
• Be able to cope in a busy environment.
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The common physical requirement for any reception area
• Comfortable chairs.
• Good lighting system.
• Decorations clear sign posting.
• Adequate privacy.

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Reception Procedures

-Health records technician will be responsible for reception of patients in the

following main areas.
• Outpatients.
• Admission.
• Accident and emergency department.
• Treatment investigation department.
The patient information is processed, verified and validated.
Once this process is complete the patient is registered at the healthcare
providers’ facility.
Records technicians/receptionists handle the appointments/scheduling after
registration of the patient.
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• Patients can be registered as outpatients or inpatients Patient full
names.
• Environment should be conducive and patients should be interviewed
individually and in privacy.
-Patients should be given one unit number and ensure patients are not
registered twice.
-Ask the patients whether he or she had attended the hospital before.
-Cross-checking of patients details with the patients master index or
Electronic patient Registration system is necessary.

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2. Registration of patients / clients
• This is the completion of documentation of personal and health data
before a patient is treated.
• Registration falls in two procedures
Outpatients
Inpatients
For the outpatient consultative clinics, registration is carried out before
the patient attends the clinic. The environment should be conducive
and the patients should be interviewed individually and in privacy. The
patient is registered, a file is opened and an appointment is given prior
to the clinic day
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• Another important factor that should be noted is that the patient
should only be given one unit number and the patient should be
asked whether s/he has attended that hospital before,; if the answer
is no then a new number should be given to prevent duplication of
numbers. Whether the answer is yes or no this should be checked
with the patient master index.

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3. Initiation of patients file

-The identification details that are taken during the registration time are used to create
the patients file. These are:
• Patient full names (preferable three names).
• Date of birth.
• Hospital number.
• Address.
• Occupation.
• Marital status.
• Religion.
• Name of the next of kin and address.

-The patients master index card should also be created during the time that the record is
being created and filed immediately. This will help to answer inquiries incase the patient
happens
04/25/2025 to lose the attendance card. 230
• Many hospitals have formal systems of pre-registration- this is sending
the patient a simple form to be completed. This will ask for all the
identification details to be confirmed. Any form used should be as simple
as possible to make it easy for patient to complete it . This form when
returned will be used to create the patient’s/clients health record. The
use of mechanical documentation ensures continuing use of the same
data throughout the patients stay in the hospital.
• The master index cards should also be created during the time that the
record is being created and filed immediately. This will help to answer
enquiries in case the patient happens to loose the attendance card.

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Organization of a health Record

Each hospital has its own procedures for organizing a health record. ...

After the patient is discharged from the hospital, a summary of the

patient's diagnoses and treatments may be prepared by the attending
physician and inserted at the front of the health record

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Organization of health records
This is a function devoted to the management of information in an
organization throughout its life cycle
It includes identifying, classifying, storing, securing, retrieval, tracking
and destroying or permanently preserving records
It can be manual or digital or both

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The unit health records system
• This is a health records system where ONE patient is given ONE
number for the rest of the stay or attendance in one hospital

• Define the unit system: this is a health records system in which all
health records notes, relating to one patient are contained in one case
folder…. The patient is the unit

04/25/2025 234
1. Initiation of the Unit System

• It is necessary to assign a unit to a patient attending for the first day

or time. The unit is the patient and each patient is given one number
for subsequent stay or attendance in one hospital.
• -A six digit number is normally used ranging from 1-999999. Some
health records officers or technicians prefer to insert the zeros from
the beginning .i.e. 000001. This depends on policy of the institution.
• -When an old patient attends the hospital, the old notes are supposed
to be retrieved as the unit number. A tracer card should be inserted
where the old records were indicating old unit number.

04/25/2025 235
2. Prevention of duplication

Duplication in the use of unit number can be prevented by:

• Not giving the same number to two patients.
• Not giving the same patient more than one number.
• Observing legibility.

When a patient attends the hospital he should be asked whether he

had attended the hospital before. If a patient says yes or no, across
check can be done through the patient’s master index or through
checking from the Electronic Patient Registration System ascertain this.

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3. The unit number register

It is important to maintain the unit number register which includes the

following:
• Full names of the patient.
• Address.
• Date of birth.
• Registration number.
• Specialty to which patients have been referred.
• Next of kin etc.
-The quality of the health records will reflect on the type of health care being
rendered to the patient or client
04/25/2025 237
Feedback
It should be provided from the health facility and other departments
that need them

04/25/2025 238
4. Contents of the unit health record/health Record folders

• These are medical records forms used in the hospital for the management of
the patient and kept in the patient’s folder, they vary from one health
institution or country to another in accordance with the medical policy in
operation. The medical care history should be comprehensive, its contents
should be capable of including all the information likely to be required by the
state, hospital, medical and other professional staff, authorized independent
researchers and other stakeholders who may consult the health record.
-It should be remembered that it is the legal responsibility of the health record
and information technician to maintain confidentiality of the patient’s medical
history and should take every administrative precaution to assure that the
records or any of its contents are not released to unauthorized persons.
• The ideal case records should the following contents or forms.
04/25/2025 239
1. The folder: when selecting the folder, the following points should
be noted
o Strength of the Manilla
o Method of fastening in documents
o Clarity of numbering on the outside cover
o Cost of the folder
The folder should be made of tough manilla with a gusset and single or
double fold inside, through which are threaded metal or plastic prongs
with which the loose sheets may be fastened into the folder.

04/25/2025 240
• 2) Identification sheet /registration form front sheet:-This is the sheet where
the patients identification procedures are recorded, these include; name,
gender, occupation, religion, residence amongst other demographics.
-An ideal identification sheet should have the following characteristics.
-The doctor in charge of the patient must be able to remind himself at a glance
of the personal facts about the patient without going through the whole file.
-Persons seeking to compile the most commonly required statistics will easily
find them in the same place. The information should be complete and accurate
so that anyone writing to the patient can send the letter to the correct address.

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• 3 )Clinical history sheet:-This is where the doctor writes his notes
when clerking the patient, this will include the doctors record of the
patients immediate pre-history and his present illness or injuries, the
sheets forms a continuous history which the doctor writes and this
achieves a chronological statement about the patient clinical history.
The result of the physical examination carried out by the doctor can
also be recorded here.
• 4) Continuation sheet:-This is similar to history sheet and has all
clinicians seeing the patient and subsequent episodes. The doctor
should enter their findings on these sheets. All entries should be
dated by the attending doctor. These sheets give the progressive
clinical narrative.
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• 5) Treatment sheet:-This is used for recording treatment instruction in the wards. It is
usually attached to the patient’s bed board while the medical records folder is kept at
the nursing stations. On discharge of the patients, the treatment sheet is incorporated
in the folder.
• 6) Anesthetic record:-This is a form where anesthetic techniques and other details by
the anesthetist are recorded.
• 7) Prescription chart:-This provides the doctors drugs prescription for both out and
inpatient. The form must be filed back in the case folder from the pharmacy so that the
doctor treating the patient can see what previous medications had been prescribed for
the patients.
• 8) Diet sheet:-It is a special diet form which is required for the patient diet monitoring.
• -The form should contain instruction for the principal diets prescribed.

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• 9) Temperature, Pulse and Respiration Chart (TPR):-These charts are varied, designed
and are used four hourly, two hourly and four hourly they are held according to the
practice of particular hospitals and for seriously ill patients.
• 10) Clinical photography:-Photography is increasingly being used in hospitals for
clinical as well as teaching purposes. Clinical photographs will be taken when the
patient is automatically in an interesting condition where he or she may pass through
several stages of treatment e.g. in plastic surgery a photograph is often taken at
intervals to record progress. Special mounting sheet should be used for filing
photographs.
• 11) Consent forms:-Consent certificates must be obtained for all operative procedures
and should be by either the patient’s next of kin or parents if patient is minor. For
operative interventions, anesthesia, post mortem examinations etc. and all the
recordings must be kept in the file.
• 12) Inpatient summary / discharge summary:-A summary should be completed for
every patient on discharge or upon death. A special form is provided for this purpose
and normally the summary should be dictated by the medical officer or the
consultant. The diagnostic coding in accordance with the international classification 244
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(ICD) is carried out using this form e.g. Malaria=B54, SVD 080.0
• 13) Correspondence:-All correspondence which is of clinical
importance to the patient will be incorporated in the case record e.g.
referral letters between hospitals/clinics. The foregoing list of medical
records contents is by no means exhaustive and will largely depend
on requirements of a particular health institution.
• 14) Report form:-All diagnostic investigations e.g. laboratory,
radiology and other departments’ results should be fastened to the
patient file. Special mounting sheet are used for this purpose.

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Others include:
15. Surgical operation chart: these are special forms provided on which
operations may be recorded. They normally contain sections in which
the names of all surgeons and anaesthetics taking part in the operation
are to be recorded and there may be provision for special remarks
about drainage, blood loss, special recovery treatment etc

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Report mount sheet: many reports which are smaller than the size of
most forms have to be filled in the folder. They are usually mounted on
a report mount sheet. These mount sheets vary in designs and
methods of gumming. There are two possibilities ; all report forms may
have a gummed edge and be stuck onto the mount sheet or the mount
itself may have a series of gummed strips onto which all reports will be
stuck.

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Coordination with other
departments
• The Health Record and information officer in a health facility is expected to
coordinate the day to day administrative function with other departments in the
hospital. No department is important than the other. They should work together
as a team for the achievement of quality medical care rendered to the patient
Working relations with other department
• To co-operate with accounts section on day to day handling of registration,
Admission and lab investigation cash and settlement of accounts
• To coordinate with computer section in generation of any statistical reports
required by the management and in case of any computer problems
• To coordinate with the doctor’s secretary in issuing medical records to doctors for
project study and seminars

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Transcription

Transcription services covering discharge summaries, operation reports,

outpatient letters and medical- legal correspondence (using word
processing facilities).

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Organization and management of reception,
registration and initiation of patient/client health
record
definition of:
1. Reception
Reception is an act of greeting and welcoming patients, clients to the facility

-The right person should always do the work of reception.

-It requires cool efficiency, ability to convey the right message, maintain
confidentiality and being compassionate.
-He should have ease of assurance of manner and pleasant appearance
-Should convey to the anxious patients that are there is nothing to worry
about while in the hospital premise since there is better care to be provided
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2. Registration of patients / clients:
- This is the completion of a documentation of personal and health
data before a patient is treated. It falls in to two procedures- that of
outpatient and inpatient.
- For the outpatient consultative clinics, the registration should be
carried out before the patient attends the clinic. The environment
should be conducive and the patients should be interviewed
individually and in privacy. The patient is registered, a file is opened
and an appointment is given prior to the clinic day
- Another important factor that should be noted is that this patient
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Should only be given one unit number and the patient should be asked
whether s/he has attended that hospital before. If the answer is no,
then a new number should be given to prevent duplication of numbers.
Whether the answer is yes or no this should be checked with the
patient master index card.

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3. Initiation of patients records
The identification details that are taken during the registration time is used to create
the patients file. The registration details are:
i. Patients full names
ii. Date of birth
iii. Hospital number
iv. Address
v. Occupation
vi. Marital status
vii. Religion
viii. Name of next of kin address of next of kin
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• Many hospitals have formal systems of preregistration. This is sending
patient simple form to complete. This will ask for all the identification
details to be confirmed. The form used should be as simple as possible
to make it easy for the patient to complete it.
• This form when returned will be used to create the patients/clients
health records. The use of mechanical documentation ensures
continuing use of the same data throughout the patients stay in the
hospital
• The master index cards should also be created during the time that the
record is being created and filed immediately. This will help to answer
enquiries in case the patient happens to loose the attendance card.
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 Reception Procedures

-Health records technician will be responsible for reception of patients in the following main areas.
1. Outpatients.
2. Admission.
3. Accident and emergency department.
4. Treatment investigation department.
-The patient information is processed, verified and validated.
-Once this process is complete the patient is registered at the healthcare providers’ facility.
-Records technicians/receptionists handle the appointments/scheduling after registration of the
patient.
-Patients can be registered as outpatients or inpatients Patient full names.
-Environment should be conducive and patients should be interviewed individually and in privacy.
-Patients should be given one unit number and ensure patients are not registered twice.
-Ask the patients whether he or she had attended the hospital before.
-Cross-checking of patients details with the patients master index or Electronic patient Registration
system is necessary.
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1. Outpatient receptionist

• Start with the Reception Desk as soon as patients walk in the door, the
reception should be their focal point of attention to promote easy check-in.
• In order to ensure that registration process is efficient for both the receptionist
and the patient, the reception of the desk must be chosen with care.
-The clinic list will be the basis for collection of all outpatient attendances. It is
obvious that great care must be taken in the collection of these figures.
-All patients who attend outpatients’ clinics or departments must be captured.

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2. Admission office receptionist

• The inpatient receptionist should be aware of the patients who have

come or called to come for admission. She should be well informed
about visitors hours, hospitals, wards/facility well prepared for the for
the patient such that she can afford a few moments with each one
make each individual feel a sense of welcome.

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

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4. Treatment and investigation department
receptionist

• -The areas attended by these patients include,

• Physiotherapy.
• Radiotherapy.
• Occupational therapy, etc.
• -Receptionist in radiology department has a duty of explaining to the
patients preparations necessary before such examinations are done,
e.g. barium meal, barium enamel treatment all clients with courtesy,
respecting and directing them accordingly

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Receptionist
-Receptionist should always anticipate patient’s problems and not wait until she is presented
with a question.
-She must be fully aware of the clerical duties, put attractive flowers which can do much to
improve the appearance of any reception areas as well as candy shops from where the patient
can buy certain requirements while they are waiting or should they find out that they were
required to have something but probably forgot to bring them along, they can buy.
-The receptionist functions are of such enormous to the hospital. A good receptionist should:

Be smart in appearance.

Be able to speak and express herself clearly.
Be well informed and be able to give information quickly and accurately.
Be polite and sure of what one is doing at all time.
He should be pleasant and good mannered.
Have strong interpersonal and communication skills.
Be friendly and confident and enjoy meeting and dealing with a variety of people.
Have good organizational skills and able to priorities workload.
 Be able to cope in a busy environment.
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The common physical requirement for any reception area
Comfortable chairs.
Good lighting system.
Decorations clear sign posting.
Adequate privacy.

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Categories of health records and
their sources
1. Types of health records
• There are various types of medical records generated by hospitals, labs, doctors’
offices etc. Each one will have a different type of content that require different type of
formatting standards.
• The most common types of medical records that a medical transcriptionist transcribes
and manage in hospital includes :Patient History and physical examination report,
consultation report, operative report, radiology report , pathology report, laboratory
report, emergency report, progress note report, therapy report, clinical notes,
autopsy reports, biopsy reports, psychiatric observations ,x- ray reports, scan
reports, referral letters, Daily reports, discharge summaries .
• There can be more types of medical records that come from a medical facility.
However these are the most widely used and transcribed medical records. These
records can be grouped into the following categories
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1. Case records/inpatient records
• An inpatient is a recipient of medical services who is admitted to a
health facility and receives health care services, room, board and
continuous nursing service in a unit or area of the hospital where
patients generally stay overnight.
• Case records are records created for patients who get admitted into
the hospitals or who attend the various consultant clinics. The
contents will constitute the contents of a typical health record.

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

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• 3. Diagnostic records
• These includes the records of diagnostic investigations both in the
outpatient and inpatient department e.g. laboratory, radiology and
cardiology reports.

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• The medical record includes a variety of types of "notes" entered over
time by health care professionals, recording observations and
administration of drugs and therapies, orders for the administration
of drugs and therapies, test results, x-rays, reports, etc. The
maintenance of complete and accurate medical records is a
requirement of health care providers and is generally enforced as a
licensing or certification prerequisite.
• The terms are used for the written (paper notes), physical (image
films) and digital records that exist for each individual patient and for
the body of information found therein.

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• Medical records have traditionally been compiled and maintained by
health care providers, but advances in online data storage have led to
the development of personal health records (PHR) that are
maintained by patients themselves, often on third-party websites

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A health record being pulled

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Organization of Health records
services
• Kenya's health care system is structured in a step-wise manner so that
complicated cases are referred to a higher level. Gaps in the system
are filled by private and faith based health facilities

1. Community unit- the lowest level of health care. Deals with referral
of cases to the health facility
- a community health worker mans this unit

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2. Dispensaries
- Lowest point of care
- Run and managed by enrolled and registered community health
nurses
- Provide outpatient services eg treatment of minor ailments and
primary health care services like immunisations
3. Health centres
-these are run by clinical officers

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- Provide comprehensive primary care eg childhood vaccination
- Offer treatment
- Are medium sized to cater a population of about 80,000
- Its staff include clinical officer, nurses, administrator, lab, pharm.tech,
records, nutritionist, driver, support staff
- It has outpatient, in patient, lab, pharmacy, minor theatre, maternity,
MCH, kitchen, students hostels

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3. Sub county hospitals
- All services of a health center plus caesarian section and other procedures.
Many are managed by clinical officers and a good number have medical
officers
4. County referral hospitals
- All services of a sub-county hospital plus comprehensive medical and surgical
services. They are managed by medical superintendents
- Act as a referral Centre for the smaller units
5. National referral hospitals- eg MTRH, KNH
All services of county hospitals, plus other specialized services eg chemotherapy,

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• Private clinics- most fall in the dispensary level
• Faith based hospitals- dispensary, health centre and hospital levels
• Maternity nursing homes – health centres

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Levels of care in Kenya (KEPH
LEVELS)
Level of service Place of health Tier of service Point of care Staff Report
care delivery submitted to
Level 1 community Tier 1 community chw CHEW

Level 2 dispensaries Tier 2 Primary care nurse Sub county

HRIO
Level 3 Health centres “ “ Nurses/cos ‘’

Level 4 Sub district and “ “ Cos/med supt ‘’

district
hospitals

Level 5 provincial Tier 3 County Med Upload to DHIS

hospitals hospitals supt/consultant
s
Level 6 National Tier 4 National CEOs ‘’
referral hospitals
hospitals

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Health records and information
activities
• Reception of patients/clients
• Registration of patients
• Maintenance of confidentiality of patients information
• Filing and retrieval of patients files
• Coding and indexing diseases according to the international
classification of diseases – ICD-10
• Collection, analysis and dissemination of health information/data
• Creating health indicators for monitoring and evaluation of health
systems performance, health status and health determinants
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Sections of the health records
department
• General out patient department
• Consultative clinics- SOPC,GOPC,POPC,MOPC
• Statistics section / medical records statistics- including statistics on notifiable
conditions
• Coding and indexing- medical data classification
• Computer section
• Health records library/ filing section
• Inpatient sections
• Admissions and discharge /death
• Allocation of beds / bed bureau
• Medico-legal cases
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• Radiology section
• Ward services section
• Accident and emergency section
• Children emergency section
• Staff clinic section
• Physiotherapy and occupational therapy section
• NHIF

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TYPES OF RECORDS REQUIRED IN
HOSPITALS
• Below is a brief overview of the types of records found in a typical general hospital.
Note that in practice not all of these records are necessarily the direct
responsibility of a single hospital records manager or medical records
administrator. While the ideal is that the hospital records manager should be
responsible for all records in the hospital, in practice technicians at the local level
may maintain records such as X-rays and pathological preparations.
• Ideally, the hospital records manager will be responsible for all records in the
hospital, but in reality such records as X-rays and pathological preparations may be
maintained by technicians at the local level.
• It should be noted that many types of records created to support diagnosis and
treatment are not necessarily the direct responsibility of a single hospital records
manager or medical records administrator, but are maintained at the departmental
level.
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1. Patient Case notes
• Patient casenotes form the largest and most complex series of records
required in a hospital. Casenotes are created or written when a patient
comes into contact with any member of the medical staff. Notes may
also be created to record contact with nurses, physiotherapists and
others involved in patient care. Casenotes include patient histories,
diagnostic test results and temperature, blood pressure and other
charts, as well as records of operations and other forms of treatment.
• In most hospitals, the notes about each patient are kept together in
one file bearing the patient’s name and other personal details. The file
may also contain referral letters from health centres or family doctors
and other documents relating to the patient’s condition. Over a period
of time, the documentation will build up to form a complete medical
history of the patient.
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• The principle of maintaining a single file for each individual patient is
crucial to the continuity of patient care. Besides notes created when
individuals are admitted to hospital wards as in-patients, notes should
also be generated when they attend as out-patients. Specialist out-
patient clinics may create extensive notes about each individual.
• All these records need to be kept on the same individual patient’s file.
Accident and emergency departments and general clinics are likely to
produce fewer notes, and in some hospitals they may create no notes
at all. The records created in out-patient departments will vary
according to local circumstances; in general, clinic attendances produce
a smaller quantity of notes per patient than ward admissions.
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2. X-rays
X-ray films are large-size photographic records produced for diagnostic
purposes in response to a request from a clinician. They form part of a
patient’s case history, but because of their size they cannot be kept in
the files containing the casenotes.
X-rays are usually filed separately, according to a unique identifying
number that is linked with the patient’s name. Requests for X-rays can
be made on a printed form and it is usual for the same form to be used
subsequently for a written report based on examination of the X-ray.
This form or a copy of it is placed in the casenote file.

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3.Pathological Specimens and Preparations Specimens
Taken from patients (such as plasma, serum, bodily fluids, swabs, wet
tissue or whole blood samples) and the preparations made from them
for pathological examination and diagnosis are also part of a patient’s
case history.
However, as with X-rays, the format of specimens and preparations
makes it impossible for them to be housed with the casenotes.
Specimens and preparations are usually kept in labelled boxes or on
shelves. Again, it is usual for a combined request and report form to be
used and for this form, or a copy of it, to be placed in the patient’s file.

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4. Patient Indexes and Registers
One or more indexes should be maintained, either in traditional card index
form or electronically, containing the names and other appropriate details
about the hospital’s patients. A single central index containing data about
all its patients may be known as the ‘master patient index’. This index
serves as a finding aid for the patient case notes and may also provide
location information for X-rays and other diagnostic documentation.
In addition to providing access to the casenotes and related documents,
the index forms an important record in its own right. In some hospitals
local indexes may also be maintained in individual departments. Indexes
serve as finding aids for the patient casenotes. Besides the indexes, various
chronological registers of patients may be maintained, either centrally or
in individual departments.
.
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• Any specialist department is likely to maintain a day book or register
in which is recorded information about each patient seen or request
received. Chronological registers may also be used by the hospital to
record admissions, discharges, births and deaths of patients. The
management of patient indexes is discussed in more detail later in
this lesson

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5. Pharmacy and Drug Records
The prescription and supply of drugs generates a variety of records, including
pharmacy stock, ordering and dispensing records, requests for drugs from
wards and departments, drug administration records and prescriptions for
individual patients. The receipt and issue of all drugs should be recorded.
Records about drugs are often held by both the pharmacy and the ward, and
so cross-referencing and uniform management is important to ensure that
documentation can be retrieved easily.
Information about dangerous or ‘controlled’ drugs is often recorded in
particular detail in both the hospital pharmacy and in individual wards and
departments, in order to ensure proper and appropriate use of these drugs.
In many countries there will be statutory requirements for the creation and
retention of appropriate pharmacy records.
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6. Central Administrative Records
Minutes and papers of major committees and of the governing body, if there is one,
serve as the central record of the hospital’s affairs. The hospital administrator’s files and
correspondence will reflect the implementation of policy and also the hospital’s day-to-
day activities in so far as they need his or her direction.
A hospital’s administrative records will be little different from those found in non-
medical organisations of equivalent size. Hospitals also require records relating to
finance, personnel, buildings, accommodation, stores and other such services, although
they will be little different from those used in non-medical organisations of equivalent
size.
Besides these records, annual and statistical reports will probably be prepared,
providing summaries of hospital activity.
Legal case files and duty officers’ logs are other key hospital records. Duty officers’ logs
may be used to record unexpected incidents which occur when day-time hospital staff
are not on duty.
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7. Administrative Records in Clinical Departments
The range of records kept by clinical and other clinical departments will
depend on the organisation of the hospital and the extent to which
individual departments (or groupings of departments under a single
director) are independent of the hospital’s central authority.
The greater the independence of the clinical department, the more
extensive and significant its records. If clinical policy is set at the department
level, the records of the departmental head will take on greater importance.
If the head is entirely subordinate to a medical director or hospital
administrator, the definitive policy records will be held at the centre.
Regardless of the arrangement, however, all heads of departments and
senior medical staff will probably keep their own papers on administrative
and professional matters.
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8. Nursing and Ward Records
The office of the chief nurse will generate records of the type found in any office with an
executive or administrative function: correspondence, reports, minutes of meetings, staff
records and so on.
The chief nurse may be expected to keep copies of any rules and procedures issued for
nursing staff or for patients: these are important records, though unlikely to be bulky.
In the wards, records may be produced in larger quantity. Wards may maintain their own
admission registers, in addition to the hospital’s central record of admissions and discharges.
Property and clothing books may be used to provide a record of any possessions received
into custody when patients are admitted and to document their return to the patient or his
or her representative on discharge or death.
Nurses may be required to write activity reports, typically in a book kept on the ward for
inspection by their managers, and they may also keep records of nursing care for their own
and their colleagues’ use.
As noted above, drug records should also be maintained in each ward..
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9. Educational Records
The officers, boards and committees of medical and nursing schools will
produce their own records: minutes, correspondence, reports and so
on.
Autonomous schools will also produce the usual range of finance,
personnel, estates and accommodation records.
Educational records may also be found if there is a teaching component
within the hospital. The school may issue an annual report and a
calendar or handbook setting out details of courses.
Records relating to the students themselves — for example,
applications, study records, examination results, payment of fees,
records of attendance, prizes and scholarships — will also be
generated.
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10. Personnel records:
Personnel Records are records pertaining to employees of an
organization. These records are accumulated, factual and
comprehensive information related to concern records and detained.
All information with effect to human resources in the organization are
kept in a systematic order.

