Hospital Medical Records Management Manual

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HOSPITAL
MEDICAL RECORDS
MANAGEMENT MANUAL
H108.45
H79m
DEPARTMENT OF HEALTH
REPUBLIC OF THE PHILIPPINES
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. HOSPITAL MEDICAL RECORDS
. MANAGEMENf MANUAL .
Department of Health
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Second Edition
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Republic of the Philippines
The second edition of the Hospital Medical
Records Management Manual is a publication of
the Health Finance Development Project of the
Department of Health.
This publication was made possible through
support provided by the U.S. Agency for
International Development (A.LD.), under the
I erms of Contract No. 492-0446-GOQ-Zl14-00. The
opinions expressed herein are those of the
author(s) and do not necessarily reflect the views
of the U.S. Agency for International Development.
TABLE OF CONTENTS
IlL MANPOWER/PERSONNEL
IV. THE NUMBERING SYSTEM
The Unit Number
Assignment of the Unit Number
Assembly of the Medical Record
1
1
3
3
5
6
6
8
17
18
19
19
20
20
20
20
23
29
30
30
31
Page No,
MEDICAL RECORD POLICIES
AND STANDARDS
Standards
'Record Completion
Release ofinformation
Policies for. Doctors .
on Release of Information
Policies for Nurses
on the Release ofinformation
Other People Concerned
Symbols and Abbreviations
PHYSICAL FACILITIES AND EQUIPMENT
Filing Cabinets
Arrangement and Distances of Cabinets
Working Tables
Proper Lighting
Proper Ventilation
Proper Temperature
Aesthetic Consideration
II.
AUTHORIZATION
MESSAGE
FOREWORD
PREFACE
ACKNOWLEDGMENTS
LIST OF FORMS
LISTOF ABBREVIATIONS,
INTRODUCTION
Philosophy of the Medical Record Service
Objectives of the Medical Record Service
The Medical Record Service
Functions of the Medical Record Service
The Medical Record
Uses of the Medical Record
The Patient
Health Care Provider
Hospital
Government and the DOH
Organization and Administration
Organizational Chart
Chapter
I.
43
43
43
44
44
44
44
45
45
45
46

48
48
48
49
49
50
51
51
51
52
53
53
53
54
38
39
39
39
40
41
41
41
41
41
42
42
42
42
43
Page No.
31
31
31
33
33
34
36
38
Types of Formats
Source-oriented Medical Record
Problem-oriented Medical Record
Integrated Medical Record
Analysis of the Medical Record
General Documentation Guidelines
Quantitative and Qualitative Analysis Procedures
Coding and Indexing of Disease and Operation
Reporting and Coding Diagnosis, .
Operations and Procedures
Simple Coding Procedures
Method of Reporting Final Diagnosis
Principal Diagnosis
Symptoms
Hospitalization for Investigation
Injuries/Poisonings
Abbreviations
Qualifying Expressions
Procedureand Operation Coding
Statistics
Needs for Statistics
Administrative Level
Clinical Level
Outside Agencies
Formulas Used in the Computation
of Hospital Indicators
Measure of Hospital Utilization
Daily Census
Percentage of Occupancy
Average Length of Stay
Measure of Hospital Performance
Death Rate
Post OP Death Rate
Anesthesia Death Rate
Maternal Death Rate
Infection Rate
Consultation Rate
Autopsy Rate
Caesarean Rate
Perinatal Statistics
Fetal Death Rate
Neonatal Death
Filing of Medical Record
Terminal Digit Filing
Procedure in Filing Patient Index Card
NewAdmissions
Re-admissions
Rules in Alphabetical Filing
Loose Sheets
Sorting of Loose Sheets
Locating the Record
Filing Loose Sheet
Page No.
77
76
75
79
93
94
95
%
Retrieval of Medical Record
Indexes 54
Master Patient Index 54
Disease Index 55
Operation Index 56
Physician's Index 57
Registers 57
Admissions 58
Discharge 58
Birth :f)
:f)
Out-patient 60
Essential Requisites for Easy Retrieval . 60
Retrieval Procedure 61
Request for Medical Record for Studies
and Research 61
Retention and Disposal of Medical Record 62
Procedure in the Disposal of Medical Record 63
Disposal Schedule of Medical Record Service 64
V MEDICAL RECORD OF DISCHARGE PATIENT 65
Processing Medical Record of NewPatients 65
Processing Medical Record of Re-admitted Patients 66
VI. MEDICO-LEGAL ASPECTS 67
Ownership of the Medical Record 67
Accessibilityand Confidentiality 67
Medical Information of Mental Patients 68
Requests for Information from the Media 68
Records Subpoenaed by Court 69
Consent 70
Handling Telephone Inquiries 72
Dealing with People 73
VII. QUALITYASSURANCE FOR
THE MEDICAL RECORD SERVICE
The Medical Record Service and
the Quality Assurance Program
Steps in Developing a Quality Assurance
Program for the MRS
Expected Outcomes of the
Quality Assurance Program
VIII. MEDICAL RECORD FORMS
Medical Record Forms
Ten Basic Forms
Supplemental Forms
Concept of "SET" and "BLOCK"
APPENDICES
Listing of Common Causes of Mortality and Morbidity
with the Corresponding ICD Code Numbers
Forms
GLOSSARY
REFERENCES
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OFFICE OFTHE SECRETARY
SANLAZAROCOMPOUNO
RIZAL AVENUE,STA CRUZ
MANILA, PHIUPPINES
TEL NO. 711-60-80
AUTHORIZATION
January 6, 1994
In accordance with the authority vested on the Secretary of Health, I hereby declare the policies,
regulations, and instructions in this Hospital Medical Records Management Manual shall govern the
organization, management, and activities of th Medical Records Service in government hospitals until
modified by order of the Department of Health or by law.
Republic: of thePhilippine.
DEPARTMENTOFHEALTH
OFFICE FOR HEALTH FACILITIES,
STANDARDS AND REGULATION
Sen Lazaro Cmpd., Sta. Cruz Manila
Tel No. 71195-72, FaxNo. 711-95-09
MESSAGE
January 6, 1994
The Hospital Operations and Management Service of the Department of Health has been
tasked to develop operations manuals specifically for DOH hospitals that may be of use to other
public and private hospitals.
These manuals would serve as standard reference materials for DOH hospitals to aid
administrators and practitioners in following standard operating procedures in the management and
practice of the different hospital services or units. Likewise, it may also serve as a reference guide for
other public and private hospitals.
These manuals provide guidelines in the performance of duties and responsibilities of hospital
personnel as well as outline steps necessary in the effective and efficient operation of each unit or
service. The procedures in these manuals will assist them In the process necessary to operate an
effective and efficient hospital.
This is an attempt to develop standards and achieve uniformity of procedures in different
hospitals.

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JUAN It 4NAGAS, M.D.
Undersec tary on Health
Facilities, Standards
and Regulations
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OFFICE OFTHE SECRETARY
FOREWORD
SANLAZARO COMPOUND
RlZAl AVENUE, STA. CAUZ
MANIlA, PHIUPPINES
TEL NO. 711-60-80
Aware of the need to upgrade the Medical Records Serviceof Department of Health hospitals,
the Bureau of Medical Services in coordination with the World Health Organization produced the
first document on medical record management of the country, the "Manual of Medical Record Proce-
dures" in 1980.
The need to revise and update the manual in response to the everchanging thrust of the
Department of Health, as a result of change in administration and the changes brought about by
man's quest for more knowledge and information in the medical field and the very rapid changes in
modern technology necessitate revision and updating of this manual.
Appropriate and timely revision of the said manual is needed to guide health care facilities in
its effectiveand efficient management operation and control. Effective management of the hospital
systemrequires not only financial data but also quantitative and qualitative information on the scope
of every activity the institution is engaged in.
Patient care is the major activity in a hospital where a medical record needs to be created and
maintained for each patient treated by the facility. Knowledge of, and competence in the effectiveand
efficient management of the medical record is necessary in the attainment of quality patient care.
Although the Medical Record's Service is not directly involved in patient care, information
contained in the data base maintained by this vital service component serves the members of the
medical and allied staff in effectively managing their patients. The extracted data from the medical
record mainly helps health planners in assessing the effectiveness and adequacy of health care deliv-
ered. Furthermore, it is also used by the hospital management in planning, decision-making and
management control.
,
Successin the implementation of this manual rest heavily on the support of health managers/
administrators and the full cooperation of the people concerned. It is also believed that to best utilize
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the statistical data/information from the medical records, the medical record needs to be properly
explained to those responsible for creating and maintaining the records. They are as follows:
* Doctors
* Nurses
* Medical Record Service Staff
* Members of Allied Medical Staff
I believe that as the user moves on to the manual itself he/she will want to look forward to
finding and following the author's reasoning that this Medical Records Management Manual prepares
us to better understand the need to standardize medical record policies, systems, and procedures. I
am fully convinced that the outcome of the full implementation is worth an effort and believe that
what will emerge will be a more effective and efficient Medical Record Service to enhance attainment
of quality patient care, the ultimate objective of establishing a hospital.
MA. R ~ GALON, MD., MHA
Director III
Hospital Operations and
Management Service
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PREFACE
The patient's medical record is believed to be the primary repository of
information concerning patient health care. This explains the fact why
there is an increasing demand for its legitimate use by health professionals
and policy makers.
Nowadays, most people working in this line of profession are exerting
more effort and spending more resources to ensure the creation and
maintenance of quality medical records for quality statistical data.
It is in this context that the Department of Health (DOH) through the
initiative of the Hospital Operations and Management Service (HOMS),
one of the four (4) offices under the Office for Hospitals and Facilities
Services (OHFS), recognizes the need to upgrade the capability of the Medical
Records Service (MRS) of government health care facilities, Coupled with
the previously cited idea is the different ways of how medical records are
handled and managed by the different hospitals. Although there is an
internationally accepted medical record standard, the local medical record
practitioners seem not aware of its existence. .
Even with observed shortcomings, the medical record practitioners have
been slowin recognizing the need to improve their profession because most
of them lack the necessary theoretical background.
In the formulation/development of standards and ideal systems and
procedures, the inputs of the medical record practitioners who attended the
seminar-workshops on medical record management conducted by HOMS
served as invaluable data.
This manual is designed for four purposes: first, to answer the need for
a basic information-generating material in this field; second, to serve as a
guide in the day-to-day operation of the MRS; third, for use as a "reference
material in the health facility; and fourth, as a management aid for health
managers/administrators. In short, this manual serves a wide range of
users, namely:
* doctors
* nurses
* allied health professionals
* health managers/administrators
* medical record staff
* researchers
The content of this manual is divided into chapters arranged according
to the envisioned workflow of the MRS. As such, the medical record
practitioners shall be reminded of the series of procedures to follow ill
processing the medical record. Evident is the inconsistent use of disease
and operation code numbers based on the International Classification of
Diseases (lCD) and the International Classification of Proceduresin Medicine
the very reasonwhy a listing of the commonly encountered diagnosis
with the corresponding ICD code numbers was incorporated. Moreover,
the problem of nonstandard forms as observed shall be properly addressed
by the inclusion of the different suggested medical record forms, both the
basic and the supplemental.
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This manual advocates the prompt development of standards and pro-
cedures in the MRS of government health care facilities, It is believed that
there is a need to standardize policies, systems and procedures to improve
the care of both individual patients and the entire population, and concur-
rently, to reduce resource wastage{cost-effectiveness} through the continu-
ous improvement of quality care.
Success in the implementation of this manual depends on the coopera-
tion and coordination of the people involved in the creation, utilization,
and maintenance of medical records, and perhaps some sacrifice and com-
promise as well.
Finally, I am deeply indebted to all individuals and institutions for their
support during the tedious preparation of this manual.
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EMMANUEL M. LAGUSTAN
Medical Record Adviser
Hospital Operations and
Management Service
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ACKNOWLEDGMENTS
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Recognitionand thanks aregiven to DR. MAMARGARITA M. GALON,
Director III, Hospital Operations and Management Service, for the
inspiration, support, and encouragement given throughout the preparation
of this manual.
To all the medical record practitioners who attended the Seminar-
Workshop on Medical Record Management (1988-89), my utmost gratitude
for unselfishly sharing their knowledge and experience which served as
invaluable inputs in the formulation of policies, standards and ideal systems
and procedures.
Recognition is also given to those people who made possible my study
grant in Sydney, Australia, whereI enhanced professional expertisein Medical
Record Administration (Health Information Management) which greatly
influenced the content of this comprehensive communication tool.
Gratitude is extended to MS. ALMAQ SORRA for the clerical help
done, MS. FENELlAMYLENEM. HAMO for some data entry suggestions,
and to MR. CHITO NULOD for binding and reproduction assistance.
Finally, I would like to extend special thanks to friends who in their
own way, extended assistance in the preparation of the manuscript.
LIST OF FORMS
Hospital Daily Census Report
Monthly Analysis of Hospital Service
Consent Forms
Consent to Involvement in Clinical Trials (Therapeutic)
Consent of Recipient to Operation,
Transplantation, or Grafting of Tissue
Informed Consent for Surgery, Anesthesia,
or Other Procedures
Discharge Against Medical Advise
Consent to Release of Patient Medical Information
Consent to Remove Organ for Transplant
(Living Donor)
Voluntary Sterilization Consent Form
Therapeutic Abortion
Refusal to Permit Blood Transfusion
Consent to the Administration of
Electro-convulsive Therapy
Consent to Autopsy
Refusal to Consent Autopsy
Notification to Physician of Request for Access
Request for Access to Medical Records
Certificate of Confinement
Medical Certificate
Disposition of Cadaver
Medical Record Forms (Basic)
Admission-Discharge Record
History
Physical Examination
Doctor's Order/Nurses Compliance Sheet
Laboratory Report/Result
Graphic Chart (Centigrade)
Graphic Chart (Fahrenheit)
Progress Notes
Nurses Notes and Treatment Record
Discharge Summary
Other Supplemental Forms
Medication Record
Parenteral Fluid Sheet
Progress Notes - Rehabilitation Medicine
Diabetic Record Sheet
Anti-coagulant Therapy Record
Vital Signs Record
Pulmonary Function Test
Pulmonary Laboratory Blood Gas Analysis
Intravenous Fluid Sheet
Fluid Intake and Output Chart
Operation Block
Pre-Anesthetic Assessment
Operation and Anesthesia Record
Anesthesia Record
Operative Record
Operating Room Record
Recovery Room Record
Surgical Recovery Room Record
Tissue/Biopsy Report
Delivery Block
Prenatal Record
Labor Record
Summary of Parturation
Newborn Record
ECG/EKG Block
Electrocardiogram Report
Electrocardiogram Tracing
UST OF ABBREVIATIONS
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AO
AP
COA
COH
DAMA
DO
DOA
DOS
GSIS
HOMS -
ICD
ICPM
MPI
MRN
MRP
MRS
NBI
OP
PE
PC
PMCC
P.N.P.
POMR
QAP
RA
RMAO
SOAP
5.5.5.
TPR
WHO
Administrative Officer
Attending Physician
Commission on Audit
Chief of Hospital
Discharge Against Medical Advice
Department Order
Dead on Arrival
Doctor's Order Sheet
Government Service Insurance System
Hospital Operations and Management Service
International Classification of Diseases
International Classification of Procedures in Medicine
Master Patient Index
Medical Record Number
Medical Record Practitioner
Medical Records Service
National Bureau of Investigation
Operation
Physical Examination
Philippine Constabulary
Philippine Medical Care Commission
Philippine National Police
Problem Oriented Medical Record
.Quality Assurance Program
Republic Act
Record Management and Archives Office
Subjective, Objective, Assessment Plan
Social Security System
Temperature, Pulse and Respiratory
World Health Organization
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INTRODUCTION
Medical records are important clinically for the immediate diagnosis,
treatment, and welfare of the patient. Likewise, these are vital to the hospital
for the evaluation of its services, and in the improvement of its effectiveness
through lowered mortality, morbidity, and better patient care.
The medical record is a written tool of communication used by the
members of the medical and allied medical staff in the efficient and effective
management of patients. It servesas source material for analysis, evaluation,
education, research, and studies of the quality of medical care rendered.
Most importantly, the medical record is also considered as the
fundamental building block in the development of health information
systems. In this regard, a good quality medical record needs to be created
and maintained for each patient. To attain such, prompt recording of all
findings and observations need to be done by those concerned. An old
medical record management adage, "The quality of information that can be
retrieved is totally dependent on the quality of records created/maintained,"
should always be in the mind of people involved in the creation/maintenance
of medical records.
PHILOSOPHY OF 1HE MFDICAL RECDRDS SERVICE
The MRS is tasked to enhance patient care through the use of data
contained in the medical records; either individually or collectively.
OBJECTIVES:
* To improve the accessibility of medical records;
* To create quality medical records;
* Toencourage greater utilizationof hospital statistics generated in the MRS;
* To implement staff development;
* To increase quality assurance programs not only in the MRS, but in
the hospital where relevant; and
* To participate in research and studies which the facility, the members
of the medical and allied staff, and other authorized researchers are
engaged in.
1HE MEDICAL RECORDS SERVICE
The general function of the MRS is to provide an organized system of
measuring quality patient care and to ensure that sufficient data is written
in sequence of events to justify the diagnosis, warrant the treatment and
end results.
This department is responsible for the processing, analyzing,
maintenance, and safekeeping of all medical records created/maintained in
the hospital in the course of giving medical care to patients.
The medical record is a vital tool in the health team's provision of
patient care. As the service component responsible for the custody and
maintenance of these records, the MRS plays a key role in patient care
through the generation of data from the record and other related sources.
For the MRS to function as an indispensable support service in the
delivery of quality patient care, it must perform the following functions:
1. Maintain all medical records in accordance with the principles and
practices of efficient and effective medical record management.
2. Maintain comprehensive indexes (e.g., Master Patient Index, Disease
and Operation Index, Physician's) and registers (e.g., Admission and
Discharge, Operation, Delivery room (DR), Out-patient Department
(OPD) and Emergency Room (ER), and Birth and Death Registers).
These are important records for patient identification and also
considered as indispensable retrieval tools.
3. Review records for completeness and accuracy, coding of diseases,
operations, and special therapies according to approved nomenclature
and classification.
4. Maintain a comprehensive and up-to-date record for hospital patients
to ensure that all relevant information on each patient is collected,
placed in the record, and filed accordingly.
5. Collate and compile data and produce statistical reports required by
the DOH and respective hospital management.
6. Provide records of patient data for use in approved research programs.
7. Respond to all subpoenas and medico-legal cases directed to the hospital
8. Maintain and safeguard the confidentiality of the medical record.
9. Provide records, upon request, for patient's attendance to OPD and
the wards.
10. Ensure that all reports and results are promptly and accurately filed in
the corresponding patient record.
11. Participate in research activities and studies conducted by doctors
and authorized researchers by providing needed data and other
information.
12. Prepare periodic reports on morbidity, birth and death, utilization of
hospital beds, rate of bed occupancy, out-patient service rendered, as
well as compilation ofstatistical reports on type ofsurgery performed,
types of diseases treated or cases receiving special form of therapy,
and other related data. .
lHE MEDICAL RECORD
A medical record is a compilation of pertinent facts of a patient's life
history including past and present illness(es) and treatment(s) entered by
health professionals contributing to that patient's care.
The medical record has a variety of uses by a wide variety of personnel.
Within guidelines of confidentiality and patient interest, the scope of the
medical record as a resource material is limited only by the quality of the
content and the needs of the prospective users.
USES OF THE MEDICAL RECORD
The major functions of the medical record are listed below according to
the main user groups.
THE PATIENT
As a clinical history of the patient's treatment at the hospital.
As documentary support or evidence of confinement, diagnosis, and
. treatment received as a hospital patient.
HEALTHCARE PROVIDERS
As a reliable reference of the clinical history of the patient.
As a tool/instrument to enable the various health care provider to
assess their role in the patient's total care.
As a record of the treatment ordered and given for the patient's
continued care and treatment.
As data source for research, both retrospective and concurrent.
As an educational tool in the training of and feedback to the staff,
and for assessment of clinical procedures.
HOSPITALS
As a basis for statistical data used in assessingquality and effectiveness
of patient care; past performance; and workload for the projection of
demands, and planning and allocation ofhospital resources.
To form patient profiles to determine market demands for more
effective provision of service.
GOVERNMENT AND THE DEPARTMENT OF HEALTH
For the provision of statistical data to aid resource allocation on an
area, state and national basis.
To provide morbidity data to project health trends within the
population for the assessment within and against, national and
international health patterns.
ORGANIZATION AND ADMINISTRATION
The MRS is organized and administered to facilitate the provision of
medical records which provide pertinent information on illness, diagnosis,
and treatment being given in the health care facility and allow for more
effective and efficient patient care.
This service shall function under the direction, supervision, and control
ofa Medical RecordOfficer, who is directlyresponsible to the Administrative
Officer (AO).
CRITERIA FOR AN EFFECTNE MRS ORGANIZATION

1. Written objective reflecting the role of the facility and guiding the
activities of the service are readily available.
2. The objectives are reviewed and revised as necessary.
3. Anorganizational chart shows clearly established lines of responsibility,
authority and communication with the service and between other
services.
4. Written and dated job descriptions are given to each staff member
upon appointment which should at least specify the following:
Qualifications required for the position
Lines of authority
Accountability, functions and responsibilities
Frequency and type of appraisal
Terms and conditions of the service
5. The organizational chart and job descriptions are reviewed at least
every five (5) years and revised w h e n e v e ~
Staffing patterns are altered
There is a restructuring of the MRS
The role of the facility changes
Services are added or deleted
6. A Medical Record Committee or its equivalent, at secondary and
tertiary level hospitals, shall assist the Medical Record Supervisor in:
a. Determining standards and policies for the service.
b. Reviewing the different medical record forms and to come up with
relevant oneswhen needed.
c. Recommending action to be taken when problems arise in relation to
medicalrecords and the MRS.
d. Ensuring that the clinical information recorded is adequate to
maintain quality medical records, this is done by regularly
analyzing the content of the medical records.
MEDICAL RECORD SERVICE
ORGANIZATIONAL CHART
Fundamental to effective management is the development of an
organizational chart which shows the lines of authority and responsibility.
The organizational chart likewise indicates the channelof communication
and protocol. -
In the formulation of the organizational chart, one should think of the
institutional objective as well as the principles of effective organization.
The following are suggested organizational charts for the different
categories of government hospitals (primary, secondary and tertiary).
CHIEF OF HOSPITAL
ADMINISTRATIVE OFFICER
MEDICALRECORD OFFICERI
MEDICAL RECORD CLERK
PRIMARY HOSPITAL (25 Beds)
. MEDICAL RECORD SERVICE
CHIEF OF HOSPITAL
ADMINISTRATIVE OFFICER
MEDICAL RECORD OFFICER III
SECONDARY LEVEL (100 Beds)
CHIEF OF HOSPITAL
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ADMINISTRATIVE. OFFICER I
MEDICAL RECORD
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MEDICALRECORD
OFFICER IV COMMITTEE
MEDICAL RECORD MEDICAL RECORD,
OFFICER II OFFICER II
MEDICAL MEDICAL MEDICAL
RECORD RECORD RECORD
OFFICER I OFFICERI OFFICERI
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STATISTIC TRANS-
IA"'A''ISIS
CLERK IcRIPTION CLERK
CLERK
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MEDICO- FILE/ .
LEGAL
r o ~ i r t T T
CLERK CLERK
TERTIARY LEVEL (200 Beds)
The Medical Record Committee should function as a separate committee
or it could also function as the Forms Committee should management
decide. But for a tertiary teaching, training, and research hospital, it would
be ideal to createboth committees for more effective control and supervision.
MEDICAL RECORD POllCIFS
AND STANDARDS
Policies and standards are important in medical record management to
achieve a more-uniform practice for effective medical records management.
Standards and policies suggest two things which are consensus and guides.
Policies and standards are crucial, but their application may not fit
every possible situation encountered, most especiallywhere material resource
is lacking. Hence, modifications which may mean deviations from standards
shall be warranted. Modification should not deviate from the standard to "
the extent of adversely affecting the level of performance and quality of
patient care.
The patient's record should contain complete and accurate set of
information to facilitate effective patient care and its evaluation.
1. STANDARDS
An accurate record is maintained to facilitate optimal patient care
and allow for evaluation of the care provided.
1.1 The record is sufficiently detailed to enable:
a) The patient to receive continuing care
b) Effective communication within the health team
c) The Attending Physician to have available information required
for the consultation
d) Other medical practitioners and health personnel to assume
the patient care
e) Concurrent or retrospective evaluation of patient care
1.2 Entries into the records are made only by duly authorized persons of
the facility and are dated and signed, containing designation.
1.3 All entries, including alterations, must be legible.
1.4 Only abbreviations and symbols approved by the Medical Record
Committee are to be used.
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HospitalMedical Records Management Manual
1.5 If possible, original copies of all reports made by medical, nursing,
and allied health professionals are filed in the record.
1.6 Each record should at least contain the following data:
a) A unique medical record number or reference
b) Patient's full name
c) Address
d) Date of birth
e) Sex
f) Person to notify in case of an emergency
1.7 An "ALERr' notation, for the conditions such as allergic responses
and drug reactions, is prominently displayed on the face sheet of the
record.
1.8 The record contains a written admission diagnosis by the medical
practitioner.
1.9 The record contains a patient's history, pertinent to the condition
being treated, including relevant details of:
a) Present and past medical history
b) Family history
c) Social considerations
11) A sufficiently detailed report of a relevant physical examination (PE),
performed by a medical practitioner, should be included for the
purpose of admission.
111 Evidence that the patient has given informed consent is available.
112 Drug orders are written in the record by the medical staff.
ill Therapeutic orders and orders for special diagnostic test are noted in
the record.
ill There is evidence in the medical record that patient care plans were
made.
115 Progress notes, observations, and consultation reports are written by
medical, nursing, and allied health staff to record all significant events
such as alterations in the patient's condition and responses to
treatment.
U, The front sheet is completed at the time ofdischarge or as soon as the
relevant information is available. It contains all relevant diagnoses
and procedures using the terminology of a current revision of the
International Classification of Diseases (ICD).
lI7 A discharge summary for each patient should be completed within 48
hours of patient's discharge, with a copy remaining- in the medical
record. The discharge summary should at least include the following:
a) Discharge diagnosis
b) Procedures performed
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Hospital Medical Records Management Manual

c) Follow-up arrangements
d) Therapeutic orders
e) Patient instructions (where necessary)
When a patient is transferred to another facility, a discharge
summary should accompany him/her.
118 When an autopsy is performed, a provisional diagnosis is noted in
the medical recordwithin 72hours and the medical record is completed
within 15 days following the death. A copy of the autopsy report is
filed in the medical record.
2. RECORD COMPLETION
2.1 The medical record should be completed within 48 hours after the
discharge of the patient.
2.2 History and PEshould be completedwithin 24 hours after admission.
2.3 An incomplete chart, not completed within 15 days after patient's
discharge, shall be considered a delinquent chart.
2.4 The attending physician has the final and major responsibility for
completeness and accuracy of the data entry in the record. He is also
encouraged to raise the level of qualityofthe individual health record
and sustain a high level of recording.
2.5 Residents and interns may be delegated the duty of recording medical
information as history, PE, and discharge summaries. their entries
have to be reviewed, corrected, and countersigned by the attending
physician.
2.6 The Medical Record Practitioner assists the attending physician in
reviewing records for completeness by checking for omissions and
discrepancies and helps ensure that medical records comply with set
policies and standards.
3. REI EASE OF INFORMATION
Release of health information is a very sensitiveissue in several respects.
The confidentiality of the medical record should always be the concern of
people involved in the release of health information.
3.1 General Policies
3.1.1 The hospital shall safeguard all information contained in the
health record against loss, destruction, or unauthorized use.
3.1.2 All information in the health record shall be treated as
confidential and shall be disclosed only to authorized
individuals.
3.1.3 It shall be the policy of all government hospitals not to use
the medical record in any waywhich will jeopardize the interest
of the patient. But the hospital may use the record to defend
itself against any accusations.
3