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They include job and employer-related files such as the job application, performance
reviews, and employee time-off records. The 10 documents that are nice-to-have in an
employee personnel file are: Signed offer letter or employment agreement,
• Signed offer letter or employment agreement
• Receipt or signed acknowledgment of the employee handbook
• Job description for the position
• Job application (if one was used)
• Resume (if one was provided)
• Performance evaluations, including awards or citations for excellent performance
• Warnings and/or other disciplinary actions, including summaries of customer or
employee feedback and notes on attendance
• References and/or background checks
• Drug test results
• Leave of absence, sick time*, and vacation time records
• These are nice to have documents
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Basic items in the personnel file
• Basic employee information (name, address, and phone number) and
emergency contact details
• tax withholding forms
• Payroll and compensation information, including any paycheck or pay card data
• Contracts or agreements between the employee and the employer, such as a
non-compete agreement, an employment contract, or an agreement relating to
a company-provided car or business credit card
• Forms relating to employee benefits, such as enrollment forms and beneficiaries
• Child support/garnishments and/or legal or litigation documents (if any)
• Workers compensation claims (if any)
• Termination documents, such as reasons why the worker left or was fired,
unemployment documents, insurance continuation forms, etc.
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11. Archival records
archival records' connotes documents rather than artifacts or
published materials, although collections of archival records may
contain artifacts and books. Archival records may be in any format,
including text on paper or in electronic formats, photographs, motion
pictures, videos, sound recordings.
An archive is an accumulation of historical records or the physical place
they are located. Archives contain primary source documents that have
accumulated over the course of an individual or organization's lifetime,
and are kept to show the function of that person or organization.

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11. Office records:
organization or administrative unit that is officially designated for the
maintenance, preservation, and deposition of record copies eg general
account books, (journals, ledgers), cash books (receipts, and
payments), banking records -(bank and credit card statements, deposit
books, cheque butts, and bank reconciliation)

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12.Basic library procedures
Basic library procedures: Processing library materials
Before items can be shelved and then circulated from the library, they need to be
physically prepared. Library materials go through processing so that they can be located,
used, and returned to the library from which they originated. Each item in the library
must go through physical processing including the applicant of:
• accession numbers (manual systems)
• circulation cards (manual systems)
• pockets (manual systems)
• plastic covers, laminates, or cases to protect materials.
• barcodes (automated systems)
• detection strips or slips.
• property stamps.
Processing can either be done in-house (i.e. in the library) or purchased through a vendor.

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Purchased versus in-house processing
• Processing can be a tedious, time consuming, and labour intensive procedure. In an effort to save
time and money, many large libraries have centralized technical services or entered into
cooperative agreements with other libraries. In large libraries or systems, the centralized
processing unit will handle acquisitions, cataloguing, and preparation of materials for different
libraries. All sizes and types of libraries have turned to outside vendors and have contracted
processing services. Most book jobbers (i.e. companies that sell large volumes of books to
libraries such as Baker and Taylor, Midwest, or Coutts) offer processing services. As well, there are
now a number of companies that offer complete cataloguing and processing services

• If a vendor cannot meet particular processing specifications or, if a library cannot afford to
contract processing services they will opt to process materials in-house. Even if funds are
available, there are usually materials that end up being processed in-house. For example, if
materials are donated to the library, it may not be worth the cost to send them for outside
processing. As well, if a library is moving from a manual to an automated circulation system
and/or purchasing a theft detection system, extra funds may not be available to add barcodes
and/or detection strips

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Steps involved with processing
materials
• There is some variation in the steps involved with processing
materials depending on whether a library is using a manual or
automated circulation system. Basic physical preparation includes:
1. Inspection
The material should be examined for any physical defects such as (e.g.
damaged covers or folded pages). If a book or other item purchased by
the library is defective, it can usually be returned. However, it will not
usually be accepted for return by the vendor if it has gone through
processing. A new book should be carefully and properly opened in
order to prevent spine damage:

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2. Identification
• Most libraries label their materials with some form of permanent identification that gives the name of the
library and its address. Identification is done to discourage theft and to ensure that lost library materials are
returned to the library from which they originated. As well, identification is relatively inexpensive means of
publicizing the library.

Ownership stamps are usually applied in all of the following places in books:
a) Along the top, front or bottom edge of the book:
• Stamps in these locations are easily seen and cannot be erased or torn out easily. Very thin books cannot be
stamped along the edge, In order to stamp the book on the edge, it must beheld tightly closed. Because the
stamp must be narrow enough to fit between the covers, it usually only states the name of the library. Any
type of rubber stamp can be used and these can be custom ordered from any office supply store.

b) Title page, inside front cover, or inside back cover:

• Again, these can be done with a rubber stamp. Because this is a large area, the stamp used on these
locations includes the name and address of the library. Instead of a stamp, some libraries will l purchase
special book plates that are pasted on the inside front cover. A book plate can be designed so that additional
information might be typed onto it (e.g. “This book was donated by the Smith family in memory of their
son, John.” Book plates can also be generated in-house on a laser printer.

c) Pockets:
In libraries with manual circulation systems, the pocket is usually stamped with the name and address of the
•04/25/2025 299
library. Pockets can also be ordered with preprinted name and address information.
3. Assignment of accession numbers
• Each item in the library should be uniquely distinguished from every other item. This
helps in the process of identifying whether a given copy of an item has been returned
and in inventorying the collection. Although the first copy of an item has a unique
author and title, additional copies are not unique in this regard. One way of handling
this problem is to assign a copy number to the record for the item (e.g. c.2). This
eliminates the need for an accession number. Materials can also be distinguished from
one another by assigning a unique number to each item. This process varies
depending on whether the library uses a manual or automated circulation system.

a) Accession numbers in manual circulation systems

• In libraries with manual systems, the accession number is usually stamped (or written)
on the Circulation card and/or pocket – if it is done on both, ensure that the correct
card is placed in the correct item
• Shelf list card – this is done for inventorying purposes
• Title page – helps to identify the book if the pocket and circulation card go missing
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b)Accession numbers in automated circulation systems
• In libraries with automated circulation systems, barcodes provide a
unique accession number for an item. Remember that there are two
types of barcode – Codabar and Code 39. In both barcodes there are
unique information in the bar code for a particular item. In the
Codabar, the eight digits following the first five, represented the item.
In the Code 39 barcode, the last seven digits are unique to a particular
item

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• Barcode labels are either “smart” or “dumb”. Smart barcodes are
specific to an item. Each item in the collection is assigned a unique
barcode number by the automated system, usually during the
cataloguing or acquisitions process. During barcode label production,
the computer program associates the appropriate call number and
copy number with each barcode. When the barcode labels are
printed, the call number and title of each item is include on the
barcode label. The barcodes are usually printed in call number order
for ease of application during processing.

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• Dumb barcode labels can be used on any item. The barcode number is not associated
with a particular item prior to affixing it to the item. During processing, staff must
electronically link the barcode number to the item record (catalogue record) . The
barcode label is then affixed to the item. Usually a dumb barcode label will have an
eye-readable number printed below the barcode. The library may also choose to have
the library name printed above the barcode as a means of identification.

Smart or dumb barcode labels are put on materials in the following locations: Inside
the front or back cover – this protects the barcode label from being damaged but adds
a step at the circulation desk because the book has to be opened.
• On the front or back cover – this makes it easier to circulate the item because the book
does not have to be opened but the label may be subject to damage from patron use.
• On both – this gives you more options but increases your processing costs.

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4. Preparation of circulation cards, pockets, and due date slips
• a) Circulation cards
• Circulation cards are a key component of manual circulation systems where they
are used to identify who has borrowed material and when the material should be
returned to the library. Circulation cards should have the following information on
them: call number, author, title, accession number, and copy number. Some
libraries may also add the price as reference information in case the item is lost
or damaged by the patron. The lower section of the circulation card is used when
the item is checked out in order to record borrower information and due date.
Circulation cards come in a wide variety of colours, paper weights, and sizes (3” x
5” is very common).

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b) Pockets
• The pocket holds the circulation card and sometimes information
about when the item should be returned. Pockets range from narrow
strips to heavy paper. As noted earlier, pockets can be printed with
the library’s name and address. The pocket can also have a date due
information area on it. This eliminates the need for a date due slip.
Pockets can be attached by:Using glue or a glue gun

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c)Date due slips
• Date due slips are placed in library materials as a courtesy aid to the patron. They can be
used by the patron to determine when the material should be returned to the library.
Pockets may be pre-printed with a grid for date due information. Other options are “slips”
that are attached above or below the pocket. These can be purchased from library supply
companies and come ungummed, pregummed, or pressure-sensitive. Even libraries with
automated circulation systems may opt to insert a date due slip in order to ensure the
patrons are aware of the length of time they can keep the material. Many automated
circulation systems would automatically print list of items that the patron borrowed along
with the due dates. This would be handed to the patron at the end of the check-out
procedure. However, if the patron loses this information and there is no date due slip in
the item, they will likely have to call the library to find out when material is due. A
bookmark prestamped with due date inserted into each book eliminates the need for a
pocket and still provides a date reference to the patron
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5. Preparation of call numbers
• Call number labels identify the location of library materials. Call
number labels would include the call number of the item and other
special indicators about where the book would be located in the library
(e .g. audiovisual area, reference, reserve, etc.) In the past, an electric
stylus was used to hand letter the call numbers in a contrasting color
directly onto the spine of a cloth-bound book. This system required
excellent lettering skills and could be frustrating because the stylus
needed time to heat up and could cause finger burns. Shellac was used
for coating the lettering so that it would be durable. This was dabbed or
sprayed on and required a work area with good ventilation.
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• Three types of pressure sensitive labels are widely used: cloth, foil back, and paper.
a) Cloth labels
• Cloth labels last longer than paper and foil back labels because of their high tear resistance. They are
more resistant to water and conform to curved book spines better than paper labels.

b) Foil back labels

• Foil back labels are more pliable for better adhesion to an irregular or curved surface. They are highly
recommended for use on fabric, cloth, and shiny surfaced books. The foil back prevents the adhesive from
penetrating through the label. Adhesives can discolor the label, attack the print, and cause it to fade. Foil
labels are opaque and therefore you cannot see the underlying information. They are excellent for
placement over existing spine labels or barcode labels. However, they are more expensive than cloth or
paper labels.

c) Paper labels
• Paper labels are less expensive than cloth or foil back labels and are a good all-purpose label. They are
smudge resistant and conform well to book covers and other paper surfaces.
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6. Attachment of a protective covering
• Protective coverings are used to protect book jackets, prolong the life
of materials, increase the attractiveness of materials, and protect call
number labels. Clear mylar covers can be purchased as part of the
processing contracted from a jobber or commercial cataloguing
service. Libraries can also apply covers in-house and have a variety of
choices including:single sheets precut to fit various sizes of books

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Others
• Discharge summary form- this form usually comes in duplicate, contains the
patients summary, prescriptions, followup visits, condition on discharge, and
amount to be paid.
• Discharge documentation : medical diets reports
• Discharge list- daily ward statement –list of all patients generated by the nurses in
the wards on a daily basis
• Patients clinic records-
• Admission records
• Supplies and procurement records
• Mortuary records
• Accounts records
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Community records
• A community is a small or large social unit (a group of living things) that has
something in common, such as norms, religion, values, or identity. Communities
often share a sense of place that is situated in a given geographical area (e.g. a
country, village, town, or neighborhood) or in virtual space through communication
platforms.
• Presently, community health workers are neither paid nor remunerated across
many African countries, including Kenya. According to Amref, CHWs play a critical
role in saving lives, especially at the community level where people lack access to
the formal health system
• Community health workers (CHWs) often live in the community they serve. They
spend much of their time traveling within the community, speaking to groups,
visiting homes and health care facilities, distributing information and otherwise
connecting with local people.
• A community health unit is a health service delivery structure within a defined
geographic area covering a population of approximately 5,000 people. ... Each unit is
governed by a Community Health Committee ( CHC ) and is linked to a
specifichealth facility.
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The following revised tools were reviewed, presented, and approved by
the DCHS M&ETWG:
• MOH 513 Household Register
• MOH 514 Service Delivery Log Book
• MOH 515 Community Health Extension Workers Summary
• MOH 516 Community Health Unit Chalkboard
• MOH 100 Community Referral Form •
• Community Treatment and Tracking Register
• Support Supervisory Checklist
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Community Health Information System (CHIS) The system collects the information obtained
through such tools as;
- CHIS Household Register (MOH 513) which gives the denominators for measuring the service
delivery of the CHVs. It is filled out by CHVs every six months and reported to CHEWs l
- CHVs Service Delivery Log Book (MOH 514), which is a diary that CHVs use to collect
information from the household during their visitation as they give messages and services. The
Log Book is submitted by CHVs to CHEWs for summary
- Community treatment and tracking register, which is a treatment register used by CHVs when
offering integrated community case management
- CHEW Summary (MOH 515), which is filled monthly by CHVs using the information from the
Community Service Log at the end of month and after six months, using the updated
Household Register l
- CHIS Chalk Board (MOH 516), which displays the general health status of the community unit,
the demographic characteristics of the population update every six months served by CHU and
service that are reported monthly by CHEWs. The information displayed outlines The action
areas/displayed in the community dialogue days and action drawn by the community to
improve the output
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Master Community Unit List (MCUL):
These are an added organisation structure for community units
inventorying the Master Facility List (MFL) and the link will be made by
the data field for the link facility. MCUL is established to provide an
authoritative and reliable inventory of all community units established
across the country.

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Creating and maintaining of manual
and electronic health records
indices
• Definition of Indices: : A more or less detailed alphabetical listing of names,
places, and topics along with the numbers of the page on which they are
mentioned or discussed.
• indexes and registers allow health information to be maintained and retrieved by
health care facilities for the purpose of education, planning and research.
• Register: collection of information, such as a hospital's admission/discharge
register; use register to verify information
• Registry: structured system for collecting and maintaining health information
about a defined population so that analyses and reviews can be performed; use
registry to collect data
• indexes, registers, and registries: considered secondary sources of patient info,
because it contains data abstracted from primary sources of info (medical record,
etc.)
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There are different types of health records indices used and maintained
in a health record department, these include:
• The patient master index.
• The diagnostic index (Disease index)
• The operation index.
• The waiting list index.

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1. The patient master index
Also known as master person index
• -This is an alphabetical key to numerically filed case records. It is an
index referencing all patients known to an area, enterprise or
organization.
• -The master patient index contains identification information of all
patients admitted to a healthcare facility and is the key to locating a
patient’s medical record.
• The MPI is retained permanently and filed alphabetically by the
patients last name

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• Importance-An important index in case a patient has lost his
attendance card.
• The main purpose of the MPI is to provide continuity of care.
• It is important to link the patient to their established medical record
• The medical practitioner needs to ask the patient if he has been
previously seen in the facility
• This process prevents duplication of multiple medical record numbers
for one patient
• For the facility, the MPI provides a customer database

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The following must appear in an index card;
1. Patients names
 Surname. ---last name
 first Name…….patients other names ..1st and 2nd
2. Patients address
 Address…..to include the street, city and zip code, home/residencial and tel.no / land mark
3. Their Date of birth.
 Make sure to use the mm/dd/yyyy format
4. gender
 Sex. …either male or female
4. Hospital number…..
 for easy retrieval and filing
 Assigned by the facility
5. Name of the facility and /or the provider
6. Type of care received
 Such as inpatient, outpatient, emergency or physicians office
7. Space left for change of address….in case they move out to a different location
.04/25/2025 319
others
• Race/Ethnicity
• Other unique identifying information, which will assist the identification of the
patient, such as the mother's maiden name, national identification number or
social security number. (This information is limited by the amount of space
available, i.e., computerized database or index card.)
• Visit Level
• Account number – the billing number used to identify admission or encounter
charges
• Admission and discharge dates - for inpatient hospitalizations
• Type of service – inpatient, emergency, outpatient surgery, etc.
• Encounter date or date of service – for outpatient visits
• Disposition – discharged, transferred, or died
• Admitting and/or attending physician's name
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Example of Master Patient Index Card
_______________________________________________________
DOE, John William MR# 17-28-42
17 Western Avenue DOB 02/17/1949
Anytown, Indiana 46321 Sex: M
219-555-3083
Adm Date Dis Date Service Physician Account #
02/14/2004 02/17/2004 IP Smith 04-3332112
05/16/2004 OPS Jones 04-3332866
_____________________________________________________

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Manual Master Patient Index

a. For inpatients, the procedure for a manual master patient index could be as
follows:
• 1) Each day the admission registration staff notifies the health record
department of all patients registered in the facility. This may be done by
sending copies of the admission slips for all patients admitted to hospital,
which are usually the carbon copies or computer printouts of the registration
forms or face sheets.
• 2) The MPI is checked to see if any of the patients whose names appear on
the admission slips have been previously admitted and if they have an index
card. If yes, these cards are pulled out and the current admission information
is recorded. The demographic information on the index card must also be
checked for any changes in name, address, etc
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.3) If the patient has had no previous admission, and therefore no card
in the MPI, a new index card is prepared.
4) In some hospitals the completed cards of inpatients are filed in a
separate file, called the "in-hospital" or “in-house” file, and remain
there until the patient is discharged.
5) At discharge, the MPI card is removed from the "in-hospital box" and
the discharge date is recorded. If a death occurred the date may be
recorded in red. The patients' index cards are then filed into the MPI.
Given the importance of the integrity and accuracy of this index, many
hospitals have a second person check the filed card for accuracy.

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b. Organization of the MPI In the absence of a computerized MPI,

special index cards or books or may be used for the listing of patients' names, with index
cards being the most preferred. The most popular and efficient method of maintaining the
MPI is on index cards arranged alphabetically in a vertical file with a separate card for each
patient.
Using this method a single index card can be located readily in one search. If using a book, it
is divided into alphabetical sections.
Names are listed under the first letter of the surname in chronological order by date of
admission.
This method is only feasible for a small facility, but retrieval becomes cumbersome and
increasingly difficult for large hospitals, or where the volume of patient admissions or
encounters is great, because a strict alphabetical order is maintained.
This method is NOT generally recommended for a MPI.
It is not recommended to maintain the master patient index by year of admission or
encounter.
This is not a good method as patients often forget the date of their last visit, or if they were
ever admitted to a particular hospital at all.
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• Much time is lost searching through several sections of the index for
the appropriate index card.
• Nor is it recommended to separate the MPI by sex, that is, to file the
cards of male patients in one file and the cards of female patients in
another file

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Computerization of the Master Patient Index (MPI)
• As hospitals move to automation, many have already computerized their MASTER PATIENT INDEX.
When considering an automated medical record system, the MASTER PATIENT INDEX should be
the first procedure to be computerized. The information in a computerized MPI is the same as
that recorded in a manual one.
• As for a manual system, the objective of a computerized MPI is patient identification. The main
function is the entry, storage and retrieval of the patient’s name and MRN.
• • This system would require a group of programmes that would be accessed by users via
computer terminals and/or printing terminals. The programmes would be designed to enable
access to the information held on the MPI file, and to build or modify the file information, as
required by the hospital.
• • As discussed, the MPI holds information on all patients who have attended or have been
admitted to a hospital. Clinical details are NOT held on this file, only basic information required to
IDENTIFY the patient.
• • As with a manual file, a computerized file would be cumulative. That is, new patients would be
continually added to the file. Previous patients are NOT deleted, as their details are kept available
for future attendance or admission, or for any other need to retrieve a patient's medical record

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Implementation of a computerized MPI
• Computerization of the MPI would be spread over a period of time through
• • entry of information already held on index cards from the manual MPI
card system including all patients in hospital at the time of implementation;
• • inpatient registration; and
• • outpatient registration.
• The entry of data on new patients should be completed at the time they are
admitted as inpatients or registered as outpatients, that is, in the Admission
office for inpatients and the outpatient department registration desk for
outpatients.

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Search programme
• As for the manual system, in a computerized MPI, the search
programme should enable the operator to locate a particular patient
to determine if that patient has been in hospital previously and has a
medical record number.
• Limited information on a number of patients (one patient per line)
may be displayed on a screen for review or further action. These can
be displayed by:
• • patient name giving hospital number; and
• • hospital number giving patient name
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When the particular person is identified, the full index file information for
that selected patient may be displayed on the screen. If there are
changes to a patient’s identification details, they should be made at the
time of admission..
• • When retrieving information, strict security codes should be used to
prevent unauthorized access and alterations. Each user should have
his/her own user name as well as a password, which is assigned by the
computer manager and changed periodically.
• • Only an authorized user should be able to access information relating
to a patient and to change, add to or delete records on the master file

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REMEMBER AS IN THE MANUAL SYSTEM, NO NAME MAY BE ENTERED
INTO THE MPI WITHOUT FIRST CHECKING IF THE PATIENT ALREADY HAS
AN ENTRY IN THE INDEX.

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The MPI should force a name search before a name can be entered, unless the name is
being entered with a pre-existing medical record number.
Important Points for the Operation of a Computerized MPI
• • All name searches should use the name and at least one unique patient characteristic
(see PATIENT IDENTIFICATION). • As in a manual system, correct spelling of names is
vital to minimize duplicated registration of a patient. • Entry of at least one unique
patient characteristic is compulsory when adding a patient to the MPI.
• • Entry of the medical record number is compulsory when adding a patient to the MPI.
• • The computer automatically issues medical record numbers in strict numerical order.
• • The MPI should enable the manual entry of pre-existing medical record numbers.

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Reports generated from the MPI should include:
• • a daily printout of numbers issued, in number order, creating the
NUMBER REGISTER; and
• • regular printouts in alphabetical order of all names by family name
or by first name depending on the naming conventions of the country.

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Before planning such a system, however, many administrative decisions
must be made. Some important ones include
i. sufficient funds are available for its development and implementation;
ii. the type and size of computer required, and that sufficient computer
terminals are available to meet the needs within the funds available;
iii. trained staff are available to install and maintain the system;
iv. the hospital has a computer support team available to assist if
hardware or software problems arise;
v. all clerks have keyboard and mouse training, and are also trained in
the use of the relevant software;.
vi. a computer terminal is available to the clerical staff and should not be
locked away in the manager's office;

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VI. appropriate furniture is made available (power points, electric
cables, chairs and desks). Furniture provided for computers in
Medical Record Departments is often taken away by managers for
other offices. This should not be permitted;
VII. security procedures should be arranged to avoid the use of the
computer for games and other non-medical record functions, and
to protect the computer from viruses; and
VIII. authorized staff should be issued with passwords, which are
changed regularly to prevent unauthorized access.

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3. The MPI should be a continuous file, that is, not divided into years.

4) A MPI card should be removed from the file only for updating or placing in the in-
hospital box.

5) Occasional auditing of the MPI is recommended to monitor filing accuracy. This can
be done by having the file clerk place a slightly higher card of a different colour behind
each individual card at the time it is filed. A second person, known as the auditor or
checker, removes the audit card after checking that each card has been correctly filed.
It is useful to audit the filing done by new personnel to ensure that they are applying
the rules correctly.

6) A patient whose name has changed since a previous admission will need a new
index card. The new index card should be cross-referenced to the original index card.
All information recorded on the original card should be entered on the new card. The
original card should be cross-referenced to the new card.
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• Creation of the master patient index-It is created when the patient is
being registered

04/25/2025 336
• master patient index (MPI)
aka master person index (MPI), links a patient's Medical Records Notes
with common identification data elements, retained permanently
because it serves as the key to finding patient's record, organized by
patient name
• automated MPI
resides on a computer and consists of a database of identification data
about patients who have received health care services from a facility

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• admission/discharge/transfer (ADT) system
used to input patient registration information which results in the
creation of an automated MPI database that allows for the storage and
retrieval of the information
• ADT software
can generate standard reports such as list of patients admitted, facility
occupancy rates, expected account receivable, current inpatients, list of
patients discharged or transferred, patient profiles, transfer reports to
units within facility, user-defined reports

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• manual master patient index (MPI)
requires typing or hand posting of patient identification information on
preprinted index cards, housed in vertical file, with one card generated

04/25/2025 339
A typical layout of the card which measures 3” x 2 ½ ” or 5” x 3” would
be figure 1; patient master index card in the next slide

04/25/2025 340
Name of patient Hospital no.

Date of birth.

Sex

2 ½ ‘’

Address

Space for change of address

3’’

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Filing techniques used in filing patient master index
(i) Sorting-This means putting the cards into groups before they are
filled. It’s the first most important step.
- There are two methods of sorting most appropriate to master index
e.g.
 pigeon holes – each lettered for the initial sorting of the index cards
and sort files- this is a series of flaps each bearing a letter of the
alphabet arranged on a solid base
(ii) Filing-Putting card in order as per the system of filing laid down. It
requires a lot of concentration. Check files in front and behind.
(iii) Checking cards order-Confirming if cards are filed in order or if all
the cards are present in the equipment. This avoids mistakes which do
occur
04/25/2025 therefore constant checking of filed cards is required 342
 (iv) Diagnostic index-It lists diseases, conditions and injuries by the specific
code number for each condition or injury based on a clinical classification
system to allow for retrieval of records for research by each specific code.
Health record personnel willing to carry out a study on any particular
disease from the index can obtain the case folder. The diseases index will
provide the number of the relevant case records and provide some minimal
data about the patient’s age and outcome of episode treatment
v. Reference to index: once cards have been filed and checked they should
only be removed when the address needs to be changed. Cards should
never be so packed as to prevent checking and filing.

The most important to note here is that the MPI should be filed strictly
alphabetically and only one member of staff should work on the cards any
one time to prevent cards from being misfiled.
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Equipment's used for filing the MPI
i. Cards- must be of good quality. It’s the most basic record document
in most MPI
ii. Drawers-cards may be filed ‘blind’in drawers, one behind the other in
an upright position
iii. Strip index- as the name indicates, this consists of series of thin
wooden strips coated with paper on which the details required for
the MPI are typed or written. Strips are filed on metal panels with a
fold of metal down each edge which holds the strips in place. The
panels are hanged on a central revolving spindle so that they fan out
like leaves on open book. They may also be mounted on a wall. This
is recommended for the waiting list and not the MPI
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• Strip index- one line entry is made in narrow strip metal made up of
thick chalkboard paper which is fitted in a frame in such a way that all
the strips fitted in the frame are visible at a glance. It is flexible and
expensive
• Visible edge card-a visible file-card system including a holder and a
plurality of cards with cooperating means for pivotally mounting the
cards in the holder in superimposed, overlapping, stepped
relationship with a portion of the face of each card adjacent its lower
edge, visibly exposed

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• Carousel- are what people swipe through when viewing your ad in the
carousel format; each combination of image and or video, headline
and link or call to action constitutes a carousel card. U can use up to
10 carousel cards in a single ad
• Color coding - mark things with different color as a means of
identification

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iv. Elevator files-
The cards are usually filed in trays about a foot long and several of
these trays are filed in a shelf in the machine. The machine looks like a
large metal cabinet which may be up to 5 ft high and up to 10 ft wide,
with an opening at the top.
In this opening, 2 or 3 of the shelves with their trays of cards are
visible. The largest elevator file would probably hold 900,000 index
cards. The large files are electrically driven. If the card is wanted the
filing clerk presses a button indicating the shelves to rotate until the
correct one arrives at hand level. The clerk then looks in the
appropriate tray for the card. Smaller elevator files are manually
controlled.

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vi. Card wheel- in this type the cards are attached to a large upright
central wheel which is rotated until the required section come to the top.
Its not suitable for very large hospital
vii. Carousal type files: cards are housed in open metal boxes which are
attached to a central upright spindle. The boxes can be swung out for
use and then folded back towards the spindle when finished.
Advantage: - because the boxes are attached right round the stem,
several clerks can have access at once
-the equipment is space saving considering the number of cards that can
be housed
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• Viii. Guide cards and back stops
All the equipment described above except strip index will need some
guide card or back stop.
Function- to subdivide the file into reasonable sections, so that not too
much time is spent hunting through several hundred cards before finding
the precise section of the file that is needed.
whichever guide card chosen, clear bold lettering will aid both filing and
finding the cards.
Backstops are the pieces of metals that stops the cards in the drawer that
is not full from sliding down
Backstops should be firm enough to stay in place when a drawer is closed
too roughly, but mobile enough to be readily adjustable as the card have
to be expanded backwards
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04/25/2025 350
3. Supplies and equipment for a manual Master Patient Index Index cards,
index guides and filing equipment are needed for maintaining a manual
MPI.
a) Index cards - 3 x 5 inch cards (7.5 x 12.5 cms) are generally used, but
the size may vary depending on the amount of information to be
recorded. Since the MPI is a permanent file, the card must be durable
to withstand much handling. Remember, however, that the heavier
the card, the more space required in the file.
b) Index guides - Index guides for an alphabetical or phonetic MPI file
facilitate the location of an individual patient's card. Being slightly
larger than the patient's card, the top of the guide with an initial letter
of a
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common surname is extended above the other cards, thus serving as a
guide. Phonetic index guides will require, in addition to guides with initial
letters or surnames, sub guides indicating basic code numbers. The size
and activity of the index will determine the number of guides needed.
Sturdy construction of guides is also essential.
c) Filing equipment - Patients' index cards may be filed in cabinets
suitable to the card's size. If 3 x 5 inch (7.5 x 12.5 cms) cards are used,
they are usually filed in vertical, eight-drawer, triple compartment file
cabinets. A power file is considered feasible when the MPI has more than
500,000 actively used cards. At the touch of a button, a power file delivers
the required section of the index to the front of the file for easy access.
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Benefits of MPI
• Linking data to provide “patient-centric” care across the continuum
• Meeting the goals of Population Health, which rely on matching
individual healthcare records
• Providing metrics that are useful for researchers and system analysts
• Finance departments rely on good data for programs like value-based
purchasing, revenue cycle management, and risk-share
reimbursement modeling.

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Advantage: there is speedy access to all cards while the clerk is
comfortably siting on a chair

Disadvantage: the machine is expensive and may not be affordable by

some of the health facilities

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4. Computerized Master Patient Index
As mentioned earlier, It is also possible to maintain the MPI in a
computer. At the time of admission to a facility, the registration staff
searches the computer database for a particular patient. If the patient
has been in hospital or attended a clinic previously, the patient’s
information is displayed on the computer screen. The registrar then
updates any demographic information that has changed since the
previous admission or visit. If the patient has not been to the hospital
previously, the registrar collects the patient demographic information
and the system automatically assigns a new registration, or medical
record number, and stores this information in its memory. At the time
of the patient’s discharge, the date of discharge is entered into the
system, thereby completing the current MPI entry.

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SUMMARY
The master patient index (MPI) is a permanent listing of all patients
who have ever been admitted to, or treated by, the clinic, doctor or
hospital. MPI cards should be prepared as soon as possible following
the registration of a new patient and not later than 24 hours after the
patient's presentation to the clinic or admission office.
As the MPI is the key to finding a patient's health record, in a manual
system they must be filed promptly in alphabetical or phonetic order.
The type of equipment required will depend upon the type and size of
the cards used. The size generally used is a 3 x 5 inch card (7.5 x 12.5
cms).
Regardless of the size of the card, however, only basic identification
information needed to promptly locate a medical record should be
recorded.
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MPI cards must be filed promptly and removed only for updating
information.
To help find a card guides should be used at regular intervals. If
computerization of hospital information is considered, the registration
process and the MPI should be computerized first, if computer storage
is available.
The patient demographic and visit information contained on the cards
can be stored in a computer database, and at the time of a patient's
admission to, or outpatient encounter at a hospital, the staff can check
the name and file number via a computer terminal in the office

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(2) Diagnostic index-
- It lists diseases, conditions and injuries by the specific code number
for each condition or injury based on a clinical classification system to
allow for retrieval of records for research by each specific code.
• A system for recording diagnoses, diseases, or problems of patients or
clients in a medical practice or service, usually including identifying
information (name, birthdate, sex) and dates of encounters.
• -Health record personnel willing to carry out a study on any particular
disease from the index can obtain the case folder. The diseases index
will provide the number of the relevant case records and provide
some minimal data about the patient’s age and outcome of episode
treatment.
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• The medical record can be used for research, education, patient care
evaluation, and as a source of morbidity statistics. These uses will vary with
the type of health care facility and will influence the procedures that are
adopted. For example, a university hospital will require a disease index to
locate medical records for clinical research; a health centre would probably
not have need for such an index. In some countries, outpatient morbidity data
might be reported routinely while in others these data might be obtained by
sampling medical records. It is important to define for each type of health
care facility
(1) the anticipated uses that will be made of the medical record for research,
education, patient care evaluation and
(2) the characteristics of its reporting systems.
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Equipment used to maintain the diagnostic index
I. Vertical index card
II. Visible edge card
III. Computers
IV. Matching cards
V. Slotted punched cards

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Applications of computerized diagnostic index
Benefits of a diagnostic index
-means of accessing records of any groups of patients for further study
-it has a wealthy of summary information contained in the database itself
- Ability to search for vaguely remembered interesting cases
Use of databases for analysis is a powerful tool that current computer
softwares provide
Once the database is set up and the habit of recording data along the way
is established , information can be retrieved by a few simple key strokes
The choice of software is a matter of personal preference , fox pro 2 is an
excellent database manager

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3. Operation index
• -Besides the diagnostic index, operation index needs to be coded just
as do diagnosis.
• -Its list operations and procedures by a specific code number based
on an operation procedural classification system. The index enables
the retrieval of medical record patients who have undergone a
specific operation or procedure while in hospital.
• Also known as ICPM – international classification of procedures
manual

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Equipment used to maintain operations index
-the information is recorded on the same media as the disease index.
I. Vertical index card
II. Visible edge card
III. Computers
IV. Matching cards
V. Slotted punched cards

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Identifying factors recorded on the operations index include
- case record number- inpatient number
- Sex
- Age
- Surgeon
- Outcome of episode
- Date of discharge

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4. . Waiting list index
• Definition: This is an index for all patients awaiting admission or
treatment on a day case basis.
• -A waiting list admission occurs when a patient whose name was on an
inpatient or day waiting list for the specialty is admitted to that specialty
as planned. Waiting admission therefore cover all patients whose names
were on a true waiting list, admission waiting list or a planned repeat
admission waiting list for the specialty are admitted as planned.
Function of waiting list index
• Enquiries can be answered from individual patients.
• Easy for consultants to know how many patients are awaiting his care.
• Assist in understanding utilization of available beds in a health
institution.
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Types of waiting lists
They are: 1. Centralized.
2. Decentralized.
1. The centralized waiting list
-The waiting list is held in one office and contains the names of all
patients awaiting admission under all consultants.

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

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2. Decentralized waiting list
This is maintained in several places, possibly by each consultant’s secretary or by individual
wards.

Advantages
• The list is short and become easy to maintain.
• Consultants need not to go to central office to select their patients from the waiting list.
• The records staffs get familiar with the patients and can call them by their names.
Disadvantages
• Several staff will be deployed in the maintenance of the waiting of the waiting list in
different areas.
• Expensive since each department will need to use its equipment.
• Record staff will have to walk to the central waiting list department to check on the
discharges from the daily bed return.
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Creation of waiting list
-Most of the waiting list records are initiated in the out- patient clinic. Some other
patients may come from another hospital and be put in the waiting list for another
different hospital, where there are more beds or facilities
-There are four ways in which information can be conveyed to the waiting list.
1. Card-The card is created to every patient who is to be admitted. The card will be
filled and form part of the waiting list.
2. The nurse or doctor may send a list of patients to be included in the waiting to
the records department for action.
3. List-

4. Letter-A consultant in one hospital may wish to include his patient’s name in his
waiting list.in another hospital for his name to be included in that waiting list . In this
letter he will include diagnosis and priority for admission.
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• A case folder will then be created for this patient . The information to be included in
this record are:

• Patient’s name.
• Address.
• Telephone.
• Holidays.
• Diagnosis.
• Operation to be carried out.
• Duration of stay in the hosp
• Name of surgeon/consultant
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Procedures of selecting the patient on the waiting list
• The patient is selected from the waiting list by the consultant.
• The record staff writes to the patient or telephones him inviting him.
• The records are got out from the file and sent to the documentation.
• The waiting list card is sent to the admission so that the day the
patient comes in, the admission office checks the record, when
he/she comes the details are checked and confirmed.
• The patient is admitted and sent to the ward.
• When the patient has been discharged his name is removed from the
waiting list.
• Certain checks are made on the waiting list to remove the names of
patients that may have been admitted through accident and
emergency department that have died.
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Checks to be made on the waiting list
• Checking for completeness.
• Checking for accuracy.
• Checking for deaths.
• Checking for duplication

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

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Statistics
• -Regular returns will be needed for the number of patients on the
waiting list. These returns are in the form of the number of patients
waiting for admissions under consultant e.g. number of males,
females or children may be shown separately with specific clinics.

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Organisation and management of manual and
electronic patient/client schedules and follow ups
and clinic preparation
Definition: This is the giving of day, date, time and clinic of attendance
to individual patient or client.

Patient scheduling is an art. On the other hand you want to maximize

your cares team’s productivity and see as many revenue-generating
patients as possible. On the other hand, you want to avoid long patient
wait times and keep patient satisfaction high by giving each the
attention they deserve

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 Follow up is the act of making contact with a patient or caregiver at a
later, specified date to check on the patient's progress since his or her
last appointment. Appropriate followup can help you to identify
misunderstandings and answer questions, or make further assessments
and adjust treatments.
• Care given to a patient over time after finishing treatment for a
disease. Follow-up care involves regular medical checkups, which
may include a physical exam, blood tests, and imaging tests.

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Concepts of scheduling

1. Patients should be distributed evenly to various clinics depending

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

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Importance of scheduling in health
care
Scheduling aims to improve the match between healthcare resourcse
(doctors, nurses, rooms, equipment, machines) and patient needs.
A good scheduling system reduces waits for patients while improving
the utilization of critical resources.

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Importance of patient scheduling
1. Email, text, and phone call reminders
• More often than not, patients forget they even have an upcoming
appointment. Likewise, the chances of no-shows increase the more time there
is between each appointment.
• The article "NHS to reveal cost of missed appointments" mentions the fact that
the cost of missed medical appointments is on the rise. To avoid the expenses
associated with no-shows, it's important to remind your patients of their
upcoming appointments.
• You can do so through email and text; just make sure you send reminders with
plenty of lead-time. If you don't receive a response and the appointment is
less than 24 hours away, consider calling the patient to make sure they're still
coming.
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• If your hospital has a patient portal on its website, you can require
patients to check-in to their appointments a day or so before the
appointment date. Pre-appointment check-ins help expedite the
appointment process, which is a benefit for your patients and your
hospital.
• You can also setup check-in alerts through the patient portal that
notify your patients when they fail to check-in ahead of time.
• These alerts, which can be sent by email or text via push notifications,
also serve as reminders themselves.

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2. Schedule flexibility
• Convenience is one of the main factors when it comes to your patients making it
to their appointments.
• By offering a flexible appointment schedule, you can meet the scheduling needs
of each individual patient, which greatly reduces no-shows.
• To accomplish this, make sure you offer appointments five days a week. Likewise,
consider offering limited appointments on Saturdays as well. In addition, consider
offering family appointments, which allow multiple family members to meet with
their primary care physician during the same visit.
• Finally, try to be as flexible as possible with rescheduling cancelled and missed
appointments. If a patient is willing to reschedule at a later date, give them any
and all options that meet their criteria, especially if they notify you in advance
about their cancellation.

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How to Effectively Scheduling and
Manage Patient Appointments
Here are 5 tips on how to keep your medical appointments organized:
• Offer your patients time-slot options when scheduling the appointment.
• If the appointment was made in person, give your patient a reminder
card.
• If the appointment was made well in advance, send reminders via mail
or email near the appointment date.
• Consider making phone calls to confirm the day before or day of the
appointment.
• Upgrade any manual appointment books to browser-based software.
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Importance of patient reminders
• This follow-up appointment helps keep patients on the path to recovery
• and helps to reduce readmissions
• patients can ask questions about medications, wound care, and more
• providing the opportunity for their physician to establish that the patient
is indeed recovering properly.
• appointment reminders can effectively help reduce these no show rates,
thereby reducing readmissions and improving patient outcomes
• , it is easy to send automated call or text outreach to patients to confirm
their appointments without significantly adding to the workload of
employees
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• . The reminders can also include educational information such as
building location, pre-appointment instructions, and more.
• With appointment reminders, providers can be notified of patients
who wish to reschedule, need additional assistance, or simply do not
respond to outreach. These patients can then be contacted to resolve
issues and ensure they are prepared for their follow-up.

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summary
1. How to schedule patients effectively
• Schedule from noon: Try your best to schedule morning appointments from
noon backward and afternoon appointments from noon forward. Establishing
this as the standard will help you maintain maximum productivity and ensure
that the bulk of the day is scheduled out.
• Implement patient self-scheduling: Studies show that the majority of patients
prefer to schedule their own appointments online. Even better, 26 percent of
appointments scheduled online are for the same day or the next day, filling up
empty spots on your schedule. Practices now have the ability to offer real-time
patient scheduling anytime and from anywhere with Internet access. Online
scheduling is new to healthcare and offers
greater convenience for both practice and provider.
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2. Prioritize appointments: Patient visits vary in degree of time
requirement and level of care needed. Consider these factors as you
decide where and when to schedule your patients or whether you even
need to put them on the schedule at all
3. Confirm appointments with text and email appointment reminders
. Utilizing an appointment reminder software system will improve upon
the number of on-time arrivals and kept appointments. No-shows are
costly and inconvenient especially when you are a particularly busy
practice and have a good size waitlist. Both provider and patients miss
out when a no-show occurs.

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4. Create a patient waiting list. Last minute cancellations may be
frustrating; however, with a patient waiting list, you are armed and ready
when this unfortunate event occurs. Try using a patient scheduling
platform that includes the ability to keep a list handy and ready to be
notified. Being able to send out a mass notification of your immediate
open slot is a huge time saver and revenue maintainer. Instead of
grabbing the phone when you get that dreaded appointment cancellation,
quickly access your stored digital patient wait list and send out a quick
message encouraging your patients to call you rather than the other way
around which results in a waste of precious time that could rather be
spent on more productive activities such as getting to know your patients
better or increasing billing collections.
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5. Use Automated Patient Recare and Recall. Having a patient recall
system in place ensures that patients return for their regular care
appointments keeping your schedule consistently fuller. This type of
system can also bring back patients who haven’t been in to see you for
their regular care appointments in years by simply sending out a
reminder email, text or voice call letting them know it’s time to
reschedule.

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Types of appointment systems
-There are two types of appointments, they include:
• 1. Centralized
• 2. Decentralized
• 3 .combined

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Purposes of
appointments/scheduling
1. To reduce patients waiting time.
2. To provide an even spread of work over the whole clinic session.
3. To allow the hospital to prepare in advance for each and every patient
for registration at the time of the clinic can be reduced.
4. To provide for special clinic arrangement e.g. recording of social
history of patients, removal of plaster.
5. To cater for issues of transport and distance difficulties from their
house to the hospital and back.
6. To provide for teaching arrangements. A consultant may wish to issue
an interesting case to the medical students.
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Sources of appointments
• Using patients - new patients, active patients, finding patients
• Using recall letters on set time frames
• Diaries
• Emails/sms
• Use of nurse/practitioners
• Telephone calls
• Use of primary teams- chvs
• Family physicians

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Sources of requests for the appointments in
hospitals

• Patients telephoning personally to make appointments.

• Physicians or private practitioners wanting to book appointments for
their patients through telephone or writing.
• Letters from other health institution given to come and book their
appointments.
• Patients already discharged from the hospital making a return
appointment.
• Patients referred from one clinic to another.
• Patients can come from outpatient clinics.

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queuing theory in application to
patient/client scheduling
Queuing theory is the mathematical approach to the analysis of
waiting lines in any setting where arrival rate of subjects is faster than
the system can handle. It is applicable to healthcare settings where the
systems have excess capacity to accommodate the random variations.
- Its used as a short term measure
- For resource planning

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- Used in walk in:
patients clinic
phone calls from physicians to health management organisations,
emergency departments, outpatient clinics and surgeries,
pharmacy,
 physicians offices,
 infrastructure planning for disaster management and
 public health.

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Examples of que disciplines
• Queue: aggregation of items waiting for a service function
• Arrival rate: mean rates arrival per unit of time / clients arriving to
the system per unit time
• Service rate: average number of service rendered per unit of time
• Service discipline: value by which customers to be served are
selected eg FIFO – first come, first served, LIFO- last come first served,
priority selection rule eg male, female , SIRO – service in random
order, priority service etc
• Average departure rate: clients leaving the system –completing the
service per the same unit time eg per 30 seconds

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Behavior of calling population has the following
connotations

- reneging – someone on the que leaves service completely,

- Baulking- doesn’t join the que at all, but shunts the que
- Jockeying-moving back and forth queues seeking for fastest moving
que
- Blocking- when a que system places limit on a queue length

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Applications of the que theory
• If one is interested in only their counts and not identity
• If one represents the times customers leave by the points on real line
• It provides the counts of departures but not the identity
• It represents departure times
• Average arrival rates during the time intervals
• Deals with stationery arrivals
• Cost per unit of time
• Average que length

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A typical queuing process
Patients/clients arriving

……... Service ... …..…served patients/clients leaving

facility

Discouraged patients/clients leaving

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Characteristics of queuing process
1. Arrival pattern of patients/clients – knowing the time between
successive patients arrivals ( inter-arrival times)
2. Service patterns – single or batch service
3. System capacity – eg limitations of waiting rooms, hence some
patients are barred from entering at some length
4. Number of service channels – eg multi server queuing system to be
fed by single line; parallel service stations that serve clients
5. Stage of service – one or more stages eg physical examination such
as throat examination, blood tests, electrocardiogram . Recycling
may also occur where feedback is required
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Equipment's used in scheduling
• Calendar
• equipment scheduling – for specific rental durations and reserve your
gear to avoid overbooking
• Barcode scanning
• Signable documents- create invoices , contracts and quotes and
patients sign digitally

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Centralized and decentralized
scheduling system and combined
• Centralized – all schedule requests are handled by a single dedicated
scheduler or a team of schedulers
• Decentralized – scheduling is managed by certain staff or team
members who have exclusive domain knowledge regarding providers
and/ or other practice locations ‘ schedules that other staff or team
members don’t
• Combined – combination of the two

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Centralized scheduling
• Staff are free to focus on other priorities eg capture and verification of
demographic information, revenue management
• Increases patient satisfactions- it allows easy access to online
appointment scheduling
• Hiring right number of staff by observing the strategies that work well,
trainings,
• Communication is centrally
• Enables use of new health care technologies eg online booking, chat
features,

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Centralized appointment system

• -This means that all the appointments for the various clinics are made in
one central place
Advantages
• The master index will be near the area for quick reference.
• Control of staff, stationery and equipment by the health record information
officer is easy.
• Each of the appointments record staff becomes familiar with the working
system for various consultants.
• All enquiries concerning appointments are referred to one area/ place.
• Urgent cases can be channeled quickly for respective clinics.
• When one record staff is sick or goes on leave other clerks continue with
the work.
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Pros of centralized
• Streamlined workflows – breaking up scheduling responsibilities eg
others handling scheduling and reschedules and cancellations while
others handle incoming calls, which ensures all patient requests are
handled
• Increased control- assigning tasks to one person
• Measurability- using various tools and procedures to ensure that work
is completed and success of workflows

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Cons OF centralized
• Lack of flexibility – if simple schedules are not kept – then its can be
tough – having to moving stuff all around – consider group messaging
• Decreased awareness – as manager, aren’t aware of every scheduling
snag/issue making it super important to have some way to connect to
the practice
• Potential return on their investment loss – if clear goals are set,
metrics aren’t followed and monitored, processes aren’t
analyzed ,processes may not be a good return on investment

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Disadvantages of centralized
• It creates congestion of patients.
• Increases the patients waiting time

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Decentralized scheduling (multi
location practice- focus on few
selected locations )
Pros
- Heightened awareness of practice schedule- team members much
familiar with providers schedules
- Increased employee involvement – provides more availability of staff
members to wear a variety of hats and help with additional patient
engagement tasks
- Improved patient interaction- practice mangers and staff members
have more opportunity to interact patients in person which can help
boost patient satisfaction

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

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Cons of decentralized
• Overwhelmed staff- too many scheduling tasks for a decentralized
staff to complete making it too difficult to hold accountable for other
schedule relayed tasks like follow up with, no shows or monitoring
metrics
• Training snags – difficult to train new staff on procedures at each
practice location
• Less efficient workflow- not having dedicated schedulers can make it
difficult to ‘keep the rhythm’ due to various interruptions that arise

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Decentralized scheduling
Disadvantages
• The master index is far from the appointment area.
• Control of the available resources is difficult.
• When the records staffs who man the clinics is sick or on leave, the
work may be interrupted.
• Enquiries concerning appointment are directed to different place.