3.1.4 The release of information is delegated to the supervisor of
the MRS.. But in cases where the medical record practitioner
encounters problems regarding the release of information, the
matter should be referred first to the Administrative Officer
(AO), or to the Chief-of Hospital (COH) for proper solution.
3.1.5 No release of information with clinical value shall be done
without written consent from the patient himself.
3.1.6 The medical record is the physical property of the hospital.
However, since the information written on the record is the
patient's personal history, he/she also has a right to the said
record.
In cases where litigation is likely to happen and is intended
against the hospital or any other personnel of the health care
facility, the Medical Director/COH may refuse or deny access
to the record even with the patient's written authorization,
until the court declares otherwise.
3.1. 7 Request for medical certificate or clinical information when
the patient is still confined shall be referred to the attending
physician.
Should the AP decide to release the certificate while
the patient is still confined, a Certificate of
Confinement shall be issued.
No certificate of confinement shall be issued where
the patient concerned is already discharged, instead, a
medical certificate shall be issued.
No medical certificate shall be released without the
signature of the Chief of Professional Staff and the
hospital seal.
On the other hand, no medico-legal certificate shall
be released without the signature of the Director/COH
and the hospital seal.
3.1.8 Information of no clinical value can be disclosed by the staff
of the health care facility. However, hospital policy should
first be consulted and utmost care taken into consideration
before the release of non-clinical information. Such
information includes the following:
Name
Address
Attending physician
Name of relative with patient during admission
Admission and discharge dates
3.1.9 Where the patient is a minor, consent of either one of the
parents or the legal guardian shah be secured before any
information of clinical significance is released.
3. LIOThe medical record shall not be taken out of the hospital
premises except on court orders.
Those authorized to do research and studies shall use
the records inside the MRS.
4
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3.1.11 Incomplete medical records shall be referred to the attending
physician before entertaining any request to access and review
the medical record.
3.1.12 In cases where the patient is in critical condition and does
not have someone with him/her to give consent, the medical
record practitioner shall release, information only after
consultation with the Director/COH.
3.1.13Verbal request for clinical information shall be discouraged
in favor of written requests.
3.1.14 The staff of the Medical Social Service (MSS) shall have access
to the medical records for purposes of establishing patient
classification. They may also reveal the social content of the
record to organized and reputable social agencies who have a
legitimate reason for inquiry.
3.1.15 Information may be released to other health care facilities,
upon written request, that the patient is now under care.
3.1.16 Hospital management may, at its discretion, permit the use of
medical records for research and studies, only stressing that
no information which will directly identify the patient shall
be published.
4. POllCIES FOR DOCTOR'S RELEASE
OF INFORMATION
..
4.1 Doctors and members of the allied health profession may reviewrecords
of patients presently under their care.
4.2 Doctorswho aremembersofthe medical staff but not membersofthe team
assigned to the patient shallbearmed witha writtenauthorization signed by
the patient before they aregiven access to the record.
4.3 The privilege against disclosure belongs to the patient and not the
treating physician, therefore, the patient has the right to claim for it
or waive it. In which case, the doctor's approval is technically not
necessary. But it would be a good practice to notify the doctor prior
to release of any information, as a sign of courtesy.
4.4 The hospital management may permit use of the medical record for
research and studies, the medical record being the physical property
of the hospital. The hospital may also withhold access to the medical
record until a subpoena is issued.
4.5 Outside doctors intending to do some research/studies in a particular
hospital shall seek the written approval of the management before
they are given access to the medical record.
4.6 Insurance company doctors shall need proper written authorization
from the patient, or a duly accomplished insurance waiver, before
they are given access to medical record.
4.7 Company physicians who are presently caring for a patient shall be
given medical information only upon presentation ofa formal request
addressed to the MRS. '
4.8 Consultants shall have access to records of patients referred to them.
5
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4.9 Resident doctors and the rest of the medical staff may request the
MRS for records 'needed for their research and studies. But in cases
where there is suspicion that their wish to access will jeopardize the
right of the patient, doctor-and the institution, access shall be denied
by the medical record staff.
4.D It shall be the responsibility of the attending physician to inform his
patient about his medical condition.
5. POliCIES FOR NURSES
ON RELEASE OF INFORMATION
5.1 Nurses may borrow/sign-out old records per doctors instruction for
ward use.
5.2 In the ward, student nurses shall have access to the records of patients
assigned to them.
5.3 Private nurses shall only be allowed to reviewrecords of those patients
assigned to them.
5.4 All staff nurses may be given access to medical records not assigned
to them for purposes of conferences and case presentations. After the
conference, the record shall be returned to the MRS.
5.5 Ward nurses may review all records for purposes of compliance to
requirements before forwarding said records to the MRS.
5.6 Ward nurses should always see to it that charts are in a secure place
away from the patients or the patient's relative.
6. 'OTHER PEOPLE CONCERNED
6.1 The lawyer representing a patient shall only be given access after
presenting a written authorization duly signed by the patient.
6.2 An insurance verifier shall be required a waiver before being given
access to the record/information about a patient. The original copy
of the waiver shall also be countersigned' and dated by the insurance
verifier and shall be filed with the record.
* Insurance verifiers representing the Social Security System(SSS)
and the Government Service Insurance System (GSIS) shall
review medical records for compensation purposes per
Warranty No. 10of the Philippine Medical Care Commission
(PMCC).
6.3 Researchers from other medical institutions could gain access to medical
records onlyaftercomplyingwithrequirements setbytheinstitution concerned.
6.4 Patient's relative making inquiries about their patient shall be referred
to the attending physician.
6
HospitalMedical RecordsManagement Manual
6.5 Law enforcement agents (Philippine National Police(PNP), Philippine
Constabulary (PC), National Bureau ofInvestigation (NBI) and others)
shall need a written request duly signed by the Chief/Director of their
respective agency before being given access to the record. Should it be
possible however, to get the written consent of the patient, a written
request from their agency is no longer necessary.
6.6 Patients also have a right to their record. But to prevent
misinterpretation of medical information which may leadto litigation,
patient may not be allowed access to his own record. However, his
physical and mental condition shall be explained only bythe attending
physician. .'
6.7 The. health care facility may, in some situations, release health
information evenwithout the written authorization. Such situations
are as follows:
6.7.1 Court Order
A hospital or other health care facility must release health
information in response to court orders.
6.7.2 AdministrativeAgency Order
A provider must release health information when there is an
adjudicative order from an administrative agency authorized
y l ~ .
6.7.3 Subpoena
In a court proceeding, a party or an administrative agency
may issue a subpoena, subpoena duces tecum, or notice to
appear coveringhealth information held by a health provider.
Where the subpoena is valid, the hospital must disclose the
health information.
6.7.4 ArbitrationOrder
Either an arbitrator or an arbitration panel may issue an order
authorizing the discovery of health information in an
arbitration proceeding.
6.7.5 Search Warrant
Agovernment lawenforcement agency which has been issued
a search warrant is entitled to receive any health information
covered by the warrant.
6.7.6 Medical Research
Health information may be disclosed to public agencies,
clinical investigators, health care research organizations or
accredited education or health care institutions for purposes
of bonafide research. But before the medical information is
released, the medical record staff should take reasonable steps
to ensure that theresearch is legitimate, and proper safeguards
in the release of information are instituted.
7
SYMBOLS AND ABBREVIATIONS
The following is a list of internationally accepted symbols and
abbreviations used in the health record service/department
Symbols and abbreviations not listed below but accepted for use by
your respectiveinstitution shall be inserted here upon the recommendation
of the hospital's Medical Record Committee.
abd.
a.e.
AF
AFB
AIDS
AMA
ambo
AMI
AODM
ARF
ARDS
AS
ASHD
AVR
AP & Lateral
A&P
ax.
BAM
BBA
BCC
BID
BKA
BM
BMR
BNE
BNS
BOM
BP
BPH
BRM
8
A
abdomen
before meals (p.e..- after meals)
atrial fibrillation
acid fast bacilli
acquired immune deficiency syndrome
against medical advice;
ambulatory; walking
anterior myocardial infarction
adult onset.diabetes mellitus
acute renal failure
adult respiratory distress syndrome
aortic stenosis
arteriosclerotic heart disease
aortic valve replacement
anterior posterior
auscultation and percussion (listening with
stethoscope and tapping with fingers)
axillary (armpit)
!!
bilateral augmentation mammoplasty
born before admission
basal cell carcinoma
twice daily; tid . three times daily;
qid - four times daily
below the knee amputation
bowel movement
basal metabolism rates
bladder neck elevation
bladder neck suspension
bilateral otitis media
blood pressure
benign prostatic hypertrophy
or benign prostatic hyperplasia
bilateral reduction mammoplasty
..
BRP bathroom privileges
BS bilateral salpingectomy
BSO bilateral salpingo-oophorectomy
BUN blood urea, nitrogen (kidney function test)
Bx. biopsy
C
CA carcinoma
CABG coronary artery bypass graft
CAD coronary artery disease
CAT computerized axial tomography
CBC complete blood count
CBD common bile duct
GD. communicable disease
CHF congestive heart failure
CI coronary insufficiency
CMD chronic mental deficiency
CNS central nervous system
COPD chronic obstructive pulmonary disease
CRF chronic renal failure
CRHD chronic rheumatic heart disease
CVA cerebro vascular accident (stroke)
CVD cerebrovascular disease
ex cervix
CXR chest x-ray
C&S culture and sensitivity
D
DAMA discharge against medical advice
DC discontinue
DIC
disseminated intravascular coagulation (of newborn)
dist. distilled
DJD degenerative joint disease
DLE disseminated lupus erythematosus
DM diabetes mellitus
DNS deviated nasal septum
Dr. doctor
DT delirium tremens
DU duodenal ulcer
.
DUB dysfunctionaFGterine bleeding
/
DVT . deep-vein-thrombosis
"
Dx. diagnosis
..
9
f
10
EAC
ECE
ECG orEKG
ECT
EEG
EENT
EPA
ER
ESR
EST
ETA
EUA
F
FB
FBS
FH
FI'
FL
fld.
FO
FS
FTGRAFT
FT
PUO
Fx.
GA
GE
GIT
GM
GN
GNC
GSW
gtts,
GU
GUT
GYN

external auditory canal
extra capsular extraction
electrocardiogram or electrocardiography
electro-convulsive therapy
electroencephalogram
eye, ear, nose, and throat
erect posterior anterior (chest x-ray)
emergency room
erythrocyte sedimentation rate
electric shock therapy
elongation of tendon achilles
examination under anesthetic
E
fahrenheit (temperature scale)
foreign body
fasting blood sugar
family history
for investigation
false labor
fluid
for observation
frozen section
full thickness graft
full term
fever of unknown origin
fracture
G
general anesthetic
gastroenteritis
gastro-intestinal tract .
grams
glomerulonephritis
general nursing care
gun shot wound
drops
gastric ulcer
genito-urinary tract
gynecology
LHF left heart failure
LIH left inguinal hernia
LLL left lower lobe
LLQ. left lower quadrant
LMP last menstrual period
LN lymph node
LP lumbar puncture
LSCS lower segment cesarean section
LSO left salpingo-oophorectomy
LSV ligation and stripping of varicose veins
LUSCS lower uterine segment cesarean section
LUQ left upper quadrant
LVF left ventricular failure
LVI left ventricular tachycardia
M
M male
med. medical (or medication)
mg milligram
MI myocardial infarction
mid. middle
min. minute
MS multiple sclerosis
MVA motor vehicle accident
MVR mitral valve replacement
N
NEe not elsewhere classified
ned no evidence of disease
neg negative
NG naso-gastric
NIDDM non insulin dependent diabetes mellitus
NOF neck of femur
NOS not otherwise specified
NPO nothing by mouth (nothing per os)
NSA no significant abnormality
N&V nausea and vomiting
0
OA osteoarthritis
00 right eye
OBS organic brain syndrome
12
OE
OM
OPD
OPS
OR
OS
OT
OV
P
PA
PAT
p.c.
PDA
PE or PX
Ped. or Pedia.
PGS
PH
PI
PID
PIE
PMB
PMD
PMH
PND
PNP
pre-op
pm
p.o.
POP
POP (OB)
post-op
PPH
PR
p.r.n.
PROG
pt.
PT
otitis externa
otitis media
out-patient department
out-patient service
operating room
left eye
occupational therapy
both eyes
f
pulse
. . .
pernicious anemia
paroxysmal atrial tachycardia
after meals (a.c. before meals)
patent ductus arteriosus
physical examination
pediatrics
post gastrectomy syndrome
past history, personal history
present illness
pelvic inflammatory disease
pulmonary interstitial emphysema
post menopausal bleeding
progressive muscular dystrophy
past medical history
post nasal drip
pneumoperitoneum (injection of air into
the peritoneal cavity, used as TBtreatment)
pre operation
as needed
per os or by mouth
plaster of paris
persistent occipita presentation
post operative
post partum hemorrhage
per rectum
when necessary
prognosis
patient
physical therapy
13
PUO pyrexia of unknown origin
PV per vagina
PVD peripheral vascular disease
Q.
q every
q.d. every day
q.h. every hour
q.i.d. four times daily
qod every other day
R
R respiration
RA rheumatoid arthritis
RBBB right bundle branch block
RBC red blood cell
RDS respiratory distress syndrome
reg regular
RF rheumatic fever
RH+ rhesus factor positive
RH- rhesus factor negative
RHD rheumatic heart disease
RHF right heart failure
RLL right lower lobe
RLQ
right lower quadrant
RML right middle lobe
RMR right medial rectus (eye muscle)
ROS removal of sutures
RPC retained products of conception
RSO right salpingo-oophorectomy
RTA road traffic accident
RTI respiratory tract infection
RUL right upper lobe
RUQ right upper quadrant
RX prescription - treatment prescribed
S
SBE sub-acute bacterial endocarditis
SCC squamous cell carcinoma
SH social history
SID ) sudden infant death syndrome
SIDS)
SLE systemic lupus erythematosus
14
.... .'
SOB short of breath
SOBE short of breath' on exertion
SOL space occupying lesion
SPP suprapubic prostatectomy
Spp & P
smith-peterson pin and plate
s.s. soapsuds
SS one half
SSS sick sinus syndrome
SSG split skin graft
staph. staphylococcus (germ)
stat at once
STD sexually transmitted disease
STS serologic test for syphilis
SVD spontaneous vaginal delivery
SVT supra-ventricular tachycardia
I
T temperature
T4
thyroxin
TAH total abdominal hysterectomy
Tab. tablet
TB tuberculosis
tbsp. tablespoon
TBR tuberculin reactor
TCI transient cerebral ischaemia
THR total hip replacement
TIA transient ischemic attack
tid three times daily
1's tonsillectomy
T's & Ns tonsillectomy and adenoidectomy
TMC threatened miscarriage
TO telephone order
TOP termination of pregnancy
tsp. teaspoon
TSS toxic shock syndrome
TUR transurethral resection (usually bladder)
TURP transurethral resection of prostate
U
UA urinalysis
UD under-developed
UDT undescended testicle
UN under-nourished
15
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Hospital Medical RecordsManagement Manual
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URI
URTI
Un-
VBI
VDH
VDRL
VEB
VF
VIa
VPS
VSD
VT
W
WEe
WD
'WG
WN
wt.
upper respiratory infection
upper respiratory tract infection
urinary tract infection
v
vertebro-basilar insufficiency
valvular disease of heart
slide test-venereal diagnostic research laboratory slide test
(flocculation test for venereal disease)
ventricular ectopic beats
ventricular fibrillation
by way of
ventriculo-peritoneal shunt
ventricular septal defect
ventricular tachycardia
. .
vancose vems
W
white blood count
well-developed
wolfe graft
well-nourished
weight
PHYSICAL FACILITIES
AND EQUIPMENT
Ideally, the medical record room shall be big enough to accommodate
active, inactive, and in-eoming medical records.
The Medical Records Service (MRS) room should be properly ventilated
not only for the protection of the records but also for health reasons on the
part of the staff.
Volatile and flammable liquids must not be placed inside the record
room, and a "NO SMOKING" sign must be posted inside the MRS.
In the event that the space allocated for the MRS is not enough to
accommodate all records in the file, a plan to transfer inactive records to the
inactive file should be considered. This will decongest the filing area, giving
way to incoming records, and will make the retrieval process easier.
Spacerequirement can be calculated by the use of the following formula:
(Annual discharges) + (New OPD) x
(Retention period)
STORAGE SPACEREQUIRED;
(Records per meter)
Example:
Data Given:
Annual discharges
NewAdmissions
Re-admissions .
Annual New.OPD
registration
Retention period
No. of records/ meter ;
23,000
6,720
16,800
3,000
25 years (Phil. Law: R.A. 4226/
M.C. 77 s. 1981)
50 records
17
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23,000 + 3,000 x 25
STORAGE SPACE REQUIRED =------
50
650,000
50
= 13,000 METERS OF SHELVING
Note:lO%of the computed required storage space should be added to the
computed value to account for the projected increase in number of
patient/year.
.. 13,000 + 1,300 = 14,300 meters of shelving
To calculate for the number of meters of shelving for each terminal the
formula is:
No. of meters
required for
each section
Meters of shelving required
No. of sections in file
14,300
100
= 143 meters/primary section
FILING CABINETS
FILING CABINETS FOR MEDICAL RECORDS
There are two types of filing cabinets used in the medical record service:
the open and the closed shelves filing cabinets. Of the two, the. open shelf
type is more popularly used because of its advantages (e.g., space saving,
ease of filing and retrieval). It also has its disadvantages (e.g., accumulation
of dust, problem of security), but these are outweighed by its advantages.
High stocking cabinets can be used to maximize the storage capacity of
the filing area. However, provisionfor "kick stools" or "safety pulpit ladders"
should be considered for the convenience and safety of the file and retrieval clerks.
(Diagram)
n
/I

q
..J:
f;;
'/ 'l=1L6
11./
\

7
rTL'
r" I
-
8 L
IMTtiICCf
,.---....... t 1----..
..
CABINETS FOR INDEXES
Cabinets for indexes come in standard sizes and these are often times
made of steel.
For the master patient index the cabinet must be able to accommodate
3"x 5"index cards. Whereas, for the disease.operation, and physician indexes
a cabinet for 5" x 8" cards should be used.
ARRANGEMENT AND DISTANCES OF CABINETS
The physical arrangement of the cabinets has a direct effect on the
efficiencyof the filing and retrieval processes. The cabinets should be arranged
for minimum walking. It is also important to remember that the direction
of the expansion of the files should always be from left to right.
A back to back arrangement of filing cabinets should, also be highly
considered because this saves space.
(Diagram)
t
;
IDfAL ARRA_1I7 OF PIING rA8IItCTS
(O"'n .M1tIft>
WORKING TABLES
The physical arrangement of employee's tables should be in accordance
with workflow. Effonsshould be made to lessen travel time of paper within
the department, to improve output and increase efficiency, by placing
employeesIn their right places. The arrangement of employees should also
be aimed at improving communication and coordination among etnployees.
Employees in constant contact with patients/clients should be positioned
near the main entrance. Employees doing technical jobs like coding and
statisticians should be placed in an area free from distraction and noise, as
much as possible near the Medical RrecoredSupervisor for better supervision
and control.
Transcriptionists/typists who produce noise in the performance of their
tasks need to be placed a little further awayfrom other employees. As much
as possible their area should be acoustically treated to lessen distraction.
The medical recordadministrator's (supervisor's) room should be situated
strategically in a place where he can monitor his subordinates' for more
effective supervision and control. -
Distances between tables of employees should be maintained at 1-1.5
meters to facilitate easy movement, a space of 5.57m per employee must be
maintained.
19
PROPER LIGHTING
Research shows that proper lighting directlyaffectsemployeeperformance
to a certain degree.
The level of lighting requirement (in foot candle) varies from activity to
activity. A 100 foot candle light is required for the following activities:
regular office work, reading or transcribing, handwriting, active filing, index
referencing, and mail sorting. Age level has also direct influence on light
requirement. Older people tend to work efficiently and effectively in well-
lighted working areas. Younger people, on the other hand, tend to prefer not
too highly illuminated working areas.
The light in the storage and filing area should be situated in between
cabinets and should run parallel with the arrangement of the cabinets. It is
to maximize the illuminating capacity of the light.
(Diagram)
PROPERVENTILATION
Another important thing to consider in planning for a good medical
record layout is good ventilation. It is not only considered for health reasons
but also for the protection of the records. Filing and storage areas with very
humid conditions also have bad effectson the medical records. Papers absorb
moisture to some extent and this could affect the quality of the record.
PROPER TEMPERATURE
It is a fact that temperature affects the performance of a person. The
temperature should not be too warm nor too cold. Temperature which is
just right and conducive for working should be provided.
AESTHETIC CONSIDERATION
Research shows that the color of the working area has some effect on
employees' performance. So the medical record administrator/supervisor
needs to consider light and color combinations to enhance the effectiveness
of his subordinates.
20
The MRS should have enough working area for its staff. Likewise, a
completion area, where doctors and researchers can do their work, should
be provided. This shall include the following:
* Tables
* Chairs
* Pigeon hole for incomplete charts
Aside from a good record room facility, the MRS must also be provided
with good and dependable office supplies for efficient performance. The
basic equipment and supplies needed are the following:
* Working tables and chairs
* Typewriters
* Coding tools
* Telephone service
* Dry seal
* Numbering machine
* Stapler
* Index card sorter
* Pencil sharpener
* Sufficient filing cabinets for records, indexes, and registers.
* Photocopying machine
Ifit is within financial possibility, the MRS should try to acquire modern
equipment because of the many benefits it offers. Some of these equipment
are the following:
* Computers
* Dictating equipment
* Transcribing machine
* Micrographics
--- ----.--
Department of
11111111III
D327
H108.45 H79m
- .....=-=....=.----
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II,
MANPOWER/PERSONNEL
The Medical Records Service (MRS) is considered as a storage area of
patient information, or simply the information center of the hospital. For
the service to be efficient and more responsive to the needs and demands of
its clientele, it must havethe necessary number of personnel/staff in relation
to its bed capacity and the volume of work to be done. '
The number of staff required by the MRS is determined by the type of
the hospital. A research hospital which needs a more comprehensive and
sophisticated records-keepingsystem will naturally require a greater number
of staff compared to an institution which is not engaged in research and
teaching. Furthermore, one staffmember will be required for every 20 beds
of the hospital.
The classification of personnel in the MRS of a hospital will depend on
any of the following:
The classification of the DirectorjCOH
Category and bed capacity of the hospital
Listed here are the qualification requirements and job descriptions
for the different classifications of personnel.
POSITION TITLE:
MEDICAL RECORD OFFICER IY, MEDICAL RECORD
SUPERVISOR. CHIEF MEDICAL RECORD SERVICE
MINIMUM QUALIFICATION STANDARDS:
Must have a college degree with units in Anatomy and
Physiology; , ,
Must have first grade civil service eligibility;
Must have thorough knowledge of medical terminologies;
Must have attended a training course in medical record management;
Must have at least five (5) years of in the record
, '
department of a reputable hospitalj institution; and
Must have assumed supervisory or related posirion..
23
JOB DESCRIPTION:
Shall act as the head of the service/department;
Shall attend court proceedings and represent the hospital in court
cases involving subpoena of medical/clinical records; .
Shall represent the department to top management;
Shall exercise direct administrative supervision and control over all
subordinates in the department;
Shall establish policies and procedures for the content, control, storage,
and retrieval of records;
Shall ensure the maintenance of the patient's right to privacy and
confidentiality;
Shall organize workflow throughout the service;
Shall meet and dicuss with the administration of other departments
within the hospital, issues related to the MRS;
Shall supervise the evaluation and quality control of specified areas
within the MRS;
Shall serveon appropriate committees and attend meetings of relevance
to the MRS;
Shall answer by correspondence or by telephone, inquiries regarding
information recorded in the patients' charts;
Shall plan staff, space, and equipment of the department;
Shall assist the medical staff in research projects;
Shall keep abreast of current medical record practices; and
Shall perform other related functions as may be assigned by the
immediate supervisor
POSITION TITLE:
MEDICAL RECORD OFFICER III
MINIMUM QYALIFICATION STANDARDS:
Must have a college degree with units in Anatomy and Physiology;
Must have thorough knowledge of medical terminologies;
Must haveattended a training coursein medical record management; and
Must have at least four (4) years of experience in the MRS ofa reputable
hospital one years of which must have been of supervisory capacity.
JOB DESCRIPTION:
Shall be a department head or assistant to the Chief of-the MRS;
Shall, as the head of the MRS in a small hospital, plan, organize, and
control all activities in the section;
Shall, as an assistant to the head of the MRS in a large hospital,
manage the section in the absence of the section chief; and
Shall perform other related functions as may be required by the
immediate supervisor.
24
..
..
POSITION TITLE
MEDICAL RECORD OFFICER II
MINIMUM,QUALIFICATION STANDARDS:
. Must have first grade civil service eligibility;
Must have completed the medical record training;
Must haveat least three (3) years of medical record work in a reputable
hospital; and
Must have thorough knowledge of medical terminologies.
lOB DESCRIPTION:
Shall act as the department head in smaller hospitals oras an assistant
Chief in a big hospital; .
Shall, as head of the MRS in a small hospital, plan, organize, and
control the activities
Shall, as an assistant to the head of the MRS in a large hospital, act as
the unit head in the absence of the section chief; and
POSITION TITLE:
MEDICAL RECORD OFFICER I
MINIMUM OUALIFICATIONSTANDARDS:
Must have completed the medical record training;
Must have at least two (2) years of medical record work in a reputable
hospital; and
Must have thorough knowledge of medical terminologies.
lOB DESCRIPTION:
Shall act as the department head in small hospitals (e.g. community
hospitals) or as an assistant to the head/supervisor of the MRS in a
bigger hospital; .
Shall, as head of the MRS in a small hospital, plan, organize, and
control the activities
Shall, as an assistant to the head of the MRS in a large hospital, act as
the unit head in the absence of the section chief; and ';
immediate supervisor.. :.
.;.'
25'
POSITION TITLE:
CODER
MINIMUM OUALIFICATION STANDARDS:
Must havecoUege level education with units in Anatomy and Physiology;
Must have 'thorough knowledge of medical terminologies;
Must have at least one (1) year of experience as disease and operation
coder in a reputable hospital; ,
Must have second grade civil service eligibility; and
Must be well acquainted with the different coding tools.
lOBDESCRIPTION:
Shall work directly under the supervision of the chief of the MRS;
Shall analyze specific portions of the medical record and assign code
numbers to diseases and operations based on the accepted classification
system;
Shall update and maintain the disease and operation index file;
Shall file disease and operation indexes numerically by disease and
operation codes; and
Shall perform' other related functions as may be assigned by the
POSITION TITLE:
MEDICAL TRANSCRIPTIONIST
MINIMUM QJ,JALIFICATION STANDARDS:
Must have at least two (2) years of college education;
Must have second grade civil service eligibility;
Must have thorough knowledge of medical terminologies; and
Must be proficient in operating the transcription machine/typewriter
lOB DESCRIPTION:
Shall transcribe operating room reports and other dictated/recorded
information; ,
Shall type/encode letters and reports, birth and death certificates; and
immediate supervisor
POSITION TITLE:
MEDICAL RECORD CLERK
MINIMUM OUALIFICATION STANDARDS:
Must have at least two"(2) years of college education;
Must have second grade civil service eligibility;
Must have at least worked in the MRSof a hospitalor other related office;
Must have thorough knowledge of medical terminologies; and
Must be proficient in typing
26
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lOB DESCRIPTION:
Shall arrange and assemble the medical records of discharged patients
of the hospital;
Shall collect and compile data from medical records for statistical
and other related reports;
Shall review medical records to ensure that required reports and
signatures' have been included (quantitative and qualitative analysis);
Shall prepare the daily census report;
Shall maintain surveillance ofincomplete medical records and prepare
reports of delinquent doctors;
Shall process birth and death certificates; and
POSITION TITLE:
FILE/RETRIEVAL CLERK
MINIMUMOUALIFICATION STANDARDS:
Must have at least two (2) years of college education;
Must have civil service eligibility;
Must have a background in the process of filing and retrieval; and
Must have attended a training course in medical record management.
lOB DESCRIPTION:
Shall file records and indexesaccording to the established and approved
system;
Shall incorporate loose reports/sheets to respective charts;
Shall maintain a follow-up system for borrowed/needed charts;
Shall maintain and update the patient master index;
Shall retrieve requested records for follow up, research, and studies;
Shall maintain the proper filing of the medical records and periodically
check files for misfiled records; and
Shall perform other related functions. as may be assigned by the
27
TABLE ON
MANPOWER REQUIREMENTS
(Based on theresult of thevalidation workshop, RTIM, April 2fr27, 1991).
POSITION TITLE
BED CAPACITY
10-15
25 50 100 200 300
MEDICAL RECORD
- - - - - 1
OFFICER IV
MEDICAL RECORD
- - (1) 1 1
OFFICER III
-
MEDICAL RECORD
(1) 1 1 2
OFFICER II
- -
MEDICAL RECORD
1 1 1 1 1 2
OFFICER I
MEDICAL RECORD
1 2 3 5 5 -
CLERK
TOTAL 1 2 3 5 8 11
28
J
'lliE NUMBERING SYSTEM
The numbering system employed has a direct influence on the filing
system. Upon admission, the patient number should be assigned. The serial,
unit, and the serial-unit numberingsystems areusedin numberingmedicalrecords.
SERIAL NUMBERING
Under this method, the patient receives a new number on every
in-patient admission or out-patient visit to the hospital or clinic. That
is, the patient is treated as a new patient each time with a new number,
new index card and new record, filed totally independent from the
previous records.
Serial numbering is not used extensively today and is only useful
in small hospitals with a low rate of readmission.
UNITNUMBERING
Under this method, the patient is assigned a unique identification
number on his first contact with the hospital, whether it is for an
admission, emergency room attendance or out-patient clinic visit.
The same number is kept and used on all subsequent visits, whether
as an in-patient, out-patient, or emergency patient. Having one number
assigned per patient and only one Master Patient Index (MPI) card
makes for easier access to the patient's medical record.
This number is normally related to one single record containing
all the needed information on the patient. This data can originate
from different clinics or wards, at different time periods: If no unit
record is possible, the unit numbering system 'can be used to link
medical records that are physically located in different places.
SERIAL UNITNUMBERING
Under this method, a number is given for every admission but all
previous records brought forward to the patient's latest admission. A
tracer is left where the previous records were pulled out to indicate
where the records are now filed.
29
lHE UNIT NUMBER
A patient who is admitted to or attends an out-patient clinic is issued a
six-digit identifying number. This is called the patient's unit number, hospital
number, or Medical Record Number (MRN). The same number is used no
matter what ward or clinic the patient visits, or how often; and regardless of
the time lapses between visits.
It is handy to think of the MRN as three sets of two- digits. These are
referred to as the primary, secondary, and tertiary numbers.
Example ofa Unit Number:
20 76 95
Tertiary . Secondary Primary
ASSIGNMENT OF TIlE UNIT NUMBER
The collection of patient data and the assignment of a medical record
number should be the first step in every admission or visit to a hospital or
health center and it is usually done at the admitting office. This facilitates
the retrieval of properly identified documents.
Twoways where numbers can be assigned are:
(a) CENTRALIZED
The responsibility for number allocation is retained or assigned
in one place only, usually the admitting office or the Medical Record
Service..
If a patient arrives at the registration area, the area concerned is
contacted for the unit number.
(b) DECENTRALIZED
Predetermined blocks of numbers are often issued to the patient'
admitting area. This is usually done by the hundreds, depending on
the projected number of patients for the day. In this process, care
should be taken as chances of duplication are greater, compared to
when only one area is in charge of assigning patient numbers.
Six-digit numbers are used ranging from 00-00-00 to The
very first record received by the MRS shall be numbered,
the second record, "00-00'01"; and so on, until the first hundredth
record, which shall be numbered "00-00-99", is reached. The record
after this shall be numbered the next, then
followed by and so on, until it reaches ."00-01-99".
Number the records seriallyand add the necessarydigit to complete
the required six digits: An MRS maintaining a centralized records-
keeping system must keep numbering patients regardless of whether .
the record is for in-patient or for out-patient. Whereas, the MRS with
a decentralized records-keeping system should maintain a separate
number for the in-patient and the out-patient record. .
The last record that you receive in any given day plus one (I) shall
represent the total number ofpatients the hospital has served. Meaning
if the last number assigned is 00-20-99, then the hospital has served as
total of 2,100 patients. .
30
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ASSEMBLYOF lHEMEDICAL RECORD
After the patient is discharged from the facility, the medical record is
, forwarded to the MRS by the members of the Nursing Service.
. After receiving the medical records, the MRS performs some procedures
essential to the' filing and storage. process.
There are three types of format used, in assembling the medical record.
These are as follows: '
1. Source-oriented medical record
2. Problem-oriented medical record
3. Integrated medical record
The format which best fits the institution's need and that which is
approved by management should be adapted by the MRS.
1. SOURCE-ORIENTED MEDICAL RECORD
This is the conventional format of arranging the medical record. The
patient record is organized in sections according to the patient care
department which provides care and data. The record is arranged in reverse
chronological order for the convenience of the doctors in the ward. Upon
the patient's discharge, the MRS re-arranges the record based on the
approved sequence.
ADVANTAGES:
* It is easy to determine the assessment, treatment and observations a
particular department has provided.
* Most health professionals are familiar with this conventional or
traditional way of arranging the medical record.
DISADVANTAGES:
*
*
Prompt determination of all the patient's problems is riot possible.
Determiningallthe treatments provided to the patient would bedifficult
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2. PROBLEM-ORIENTED MEDICAL R E ~ O R (POMR)
This is the most logical format of arranging the medical record and it
is computer-based. The four basic components of this format.are as follows:
a. The data base, which includes the following information:
* Chief complaints
* Present illness '
* Patient's profile
* 'Past history and reviewof the system
* Physical examinations
* Base-line laboratory plan
31
b. The problem list is a mere listing of all the problems which need
medical management. Problems are numbered and tided from the
most to the least severe complaint of the patient. The list may include
anything that requires management from past and present social,
economic, and demographic problems. It mayalsocontain a statement
of a symptom, an abnormal finding, a physiological finding, or a
specific diagnosis. Addition or changes are made in the list as new
problems are identified and active problems resolved.
c. The initial plan describes the steps to be taken in order to learn more
about the patient's condition, the treatment to be applied, and ways
to educate the patient about his physical condition.
Specificplans for each problemaredelineated and fall under three
categories:
More information for diagnosis and management
Therapy
Patient education
. Plans are numbered corresponding to the problems which theyaddress.
d. The progress notes are follow-ups for each problem. Each note is
preceded by the number and title of the appropriate problemand may
include all of the following elements:
Subjective (symptomatic)
Objective (measurable, observable)
ASsessment (interpretation or impression of the current condition)
Plan statements
The acronym for this process is SOAP, and the writing of progress
notes in the POMR format is often referred to as "SOAPING".
Emphasis is on unresolved problems. A slightly different way to
describe the patient's progress, other than the narrative method
mentioned, is through the use of flow sheets. Flow sheets are
recommended in situations where several factors are being monitored
or when the patient's condition is changing rapidly. The discharge
summary and transfer note are also included in the progress note
category. These should address all the numbered problems on the
patient's list. It may be necessary for the physician to write an overall
summary and use flow sheets to clarify the patient's progress. It is
recommended that certain forms (e.g., physician's orders, consultant
reports, and nurses' notes) be in the problem-oriented style, with
reference to titled and numbered problems. Other data in .the record
maybe in theconventional format, suchaslaboratory andoperative reports.
ADVANTAGES: -
32
Physician is required to consider the patient's problems in itstotal context.

The recordclearly indicates the goals and methods of the physician in
treating the patient.
Medical education is facilitated by the documentation of logical and
thorough processes done by the attending physician.
Quality assurance process is easier because the data is logically arranged.
DISADVANTAGES:
The format usually requires additional training for the medical and
professional staff.
To be effective in a facility, a significant number of physicians must
be convinced of the system's worth or at least must be willing to try it.
3. INTEGRATED MEDICAL RECORD

In the integrated format, the information is organized in strict reverse
chronological order, with the most current entries at the beginning of the
record. The forms from various sources are intermingled, thus, history and
physical examination may be followedby a progress note, a nurse's note, an
x-rayreport, a consultation, and so on. The forms for each episode of care
are organized in separate sections of the record.
ADVANTAGES:
All information on a particular episode of care is in a single file, thus,
providing a clear picture of the patient's illness and response to
treatment.
A patient's progress can be determined promptly because the current
notes of all disciplines are together in one file.
The number of specialized forms is reduced.
The team concept of health care is encouraged.
DISADVANTAGES:
It is difficult to compare similar information over a series of admissions

because the reports are not in the same section as that of the record.
Only one person can document at a time.
It may be difficult to identify the professions/ position of the
individuals making the entries unless notes are always followed by the
title of the recorder.
Physicians often feel their documentation requires some manner of
indication (e.g., highlighting) to differentiate it from that of other
professionals caring for the patient.
, '
ANALYSis OF TIlE MEDICAL RECORD
Since chart analysis ensures maintenance of quality medical records
through proper documentation, it is one of the most important functions
of the MRS.
The medical record reflects the quality of care rendered to patients. As
such, at any point in time during admission, the record should accurately
and clearlydocument the care provided.
Since the major concern of most doctors and nurses is the care of the
patient and not the documentation of data, most medical records forwarded
to the MRS are lacking in some important requirements.
33
The MRS is responsible in helping the members of the medical and
paramedical staff inspotting deficiencies to correct errors and omissions.
Analysis is the process of evaluating and/or checking medical records to
ensure completeness, accuracy, and adequacy of documentation. Both
quantitative and qualitative analysis should be performed on the medical
record.
The general documentation guidelines used to ensure quality
documentation and hence, produce quality medical records are as follows:
I. There must be a medical record for each patient confined/treated in
the health care facility.
2. Documentation in the medical record should reflect the patient's
physical condition, and the orders and care provided from admission
to discharge.
3. Documentation should reflect observation and should be objective
and non-judgmental.
4. There should be a standard format for medical record documentation
which should include demographic and assessment data.
5. A unit record should be maintained for;each patient. This shall include
all admissions to the facility, discharge summaries and quality
documentation by the physician and other inter-disciplinary team
. members who participated in the care of the patient.
6. All documentations must be legible and written in ink or typewritten.
Z Any person making an entry on the record must date and sign his
entry or properly authenticate the entry made.
8. Documentation of the medical record should be completed within 48
hours upon patient discharge. History and Physical Examination (PE)
should be completed within 24 hours upon admission of the patient.
9. Every institution should develop an ongoing reviewof medical records
to assure quality documentation. This could be one of the major
duties of the Medical Record Committee.
10. It should be the policy of every health care facility not to allow the
use of abbreviations in writing the diagnosis. But for symbols which
might be written by the authorized person, an explanatory legend
shall be approved by the said institution.
11. Short forms likelaboratory and other results should be securelyfastened
to the record to prevent loss.
12. The medical record is a legal document, so no form may be detached
once it is filed with the chart. Furthermore, there should be no erasures
of any sort. To correct an error:
* Draw one single line through the information to be corrected or change.
* Write th word "ERROR" and affix initial and date; and lastly,
* Write the correct entry near the information to be corrected.
34
*
*
...
13. In cases where the patient wants some data corrected especiallyon the
sociological data, it shall not be done in the original entry, but should
.appear as an amendment only.
14. The medical record shall contain all original copies of examination
results, operations and other required forms.
For the medical record of a patient to be complete, it must include the
following forms, properly accomplished, signed, and dated:
I. Patient's Data Sheet: Includes patient's personal data like name, address,
patient number, and other social data.
2. Admitting and final diagnosis, aswellas a description ofany operation
and procedures performed.
3. History sheet: contains chief complaint, personal and family history
(past and present).
* Past history records the previous operations and illness of the
patient, and particularly those that might be related to the
present illness.
Social history presents fum about the patient's life and habits
that might affect his condition. If, for example, he has an
allergic condition, it may be important to know his diet, the
pets he own, the plants thar grow around his house, and the
materials he comes in contact with at work and at home.
Family history records the diseases which members of the
patient's immediate family haveor have had.. Most important
are those that might directly affect the patient either through
heredity or contact. . .
4. Physical examination sheet: contains all pertinent (positive and
negative) findings and impressions.
5. Physician's order: contains all of the doctor's order.
6. Laboratory Report sheet: contains results of all diagnostic, laboratory,
and x-ray procedures.
7. Consultation reports: adequately record the consultant's findings on
physical examination of the patient, as well as his opinion and
recommendations.
8. Progress notes sheet: includes doctors' positive and negative
observations and comments. It gives a chronological picture of the
clinical condition of a patient.
9. Discharge summary: summarizes the significant findings and events
occurring during the patient's hospitalization, final diagnosis,
operation (if performed), complications (if any), condition on
discharge, recommendations and arrangements for future care (OPD
follow-up treatment), and classification of injury (if it is a medico-
legal case).
10. Anesthesia report sheet (if performed)
35
r -
11. Recordofoperation: records and authenticates a pre-operative diagnosis
before surgery. The-record should then contain a report of all findings,
a description of the technique used, a description of any "tissue"
removed, and a post-operative diagnosis.
12. Nurses' notes (recorded in a brief narrative style): contain the notes of
all the nurses who tended the patient. These include their observations
of the patient, the treatment given, the response to treatment, and
any unusual occurrences. The first page shall always contain a record
of checking the patient in the unit, recording his physical condition
at the time, and the listing of personal belongings he has brought
. with him. The admission portion is completed when the patient is
first admitted to a particular nursing unit; while the discharge portion
is completed when the patient is discharged from the unit. The
discharge notes should include basic information such as the time of
discharge, the condition upon discharge, and person with the patient.
This also includes the medication/ instructions and the advice for
follow-up consultations.
13. Birth and death certificates, if either of these events occurred.
14. Other sheets: medication and treatment, vital sign sheets. graphic
chart sheet, etc.
QUAUTATIVEANDQUANIITATIVE
ANALYSIS PRcx:::EDURFS
After recording and assembly, the chart undergoes the process ofanalysis.
The analysis clerk should perform the following:
I. Check basic forms required by the case:
a. Check all forms explicitly ordered.
b. The analysis clerk needs to read the doctor's order and
countercheck it with the nurses' notes to confirm whether or
not the order was carried out.
c. When the nurses' notes say so, the analysis clerk should see to
it that the result of such an order is attached
d. The analysis clerk also checks on the explicitly ordered forms.
(Forms included in a block)
2. The analysis clerk should check all information required by the case;
a. Every page should contain the name and hospital number of
the patient.
b. Every form should be properly filled.
c. Accounts of all tests, treatments, and observations should be
reflected in the record.
3. The analysis ~ l r should check all necessary authentications;
a. Check whether or not all reports of treatment, medication,
examination or evaluation of the patient are dated and signed
by the person who made the report.
b. Similarly, check if all orders were dated and signed.
36

c.. Doctor's orders received and written by a licensed nurse on
the medical record must be signed and dated by the nurse and
countersigned by the doctor.
4. Analysisclerkshould check ifan necessaryauthorizations are attached
to the chart.
a. Check if authorization is dated, signed by the patient, and
signed by a witness (these are needed in order for the
authorization to be considered valid). \
b. Check if special procedures performed have corresponding
authorization.
c. If there is surgical intervention, check if there is surgical
consent.
5. Analysis clerk should check for errors or unexplained inconsistencies.
a. Check spelling of names and correct hospital number,
b. Check if there is a disagreement between one part of the record
and another (e.g., if the pre-operative diagnosis does not agree
with the post-operative diagnosis), the discrepancy should be
noted and!or referred to the attending physician. .
c. When the clerk analyzing the medical records finds one which
is incomplete, he should attach a "Deficiency Slip" and then
check an those items which require completion. The chart
should then be placed in a preset area so that the doctor
concerned will know that it is awaiting his attention.
d. Deficiency slip shan be attached at the upper left hand side of
the record, and a tracer slip is filed for easy retrieval.
e. Analysis clerk sorts out analyzed charts Into complete and
incomplete charts.
f. Analysis clerk forwards the complete charts to the diseaseand
operation coder.
g. Filesthe incomplete charts in the pigeon hole, by the doctor's
name.
h. Ifthe Standard Operational Procedure(SOP) requiresthe MRS
to re-route incomplete charts to the areas concerned, then, the
analysis clerk must do so.
I. Upon receipt of completed charts, the analysis clerk should
review charts for specific areas completed as shown in the
deficiency slip.
J. Reviewed charts are forwarded to the disease and operation
coder.
Simultaneously done with analysis. is the preparation and
accomplishment of the service discharge slip which is forwarded to the
statistician for entry into the Daily Cumulative Statistical Form.
37
CODINGANDINDEXING
OF DISEASES AND OPERATION
REPORTING AND CODING DIAGNOSIS.
OPERATIONS AND PROCEDURES
Coding of diagnosis or problem is the process of assigning numbers to
represent diagnosis or problems. This is done to allow for a systematic
sorting of medical records by diagnosis and operations for easy retrieval.
Coding is performed to meet internal and external demands for information.
Internally, coding, when done correctly, helps achieve accurate, precise, and
meaningful statistics which may be used by the management to plan and
evaluate program implementation. Likewise, this acts as an aid to assess the
quality of care rendered and to make decisions about staff, facility, and
resource allocation. Externally, other agencies and third party payers use
this information to forecast health care needs, evaluate the utilization of
health care facilities and the appropriateness of health care cost, and conduct
epidemiologic studies.
Disease Index is a numerical listing of patients' records by code number
assigned to diseases and/or condition for which the patient is treated.
Diagnosis is a statement by the physician of the patient's health problem.
Final Diagnosis includes the admitting diagnosis, interim diagnosis and
discharge diagnosis.
a. Admitting diagnosis is the condition stated on entry (prior to
entry) to the facility as the reason for hospitalization.
b. Interim diagnosis is an additional diagnosis that describes a
condition arising after admission that modifies the course
and treatment of the patient's illness or the health care required.
c. Discharge diagnosis is the condition stated at the time of
discharge. In cases ofdeath, the discharge diagnosis will usually
be the immediate cause of death and any underlying cause.
Principal diagnosis is the diagnosis chiefly responsible for the admission
of a patient. -
All diagnosis, operations and procedures performed shall be coded using
the International Classification of Diseases (ICD), and the International
Classification of Procedures in Medicine 9
th
edition per Department Order
104-D s. 1991, dated 4 April 1991.
Coding can be performed with the use of the ICD books or any of the
availablecoding tools approved by the DOH. Each book is a cross index to
the other, so that from the diagnosis, one learns the code or from the code,
one will know the diagnosis. Every final diagnosis and complications or
name of operation performed is listed on the face sheet, by the relative code.
These codes should be entered in the correct order in the marked area.
The coding clerk must be able to detect poorly-defined diagnosis. In
cases where the diagnosis is not clear, the coding clerk should refer it to the
attending physician for clarification.
When the code numbers have been entered on the facesheet they should
also be recorded on the cards making up the "Disease and Operation Index".
These cards should be of good quality to withstand considerable handling.
A 5" x 8" card printed on both sides shall be used.
38
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Hospital Medica/Records Management Manua/
The disease and operation index should be kept in file drawers, and
when any particular card is filled up, a new one should be added to be filed
in front of the old one. For clarity, only one diagnosis should be recorded in
one card. The year in which the entries are made should be written in the
box provided.-Should that year end while a card is still unfilled, a line
should be drawn under the last entry to show the cut-off date.
Since doctors often require charts from a certain year when studying the
treatment of a particular diagnosis, the recording of "other diseases" by
their codes would enable doctors to clearly define the particular charts they
wish to study.
SIMPLE CODING PROCEDURE:
1. Locate the main term in the alphabetical index.
2. Refer to any notes under the main terms.
3. Refer to any sub-terms indented under the main term.
4. Followcross-referencing instruction, if the needed code is not located
under the first main entry consulted.
5. Verify the code number in the tabular list.
6. Read and be guided by any instructional terms.
MEfHOD OF REPORTING FINAL DIAGNOSIS
(Morbidity Code)
The attending physicians are requested to carefully specify all diagnoses,
operations and procedures, external causes of injuries and poisoning and
places ofoccurrence. (If no firm diagnosis has been made, the manifestation
which best accounts for the period of in-patient care shall be written by the
attending physician, in which case shall be coded by the Medical Record
Practitioner (MRP). This condition may be a complication or a recurrence
of an earlier condition of the patient which required care on its own.
PRINCIPAL-DIAGNOSIS
The cause of death should be listed as the principal diagnosis only if it
was chiefly responsible for the admission to the health care facility.
For patients with cancer, the primary site should be coded first except
when;
The primary site is unknown, add 199.1 for unknown primary.
The primary site has been operated and removed, code secondary site
and appropriate V code for "History of malignant neoplasms of site."
The reason for hospital admission is related specifically to a secondary
site rather than the primary site, V codes are usually supplementary
codes but occasionally may be listed as the principal diagnosis.
Adenoma is known to be benign neoplasm, but when the word benign
is preceded by the word malignant, the resulting final diagnosis shall be
coded under malignant.
Example:
Adenoma of the Colon 211.3
Malignant adenoma of the colon 153. 9
39
Hospital MedicalRecords Management Manual
A neoplasm diagnosis which does not specify whether a malignant
neoplasm is a primary or secondary site, it should be presumed primary,
unless,the malignant neoplasm is of lymph nodes or glands.
Neoplasm of the lymph glands are presumed to be secondary unless the
diagnosis specifies they are primary. A separate code 155.2' is -provided for
malignant neoplasms of the liver whose behavior is not specified as primary
or secondary.
Terminology referring to metastatic cancer is often not very clear.
Diagnosis stating cancer "metastatic from" a site shall be interpreted as
primary to that site and neoplasms described as "metastatic to" a site shall
be interpreted as secondary to that site.
Example:
Carcinoma of the cervical lymph nodes metastatic from prostate,
shall be coded prostate as the primary site 185, and cervical lymph
nodes as secondary
Morphology coding, or simply called the M codes, is of special interest
in tumor registry and in planning for radiation, surgery, and chemotherapy
in the pathology department. When the diagnosis has more than one
qualifying adjective, choose the M code with the higher number.
Example:
Undifferentiated scirrhous carcinoma involving the hard palate
and lateral wall of the oropharynx.
Undifferentiated (8020/3)
Scirrhous (8141/3)
Hard palate 145.2
Lateral wall oropharynx __ 149.8
Therefore, the complete code for this diagnosis should be: M Code
used: (8141/3) 145.2, 149.8.
Where the attending physician uses non-standard medical terms which
coders could not find in the rCD books, the coder should likewise refer the
case to the attending physician for alternate terms used in the classification
system.
SYMPTOMS
_____ 276.1 - the underlying cause of
this condition has not
beenestablished
Fever of unknown origin 780.6 (pyrexia)
Suspected CA of the larynx _' 235.6 (ruled out)
A symptom or ill-defined condition should not be reported as the final
diagnosis ifa more defined diagnosis or cause of the symptom or condition
is known. '
Example:
Hyponatremia
40
Hospital Medical Records ManagementManual
HOSPITAl TZATION FORINVESTIGATION
Where a patient is admitted just for investigation, the condition after'
the said investigation shall be stated as the final diagnosis.
INJURIES/POISONINGS
For injuries, the nature of the injury should be specified (e.g., fracture, bum,
open wound), the bone, organ, or part ofthe body affected should be mentioned.
For poisonings, the poisoning agent must always be mentioned.
. ABBREVIATIONS
Final diagnosis should not be abbreviated as they may be ambiguous.
QUALIFYING ExPREsSIONS .
Qualifyingexpressions indicatingsomedoubts to the accuracyofthe diagnosis
should be ignored(e.g., apparently, presumably, possibly, probably, etc.).
PROCEDURES AND OPERATION CODING
An operation or procedure is defined as one which:
* is performed in any operating room;
* carries an operative or therapeutic risk; and
* requires highly specialized equipment or facilities
,;. ",
5-690
8-114

. 5-752

9:263
1-630
5-428
5-470
.5-982
1-472
4-251
5-640
5-988
Principal Operation or Major Procedure is the main procedure performed
during an individual hospitalization episode. .
Where there is more than one procedure or operation performed, all
procedures aside from the major operation shall be coded.
Some procedures are classified in more than one chapter or code number,
of the International Classification of Procedures in Medicine (ICPM),
depending on the reason for the procedure being undertaken..
Example:
Appendectomy
Prophylactic Appendicectomy
Cervical Smear
Routine Cervical Smear
Circumcision, Male
Female (ritual) circumcision
Cystoscopy for removal of
foreign body
Ureteric cystoscopy
Diagnostic Dilatation and
Curettage
Dilatation & Curettage for
of pregnancy'
Episiotomy
Routine Episiotomy
Esophagoscopy
Esophagoscopy for dilatation
41
Terms which indicate the surgeon's access route are not coded if details
regarding the procedure carried out are available.
Example:
If a laparotomy and appendicectomy are performed at the same
time, then the laparotomy is not coded. Laparotomy will only be
coded when no further procedure is performed.
STATISTICS
Statistics are numerical facts which break down data into concise, useful
form. It involves the process of collection, analysis, interpretation and
presentation of facts as numbers.
Accurate and comprehensive data collection is vital in statistical
preparation and the effectiveness of statistical reports depends upon the
terminology used. There must be a mutual/common understanding of its
meaning betweenthe person who preparesthe statistical report and its users.
It would also be essential to knowwhat data to collect and how to collect
them.
NEEDS FOR STATISTICS:
1. To provide data for management activities:
a. Planning
b. Controlling
c. Evaluating
2. Comparison of past and present performance of the facility
3. Appraisal of patient care by medical, nursing and allied health
professionals
4. Provide information in the preparation of reports of outside agencies
5. Meet legal requirements
6. Funding (if it is a government hospital)
7. Researchand education
ADMINISTRATIVE LEVEL:
1. Decision making and evaluation
2. Cost accounting
3. Budgeting and resource allocation
4. Organizing staffing levels
CLINICAL LEVEL:
1. Assessment of the quality of care rendered
2. Appraisal of health personnel performance
3. Teaching and tabulating instrument
42
{Admissions up (Discharges/deaths
+ to the next - between census
census hour) taking hours)
OUTSIDE AGENCIES:
1. Data for accreditation purposes
2. Licensure of approved hospital and their services
3. Disbursement of funds
The importance of accurate statistics as a tool of management cannot
be overemphasized. It is the responsibility of the Medical Record Officer to
ensure that the medical statistics produced for his hospital are accurate and
available.
The basis for many medical statistics is the hospital Census Report
Forms. Computation should be done as soon as possible after work starts
each morning. The aim is to monitor the movement of in-patients in and
out of the hospital over the previous 24 hours, cut-off time is 12:01 to 12:00
midnight. .
The foUowing form layout is recommended for aU government hospitals.
Its use will ensure that the Medical Record Officer will be able to accumulate
the figures required.
The floor census may be accomplished by the nurses, the admitting
office, or by the MRS, a copy of which shall be distributed to the designated
services of the hospital.
The first form layout is accomplished daily, whereas, the second form is
accomplished monthly. Data are derived from the accomplished daily census
reports.
FORMULAS USED IN lHE COMPUTATION
OF HOSPITAL INDICATORS
I. MEASURE OF HOSPITAL UTILIZATION
DAILY CENSUS:
(In-patients
CENSUS= remaining
at midnight)
AVERAGE DAILY CENSUS:
This is the average number of in-patients per day. This figure is
derivedfrom the daily census plus the patients admitted and discharged .
on the same day.
(Total service days for aperiod)
Average daily census =
(Total days in the same period)
Total days of care/service days is compiled on the Daily Census
Report and the grand total for the month is listed on the last day of
that month..
Newborn census must be reported separately. Average daily census.
can also be figured by the wards or specialty departments using the
same formula.
43
PERCENTAGE OF OCCUPANCY
This is the percentage of in-patient beds occupied over a' given
period of time.
x (Total days in
the same period)
(100) x
(Total in-patient service
days for a period)
OCCUPANCYRATE =----'--------
, ,
(Total Number of
authorized beds)
Newborns must not be included in the computation for these are
made separately. Beds in the Labor Room (LR), ER, Clinics,
Examination rooms, Recovery Room .(RR) or temporary set-ups for,
temporary overflow (cots, beds in hall, etc.) or beds in the ward set-up
but with no staff or patients using them (vacant or closed off area or
wards, stored beds) are not to be counted. To be counted, a bed must
be permanently in use and capable of being staff just as any other bed
(700/0 is the minimum required to stay "even" or support the hospital's
existence at no profit whatsoever).
(Total length of stay for discharged
patients for a period)
AVE. LENGTHOFSTAY=----------
(Total discharges and deaths
.in the same period)
Total length of stay of patients discharged during the month
(regardless of the date of admission) is taken from the Daily Analysis
of Discharges compiled in the MRS. Actual days of confinement is
taken from each patient's chart and totalled for the month. The figure
arrived at is used as the numerator in computing for the average
length of stay. . ,
A patient admitted and discharged that same day is considered as
having stayed one day. .
In computing for the length of stay, the-date of admission is
counted but not the day of discharge.
Newborns must not be included in computing for this indicator.
II. MEASURE OF HOSPITAL PERFORMANCE
GROSS DEATH RATE:
This is a comparison of all in-patient deaths to all discharges for
a given period.
{Total deaths (incl. newborn)
for a given period} x ,(100)
DEATHRATE = --"------'-----'----'----
(Total discharges and death for the saDle period)
Do not includeDead on Arrival (DOA),stillbirth,and ERdeaths. Include
newborn in computing for this indicator. Below 3% is acceptable.
44
NET DEATH RATE
The net death rate produces a lower figure than the gross death
rate. This is also known as institutional death rate.
[{Deaths (incl. newborn)} -
{those under 48 for the period}] x (100)
Net Death Rate =
(Institutional [l Total no. of discharges (incl. deaths &
Death Rate) newborn)} - {deathunder 48hours for the period}]
Death occurring at the ER is not counted if the patient is not yet
considered admitted. 0.5- 2.5%rate is acceptablebywesternstandards.
POST-OPERATNE DEATH RATE
A post-operative death is one occurring within 10 days of the
operation and was due to, or connected with, the surgery performed.
(Total post-operative
deaths for a period) x (100)
Post-operative =
Death Rate (Total patients operated
for the same period)
Up to one percent (1%) is considered normal.
ANESTHESIA DEATH RATE:
An anesthesia death is a death that occurs while the patient is
under anesthesia or caused by anesthetics or agent used by an
anesthetist in the practice of his profession.
(Total no. of death caused by
anesthetic agent for a period) x (100)
I
'I
Anesthesia =
Death Kate (Total no. of anesthetics administered
for the same period)
MATERNAL DEATH RATE:
These are deaths resulting from obstetric complications of the
pregnancy state (pregnancy, labor, and puerperium) from
interventions, omissions, incorrect treatment, or from a chain ofevents
resulting from any of the above..
{(Total no. of direct maternal
deaths for a period) x (100)}
1
Maternal
Death Rate {Total no. of maternal (obstetrical) discharges
(including) deaths for the period}
45
{Total discharges & deaths from hospital
(ward) for the same period}
To be counted, death must occur between conception and
puerperium. Up to twenty-five percent (25%) is considered normal.
Count only those patients whose death was a result ofan obstetric
complication of the pregnancy, labor or the puerperium or from
interventions, omissions of treatment or chain of events resulting
from any of these.
A woman who dies following an abortion is a maternal death, as
in an obstetrical patient who dies before the delivery of a cause due to
pregnancy.
Non-maternal death rate is an obstetrical death resulting from
accidental or incidental cause and not related to pregnancy or its
management.
A. MORBIDITY
GROSSINFECTION RATE:
Those infection which have occurred following dean wound
operations or births, or havedeveloped in medical cases after admission
to the hospital.
{Total no. of infections in hospital
(or ward) for a period} x (100)
Infection = ----------------
Rate
The infection to be included must be hospital acquired and must
be so determined by a committee or a physician.
Up to two percent (2%) is considered normal.
NET INFECTION RATE:
(Total number of infections debited
against the hospital for a period) x (100)
Net Infection = ----------------
Rate (Total number of discharges in the same period)
POST-OPERATNE INFECTION RATE:
These are infections occurring after a clean surgical operation
(O.P.) or procedure.
(No. of infections occurring
after clean surgical O.P.) x (100)
Post-o.P. = --------------
Infection Rate (Total no. of clean surgical O.P';
procedure for the period)
46
1
I
B. MEDICAL
CONSULTATION RATE:
This is the ratio ofconsultation following an attending physician's
request, to a consultant, to examine a patient and givea second opinion.
{Total consultations
(all Depts.) for a period} x (100)
Consultation =-------------
Rate (Total discharges and deaths)
Include newborn in computing for this indicator. Twenty percent
(20%) is considered normal for teaching hospitals. A ten to fifteen
percent (10-15%) rate is acceptable by western standards.
AUTOPSY RATE:
It is the ratio of all autopsies performed in the hospital to all in-
patient deaths. .
(Total autopsies performed
for a period) x (100)
Autopsy Rate
(Total number of deaths of patients
whose bodies are available for autopsy)
In computing for this indicator, do riot include DOA,stillbirth,
and fetal deaths. A seventy percent (70%) rate is considerednormal
for teaching hospitals. A twenty to twenty-five percent (20-25%) is the
minimum rate acceptable by western standards.
NET AUTOPSY RATE:
(Number of autopsies performed
on in-patients deaths) x (100)
Net Autopsy =--------------
(Total number of deaths minus
unautopsied cases)
The following are four exclusions in computing the net autopsy rate:
* Stillbirth
* Dead on Arrival
* Death at E.R. when patient is not admitted
* Medico legal cases, given to the proper authority
47
{Total no. of birth (incl. intermediate and
late fetal deaths) for the period}
r
C. OBSIEIRICS
CAESAREAN RATE:
It is a comparison of the number of caesarean sections performed
against the total number of deliveries.
(Total caesarean sections
in a given period) x (100)
Caesarean Rate = --------------
(Total deliveries for same period)
A three to four percent (34%) rate or loweris acceptable byWestern
Standards.
Note: Regardless ofwhether the delivery produces one child, twins,
etc. and whether a dead or live newborn is delivered, the mother
is considered to have delivered only once.
D. PERINATAL STATISTICS
Perinatal period is that which extends from the gestational age at
which the fetus attains the weight of 1000gm. (equivalent to 28 weeks
gestation) to the end of the seventh completed day (168 hours) of life.
LNEBIRTH:
This is defined as the complete expulsion or extraction from the
mother of the product of conception, irrespective of the duration of
the pregnancy, which, after separation, breathes or shows any other
evidence oflife, such as beating of the heart, pulsation of the umbilical
cord or definite movement of voluntary muscles, whether or not the
umbilical cord has been cut or the placenta is still attached. Each
product of such a birth is considered live born.
FETAL DEATH: (STILLBIRTHRATE)
This is death prior to the complete expulsion or extraction of a
product of conception from its mother irrespective of the duration of
pregnancy. The death is indicated by the fact that after such separation,
the fetus does not breathe or show any other evidence of life, such as
beating of the heart, pulsation of the umbilical cord or definite
movement of voluntary muscles.
(Total no. of intermediate and!or
late fetal deaths for the period) x (100)
Fetal Death = ---------------
Rate
Below two percent (2%) is considered normal.
48
..
Hospital-Medical Records Management Manual