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How to effectively schedule and
manage patient appointments
• Offer patients time slots when scheduling the appointments
• Give patient reminder card if made in person
• Send reminders via mail or email if the appointment is made well in
advance, when the appointment date is near
• Consider making phone calls to confirm the day before or day of
appointment
• Upgrade any manual appointment books to browser based software
With online scheduling you can better organize your patient appointment
reminders and notify your patients automatically of schedule changes

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Patients reminder system
• A simple reliable tool to make patients appointment reminder calls
can reduce no shows , increase practice revenue and lead to better
patient compliance

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Benefits of a Patient Appointment Reminder
System

• Improve office efficiencies – Reduce staff time spent on the phone for out-
bound calls
• Higher patient arrival rates – Use medical appointment reminders to
provide the date and time for an upcoming appointment
• Improve patient preparedness for appointments – e.g. Include specific
patient messaging such as “no food or drink after midnight” for those
patients having lab work
• Improve compliance – Remind patients of annual exams and unscheduled
treatments
• Recall patients who missed appointments or need follow-up appointments

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How Automated Patient Appointment
Reminders Work

• HealthWave Connect® – our cloud-based appointment reminder

solution – integrates with practice management systems. The
software pulls contact and calendar data from your practice
management system to create call files.
• The patient reminder calls are made during the times you choose on
PhoneTree’s infrastructure – freeing you from the responsibility to
maintain a large volume of phone lines. While there are certain best
practices recommended for message construction and delivery
logistics, each installation of reminder software is customized to meet
your practice’s specific needs for patient appointment reminders.

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Automated Appointment
Reminder System
• Leading healthcare providers agree that
automated appointment reminder systems are crucial to increasing practice
revenue and reducing patient no-shows – a problem representing the most
significant loss of revenue to healthcare providers.
• Despite the rise in patient demand and federal incentives via the HITECH Act,
most practices still use outdated communication systems. With Alert Solutions’
Patient Communication Suite, healthcare providers can send
automated appointment reminders using the channels most preferred by
patients– email, voice and text messaging.
• Automated appointment reminder messages use patient-specific elements and
two-way interaction to maximize patient response rates and
increase patient engagement.
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The benefits of sending automated patient appointment reminders include:
• Reduce Patient No-Shows – Studies show automated appointment
reminders drastically reduce no-shows
• Reduce Patient Communication Expenses – Eliminate manual staff calls
and the ink, paper and mailing costs required of postcard reminders
• Generate More Appointments – Know in advance which appointments
have been cancelled, giving your practice more time to fill them
• Improve Staff Productivity – Free your staff to take on other
responsibilities, so they can focus on greeting patients instead of on
repetitive and routine calls

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Four types of technology interventions are particularly worth noting
and are briefly described below.
1. Computer home reminder system
• One study by Boman et al. (2010) targeted patients suffering from
memory problems associated with acquired brain injuries (ABI).
• A set of electronic memory aids was provided in a home-like training
apartment to assist patients in remembering forgotten activities.
Patients stayed in the apartment for five days, during which time their
activities were monitored. Defined activities that were performed
were registered into the system and forgotten activities triggered an
automated reminder or alarm to remind the patient of the activity.
The number of triggered reminders was used to measure changes
through the stay. By the completion of the five days, patients
demonstrated significant improvements with the use of the memory
aids.
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2. Tethered Personal Health Records (EHRs)
• Patient Gateway, a patient personal healthcare record (PHR) system was
linked to the healthcare organization’s electronic health record (EHR)
system. Reminders for seven conditions (bone density testing, cholesterol
testing for coronary disease or diabetes, general cholesterol testing,
influenza vaccination, mammography, Pap smear and pneumococcal
vaccination) were sent to patients from the EHR to the PHR.
• Tethered PHR systems allow patients to access their own records through a
secure portal and view, for example, reminders, lab results, and health
screenings history. Study participants in the Pap smear group that opened
the reminders completed Pap smear testing significantly more often than
matched controls. Reminders for testing for the other conditions were not
significant, however the reasons for the differences were not fully explored
in this study.
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3. Portable electronic reminder service
• A personal response unit was used in one study to remind patients to
take medications. The personal response unit (PRU) was a small,
portable, battery powered device that was programmed by the
patients’ general practitioner in consultation with the pharmacist to
send audible and visual medication reminders at designated times
throughout the day. The PRU also displayed the date, time, and
weather. Once the device sent an alert, the patient pressed a button
on the device; otherwise the device sent continuous alerts at
designated intervals. The device was programmed in the physician’s
office and taken home by the patient. Results demonstrated that
physician review of patient compliance status, patient self-assessed
medication compliance, and patient perceived self-care ability all
significantly improved.
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5. Electronic personal response unit
• This study demonstrated a health IT intervention that can support
patient’s adherence to prescribed medication. Patients were given an
electronic reminder system called Telesvar (TS). About the same size
as a cell phone, the TS device used text messaging to receive and
send short messages to and from a server. Patients pressed a button
to confirm they had taken their medication. If a patient did not
confirm that they took their scheduled medication, the server sent a
code to the TS device and triggered the reminder signal, which was
repeated in 30 minutes if still not confirmed. Electronic reminders,
when compared to pill count, were a less reliable method to measure
adherence.

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Sms and text reminder
• Stop wasting valuable time tracking down your clients and customers.
With Appointment Reminder, you can schedule reminder messages in
your favorite calendar application and automatically remind your
customers about their upcoming appointments.
• But what makes Appointment Reminder so unique? Unlike many
other automated appointment reminder software, Appointment
Reminder works seamlessly with the most popular scheduling
applications like Google Calendar and Outlook Calendar, so that you
don’t have to learn a new system to start saving time and money.

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Sources of requests for the appointments in
hospitals

• Patients telephoning personally to make appointments.

• Physicians or private practitioners wanting to book appointments for
their patients through telephone or writing.
• Letters from other health institution given to come and book their
appointments.
• Patients already discharged from the hospital making a return
appointment.
• Patients referred from one clinic to another.
• Patients can come from outpatient clinics

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Clinic preparation

• -Two days prior to the clinic list should be sent to the appropriate
sections, one to the filing area and the other to the consultant in
charge of the clinic area.
• -All the records and documents should be pulled out, all the
pathological results should be inserted in the correct files and kept in
the pigeon holes for the clinical methods to come and collect.

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• The clinic receptionist should make sure all the documents are such as
x-rays are recorded each and every patient attending the clinic.
• -The clinics are prepared two days in advance to reduce the patients’
time before he is seen by the physician. At the end of the clinic the
receptionist should ensure that all records are returned to the central
library ready for filling.

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Follow up procedure

• Definition-The process of keeping in touch with the patients so that

certain objectives can be met.
• Purpose of follow up
• To make or not changes that have occurred in terms of relieve/
improve treatment given.
• To be able to provide immediate treatment as soon as need arises.

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Follow up procedures/ policy

The basic rules for follow up procedures include:

1. Full registration of the patients.
2. Recording against all dates of attendances.
3. Specific instructions as regards the methods of procedures or
methods.
4. Limitations of time in respect of the various patients to be followed
up.

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What is an outpatient
appointment?
• -An out- patient is when a doctor refers a patient to a hospital for a
medical problem. The hospital will send a letter to a patient
confirming the name of the consultant, the location of the clinic and
time of the appointment

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OUTPATIENT CLINIC WAY OF
WORKING
1. Waiting
• We always endeavor to work on time. Nevertheless, it is possible that you have to wait a
little bit longer than anticipated. Occasionally physicians are called away to handle an
emergency case. Or a discussion with another patient may overrun. This generally occurs
unexpectedly. The outpatient clinic staff will tell you if the consulting hours are
overrunning.
• You can help to keep waiting times down by always showing up on time at the
outpatient clinic. Please allow for bad traffic and weather conditions and ensure you
have sufficient time to find a parking space.
• Sometimes confusion arises because patients who arrive later are nevertheless seen
earlier. This may be due to:
• patients being seen in appointment order rather than in order of arrival.
• a patient having an appointment with a different physician to the one you are seeing.
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2. Different physician?
• In principle, you will be seeing the physician with whom you have an appointment.
Occasionally, something unexpected may occur, leading to your physician having to
leave. In such cases, another physician will take over the appointment. We will
inform you of this when you report to the desk. In a number of outpatient clinics this
will also be posted on a board at the desk. You will then see a different physician.
3. Examinations
• The physician will examine you physically if this is necessary. Sometimes further
investigation is warranted, such as a blood test or X-rays. We endeavor to ensure
that such examinations are performed immediately after you have visited the
outpatient clinic. Sometimes this is not possible, in which case we will make an
appointment for another day.

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Regulatory viewpoint

• -Outpatient Did Not Attend (DNA) rates vary between hospitals,

regions and area of specialty. Current opinion is that DNA rates can be
reduced by reviewing appointments and other procedures from the
point of view of outpatients.

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• The care quality commission (CQC) assesses individual hospitals,
trusts on their DNA rates and has stated that large numbers of missed
appointments may bring poor provision of community services. High
DNA rates may also be an indication of inappropriate referrals and
reflect the quality of the interface between primary care surgeries,
clinics, primary care trusts and secondary care in hospitals

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Why do patients miss their
appointments?
Studies investigate why people do not attend their outpatient
appointments have revealed a number of possible reasons, the
following are four common types of issues related to missing
appointments without notifying the clinic staff:
1. Emotions- fear and anxiety about both procedures and bad news.
2. Perceived disrespect by the healthcare system.
3. Not understanding the scheduling system.
4. Distance and finances may force patients to miss appointments.
5. Inconvenience caused by friends, relatives on the alternatives of
treatments.

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Return appointment
There are obvious advantages to such appointment made in the clinic for
example;
• If a clinic for which a doctor has requested a future appointment is ready
fully booked the receptionist will be in good position to speak to him direct
and find out if he wishes to see an extra patient on that day.
• Or whether he wishes the appointment to vary by bringing the patients
sooner or later than originally intended.
• The receptionist will also be aware of the test that are being ordered at the
current attendance and will be able to make a note against the result of
these tests if it will be needed.
• Also the patient will have to talk to one receptionist instead of a receptionist
and to an appointment clerk.
• This will save the patient a lot of walking and time
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summary
• The appointment sysyetm underpins most of the practice’s operations. It
should be well designed and effectively administered so that it may
support patient care and safety. It will also contribute to effective time
management and will assist in monitoring patient attendance.
• It can be paper or computer based
1. For computer based:
There should be clear protocols for staff regarding communication with
practioners about cancellations or reschedules appointments as these
willa disappear off the days appointment list as are cancelled or moved

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It should be linked to practioners desk where non attendance and
cancellation are retained on daily scheduling screen
There should be a protocol for staff to add, cancel or reschedule
appointment s back onto the bottom of the days appointment list
with a notation. This will make practitioners to easily review the
changes and make a decision as to whether follow up action is
required

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2. Paper based appointment system
Record at the bottom of each appointment page the names of the
patients who cancelled or DNA-did not attend. Reson for cancellation/
non attendance and the rescheduled date, if applicable. This can be
photocopied and presented to the practioner
Record the above details on a weekly,/daily list, and provide these to
the doctor at the end of the session/day for action and its
documentation. If documenting action on a day list, ensure these list
are archived as a record of patient compliance.
If u have recalled a patient for a scheduled appointment an “R”
(recall) placed against their name will alert the staff and the
practioner if this patient cancels the appointment or does not arrive
for the scheduled appointment
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Revision questions
• . SAMPLE QUESTIONS
SECTION ONE (Multiple choice question)(10marks)
Indicate the most appropriate response in the examination booklet
1. Which one of the following documents in the patient file is used to carry out diagnostic coding?
• A. Nursing Cardex
• B. Medical History form
• C. Continuation Sheet
• D. Discharge Summery
2. Clinic preparation entails the following activities except
• A. Sorting
• B. Retrieval
• C. Editing
• D. Tracing
3. The following are permanent records, which one is not?
• A. Maternity records
• B. Registers of births
• C. Registers of deaths
• D. Registers of surgical procedures
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4. All listed below are health records indices, which is the odd one out?
• A. Waiting list index
• B. Bed bureau index
• C. Operation index
• D. Diagnostic index
5. One of the following information is not included in an index card, which one is it?
• A. Name of the patient
• B. Diagnosis of the patient
• C. Patient hospital number
• D. Space left for change of address
6. These are the checks made on the waiting list except?
• A. completeness
• B. Eligibility
• C. Accuracy
• D. Deaths
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7. A unit number register contains the following information except?
• A. Address
• B. Date of birth
• C. Full names of patient
• D. None of the above
8. Which one of the following is not a special health record?
• A. Radiotherapy records
• B. Casualty records
• C. Out-patient records

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• D. Genito-urinary records
9. The following equipment is used to record appointment which one is
not?
• A. Loose leaf binder
• B. Bound volumes
• C. Diaries
• D. Visible edge cards
10. When selecting a folder the following points should be noted except?
• A. Strength of manila
• B. Cost of the folder
• C. Clarity of numbering on the inside cover
D. Method of fastening documents
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11. The following persons contributed towards the development of medical records
system, except?
• A. Abraham Lincoln
• B. Grace Whiting Myers
• C. Imhotep
• D. Hippocrates
12. Which one of the following is not a quality of Health Records and Information Officer?
• A. Integrity
• B. Generosity
• C. Humility
• D. Adaptability
13. Which Country is famed with keeping of early records?
• A. Germany

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• B. Britain
• C. Canada
• D. Egypt

14. The following are the content of a case folder, exept?

• A. Consent Form
• B. Prescription chart
• C. Tally sheet
• D. Surgical Operation sheet
15. In the Unit medical Records, the unit is the?
• A. Master Index
• B. Patient
• C. Record
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• D. Folder
16. The following are qualities required in a receptionist, except?
• A. Appear neat
• B. Be proud
• C. Be Empathetic
• D. Be Competent
17. The following are used to file the waiting list, except?
• A. Card wheel
• B. Strip wheel
• C. Visible edge card
• D. Bound Volumes
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18. All listed below are ways of conveying information to the waiting list,
except?
• A. Cards created for every patient
• B. Nurse or Physician sending list of patients to be added to waiting list
• C. Letters from a consultant
• D. Letters from in patient department
19. Putting records in order before filing is sometimes referred to as?
• A. Tracing
• B. Filing
• C. Sorting
• D. Follow-up

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• SECTION TWO (Write TRUE or FALSE in the examination booklet)
• For a file already outside the filing area, a common tracer card will show its where about when
you check it in its usual place in the filing area.
• In a centralized appointment system, all enquiries regarding clinic appointment would be
directed at different places.
• Terminal digit filing system is where is a health record system where the middle two (2) numbers
are considered when filing the documents.
• Mobile raking is the most economical filing method as far as space is concerned.
• It is not necessary to include the reason for extraction and the borrower’s signature on a trace
card.
• One advantage of straight numerical filing system is that the growth of files in the filing area is
evenly distributed.
• A unit number in Health Records is the same as primary key in Electronic Medical Records.
• Misfiling is normally reduced when straight numerical filing system is put in place.
• A tracer card that can be used more than Eighty (80) times is termed as personal tracer card
• The relationship between Health records department and other department in healthcare
provision is the patient / client.
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• The diagnostic index is the alphabetical key to numerically filed case records.
• Filing Trolleys, Kik stools/ ladders, sorting equipment are also referred to as Auxiliary
Equipment
• The bed bureau is not a section in medical records department dealing with admission of
emergency patients.
• Canadian association of Health Records was formed in the year 1948 whereas the Association
of Records Officers in Britain was formed in 1942.
• Editing is an objective method of applying a yardstick to the quality of professional
performance.
• In case of a minor the consent form should be signed by a parent or guardian before an
operation is carried out.
• Registration is the completion of documents of personal and social data after a patient is
treated.
• Taking down the identification details of patient through telephone and writing of a letter
before a patient attends the hospital is also known as pre-registration.
• Auditing is the arrangement of all forms inside a case folder in a prescribed manner.
• In Egypt Hippocrates, known as “father of medicine” was born about 460 BC.
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• SECTION THREE (fill in the blank spaces)(20 marks)
• The term used to describe a variety of processes through which information is
reproduced mechanically is known as…………………………………………
• …………………………is the objective method of applying a yardstick to the quality of
professional performance.
• …………………………..is a method used to find out the where about of all records at any
given time
• Health Records and Information officers program was started at Kenya Medical Training,
Nairobi in the year…………………………
• A health Records system in which all health records notes relating to one patient are
contained in one case folder is………………………………
• …………………is a case where a patient authorizes release of his/her health information but
does not involve signing of any document.
• ………………………is a type of filing that entails a normal sequential order such as 1, 2, and 3.
• ………………………..is defined as customer satisfaction process.
• ………………………..is a record in digital that is capable of being shared within a cross
different healthcare settings .
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The act of removing files that are not currently in use to give space for new
ones in the library is known as…………………………………………..

SECTION FOUR. Essay Questions

1. (a) Briefly talk about the term subpoena. (5marks).

(b) List Ten (10) instances under which medical records can be used as
evidence. (10 marks)

2. State and explain Five (5) importance of Health Records. (15 marks)

3. Describe Five (5) purposes and Five (5) Concepts of scheduling

appointment. (20 marks)
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CAT 1-HRM 106-27th june 2019
1. Differentiate between the following terms
-health records and public records
-telemedicine and telehealth
2. What is:
-registration
-state two types of registration
3. Identify any five departments in a health facility and explain how
they are related to the health records and information department

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4. Briefly explain the five values of health records
5. The records are visible evidence of what the hospital is
accomplishing. State at least ten different types of hospital records
6. Highlight any four benefits of health information technology in
health care
7. Name four types of indices used in health records

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To revise
• What is internet
• What is intranet
• Beneficence
• Autonomy
• Justice
• fidelity
• Contents of discharge summary- reason for hospitalization, significant findings, procedures and
treatment provided, discharge condition,patient and family instruction,attending physician
signnature
• Principles of medical practice
• Ettiquette
• Law
• Ethics
• Professionalism
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• Clinical uses of health records
-ancillary equipment in the appointment system
• Methods of filing the waiting list
• Contents of a discharge register
• Size of diagnostic record form
• Various acts and what they stipulate eg
• government official secrets act
• Mental health act
• Public health act
• Civil registration act
• Primary and secondary keys
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• Canadian association of Health Records was formed in the year

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Discuss the following Acts related to Health
 Mental health act
 Government official secret Act
 Civil registration act
 Records disposal act
 Records archives act
 Criminal procedure code
 Radiation protection act
 Works man compensation act
 Public health act
 HRIM health act
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Organisation and management of
admissions and discharges of
patients
ADMITTING AND DISCHARGING PATIENTS/CLIENTS
Learning Objectives
The learner should be able to:-
• Describe admission and discharge procedures and their sources.
• Edit and audit the record
• Collect, compile, analyze, disseminate and verify returns.
• Code and Index
• Identify the types of records to be kept.
• Describe how appointments are made in this department
• Describe how patients are disposed of from this department

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 • Describe the legal requirements to be observed in this department.
• Define a waiting list
• Describe the functions of a waiting list.
• Explain the types of waiting lists
• Describe how to maintain a waiting list
• Explain the methods of filing to be used.
• Describe the procedures used in admitting patients.

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ADMISSION PROCEDURES
• Patients/clients should be supplied with a booklet containing information
about the hospital before they are admitted. If they are emergency patients
then they should be supplied with the booklet after admission. The book
should contain the layout of the hospital, visiting times for relatives and
visitors. The wards should be easily be identified. Accommodation for
relatives of very ill patients/clients, mothers, ill babies should be available.
After admission patients/clients should be guided to the ward by a member of
staff to the sister or nurse responsible for reception and documentation of
patients in the ward. This will ensure a feedback of information to the health
records/information department.

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SOURCES OF ADMISSION
Admissions can come from different sources:-
1. Accident and Emergency department
2. Outpatient clinic
3. Other hospitals
4. In-patient waiting list

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DISCHARGE PROCEDURES

• Admissions and discharge registers should be maintained in all health

institutions. The register should provide for full name of the patient,
date of birth, admission date, discharge date, diagnosis and the length
of stay at the hospital.

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04/25/2025 462
DISCHARGE PROCEDURES
• While in hospital, the patient’s medical record develops with the recording
of clinical information by doctors and other health professionals. Results
of pathology tests etc., are added as they are received. Nurses record
daily progress notes and special observations. If a patient has any special
tests and/or surgical procedures, relevant information is included.
• On discharge/death of the patient the medical record, including ALL forms
relating to the admission plus any previous records, should be sent to the
Medical Record Department as soon as possible or within 24 hours.
• Medical record staff responsible for the discharge procedure should be
trained to ensure that the medical records are completed promptly and
correctly.
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Receipt of Medical Records
• The discharge procedure begins with the receipt of the medical records of
discharged/dead patients.
• • The medical records of discharged patients or patients who have died should be
sent to the Medical Record Department by the ward staff the day of discharge or
death, or the next morning. In some countries, a staff member from the Medical
Record Department collects the medical records of discharged/dead patients from
the wards at a specific time every day. This is time-consuming for the Medical
Record Department so a central collection point should be designated. If this is
done, the ward staff can take all medical records of discharged/dead patients to this
point by a certain time each day where they are collected by the Medical Record
Department staff.
• • In many countries, Admission Office staff or the Business Office are responsible
for the daily bed census, which they receive from each ward at the beginning of the
day. From the bed census forms, staff are able to record details of discharges and
deaths and prepare a DAILY DISCHARGE LIST. This list is important and should be
duplicated and sent to a number of sections in the hospital including the Accounts,
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Catering, Inquiries and the Medical Record Department.
Computerized Admission, Transfer and Discharge (ATD) System
• Like the MPI, the ATD system is one of the most computerized systems involving medical
records. The introduction of this type of system enables staff to maintain a file on all
patients currently in hospital, awaiting admission and recently discharged. It also enables
authorized users around the hospital to have direct access (via a computer terminal) to
the file and automatically generate bed census and other daily statistics required by the
hospital administration.
• The objectives of such a system are to:
• • provide an inpatient booking service for patients awaiting admission;
• • keep records of the bed state and bed allocation;
• • trace patients for inquiries;
• • provide daily patient census reports and related statistics;
• • provide information for the MPI (directly linked to the MPI system); and
• • provide a complete data base for all authorized users of patient identification and
location information.
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Within such a system, a data file is maintained on all patients:
• currently in hospital;
• awaiting admission; and
• recently discharged.
In a computerized admission (transfer and discharge system) all
admissions are entered at the time of admission and the discharge
details are entered for all discharged /died patients at the time of
discharge or death

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MAITENANCE OF A BED BUREAU:-
• Hospital bed bureau:-
Definition:
• A hospital bed bureau is a system used to manage the availability,
allocation and utilization of beds by the hospital to admit patients
from the waiting list. It shows the location of the bed in the ward,
and when a bed will fall vacant for the next admission.

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EDITING AND AUDITING OF THE HEALTH RECORD
• Editing of the record is the arrangement of all the forms inside the unit folder in a
prescribed manner. This can be decided by the hospital concerned. It can either be
done chronologically or in order of speciality. This can be done by the ward clerks if
they are available.
• After the record has been edited it should be returned to the health records
department. In the department the records should be cross checked with the daily
bed returns to ensure that all records have been received in the records department.
• After this, the records will be coded and then indexed ready for filing back to the
library. The health records and information officer should complete all the
information that is supposed to be contained in it is there. The discharge procedure
cannot be complete until the record returns back to the file.

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• The patient is then given a return appointment to a consultative clinic
and this is recorded on his attendance card. When the patient comes
back to the clinic his record should be available in the clinic.

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THE MEDICAL AUDIT

• The Medical Audit has been defined as an “objective method for

applying a yardstick to the quality of professional performance.”
• It is the method of evaluating quality of medical care given to a
patient. It is a tool to enable the administrator and the medical staff
to uncover inefficient service and to point away to an improvement of
standards in the health facility- a tool of management. It is important
to evaluate the care rendered to the patients in terms of lives saved,
avoidable deaths and patients rehabilitated back to society. This
evaluation is carried out by health records committee.

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ACCIDENT AND EMERGENCY RECORDS
PROCEDURE

• After a patient has been seen at the health centre he may be having
some ailment which needs immediate and urgent attention. Definitely
the doctor will refer him to a hospital for immediate attention. He will
find himself in an accident and emergency department. Also patients
with any type of accident will be brought to this department directly.