Fetal deaths are classified as:
a. Early Fetal Death = less than 20 weeks gestation
(500gm. or less)
b. Intermediate Fetal Death = 20 weeks of gestation
but less than 28 (501-1,000 gm)
c. Late fetal death = 20 or more weeks Ofgestation
(1,001 gm - stillbirths)
NEONATAL DFAlHRATE
QNFANT NEWBORN MORTAUIYRArE):
,This is the death of a child whose heart beat after complete
expulsion or extraction from the mother, and died within 28 days of
birth.
(Total number of newborn
deaths for the period) x (100)
Neonatal death = -------------
Rate {Total no. of Newborn infant discharges
(incl. deaths) for the same period}
Fetal deaths of less than 20 weeks should not be included as well
as those who were admitted after their deliveries/births outside the
hospital. For Infant Death Rate, below 2% is acceptable' in western
standards. .
Neonatal Death could be divided into:
a. Neonatal period I - from the hour of birth through
. 23 hours and 'JJ minutes
b. Neonatal Period II - from the beginning of the
24th hour of life through 6 days, 23
hours, and 'JJ minutes
c. Neonatal Period III - from the .beginning of the
7th day of life through 27.days, 23
hours, and 59 minutes.
FILING OF MEDICAL RECORD
An efficient filingsystem is a vital requirement in an efficient and effective
MRS. All records should be filed in one established sequence. A filing area
which will ensure the rapid location and retrieval of records must be
maintained. There are several systems of filing medical records, among
these are:
ALPHABETICAL - all records of discharged patients are filed in strict
alphabetical order from A to Z. This is otherwise known as the
dictionary arrangement of filing.
NUMEll.ICAL" all records are- filed by their ~ i s s i o n number.
BY YEAR - charts may be filed either alphabetically or numerically by
year of discharge.
49
TERMINAL DIGIT FILING
For terminal digit filing, a six digit number is used and divided into
three (3) parts.
1. Part I - The PRIMARY digits which are the last two (2) digits on the
right hand side of the number.
2. Part 2 - The SECONDARY digits which are the two (2) middle
numbers.
3. Part 3 - The TERTIARY digits which are the first two (2) digits on the
left of the assigned number.
For example, the unit number 19-30-90, is divided as follows:
19 20 90
Tertiary Secondary Primary
The record of those who have been in-patients of the hospitals are filed
and stored in terminal digit order. This means that they are filed in order of
primary digits (that is, last two digits of the medical record number and
then the secondary digits and finally the tertiary digits).
When filing charts under the terminal digit system, the unit number is
first considered. This should be divided into three parts - in pairs ofdigits.
Taking chart 509326, this divides as follows 50-93-26 and the process of filing
commences by considering the right hand or "terminal" pair ofdigits which,
in this example, is "26". Aterminal digit filing area should have 100primary
sections starting from 00, 01, 02, 03, 04, 05,...99.
When filing , the clerk will take the chart to the primary section
corresponding to the terminal pair of digits. Once in the right terminal,
the row of records is located by considering the secondary and the middle
number which, in the above example, is "93". Within each secondary section,
charts are filed in order of their tertiary (left hand) pair of digits. The
advantages of terminal digit filing are numerous. As records are added to
the filing area, they are equally distributed throughout the 100 primary
sections. Thus, congestion of one particular area of the file room is
eliminated. This system makes quality control possible since it gives clerks
the fixed responsibility for certain sections of the file. This also prevents the
backshifting of records which usuallyhappens in other types offiling systems.
If you are looking for a record, it should be in the order shown belowor
a tracer should be in its place. An example of sequence is:
46-52-02
47-52-02
48-52-02
49-52-02
98-05-26
99-05-26
00-05-26
01-06-26
98-99-30
99-99-30
00-00-31
01 - 00 - 31
Note: A misfiled record may take hours to locate or could be lost forever.
File all records correctly.
50
07
06. 77
05 77 50
04 77 50
03 77 50
02 77 50
01 77 50
77 50
50
00
l
77
50
The lllustration above shows how charts are filed in terminal "50".
PROCEDURE IN FILING PATIENTINDEX CARD
NEWADMISSIONS:
1. Check alI new admissions from the daily census report.
2. Check the Master Patient Index (MPI) to make sure the patient has
not been previously admitted to the hospital, otherwise, the patient
may already have one.
3. Prepare an MPI for each new patient admitted in the hospital.
4. Pre-sort alI finished MPIs.
5. File the MPI's in the in-house box alphabeticalIy according to the
patients' last name (surname).
6. After the patient's discharge, pulI out the MPI from the in-house box.
7. Pre-sort pulIed-out MPI cards.
8. Filein the MPI card cabinet folIowing the rules in alphabetical filing.
(Refer to rules on alphabetical filing, p. 52)
RE-ADMISSIONS:
1. Check re-admissions from the daily census report.
2. Check the MPI to make sure whether the patient has been previously
admitted to the hospital, otherwise, he may already have one.
3. PulI out the MPI from the index card cabinet.
51
r-
4. Pre-sort the pulled-out MPIs alphabetically.
5. File the MPI's in the in-house box alphabetically according to the
patients' last names.
6. After the patient's discharge from the hospital, pull out the index
card from the in-house box.
7. Pre-sort the alphabetically pulled-out MPIs.
8. Re-file in the MPI cabinet following the rules on alphabetical filing.
RULES ON ALPHABETICAL FILING:
1. Place the surname first, then the given name, followed by the middle
name or initial, and file in strict alphabetical sequence.
2. Arrange index cards in alphabetical order.
1 When a patient requires more than one card to accommodate all of
his admissions, the cards should be arranged in chronological order,
with the earliest date first, working from front to back in the drawer.
4. If there is more than one person with the same surname and given
name, the cards should be arranged alphabetically by middle initiaL
If no middle initial is given, the cards should be arranged according
to birth date, filing the oldest card first.
5. Names with prefixes of D, dela, De, Des, Di, Du La, Me, Mac, Ma,
Van, \bn, etc. are filed alphabetically as De-l-a-Cr-u-z; De-l-a-F-u-e-n-t-e.
6. Names beginning with Sta. and St..are filed as S-a-n-t-a, and S-a-i-n-t,
as in S-a-n-t-a-M-a-r-i-a and Sa-i-n-t,
7. COmpound or hyphenated names are filed as one word; thus, Navarrete-
Clemente would be filed under N-a-v-a-r-r-e-t-e- Cd-e-m-e-n-r-e.
8. Names with religious titles such as Reverend, Mother, Father, Brother,
and Sister are filed under the surname, the titles disregarded, followed
by the given name. Father Jose Romero is filed as Romero, Jose or
Romero, Jose (Father).
9. If an initial is given instead of a person's first name or middle name,
the rule is "file nothing before something." Thus, J. Romero would
precede M. Jose Romero and Miquel Jose Romero.
10. It is customary for people of Spanish descent to combine the name of
the mother with the name of the father, For instance, with the name
Soto Ramirez, Soto is the surname of the father, and Ramirez is the
surname of the mother. They are filed in alphabetical sequence, the
father's name first, followed by the mother's name. Thus, the name
Maria Dolores Soto Ramirez would be filed in the section of the file
in the following order; So-t-o-Ra-m-i-r-e-z, Maria Dolores.
11. If the patient's name has changed since a previous admission, a cross-
reference should be made to the former name. For instance: if Dayrit,
Josefina is admitted, a cross-reference should be made to her previous
admission as Manalastas, Josefina.
52

12. When looking for a given person's name card, one must keep in
mind that there may be many spellings ofthe same name. Athorough
search must be made under everypossible spelling of the name before
stating that there is no card for that name.
13. The MPI should contain sufficient alphabetical guides for speedy
reference. As a rule, no more than 20 cards should be filed behind a
guide.
14. To maintain uniformity in the patient index when a personnel change
is made, filing directions should be explicit. Whenever possible, only
one person should be responsible for filing the index cards.
15. Card files should be audited regularly for misfiled records.
16. Additional training of MPI clerks should be provided as necessary.
LOOSESHEETS
Vast quantities of unattached laboratory, E.C.G., and other test results
(loose sheets) are produced daily and make their way to the MRS. These
reports contain vital patient information and it is essential that they are
filed promptly and accurately to maintain complete, comprehensive and
effective medical records.
SORTING OF LOOSE SHEETS:
Loose sheets are delivered to the MRS from the different services of the
hospital. The in-patient sheets should be separated from the out-patient
loose sheets in a decentralized medical record keeping system. Then they
are pre-sorted terminally in preparation for the actual filing process. The
procedure is as follows:
1. Separate loose sheets that have been stapled together.
2. Date s t ~ all loose sheets received.
3. Check names and numbers on the loose sheets.
Note: For loose sheets forwarded to the MRS without corresponding
numbers, the MPI should be consulted.
LOCATING THE RECORD
1. Refer to the in-house box to determine whether or not the patient has
already been discharged.
2. For patients whose names are not in the in-house box, consult the
MPI for the MRN, then retrieve the record from the permanent file
area.
3. Medical records shall be filed by the terminal digit filing system. (See
Terminal Digit Filing, p. 50)
4. Records which are not in the permanent filing area.should be recalled
from respective borrowers to incorporate loose sheets.
5. Retain any loose sheets that were not filed the first time for a future
attempt.
53
*
*
FILING LOOSE SHEETS
I. Check and re-check patient number and date on the report if they
correspond to the number and date indicated on the medical record.
2. File the loose sheets using the "Assembly of Records". list as a guide to
correct filing order.
3. First admissionis filed at the bottom with subsequent admissionon top.
4. Reports from each department are filed chronologically within each
admission.
5. Maintain statistics of loose sheets received by the MRS for any
administrative use.
RETRIEVALSYSTEM FOR THE UTILIZATION
OF MEDICAL RECORDS
All medical records not in the processing stage and those not in use are
expected to be in the file/storage room. Inherent to documents and records
is the property to be retrieved from the permanent file for further use- one
of the main reasons why they were maintained.
A good retrieval system directly affects the total efficiency of the MRS.
It would be a good practice for small hospitals with a small filing!
storage area to transfer inactive records to the inactive file to give way to
incoming records, to decongest the area, and to make retrieval easy.
It shall be the policy of the facility to maintain a filing system that shall
facilitate accessibility and prompt retrieval of the records. The system must
be consistent (i.e., it must not vary from' one record to another), and it must
be maintained in a definite sequence at all times.
A retrieval processwill not be efficient and effective if there is no provision
for adequate finding aids, captions, locator aids, and retrieval tools.
Retrieval tools in the medical record are classified into three,
namely: (1) indexes, (2) registers, and (3) tracers.
The following indexes shall be maintained by the MRS:
MASTER PATIENT INDEX (MPI) - The MPI is one of the most
important tools in the MRS.
* It is the keyin locating medical records maintained in the file.
* It servesto identify the patient and helps in the retrieval process
of medical records.
* The patient index is maintained as a permanent file.
MPI is maintained manually in a 12cm x 7cm or 3"x 5" card.
It is filed in strict alphabetical order by the patient's name.
The minimum data requirements for the Patient Index card are as
follows: the patient's name, address, date of birth, hospitsl/record
number, date ofadmission, and the name ofthe attending physician.
54
Sample of a Patient Index:
NAMEOF HOSPITAL
PATIENT INDEX
f
NAME: FAMILY FIRST MIDDLE HOSPITAL NO.
AGE DATE OF BIRTH SEX STATUS
ADDRESS: -r-r-'
ADMISSION DISCHAJl{;E ATIENDING ADMISSION DISCHAJl{;E ATIENDING
~ H Y S I I N PHYSICIAN
DISEASE INDEX - is a listing on a card for specific disease based on
standard classification/nomenclature, arranged according to code
numbers.
Sample of a Disease Index:
NAMEOF HOSPITAL
DISEASE INDEX
CODE NO. DISEASE: YEAR
Hospital Patient Age Other Result O.P. . Date Attending

No. Name M F Disease Adm. D Physician
55
.---------------.1!"'"""0"'1.-,.
A disease index is a numerical listing ofthe code numbers assigned
bythe medical record practitioners to represent each patient's diagnosis.
These code numbers are taken from the coding tools approved by the
DOH.
The disease index serves as a valuable resource to retrieve records
with specific disease or problem, hence, very useful for research and
studies.
An entry on an index card should be made for each code number.
(Example: If the final diagnosis of the patient is Pulmonary
Tuberculosis [code no. 011.9) with bronchial asthma [493.9)), an entry
would be made on one card for code 011.9 and another card for code
number 493.9
Code No. 011.9
Hospital Patient Age Other
Number Name M F Diagnosis
493.9
Card No. I
Code No. 493.9
Hospital Patient Age Other
Number Name M F Diagnosis
OIL9
Card No.2
OPERATION INDEX - is a listing on a card for a specific operation
according to standard classification/nomenclature, arranged according
to code numbers.
Sample of an Operation Index:
NAME OF HOSPITAL
OPERATION INDEX
Code No. Operation: Year
56
Hospital Patient Age Other Result Diagnosis Date Attending
No. Name MF O.P. Adm. Physician
. .. I . " ',' . '. '."
PHYSICIAN'S INDEX- is arecord of the work done and end results of
, treatment rendered by the' physician practicing in the hospital or an
index containing a list ofall the patients a doctor has. These cards are
filed alphabetically according to the doctor's name.
'Sample of a Physician's ~ d e x
NAME OF HOSPITAL
PHYSICIAN'S INDEX
Code No Physician's Name' Year
I
I
:
Date Hospital Patient Age Discharge Days. Service Cons. Result
No. Name M F Date
NUMBER INDEX - is the patient identification number control.
In cases where only the number of the patient is known, the
name can be traced from the number index. This is maintained in a
3" x 5" index card...
Sample of a Number Index:
NAME OF HOSPITAL
NUMBER INDEX
PAGE
Hospital No. Patient's Name
REGISTERS
YEAR
Date Admitted'
Registers are official recording of items, names, or actions entered in a
book or a logbook.
The register.is.a vital document in the MRS. Veryoften, statistical data
is required and the only record available will be this register. It is very useful
as a cross reference because ,it can identify all patients by name and by
number.
57
ADMISSIONREGISTER - This is a list of all patients admitted in a
particular hospital. The minimum data requirements for admission
register are as follows: patient's name, date of birth, patient/hospital
number, admission date, name ofattending physician, and the section!
area where the patient was admitted from.
This register shall be done daily as patients are admitted and/or
discharged. Each section of this register shall be maintained in
chronological order. This register is a permanent record, and as such,
all entries shall be made in ink.
Sample of an Admission Register:
ADMISSION REGISTER
Page No.
Patient Adm. Patient's Rm.

Birth iNtending Admitted
Numbe Date Name No. M F Date Physician From
DISCHARGE REGISTER - The minimum data requirement for a
discharge register are as follows: patient's name, patient/hospital
number, discharge date, name of the attending physician, and
disposition.
Sample of a Discharge Register:
DISCHARGE REGISTER
Page No
-..
Discharge Patient Patient's Physician Adm. Diagnosis Result
Date Number Name Date
58
,
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BIRTIf REGISTER - this is a chronological listing of all the names
of the children delivered in a particular hospital,
Sample of a Birth Register:
Page No. _
BIRTH REGISTER
Hospital Patient Child Delivered Day/lime HI Wt No. of Attending
No. Name Name By: Delivery Del. Physician
DEATIf REGISTER
This is a record of all the deaths occurring within the hospitaL
This is a log of all the names of the patients who died in a
particular hospitaL This is arranged according to the date of
death.
Sample of a Death Register:
Page No. _
DEATH REGISTER
Patient Patient's