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1. Records to be kept.
• (a) Firstly a register must be maintained at the Accident and
Emergency department. The following information should be included
in this register; name of patient, address, age, doctor referring him,
time of arrival, brief description of injury, brief details of treatment,
and the mode of disposal. The particulars of the person who has
brought this patient to the accident and emergency departments
must be taken also. If it is a police officer his number must be
recorded in the register. The register may be in loose leaf form or in
bound volumes. From the register statistics of attendance will be
compiled.
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(b) Clinical record
(i) Single card measuring 8x5 or 6 x 4 on which the identification details
are recorded. For an R.T.A (Road traffic accident) patient, time and
place of accident must be given and the space left for the clinician to
write on.
(ii) Two part card
A card with carbonized part made from N.C.R material. The card is
made up in an envelope from so that x- ray reports and any other
correspondence may be filled in it.
(iii) Thick paper envelope four and an eighth by five and three quarters
inches (half the size of A4 paper). The envelope will serve as a card and
a pocket for reports.
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2. Appointments
• Most patients attending this department rarely come back for return
appointment. For those patients that need return appointments this
can be carried out in two ways:-
• (i) Appointment register may be retained by the receptionist and the
appointment written on the patients attendance card.
(ii) Pre-printed appointment cards for each day and time may be given
to the patient. A different colour of the card could be kept for each day
of the week and when a patient arrives seeking an appointment a card
is simply pulled out and given to him.
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3. Disposal of patients
Disposal of patients attending this department could be in one of these
categories:-
i. Treated to finality and discharged.
ii. Treated initially and referred back to the nearest health centre.
iii. Referred to an out-patient consultant clinic.
iv. Referred to a consultant clinic in another hospital.
v. Admitted to the wards for further treatment. Here full documentation
for admission will be carried out before the patient goes to the ward.
vi. Transferred to another hospital for further treatment.
vii. In the case of patient who has been brought dead (B.I.D) the doctor just
goes to certify the death and the body is conveyed straight to the
mortuary.
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4. Legal requirements
• It is important to note that the same legal requirements that are applicable
to other health records as far as retention is concerned still apply in accident
and emergency records. They may be retained for a minimum of six years
after the last attendance. The records may be filed numerically or
alphabetically depending on the number of records created annually. At the
beginning of the year, 1st January, a new file is started. The records should be
kept o\in lock because most of these records are usually required in court
and as much details as possible should be recorded. Most patients who have
been involved in road traffic accidents need some claims in future. Therefore
statistics for these patients may be sent to finance department so as to issue
the necessary claims.
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WAITING LIST FOR IN-PATIENT AND DAY CASE
TREATMENT

A waiting list is an index of all patients waiting admission to hospital or

waiting treatment on a day case basis.
1. Functions of a waiting list.
• The waiting list must be organized that enquiries can be answered
from individual patients wanting to know when they are supposed to
be admitted in the health institution. Individual consultants would like
to know how many patients are on their waiting list should
immediately be furnished with such information. The main function of
the waiting list is to be able to make full use of the available beds in a
health institution.

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2. Types of waiting list
The waiting list may be maintained in various ways:-
(i) Centralized waiting list
• This waiting list is held in one office and contains the names of all
patients awaiting admission under all the consultants in the hospitals.
(ii) Decentralized waiting list
• The decentralized waiting list will be maintained in several places
possibly each consultants secretary, or an individual wards or
individual departments.

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Advantages of centralized waiting list
i. Gives a fair representation of all the demands being made on the in-patient
facilities.
ii. All enquiries are referred to one place.
iii. Staffs dealing with the waiting list develop skills in dealing with enquiries,
and in the maintenance of the waiting list.
iv. Updating procedures such as change of address, death are easily carried
out.
v. Checking admissions and discharges from the daily returns is easier.
vi. When one staff falls sick or goes on leave another staff can carry on with the
work
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Disadvantages of centralised waiting list
i. Consultants need to walk to the central office to select their
patients from the waiting list.
ii. The list become so big so that some patients may be left out of the
waiting list

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Advantages of decentralised waiting list
i. Consultants need not go to the central office to select their patients from
the waiting list.
ii. The secretaries get familiar with the patients and can call them by name.
Disadvantages of decentralised waiting list
I. Several staff will be deployed in the maintenance of the waiting list in
different areas.
II. It will be very expensive since each department will need to use its own
equipment.
III. A clerk will have to walk to the central records department to check for
admissions and discharges from the daily returns.
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Creation of the waiting list record
• Most of the waiting list records are initiated at the out-patient clinics. Some
other patients may come from another hospital and be put in the waiting list for
another different hospital, where there are more beds or facilities. There are
four ways in which information can be conveyed to the waiting list:-
1. Card – The card is created for every patient who is to be put on the waiting list.
This card will be filed and form part of the waiting list.
2. The nurse or doctor may send a list of patients to be included in the waiting list
to the records department for action.
3. Letter – A consultant in one hospital may wish to include his patient’s name in
his waiting list, in another hospital for his name to be included in that waiting list.
In this letter he will in clued diagnosis, and priority for admission. A case folder will
then be created for this patient. The information to be included in this record are:
the patients name, address, title, telephone number, holiday dates, diagnosis,
operation to be carried out, duration of stay in the hospital, name of the surgeon,
or consultant.
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Method of filing
• A waiting list contains dozen names and needs two files:-
1. Alphabetical index of the names of all patients on the waiting list. These
cards should not be removed until the patient is admitted.
2. Consultants list will make provision for date, time, and ward. These lists will
have priorities indicated – routine, soon, and urgent.

• These two files should be able to answer an enquiry from a patient

and consultant

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 Filing equipment
• The type of filing to be used will depend on the size of the list.
(a) Visible edge card filed in trays
• When this is used to maintain a waiting list may be in the form of manila flaps, with a rigid bar
at the top and a transparent plastic pocket about half an inch deep at the lower edge of each
flap. A card is inserted into this pocket and the flap is held in a metal tray in such a way that all
the information in the plastics is visible. Date is put on the list, diagnosis, operation and
admission priority is put to allow the consultant to select his patients.
(b) Strip index
• A strip index is limited in space so that no space is left for change of address. It can only be
used if the list is not too long. It has already been mentioned as one of the equipment used in
the maintenance of the patient master index card.
(c) Diaries
• Each consultant could have a diary for his patients put on the waiting list according to dates.
Its danger is that a patient can easily be missed or overlooked on date which passed.
(d) Colour coding
• Colour coding could be used to indicate soon, urgent and routine case.
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Procedures for admitting patients from list
1. The patient is selected from the waiting list the consultants
2. The clerk writes to the patient or telephones him inviting the patient to the
hospital
3. The records are got out from the files and sent to the documentation office.
4. The waiting list card is sent to the admission office so that the patient is
expected on the day he comes in. the admission office checks the record
before the patients comes. When he comes his details are checked and
confirmed by the admission office.
5. Patient is admitted and sent to the ward.
6. When the patient has been admitted his name is removed from the waiting list.
7. Certain checks are made on the waiting list to remove the names of the patient
who have died to remove their names from the waiting list.
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 Statistics
Regular returns are compiled from the waiting list for hospital activity
analysis. The procedures described above also apply to patients who
come for day case treatment. Special letters are sent to these patients
because of preparations needed if general anaesthesia is to be given.

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• Medical audit: review of the clinical care of patients provided by the
medical staff only
• Example: the annual report from enhanced surveillance for tuberculosis
showed that the rate of completion for tuberculosis treatment was only
40%for a district for all cases notified in 2007. this was way below the
recommended standards recommended by WHO. Hence this audit was
done for all the TB cases notified in 2007, in order to find the possible
causes and take measures to improve the completion rate

• Clinical audit: the review of the activity of all aspects of the clinical care of
patients by medical and paramedical staff
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Maintenance of a bed bureau:-

• A hospital bed bureau could either be managed manually or electronically.

In the manual environment, the officer in charge of bed allocation
monitors both admissions and discharges routinely in order to report on
available beds and inform the officer maintaining the waiting list of such
beds as and when they fall vacant or even project when beds are most
likely to fall vacant. This is done by keeping a notice board with the
location of all the wards and their bed capacity. The notice board has two
colour strip cards which are put in pocket bags, red for occupied beds and
green for vacant beds.
• The electronic aspect is more user friendly because the patient waiting list
is automatically integrated and interfaced (the whole process is on line
and data is available to all at real-time)with the admission and discharge
modules and bed availability can be accessed automatically as and when a
bed falls vacant, the officer in charge of bed placement can therefore admit
patients on the waiting list as beds become available .
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Maintenance of bed bureau

Bed bureau: Definition-The bed bureau section of the medical records department
is the section that is admission for emergency patients.
• The functions of the bed bureau
• To pass messages to the medical records library for the initiation of the case or
the retrieval of the old ones.
• To locate a bed to which the patient may be admitted.
• To receive telephone calls from general practitioner who which to have patient
admitted on emergency and to whichever department which receives emergency.
• To answer patients relatives enquiries.
• -It is important to note that the bed bureau staff must have an exact and up
knowledge of bed state of every ward in the hospital.
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• The bed bureau may consist of a series of hooks; slotted racks, peg
boards, planning etc. divided into as many section as they are wards.
• -A bed bureau can save lot of medical and nursing time in locating
empty bed emergency admissions

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• What information to gather about the bureau
• -The ward clerks or nursing staff gather information about bed state
with information concerning:
• i) Patients unlikely to live in the next 24 hours.
• ii) Patients who have been discharged or died and have left a vacant
bed.
• iii) Patients likely to be discharged on the next visit by the consultant.
• iv) Delayed discharges

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• What to do with gathered information about bed bureau
• -The information is processed by the ward staff in their assessment of the situation
ward.
• -The information may be stored informally or on statement sheets.
• -The information is passed (distributed) to the bed manager who gathers an overall
view the hospital/medical directorate situation by ‘’processing’’ the information
received in each ward. This may be via face-to- face contact, over telephone or in a few
cases direct network link.
• -Information on emergency admissions is gathered from vacancy and emergency unit.
Doctors amongst other professionals by the bed manager casually on a piecemeal basis
except when the bed manager comes on shift in the morning. The information is
processed by a matching of new need and current bed stands one minute by minute
(matching of supply to demand).The key factor here is that the situation is rarely stable.
• -Information on elective work is processed as a delivered sheet of potential booked in
according to consultant.
• -Further information on potential influx is gathered informally
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• What record staffs should know in maintaining filing system for bed
bureau
• Have a wide knowledge of departments, hospital sites, procedures
and medical terminology.
• Provide routine enquiries, advice and assistance to service users.
• Completion of paper record and then computer record for all General
Practitioners referrals.
• Record number of emergency bed bureau referrals on data base
(entering total types of referrals on a daily basis for use in statistical
information production).
• Recording admissions totals for all sites for use in statistical
information production
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• Communications and relationships within bed bureau users
• Liaison with General Practitioners who require patient admission and/ or advice on
patient referral i.e. which site for a particular specialty.
• Liaison with various members of staff within hospital to maintain the service of the
bed bureau i.e. patient flow managers for updating bed availability on particular
sites.
• Speaking to specialty clinicians for advice on Patient admissions.
• Liaison with ambulance service operation room assistants to ensure patient
transport is arranged as required.
• Dealing with delays and contacting General Practitioners and patients advising of
delays or problems.
• Liaison with hospital health emergency planning officer during major incidents or
national emergencies.
• Liaise regularly with the capacity management team to ensure that Emergency Bed
Bureau services are being maintained effectively and appropriately.
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• Major challenges about bed bureau
• Collation of high volume of information requiring accurate
documentation.
• Advising General Practitioners of alternatives to admission in a culture
of change and new initiative.
• Negotiating changes to wards (zone) due to capacity demand with
conflict from the General Practitioners.
•

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EDITING AND AUDITING OF THE HEALTH RECORD
• Editing of the record is the arrangement of all the forms inside the unit folder in a prescribed
manner. This can be decided by the hospital concerned. It can either be done chronologically or
in order of speciality. This can be done by the ward clerks if they are available.
• After the record has been edited it should be returned to the health records department. In the
department the records should be cross checked with the daily bed returns to ensure that all
records have been received in the records department.
• After this, the records will be coded and then indexed ready for filing back to the library. The
health records and information officer should complete all the information that is supposed to
be contained in it is there. The discharge procedure cannot be complete until the record returns
back to the file.
• The patient is then given a return appointment to a consultative clinic and this is recorded on his
attendance card. When the patient comes back to the clinic his record should be available in the
clinic.
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• • Discharge lists should be kept in date order in the Medical Record Department.
The list should contain the patient's name, age, treating doctor, ward, and
service, that is, whether medical, surgical, obstetric, orthopaedic, etc., and
whether the patient is alive or dead. Discharge lists are usually used to prepare
the hospital inpatient statistics.
• • By using the discharge list, the staff responsible for the discharge procedure in
the Medical Record Department can check to see if they have all the medical
records of discharged/dead patients from the previous day. If any are missing,
they should contact the ward to find them. Once a patient has been discharged,
the medical record should be returned promptly to the Medical Record
Department. Failure to do so may result in a missing medical record. Once the
patient is no longer in the ward, their medical record can easily be misplaced

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Condition And Nursing Dependency
• Each afternoon, the computer operator should print a ward list for each ward.
These can then be distributed to the wards, where errors or any change of
condition will be noted. The nursing dependency for each patient can also be
noted at this time. This printout can then be used for the daily bed census
and then returned to the central admission area at a designated time each
day to enable the keyboard operator to amend the files accordingly.
(SEE dailly bed return…..to download)
printout can then be used for the daily bed census and then returned to the
central admission area at a designated time each day to enable the keyboard
operator to amend the files accordingly.

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Service Analysis Statistics
• • This enables a breakdown of clinical services to be prepared for the
administration. On receipt of the medical record, the medical record staff
can check the service under which the patient was treated and record it on
the discharge list, if not already recorded. The details on the list are then
keyed into the system to produce the required statistics.
Other statistical information
• • Information regarding post-operative deaths and autopsies, plus obstetric
information such as deliveries, maternal deaths, multiple births, foetal
deaths and infant deaths are also keyed in at this time, if not already
recorded on file
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Disease Classification and Clinical Coding
With the completion of the discharge procedure (before the medical record
is ready to be filed) two important procedures need to be undertaken: They
are clinical coding and the collection of health care statistics.
Clinical coding, one of the most important procedures should also be carried
out in the Medical Record Department. Clinical coding is the translation of
diseases, health related problems and procedural concepts from text to
alphabetic/numeric codes for storage, retrieval and analysis of health care
data. Staff responsible for coding should be formally trained by attending
clinical coding courses offered at a local or regional level

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Management and maintanane of
health records
Learning Objectives
The learner should be able to:-
• Define filing
• Importance of filling
• Mention and describe filing systems
• Differentiate between filing system and method
• Explain how to convert sequential to terminal digit
• Describe and mention filing equipment used to file case records and x-ray films
• Define and mention ancillary equipment
• Define and discuss tracing
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Filing:
It is a process of arranging documents in a systematic manner for easy
retrieval,
N/B While defining filing try your best to mention the following key
words:
• Process
• Arranging
• Systematic way/manner

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Filing method
• Filing method: it is a process of arranging documents in a systematic
way considering certain pertain
• Filing system
• Definition: it is an array of documents/records that conforms to a plan
N/B A system means that things/documents are already arranged in a
certain way either considering alphabets, time/ date , or certain
assigned numbers,
• System: It is an array of things that conforms to a plan

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Here are three types of filing methods
1. Alphabetical
2. Numerical
3. chronological
Importance of filing
• Easy retrieval of documents
• Easy tracking of documents/records
• To keep library, office neat
• It makes (M&E )monitoring and evaluation simple
• Increases efficiency in a given facility or organization
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1. Alphabetical filing system
It is an array of documents, medical records considering / using
letters of their names alphabetically i.e. Medical records for the
clients below are arranged in that order considering starting letters of
their name
• Albert ,(1)
• Beatrice,(2)
• Nassiuma(3)
Alphabetical filing really has little place in any discussion of the filing
of case notes. The main disadvantage of using this method of filing is
that it grows very unevenly and spreading of notes or x- ray files can
be very difficult if the file is used for many years and the number of
files becomes very large
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Advantages of using alphabetical filing system
• It is the suitable link between Master patient index card that is also
filed alphabetically
• It is simple to use compared to terminal digit
Disadvantages of using alphabetical filing system
• It grows unevenly thus interfering with expansion space setting
• It consumes a lot of time in filing and retrieving especially when they
are a lot of medical records

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2. Chronological filing system
• Chronological: it is an array of documents, medical records considering time or
date when it was created
• Mostly it is used in arranging documents, records in a case folder from downwards
to upwards
• This is a method of filing where records are filed using dates when the record was
created. It cannot be used to file case records except that it can be used to arrange
records inside the case folder. It is not recommended for filing in a big library
Advantages of using chronological filing system
• Simple to use in small number of medical records
• It saves in filing day to day created records
Disadvantages of chronological filing system
• Not used in big libraries
• It is time consuming in retrieval of records especially in relatively large libraries

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• Numerical filing system
In this system two ways of filing can be adapted:-
• (a)Straight numerical
• (b) Terminal digit filing system.
Numerical filing system: it is an array of documents /medical records
considering different specific assigned digits ,numeric numbers in a
certain sequence

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a) Straight numerical filing system
- This is probably the filing system that comes automatically into people’s mind:-12 3 4 5 6, 1
2 3 4 5 8. It is probably the most suitable method of filing for small records library where
there is no necessity to go into the fairly elaborate detail needed to install a terminal digit
system.
• In this system documents are numbered and arranged in straight line sequence i.e.
1,2,3,4,5 .or 00001,00002,00003 in some facilities or institutions they might decide to
add zero like in the second example above also they can use F or M indicating sex i.e.
F/0003,M/0001
• Lastly they might decide to add an organization or institution name in abbreviated form
i.e. kmtc/f/0002
• Provided documents are from 1,2,3 .etc that’s straight line filing system
• Advantages of straight numerical filing system
• Simple to implement and use compared to alphabetical
• Time saving in retrieval and filing of medical records
• Suitable being used in small libraries
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Disadvantages in of using straight numerical system
• It is un economical to filing space due to growing in one direction
• It is used only in small libraries

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• With straight numeric filing, it is a good idea to have one medical record clerk
responsible for the filing procedure (depending on the volume of work). If it is too
much filing for one person, it could be shared between the medical record clerks.
They should file at different times of the day to prevent congestion in the filing area.
• Examples of Straight numeric filing:
345 7650 91234 105997 234879
346 7651 91235 105998 234880
347 7652 91236 105999 234881
348 7653 91237 106000 234882
349 7654 91238 106001 234883
350 7655 91239 106002 234884
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• b. Terminal digit filing system (TDF)

• Terminal digit filing (TDF) systems is the most often utilized filing methodology within an HIM
department or medical library. TDF is the only way to keep files expanding at an even rate
• . When trying to maintain a straight numeric filing system it is impossible to predict how much
space to allocate to the randomly based file numbers that come into the file room.
• In a TDF system the last two, three, or four digits of the number is treated as a single number.
Since all numbers in the file are sorted by their ending digits, each section contains
approximately the same number of folders, so the file shelves are divided
• In a TDF system the last two, three, or four digits of the number is treated as a single number.
Since all numbers in the file are sorted by their ending digits, each section contains
approximately the same number of folders, so the file shelves are divided for easy expansion.

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The benefits of TDF include:
• Files are equally distributed throughout the file room.
• File room staff productivity is increased.
• Shelf and space planning is more efficient.
• Pre-sorting is easier.
• Workload assignments are streamlined.
• Purging is easier.
• The process works in a large or small department and across
specialties.
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• The biggest disadvantage of terminal digit filing is;
• 1.The filing room personnel’s fear of learning the systemProcess
reduces transposed numbers File location is immediate.It thus need
only trained personnel.
• 2.It is used in small libraries
• 3.It is also economical to filing space due to growing in one direction

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• The filing system was first used in the United States hospitals and has
been the standard method of filing in that country. Anyone starting a
new records department would be well advised to start with it from
the beginning. The main difficulties experienced with the traditional
sequential filing system are:-
• Growth is at one end of the file because this is the busiest section of the
library.
• Gaps are usually left after weeding of notes
• Transposition of figures occurs whenever one is dealing with big numbers.
Terminal digit filing system overcomes these difficulties. Its main principles
are as follows:-

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 . The library is divided into 100major sections numbering from 00 to 99.
Each major section is again divided into 100 sub-sections. This means that
the library is now divided into 10,000 sections. Each section should be
labelled properly.
The hospital number should be thought of as three pairs of digits e.g. 1 2
3 4 5 6 as 12-34-56. 56 is the terminal digit, 34 is the middle digit, and 12
is the primary or first digit.
• The record will be filed in the major section appropriate to the
terminal digit (last two numbers in section 56.
• Within major section 56, it goes behind the sub-section guide
appropriate to middle digit (middle two numbers) 34.
• It is then filed in the order of primary digit 12.

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• ) Advantages of terminal digit filling system are:-
• New and old records are evenly distributed throughout the records
library.
• Chance ensures that an equal number of records and loose filing
returns each day to each major section. Trials have shown that where
1,500 records are filed daily, 150 records will be returned to each
section daily
• There is no annual shift-back or closing up of notes after weeding, to
make room for new records.
• Sorting notes is simpler.
• New staff find the system very much easier to learn than sequential
filing-probably because the library is much more static and the 00s
are always in the same place.
• Fewer misfiles occur. This is because the filing clerk is concentrating
on only two digits at a time.
• Tracer cards can be written in advance when preparing a clinic.
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• Definitions:

• Terminal digit order: A system of filing using a six-digit number (or

higher) that is divided into three parts, whereby the last two digits are
considered primary.
• Primary digits: The last two digits to the right in the number.
• Secondary digits: The middle two digits in the number.
• Tertiary digits: Any remaining digits

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• Procedure:

• 24-00-33 example 1
• 24 00 33
• Tertiary Secondary Primary
• Digit Digit Digit

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Example 2
34 56 78
Tertiary secondary Primary
• With this method, the filing area can be divided into 100 sections for the primary digits 00 - 99. This then allows the
filing to be distributed among a number of clerical staff.
• Within each primary section, medical records are grouped by the secondary digits and, again, this ranges from 00 - 99.
• Within each secondary section, medical records are grouped by the tertiary digits and, again, this ranges from 00 - 99.
• To file a medical record, after locating the primary and then the secondary section, the clerk files the medical records
by the tertiary digits. For example, to file the number 3456-78, the “78” primary section needs to be located then the
“56” secondary section. The record 34-56-78 is then filed before 35-56-78 and after 33-56-78. A series of numbers
would run as follows:
32-56-78
33-56-78
34-56-78
35-56-78
.

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• Locate the primary digit first and proceed to the corresponding section. Using
example #1 above, the HRIO /clerk would proceed to section “33” first.
• After locating the primary section, identify the secondary digits and proceed
to the corresponding shelf within the primary section. Using example #1
above, proceed to the shelf with the digits “00.”
• After locating the correct secondary digit, identify the tertiary digits. These
digits are filed in numerical order.
• Disadvantages of terminal digit

• It needs trained staffs

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(d) Conversion of straight numerical filing to terminal digit order
• Before one changes from straight numerical filing system to terminal digit filing
system, one should make sure that there is enough:-
• Space
• Manpower – trained
• Shelves constructed
• Medical forms
• Pre-printed folders
• One day should be set on which to start the system. The first patient who comes
should be issued with a unit number 01and the second patient who comes next
02. This should continue until the number 999999 is reached. When an old
patient has been issued with a number in the previous year comes, his record
should be pulled out and brought forward to the new unit number. If a patient
does not turn up, his record should be left in the old file.
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• Some hospitals also use a color code on the folder to assist with
identifying the medical record quickly and to improve the efficiency of
the filing clerks

• Remember THIS METHOD IS NOT RECOMMENDED FOR SMALL

HOSPITALS OR HEALTH CARE CENTRES AND ALSO NOT IN COUNTRIES
WHERE THE TRAINING OF PERSONNEL IN THIS METHOD IS NOT
AVAILABLE.
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Filing equipment used to file case
records and x-rays
1. Shelf filing
• These are rack-like structures made of wood or metal , either fixed on
the wall or fixed in a way to stand upright with partitions where
documents/x ray films are filed
• They are ..feet high with paths between to allow movement of staffs
• These paths are called gangways
• Main gangway should be 155 cm wide
• Sub gangways 95-100 cm wide to allow movement of the trolley

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This is the most used filing equipment and probably more suitable for
filing large quantities of notes or x-ray films than any else. Metal is
more suitable than wood. There are some advantages and
disadvantages of shelf filing.
• i) Advantages
• (a) Records can easily be filed and pulled quickly since the shelves are
open.
• (b) More records can be filed on the shelves than in the cabinets.
• It is cheaper to construct and maintain compared to carousel
• Suitable for filing large quantities of documents compared to cabinets
• Documents are filed quickly since they are open
• Allow air sufficient air circulation in records and entire library

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• (ii) Disadvantages
• If the shelves are constructed high light cannot penetrate the lowest
shelves
• If shelves are constructed high the shortest clerk has to climb the ladders
or the kick stools
• Shelves are not dust proof
• Shelves are not fire proof
• Shelves are not water proof

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 Diagram indicating gangways measurement

04/25/2025 532
• 2. Filing cabinets
• These are cupboard structures made of metal with lockable drawers , they are recommended in
smaller libraries
They provide ideal filing conditions:-
• Good access
• Dust-proof
• Convenient height
• Provide attractive appearance

• Advantages of using cabinets

• they are dust proof compared to shelves
• They have convenient height compared to shelves
• Provide attractive appearance compared to shelves
• They are secure because are lockable
•
• Disadvantages of using cabinets
• They are expensive to purchase & maintain compared to shelves
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3. Suspended filing
• This form of filing is never suitable for a large number of case records
and x-ray films on the ground of cost and amount of space taken up.
Basically it consists of manila pockets hanging from two metal bars
and providing a v-shaped space into which notes can be filed. The
metal hanging bars have flat tops to indicate the unit numbers filed in
each pocket. Suspended filing can be installed in filing cabinets, with
addition of special framework on which to hang the pockets or it can
take place of the shelves in horizontal units.

04/25/2025 534
• These are manila pockets suspended on two or four metal bars
providing a “ V” shaped space where records are filed
• While implementing this you are supposed to consider durability of
material used in creating pockets though it is used to sore records
with less weight
• You are supposed to indicate numbers or sections on pockets for easy
filing and retrieval of records

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• Disadvantages
• Provide less filing space
• It is expensive to install
• Advantages
• It is ideal for filing administrative records where files are slim.

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• 4. Mobile raking
• This is the most economical filing method as far as space is concerned. A
series of shelves, contained in a rigid frame with backing, are run on rails.
One set of shelving is fixed and then there maybe three mobile sets
• It will be immediately obvious from this that if all five sets of racking were
static, far more room would be taken up by the gangways necessary to gain
access to both sides of the racks.
•
• Disadvantages
• No gangways which could cause hold ups.
• Access may not be possible by more than two clerks at a time.
• The pushing of the racks could be a formidable task.
• It is expensive
• Advantage
• It saves space
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• A series of shelves contained in a rigid frame with backing ,are run on
rails
• One set of shelf is fixed and three sets are movable ,lets have a look
on the diagram below at birds eye view angle
• Mobile racking

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04/25/2025 540
• Advantages of mobile racking
• It is economical on space because of adjustable gangways
• Enhances security on records when the racks are moved together
•
• Disadvantages of mobile racking
• Expensive to install compared to ordinary shelves
• It needs two or more staffs to push in odder to access filed or file
records
•
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5. Circular, carousel filing
• These units consists of a series of shelves or suspended files rotating
round a fixed spindle- a large version of the carousel described in the
section dealing with the master index. Their great virtue is that the
files can be placed against a wall and rotated to bring the files that are
needed to the front- they are therefore space saving. This type of
installation is undoubtedly more expensive than many others. It
should be looked at last for interest and for the space saving principle.
•

04/25/2025 542
•It is a wheel like structure with boxes around it rotating round on a fixed spindle at its center with a stable base
Diagram

04/25/2025 543
• Advantages of a carousel
• Minimizes staff movement he or she simply swing to access required box
• Efficiency in filing and retrieval of records because more than two staffs
can use it at once
• It is prestigious
• Disadvantages of a carousel
• Expensive to purchase and maintain compared to shelves
• It accommodates smaller number of medical records compared to
shelves

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6. Elevator files
• These are very large relatives of the elevator files described in the master
index section. They are extremely expensive and quite out of the financial
range of most records departments. However, they should be recognised
as a possible form of filing.
• The records are stored in boxes, on trays, as in the smaller index card
elevator files. The difference is that elevator files for notes probably extend
upwards for twenty feet or more. As the operator presses the correct
button, the shelves will rotate until the correct one presents itself at filing
level. The argument for their installation apart from the convenience of
never having to walk, bend or stretch to pull file records is that valuable
ground floor space no longer needs to be allotted to the records library as
most of the notes are stored on one or two floors above while still being
available at the most convenient point. It is not possible to use this
method in a busy library.
04/25/2025 545
advantages
• Files/records are stored in boxes attached to the conveyor belt
• The key board assist in selecting required section
• Advantages of an elevator
• Minimizes staff movement
• Prestigious
• Designed to avoid ergonomic hazards ie bending and excess stretching while filing
and retrieving of records
• Sores large number of files compared to the carousel
• Disadvantages of an elevator
• Expensive to purchase , maintain and installation
• It is uneconomical to space ,it requires twenty fit high
• It can bring standstill on job when there is no electricity
04/25/2025 547
7. Cartwheel
•It is a wheel with boxes where records are stored fixed on an upright vertical stand as shown below
Diagram

7.

04/25/2025 548
• There are two other filing methods which must be referred to, but
purely on a historical basis because they are unlikely ever to be used in
modern records departments. They are:-
8. Bound volumes
• These have been referred to already in the description of the unit
system. As items of historical interest, and sometimes for clinical
purposes, the bound volumes must be stored carefully but note will
never again be kept in this form.
9. Box filing on shelves
• When records are finished with, they are sometimes packed into
cardboard boxes and filed on shelves. It is hardly necessary to point out
that access to a set of notes that is packed in one cardboard box at the
bottom of a pile of several such boxes is not easy to get at.
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04/25/2025 550
Bound volumes

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04/25/2025 552
There are other major items of filing equipment should be mentioned
i. Color coding
• Colour coding can be applied to both notes for a variety purpose
• Where colours are used in ten sections ,the colours should be nine
under each colour representing a number between 1-9
• Can be used in terminal digit filing system but it has some
disadvantages and advantages
• It is attractive ,but to colour blind staffs it becomes a predicament in
filing and retrieving of files

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• Colour coding can be applied to both notes for a variety of purposes.
It is traditional that ten colours should be used for the ten main
divisions of terminal digit filing. Thus each number 1-9 has a different
colour. Colour can be used to identify a particular number except that
a few individuals suffer colour blindness. Colour coding can also be
used to indicate the year when the record was created. This can be
affected by the use of coloured cello tape or adhesive levels.

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ii. Dividers
• Documents as heavy and at the same time as flexible as case folders
and x-ray films need plenty of support. This is provided by dividers for
any sort of shelf filing. Ideally these dividers are metal, and reach
from the bottom of one shelf to the top surface of the shelf below,
being firmly attached to both shelves. They thus provide support not
only for the files but also for the actual shelf unit, by adding rigidity.
The metal dividers can be supplied with a rolled edge similar to that
used for the shelf units. Notes should be divide every 12” and x-ray
films divided after 6” otherwise they soon “droop” and become
permanently misshapen.
04/25/2025 555
9. Ancillary equipment

• The efficiency of a well laid out, carefully filed records or X ray records
library can be significantly increased if certain basic items are
provided in addition to the most suitable type of shelving
• (a) Filing Trolleys
• If clerks are to walk round the filing area with armfuls of notes,
putting them down each time they withdraw or file a record they will
be very tired by the end of the day. Trolleys should be strong and large
enough to be able to carry heavy loads of case records and X ray films.

04/25/2025 556
• (b) Kick stools/ladders
• These are necessary for the shortest clerk to climb on to reach of shelf as high as 7
feet. Any ladder or Kik-stool should be light and easily moved.
• c) Sorting equipment
• Sorting equipment for case records and X ray films will certainly be some form of
pigeon hole. It is usually very important that this vital task is not attempted with
inadequate equipment.
• Where terminal digit is used, it is desirable to have one hundred pigeon holes, one for
each terminal digit. These should be clearly numbered. As the files come back to the
library, form, clinics, secretaries, wards, they can be filed straight into the appropriate
pigeon hole of the sorting unit. The filing clerk responsible for each section of the
library will ten take on pigeon hole numbers, sort them out and file them

04/25/2025 557
• d) Preparation tables
• These tables can be used for sorting the notes for filing for preparing
the clinics. There should be enough space for each clerk and the table
should be large enough

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TRACING AND RETRIEVAL OF
HEALTH RECORDS
• There are three systems of tracing most commonly used in a records
library
• a) The common tracer card
• Enough supply of tracer cards is kept in the library. When a record is
removed from the filing area it is replaced by a tracer card. When the
record is returned to the file the tracer card is removed and the notes
filed back. The tracer card is cancelled and reused for another set of
records-hence the adjective “common’. The common tracer card should
be made of strong card as it may be used up to eighty times before it is
full. The information to be recorded on the tracer card should be as
follows:
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• Date
• Destination (ward or clinic)
• Hospital Number
• Patient’s full names
• Reasons for extraction
• Borrower’s signature.
• Some special mention should be made about the date. Where the notes are being extracted
for an outpatient clinic the date recorded on the tracer card should be the date of the clinic
not the date of extraction.
• When the patient is being admitted, the date of admission should be included on the tracer
card. If the notes are for research or for a letter to be written, the date should be the date of
extraction. The tracer card should be one quarter inch larger that the notes so that it can
guide the filing clerk of where the notes should be inserted.
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• Advantages of the common tracer card
• I can be used 80 times for different patients.
• A clerk can prepare a whole clinic in advance while seated.
• It tracer cards are used for x- rays envelopes size 15” x 18”, the tracer
card should be more than the envelope so that it can act as a guide to
locating the correct place and filing the films back. The same
information will be recorded as on the cases for record tracer cards.

04/25/2025 561
• (b) Library tracer system
• Each case record has a small pocket inside the cover in which is held a small card with
the patients name and the hospital number at the top, and a series of lines below on
which borrower and date may be entered, very much on the principle still being used
by public libraries. When the notes are withdrawn from the file the card is marked
with date and name of the borrower and filed in a small tracer card index. When
notes are returned to file, the card is extracted from this index, the entry cancelled
and the card filed into the pocket in the folder which is itself then re-filed.
• Disadvantages
• This system is recommended only for a small library.
• There is no object left in place of the file to show where the record is.
• Misfiling is likely to occur.
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• Advantage
• Because the card is created permanently when the folder is created,
the facts are always right.
•(

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• c) Personal Tracer Card
• This card is created the same time as the case folder and identified with
the patient’s name and hospital number. It is filed inside the folder and
is only taken out of file when the notes are taken out of the file. The
same details as the common tracer card are entered onto it.
• Advantages
• When the record cannot be traced the details of the previous
destination may give a clue as to the destination of the record.
• No transposition of numbers since the number is created permanently
on the card.
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• The importance of the tracer systems cannot be overstressed. It is no
excuse that notes cannot be found because the tracer is out of date.
This will not help the patient. Like any other procedure, the tracer
must help to achieve instant availability of the patients’ notes when
they are needed.

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Locating Misfiled Medical Records
• Regular checks should be in place to ensure that the file has no missing medical records or medical
records filed in the wrong place. To check for a misfile, the staff should:
• • Look for the transposition of digits in a number. For example, 131234 may be filed as 131243 or
121334.
• • Look for missing files under similar looking numbers such as "3" under "5" or "8" or vice versa. Or
"7" or "8" under "9".
• • Check for a certain number such as 584 under 583 or 585 or under a similar combination.
• • Check the transpositions of first and last numbers.
• • Check the medical record just before and just after the one needed.
• • Check the shelf immediately above and below where the record should be filed.
• In addition, once a month, the file room should be checked to ensure that: • all records are standing
straight on the shelves; • there is no dust on the shelves (including the very top shelf) and • the floor is
clean.
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Culling medical records
Culling medical records that have NOT been used for a specified
number of years is the removal of medical records from the active file
room. In some countries, this is also called “PURGING”. But we will use
the term “CULLING”.
Remember An ACTIVE MEDICAL RECORD is one that is still being
actively used for patient care. An INACTIVE MEDICAL RECORD is one
where the patient has not attended the hospital for a specific number of
years.

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• If you recall when we discussed the medical record, we said that the
year of attendance should be on the medical record folder. This is used
to indicate whether the medical record is ACTIVE or INACTIVE.
• • Each new year a patient attends, the year printed on the folder is
crossed. For example, if a patient attended in 2003, a line is drawn
through the number. If he has not been since that date, (and the policy
states that medical records will be kept in active files for five years) in
the year 2008, the file can be culled and removed to secondary storage.
• • The date on the outside enables the medical record staff to see when
the patient was last at the hospital. This means that they do not have
to search through the medical record to find the date of the last
attendance.
• •.
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Computerized Record Location/Tracking System
• Many types of computerized file location/tracking systems are
available. With such a system, the location of a medical record can be
readily found. In addition, a list of previous places where the medical
record was sent can be printed, e.g.; clinics including the date when
the record was sent to that location. Some hospitals use a bar code
system as seen in department stores and super markets while other
enter details via a computer terminal in the Medical Record
Department

04/25/2025 569
• The aim of culling is to remove INACTIVE medical records from file to make more filing
space.
• • There should be a hospital policy stating how long medical records should be kept in
the ACTIVE filing area. This is referred to as the RETENTION POLICY (see MEDICAL
RECORD POLICIES).
• • The medical records that are removed from the file are records of patients who
have not been to the hospital within the last two, five, seven or 10 years, depending
on the RETENTION POLICY of the hospital/ health authority and/or space available for
active filing. The culled records can then be stored in secondary storage or destroyed.
• • Culling should be done every year. Either culling is carried out in the same month
each year, or a regular program of culling is carried out throughout the year as part of
normal duties

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• Brain storming questions
• Name three methods of filing(3mks)
• Name four filing systems(4mks)
• Highlight the difference between filing system and filing method (4mks)
• Write short notes on filing equipment (20mks)
• Discuss main types of filing systems (15mks)
• Write short notes on ancillary equipment under case folder and x-ray film management(8mks)
• Differentiate between a cartwheel and a carousel (3mks)
• Highlight disadvantages and advantages of a filing system applied on an MPI card (5mks)
• Name four ancillary equipment under appointment systems(4mks)
• What is an ancillary equipment (1mk)

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MODULE 2: CERT MARCH 2019
1. Legal aspects of health records

2. Acquisition of health records equipment

3 Managing special health records

4 Establishing health records department

5 Developing and designing health records

6 Appraissal, disposal, and archiving of health records

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MODULE 1: UPGRADING: ASSUMED
TO HAVE BEEN COVERED
1 Introduction to Health Records Management

2 Organization and management of reception, registration and initiation of patient/client health

records

3 Organization and management of Health Records Indices

4 Organization and management of patient/client schedules, follow-ups and clinic preparation

procedures

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MODULE 2: UPGRADING: ASSUMED
TO HAVE BEEN COVERED
1 . Organisation & Management of Admissions & Discharges of Patients/Clients;

2 Management & Maintenance of Health Records.

3 Acquisition of health records equipment

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MODULE 3: UPGRADING:
1
Legal aspects of health records

2 Managing special health records

3 Establishing a Health Records and information Department

4 Developing and Designing Health Record Forms

04/25/2025 575
LEGAL ASPECTS OF HEALTH RECORDS AND VARIOUS
ACTS RELATED TO THEM
• Learning Objectives
• The learner should be able to:-
• 1. Analyze and interpret legal aspects concerning:-
• Confidentiality
• Disclosure
• Ownership
• Retention
• Security
• Consent of Operations
• Medical Records Ethics
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1. Confidentiality
• Information concerning a patient is confidential and should not be released to any
unauthorized persons. If a member of the hospital staff improperly discloses ay
information concerning a patient whereby that patient suffers material loss, the
patient can easily sue the hospital and the officer who is in breach of his duty had
made any improper disclosure. If a hospital authority is to minimize its risk in the
matter, it is suggested that it should have a rule for strict secrecy about all information
regarding patients, their diseases, their affairs, and the affairs of their families
obtained by any officer in the course of his duties. Further it is recommended that:-
• No unauthorized information should be given concerning patients or former patients.
• Apart from normal replies, and enquiries concerning the progress of a patient’s illness is to be
given except from instruction of the consultant.
• Case notes are not produced to unauthorized members of staff.

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2. Disclosure of information
• There are five main categories under which contents of patients records can
be disclosed;-
• Consent by the patient which could be expressed or implied.
• If there is a court order.
• If the interest of the doctor or hospital cannot be otherwise safeguarded.
• If transference between hospitals, clinics or doctors in the interest of the
patient.
• If there exists a higher duty than the private duty e.g. notification of infectious
diseases, notification of births and deaths registration, and notification of
poisons.
04/25/2025 578
Disclosure with patient’s consent
• A patient can give his consent for disclosure either expressly or implicitly. Implies consent
arises only in certain limited circumstances as, for instance, when records are disclosed to
another medical agency for purpose of continued treatment. Express consent is obtained
when the patient signs a document authorizing the hospital to disclose his medical history
for some specific purpose.
• In general the consent form should always indicate the reasons for disclosure, and no
disclosure should be made except for that reason. If the reason and purpose change,
specific consent should again be obtained. Where a consent form reaches the hospital, the
hospital is at liberty to disclose and the patient would have no ground for complaint if the
disclosure was wider than he intended.
• In cases where requests for clinical information are received from solicitors claiming to be
acting on behalf of the patient care should be taken to make sure that the solicitors really
are acting on behalf of the patient, and not, in fact against him.
04/25/2025 579
• Requests from insurance companies and similar bodies should only be
acceded to with the patient’s written consent but should be referred
to the hospital authorities.

04/25/2025 580
• Disclosure by an order of court
• A court in the pursuit of justice may make an “Order for Discovery” or
a Subpoena to produce case records. There is no question but that
such an order must be obeyed. Generally the appropriate person to
attend court and produce the appropriate record would be the
Records officer. It is the original document that should be produced in
court but if the original document cannot be traced then the court
may accept the photocopies but photocopies must be certified to be
the true copy of the original document.

04/25/2025 581
• Disclosure to safeguard the interests of a doctor or hospital
• If an action is brought against a hospital or doctor, then the disclosure
of a patient’s record may be done. Of equal importance is the fact
that disclosure is permissible if the hospital is to work effectively.
Disclosure of the contents of a medical record is necessary between
departments or between members of medical staff in the hospital and
this is justifiable of course, as being in the patient’s interests. Such
disclosure if made publicly by any member of the hospital staff,
resulting in the patient’s interest being adversely affected could
result in action for damages.

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Disclosure in transfer of information between authorized medical agencies
• A doctor dealing with a patient has full rights of access to any clinical data made
at the time (except of course, where patient has been referred for treatment who
is acting for a third party). When a patient is seen subsequently by another,
strictly speaking that doctor has no legal right of access to the notes made by the
previous doctor.
• Disclosure as a ‘higher” duty
• The existence of the higher duty may be said to apply when the interests or
needs of the public are better served if there is some relaxation of the private
duty and in some cases there is a clear legal duty to give information which
supersedes the doctrine of confidentiality. More common instances are in the
following circumstances:-
04/25/2025 583
• Notification of infectious diseases by medical doctors to local medical officers of health under
the Public Health Act (1936).
• (ii) Notification of the cause of death under the Births and Deaths registration Acts1836-1926.
• (iii) Notification of the industrial poisonings under the Factory and Workshop Act 1901.
• (i) to (iii) above represent statutory obligations, whereas (iv) below are good causes. A
statutory obligation must be complied with, whereas although a good cause should be there,
there is no breach of law if it is not.
• (iv) Claims for sickness benefits under the National Insurance Acts.
• Exchange of records between doctors for research purposes.
• Disclosure to a central body for collective statistical purposes e.g. hospital activity analysis.
• In the foregoing instances, it is plain that the disclosure is in the publics interest.

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• Ownership
• The records do not belong to the patient even if fees have been paid.
The records belong to the various health institutions which created
them. In the case of government institutions they belong to the
government. Case records of private institutions belong to the
institutions because they have contributed to the creation of the
records.

04/25/2025 585
• Retention
• The Public Records Act stipulates that authorities responsible for public records
have a duty to make proper arrangements for selecting those records which
should be permanently be preserved and for disposal of the rest. There are some
records that were spelled out by that Act and they should not be destroyed.
• Post Mortem books
• Summaries of clinical notes
• Discharge registers containing diagnosis
The rest of the health records in the folder may be destroyed. This should be done
six years after the patient’s last attendance. Each hospital should be able to decide
on which records to be destroyed depending on the institution’s demands

04/25/2025 586
• Security
• It is the responsibility of each and every health institution to ensure
that there is security in storage and handling of health records. This
security could be maintained by:-
• Providing adequate security in the departmental procedures and use of
equipment.
• Instructing lay staff on the confidentiality of health records.
• Require all lay staff to sign a declaration of secrecy.
• Health records staff accepting responsibility for disclosure of contents
of health records in their possession.
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• Consent for operations
• It is legal requirement that a health institution should obtain consent from
patient/ client before an operation or anaesthesia is administered to him in
order to safeguard it. This only becomes difficult in the case of children and
unconscious patients. In the case of unconscious patient, the surgeon should
carry on with the necessary procedures. In case of somebody under 16 years
it is necessary for parent or guardian to give consent. In case of emergency,
consent should not delay the procedure because this could increase the risk.
In case the operation is to be done on the child the father is the right person
to give the consent but if the father is not accessible, the mother’s consent
would be acceptable. Failing that of the father, mother and then, a legal
guardian would be obtained
04/25/2025 588
• Married women would give consent on their own right just as single
women. It is wise to obtain the husband’s consent particularly where
sterility may follow an operation. For mentally disordered patient the
consent of the nearest relative should be obtained.
•

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Medical records ethics
In Greece, Hippocrates, known as the “father of medicine” was born
about 460 BC. He was the first to cast out superstition and to practice
medicine on scientific principles. He was the author of the Hippocratic
Oath, which is pledged by physicians and other health workers
including health records personnel. It states in part: “whatsoever in my
practice or not in my practice I shall or hear amid the lives of men
which ought not to be noised abroad- as to this I will keep silence,
holding such things unfitting to be spoken”. That is how confidentiality
of health records originated and should be maintained until today.

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04/25/2025 591
MANAGEMENT OF SPECIAL HEALTH
RECORDS
• Learning objectives
• The learner should be able to:-
• Define special health records.
• Describe types of special health records.
• Describe the security and control of special health records.

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• What are special health records?
• They are records that are confidential and necessitate proper care
and security
• They include
• Psychiatric records (infectious diseases).
• Tuberculosis records
• Radiotherapy records.
• Genitourinary records
• HIV/ AIDS records
• Maternity records.
• Anaesthesia
04/25/2025 593
• Accident and emergency
• Radiology
• Radiotherapy
• Mch/fp
• Cwc
• STI/HIV/AIDS
• Accident & emergency records
• Gender based violence Records
• Medico legal Records
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• Psychiatric records
• The way psychiatric records are maintained is different from the way the general records are
maintained. This is prescribed in the Mental Health Act. The admission of psychiatric
patients may be “informal or formal”. Informal means a patient is admitted without legal or
other formalities and the hospital has no right to detain him in the hospital against his will.
•
• Admissions are carried out in reference to the Mental Health Act. Discharge procedures are
also carried out in the same act.
•
• The records officer must ensure that the information inside the record is accurate. The same
responsibility being carried out by the health records officer in a general hospital are the
same ones carried out in a psychiatric hospital except for the addition to the special
statutory work arising from the operation of the mental health act.
04/25/2025 595
Tuberculosis records
• Tuberculosis is one disease (cancer is the other) for which an attempt is made to
complete registration to identify that population. Since it is an infectious disease
notification must be made to the “Medical Officer of Health. A register is
maintained for this notification. Copies of the notification of new cases are sent
to the chest clinic. A unit record is opened for this patient and the information
contained in it should be very comprehensive.
•
• The records belonging to these patients are supposed to be kept for long
periods and therefore the case folder must be made for sturdy material to resist
wear and tear. The notes should be written in foolscaps instead of a4 size
papers
04/25/2025 596
• Radiotherapy records
• Radiotherapy department present a special records problem. All
radiotherapy cases are supposed to be registered nationally for perpetual
follow-up. These records could be filed in a separate area but given the unit
number, and copies of the notes for the same patient from other units in
the hospital incorporated in the same unit file. This should be a
radiotherapy number given to each patient to be used for National Cancer
Registration. This number is prefixed by the year of first registration and is
used in all follow-up correspondences, until the patient dies. The prefix to
the year of registration number is a precaution against confusion with unit
number which will be used for treatment and all other occasions in the
hospital.
04/25/2025 597
• Genitourinary diseases: these are conditions related to the urinary
and general organs.

04/25/2025 598
• Security and control of special health records
• The special health records should be if possible locked in cabinets and
the keys kept by the health records & information department.

04/25/2025 599
• Worker’s compensation
• -In most countries a person injured in the course of his or her duties
and while acting scope of his or her employment is entitled to
compensation for bodily injury and other
• -The medical record is used as evidence to show the date of injury,
the type and see injury and the patient’s expected recovery obligation
to make his notes available to subsequent doctor in the general
interest of the patient

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• Records department should therefore make available promptly and
freely such data to other department or doctors at their request
except of course where the cosign is not serving a patient medically
but in the interest of a third party. There is no question of improper
disclosure when one doctor calls another into consultation over a
case.
• -The circulation of clinical data amongst medical authorities is
guaranteed so long as these medical authorities are acting in the
medical interest of the patient, this does not require the patients
consent as it is being done for his benefit and without detriment to
his medical interest.
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• Records department should therefore make available promptly and
freely such data to other department or doctors at their request
except of course where the cosign is not serving a patient medically
but in the interest of a third party. There is no question of improper
disclosure when one doctor calls another into consultation over a
case.
• -The circulation of clinical data amongst medical authorities is
guaranteed so long as these medical authorities are acting in the
medical interest of the patient, this does not require the patients
consent as it is being done for his benefit and without detriment to
his medical interest.
04/25/2025 602
• Caution should be shown in those cases where for example a factory
data or general practitioner writes in the interest of the patient’s
employer to whether on medical grounds patient should be retained
in his employment.
• -The patient should be informed of the nature of such request and
asked for his consent to disclosure of such a request. As previously
stated disclosure in the interest of the patient does not need the
patient consent and transferable of information or records between
hospital/doctors in the interest of a patient is an everyday occurrence

04/25/2025 603
• A patient may be legally aggrieved if his treatment was prejudiced by his records
not being so transferable and in good time. A successful action for damages might
conceivably be brought for instance by a patient who undergoes an operation which
could have been unnecessary if the notes of the previous treatment in another
hospital had been available.
• -Patient sends a letter to the hospital requesting the information. The lawyer must
include the patient’s written authority, giving the hospital permission for the
release of the requested information. The hospital is NOT legally bound however to
release information if it affects the hospital or the attending doctor or other staff.
• The procedure to be followed when handling this request is as follows
• Request from lawyers are usually registered and date of receipt of request recorded
by the hospital administration and forwarded to the MRO for processing.