Adm. Date of limeof ervice Attending
Number Name M F Date Death Death Phvsician
..
OTIfER REGISTERS - Other required registers that government
hospitals need to maintain are. as follows: Out-patient register,
Emergency Room Register, Delivery Room Register, and Operating
Room register.
59
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OUT-PATIENT REGISTER - Every out-patient who comes in for
consultation must be listed in the OUT-PATIENT REGISTER.
Page No, _
OPDREGISTER
Date Hosp. Re-Adm. Name
Jj:.-
Diagnosis Service Attending
No. Adm. (Surname, [}.-iF hysician
First,MI)
If a logbook is utilized for this purpose, at the end of the year, it
should be forwarded to the MRS for safekeeping, as it is classified as
a permanent file/record.
If, however, this register is maintained on a loose sheet or loose
leaf, at the end of every month it must be forwarded to the MRS for
thepreparation ofNotifiable or Reportable Diseases which isprepared monthly.
This is also necessary for the compilation and collation process.
ESSENTIAL REQUISITES FOR EASYRETRIEVAL
1. EFFICIENTAND EFFECTIVE FILINGSYSTEM
This is an important factor that makes retrieval easy because it is
adaptableto the type of records maintained. Proven to beveryeffective
in managing voluminous health records is the terminal digit filing
system. However, to be truly effective, it needs to adapt the
corresponding unit numbering system.
2. TIME
Time element is very crucial in medical record management.
Retrieval time of medical records should be as short as possible because
the information that may be retrieved from the chart might .be the
deciding factor between the patient's life or death.
3. MONITORING OF CHART MOVEMENT
Another important factor to consider in the efficient and effective
management of medical records is the full knowledge of the movement
of the records. This is the reason why the MRS should' maintain an
.effective trackingor follow-up system. The useof such a system coupled
with the full knowledge of the workflow will help the medical record
staff control the records more effectively.
4. GOOD PHYSICAL LAYOUT
For a good physical layout, the MRS should consider flexibility
and functionality. The arrangement of the employees should (1) follow
the workflow, (2) facilitate smooth flow of paperwork, and (3) improve
coordination between employees.
The physical location of the MRS should be near the OPD and ERas
theactivity rate of medical records is considered high in these services.
60
RETIUEVALPROCEDURE
1. Authorized requesting party fills up borrower's slip form.
2. Requesting party/authorized representative brings the request to the
MRS and hands it to the medical record personnel.
3. Medical record personnel receives and verifies whether the borrower is
authorized to borrow. He also checks the MRN on the request form.
4. Those requests without the corresponding MRNs shall be checked
against the MPIs. Records of requests with MRN/patient numbers
shall be pulled out from the permanent file.
5. After retrieving the record, charge-out needed/borrowed charts to the
authorized borrower.
* Record the borrowed chart in the tracking system employed.
* Insert the tracer card in the place where the record was pulled
out.
6. The borrower/authorized representative acknowledges' receipt of the
record.
REQUEST FOR MEDICAL RECORD
FOR STUDIES AND RESEARCH
Authorized physicians/researchers shall accomplish the borrowers' slip
forms and forward them to the MRS (at least.a 24-hour notice should be
given for the preparation of the charts).
The medical record personnel receives the request and checks its
authenticity. The requesting party is then asked the variables and limitations
of the study.
The medical record personnel checks the code number of the disease/
operation for research and retrieves the corresponding index card. (SeeFiling
and Arrangement of Disease and Operation Index, pp. 55-56 ) .
The medical record personnel (Retrieval clerk) reviews the disease and
operation index to determine which' charts 'to retrieve, considering the
variables specified by the researcher.
The retrieval clerk then retrieves the records from the file and performs
the charge-out procedure,
The retrieval clerk then notifies the authorized borrower when the charts
are ready for pick-up.
The authorized borrower/representative acknowledges receipt of the
medical records requested.
61
RETENTIONAND DISPOSAL
A. RETENTION
Retention period is the period of time established and approved by
authority after which records are deemed ready for inactive storage or
destruction.
Medical records should be keprby the facility for the duration of time required
bythe statuteoflimitations or bythe'DOH record retentionregulation. This is the
HospitIl licensureAct otherwise known asRepublicAct 4226, which requires hospitals
to maintain medical records for 10 to 25years.
Aside from this legislation, DOH came up with Ministry Circular 77,
series 1981 which further qualifies the 25year retention period for all hospitals
under the DOH regardless of its category/classification.
The medical record is also influenced by the following factors:
1. ACTMTY/USAGE OF DATA:
This can be assessed by determining the number of requests for
information from the records as well as the type of information
requested. This reflects the clinical value of the medical record.
2. SIZE AND TYPE OF SPECIALIZATION OF
THE HEALTH CARE FACILITY
Teaching-training and research hospitals maintain their medical
records longer than hospitals not connected with medical schools or
not engaged in research and studies.
3. AVAILABLE SPACEAND ALTERNATIVES
Because ofiegal considerations, the MRS with a small filing area
must maintain a secondary filing space for inactive records. Active
records are usually maintained for five (5) years after which they are
transferred to the inactive file until they reach the required retention
period.
4. ATTITUDE
The people involved in medical records influence record retention
(in terms of its use for patient care, clinical research, and education).
B. DISPOSAL OF RECORDS
Disposal of medical records in government hospitals/institutions is
governed by DO NO. 13-A and 13-B.
Department Order 13-A, Article III, Rule 2.2, specifically states that,
"Agencies shall not dispose of their records earlier than the period indicated
for each record series. However, records may be retained for longer periods
, if there is a need to do so".
The disposal of records must be done in close coordination with the
Records Management and Archives Office (RMAO), the government agency
in charge of record disposal.
62
Hospital Medical Records Management Manual,
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PROCEDURE IN THE DISPOSALOF MEDICAL RECORDS
1. Check the Record Disposition Schedule for records which has reached
the required retention period (MC 77 s.1981).
2. Pull out medical records from the file.
* Check the year when the record was last activated. (This
appears on the upper right hand side comer of the folder.)
DIZON, EDWARD
1987
1988
1989
1990
02
98
- - year of activity
78
78
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Note: In this example, the patient was first admitted in 1987,
re-admitted in 1988, and was last admitted in 1990.
3. Prepare a list of records for disposal.
4. Communicate with the RMAO regarding a request to. dispose of
medical records addressed to tile Chief, Current Records Division,
Records Management and Archives Office, through the Director,
Hospital Operations and Management Service, Department of Health,
Manila. HOMS will endorse the request to the said office.
5. Upon receipt of the request, the RMAO will assign a record
management analyst to appraise and examine the records for disposal.
Finally, the record analyst will also recommend the manner or method
to be used in the disposal of the record.
6. The director ofRMAO will issuethe authority to dispose of the records
and the manner of disposal.
7. Actual disposal shall be directed by the Director of RMAO or the
Head of the agency.
8. A certificate of disposal shall be prepared in triplicate by the agency,
witnessed by representatives of the Commission on Audit (COA),
RMAO, and a representative from the agency.
The certificate shall include the following information:
* Nature of the record
* Manner of disposal
* Place of disposal
* Date of disposal
* Approximate volume in cubic meters
* Weight of the records
The original certificate of disposal goes to the agency, one copy to
COA, and one copy to RMAO.
63
DISPOSALSCHEDULE FOR MEDICAL RECORDS SERVICE
64
Document type
Admission and Discharge Register
Birth Register
Correspondence Log Book for MRS
Daily census Report
Death Certificate (file copy)
Death Register
Disease and Operation Index
ER Blotter/ER Register
In-patient Records
Adults
Teaching-training and
research, and
Provincial Hospitals
District/Community
Hospitals
Minor (all)
Psychiatric Hospital
Laboratory Report Copies
Labor Room Register
Number Register
Out-patient Records
Operating Room (OR) Register
Master Patient Index!
Patient Master Index
Research Requests
Subpoenas
If no record
X-ray Result/Report
- If filed with the chart
- If no record
-;
Disposal Schedule
Retain permanently
Retain permanently
Seven (7) years after the date of
the last entry.
One (1) year after
Retain permanently
Retain permanently
Retain permanently
Retain permanently
25 years
25 years
Until the child reaches the age
of maturity (18 yrs.) plus an
additional five (5) yrs.
Retain permanently
If filed in the in-patient, retain
as for in-patient record
Retain permanently
Retain permanently
Retain as in-patient records
Retain permanently
Retain permanently
10 years
Retain as for in-patient
Retain as for correspondence
Retain as' for in-patient record
Retain for 10 years
MEDICAL RECORDS OF
DISCHARGED PATIENTS
Medical records of discharged patients are delivered/ forwarded to the
MRS every morning from the different wards of the hospital. The records
are then sorted alphabetically. The medical record clerk processes the new
admissions and re-admissions according to the following procedure:
1. Pull the corresponding cards from the in-house box.
2. Sort and divide the records into new and re-admission
3. Process chart following procedure in filing patient indexcard(see p. 55) and
terminal digit filing (see p. 50).
NEWADMISSIONS
1. Check the Master Patient Index (MPI), to make sure the patient was
not previously admitted to the hospital and therefore mayalready
have an existing medical record.
2. Prepare a folder for the record.
3. Assemble the admission into the folder following the assembly of
record order (see p. 31 ).
4. Stamp the current year on the upper right hand corner of the folder.
indicating the year of admission.
5. Records of dead patients could be marked accordingly, placed in
separate file and entered in the death register.
6. Allocate/forward incomplete records, according to the attending
physician(s), to the proper units for completion.
65
RE-ADMISSIONS
1 Locate the old record.
2. Assemble the newmedical records and incorporate them with the old .
records. ensuring that a divider is placed after the first by placing the
new medical records on top of the previous records.
1 Stamp the latest admission year on the upper right hand comer of
the folder.
4. Mark the records of dead patients accordingly and enter in the death
register.
5. Allocate/forward incomplete records. according to the attending
physician(s). to the proper units for completion.
66
MEDICO-LEGAL ASPECTS
OWNERSHIP OF THE MEDICAL RECORD
The medical record is the physical property of the health care facility
and is maintained for the benefit of the patient, the physician, the health
care facility and the community. As a general rule, ownership carries with it
the right and power to control the utilization of the said property. For
medical records, ownership is not absolute because the patient also has a
right to the information written on the record, that being his health history.
ACCESSIBILITYAND CONFIDENTIALITY
As a general rule, all the peoplewho are directlyinvolved in the treatment
of a patient shall have access to the record.
The medical record is a legal document, as such, all records shall be
stored in areas whereonly authorized staff are allowed access and appropriate
security measures are instituted. No information concerning a patient or
client shall be released to another person without the consent of the patient.
* Where the patient is a minor, a person below 18 years of age,
authorization of the parent or legal guardian should be obtained.
* If the patient has died, the consent must be signed by the identified
next of kin, or by the administrator or executor of the decedent's
estate.
In the event the patient is unable to sign the authorization by reason
of physical or mental disability, the authorization should be signed
by the next of kin or the legally appointed guardian. If possible.
verification of such disability should be obtained from a physician.
A person who is a minor but is married or self- supporting and living
apart from his/her parents may sign his own authorization.
In general, because the medical record is the physical property of the
health care facility, they should not be taken out of the hospital except
on court orders.
67
REQUESTFORINFORMATION
FROMDOCTORS ORHEALlHINSTITUTION
REQUIREDFOR CONTINUINGPATIENTCARE
Advances in health care delivery gave rise to what is known as the
"team care approach" to health care delivery. This requires a wider
range of health professionals who might have a legitimate need for
access to information from the medical record. In this sense,
institutions should formulate guidelines to restrict access to records
to those who are only actually involved in the care of a particular patient.
REQUESTFORINFORMATION
FROMTHE MEDICAL RECORD
FOR RESEARCHAND STUDIES
Health care facilities are said to own the medical records, but legally, the
"privilege against disclosure belongs to the patient and nobody else." In a
hospital setting, proper notification of the attending physician, prior to the
release of information is ideal, in order to protect the legal interest of the
doctor and the hospital as well.
In cases of research and studies, the hospital management may decide on who
can and whoshall not be given access to the medical record, the record being the
hospital's physical property. While thehospital maygive access toapatient's medical .
record for research, study, and publication, thecourtof law emphasizes the need to
protect theidentity of thepatient,which explains why thenameof thepatient isnot
mentioned in these published reports.
Aresearch proposal to be presented for approval should be accompanied bya
comprehensive protocol detailing the objectives methods and reasons for thestudy.
Records for research purposes should not beremoved from the health facility.
MEDICALINFORMATION
OF MENTALPATIENTS
Any medical information on patients with mental problems may be
released only upon presentation of a writtenauthorization from the patient's
nearest kin or by a person appointed by the court as the legal guardian.
Where the request is from a mental hospital where the patient is presently
confined, the release of information shall be acted upon without hesitation
since the use of the information is for the patient's benefit.
REQUESTFORINFORMATIONFROMlHE MEDIA
The DOH recommends that the following procedures be observed in
giving information to the press:
1. Request shall be referred by the MRS to the COHo
2. Noinformation idemifyingthepatient shall be released without proper consent
3. Where the patient concerned is conscious, his/her consent or the
legal guardian's (in case of a minor) shall be obtained regarding the
release of his/her information to the press.
68
*
4. Where media requests the privilege of photographing a patient in the
health facility, the following conditions shall be followed:
* The patient or legal guardian (in case of a minor) shall give
consent for any picture to be taken: and
The opinion of the doctor declaresthat the patient's condition
will not be jeopardized.
RECORDS SUBPOENAED BYCOURT
Subpoena is a process directed to a person requiring him to attend and
to testify in any investigation being conducted under Philippine law. He
may also be required to bring with him books, documents, or other materials
under his control in whichcase, it is called a subpoena duces tecum.
Oftentimes, the MRS receives a subpoena duces tecum, which only
requires the medical record supervisor to bring a particular record(s) to
court.
A subpoena is legally binding on the person who receives it. The MRS
should not accept any subpoena not directly addressed to it. If a subpoena
is addressed to a particular doctor, it must be served to him personally. .'
Upon receipt of a subpoena, always indicatethe TIMEand DJU"E of receipt
Where the patient, whose record is subpoenaed, is not a party to the
proceeding before the court, the hospital should properly notify the patient
of the place, date, and time of the court hearing.
PROCEDURE TO FOLLOW WHEN TIlE MEDICAL
RECORD SERVICF/DEPARTMENf RECEIVES
A SUBPOENA DUCES TECUM
1. Check the Master Patient Index (MPI) if the person mentioned in the
subpoena was admitted/treated in the health care facility,
2. Check the file and retrieve the record.
3. Verify with the court if the case is on-calendar.
4. Re-check the chart/record for complete data entries.
5. Notify management and the attending physician about the subpoena.
6. Have the attending physician review the record for completeness of
clinical data.
7. Number all the pages consecutively.
8. Transfer the record in a secure place preferably under lock and key.
9. Access to the record shall be limited to the attending physician and to
authorized personnel.
10. Photocopy the record and, if possible, never leave the original copy in
court.
11. Always solicit a written request from the judge or the fiscal's office
before leaving the record in court for litigation purposes.
69
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HospitDl MediCQI Records Management Manua!
CONSENT
It must be taken into account that there are other legal aspects to medical
record documentation in addition to the medico-legal certificate.
As a general rule, no treatment or procedure may be performed without
the patient's consent. There are instances where consent could not be obtained
(ex, when the patient is comatose or without a legal guardian), this leaves
the doctor and the hospital open to court litigations due to negligence (for
not properly informing and advising the patient as required).
To be considered valid, a consent should be signed by the patient and a
witness and should also be dated. Aside from these requirements, the person
giving the consent should be legaIly and mentaIly competent. The consent
must be freely given to the authorized person and the patient must be weIl-
informed for him to reach a reasonable decision.
The foIlowing documents require specific signatures and must have their
legal requirements completed before they can be included in the record.
1. CONSENT TO INVOLVEMENT IN CLINICAL TRIALS
(THERAPEUTIC) (See Appendix)
2. CONSENT OF RECIPIENTTO OPERATION, lRANSPLANfATION
OR GRAFTING OF TISSUE (See Appendix)
3. INFORMED CONSENT FOR SURGERY, ANESTHESIA, OR
OTHER PROCEDURES (See Appendix)
This consent must be signed and witnessed after a doctor has
explained to the patient the nature of the operation or the procedure
to be performed. This consent must be completed before the patient
is given pre-operative medication. (See Appendix)
4. DISCHARGE AGAINST MEDICAL ADVICE (DAMA)
This consent has two parts. The first section, whenever possible,
should be completed before the patient leaves the ward (in some
cases, this requirement may cause him to change his mind). If the
patient leaves without signing, then the second part of this form should
be completed, signed by a nurse and witnessed by someone who is not
a member of the hospital staff.
5. CONSENTTO RELEASEOF PATIENTMEDICAL INFORMATION
This consent should be obtained and notarized before any
confidential information is released. Should a law enforcement agent
request confidential information, he must present an authorization
signed by his Head of Office.. This authority should always be
confirmed by caIling the said office before releasing the information.
(See Appendix)
6. CONSENT TO REMOVEORGAN FOR lRANSPLANf
(I1VING DONOR)
This consent has two parts. The first part is signed by the patient
(donor), and the second part is the confirmation which is to be
accomplished by the doctor. (See Appendix)
7. VOLUNTARY STERILIZATION CONSENT FORM
This consent requires that both parties, husband and wife, sign
the consent for it to be considered valid. (See Appendix)
70
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8. THERAPEUTIC ABORTION FORM
This form is to be accomplished by both the husband and the
wife before the procedure is performed by the physician. This also
requires the signatures of at least two witnesses. (See Appendix)
9. REFUSAL TO PERMIT'BLOOD TRANSFUSION
The patient has the right to refuse medication or treatment (e.g.,
blood transfusion) which might be against his/her religious belief.
In which case, this consent form should be properly accomplished.
(See Appendix)
10. CONSENT TO THE ADMINISTRATION OF ELECTRO-
CONVULSIVE THERAPY
This form must be accomplished in mental hospitals before the
administration of electroconvulsive therapy. (See Appendix)
II. CONSENT TO AUTOPSY
The consent to autopsy must be properly signed, by whoever is
the next of kin or executor of the deceased, before doing the procedure.
(See Appendix)
12. REFUSAL TO CONSENT TO AUTOPSY
This form should be accomplished in cases where it is applicable,
by the next of kin of the deceased. (See Appendix)
13. REQUEST FOR ACCESSTO MEDICAL RECORDS
This form must be accomplished by the patient and other
authorized parties before any information, of clinical nature, can be
released by the hospital or health facility. (See Appendix)
14. NOTIFICATION TO PHYSICIAN OF REQUEST FOR ACCESS
For the information of the attending physician, a notification
form must be accomplished, every time a request for medical
information is received by the Medical Record Service. (See Appendix)
15. CERTIFICATEOF CONFINEMENT
This certificate should be accomplished and signed by the medical
record supervisor and should bear the hospital seal. It should also
have a control number for authentication purposes. (See Appendix)
16. MEDICAL CERTIFICATE
This certificate should have a control number. It must be signed
by the attending physician and must bear the hospital seal. (See
Appendix)
17. DISPOSITION OF CADAVER
This form shows all the steps to be taken following the death of a
patient. If each item is accomplished correctly, then the hospital and
its staff will be free from any legal liability. (See Appendix)
71
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HANDIlNGlELEPHONEINQUIRIFS
The MRS receives numerous telephone calls which involve requests for
information. Great care should be taken before giving any form of
information. These inquiries may come from the following:
A. A doctor asking information about a person who has been a patient
in the hospital
B. A patient presently confined at the hospital
C. Aformer patient of the hospital whowants information about himself/
herself
D. A friend or relative of a patient
E. A police officer
F. A government agency (e.g., GSIS, SSS, NBI, etc.)
The following are the procedures for handling such inquiries.
A. .FROM A DOCTOR
1. Ensure that the doctor identifies himself clearly.
2. Find out the name of the patient; date of birth, if possible, or
other identifying information; and the approximate date of
admission.
3. Locate the patient number from the MPI in order to find the
record from the file.
4. The record shall be forwarded to the supervisor of the MRS
for him to answer the inquiry.
5. The supervisor shall take the name and address of the doctor
for reference purposes.
B. FROM A PATIENT
I Ask the patient for identifying information and find out what
he/she wishes to know.
2. Only the following data can be given directly to the patient
without the approval of the attending physician: admission
and discharge dates, name of the attending physician, and
other sociological data except any clinical information.
3. Ifan approval has been obtained from the attending physician,
the patient may have the right to access. all the clinical
information needed.
C. FROM FRIENDS AND RELATIVES
Any information about a patient shall not be given to the patient's
friends or relatives without a written consent.
D. FROM THE POUCE
Any information regarding patients are not to be released to the
police except when there is a written request signed by the head of the
police department. The police should be reminded that the said
information can only be used for legal purposes.
72
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E. FROM GOVERNMENT AGENCIES
The only information that may be released to government agencies
over the telephone are the admission and discharge dates and the
name of the attending physician. The patient's written consent shall
be required should any additional information be needed.
DEAliNG WfIH PEOPLE WHO COME TO
TIlE MEDICAL RECORDS SERVICE
A variety of people approach the MRS to make inquiries or to borrow
records. The procedures for handling such inquiries are as follows:
I. Ascertain who the person is.
2. If the person wants to borrow any record, refer to "Handling Request
for Records" (see p. 3).
3. If the person is requesting information about a patient, follow the
guidelines in "Handling Telephone Inquiries" (see p. 72) and in the
"Release ofInformationPolicy" (see p. 5). .
4. Refer any problem to the medical record supervisor.
73
74
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QUAllTYASSURANCE PROGRAM
FORTIlEMEDICAL RECORD
QualityAssurance Program (QAP) is a planned and systematic approach
to monitoring and assessing the patient care provided or the service being
delivered. Quality Assurance identifies opportunities for improvement and
provides a mechanism through which action is taken to make and maintain
these improvements.
Quality assurance should encompass the evaluation ofstructure, process,
and outcome. Structure factors include components such as staffing, funding,
and risk factors. Process, on the other hand, includes the care process and
its components like diagnostic, therapeutic, and after effects ofcare. Outcome
factors involve health status components such as physical functioning, patient
or physician satisfaction and wellness level. .
The essential elements of Quality Assurance activities are as follows:
1. Planned and Systematic Approach - a quality assurance plan should
exist and address the following:
a. Scope of the program
b. Objective
c. Methods to be used
d. The individuals to be involved in the program
2. Monitoring - there should be a systematic ongoing process of collecting
information on clinical and non-elinical performance.
3. Assessment - the periodic analysis and interpretation ofthe information
collected in order to identify problems in patient care.
4. Action - at this stage important problems in patient care or
opportunities to improve care are identified, action/ studies are
undertaken.
5. Evaluation - the effectiveness of actions taken is evaluated to ensure
long-term improvement.
6. Feedback- to be effective, results of the activities should be regularly
relayed to the staff or people involved in the program.
75
1
Action
IL- --.J
I I
Follow-up Monitoring
1__----. __--11
Ir
Feedback
.------'1 L.I__---,
Cycle of an Effective Quality Assurance
Benefits that Can Be Derived from the Ouality Assurance Program (OAP);
1. Highest level of care is achieved by assuring the quality and
appropriateness of care.
2. The institution can save money by increasing efficiency and/or by
reducing risks or simply for cost-containment purposes.
3. The program will result in an effeetive utilization of resources.
4. Adverse effects will be prevented.
The MRS and QualityAssurance Program
The Q\P of the MRS shall be an ongoing program. It must look into
the effectiveness of the services offered and resource utilization.
Some activities in Quality Assurance Programs in the health services are
peer review, medical and nursing audit, medical record review, utilization
review, morbidity and mortality review, and risk management. The main
concern ofQuality Assurance is to subject the structure, process and outcome
of health delivery to an objective, professional scrutiny.
The objective of the QAP of the MRS should reflect the overall objectives
of the organization/ institution.
Objectives:
1. To achieve good health care data/informarion processing and to
facilitate the delivery of quality patient care;
2. To attain cost-effective medical record management;
3. To see to it that all the procedures and practices of the MRS conform
with acceptable standards;
4. To assess and determine the quality of service delivered and to identify
the areas which need improvement to attain the excellent service
delivery;
5. To further improve the services contributed by the MRS in the
attainment of the institutional goals and objectives; and
6. To provide feedback to facilitate necessary corrective actions, identify
staff in-service training needs, provide an objective basis for
disciplinary actions, encourage each employee to achieve the optimum
level, and recognize excellence in employee performance in order to
institute staff development.
76
Hospital Medical Records Management ~ n u l
STEPS INVOLVED IN DEVELOPING A QUALITY
ASSURANCE PROGRAM FOR THE MRS
The procedures/steps in the development of a QAP in the MRS are as
follows:
1. The identification of problems inherent in specific process or activities
involved in medical record management.
a. The main activities involved in the Medical Record
Management are: recording, assembly, analysis (Qualitative and
Quantitative), coding, data collection, statistical preparation,
filing ofcharts and indexes, retrieval process, release of medical
information, and other legal matters.
b. An ongoing QAP shall also be done to study other identified
problems.
2. Establishment of the Objective
The general objective of Quality Assurance should be to improve
the status ofservice delivery in order to contribute to the improvement
of the quality of patient care. .
This step should specify what is to be achieved and how to attain
the set objective.
In stating the objective, use phrases such as "to ascertain", "to
. "" n" d ." d'" . "
examme , to assess, to etermme, an to investigate.
Example:
* To determine the accuracy of documentation through
qualitative and quantitative analysis.
* To assess the effectiveness of the follow-up system employed.
3. Choose the Assessment Method and select the sampler
At this stage, the sample size is to be decided on (whether it should
be document-based, questionnaire, or direct observation assessment),
and the time frame of the program is to be set.
Example:
* What percentage of the dailyadmission record is to beassessed ?
* Until what month should the assessment be done?
4. Develop Criteria and Set Standards
Identify the established standards, regulations and performance
criteria that have an impact on the MRS.
The standards for each criteria may be set individually according
to what can realistically be expected or what the goal is (e.g., 80-90%)
rather than always being set at the optimum (i.e., 100%).
There should be instructions as to the acceptable deviations from
the standards. This standard may be reset after the initial survey if
circumstances warrant.
77
In developing the criteria, select thosewhichcouldbe compared tothe set
standards. Criteria should bemeasurable rather than descriptive.
Example:
Element Standard
Consent forms should be;
a. Signed by the patient
b. Dated
c. Signed by a witness
Yes/No)
Yes/No) 100%
Yes/No)
5. Assessment of the Actual Procedure
The actual procedure undertaken is assessed against the criteria
set and the differences are noted. Assessment could be done through:
observation, statistical data, random sampling, and reports.
6. Analyze Results
Results should be properly analyzed and differences in procedure
compared with the criteria set. Determine whether the variation
is justifiable.
Since individuals absorb information in different ways, it is helpful
to summarize results by using more than one method.
7. Institute Appropriate Action
Appropriate action on identified problems must be directed to
institute some changes. These changes are as follows:
a. Changes in systems and procedures
b. Changes in policies, rules, and regulations
c. Changes in format of forms
d. Better and effective lines of communication
8. Re-evaluation of the corrective actions taken should be done to
document its effects and benefits.
It is necessary to conduct a follow up study on the same topic to
determine whether the problem' has been corrected or. not.
When setting priorities in Quality AssuranceProjects, the following
must be considered:
a. Severity of problem
b. Potential impact on the service provided and on patient care
c. Anticipated benefits (including cost benefits)
d. Staff and money resources required for the study, time required
to analyze data, and the identified problems
e. The potential for correction of the problem
78
EXPECTED OUTCOMES OF THE QUALITY
,ASSURANCE PROGRAM
L Demonstrable and higher standards of clinical and non- clinical care
and service,
2. Identification of barriers in the achievement of higher quality patient
care;
3. Motivation for the staff to be more awareofand interested in standards
of patient care and service.
4. Delivery of safe and efficient care and service.
5. Efficient and effective allocation and use of resources.
6, Commitment from staffwhich will ensure that the program is ongoing,
and improved standards are long lasting.
7. Construction input, from all staff levels, into the continuing education
program of the complex.
8. Communication at all levels about problems related to standards of
quality care and service.
9. Cooperative problem-solving, where a service involves more than one
area in the complex.
The following areexamples of medical record qyalitrassurance evaluationforms:
CRITERIA SET ON PHYSICAL FACILITIES AND
EQUIPMENT
Objectives:
L To determine whether there is a separate MRS;
2, To determine ifavailable space is sufficient to accommodate incoming,
active, and inactive records;
3. To determine if there is an allocated area to the Medical Record Staff
and doctors for the completion of medical records/charts; and
4. To look into the security of the storage/filing area to protect the
confidentiality of the Medical Record.
Criteria Sample Standard Standard j:omments
Size Set Achieved
L Is there an N/A Space sufficient to
established maintain MRD for
MRS/Unit? 25 years based on
prospected number
of patients.
2. Isthere a 6Iling N/A S-yrs. storage space for
area for Active active file; 2a-years
and Inactive In- storage for inactivefile
coming records ?
79
Criteria Sample Standard Set Standard ~ o m m n l
Size Achieved
3. Is the filing/ N/A Filing/Storage area
storage area secured to prevent
secured to unauthorized entry
ensure the
confidentiality
of the medical
record?
4. Is the area N/A There must be a
allocated for sufficient area where
completing the the staff could work
charts/records, and the doctors could
in relation to complete the charts/
the number of records.
doctors and staff,
enough?
5. Are there enough There must be enough
filing cabinets space to accomodate
to accommodate the systematic filing
. . .
of medical records mcommg, active,
and inactive
records?
Evaluation Criteria (Physical Facility and Equipment)
Administrative Function of the Medical Record Service
Criteria
y
N N/A Comments
I. Is there a manual of procedure
prepared bythe Medical Record
Supervisor ?
2. Is there a Record disposition
schedule approved by
management and the
govenunent agency concerned ?
3. Is there a policy on release of
clinical information?
4. Isthere a program of continuing
education/orientation
conducted by the MRS?
80
Policies
Criteria
y
N N/A Comments
1. Is there a policy formulated
for the release of clinical
information?
2. Is the policy for the release of
information enforced?
3. Are policies written for the
information of all concerned?
4. Is the objective of the MRS
clearly stated in the policy?
5. Is the policyformulated by the
MRS consistent with the
hospital-wide policies?
6. Arepolicies circulated for the
information and guidance of
all concerned ?
7. Does the policystatethe person
authorized to enforce it ?
8. Was the policy formulated in
consultation with all people
affected?
9. Is the policyupdated to reflect
the latest trends in Medical
Record Management ?
CRITERIA SET ON PROCESS
Medical Record Management
Objective:
To determine the qualitative and quantitative aspects of medical
records forwarded to the MRS
Criteria Sample Standard Standard Comments
Size . Set Achieved
1. Do all the pages
of the record.
bear the;
- Patient's name 100 -100%
- Record No. 100 100%
81
Policies
TOPIC: Medical Record Forms Date:
Criteria
y
N N/A Comments
1. Do all forms have space for;
a. Name-
b. Patient Number
2. Do all forms have space for
physician's signature?
3. Do all forms have space where
the date could be written by
the doctor?
4. Do all forms have the name
of the hospital?
5. Do all forms have a control
number?
PROCESS
TOPIC: Medical Record Content
Date: _
Criteria
y
N N/A Comments
1. Is the sociological data of the
patient complete?
2. Does thehistory of thepatient
contain the following:
,
,
a. Present history
b. Past history
c. Family history
d. Social history
3. Are theentries signed anddated
bythe people concerned ?
4. Does the consent form bear the
signature of the patient?
5. Isthe consent form dated and
signed by a witness?
6. Are all pages of the charts
correctly identified?
7. Are all results of the requested
examinations properly attached
to the chart ?
82
, .
Criteria
y
N N/A Comments
8,' Does the discharge note of the
nurse state the following:
a. The condition of thepatient
b. The mode of discharge
c. The person who was with
the patient
d. The medication instruction
PROCESS
TOPIC: Loose Sheets Date:
Criteria
y
N N/A Comments
L Are all loose sheets forwarded
to the MRS stamp dated?
2, Are all loose sheets filed as soon
as they reach the MRS ?
3. Are loose sheets sorted upon
receipt?
4. Are allloose sheets filed in their
correct charts ?
5. Do all theloose sheets bear the
, ,
name and the number of the
patient?
6. Does the MRS maintain a record
ofloose sheets?
PROCESS
TOPIC: Disease and Operation Coding Date:
Criteria
L Are all procedures properly coded ?
2. Are all diagnoses coded ?
3. Does the disease index card
contain only one diagnosis?
4. Does the operation index card
contain only one procedure'?
Y N N/A Comments
83
;
Criteria
y
N N/A Comments
5. Are the disease and operation
index cards arranged according to
disease and operation numbers ?
6. Isthe morphology code (M code)
used in coding neoplasms?
7. Are the disease and operation
indexes updated daily?
8. Are abbreviated final diagnosis
coded?
9. Are all diagnosis written on the
chart located on the coding
tools used?
PROCESS
TOPIC: Filing and Retrieval Date:
Criteria
y
N N/A Comments
I. Is the terminal digit filing
system employed?
2. Are records sorted prior to filing?
3. Is the unit numbering system
used?
4. Does the MRS maintain active as
well as inactive files ?
5. Does the MRS maintain a
centralized records keeping
system?
6. Are there captions to guide the
filing and retrieval process?
7. Isthefile area secured to prevent
unauthorized entry?
8. Are the cabinets arranged for a
minimum of walking?
9. Does the MRS maintain the
following indexes;
a. MPI
b: Disease index
c. Operation index
d. Physician's index
84
J
.
.Hospital MediCal Records Management Manual
Criteria
o' y
N N/A Comments
10. Are the following registers
maintained by the MRS:
a. Admission and discharge
b. OPDand ER
c. Birth and Death
d. ORand DR
PROCESS
TOPIC: Unlocated Records Date:
Criteria Y N N/A Comments
1. Are all requested records located ?
2. Are all requested records entered
intot:he
3. Isthein-house box updated daily ?
4. Are all therecords in their proper
filing places?
5. Are incomplete records filed in
their respective pigeonholes?
6. Are allthe records lent emproperly
acknowledged bythe authorized
borrower?
7. Does the SOP clearly state the time
element in borrowing charts?
CRITERIA SET ON OUTCOME
TOPIC: .Retrieval.and Completion Times Date:
Objective:
1. Todetermine whether incomplete records of in-patients are completed
within 48 hours after discharge
. .
2. Toassess if a research list can be promptly obtained from the disease
and operation indexes
3. Toassess if a research "Jist can be promptlyobtained from the diseases
and operation indexes
4. To be able to determine whether records are available any time they
are requested
85
CRITERIA ESTABLISHED
Criteria Sample Standard Standard Comments
Size Set Achieved
1. Are records 50 90%
completed within requests
48 hours after
,patient's
discharge?
2. Canaresearch 50 100%
list furnished by reqoess except records not yet
researchers, forwarded to theMRS
promptly be
obtained from the
disease or opera-
tion indexes?
3. Are all requested 50 100%
records made requests except forcharts not yet
available to forwarded tothe MRS
borrowers? and records under
process
RECOMMENDATIONS:
FOLLOW-UP:
EVALUATION:
86
OUTCOME
TOPIC: Assessment of Q!lalityAssurance Program
Objectives:
1. To knowthe extent of the implementation of the recommendations
as a result of the Quality Assurance P-rogram
2. To determine whether there is an improvement in communication
with services/departments concerned as a result of the Quality
Assurance Program .
3. To determine whether there is a need to change or revise systems and
procedures as a direct result of the Quality Assurance Program
4. To be able to know whether there is a need for staff training after
analysis and evaluation of the result of Quality Assurance datagathering
5. To know if results and recommendations have reached the people
concerned
CRITERIA ESTABLISHED
Criteria Standard
Set
Standard
Achieved
Comments
1. What is the percentage of 75.:s00f0
implementation of
recommendations and
suggestions made?
2. Hascommunication improved
between departments concerned
asa result of theQuality
Assurance Program ?
3. As a result of the Quality
Assurance Program, is there a
need to revise or change some
systems and procedures?
4. Is there a need to re-train the
medical record staff?
RECOMMENDATIONS:
FOLLOW-UP:
87
- ,
QUALITY ASSURANCE ACTMTY
SUMMARY SHEET
TOPIC:
Problems Identified:
Action:
Follow-up:
Review Date: _
QA. Coordinator _
Date signed: _
"QUALITY ASSURANCE STIJDY
Name of Hospital
FORM A. CRITERIA
TOPIC: _
Dale _
..
.C S
r
t
1
a
I n Instructions
e. Criteria .. d Exceptions for
.'
retrieval r a
1 r of
a
d data
,N 0I0-
o.
1
2
3
-4
5
6
7
8
.
9
10
QUALITYASSURANCE STUDY
NAME OF HOSPITAL
FORM B-WORK DOCUMENT
. TOPIC _
Page _
Date _
I I
CRITERIA
; ~
Document
Number
, .
.
QUALITY ASSURANCE STUDY