04/25/2025 604
• The medical record is located and the patient’s signature checked against the
signature on the consent form in the medical record.
• In some countries a charge is made for the production of medico-legal reports. The
amount charged varies from hospital to hospital and country to country and the
MRO must be familiar with the charges and regulations in his or her hospital. If a
cost is charged an account should be made out by the MRO (or hospital
administration) and included with the report. In some countries lawyers already
know this cost and in many cases a cheque is included with the letter of request.
• The information requested is identified and the attending doctor asked to write a
report. In many health care facilities a pre-designed form may be used (see example
below) or if a discharge summary is already in the medical record, it is checked and
if it includes all the requested information a copy is made. This will save the doctor
from having to write a new report.
• The medical record officer may write a brief letter acknowledging the request and
enclosing the doctor’s report. In some hospitals a ‘’with compliments’’ slip is used
instead of a letter from the MRO
04/25/2025 605
• The letter (or ‘’with compliments’’ slip), report and account (if
required) is sent to the lawyer and a copy of each documents is filed
in the correspondence section of the medical record.
• The MRO notifies the hospital administration that the report has been
sent.
• In most cases the report is all that is required. If the actual medical
record is needed the lawyer must produce a court order of subpoena
to enable the release of the medical record.

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• Subpoena or court order
• -A subpoena duces tecum is the term used in most English speaking
countries for a legal order to produce records to a court. It is usually
addressed to ‘’the custodian of medical records’’ directing that person
to appear in a given court, on a date and at a time specialized on the
subpoena, and to bring on that date the records designed for the
patient named in the subpoena.
• -After accepting the subpoena all medical records specifically
mentioned in it must be produced in court at the time and place
designated or the person subpoena is liable in contempt of court.

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• Procedure for preparing a medical record for court
• -If a subpoena or court order is served it must be obeyed
• c. Personal injury claims
• -A person may claim to have been injured through the fault or neglect of
another and sues recover damages for injuries sustained. The medical
record would be used to show how the injury happened as recorded in
the patient’s words on admission to the hospital. The medical record
would also be used to show the extent of the injuries, treatment given
duration of care and expected recovery or disability. Medical records are
used more frequently in this type of cases than in all cases combined.

04/25/2025 608
• d. Malpractice claims
• -In this type of case the plaintiff (person suing) claims damages from a
doctor, a hospital, nurse or other health professional for negligence in
rendering care or giving improper treatment. The medical record
would be used to show the mental state of the patient at the time of
making the will
• f. Criminal cases
• -Medical records have been used in many criminal cases the most
frequent use includes

04/25/2025 609
• g. Assault cases
• -To prove the assault and extent of injuries
• h. Violent or unexplained death
• To prove death resulted from natural causes, accident, misadventure or murder
• i. Sexual assault cases
• -To prove the condition of a patient on admission or attendance at a hospital
and the history of the assault related by the patient
• j. Mental competency
• -Hospital medical records may also be used as evidence in proving the mental
condition of a patient

04/25/2025 610
• Procedure for the release of medical information in a legal case
• -The hospital may permit a patient’s lawyer to view the medical record, in the
presence of a doctor, upon the written authorization of the patient. It is rare for
this to happen however and in most medico-legal cases a lawyer requesting
specific information about a particular adequate security should involve hand
delivery of the medical record from the hospital health center direct to the clerk
of the court by an employee of the hospital or health or by courier services.
• -In some countries the MRO is required to take the medical record to court or
prescribed day and time. He or She may be required to testify that the medical
record has been kept in the normal business of the hospital and to the best of his
or her knowledge not been tampered with by unauthorized persons.

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• If the medical record has not been returned to the hospital by the
specified date the MRO must check with the court to find out if the
court case is over and if it is request the pro-return of the medical
record. If not ask for the probable date of completion.
• -On return from court the medical record is checked to ensure that all
pages (forms) present. The removed correspondence is returned to
the medical record and the record returned to the file and the tracer
removed. As mentioned previously if a photocopy has been made it
must be checked as for the original and then destroyed.

04/25/2025 612
• Other important medico-legal issues
• -Remember that the laws in each country vary and you must be familiar with
your country laws for dealing with medico-legal request. In the absence of
specific statutes are regulations certain practices should be determined by the
hospital administration and MUST be followed by the medical record staff.
• -Requests for information by the police or a government department where the
patient has NOT authorized access to information from his or her medical
records should be dealt with by the attending doctor or senior health care
professional. Except in circumstances which the police can confirm that they
seek information essential to the execution of the police officer’s duty, the
information supplied should be limited to confirmation of identity and address.
Any other information may only be divulged on production of a search warrant.
04/25/2025 613
• The attending doctor or other health care professional should be responsible for
checking legal requests and release of information to ensure that only information
relevant to the request is released
• Except for the purpose of providing ongoing care and treatment for the patient, all
photocopying of the patient’s medical records requested by the patient or the
patient’s authorized nominee, should be at the expense of the patient and not the
hospital
• -As a general rule access to medical records should be restricted to health
professionals currently involved in the continuing care of the patient. Remember
that no information may be released without the patient’s consent, including the
fact that the person is a patient. Where a patient requests that NO information be
released at all, or information be released in limited circumstances, his or her
wishes must be respected.
04/25/2025 614
• Medical records may be used for research and statistics without the patient’s consent as
long as the patient is NOT identified. Medico-legal issues bring out the necessity for
accurate and adequate medical records. That is medical records that will clearly show
the treatment given the patient, by whom it is given, and when given, for the protection
of the
• Receipt of a subpoena the MRO records the date and the time the subpoena was
received and records in a diary the date and time the medical record is due in court.
• -The MRO should notify the attending doctor and hospital administration that a
subpoena has been received for the release of the medical record to court.
• -In many countries if the patient is NOT involved in the court case he or she is also
notified by the health care facility that the subpoena has been received. They are also
advised of the place, date and time of the court hearing in sufficient time allow the
patient to arrange to attend the court if he or she so wishes.
04/25/2025 615
• The MRO should locate the medical record. If the medical record is not on file the MRO
should find it and keep it in a safe place awaiting preparation for court. A tracer is made out
showing that the medical record is with the MRO for medico-legal purposes.
• -The MRO should check that all necessary information, as specified in the subpoena, is in the
medical record and that it is complete.
• -All correspondence not written at the time the patient was in hospital should be removed
as it is considered ‘’hearsay’’ and not permissible as evidence. The correspondence is placed
in a temporary folder made out with the patient’s name and MRN and kept in the medico-
legal file.
• -All pages (forms) should be numbered in ink and the total number of pages recorded on the
folder and a record of the number of pages (forms) kept with the removed correspondence.
• -In some countries the original record is not sent to court, if a photocopy is permissible as
evidence in court all forms are photocopied and numbered and the photocopy sent in place
of the original. If a copy is made note needs to be recorded in the medical record
04/25/2025 616
• indicating that a copy exists and will need to be destroyed on return from
court. Some hospitals send the original and keep a photocopy on file.
When the original medial record is returned to file the copy is removed
from file and destroyed. To protect the privacy of the patient it is
important that if a medical record is copied the copy MUST be destroyed
on return from court. The following steps apply to both original and
photocopied medical records.
• -A form of receipt should be prepared for signature of the receiving officer
of the court. This may have a limited amount of information such as the
number of the subpoena, date received, name of the lawyer requesting
the medical record, name and MRN of the patient, number of pages
(forms) and date the medical record is sent to court. The hospital may
wish to use more structured form as shown in the following example:
04/25/2025 617
• -The medical record is placed in a large envelope addressed to the
clerk of the court (or specified person) with the receipt attached to
the front. The tracer on file is changed to indicate that the medical
record was sent to the court and the date it was sent.
• -The medical record should be forwarded under adequate security to
the clerk of the court named in the subpoena and the signed receipt
obtained from the person accepting delivery.
• -The need for the hospital rule will thus be seen as there is a very
serious danger of clinical data being disclosed in this way without the
patients consent.

04/25/2025 618
ESTABLISHING HEALTH RECORDS
DEPARTMENT
• This chapter discusses how to start a new health records department in a
health care facility where none existed.
Learning objectives
• The learner should be able to:-
• Carry out a needs assessment.
• Describe the procedures in establishing a health records department.
• Organize various sections.
• Describe commissioning procedures.
• Monitoring and Evaluation.
• Principles
04/25/2025 619
Introduction:
Health record officers are acutely aware of the need for proper facilities for
the efficient and effective operation of the health record services. In fact, it
has been recognised for some time that architects, health facility planners,
administrators and heads of departments, should plan for construction of
specialty areas together, as a team. Although in many instances this has in
fact happened, for a number of departments there has been little
participation by health record officers (MROs). The reasons for non-
participation are varied and range from the MROs not being consulted or
involved because the planning authorities do not realise their ability in this
area, or the MRO has not been interested or has felt incapable of
involvement in such a daunting task
04/25/2025 620
• -The major functioning of good quality Medical Records Department
in the world is to be the CUSTODIAN of patient’s health record and to
provide prompt and efficient service to users. The benefits would be
to handle very large volume of medical data, improve efficiency, easy
storage of documents in minimal space, quick retrieval of records in
seconds at the press of button
• -A study should be carried out to know what is required in the
building of a new department ,the staff required, the equipment and
the stationary that will be needed

04/25/2025 621
1. Needs assessment
• A study should be carried out to know what is required in the
building of a new department, the staff required, the equipment
and the stationery that will be needed. This will require a lot of
funds and therefore a lot of caution will be needed in carrying out
this study. The only person to do this is the health records/
information officer because he is the one conversant with the layout
of the department and what to put in the department. It important
once the needs assessment ready a corresponding budget be
prepared for cost analysis prior to acquisition of resources.

04/25/2025 622
• A needs assessment is a systematic process for determining and
addressing needs, or "gaps" between current conditions and desired
conditions or "wants". The discrepancy between the current condition
and wanted condition must be measured to appropriately identify
the need

04/25/2025 623
2. Procedures in establishing a health records department
Before one establishes a health records and information depart he
should consider two factors:-
• The line of command
• The number of staff and jobs needed to achieve the desired results

The most important function of a health records and information office

is to store information when needed by medical and administrative
staff. In view of this a list of jobs and staff to carry them out can be
made. The line of commandment must be specified.
04/25/2025 624
The hospital administration is responsible for seeing that the health record
services of their institution have adequate facilities and equipment for the
efficient day-to-day operation of the service. The criteria to meet this
standard includes:

1. the health record department/office should be located in such a place as to

facilitate the rapid retrieval and distribution of health records

2. the Office and work space should be sufficient for health record staff to
perform their duties and for other authorised personnel to work with health
records, including records on microfilm or computer
04/25/2025 625
3. there should be sufficient storage space for health records to allow
for future storage needs. This includes:-

a) an active storage area with sufficient space to include all health

records currently in use by hospital staff, and

b) available space to provide for both active and inactive health records
being stored under statutory guidelines

04/25/2025 626
4. areas for active and inactive health record storage should be sufficiently secure to
protect records against loss, damage, or use by unauthorised persons (ACHS,1992).

The planning of a health record department, whether for a new hospital or

relocation within an existing hospital, should develop from the interaction of three
people: the health record officer, the facility's planning co-ordinator and the
architect. The MRO contributes ideas especially on the detailed functions of the
proposed department; the planning co-ordinator has an understanding of the total
requirements within the facility and co-ordinates all departmental planning and the
architect is responsible for defining, both verbally and graphically the building or
complex to meet a specified objective
04/25/2025 627
- To design a department which will offer both efficient and effective services, the
planning team must clearly define the functions of the department and the
inter-relationships of the proposed department with other departments/areas
of the facility.
- For example, will the health record department be responsible for transporting
health record, for ordering and storing health record forms, for cleaning the
department or will these functions be the responsibility of another department.
- This involves looking at procedures to be performed, staff requirements for the
performance of these procedures, the flow of work planned for the department
and the hours of services offered. This information should be stated in clear,
logical writing, with sufficient detail for an architect to understand what is
required. (Greenlaw & Biggs, 1979).
04/25/2025 628
The six phases determined by the architects (Lindell, 1974) which they believe
should be observed when designing a new hospital department are as follows:

A. Definition
phase, that is the definition of the precise need the design of the department is to
meet
B. Brief
phase, is a detailed nomination of the estimated facilities to meet the defined need
C. Department
phase, the integration of one specific area or department into the greater complex
of the total facility. In this phase the key people in the facility along with the
architect and planning co-ordinator establish ideal working relationships with other
departments
04/25/2025 629
D. Total facility
phase which looks at wants, as compared to needs, compared to available resources. A
total hospital proposal is prepared to enable the selection of the most viable scheme for
the department
E. Process
phase - at this stage attention is focused on the actual function of the individual
departments. This means that each proposed procedure to be performed in a
department is thoroughly analysed and assessed. Diagrams illustrating the various
processes and procedures, most of which were completed in the definition phase, are
extremely useful as graphic expressions of physical requirements and associated services.
It is at this phase that attention must be paid to the welfare, comfort and health of
workers in the proposed requirements for the department.
F. Department design
phase is the stage where the architect prepares final proposals to enable an optimum
design to be prepared and selected. Detailed drawings of each department are prepared,
including all special requirements. There must be a systematic means of assessing and
comparing the various schemes to enable the planning team to reach a final decision
04/25/2025 630
In this Unit we will concentrate on the first two phases since these
require the greatest participation by the health record officer and also
have the greatest applicability in improving the layout of an existing
department

04/25/2025 631
A. DEFINITION PHASE
When preparing for this first phase in the planning of a health record department, there are
five major points to be considered. These are:

1. location of the department in regard to services and inter-relationship of service areas

2. space requirements for records, for personnel and for equipment

3. functional design and logical placement of key work areas

4. system of communication within the health record department and between the
department and other areas of the facility

5. system to be used to transport health records within the department and to other
departments and wards.
04/25/2025 632
1. Location
When determining location consideration must be given to the need
for the department to be centrally located where it will provide:

· prompt service for all patients - inpatients, outpatients and emergency

· ready accessibility for medical officers and other users, and

· easy availability for administrative use.

04/25/2025 633
That is it should be:

· adjacent to the Admission Office, the Accident and Emergency Department

(A&E), the Outpatient Department (OPD)

· close to wards

· close to the administrative and business offices

· close to other service departments, e.g. x-ray, pathology, etc

04/25/2025 634
While it is desirable to have the health record department centrally
located, it is accepted that this is not always possible. If this is the case
and the department cannot be logistically situated near all these areas,
the first three should have top priority and, in most situations, the
proximity to the outpatient and accident and emergency departments
would have the highest priority, as these two areas usually have the
greatest utilisation of records with speed of access often essential

04/25/2025 635
2. Space
Regardless of the type of facility, when planning for space requirements for records, personnel
and equipment, the health record administrator must consider the following:

· population of the district served by the hospital

· hospital services proposed
· number and type of beds
· current and projected number of discharges/deaths and outpatient and emergency registrations
and attendances
· major functions to be performed in the department
· number of personnel required to perform proposed functions
· equipment most suitable for the work to be done
· extent of computerization anticipated
· type of filing system to be used
· the numbering system
· whether the record services are to be centralized or decentralized
04/25/2025 636
· whether emergency/casualty records are to be included in the main
record
· number of years of active storage
· length of time original records are to be preserved and whether
inactive records will be selectively culled or microfilmed,
· type of secondary storage required
· special services to be offered by the department

04/25/2025 637
a) Space for records
Before calculating file space required, decide how many years of health records
should be kept in active filing and estimate the number of records generated
per year
The retention schedules recommended by the local health authority for health
records should be considered when determining record activity. These
retention schedules usually take into consideration:

· the statute of limitations for legal protection, and

· state regulations

Retention for longer periods than determined by health authorities, however,

could be influenced by:
· available storage space, and
· the clinical and/or research value of the records
04/25/2025 638
Once the proposed number of records and the activity rate have been
determined the estimated number of health records over the number
of years of active filing can be calculated.

04/25/2025 639
b) Secondary storage
If a secondary storage area is considered it should ideally be located within the department, or
immediately adjacent to it, or directly underneath with its own stairway. There are a number of
advantages for keeping non-active health records readily accessible and available, two of which are
that:

· it is time saving for staff, and

· offers easy access for refiling.

If storage space is a problem and microfilming of inactive records is being considered a special
room for microfilming will need to be planned.

Health records, however, are generally filed in serial order in secondary storage allowing for
shelves to be packed to capacity, and this could allow for 80 records to 1 metre.
The reason you can get more records/metres is
(i) no need to allow for growth of individual record and
(ii) no need for working space since there will be little movement.
04/25/2025 640
c) Patients' master index
Consideration must be given to the space the patients' master index will
occupy. When all or part of the PMI is on cards, the space requirements can be
considerable. The steps to be followed in calculating the space needed to file
the index cards and guides are the same as those for the health record files
d) Planning space for personnel and equipment
When planning for personnel and equipment requirements, consideration
must be given to the functions to be performed within the department and
the services offered by the department to other areas.

The floor space is determined by the number of staff, desks, files and other
equipment necessary, and ample room must be provided for each employee.
Huffman (1994) recommends that the minimum space allocated for each

04/25/2025 641
office worker should be 5.57m2, although this estimation may vary, it is
still a good guideline
It is generally accepted that the staff of a health record department are
responsible for the initiation, completion and maintenance of a health
record for every person attending the facility as an inpatient, outpatient or
accident/emergency patient. The major functions of a health record
department usually include:
the initiation of health record documentation and the design and
control of all record forms
 initiation and maintenance of a unique patient identification system
and patients' master index (PMI
04/25/2025 642
preparation of new outpatient and accident and emergency health records and
the update of records of returning patients
· assembly, completion and control of incomplete records for discharged/died
inpatients
· classification of diseases and the collection of morbidity/ mortality statistics for
all hospital discharges/deaths
· collection of health facility statistics relating to discharges/deaths, length of stay,
occupancy rates for administrative and health department use
· filing and retrieval of all inpatient and outpatient health records with an inbuilt
record control system
· medical secretarial services covering discharge summaries, operation reports,
outpatient letters and medico-legal correspondence (using word processing
facilities)
 services to medical and other health professionals for the retrieval of health
records for research and teaching purposes
04/25/2025 643
in some situations the functions of the health record services includes
patient reception and processing in the outpatient department,
admission office and accident and emergency centres

3. Staff required
Once the functions of the department have been determined,
consideration should be given to the number of staff required. Hospital
policy regarding the number of hours in the work week and the hours of
service for the health record department (24 hours a day, seven days a
week versus some other schedule) will be a major factor in this
determination along with the functions to be performed, the number of
annual discharges/deaths, OPD and A&E attendances (if A&E reports are
incorporated in the unit record) and research undertaken by medical staff
04/25/2025 644
(a) Forecasting
Once the MRO has:
· determined the predicted number of discharges/deaths, and OPD/A&E
registrations and attendances, and predicted specialised work, e.g.
research, quality assurance, etc.
· determined the functions of the department and services to other
departments
· determined the hours of service eg 24 hours x 7 days per week or less
· defined each function and determined the tasks to be performed
· defined how each task is to be divided into manageable work units or
jobs
· analysed each job to determine the content, skills, knowledge and
responsibilities, and
· prepared a job description and job specification for each job
04/25/2025 645
the next step is to forecast the number and type of staff required to
perform each job. That is, the MRO needs to be able to predict the
number of direct employee hours required to cover the jobs outlined in
each job description. There are a number of forecasting techniques
used to cope with the problems involved with human resource
forecasting. For our purposes, traditional statistical projection, could be
used by using the correlation of staff to patient discharges/deaths and
attendances. The time to process one health record of a discharged
patient can be estimated as suggested in the following hypothetical
example:

04/25/2025 646
Collection of records from designated collection area 3 minutes
· Pulling of work cards from the hospital box 1 minutes
· Assembling record into correct order 3 minutes
· Checking record for deficiencies and retrieval of loose sheets 3 minutes

· In case of, retrieval of old notes or if new patient, preparation of new folder re-admission 3
minutes
· Assigning record to appropriate doctors for completion 2 minutes
· Filing record in incomplete file area 2 minutes
· Filing work card in work box 1 minutes

· Filing outguide on file 2 minutes

TOTAL - 20 minutes

By the above calculations, it is estimated that the discharge procedure for each record takes 20 minutes. If
there are 70 discharges/deaths per day for seven days, the total time to process these records would be
04/25/2025 647
• 70 x 20 x 7 = 9800 minutes or 163.3 hours If each clerk worked 7.5 hours per day for five
days, the number of staff required for this process would be:
•
• 163.3 37.5
• = 4.35
•
• That is, 4.5 full-time equivalent staff members would be required to complete the
discharge procedure in a hospital with approximately 25,480 annual discharges/deaths.
•
• A similar procedure could be undertaken for each job within the department using the
prepared job descriptions

04/25/2025 648
• Relief staff based on estimated absences such as recreation leave, sick
leave, etc. should also be determined, as should supervisory and
professional staff requirements
b) Health record officer's office space

• Since privacy is desirable for the chief health record officer (for talks
with personnel, doctors, lawyers, administrators), a private office may
be necessary. However, in smaller hospitals the MRO may prefer to
be with the staff in the main department area

04/25/2025 649
• c) Other special areas

• · A section of the health record department should be provided away

from the flow of traffic for the medical staff so that they can complete
their records or review records for research in reasonable quiet and
comfort.

• · A special area is often required for typists/word processors. Medical

transcription should be confined to one area because of noise - sound
proof booths or partitions help reduce the noise of typewriters/printers
04/25/2025 650
4. Equipment
The number of staff and the functions of the department will determine
the equipment required.

As well as planning space requirements for records and personnel,

consideration must also be given to the allocation of sufficient space for
the equipment required to cover the defined functions of the
department.

The major areas for consideration are:

04/25/2025 651
a) Filing

Type of shelving to be used is important and it is generally accepted that open

shelving is the most practical. It utilises less floor space than other forms of
filing equipment, allows for faster filing and retrieval and lends itself to any type
of filing system used. Once the amount of shelving required is calculated, the
amount of floor space required for the shelving can also be calculated using the
width and length measurements of each bay of shelving.

The space should also be allocated for aisles and it is generally accepted that
main aisles should be 150-155 cms wide and secondary aisles 90-95 wide
04/25/2025 652
b) Computer facilities

The level of initial computerisation would have been defined in the determination
of functions and job analysis and sufficient space must be planned for terminals
and ergonomically sound work areas. If the entire department is not air
conditioned, provision should be made to protect the computers from excessive
heat and dust.
c) Dictating/transcription

Appropriate space for dictating and transcription services needs to be carefully

planned to allow for ergonomically sound facilities and work areas. The use of a
dictating service with a central receiving unit encourages doctors to dictate
reports and discharge summaries promptly. Word processors are now widely
used in health care facilities and appropriate space must be allocated to ensure
efficiency and also the health and well being of the staff
04/25/2025 653
d) General

The number and therefore, space requirements, of desks, chairs, typewriters,

telephones, filing cabinets and other office equipment will be based on the
jobs to be performed and the number of personnel required. Staff working
different shifts can occupy the same work area.

Department personnel should have a place to store their belongings

(handbags, umbrellas, coats, etc) safely. A tea or lunch room should be
available for staff to take their break so that they do not eat and drink at their
desk. Convenient access to hand-washing and toilet facilities is needed.
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• e) Special space

• Space requirements for a photocopier, storage cabinet (for supplies and

folders, etc), book shelves, and any other special equipment should also be
defined at this stage. If microfilming is planned, space for the necessary
equipment, e.g. microfilm camera, reader-printer, jacket-filler, filing cabinets
and work area must be considered in the planning stage.

• The predetermined departmental functions, job descriptions and number of

proposed staff, however, will enable the MRO to determine the equipment
and furniture needed and the approximate space required for the work are
04/25/2025 655
5. Functional design and logistical placement of key work areas
When considering functional design and layout, a key consideration is work flow. At this
stage of definition, the MRO should prepare work flow diagrams to indicate the work flow
from procedure to procedure or desk to desk.
Keeping in mind that:

· desks should be arranged so that paper moves in a straight line and only a short distance
at a time

· desks should be next to each other for procedures performed in sequential steps

· amount of floor space required will depend largely on record activity and whether or not
data processing or microfilm programs are established, and

· equipment should be chosen for reasons of both efficiency and appropriateness.

04/25/2025 656
The use of a movement diagram (Stoner, Collins & Yelton 1985) which is
an overlay of the flow of work through the layout, can assist with
determining that furniture and equipment are placed effectively.

When preparing a layout for the architect, the MRO should be able to
use appropriate terminology and blueprint symbols to illustrate the
essential features such as columns, lifts, doors, windows, furniture and
equipment, etc. This will give everyone including the MRO, a visual
image of the proposed department.

04/25/2025 657
6. System of communication
• During the definition stage, consideration must be given to the communication system to be
used within the department and between the health record department and other departments
or areas.