NAME OF HOSPITAL
FORM C-SUMMARY
TOPIC _ Date _
. Study Objectives Source Document(s)
No. in study
Tune period mstudy
_LJ-
to ----l----l_
Assessment method
Original study? Date oforiginal study ----l----l_
No. Criteria Overall
Results
Total Rate CONCLUSION/PROBLEMS/
No. in /0 RECOMMENDATIONS/ACTION/FOLLOW-UP
..
,
.' .
e.,
. 92
...."
., ,
'....
""
"
c..;
MEDICAL RECORD FORMS
A form is an intelligence document, an advisor, an instruction, and a
record. It is also an instrument to collect, record, transmit, request, report,
evaluate, store, and retrieve data. A well-thought and properly-designed
form facilitates the collection of only the needed and relevant data and thus
prevents the excessive use of resources.
Research shows that a hospital spends at least 1% to 2% of their entire
expenditure on the printing and supply of medical record forms. With the
present escalating hospitalization cost beyond the reach of an ordinary
Filipino citizen, coupled with general economic recession, there is an urgent
need to cut down on health care expenditures. However, cost control measures
must be achieved by the standardization of forms used in the MRS and not
by sacrificing overall quality care. In 1969, a study group from the World
Health Organization (WHO), recommended that "consideration should be
given to standardizing the medical record at the national level, to include
the size of the folder, the size of the record form, and the content ofthe case
summary. This should be within an individual hospital or with all hospitals
of a system."
Effectiveforms management should be an integral part of medical record
management. A Forms Committee shall be established to help the Medical
Record Supervisor in determining forms needed by the hospital as well as in
the proper design of the forms. The function of the Forms Committee can
also be performed by a Medical Record Committee, if this committee is
already in existence and should management decide.
Medical record forms consist of standard/basic and supplemental/special
forms. Standard forms are those that are commonly found on all patient
charts. Supplemental forms are forms added to selected patient's chart
during their hospitalization. The addition of supplemental forms depends
upon the patient's care and treatment.
Some hospitals usually include other forms which the MRS and the
Forms Committee has approved. These forms could also be considered
"standard forms" for their own hospital only.
Ii
All hospitals have forms that correspond to the ten "BASIC" or
"STANDARD FORMS" only they may be called differently. Some of the
common names of the basic forms are as follows:
1. Admission-Discharge Record, Summary Sheet, In-patient Summary,
Patient Information Sheet, Patient's Identification, Clinical Cover
Sheet, Face Sheet
2. Conditions of Admission and Authorization for treatment
3. Personal History Record
4. Physical Examination Record
5. Physician's Order and Doctor's Order Sheet
6. Laboratory Record, Laboratory Report, Laboratory Results
7. Clinical and Graphic Record- Graphic Chart and Temperature, Pulse,
and Respiration (TPR) Chart
8. Progress Record, Progress Notes, Progress Doctors's Notes
9. Nurses' Notes - Nursing Record and Bedside Record
10. Discharge Summary
SUMMARY OR FACE SHEET
The summary or face sheet is used to summarize the patient's hospital
stay. The attending physician usually accomplishes this form at the patient's
dischargedate. Other information about the patient (e.g., admission diagnosis,
relatives ofthe patient, healthinsurance policy, etc.) maybe included.
LABORATORY REPORT
The laboratory report sheet is used for filing reports of laboratory
findings. This sheet must allow the results of the laboratory tests to be
pasted systematically.
GRAPHIC SHEET OR CLINICAL RECORD
The graphic sheet is a graphic representation of the patient's vital signs
(e.g., TPR and blood pressure) for the period of hospitalization. Vital signs
are normally taken at least twice a day or depending on the doctor's order.
Information on other treatments and measurements (e.g., enemas, bowel
movements, height, weight, intake and output) may also be recorded on the
Clinical Record Sheet.
MEDICATION RECORD
This form contains all the medications given by the nursing staff. As
new medications are ordered by the attending physician, the name of the
drug, dosage, administration route, and frequency of administration are all
written on this form.
PROGRESS NOTES
This form should provide a summary of the condition of the patient
upon admission and the chronological record of the patient's progress. This
form should record consultations, complications, condition of surgical
wounds, development of infection, removal of sutures and drains, use of
casts and splints, and any other pertinent data. Progress Notes should
conclude with a summary of the case with condition on discharge.
APPENDICES
I

t.
SUPPLEMENTAL CHARTFORMS
Supplemental forms are added to the basic chart forms to make it
complete as required by the case. Some supplemental forms may be considered
basicforms bya certain type of health care booty, but other hospitals may not
This classification of the different kinds of forms in the medical record
is influenced by the type of health care facility. For example, a maternity
hospital may consider pre-natal form as a basic form, but a pediatric hospital
may regard this as a supplemental or special form.
Some of the common supplemental forms are as follows:
1. OPERATING ROOM RECORD
Operating room record is a part of the "Operation Block." Other
forms that goes with the operation block are the consent for surgery,
anesthesia record. and the recovery room record. When a tissue is
removed, there shall be a tissue report or biopsy report.
TISSUE/BIOPSY REPORT - Where a tissue is removed during
operation a tissue/biopsy report should be forwarded to the pathology
section together with a corresponding request. The original copy of
this report shall become part of the medical record.
2. CONSULTATION FORM
A doctor may wish to obtain the opinion of another doctor or
specialist. in which case, a consultation form is accomplished. This is
also the same form where the consultant writes his findings.
3. DIABETIC RECORD
This form is placed in the charts of patients who are receiving
medication for diabetes. The form also contains the results of blood
test and urine studies done to monitor the effects of diabetic
medication.
4. ANTI-COAGULANT THERAPY RECORD
5. VITAL SIGNS RECORD
6. PULMONARYLABORATORY BLOOD GAS ANALYSIS.
7. PULMONARYFUNCTION TEST
8. FLUID INTAKE AND OUTPUT CHART
9. PARENTERAL FLUID SHEET
10. INTRAVENOUS FLUID SHEET
95
TI-lE CONCEPrOF "SET"AND"BLOCK" FORMS
The concept of"set" and"block" forms in the medical record helps to
determine the completenessof the medical record. . .
A "set" is a collection of forms of the same type treated as a unit. A
good example of this are the progress notes, nurses' notes, 'ere, A "block" is
a collection ofdifferent types offorms' treated as a unit. Examples of blocks
.. are Operation block, Delivery block, and Electrocardiogram (ECG/EKG)
block.
Thorough knowledge of the different components of a block facilitates
faster quantitative analysis ofthe medical record. A procedure considered to
le one of the major functions of the Medical Records Service.
96
I1STINGOF COMMONMORTAlITY;
MORBIDITY: AND CONSULTATION DIAGNOSIS
IN GOVERNMENf HOSPITAlS
This listing includes the most common diagnosis, operation, and
procedures reported by government hospitals. The following data weretaken
from statistical and other reports prepared by the different hospitals. The
disease and operation index of some assessed and evaluated hospitals were
likewise used as a source material for this listing.
ICD 9 CODE NO. DISEASES/CONDITIONS
OPERATIONS/PROCEDURES
ABORTION
Complete abortion
Incomplete abortion
Spontaneous abortion
Threatened abortion
ACCIDENT. CEREBROVASCULAR (CVA)
With paralysis
Old or healed with paralysis
ACQUIRED IMMUNEDEFICIENCY
SYNDROME (AIDS) (NOS)
With specified infection
Causing other specified infections
With specified malignant neoplasms
ADMISSION FOR
Chemotherapy
Radiotherapy (solely)
ADVERSE EFFECTS. DRUGS (NOS)
AMOEBIASIS
Amoebiasis colitis
Amoebiasis, Instestinal
Amoebic Dysentery
ANEMIA
Anemia with hypotension
Chronic blood loss anemia
Iron-deficiency anemia
Pernicious anemia
Posthemorrhagic anemia
Severe anemia

I
ACCIDENTS
Dislocations
Food poisoning (NOS)
Fractures
Physical Injury
Trauma and other current injuries
6J1.9
6J1.8
6J1.9
634.9
640.0
E928.9
830-839
005.9
800-829
830-839
959.9
436
436 & 344.9
344.9 & 438
044.9
042.0
042.1
042.2
V58.1 .
V58.0
995.2
006.0
006.9
006.1.
006.0
285;9
285.9, 458.9
280
280
281.0 ,
285.1
289.8
ICD 9 CODE NO.
"-'
DISEASES/CONDITIONS
.OPERATIONS/pROCEDURES
ANGINA PECTORIS
ANOPLASTY
ANOREXIA(loss of appetite)
ANXIETYSTATE
APPENDICITIS (NOS)
Appendicitis; acute
Appendectomy
Rupture Inflamed appendix
AKfHRITIS. RHEUMATOID. CHRONIC
ASPHYXIA NEONATURUM
ARREST
Cardiac
Cardiorespiratory
Respiratory
ARl"ERIOSCLEROSIS. ARl"ERIOSCLEROTIC
Cardiovascular disease ASCVD
Cerebrovascular disease
Extremities (peripheral)
Generalized
Heart (disease) ASHD
ARTHRALGIA (pain in joint)
ARTIFICIAL OPENING STATUS
Colostomy
Cystostomy
Gastrostomy
Ileostomy
Other artificial opening,
Gastrointestinal tract
Other artificial opening,
Urinary tract
Other specified site (NOS)
ASCITES. ABDOMINAL
ATELECTASIS. PULMONARY
BELL'S PALSY
BIOPSY OF CERVICAL LYMPH NODE
BLEEDING. POSTMENOPAUSAL (PMB)
BLOCK. LEFT BUNDLE BRANCH
BRONCHITIS (NOS)
Acute Bronchitis
Asthmatic
Emphysematous
413
5-4%
783.0
300.0
541
540.9
5-470
540.0
714.0
768.9
427.5
799.1
799.1
429.2
437.0
440.2
440.9
414.0
719.4
V44.3
V44.5
V44.1
V44.2
V44.4
V44.6
V44.8
789.5
518.0
351.0
1-586
627.1
426.3
490
466.0
491.2
491.2
..
DISEASES/CONDmONS ICD 9 CODE NO.
OPERATIONS/pROCEDURES
. . . .
BRONCHOSCOPYWITH BIOPSY 1432
BURNS
erythema (first degree)
blisters, epidermal loss (second degree)
full-thickness skinloss(third degree, NOS)
deep necrosis of.underlying tissues
(deep third degree)
CESAREANSECTION
lowsegment (low transverse)
classical
cervical
extraperitoncal ceasarean section
CARCINOMA (See Neoplasm, Malignant)
CATARACT
mature (senile)
presenile
PHYSICAL CHECK-UP
CHEILOPLASTY
CHOLECYSTECTOMY WITH INTRA-
OPERATIVECHOLLANGIOGRAM
CHOLERA
CIRRHOSIS. LIVER
CLEFT LIP & PALATE
COLD. COMMON.
COLITIS <NOS)
due to radiation
infectious (NOS)
Ulcerative
COLOSTOMY
colocentesis
closure
formation
loop
- excision of lesion
- hernia
- reVlSlon
COMATOSE
COMPLICATION OF
colostomy
ileostomy- .
tracheostomy
CONCUSSION
CONSTIPATION
949.0
.1
.2
.3
.4
5-74
5-741
5-740
5-741
5-742
366.1
366.0
V70.0
5-898
5-511
001.9
571.5
749.2
460
558.9
558.1
009.0
556
5461
5461
5465
5461
5460
5460
5464
780.0
569.6
569.6
519.0
850.9
564.0
DISEASES/CONDmONS
CONVULSION (cerebral)
CORPULMONALE
COUGHS
CYSTOSTOMY (urinary bladder)
suprapubic
CYANOSIS
CYSTITIS (NOS)
DEFICIENCY. VITAMIN (NOS)
DEHYDRATION
DELIVERY
normal
spontaneous
cesarean
paturition
PUFT
still birth
DEMENTIA
presenile (NOS)
senile (NOS)
DEPRESSION (NOS)
neurotic
DEPRESSIVE REACTION. BRIEF
(GRIEF REACTION)
prolonged
DERMATITIS (NOS)
due to drugs or medicines
due to radiation.
exfoliative
seborrheic
DIABETES
mellitus (all inclusive)
use the following fifth digits:
o-adult-onset or unspecified as to type
1 - juvenile type
diabetic coma
(with ketoacidosis)
diabetes with gangrene
diabetes insipidus
diabetic ketoacidosis
DIARRHEA (NOS)
infectious
acute
DILATATION & CURETTAGE
DIPTHERIA
ICD 9 CODE NO.
780.3
416.9
786.2
5-572
5-572
782.5
595.9
269.2
276.5
650
650
669.7
650
650
779.9
290.1
290.0
311
300.4
309.0
309.1
692.9
692.3
692.8
695.8
690
250.0
250.2
250.6 + 785.4'
253.5
250.1
558.9
009.2
009.3
5-{;90
032.9
ICD 9 CODE NO.
DISEASES/CONDITIONS
OPERATIONS/PROCEDURES .
DISEASE
chronic obstructive lung. disease (COPD)
chronic bronchitis
emphysema
bronchial asthma
broncheictasis
tuberculous
asthma, intrinsic
extrinsic asthma due to detergent
heart (organic)
cerebrovascular (NEe)
viral (NEe)
DISLOCATION. HIP. TRAUMATIC. (NOS)
DISORDER. SLEEP. (NOS)
DISTENTION. ABDOMINAL
DOGBITE
DYSARTHRIA
DYSCRASIA. BLOOD. (NOS)
(See also Leukemia)
DYSPNEA (shortness of breath)
DYSPHAGIA (NOS)
DYSURIA (PAINFUL URINATION)
EMBOLISM. PULMONARY
ELECTROLYTE IMBALANCE
EMESIS (VOMITTING)
EMPYEMA (NOS)
With Fistula
ENTEROSTOMY
with modification
ENURESIS (NOS)
EPIGASTRIC OR ABDOMINAL DISTRESS
(NOS)
EPILEPSY (NOS)
ERYTHEMA (NOS)
ESOPHAGEAL REFLUX
EPISIOTOMY WITH MID-
FORCEP DELIVERY
EXAMINATION. HEALTH
(See Physical examination)
4%
491.8
491.2
493.9
494
011.5
493.1
507.8
429.9
4JZ9
078.8
835.9
780.5
787.3
071
784.5
289.9
786.9
787.2
788.1
415.1
276.9
787.0
510.9
510.0
5-463
5-464
788.3
789.0
345.9
695.9
530.1
5-722
FAILURE
Cardiorespiratory
Congestive heart failure (CHF)
Hepatic, acute
Respiratory
Renal, acute
Renal, Chronic
FEVER (NOS)
Typhoid.
Denque
Interic
Hemorrhagic Fever
FEVEROF UNKNOWN ORIGIN (PYREXIA)
FIBROCYSTIC DISEASE
Breast
FISTULA
Anorectal
Tracheoesophageal, following tracheostomy
FRACTURE
Hip (NOS)
Pathologic
GANGRENE (NOS)
Arteriosclerotic
Diabetic
GASTRITIS
Acute
Severe
GASTROENTERITIS (NOS)
Acute
With Amoebiasis
Infectious (NOS)
Infections due to Escherichia Coli
Viral (NOS)
GLAUCOMA. OPEN-ANGLE.
CONGENITAL
GOITER
Adenomatous
Diffuse
GLYCOSURIA
GUN SHOTWOUND (seewounds open)
HANSEN'S DISEASE (See Leprosy)
HEADACHE (cephaIgia)
HEMATURIA
799.1
428.0
570
799.1
584.9
585
780.6
002.0
061.
002.0
065.9
780.6
610.1
565.1
519.0
820.8
733.1
785.4
440.2 + 785.4'
250.6 & 785.4
535.5
535.0
535.0
558.9
535.0
535.0, 006.9
009.0
008.0
008.8
743.2
241.9
242.0
791.5
0399
784.0
599.7
455.1
5-493
789.1
550.9
786.8
431
578.9
666.1
430
573.3
070.3 + 573.1'
VIOA
VIOA
VlO.5
8-853
8-860
8-853
786.3
V14.5
V14.1
V14.8
V14.0
V14.2
V14.9
V45.0
ICD 9 CODE NO.
HEPATOMEGALY
HERNIA
Inguinal
HICCOUGHS
HISTORY OF
Allergy to
Narcotic agent
Other antibiotic
Other medication (NOS)
Penicillin
Sulfa
Unspecified medication
Cardiac pacemaker
Malignant Neoplasm of
(Usethesecodes when neoplasmhas been removed) ..
Abdominal cavity (NOS) VlO.8
Anus VlO.O
Bladder VlO.5
Bone VlO.8
Brain VlO.8
Breast VI0.3
Bronchus VlO.1
Cervix uteri VIOA
Connective tissue (NEC) VI0.8
Digestive system (NEC) VI0.0
Esophagus VlO.O
Eye VI0.8
Gallbladder VI0.0
Genital organ or tract (NOS)
Female
Male
Kidney
DISEASES/CONDITIONS
DIALYSIS
Hemodialysis .
Peritoneal
Renal
HEMOPTYSIS
HEMORRHAGE
Cerebral
Gastric Hemorrhage (gastrointestinal)
Post Partum
Subarachnoid
HEPATITIS
Hepatitis B, viral
HEMORRHOID
Hemorrhoid Internal Thrombosed
Hemorrhoidectomy
ICD 9 CODE NO. DISEASES/CONDmONS

Large intestine
And rectum
Larynx
Liver
Lung
Mouth
Nervous system (NEe)
Ovary
Pancreas
Penis
Pharynx
Prostate .
Rectum (includes rectosigmoid
junction and overlapping sites)
Respiratory organs (NOS)
Salivary gland
Skin
Small intestine
Stomach
Thyroid
Tongue
Urinary organ (NEe)
Uterus (NEe)
Vagina
H.I.V. POSITIVE STATUS
HODGKIN'S DISEASE (NOS)
HYPERESTHESIA SKIN
HYPERKALEMIA
HYPERTENSION. HPN (NOS)
Malignant
HYPERTROPHY, PROSTATIC. BENIGN
HYPOGLYCEMIA
HYPOKALEMIA
HYPOTENSION. ORTHOSTATIC
HYSTERECTOMY
Total abdominal
Partial
IMPACTION. FECAL
INCONTINENCE
Urine (stress) (neurogenic)
Feces
INDIGESTION
VIO.O
VIO.O
VlO.2
VlO.O
VIO.I
VIO.O
VIO.8
VIOA
VIO.O
VIOA
VIO.O
VIOA
VIO.O
VlO.2
VIO.O
VlO.8
VlO.O
VlO.O
VlO.8
VlO.O
VlO.5
VIOA
VIOA
795.3
201.9
782.0
276.7
401.9
401.0
600
251.2
276.8
458.0
5-683
5-683
5-683
560.3
788.3 .
787.6
536.8
ICD 9 CODE NO.

DISEASES/CONDITIONS
INFARCTION
Myocardial"Acute
(8 wks. old or less), (NOS)
Subendocardial
Myocardial, old or healed
INFECTION
Genito-urinary tract (see also urinary tract)
Upper-respiratory tract, Acute (NOS)
Urinary Tract
INFLUENZA
INJURIES. PHYSICAL (NOS)
INSUFFICIENCY
Chronic respiratory (NOS)
Coronary (acute or subacute)
JAUNDICE (NOS)
KIDNEY DONOR
KOCH'S DISEASE
(See Tuberculosis)
LAPAROTOMY. EXPLORATORY
LARYNGITIS
due to radiation
Acute
. Chronic
410.9
410.7
412
599.0
465.9 .
599.0
487.1
959.9
786.0
411.8
782.4
V59.4
5-541
508.0
508.1
LEPROSY
(see also Hansen's Disease)
Macular Tuberculoid 030.1
LEUKEMIA
(See also Blood Dyscracia)
(Always use M-code or Morphology code to
facilitate cancer/neoplasm research.)
Lymphatic 204.9
Lymphosarcoma cell 207.8
Monocytic (NOS) 206.9
Myeloid (NOS) 205.9
Other Specified type 207.8
Unspecified 208.9
LIGATION V25.2
Female
Tubal, Bilateral 5'<;64
Tubal, Unilateral 5'<;69
Male
vas deference, bilateral 5-981
vas deference, unilateral 5'<;36
LUMBAGO 724.2
ICD 9 CODE NO. DISEASES/CONDmONS
LYMPHOMA
Benign (NOS)
Malignant (NOS)
Follicular or nodular
LYMPHOSARCOMA (NOS)
Follicular or nodular
Mixed cell type
MALARIA
Cerebral Malaria
MALNUTRITION (NOS)
Severe
Severe dehydration 2 degree
to malnutrition severe,
MEASLES
MELANOMA. MALIGNANT. SKIN. (NOS)
MENINGmS
Bacterial
Meningoencephalitis
229.0.
202.8
202.0 .
200.1
202.0
200.8
084.6
084.9
263.9
262.
276.5,262
055
172.9
322.9
320.9
036.1 + 323.4*
358.0
203.0
429.0
787.0
570
195.2
154.3
188.9
170.9
346.9
072.9
072.0 + 604.9*
072. I + 321. 5*
072.2 + 323.4*
METASTASIS
(See Neoplasm, malignant, secondary)
MIGRAINE
MUMPS
Mumps orchitis
Mumps meningitis
Mumps encephalitis
MYASTHENIA GRAVIS
MYELOMA. MULTIPLE
(Use M-code)
MYOCARDmS (NOS)
NAUSEA. VOMmNG
NECROSIS. LIVER
MEOPLASM, BENIGN
Brain 225.0
Digestive tract (NOS) 211.9
Endocrinegland (NOS) 227.9
Nervous system, other 225.9
Respiratory system (NOS) 212.9
Urinary organ (NOS) 223.9
MEOPLASM. MALIGNANT. PRIMARY SITE
(Ifprimary site has been removed, see "history of")
Abdominal cavity (excluding Intestinal tract)
Anus
Bladder (NOS)
Bone, primary (NOS)
J
,
OPERATI<?NS/PROCEDURES
Brain (NOS)
Breast
female (NOS)
male (NOS)
Bronchus (NOS)
Cervix uteri (NOS)
Connective tissue, (NOS)
Digestive system (NOS)
Endocrine gland (NOS)
Esophagus (NOS)
Eye (NOS)
Gallbladder
Genital organ or tract (NOS)
female
male
Gum (NOS)
Kidney (NOS)
renal pelvis
Large instestine (NOS)
and rectum
appendix
ascending colon
descending colon
hepatic flexure
overlapping sites of colon
sigmoid colon
splenic flexure
transverse colon
Larynx (NOS)
Liver, primary site
Lung (NOS)
Lymph gland, primary (NOS)
Mouth (NOS) .
Nervous system (NOS)
Ovary
Pancreas (NOS)
Penis
Pharynx
Prostate
Rectum
rectosigmoid junction
overlapping sites of rectum
rectosigmoid junction, and anus
Respiratory tract (NOS)
Salivary glands (NOS)
Scrotum (includes skin)
Skin (NOS)
Small intestine (NOS)
Soft tissue (NEC)
Stomach
Testis, testes
191.9
174.9
175.9
162.9
180.9
171.9
159.9.
194.9
150.9
190.9
156.0
184.9
187.9
143.9
189.0
189.1
153.9
154.0
153.5
153.6
153.2
153.0
153.8
153.3
153.7
153.1
161.9
155.0
162.9
202.9
145.9
192.9
183.0
15Z9
187.4
149.0
185
154.1
154.0
154.8
165.9
142.9
187.7
173.9
152.9
171.9
151.9
186.9
-,
199.0
198.7
198.1
198.5
198.3
197.8
198.0
197.5
197.0
1%.9
198.4
198.6
197.5
197.3
198.2
197.4
198.3
197.8
197.8
198.1
583.9
5-554
5-553
560.9
788.5
5-{i52
5-{i54
5-{i51
5-{i52
5-{i83
5-{i53
5-{i53
786.0
733.0
382.9
380.1
386.3
382.9
ICD 9 CODE NO.
OBSTRUCTION. INTESTINAL
OLIGURIA. ANURIA
Oophorectomy
bilateral
partial
unilateral
with hysterectomy
removal tube (fallopian)
salphingectomy
ORTHOPNEA
OSTEOPOROSIS,' SENILE
Otitis .
externa
interna
media
DISEASES/CONDmONS
Thyroid 193
Tongue (NOS) 141.9
Urinary organ (NOS) 189.9
Uterus 179
Vagina 184.0
Vulva 184.4
NEOPLASM. MALIGNANf, SECONDARYSITE
Generalized, Carcinomatosis,
multiple unspecified sites
Secondary Neoplasm, Malignant
Adrenal gland
Bladder
Bone
Brian
Digestive organs (NEC)
Kidney
Large intestine
Lung
Lymph gland (NOS)
Nervous system (NEC)
Ovary
Rectum
Respiratory organ (NEC)
Skin
Small intestine
Spinal cord
Spleen
Stomach
Urinary organs (NEC)
NEPHRITIS
Nephrectomy
Complete
Partial
ICD 9 CODE NO.
,..
DISEASES/CONDITIONS
PAIN
Abdominal
Arm
Back
low
Bladder
Bone
Chest
wall (anterior)
Colon
Facial
Generalized
Head
Jaw
Joint
Leg
Muscle (NOS)
Nerve (NOS)
Post operative
Rectal
Sciatic
Stomach
Throat
Tooth
Urinary tract
PALPITATIONS
PJ\P.APLEGIA (LATE EFFECD (NOS)
Late effect of spinal cord injury or lesion
PARASITISM, INTESTINAL (NOS)
PARKINSON'S DISEASE
Due to drugs
PERICARDITIS (NOS)
Acute (NOS)
PHARYNGITIS
PHARYNGITIS. DUE TO RADIATION
Acute
Chronic
PHYSICAL EXMINATION
PLEURAL EFFUSION
PNEUMOCYSTOSIS (PNEUMOCYSTIS)
PNEUMONIA (NOS)
Aspiration
. Broncho (NOS)
Bronchopneumonia with measle
Hypostatic .
789.0
729.5
724.5
724.2
788.9
733.9
786.5
786.5
789.0
784.0
780.9
784.0
526.9
719.4
729.5
729.1
729.2
998.8
569.4
724.3
536.8
784.1
525.9
788.0
785.1
344.1
344.1 & 907.2
129
332.0
332.1
420.9
420
462
508.0
508.1
V70.0
511.9
136.3
486
507.0
485
055.1 + 484.0'
514
DISEASES/CONDmONS
Post measle
Radiation
Streptococcal lobar
Tuberculous
PNEUMOTHORAX
Spontaneous
Traumatic
POISONING
Food
POLIOMYELITIS
POLYURIA
PREGNANCY
Prematurity
PROSTATITIS
Prostatectomy
Prostatectomy, suprapubic
Prostatectomy, transurethral (T.U.R.P)
PROBLEM with
Alcoholism in family
Disfigurement
head
limb
neck
trunk
Family
marital problems
parent-ehild problems
child abuse
parent-child conflict
Interpersonal problems, (NEe)
Lack of knowledge (re: diagnosis or care)
Legal
Motor problem
head
limbs
neck and trunk
Loneliness/isolation
living alone
loneliness (NEe)
social isolation
Other specified problems
influencing health status
Sexual function, (NEe)
ICD 9 CODE NO.
055.1 + 485.0*
508.0 .
482.3
011.6
512
860.0
960-979
005.9
045.9 + 3232*
788.4
765.1
601.9
5-605
5-602
5-601
V61.4
V48.6
V49.4
V48.7
V48.7
V61.1
V61.2
V61.2
V62.8
V62.5
V62.5
V48.2
V492
V48.3
V60.3
V62.8
V62.4
V49.8
V41.7
ICD 9 CODE NO. DISEASEs/cONDITIONS
. OPERATIONS/PROCEDURES
Special senses and other special functions
code diagnosis or symptom if nature
of problem is known
hearing
other ear problems
mastication
sight
other eye problems
swallowing
taste
PYELONEPHRITIS
QUADRIPLEGIA (LATE EFFEC1) (NOS)
Late effect of spinal cord lesion or injury
RETENTION. URINE
RETICULOSARCOMA (NOS)
REACTION
Blood transfusion
RABIES
REPAIR, DIAPHRAGM
REPAIR, HERNIA, VENTRAL
with prosthesis
REPAIR, HERNIA, DIAPHRAGMATIC
SALPHINGECTOMY
Bilateral
For sterilization
Partial
Unilateral
SARCOMA. CONNECTIVE TISSUEAND
OTHER SOFTTISSUE(NOS)
SCIATICA
SCHISTOSOMIASIS
SCLEROSIS. MULTIPLE
SENILITY(OLDAGE.
SENILE DEBILITYEXHAUSTION)
With mental changes
With psychosis, (NOS)
SEPTICEMIA, NOS (SEPSIS)
Neonaturum
Post partum sepsis
SINUSITIS
Acute frontal
V41.2
V41.3
V41.6
V41.0
V41.1
V41.6
V41.5
590.8
344.0
344.0 & 907.2
788.2
200.0
999.8
071
5-347
5-535
5-536
5-537
5 ~ 6 5
5 ~ 6
5-980
5 ~ 6 5
5 ~ 6
171.9
724.3
120.9
340
797
290.9
290.2
038.9
711.8
670
461.1
DISEASES/CONDmONS
STAB WOUNDS
(see Wounds, Open)
STROKE
SYNDROME
Respiratory distress
Sudden infant death (SIDS)
TACHYCARDIA (NOS)
Paroxysmal (NOS)
TETANUS
Neonaturum
TONSILLms
Tonsillitis, septic
Tonsillitis, acute
Tonsillectomy
Tonsillectomy with adenoidectomy
TONSILLOPHARYNGmS
Acute pharyngitis
TRANSIENT ISCHEMIC ATTACK
TRANSPLANT, HEART
TUBERCULOSIS OF LUNG (NOS)
Primary complex
PTBfar advance
T.B. meningitis
T.B. with hemoptysis
ULCER
Decubitus
Skin (NOS)
Duodenal, bleeding
Repair of duodenal ulcer
Peptic ulcer
Bleeding peptic ulcer
Gastric with hemorrhage
Acid peptic disease
UREMIA (NOS)
Chronic
VERTIGO (DIZZINESS)
WEAKNESS
WEIGHT LOSS
(ABNORMAL LOSSOF WEIGH!)
WOUND, OPEN
(LACERATIONIClJI) (NOS)
ICD 9 CODE NO.
436
518.5
798.0
785.0
427.2
037
771.3
463
463
463
5-281
5-282
465.8
462
435
5-375
011.9
010.0
010.8
013.0 + 320:4
011.9
70Z0
707.9
532.4
5443
533.4
533.4
531.4
536.8
586
585
780.4
780.7
783.2
879.8
!
FORMS
NAME OF HOSPITAL
HOSPlJ"AL DAILY CENSUS REPORT
Service _ Floor/Section _
For the 24-hours ended midnight of. Date _
ADMISSIONS DISCHARGES (Alive)
Hospital Room Patient's lime Hospital Room Patient's lime
No. No. Name No. No. Name
Transfers IN from other floor Transfers OUT toother floor
DEATHS
- -
CENSUS SUMMARY FOR THE DAY
I. Remaining from yesterday's midnight report _
2. Admissions _
3. Transfers infrom other floor .' : _
4. Total ofNo. 1,2,3. , _
5. Discharges (Alive) this census day , _
6. Transfers out toother floor , _
7. Deaths , , , _
8. Total of5,6,7 , _
9. Remaining at 12:00 midnight (4) minus (8) _
10. Total in-patient service days ofcare _
Prepared by: _
Date: ---, _
..
.MONTHLY ANALYSIS OF HOSPITAL SERVICE
Month of
Count each patient once only
Service No. of Days Con. Inf. Deaths Autopsy
Patients care N P A
Medicine
Surgery
Obstetrics
Delivered
Adm. after del.
Aborted
Not Delivered
Gynecology
EENT
Pediatrics
Totals
Newborn (Iotal)
Ierm.Balive
Imm.B, alive
RESULTS (List each patient once only) No. ofPatients
Discharges (alive) .................................................................
Deaths: Under 48 hours ..............................................................
Over 48 hours .......................................................
Total discharges and deaths ...... , ....................................... , ..................
Fetal deaths .................................................... , ... , ............
Intermediate and late fetal death ............................................................
.
CENSUS SUMMARY (Recapitulation ofPatients remaining) ..................................
Patients remaining last day last month ......................................................
Patients admitted this month (exc..newborn) ..................................................
Newborn ...................... , ........................ , ... , ........... , .......
Total patients treated this month .........................................................
Patients discharged alive this month .........................................................
Deaths this month .................................................................
Total patients remaining .................................................................
DEATHS
Hospital No. Final Diagnosis Autopsy
NAME OF HOSPITAL
ADDRESS
CONSENT TO INVOLVEMENT IN CUNICAL TRIALS-(THERAPEUTIC)
(Surname) (Given Name)
CONSENT
I, __----,,:::---::-:----:- -;=-__-:-- herebyauthorize
Dr. to treat me/my with
(specify type(s) of drug(s) treatment to be used)
the drug(s) or other treatment presently identified as --;---;-::---7"7""---;:--;---;--;-----:--....,.,.
for the following condition _
I understand that neither I nor my doctor knows in advance which treatment I will receive and
further that both forms of treatment are currently used and considered to be accepted forms of
treatment.
I havediscussed this with my doctor and havehad the opportunity to have my questions answered.
I understand that I can withdraw from this study at any time and that this withdrawal will not
jeopardize any future treatment.
I agree to participate in this investigation.
Dated this day of 19 _
Signature of Patient Relationship to Patient _
. Signature of Witness _
CONFIRMATION
I, __---=-:-_-=-=-_--:- have explained to the above patient/person
19__ Dated this day of _
Signature of Doctor _
WITHDRAWAL OF CONSENT
I, -:-_--:--,- hereby withdraw my consent to further participation
in the investigation.
Dated this day of 19 _
Signature of Witness _
1
,
NAME OF HOSPITAL
,
ADDRESS
CONSENT OF RECIPIENT TO OPERATION,
TRANSPLANTATION OR GRAFTING OF TISSUE
CONSENT
myself
(Given Name)
Dr. --;-;;--__
upon
(Surname)
and such assistants as he/she may designate, to perform
the following operation:
and to do any additional
or different procedures during the above operation that his/her judgement may dictate.
1. I, ----,=-_-=-=-_-,- --;::-__---,- herebyauthorize
2. I am informed that the aboveoperation will involve the grafting ofthe tissue or the transplantation
of the following organs(s): _
3. The risks involved in the use of such tissue for grafting, or organs for transplantation, the
nature and effect of the operation, and possible alternative methods of procedure or treatment
have been fully explained to me. No guarantee or assurance has been given to me as to the
results that may be obtained.
4. In conjunction with the above procedure I consent to the administration of such.anesthetics as
maybe considered necessary or advisable bythe anesthetist with the exception of _
(state "none" or type of anesthesia)
Dated this -=-=-,- day of 19 _
If the patient is an infant at law, or is unable to sign, please complete the following:
Patient is an infant at law, being _ years of age, or is unable to sign because _
CONFIRMATION
I, . havedescribed to the patient/person legally responsible
for the patient the nature and effect of the above procedure(s). In .my opinion, he/she understood this
explanation.
19__ Dated this ==-- day of _
..J - -
NAME OF HOSPITAL
ADDRESS
INFOllMEDCONSENT FORSURGERY. ANBSTImSIA
OR OTHERPROCEDURES
TO WHOM IT MAY CONCERN:
I, __--:-__---,---------,__-,----------'-' years old,
(Given Name) (Surname)
married/single/widowed, herebyconsent to the performance upon __;:-:---;=-=--_--:-:::--:_,--_
-(Myself/Name of Patient)
who is my _,--=-:--:----, ~ the procedure/operation!anesthesia hereunder stated after these
(Relation)
have been fully explained to me by the doctors concerned including the risks involved and their -
alternative procedures:
Procedures/operation!anesthesia Explained by:
(Name of Hospital)
I also consent to the proper disposal by authorities of the ~ __-=:--;--,:- _
of whatever tissue may be removed from myself/the patient.
I also_consent to the taking of photographs in the course of this treatment or operation for the
purpose of advancing medical knowledge.
IN WITNESSWHEREOF, I hereunto set my hand this day of ~ 19__
at _
-_'Patient's signature or "thumb mark"
or person giving free- consent.
IN THE PRESENCE OF:
..
Witness
Interpreter
Address
Address
NAME OF HOSPITAL
ADDRESS
DISCHARGE AGAINST MEDICAL ADVICE
I, hereby certify that I am leaving/that
I am causing the discharge of -:::-:-__=---:-----:,.- from
(Name of Patient)
against medical advice. I have been informed of the dangers involved, and I release the hospital and its
staff from all liability for any ill effects which may result from this action.
Signature of Witness Signature of Patient
Date
The patient -::-:----:- left the hospital
Signature of Disinterested Witness Signature of Nurse
. Time and Date Time and Date
NAME OF HOSPITAL
ADDRESS
CONSENT TO RELEASE OF PATIENT MEDIQ\LINFORMATION
(Surname) (Middle Name) (Given Name)
I, hereby authorize
(Name of Organization) (Name of Hospital)
____-,-."--_-:-:,,,--,--;:- to release to __-:::-:-__:-=-_.....,...----:-----:- _
information requested as specified below:
(PLEASEMARK "X" IN APPROPRIATE BOX(ES)
[1 Final diagnosis
[l Operative procedures performed
[I Summary of medical condition and treatment
[I Other (specify) _
Signature
Date
SUBSCRIBEDAND SWORN TO ME this day of 19__.
Affiant exhibiting to me his/her Residence Certificate No. issued at
_________on _
Notary Public
Until December 3, 91__
..
Doc. No _
Book No. _
Page No. ::-- _
Series of 19 _
NAMEOF HOSPITAL
ADDRESS
CONSENT TO REMOVE ORGAN FOR TRANSPLANT. (LMNG DONOR)
CONSENT
(Surname)
I, : = . : c : ~ . herebyauthorize and
(Given Name)
consent to the removal of my ,--_,--,--_,--,--_,--,-- _
(name of organ(s) tissue(s))
for the purpose of transplanting it/them to _
The nature and purpose of the operation, the risk involved, the possible consequences and possible
complications have been explained to me.
In conjunction with the above stated procedure I consent to the administration ofsuch anesthetics
as may be considered necessaryor advisableby the anesthetist with the exception of _
(state "none" or type of anesthetic)
Dated this day of _ 19__
Signed _
Signature of Witness
CONFIRMATION
I, , have described to the patient the
(Name of doctor)
nature and effect of the above procedure. In my opinion, he/she understood this explanation.
NAME OF HOSPITAL
ADDRESS
VOLUNTARY STERILIZATION CONSENT FORM
(Name of Patient)
I, -..,:-::-_----:::::---:--;- oflegal ageand sound mind
(Specifyprocedure to be performed)
and residing at
(Address)
present myself to be sterilized by the following procedure _
_ ;::-----,-;:-__-;-_ ___,,---;::----;-:--to prevent future pregnancy.
I understand that:
1. There are temporary methods of preventing pregnancy I can use instead of sterilization for
planning my family;
2. That the sterilization is a surgical procedure, the details of which my physician has explained to
me;
3. That the procedure involves risks;
4. That if successful, I will be unable to have any more children;
5. That although the operation is known to be effective and irreversible, there are instances of
failure,
Understanding all these, if the surgical procedure will necessitate other added surgical or medical
measuresor procedures, I herebygrant permission to carry out these additional measures or procedure,
Signature of Consenting Spouse Signature of Client
Date Date
I HEREBY CERTIFY that I have fully explained the above information to the client and spouse,
and that they consented to the performance of the operation.
NAME OF HOSPITAL
. ADDRESS
THERAPEUTIC ABORTION
Date
This is to certify that we, the undersigned husband and wife, declare that we, each and both of
us, have been thoroughly instructed as to the effect of the proposed operation upon, _
____----::-:-_--;=---;--:- ~ wife of __- - ; : - : : - - _ - : - : - : - - : - - - - - - - : - - _ ~
(Name of Patient) (Name of Husband)
and consent to the performance of the operation Wefurther agree that this operation is necessary for the
protectionof the wife's lifeand well-being. Weabsolve hospital and
her attending physician from any responsibility for the wife's present condition and from any condition
that may result therefrom.
Wife
Husband
Signature of Witnesses:
By: _
By: _
This completed form must be accompanied by the Consulting Physician's report of examination and
recommendationfor termination of pregnancy.
NAME OF HOSPITAL
ADDRESS
REFUSAL TOPERMIT BLOOD TRANSFUSION
REFUSAL TO CONSENT
(Name of Patient)
I, __-:-:::-:---::-=----;- -=-__-,----'-- hereby expressly
(Given Name) (Surname)
withhold my consent to and forbid under any circumstances the administration of blood or its
derivatives to ::-:-__-:-::--:-----: _
during his stay in hospital.
The possibilities of serious effects have been explained to me and I fully understand them.
I release the hospital, attending doctors, and hospital staff from any liability whatsoever to me, for
any damage or injury which may be caused to -t-r-__--,-_,--,-- _
(name of patient)
in any way arising out of, or connected with this, my refusal to consent to receive blood or its
derivatives.
Date this day of _ 19__
Signed _
Relationship to Patient _
Signature of the Witness _
CONFIRMATION
I, -;::-:__-=-=,--_:-- have described to the
(Name of Doctor)
patient/person legallyresponsible for the patient, the nature and effect of the above refusal to receive
blood or its derivatives. In my opinion, he/she understood this explanation.
Date this day of _ 19__
NAME OF HOSPITAL
ADDRESS
CONSENT TOTHE ADMINISTRATION OF
ELECTRO-CONVULSIVE THERAPY
(Name of Patient)
I, -;:-:-_--;-:::-:---;- -,----_
(Address)
of ---,.,....,----, _
(Name of Doctor)
agree to the administration of electroconvulsive therapy, the effect, nature and risks of which 'have
been explained to me by -:::-::__-:-=__,-- _
I likewise agree to the administration of anesthesia for this purpose.
19__ Dated this day of _
Signature of Patient or Relative _
NAME OF HOSPITAL
ADDRESS
CONSENT TOAUTOPSY
I, -r-t-r-t-__-----, .,...,-__-r-r- being in the relationship
to --;-__-::-:--_---::-
(relation to deceased) (name of deceased)
patient, recently deceased at the above named hospital, hereby authorize the representative of the said
hospital to make such examination of the body of the said deceased and of its tissue as may be
necessary to determine the cause of death.
Signature of Next of Kin _
Relationship to Deceased _
Signature of Witness
NAME OF HOSPITAL
ADDRESS
REFUSAL TO CONSENT TO AUTOPSY
I,__. . . . . . . . = _ ~ _ . . . . ----:-=-_----: ~ . being in the relationship
(relation to deceased) (name of deceased)
patient, recently deceased at the above named hospital, hereby REFUSE TOCONSENTto autopsy on
the said deceased.
of----:--:---:-_----,-_-----,;:-- _
Signature of Next of Kin _
Relationship to Deceased _
NOTIFICATION TOPHYSICIAN OF REQUEST FOR ACCESS

To:
____________ M.D.
From: MEDICAL RECORD SERVICE
Re: REQUEST FOR ACCESSTO PATIENT RECORD
(patient/hospital number)
REQUEST FOR ACCESS TOMEDICAL RECORD
Re: Patient Name _
Date of Birth
Approximate date of treatment. _
I hereby request that ----::-::-__=---:-:----:,-- provide access to make
(Name of Facility)
medical record of the patient named above. I request this access as the:
__patient
__parent of the minor patient
__guardian of the minor patient
__conservator of the person, psychiatric
__conservator of the person
The type of access requested is :
__inspection
__copies of the record as follows:
I request access to:
entire record
__following portions of the record only:
(please print)
Name: ----:-:-__----:-:- --!-
Signature: Date: _
NAME OF HOSPITAL
ADDRESS
Cert, No, _
CERTIFICATE OF CONFINEMENT
Date
(Date Admitted) (No, Days)
(Date Discharged)
This is to certify that --=-:------:,.....,,-:---:- _
(Patient's Name)
was treated/confined in this hospital for __--::-:=--=--:-_days, from _-----:=------:---:---:----::-__
to __-:-_-::-:---:-_-:- _
(Name of person requesting)
This certification is being issued at the request of __-r-t-__:-- -r-r-r-r- _
(Purpose)
for -:=-_-----:-----: '
Medical Record Officer
(NOT VALID WITHOUT SEAL)
NAME OF HOSPITAL
ADDRESS
CertNo. _
MEDICAL CERTIFICATE
Date
(Name of Patient)
This is to certify that --;:-:,--_--::-::,----:-_,--- of
(Date Discharged) (Date Admitted)
with the following findings and/or diagnosis:
(Address)
confined in this hospitai on/from _----;:::-_:-;--:----;,--- to __----;:::----;=-:--;-_----:-;-__
__________-r-r-r-r-r-r-r-r- was examined and treated/
and would need medical attention for days barring complications.
Attending Physician
(NOT VALID WITHOUT SEAL)
DISPOSITION OFCADAVER
I. Name of person pronouncing the death
Print full name
2. Name of person informing the relatives
Print full name
3. Name of relative informed
Print full name
4. Name of person who signed the death certificate
Print full name
5. Name of person claiming the cadaver
Print full name
I, being the next of kin, affix my signature below
Signature of Claimant
Time and date pronounced
Time and date
Time and date
Time and date
If claimant is a Funeral parlor, proper authorization from next of kin is required.
6. Name and signature of mortician releasing the body
Print full name
Time and date
Signature of Mortician
NOTE: Bodies which cannot be released without proper authorization from medico-legal officers
of the NBI/Police Department/Municipal Health Officer/City Health Officer/ .
Provincial Health Officer as the case maybe are: (a) all cases of physical injuries; (b) deaths due to
suspicious circumstances; (c) deaths within 24hours from admission; and (d) deaths without diagnosis.
NAME OF HOSPITAL
HOSP. CODE ffiffiEE
ADDRESS MED. RECORD NO.
ADMISSION AND DISCHARGE RECORD
PATIENT'S NAME: (Last) (Given) (Middle) WARD/SERVICE
PERMANENT ADDRESS: TEL. NO. SEX CMLSTAlUS
OM OS OD DSep
OF OM OW
BIRTHDATE AGE BIRTH PLACE NATIONAUfY RFllQON OCCUPATION
EMPLOYER (Type ofBusiness) ADDRESS TEL.NO.
FATHER'S NAME ADDRESS TEL. NO.
MOTHER'S (MAIDEN) NAME ADDRESS TEL. NO.
,
ADMISSION: DISCHARGE: TOTAL NO. ATTENDING' PHYSICIAN
. DATE: DATE: OF DAYS
.
.
TIME: TIME: .
TYPE OF ADMISSION:
. '
REFERRED BY: -
oNEW 0 OLD 0 FORMER OPD (Physician/Agency)
.'
,
SOCIAL SERVICE
CLASSIFICATION: OA DB DC OD
ALERT:
/,-
HOSPITALIZATION PLAN HEALTH INSURANCE MEDICARE:
ALLERGIC TO COMPANY/INDUSTRIAL NAME: NAME: oSSS
n GSIS
DATA FURNISHED BY: ADDRESS OF INFORMANT RELATION TO PATIENT
ADMISSION DIAGNOSIS: ICD CODE NO.
PRINCIPAL DIAGNOSIS:
I I
I 110
OTHER DIAGNOSIS:
ITIIJO
PRINCIPAL OPERATION/PROCEDURE:
I
I I
10
OTHER OPERATION(S) PROCEDURE(S): I
I I
10
ACCIDENT/INJURIES/POISONING (E CODE) I I I
10
PLACE OF OCCURENCE
I
I I 10
DISPOSITION RESULTS: ATTEND NG
PHYSICIAN
o DISCHARGE: o RECOVERED oIMPROVED
oTRANSFERED: oDIED n UNIMPROVED .M.D.
n DAMA: 048 HOURS n AUTOPSY Signature
oABSCONDED: 0+48 HOURS '" 0 NO AUTOPSY
HOSPITAL NAME: HOSPITAL CODE:
SURNAME AGE HOSPITAL NO.
1_1_1_1_1_1_1_1_1_1-1_1_1_1_1_1_1_1_1 1-1_1_1 1_1_1_1_1_1_1_1
GIVEN NAME SEX WARD/RM.
1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1 DMDF 1-1_1_1_1_1_1_1
HISTORY
GENERAL DATA & PATIENT PROFILE
PRESENT COMPLAINT: _
PAST HISTORY: (PREVIOUS ILLNESSES AND OPERATIONS)
FAMILY HISTORY: _
OCCUPATION AND ENVIRONMENT:
Alcohol (gm/day) _
".
Tobacco -----,-- _
Drug Allergies _
DRUG THERAPY: _
Other Allergies _
(I)
..
SYSTEMS REVIEW:
GENERAL
SKIN
EENT
MUSCULOSKELETAL
RESPIRATORY
CARDIOVASCULAR
GASTROINTESTINAL
GENITOURINARY
FEMALE-REPRODUCTIVE
NERVOUS
PAST DISEASES: (Including treatment and its duration, Hospitalizations and Operations)
(2)
f
,

1-1-1_1-1-1_1-1_1_1-1-1-1-1_1-1-1-1-1 1-1_1-1
1-1-1_1-1-1-1-1
GIVEN NAME SEX WARD/RM..
1-1-1-1-1_1-1-1-1_1-1_1-1-1-1-1-1-1-1
DMDF
1-1-1_1_1-1-1-1
PERSONAL AND SOCIAL HISlDRY:
CONDITION ON ADMISSION:
BP CR _ RR _ TEMP, _
PHYSICAL EXAMINATION
NOTE: All positive findings, and all important negative findings
SKIN
HEAD-EENT
LYMPH NOTES
CHEST
Lungs:
Cardiovascular:
BREAST
ABDOMEN
RECTUM
GENITALIA
(1 )
MUSCULOSKELETAL
EXTREMITIES
NEUROLOGICAL
ADMITTING IMPRESSION:
(Admitting OPD Resident!
Attending Physician)
WORKING DIAGNOSIS/DIAGNOSIS:
(Ward Resident-in-Charge/
Attending Physician)
(Name ofHospital or Agency)
Officially Referred from/to : ~ : c : : : _ . _ : : :
(Signature over Printed Name)
History by: -----------;:;::-------:c-:-----;-:-:----:------------
(TIme and Date)
Doneon: ~ __=-__;_=____:-------------
(2)

1_1_1_1_1_1_1_1_1_1-1_1_1_1_1_1_1_1_1 1-1_1_1
1_ I _ 1_ 1-_ 1_ I _ 1_ 1
I
I_I_I_I_I_I_I_I_I_I_I_I_I_I_I_I_I_J_I DMDF 1_1_1_1_1_1_1_1
DOCTORS ORDER/NURSES COMPLIANCE SHEET
(Authenticate all Orders)
C - Carried A - Administered R - Request made
E - Endorsed D - Discontinued
Date C A R E D lime Posted
lime ORDER Signature
.
.
_ _ _ _ _ _ _ _ ~ _ _ ~ _ _ ~ _
1_1-1-1
1_1_1_1_1_1_1_1
GIVEN NAME SEX
WARDfRM
_ _ _ ~ _ _
DMDF 1_1_1_1_1_1_1_1
LABORATORY REPORT/RESULT
17
16
15
14
13
12
11
10.
9
8
7
6
5
4
3 .
2
(Attach first laboratory result on this line)
Name ofHospital
Address
Surname Age Hospital No.
[ I I I I I I I I I I I I I I I I I I I I I I ) [ I I J [ I I I I I I I I
Given Name
Sex Ward/Room
[ I I I I I I I I I I I I I I I I I I I I I II
[1M II
F
[ I I I I I I II
GRAPHIC CHART (Centigrade)
Date
Hospirat Days
Day P.O. 'or P.P.
HOUR A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M. A.M. . P.M.
F C
4 8
r z
4 i 8 4 8 "
4 8 U 4 8
'"'
4 8
'.
4 8
"
4 8 :..'
4 8
"
4 8 \f
" " " "
106
0
41
.
,
150
140 : 40
; .
, ,
, ,
130
,
,
!
,
120 39
t 102
0
,
,
0
,
"0
ec
0
w ::l
I
100

38
<
::l
, , ,
0-

90
w
I ,
99
80 98.6
0
31
, ,
98
,
10
,
91
,
SO
3So
,
,
50
9So
35.5
0
Respirntions
I
Blood Pressure
WeiOhl
13 3.,1111.7
ITotal
13 311 11/ Total 13 3" 111 Total 13 311 111 Total 13 311 11-1 Total
I
lntnke Oral I
PcrentcmI
,
I I
!
Totn l
Output Urine I
I
I I
Dra inane I
!
Emesis
I I
Total
I
Stools
I
I
00..0\001
GRAPHIC CHART (Centigrade)
Name ofHospital
Address
-
Surname Age. Hospital No.
r I I I 1I I I I I I I I I I I I I I I I I I I [ I I]
[ 11I 1/ 1I J
Given Name Sex Ward/Room
[ 1I I I I 11I I I 1I I I I 1I I I I 1I J
[ I M I] F
[ 1/ 1I I I I]
GRAPHIC CHART (Fahrenheit)
-

Hospital Davs
Day P.O. or P.P.
A.M. P.M; .
A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.IA.
HOUR
4 8

4 8
"
4 8
"
4 8
"
4 8 \1 4 8
"
4 8
"
4 8
"
4 8 \1 8 II
N

N
4
"
F
150
"
106
"
0
140 105
0
"
.
0
104
0
130
120 103
x
u
i "0
~
102
0
!!;
w
cc
w :J
~ 100
~
101
0
"
:J
'"
.. w
..
"
100
0
90
w
,-
80 99
98.6
70 98
60 . 97
50 96
.
Respirations
Blood Pressure
Weight
7-3 311 11-7 To!>173 311 117 Tola17-3 311 117 TotaI 7-3 311 117 TolaI 73 311 11-7 To!>1
~ ~ r a l ..w.
.
Parenteral
101<11
Dutcut Urine
Drainace
Emesis
Total
1---
Stoots
DO"OOO GRAPHIC .CHART (Fohrenheitl
HOSPITAL NAME:
HOSPITAL CODE:
1-1-1-1_1-1-1-1-1-1-1-1_1-1-1-1_1-1-1
1_1_1-1 1-1_1_1_1-1_1-1
_ _ _ _ _ _ _ _ _ _ _ _ ~ _ _ _ _ DMDF
1-1_1-1_1_1-1-1
PROGRESS NOTES
DATE
Progress noes shoold provia: asununary ofthe condition of the patient nn admission and chronologicalll'COll! of the
patient's progress. Theyshould record consultations, complicaions, cOnditions ofsurgical wounds, deldopmenl ofintiction,
removal of smues and drains, use of casts or splints, and any other ~ data. NolfS shoold coocIua: with afina1
summary ofthe case with condition nn dischaIge.
-
.... 26=Ffom - ,--
HOSPITAL NAME: -HOSPITAL CODE:
I_I_I_I_I_I_I_J_I_I_I_I_I_I_I_I_I_I_I
1_1_1-1
1-1-1-1-1-1-1-1
GIVEN NAME .
SEX
WARDfRM

DMDF
1-1-1 1 1 1 1 1
NURSES NOTES AND TREATMENT RECORD
DATE SHIFT SIGNATURE
Date of Discharge: _
NAME OF HOSPITAL
ADDRESS
1_1_1_1_1_1_1_1_1-1_1_1_1_1_1_1_1_1_1 1_1_1-1 1_1_1_1_1_1-1_1
1_1_1_1-1_1_1-1_1_1_1-1-1_1_1-1-1-1_1
DMDF 1_1_1-1_1_1_1_1
DISCHARGE SUMMARY
Date Admitted: _
Attending Physician: -'---- _
Admitting Diagnosis: _
Final Diagnosis: _
Chief Complaints: _
Brief Clinical History and Pertinent P.E.: _
Laboratory Findings:(Inciuding EKG, X-ray and other diagnostic procedures)
Course inthe Ward: (Include medications)
Disposition: (Indicate home medication, special instruction and follow-up)
Date Accomplished Resident Io-charge
1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1 1_1_1_1 1_1_1_1_1-1_1_1
1 I I I 1 I 1 1 1 I 1
1. I 1 I I 1 1 1
DMDF
1 1 1 I I I 1 1
MEDICATION RECORD
O-Circle all doses not given-state reason in nurses notes
DATE
DAY OF THE WEEK
Medication 11-7
7-3
._-.