• Most health record departments require numerous telephones placed at strategic points within
the department. In addition, some hospitals also prefer intercom systems between A&E and the
MRD, or the OPD and the MRD.

• If computer terminals are to be used, both as communication devices between the MRD and
other areas and for the input and output of data, the cabling for such devices is an important
part of the planning process. If the entire department is not air conditioned, consideration
must be given to air conditioning the area where the terminals are located not only to prevent
them from overheating but also to protect them from excessive dust.
04/25/2025 658
7. Transport
Consideration must be given to how the health records are to be
transported both within the MRD and to other areas. If trolleys are to
be used within the department they have to be able to be pushed
freely between desks and files. If a dumb waiter or pneumatic tube or
other automated device is to be used, special space provision in the
appropriate place must be made. Some hospitals use motorised
trolleys which need to be stored in the MRD when not in use. Provision
for all these needs must be considered in the definition phase of filing.

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8. Layout
In determining the physical layout the following points should also be considered
(Wakely, 1974, Huffman, 1990).

· it is important that full use be made of available space. Desks and files must be
arranged to provide maximum efficiency, light and air
· to eliminate the hazard of electrical cords, attention should be given to the most
convenient placing of electrical outlets for the use of any electrical equipment
· temperature control and circulation of air, i.e. adequate ventilation, fans, windows
· adequate lighting - i.e. well positioned lighting (experts should be consulted as to
levels required and correct placement). Workers should not face glaring lights
· use of colour - walls, floors, furniture and equipment (light colours for walls -
bright for accents and trims)

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to keep traffic flow in the health record department to a minimum, it may be
desirable in many hospitals to have a reception and/or waiting area where an
employee may attend to requests
· employees handling enquiries should be placed near the main entrance
· equipment should be near user and the doors wide enough for record trolleys
· desks should face the same direction with 1 to 1 1/2 metres between desks
· supervisors should be at the back of the people she/he is supervising - should
be able to see all employees without leaving desk
· two desks placed side by side in the same direction is a compact arrangement
· it is best to place the file space to the back of the department - it should not
be placed near the main entrance (for safe keeping)
· sufficient space for workers to stretch and move around.

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B. THE BRIEF PHASE
At the completion of the definition phase the MRO should be ready to
prepare a brief for the architects which will include the proposed
functions and services of the department, the preferred location, the
capacity with regard to space, staff and equipment, relationship to other
departments, and any other design features to be considered.
Requirements may be illustrated by drawing a plan
The brief should include work flow diagrams, and a proposed layout with
specific reference to ergonomic consideration in all aspects of the design.
If the MRO does not feel confident in making determinations on
ergonomic issues an expert in this area should be consulted
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SUMMARY
Effective planning of a health record department for a new facility or in
an existing one is an important responsibility which should be readily
accepted by the health record officer. As discussed previously, the
planning process MUST begin with clarification of the FUNCTIONS to be
performed and SERVICES to be offered. The health record officer is the
best person to undertake this important step and should be prepared
to do so.

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The sections of the records department must
be organized to fit one with another:-

a) The objective should be efficiency, accuracy and speed.

b) The function is to store and provide information.
c) Line of command should be understood and known by all.
d) Staff should have initiative and scope to suggest improvement.
e) There should be co-ordination of sections and departments
f) There should be continuity in the system so that work continues in the
absence of some staff.
g) Mobility- for staff to change and learn other jobs.
h) Incentive – to know why the job is being done to satisfy achievement
on completion.
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• Fire precautions
• All offices should comply with fire precautions. Fire escapes and
extinguishers should be labelled clearly. The health records and
information officer should ensure that his staff understand and
comply with implications of fire regulations. Lectures on fire drills
and precautions should be attended by his staff.
Security of information and property
• The library must be secure during office hours and after hours. Only
authorizes persons should have access during the night. It should
not be a through way to other offices. Equipments like typewriters,
Dictaphones, or machines that are very expensive and the records
office should be under lock

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• Proximity of Rooms
• Rooms with related functions should be near each other.
• Fittings
• Telephones, electric socket outlets, hoists between floors, lighting
acoustic filing on walls and ceiling should be fitted properly.
• Special sound proofing
• If the machines like those ones for mechanical documentation are to
be used they should be installed on rubber pads.

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• Storage.
• Enough storage equipment should be installed if the rooms are to
remain tidy. Store cupboards should be lockable. Shelves should be
at least I feet part and 7 feet high. Ancillary equipment should be
added to the library.

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Space
• Detailed analysis of the following must be carried out before space
can be allocated:
1. The nature of the function of the records department
Main functions being registration, appointments, medical secretariat,
waiting lists, statistics, bed bureau, microfilming, mechanical
documentation, library, storage for notes and X ray films.
2. The volume of work
This can be estimated by knowing the number of admissions, number
of outpatient attendances, number of consulting staff, any special
departments
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3. General operational policies
• Is it a seven day health records services?
• What type of secretarial services will be chosen?
• How long are the records to be retained?
4. Internal communication
• This is internal communications between records departments and
other departments in the institution. The possibilities of physical
communications are:-

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 a) Any member can transport any item from one part of the department to
another.
b) There could be a messenger to be sent from one department to
another in the institution .
c) A vertical hoist may be installed between one floor and another and by
pressing a button to indicate the floor the hoist will stop.
d) Intercom installed between sections
e) Pneumatic tube systems are installed. It is important that they should be
between the records library and the registration area and they are sited at
convenient areas on the floors that are going to be served. (Pneumatic
tubes (or capsule pipelines; also known as pneumatic tube transport or
PTT) are systems that propel cylindrical containers through networks of
tubes by compressed air or by partial vacuum. They are used for
transporting solid objects, as opposed to conventional pipelines, which
transport fluids)
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5. The Architect’s Plan
• The Health Records and Information officer should know the
architect’s plan and advise accordingly.
6. Detailed planning of sections.
• The “nerve centre” of the department is the library and should be
allocated enough space. Retention period of the records department
should be clearly laid down. The space for shelving must be properly
calculated. The type of filing equipment must be known-cabinets,
self-filing.

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• The registration and appointment areas must be easily accessible to
all out patients. It should be attractive to patient/clients for comfort
and privacy. Open counters is agreeable to the patients.
• The secretarial section may be centralized or decentralized
depending on the requirements of the institution. The master index
may be sited near the registration or appointment areas. An
intercom can connect other distant areas of the department.

04/25/2025 672
7. Planning individual rooms.
• Individual rooms should be planned depending on the functions to
be carried out in each unit. Furniture, lighting, telephones and
electrical sockets should be fitted in appropriate positions in each
room.

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Monitoring and evaluation:-
• Establishing a new Health Records and Information department
should be viewed as a project, thus the need to monitor every
aspect and stage of the implementation to ensure that the plan does
not go off truck. At the beginning of the implementation the
modalities on monitoring should be put in place as well as an end of
establishment evaluation protocol to inform on how well the
resources were utilised and whether all the activities planned were
done to specifications.(see project implementation concept and
protocols)

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04/25/2025 676
DEVELOPING AND DESIGNING HEALTH RECORDS
FORMS

• Learning Objectives
• The learner should be able to:-
• Describe the basic principles of form design.
• Describe various medical forms used in a health records department.
• Explain procedures of pre-testing medical forms.
• Describe reproduction and costing of medical forms.
• Describe control procedures of medical forms.

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• introduction:
• A Form
definition:
it is a piece of paper or a card with a format , arrangement of questions or blank
spaces for data entry
•
A Medical Record Form is a piece of paper or card on which a formal arrangement
of information is designated usually with spaces for the entry of additional data.
Each hospital has the responsibility to develop medical record forms to fit its needs.
Thoughtful designs of the forms, which will become part of the medical record, will
provide a more readable, useful, and less bulky record. Medical record forms are
essential ingredients for smooth and efficient functioning of the hospital.
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Uses of a form
• To collect data
• Record data
• Stores data & retrieves
• It brings simplicity in M&E (monitoring & evaluation procedures
• Transit data

Mention forms found in any healthy facility ?

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Purpose of Medical Records Forms:
Medical record forms can accomplish several purposes:
• To communicate patient health care and to facilitate medical
education, medical research and legal requirements.
• They can reduce writing time.
• Well-designed forms are also easier to fill out.
• It will provide uniformity in paper work.

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• Principles of forms design
As it is estimated that 0.5% of total hospital expenditure is spent on medical
records forms, before a new form is developed or an existing form revised,
the following steps can be used to compile the necessary facts and to
determine what, if any, improvements should be made.

In the development of a new form, it is advisable to ponder on the

following
• Is the form really necessary?
• What benefits will be derived from introduction of the form into the
record?
• The purposes of the form will in turn determine the information to be
included on it. Unnecessary information must not be included.
• To have only a small supply of forms prepared for trial use, because
experience frequently indicates a need for revisions. Since cost is also a
factor in continually revising and printing small quantities of forms,
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• Photocopying might be the reproduction method of choice.
• Forms should be kept simple and the variety few in number to
provide flexibility and reduce record bulk.
• All discontinued forms should be removed from the stockroom or
supply area and destroyed.

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Basic principles to consider while
designing and developing forms
summary
a) When preparing to design a form one must :-
 Know the need for the form
 Purpose of the form within the construction that apply such as budget
 Type of paper available
 Ability of the printer and ability of the user

04/25/2025 683
b ) form layout
Refers to a number of issues and can be summarized as follows
• How information is displayed on the form
• How material presented is constancy with efficiency and economy
• Attractive presentation is an important secondary purpose
• The order in which data will be requested must also be considered
along in logical connections

04/25/2025 684
between entries ,columns boxes or highlighting ,will be used to size and
type of print
They need to allow adequate space for entries
A well designed form is appropriate to the work in which it is used
for ,permits easy entry ,conveys information ,clear instructions and it
efficient to use

04/25/2025 685
c) Questions to ask before designing a form include:-
• What's the general purpose of the form?
• Is the form really necessary ?
• What benefits will be derived from the introduction of a new form?
• What information is to be provided?
• What are the operations through which the form will pass for
example data entry and sorting
• How is the form going to filled?
• Where will be attached …side or top?
04/25/2025 686
• Who will be users of the form?
• Are there any other special features which need to be considered?
• If a signature is required or authentications
In summary the general principles to be considered when designing a
form
1. All forms in health setup should be of standard size ,they should be
readable , useful and allow for the standardization of information the
kind and size of type face ,margins ,ink paper clour , and weight should
be standard within the health system ,hospital , clinic or primary health
care
04/25/2025 687
2. All forms should have a standard format i.e. where
necessary include date ,name of the patient ,name of
the facility IP number OP number and the name of
attending doctor
3. The person who will be required to use the form
should understand the language used in the form
(sometimes conduct a training session )
4. Each form should have a descriptive title e.g nurse
bed side note ,clinical notes ,laboratory report etc
5. All forms should have simple printed instructions for the use to
ensure uniformity in the collection of information
6. Captions should clearly indicate the data to be entered for example
just a name is not sufficient ,usually on wants ‘’full names of a
patient”

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04/25/2025 690
Technical specialties in form designing

• It is more of measurements used in designing forms

to enhance standardization as indicated below
• printers allow 5mm before they start printing
• Allow 20mm margin of holes to be punched or the
form to be bound ,recommended margins
at the 8mm
other sides 5mm
expect filing margins 20mm
• Spacing for handwriting; in general hand written
character to be 1cm, however it is important to
remember that too much space seems to encourage
bad handwriting
Diagram showing measurements considered in for
designing
• The diagram above it is a piece of form in target to
illustrate standardization measurements
N/B pitch or font size should be 12 or 10
lines that are used in writing guides they should
have breakups or dotted for example
Name…………. ………… ……………….(dotted)
Name---------- --------- --------------(breakups)
• The use of check boxes it is also very good and saves time for example
male and female categories may be set up in a check box
arrangement as follows
• Tick in the box appropriately
Tick in the box appropriately
7. If one piece of data depends on another , put the
dependent data after the other in the order to be filled
in ,for example date of birth ,age …previous admission
date
8. The use of colour is effective but remember that
coloured ink will affecting photocopying ,microfilming
in different ways colour strips along outside edge are
most effective and help of identification of the form but
may be expensive
9. For form management each form should have a
reference or form numbered for identification and
ordering purpose
10. A form committee should be set up ,(a sub
committee, the health information management /health
professional should be a member of the forms
committee and strict control of production of health
records forms criteria should be established
Pretesting of medical/health records forms
• It is a way of measuring effectiveness of a given
new/revised form or data collection tool before
putting it in use
• A pretest is the use of a form (or observation form) on
a trial basis in a small pilot study to determine how
well the form /tool(or observation form) works.
should check the following:

• form Format
• Is it necessary?
• Is it too long?
• Does it satisfy objectives
• is it right for the method?
• Does it provide instruction?
• Accuracy in Data collected on Indicators
• Natural Flow
• Clarity and Ease of Understanding

Often a form which is badly implemented and

introduced to the user it is worse than keeping an old
form ,therefore evaluation and testing is important
part in form designing and development
• The medical/health record form it is pretested in two
ways before launched officially
primary & secondary and this is according to the
users or consumers of data /information collected by
the very form
primary testing :
testing a given form at the primary level it is
gauging its capability of being used by clients /patients
&medical professional staffs to better health care
secondary testing:
this is testing medical/health form capability in being
used by secondary users in health ,these are:-
administrative, management
research and teaching
• Designing Forms:
• A uniform size of paper should be used. Although standard size (8 -inch by
11-inch) paper is most commonly used, 8- -inch-by-5 -inch papers could be
used to reduce waste.
• A uniform binding edge should be maintained, either a top or side binding.
• A uniform margin that is based on the binding edge should be maintained.
Chart folders on the nursing units should accommodate the uniform
margins.
• For top binding, information on forms that are to be printed on both sides
should be correctly placed on both sides for proper assembly in the chart.
For side binding the two sides should be placed head-to-head.
• Line spaces should be assigned on the basis of whether the forms are to be
typewritten, handwritten, or both.
04/25/2025 703
• The quality and weight of paper should be selected according to the
expected life of the record, the amount of use it will receive, and
whether both sides are to be used. If both sides will be printed, the
paper must be heavy enough to prevent the ink from showing through.
• Colored forms should be selected carefully because problems can occur
in photocopying or microfilming colored sheets. White paper with color-
coded borders will prove more effective for quick identification of
different forms in the hard-copy record.
• When feasible, using a rubber stamp on an existing form can eliminate
the need for special forms that are not used regularly.

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• The printer can ordinarily give advice on the physical aspects of
printed forms the kind and size of types, margins, paper color and
weight, ink, and size of the form. Remember that standard size forms
are always less expensive, facilitate filing, preclude loss, which is often
the case with irregular paper sizes. Different colors of paper and ink
will affect photocopying and microfilming in different ways.

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Basic Medical Records Forms
A total of 15 basic forms have been recommended in this manual. The person using these forms
must adhere to the format and contents prescribed and try to complete them as
comprehensively as possible. Generally these forms are self explanatory but however, the
following instructions should be observed for effective maintenance of medical records.

Admission and discharge sheet

The treating physician should document a provisional diagnosis at the time of admission and at
the time of discharge should document final diagnoses, principle and associated secondary
diseases. If an operation was performed, the face sheet must contain the name of the
operation, the anesthesia given, the date and time of discharge and the condition of the patient
on discharge.

History and Physical Examination Form

A complete history should be written describing the chief complaint, the details of the present
illness, and the patients past medical history, social history, and family history. The physical
examination form should include all pertinent findings resulting from an assessment of all the
systems of the body. It should be recorded within 24 hours of the admission of the patient.

04/25/2025 706
Progress Notes Form
Progress notes should be written as frequently as required by the condition of the patient. Progress
notes should provide a reference to the condition of the patient on admission. A chronological record
of the patients progress should be documented daily or even every few hours during a critical illness.
Progress notes should conclude with a summary of the patients general condition.

Physicians Orders
Physicians orders must be complete, specific, legible, and exact. All orders must be written in ink,
signed, and dated. Oral orders and orders over telephone to house staff or nurses should be entered in
the record and countersigned by the physician within 24 hours.

Consultation Form
A written requisition filled in on the consultation form and indicating full details of the provisional
diagnosis, the objective of the consultation and all relevant clinical points on which an opinion is
desired constitutes the consultation form. The consultant after conducting his own examination then
records his findings and recommendations on the same form and signs it.

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Consent to Operations and Investigations
A general consent for diagnostic investigation and treatment must be
obtained at the time of admission as a routine procedure. Special
consent must be obtained for: surgical procedures, discharge against
medical advice, temporary leave of absence, photographic imaging,
release from responsibility for abortion, sterilization, organ donation,
organ transplantation, or autopsy.

Anesthesia Record
A complete anesthesia record indicates the preoperative medications
given, the date, time, and effect of these medications, the type and
amount of anesthetic administered, and the technique used.

04/25/2025 708
• Operation Report Form
The operation report form should include a preoperative diagnosis, the name of
operation and a full description of the findings, both normal and abnormal of all
organs explored and the procedures, ligatures, and sutures used in the operation, the
tissues removed or altered, the postoperative diagnosis, the patients condition at the
conclusion of the procedure. The material (tissue) removed and sent for
histopathological examination must be entered in the operation record. The
operation report should be written or dictated immediately after the operation if
possible, or at least within 24 hours.

Investigation request and report forms

All requests for diagnostic investigations of blood, urine, stool, etc must be recorded.
It should contain complete and correct patient identification data. The physician
requesting the investigation should indicate the name of the unit or clinic, the
provisional diagnosis, and type of test requested in the prescribed manner. This form
should contain the date and time requested and name of the physician requesting the
test
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Blood Transfusion Request form
The blood transfusion request form is retained as part of the patient
file. This record should contain the type of blood needed, the amount
of blood requested for the patient, the date and time the blood
transfusion was given, and any reaction noted.

E.C.G. Form
This form includes cuttings from standard leads traced and the
cardiologists impression. The original tracings are mounted on the
folder in the appropriate place.

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• Nurses Notes Form
Nurses notes encompass the observations, treatments, and services rendered by them to
the patient. The nurses notes must give a chronological picture of nursing care. Precise
nursing notes act as a means of communication among nursing personnel and physicians.
These notes should also include the date, time, and manner of patients admission
wheelchair, stretcher, ambulance, etc. Interim notes during hospitalization, and a note
written at the time of patients discharge including the date and time of discharge, any
advice given to the patient, the manner of patients discharge wheel chair, stretcher,
ambulance, etc must be recorded. If the patient dies, nursing notes must include the date
and time when life apparently ceased, and the name of the physician pronouncing the
patient dead. All notes must be signed and dated with the time also indicated.

TPR Chart
The temperature, pulse, and respirations chart allows for a four hourly or twelve hourly
entry of temperature, pulse and respirations. There is also space for the graphic recording
of blood pressure, as well as written comments on urine, stool, weight, diet, and any other
observations required. This chart should be initiated in the ward on the admission of the
patient and be continued until the time the patient is discharged.
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Fluid Balance chart
The fluid balance chart is the record of the cumulation of the hourly totals of fluid intake and
output. The nature and amount of fluid administered at different intervals should be
entered. The total intake and output for every eight hours is recorded. Both sides of this
form are generally used.

Discharge summary form

The discharge summary should be concise and contain only essential information, e.g. a brief
history and pertinent physical findings, significant diagnostic investigation findings, the
course of treatment including surgical procedures, final primary and secondary diagnoses,
patients status on discharge and any advice on discharge including the follow up
appointment. The discharge summary, as a routine practice, should be written prior to
discharge of the patient. However, in exceptional cases, this summary should be completed
within a week of the patients discharge. The treating physician and the unit head should sign
the discharge summary.
04/25/2025 712
Basic Principles of Form Design

Before one designs a form he should ask himself some questions as:-
• Is the form necessary?
• Is it the best form for its purpose?
• Is it easy to use?
• Are the instructions clear and unambiguous?
• Is there any unnecessary duplication with another form?
• How can be improved?
• Is it economical in terms of paper, printing and equipment required for its use?
• Can it be combined with any other form or forms, making it a multipurpose
document?
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There are basic principles of form design that should be in one’s mind before he
designs a form. These are:-
• Simplicity
• title
• Uniformity of size and style- in particular the “standard’ location of basic
information on the form is important.
• Clear instructions on the form
• Information requested should be minimized, by pre-printing and multiple
choice questions and answers.
• Layout should be eye catching (drawing attention) to special areas of interest)
and easy to read.
04/25/2025 714
Various medical forms used in health records departments are:-
• Case folder
• Should have the name of the hospital, the patient’s name, the hospital
number, and the information “highly confidential” enclosed printed on top of
the folder.
• In-Patient summary sheet
• Contains complete clinical summary of the individual’s stay and treatment
given during the stay.
• Letter of referral
• This is a letter given to a patient by a doctor referring to a hospital or health
institution for further management.
04/25/2025 715
• Prescription sheet
• This is used for recording treatment and drugs given by the medical staff.
• Mount sheet
• This is for mounting x- rays, laboratory and other reports. It should be A4 size and made
of heavy material.
• A4 medical mount Sheets forms are designed for the medical industry with Self Adhesive
strips for the purpose of collecting and organising test data for the individual patient

• History and continuation sheet

• The physician continues to write the history of the patient’s illness, the continued
treatment.
• Operation and anaesthetic record.
• There could be special operation forms used for different operation purposes. The name
of the surgeon and the anaesthetist should be recorded on this form.
04/25/2025 716
• Temperature, pulse, respiration and blood pressure charts
• These may be destroyed after the patient’s discharge; they are
transitory records unless one is marked for retention by the Medical
officer of Health. Fluid and Diabetic charts. These once could also be
destroyed unless otherwise stated.
• Nursing Record
• Should be included in the unit record.
• Notification of discharge and discharge letter: A letter of discharge
from a health institution should be given to him and his doctor notified
as well. In this letter the drugs prescribed to him should be recorded.
04/25/2025 717
Example of mount sheeet

04/25/2025 718
• Report forms
• The report forms should be gummed onto the mount sheets.
• Post-Mortem reports
• This should be the final document and should be filed in the unit file.
• Medical social workers’ report
• This should be inserted in the case folder.
.

04/25/2025 719
Pre-testing of medical forms
• Before the form is used it may be tested by the users to see whether
it has been appropriately been designed for the work it is going to be
used for

04/25/2025 720
Reproduction and costing of medical forms
• Very often “document reproduction’ is interpreted as “photocopying’.
This is only one method of document reproduction. When a machine
is hired photocopying becomes more expensive than when it is
bought

04/25/2025 721
• Photocopying
• Manufacturing are now supplying new models of photocopying machines at ever
increasing rates.
• Spirit and wax stencil reproduction
• This is a very special yet versatile method of reproduction. The actual medium of
reproduction is a sheet of paper with fine clay-like coating on the reverse side. This
sheet is placed over the sheet of hectograph paper, the clay-like coating on the first
sheet actually in contact with the carbon surface of the second sheet. These sheets
are typed with the information or handwritten. From the master sheet copies are
made clamping to a revolving drum moistened by a spirit solvent. As the machine and
the dampened carbon impression on the master sheet is reproduced in mirror form
on each sheet. From a well prepared master sheet 300 copies can be produced.
Mechanical documentation uses this method also.
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• Other means of document reproduction
• Other means of document reproduction are offset litho and typeset
plates. Offset litho depends on reproduction by either metal or paper
(plate). The plate is placed on the rotary press and copies are made.
Typeset duplication equipment is the same as most professional
printers still in use. It is expensive to install.

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Before equipment for document reproduction is
bought the following points should be considered:-

a) What kind of documents need to be reproduced?

b) Is the material likely to be done single or double sided?
c) How many copies are required?
d) At what speed are copies required?
e) What quality of copy is required?
f) What will be the capital and the running cost-(important to
consider)

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• CONTROL PROCEDURES FOR MEDICAL FORMS
• There should be strict control of all forms and records routine to
prevent wasteful duplication in inefficient procedures. Obsolete and
redundant forms should be removed from circulation and unsatisfactory
forms amended where necessary. There should not be duplication of
any forms. Forms used for ad hoc investigations should be withdrawn as
soon as investigation is over.
• The records officer should maintain a list of all the forms with a similar
function to be kept together. This will give the records officer an
opportunity periodically to examine, combine, simplify or eliminate the
forms if necessary.
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MODERN METHODS OF DEVELOPING AND
DESIGNING MEDICAL FORMS:-

• The current technological advancement especially in the field of ICT

has made it possible to design, develop and produce health records
and information forms (tools) for data capture electronically using
computers. There are also software’s that are specifically designed for
this purpose. IN computerised environment, where EMR /EHR or
HIMS/IMS is used, data tools are predesigned and available for use,
however, In a situation where one is needed to convert manual forms
into electronic format, the health Records and Information manager
should liaise with the software developer to ensure that all the data
sets are availed in the data forms.

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04/25/2025 727
Assignment
1. Discuss Hippocrates oath in relation to legal aspects in health records
management (10mks)
Discuss the following Acts related to Health
 Mental health act
 Government official secret Act
 Civil registration act
 Records disposal act
 Records archives act
 Criminal procedure code
 Radiation protection act
 Works man compensation act
 Public health act
Assignment