Dose Route Frequency 3-11
Medication 11-7
7-3
Medication 11-7
7-3
Medication 11-7
7-3
S 11-7
I
G 7-3
N
A 3-11
T
U
R
E
J
J
,
,
\
J
I
~
NAME OF HOSPITAL
ADDRESS
_ ~ _ _ _ _ _ _ _ _ _ _ _ 1_1_1-1 1-1_1_1_1_1_1_1
1_1-1-1-1_1-1-1-1-1_1-1-1-1-1-1-1_1-1
DMDF 1-1_1_1_1_1_1-1
PARENTERAL FLUID SHEET
TIME Type of Solution, Rate, Site Medication AMf. Time
DATE Started Mode of Adm., Size & Kind . Started Added INF Disc REMARKS
Needle/Cannula By By By
NAME OF HOSPITAL
ADDRESS
~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
1-1-1-1 .1-1-1-1-1-1-1-1
1_1_1_1_1_1_1_1_1_1_1_1-1_1_1_1_1_1_1 DMDF
1-1-1-1-1-1-1-1
PROGRESS NOTES
REHABILITATION MEDICINE
Occupational, Physical,
Speech Pathology, & Orthotics
DATE
&
SERVICE
,
r
t
NAME OF HOSPITAL
ADDRESS
1-1-1_1-1-1-1-1_1-1_1-1-1-1_1_1-1-1-1
1_1-1_1
1_1_1_1_1_1_1-1
_ _ ~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ OMOF 1_1_1_1_1_1-1_1
DIABETIC RECORD SHEET
URINE BlDOD INSULlNOR COMMENTS;
DATE TIME REACIIUN SUGAR ORAL AGENT REACTIONS, SIGNATURE
ETC.
.
J
}
)
\.
I
!
r
)
!
NAME OF HOSPITAL
ADDRESS
_ ~ _ ~ _ _ _ _ _ _ _ _ _ _ _ _ _ 1-1_1_1 1-1_1-1_1_1_1_1
1_1_1-1-1-1_1-1_1-1-1-1-1-1_1-1-1-1_1
DMDF 1_1_1_1_1_1-1_1
ANTI-COAGULANT THERAPY RECORD
Patient Control % % LeeWhite Medication Time
Date Time
Time Activity Control Coag.Time (Dosage) Given Signature
.""
NAME OF HOSPITAL
ADDRESS
1_1-1-1_1-1-1-1-1-1-1-1-1-1-1-1-1-1-1
1-1_1_1 1_1_1_1_1-1_1_1
GWEN NAME SEX WARD/RM.
1_1-1-1-1-1-1-1-1-1-1-1-1_1-1-1-1-1-1
DMDF
1_1_1-1_1-1-1-1
I
1
,
,
}
I
\ VITAL SIGNS RECORD
.
INTAKE OUl1'UI' SPEC
'nME BP T P R ORAL N/G tv BlOOD MISC URINE N/G
SlOOL EMFSIS MISC GRAY. CVP
I DAre
)
(
I
)
I'
I
NAME OF HOSPITAL
ADDRESS
1_1_1_1_1_1-1_1-1_1_1_1_1_1_1_1_1_1_1
1-1-1-1
1_1_1_1_1_1_1_1
1_1-1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1 DMDF 1_1_1_1_1_1_1-1
PULMONARY FUNCTION TEST
HEIGHT STANDARD WEIGHT BSA
BEFORE AFTER
BROCNCHODILA'IDR BROCNCHODILA'IDR
PVC
FEV 1.0 SEC.
MMEFR
DF
INTERPRETATION
DOC'IDR, _
DATE: _
..
,
I
NAME OF HOSPITAL
ADDRESS
1-1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1
1-1-1_1
1-1_1-1_1_1_1_1
1-1_1_1_1_1_1-1_1_1_1_1_1_1_1_1_1_1_1 DMDF 1_1_1_1_1_1_1_1
PULMONARY LABORATORY
BLOOD GASANALYSIS
CLINICAL IMPRESSION:
REQUESTING PHYSICIAN:
Dm TIME PH PCO, BEEC BE
HCO, reo,
PO,
O,ST O,CT
PO,
YT RR
NORMAL VALUE
pH -
PCO, -
BE -
BB
7.35 - 7.45
35 -45 nnHG
-2 - +2 mmol
46 - 54 mmol
HCO -
,
TCO -
,
PO -
,
OS1 -
,
21- 22 mmol
24 - 30 mmol
90 -100 mmHG
94 - 100%
t)
NAME OF HOSPITAL
ADDRESS
_ _ _ ~ _ _ _ _ _ _ _ _ _ _ _ _ _ _
1-1-1-1
1-1-1_1-1_1-1_1
_ _ ~ _ _ _ _
DMDF 1_1_1_1_1_1_1_1
INTRAVENOUS FLUID SHEET
DATE SHIFT BOT. KIND OF VOL. errs TIME REMARKS NURSE
NO. SOWTION STRD.CONS. SIG.
:
,
,
NAME OF HOSPITAL
ADDRESS
1_1_1-1_1-1-1_1_1-1-1_1-1-1_1-1-1-1-1
1-1-1-1
~
~ DMDF 1_1_1_1_1_1_1_1
FLUID INTAKE AND OUTPUT CHART
DIAGNOSIS: ~
DATE INTAKE OUTPUT
TIME ORAL PARENTERAL TOTAL
7 3
3. II
II . 7
TOTAL
URINE DRAINAGE OTHERS TOTAL
DATE- INTAKE OUTPUT
7 3
3. II
II 7
TOTAL
DATE INTAKE OUTPUT
7 3
3 II
II . 7
TOTAL
DATE- INTAKE OUTPUT
7 3
3. II
II . 7
TOTAL
",
-
1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1 1_1_1_1
1-1-1-1_1-1_1_1.
GIVEN NAME . SEX WARD/RM.
_ _ _ ~
OMOF
1-1-1_1-1-1-1-1
1DBE COMPLETED FOLLOWING AREQUEST FROM OPERATING ROOMS
FOR PREPARATION OF THE PATIENT AND BEFORE PREMEDICATION
LMNG DIFFICULTIES
e.g. Blindness oYes oNo
Retardation oYes n No
Language oYes oNo
Other specify
IDENTIBANDS
Labelled correctly and in place
oYes oNo
CONSENT
Complete and correct
DYes n No
MEDICAL CONDITIONS
SPECIAL MEDICATIONS
Insulin oYes 0 No
Antihypertensives DYes o No
Anticoagulants n Yes n No
Corticosteroids n Yes n No
Anticonvulsants n Yes n No
FASTED FROM
Food Date .............................................................................
lime .............................................................................
Drink Date ............................................................................
lime .............................................................................
LAST VOIDED AT
Date .............................................................................
Signature : .
Print Name ..
(Nurse checking patient in Ward)
Date : .
r
NAME OF HOSPITAL
ADDRESS
1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1
1-1_1-1
1-1-1-1_1-1-1-1
1_1_1_1_1_1_1_1_1_1_1-1_1_1_1_1_1_1_1 DMDF
1-1-1-1_1_1_1-1
PRE-ANESTHETIC ASSESSMENT
OPERATION: SURGEON:
PATIENT INFORMATION MEDICAL OFFICER ASSESSMENT
Please answer the following questions ~ i h t
YES orlli2
Have you had anesthesia for Physical Status:
operations previously?
Hb. Biochem
Did you have any problem?
. CXR
EeG
Have you ever suffered from:
Heart attack Others:
High blood pressure
Stroke Significant History:
Angina
Chronic lung disease Physical Examination:
Asthma
Hepatitis
Kidney disease Pre-operative instructions:
Diabetes
Epilepsy Premedication:
Rheumatic fever
Other diseases: (describe)
What drugs do you take? Nurse Signature
Do you have any allergies? Special Instructions:
Could you be pregnant'
Signature of Patient/Parent/Guardian Signature of Medical Officer:
~
1-1-1-1
1_1_1_1_1_1-1_1
1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1 DMDF 1_1_1_1_1_1_1-1
ADDRFSs BED NO.
OPERATION AND ANESTHESIA RECORD
DIAGNOSIS:
a.m. a.m.
Date . 19
--
__p.m.
to
__p.m.
Duration
Surgeon Assistants
Anesthetist Anesthetic Quantity__
Anesthetic started Ended Duration
Complications during operation attributed to the anesthetic
Complications after operation attributable to anesthetic
Condition of patient before leaving the table
Operation performed
--
Send patient to (a) Recovery Room
(b) Ward
Remarks:
Resident
NAME OF HOSPITAL
ADDRKSS.
6NES'll!ESIA RECORD
-.AGIL : HOSP. NO. :
I I I I I I I I I I I
1_1_1_1 1_1_1_1_1_1_1
SEX- : WflRD/RH..:
H:_:_F_: :
,
,
HISTORY OF DRUG ALttINISTTRATION
RISK :ALLERGIES
,
,
1 2 3 4 5 E:. ===-:--:-::,--_
,BIOOWIISTRY
KCG
PRBI1EDICATION: OOSE
CARDIOVASC. roNCTICltI
HT. :wr: :Tlll1P :P\lLSE B.P. :CXlllSENT'
, ,
, ,
, , ,
--'-'--,---=- -:--='---
ROOTK: TII1E
HC'1'
RXSP. FUNC'1'lON QlS
PRlNIOUS OPllRATIOil
PRlNIOUS ANES'nlIlTIC EXPIlRIBNCll
ENIOCRINE FUNCTIOtl O1'HIlRS , PRIl-oPWTlVE DIAGNOSIS
: ~ , - - - = - - - . . . . , = - - - - - - - - - -
: PROrosBD OPWTION
I
~
HOURS
AGENTS
FLUIDS
uAINE OuTPuT
POSITl6N
BF
V
c
"
40 200
PULSE ..
39 180
TEMP. t.
38 160
C.V.P...
37 140
x II
ANESTHESIA
36 120
0 0
OPERATION
35 100
CHANGE
CANISTER C
34 BO
SUCTION S
33 60
REC. ROOM R
40 32
R SPONT 0
I ASST'D 0
31 20
CONTD II
SYMBOLS
ANESTHETIC AGENT POSTOPERATIVE DIAGNOSIS
DETAILED TECHNIQUE
OPERATION PERFORMED
REMARKS: INDUCTION MAINTENANCE EMERGENCE
SURGEONS ANESTHESIOLOGISTS
INST. NURSE
CIRe. NURSE
~ ""DV
NAME OF HOSPITAL
ADDRESS
1_1-1_1-1_1-1_1_1-1-1-1-1_1-1_1-1-1_1
1_1-1_1
1_1_1_1-1_1_1-1
_ _ _ _ _ _ ~ _ _ _ _ _ _ _ _ _ _ DMDF
1-1-1_1-1_1_1_1
OPERATIVE RECORD
SURGEON: ASSISTANT:
ANESTHESIST: ANESTHISIA USED:
STERILE NURSES:
OPERATION:
PREOPERATIVE DIAGNOSIS:
TISSUE REMOVED:
POST-OPERATIVE CONDITION:
PROGNOSIS:
FINDINGS: (Including the condition ofall organs examined)
OPERATION/PROCEDURE: (Including incision. ligatures. sutures. drainage, closure)
SURGEON
____---=-==:-:,---__M.D._.
...,,:..... . : .
1_1_1_1_1_1_1_1-1_1-1_1_1_1_1_1_1_1_1
1-1-1-1
1_1_1_1_1-1_1_1
GlVENNAME SEX WARD/RM.
. L. I 1-1 1_1_1-1-1-1-1_1-1-1-1-1_1-1-1
DMDF 1_1_1_1-1_1-1_1
OPERATING ROOM RECORD
SURGEON FIRST ASSISTANT SECOND ASSISTANT
ANESTHESIOLOGIST ANESTHESIA USED TIME BEGAN
SCRUB NURSE CIRCULATING NURSE OPERATION TIME
Started Ended
PRE-OPERATIVE DIAGNOSIS:
POST OPERATIVE DIAGNOSIS:
OPERATION PERFORMED:
REMARKS SPECIMEN
SPONGE INITIAL FIRST COUNT SECOND COUNT
COUNT . ONTABLE ON FLOOR ill ON TABLE ON FLOOR ill
..
ANESTHESIA AGENTS SPONGE COUNT SPONGECOUNT
MEDICATIONS & OKAYED BY: OKAYED BY:
SUPPLIES
SUTURES
_________M:D.
NAME OF HOSPITAL
ADDRESS
SURNAME
-
. AGE
HOSPITAL NO.

1-1-1_1
1_1_1_1_1_1_1-1
1_1_1_1_1_1_1_1_1_1_1_1-1_1_1_1_1-1_1 DMDF
RECOVERYROOM RECORD
__IDm ImffiARRNID

.
OBSERVATION
TIME
BP
PULSE (bpm) .
RESPIRATORY
RECOVERY SCORE
Systolic pressure
(+.) 30 ofpreop
but> 90mmHg I
Pink and Warm I
Verbal response to
Spoken Command I
Head lift with closed
mouth for 5seconds
I .
Comfortable regards
to Pain I
TOTAL SCORE
.
5

/
DATE DRUG
.
DOSAGE ROUTE INITIALS
-, -
-,
REGISTERED NURSE: ANESTHETIST:
I --
. NAME OF HOSPITAL
ADDRESS
~ 1_1_1_1 1_1_1_1_1_1_1_1
1_1_1-1-1-1-1-1-1-1-1-1-1_1-1-1-1-1-1
DMDF 1_1_1-1_1_1_1_1
SURGICAL RECOVERY ROOM RECORD
AM.
ARRNAL INRECOVERY ROOM: DATE TIME PM
SURGEON OPERATION _
ANFSIHETIC ACCOMPANIED BY DR. _
CONDmON ONARRNAL 0 AWAKE 0 DROWSY 0 ASLEEP
B II 45 IHR B II 45 2HR B II 45 JHR
200
180
160
140
120
100
80
60
40
20
Intravenous
Dressing
Packing
Drain
Catheter
Nausea: Times
Emesis: TImes
Regained:
Sensation
Consciousness
Transfercd 10
Room
TIME MEDICATIONS TIME REMARKS
Recovery Room Nurse CODE: ar.x P-O, R-O
1-1-1-1-1-1-1-1-1-1-1-1-1:1-1-1-1-1-1
I~ 1_1_1
1-1_1-1-1_1_1-1
~ ~ ~ DMDF 1_1_1_1_1_1_1_1
TISSUEjBIOPSY REPORT
SPECIMEN:
'GROSS EXAMINATION:
MICROSCOPIC EXAMINATION:
DIAGNOSIS:
Pathologist
NAME OF HOSPITAL
ADDRESS
I _ I _ I I I I I _ I I _ I _ I _ I _ I _ I _ I ~ I I _ I I
1_1_1-1
1-1_1-1-1-1_1-1
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~ _ _ DMDF 1_1_1_1_1_1_1_1
PRENATAL RECORD
VULVA
VAGINA
Cystocele
UTERUS
Corpus Size
ADNEXAE
DIAG.CON].
ARCH.
Rectocele
TR. DIAM
otmsr
PERINEUM
CERVIX
Lesion
Position
RECTAL
POST
SAG. em.
ISCH.
SPINES
Laceration
Configuration
SHAPE
SACRUM
COCCYX
TYPE ADEQ!JATE 0
PELVIS BORDERLINE 0
CONTRACTED 0
DESCRIBE:
EVALUATION: (Summary ofabnormalities, prognosis for delivery, facts ofimportance, initial medications-
________M.D.
VORL
INITIAL LAB.
EXAMINATION HGB
DATE: URINALYSIS
Rh
CYTOLOGY (PAP)
A S MICRO
-
NAME OF HOSPITAL
ADDRESS
~
1_1-1-1 1_1-1-1-1-1-1-1
I I 1
I . I
1 1 I I I I I 1 1 1 I I 1 I
OMOF
I I I 1 I 1 I I
LABOR RECORD
GR PARA AB S1'S: TREATMENT DATE
oPOSITIVE oNEGATIVE
PATIEm'S BLOOD TYPE HGB DATE HUSBAND'S BLOOD TYPE
[J itA"
O"B" 0 "AB" 0"0" o"A" o"B" o"AB" 0 "0"
PRENATAL MEDICATIONS PRENATAL D1SEASFSCOMPLICATIONS
ALLERGIES
PELVIMETRY
LABOR ONSET DATE TIME o AM PREQUENCY DURATION QUALITY
o PM
BOW o INTACT DATE TIME o AM BLEEDING DATE TIME o AM AMOUNT
o RUPTURED o PM o PM
ADMISSION DATE TIME o AM TEMPERATURE . PULSE RESP. B.P.
o PM
EENT HEART BREAST
LUNGS EXT. EFW
SUMMARY OF MATERNAL & PAST FETAL ABNORMALITIES
SIGNATURE
FIRST ESTIMATED DATE TIME o AM n SPONT. o MEDICAL
STAGE ONSET OF LABOR o PM n INDUCED o SURGICAL
DATE TIME HOUR OF R.Y. DIL %EFF STAT BOW POS BP FHT SIGN FREQ LABOR QUALITY
LABOR DUR.
SECOND STAGE
o RUPTURED DATE TIME COLOR
o SPONT. o AM OOLIGOHYD o POLYHYDRAM
BOW o ARTIF o PM o NORMAL
. DATE
TIME MEDICATIONS AND ORDERS M.D. DATE TIME NURSE
NAME OF HOSPITAL
ADDRESS
1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1-1_1 1_1_1-1 1_1_1_1_1-1...:1-1
1 1 I I I 1 I_I
1 1 1 1 1 1 1 1 1 1 I
DMDF
I 1 I 1 1 1 1 1
SUMMARY OFPARTURATION
GRAVIDA: PARA: WEEKS OF GESTATION: _
LABOR: 0 SPONTANEOUS 0 INDUCTED HOW?
FIRST STAGE: STARTED ENDED DURATION
SECOND STAGE: STARTED ENDED DURATION
THIRD STAGE: STARTED ENDED DURATION
TOTAL DURATION LABOR:
MEMBRANE: RlJP11JRED SPONTANEOUS DATE: ARTIFICIALLY DATE: _
TIME: TIME:
BABY: SEX: WEIGHT: gms. LENGTH: ems.
CONDITION AT BIRTH: 0 LMNG 0 STRONG 0 FAIR 0 WEAK 0 BORN DEAD
oCRIED SPONTANEOUS 0 ASPHYXlATEDHOW LONG? _
RESUSCITATED: 0 YES 0 NO HOW LONG>
CONDITION AFTER: 0 FAIR 0 WEAK 0 DIED ------
BREATIlING TIME: CRYING TIME:
BIRTII INJURIES/CONGENITAL ABNORMALITY: -----
CORD: 0 LOOPS AROUND NECK 0 NUMBER 0 TIGHT
o LOOSE 0 ABNORMALITY _
PLACENTA: 0 EXPELLED SPONTANEOUSLY: TIME: _
o RETAINED: HOW LONG? _
o REMOVED MANUALLY
o CALKIN'S MANEUVER
o SHOEhORN REMOVAL
o ABNORMALITY
BLOOD LOSS ANTEPARTUM PARAPARTUM POSTPARTUM
MEAURE c.c c.c. c.c, c.c.
ESTIMATES c.c. c.c, c.c.
IF OVER 500 c.c, cause c.c, c.c. c.c.
ANALGESIA:-- _
ANESTIlESIA

INTERVENTION AND INDICATION _
MEDICATION AND TIME GIVEN (MEDS.) , (TIME)
BEFORE DELIVERY, _
DURING DELIVERY _
AFTER DELIVERY
CONDITION OF MOTHE::'"R""'AF=TE=R=-CD=-=E=-=-L=-=IVE=-=il:::C
Y-:
-----------------
oSTRONG 0 FAIR 0 WEAK oCONSCIOUS 0 SEMICONSCIOUS 0 UNCONSCIOUS
BLOOD PRESSURE PULSE TEMP. HGT. FUNDUS _
ATTENDED BY: RESIDENT
DELIVERY ROOM'--:-:-:N:::::URS=-=-E=========____ CONSULTA7':N:;:-T---------
NAME OF HOSPITAL
ADDRESS
1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1 1-1 _1-1 1_1_1_1_1-1_1_1
1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1 OMOF 1,-1_1_1_1_1-1_1
NEWBORN RECORD
Birth Weight: _
Birth Length: _
HOUR AFTER BIRfH: _ ~ : _
Measurement: Head:
Circumferences-: ~ Chest:------
Abdomen:. _
DATE_.__
PHYSICAL EXAMINATION:
Agphar Score at Birth: _
Agphar Score Min. After: _
Agphar Score 10 Min. After: _
General Condition: _
L _ _ __ Tr.
Genitals
Male: Te'-st-es:----:::-----::------
Abnormalities: _
Vaginal Bleeding: _
Abnormalities: _
Extremities: _
Clubfoot: -,- _
Hip dislocation _
Femoral pulse: _
Spine: _
Anus: _
Inguinal Hernia: _
Diactatis Recti: _
Other Findings: _
Abdomen: _
Spleen: _
Kidneys: _
Liver:.. c ~ _ . . _ _
Umbilical Cord: _
Fistula: ;--;: _
Other Findings: _
Sternoclaidomastoid _
EARS:
NOSE:
MOUTH: Lip: _
Tongue: _
Palate: _
NECK:
FACE:
EYES: Conjunctives: _
Scelra: _
Pupils: _
Discharge: _
GENERAL MUSCULAR TONUS: ---,- _
SKIN: Color: _
Turgon: _
Rash: __-,- _
Desquamentation: _
HEAD: Molding: _
Scalp:--;:- _
FontanelIs: _
Suture: _
CHEST: Shape: -r-r- _
Respiration: _
Clavicles: _
Breast: _
Heart: _
Lungs: _
IMPRESSION: _
ASSISTAND RESIDENT: ~ . M.D.
RESIDENT: . M.D.
t"
MOTHER'S
THUMB MfU!J<S
(Left) (Right)
SEX: _
HOSP. NO. _
NAME OF BABY:
DATE DELIVERED,,-:--------------
DISTINGUISHING MARKS: _
BABY'S
FEET PRINT
(LEFT FOOT)
(RIGHT FOOT)
SIGNATURE OFNURSE ON DUTY
NAME OF HOSPITAL
ADDRESS
1-1-1_1_1_1_1_1_1_1-1_1_1-1_1_1_1_1_1
1-1-1_1 1-1_1-1-1_1-1-1
1_1-1_1_1_1_1-1_1_1_1_1_1_1_1_1-1_1_\ DMDF 1_1_1_1-1_1_1_1
ELECTROCARDIOGRAM REPORT
Clinical Diagnosis: _
Record Date Atrial Vent P-R QRS Qfc Qfa Axis Dev. (Sa QRS)
Number R./min. R./min. R./min. (sec) (sec) (sec) (sec) F H
RHYTHM: _
P waves: _
QRS COmplexes: _
ST segments: _
Twaves: _
Electrical Position: _ Transition Zone: _
Others: ---'''-- _
Interpretation and Remarks: _
Read by: Resident:
Consultan-t:-----------
NAME OF HOSPITAL
ADDRESS
1_1_1_1-1_1_1-1_1-1_1_1_1_1_1_1_1_1_1 1-1_1_1 1-1_1_1_1_1_1_1
1-1-1_1_1_1_1_1_1-1_1-1_1-1_1-1_1_1_1 DMDF
I-I I-I I I II
ELECTROCARDIOGRAM TRACING
CLINICAL NOTES
Digitalis
o 0
Yes No
123
Signature
aVRaVLaVF
REPORT
V
123
Signature
DATE OF TRACING
V
456
CENSUS
CFNIRAIJZEDRECORD
KEEPING
AVERAGE DAILY
IN-PATIENT CENSUS
AUTOPSY
BED OCCUPANCYRATE
GLOSSARY
ACTIVE RECORDS - records that arereferred to or areusedat least
once a month
ADMISSION - a patient who is formally accepted by a
hospital/area health service for treatment as
an in-patient (include pay only admission)
ADMITTING DIAGNOSIS - see Diagnosis, Admitting
AVERAGE DAILY CENSUS - see Census, Average Daily.
AVERAGE LENGTH - the average number of days each in-patient stays
OF STAY in the hospital for each episode of care. It is
calculated by dividing the total number of
occupied bed days fora period bythenumber of
separations in thesame period andexpressing the
result as anaverage forall in-patient discharges, or
theaverage number of days of service rendered to
each in-patient discharged during agiven period.
- average number of in-patients present each
day for a given period at time
- See Hospital Autopsy
- the percentage of available beds which have been
occupied over a given period. It is calculated by
dividing the number of occupied bed days for
the period, bythe number of available bed days
for the period, and expressing the result as a
percentage. It is a measure of the intensity of
hospital resources utilized byin-patients.
- a type of record keeping where all materials
and information about a patient are
incorporated into a single file held in a central
location In thehospital application, centralizing
files usually means that the patient, ambulatory
care, andemergencyrecords are arranged inasingle
file in a central location
- a daily listing of all patient activities
(admissions, discharges, transfers, and
deaths) within the hospital
CENSUS, AVERAGE DAILY - the aveagenumber ofinpanents, exdudingnewboms,
m::riving care each day during a reponed period;
- the average number of in-patients maintained in
thehospital each day for a given period of time
CENSUS, PATIENT - a listing of all patients occupying a bed in
the hospital at midnight
Q-IRONOLOGlCALFlUNG - filing in sequence by date
,-
CODING
CONFIDENTIALITY
CONSULTATIONS
DAILY IN-PATIENT
CENSUS
DAYS CARE
DEATH REGISTER
DECENTRAUZED FILES
DELNERY
DELNERY ROOM
DIAGNOSIS
- refers to the assigning of predetermined
numbers from authorized classification
systems to each diagnosis and operations/
procedures
- privacyof records; the issue of who should
have access to information, especially that
relatingto personal affairs and those held in
data banks
- see Consultation, Medical
- the number of in-patients present at the
census-taking time each day, plus any in-
patients who were both admitted and
discharged after the census-taking time the
previous day
- see adult day care;
- provisions during the day, on a regular basis,
of a range of services, which mayinclude health,
medical, psychological, social, nutritional, and
educational services, that allow a person to
function in the home environment
- listing of all deaths in the hospital
- records maintained near thepoint of origin rather
than under one control in a centralized area.
Also referred to as departmental files
- the act of givingbirth to either a livingchild
or to a dead fetus;
- the procedure of delivering a liveborninfant
or dead fetus (and placenta) by manual,
instrumental, Of surgical means
. - a special operating room for obstetric delivery
and infant resuscitation
- is a statement bythe physician of the patient's
health problem;
. - a word or phrase used by a physician to
identify a disease from which an individual
patient suffers or a condition for which the
patient needs; seeks, or receives medical care
DIAGNOSIS, ADMITTING - is the rondition stated onentry(prior to entry) to the
f1cility as the reason fur hospitalization
DIAGNOSIS, DISCHARGE - isthecondition stated at thetimeofdischarge. In
cases ofdeath, thedischarge diagnosis will usually
be the immediate cause of death and any
underlying cause;
- Anyone of the diagnoses recorded after all
data accumulated in the courseof a patient's
hospitalization or other circumscribed episodes
of medical care have been studied
DIAGNOSIS, FINAL - includes the admitting diagnosis, interim
diagnosis, and discharge diagnosis
DIGNOSIS, INTERIM - is an additional diagnosis that describes a
condition arising after admission that
modifies the course and treatment of the
patient's illness or the health care required
DIAGNOSIS, PRINCIPAL - the diagnosis of the condition established
after study to be chiefly responsible for
occasioning the admission of the patient to
the hospital for care
DISCHARGE DIAGNOSIS - See Diagnosis, Discharge
DISCHARGE, IN-PATIENT - See In-patient Discharge
DISCHARGE TRANSFER - the disposition of an in-patient to another
health care institution at the time ofdischarge
DISEASE INDEX - a numerical index of patient problems,
diagnosis, by individual categories (i.e., code
numbers) specifically used for research and
statistical purposes)
DISPOSAL, DISPOSING, - destroying or eliminating records that are no
DISPOSITION longer needed
DISPOSmON SCHEDULE- a plan for the preservation or orderly
disposition of records;
- an itemized list specifying dispositionintervals
EMERGENCY ADMISSION - an admission necessitated by accident or a
medical emergency; such an admission, is
processed through the Emergency Department
EMERGENCY '
OlJf-PATIENf
EMERGENCY
OUT-PATIENT UNIT
FILING
FILING RULES
FINAL DIAGNOSIS
"
FOLLOW-UP
(MEDICAL RECORD)
- is one who is admitted to the in-patient service
of the hospital, but they would still be recorded
as an emergency out-patient admission and
,subsequently as an in-patient admission.
- a hospital out-patient care unit for the
provision of medical services that are wgentlyneededto
sustain Iik or preent aitical ronsequences and that
should be pofullued immediatdy.
- process of arranging and sorting records so
they may be found when needed
- standards or guides for consistency of filing
- see Diagnosis, Final
- checking to see that materials taken from files
are returned or that items requiring later
attention are suspended, so that they will be
called up at the appropriate time
HOSPITAL - an establishment with an organized medical
staff with permanent facilities that include
in-patient beds, and medical services,
including continuous nursing services that
provides diagnosis and treatment for patients
HOSPITALAUTOPSY - post mortem examination performed by a
hospital pathologist or a physician of the
medical staff to whom the responsibility has
been delegated, wherever performed, on the
body of a person who has, at some time,
been a hospital patient
HOSPITAL AUIOPSYRATE - the ratio of the number ofautopsies performed
(adjusted) and the number of deaths of patients whose
bodies are available for autopsy in a hospital
HOSPITAL BED - a bed regularly maintained in a hospital for
the patients' use;
- bed which is maintained for continuous (24
hours) use by an in-patient
HOSPITAL FE11\L DEPJH - death prior to the complete expulsion or
extraction from its mother, in a hospital
facility, of a product of conception,
irrespective of the duration of pregnancy;
death is indicated by the fact that after such
separation, the fetus does not breathe or show
any other evidence oflife (e.g., beating of the
heart, pulsation of the umbilical cord, or
definite movement of voluntary muscles)
HOSPITAL IN-PATIENT - is a patient who is givenlodging in a hospital
while receiving physician, dentist or allied
services in the hospital;
- hospital patient who is provided with room,
board, and continuous general nursing
service in an area of the hospital where
patients generally stay at least overnight
HOSPITAL LIVE BIRTH - the complete expulsion or extraction from
its mother, in a hospital facility, ofa product
of conception, irrespective of the duration
of pregnancy, which after such separation,
breathes or shows any other evidence oflife
such as beating ofthe heart, pulsation ofthe
umbilical cord, or definite movement of
voluntary muscles, whether or not the
umbilical cord has been cut or the placenta
is attached; each product of such a birth is
considered live born
HOSPITAL MORTALITY - see also Hospital Death
~ l I E E ..,'s
HOSPITAL NEWBORN
BASSINET
HOSPITAL OlIT-PIillENT
HOSPITAL PATIENT
INACTIVE RECORDS
- accommodations with supporting services
(such as food, laundry, housekeeping) for
hospital newborn in-patients. These include
bassinets, incubators, and isolettes in the
newborn nursery.
- a hospital patient who receives services in
one or more of the facilities of the hospital
when he is not currently an in-patient or a
home care patient
- an individual. receiving, in person,
coordinated hospital-based medical services
for which the hospital is responsible
- stored records that are seldom used.
Sometimes called "non current" or "dead"
records.
INDEX
IN-PATIENT'S RECORD
IN-PATIENT
HOSPITALIZATION
IN-PATIENTS
IN-PATIENT BED
COUNT DAYS (TOTAL)
IN-PIillENT DISCHARGE
- anordered list (usuallyarranged alphabetically) of
items, names, keywords, or topics within abody
of information .
- See Hospital In-patient
- the sumof in-patientbedcount days for each
of thedays in theperiod under consideration
- the termination of a period of in-patient
hospitalization through theformal reIease of the
in-patient bythehospital;
- isthetermination of thegranting of lodging and
theformal reIease ofan in-patient bythehospital
- see Medical Record
- a periodin a person's lifeduring whichhe is
an in-patient in a single hospital without
interruption except by possible intervening
leaves of absence
IN-PIillENT SERVICE DN! - aunitofmeasure denotingtheservices received by
onein-patient in one2il-hour period
LEAVE OF ABSENCE - a dayoccurring after the admission and prior
to the discharge of a hospitalin-patient when
the patient is not present at the census-taking
hour because he is on leave of absence from
the hospital
LENGTI-I OFSTAY
(FORONE IN-PATIENl)
LIVE BIRTH
LOOSE LEAF/
SHEET
- thenumber of calendar days from admission to
discharge
- see Hospital Live Birth
-termused todescribe anysheet or information
relating to a patient which has not been returned
to theMRS with thepatient's chart
OPERATING ROOM (OR)
PATIENT CENSUS
PATIENT DAY
MAS1ER PATIENTINDEX - isacatalogue of patients admitted inthe facility
(MPI) in a kardex fonn;
- it contains thefulla.ving vita1 infunnation: patient's
name, patient's hospital number, date of birth,
sex, address, date of admission.etc,
MATERNAL DEATI-I - is the death of any woman, from any cause,
while pregnant or within 42 days of
termination of pregnancy, irrespective of the
duration and the site of pregnancy.
MEDICAL RECORD - is a collection of recorded facts concerning a
particular patient. The record contains
sufficient information to identifythe patient
clearly; to justifydiagnosis and treatment, and
to document the results accurately;
- is a compilation of pertinent facts of a
patient's life and health history including
past and present illness(es) and treatment(s),
written by the health professionals
contributing to that patient's care
MEDICAL OONSUITATION- theresponse by onemember of themedical staff
to a request for consultation by another member
of the medical staff, characterized byreview of
the patient's history; examination of the patient
and completion of a consultation report giving
recommendations and/or opinions
NETAUTOPSY RATE - the rate during any given period of time of
all in-patient autopsies to all in-patient death
minus unautopsied medico-legal or medical
examiner's cases
- an areaof a hospital equipped and staffed to
provide facilities and personnel services for
the performance of surgical procedures
- see Census, Patient
- is the unit of measure denoting lodging
facilities provided and services rendered to
one in-patient between the census-taking hour
on two successive days
PfJ1ENT MASTER INDEX - see Master Patient Index
PASS . - a period of absence of a patient that ends
before midnight of the same day
PERCENTAGE OF
OCCUPANCY
PRINCIPAL DIAGNOSIS
- istheratio ofactual patient days to themaximum
patient days as determined by bed capacityduring
anygiven period of time
- see Diagnosis, Principal
SORTING
RETRIEVAL
RECORD RETENTION
SCHEDULE
RETENTION PERIOD
i
,
QUALITY ASSURANCE' - organized setofactivities designed to demonstrate
PROGRAM (QAP) that patient care and services provided by a
hospital are the best possible within available
resources and consistent with achievable
goals, through the ongoing assessment of
important aspects of patient care, the
correction ofidentified problems, and follow-
up activities to verify that corrected problems
have not reoccurred
- see Disposition Schedule
- the time that records must be kept before
disposition; sometimes depends on the
occurrence of an event' such as contract.
closure
- the process of locating and removing items
from their retention or storage systems
- process of arranging item's in the order in
which they will later be filed
SEPARATION - see also Discharge
TELEPHONED ORDERS - orders for a patient that are telephoned to the
(TO) hospital unit bythe doctor.
TERMINAL-DIGIT FIUNG - a method of filing by the last digit (usually
the last two) of a number instead of by the
first digits as in traditional left-to-right leading
TRACER CARD - used to indicate where a record has been sent
and when it has been taken from the file.
When removing a record from a file, this must
be replaced by a tracer
,
TRANSFER
(INTRA-HOSPITAL)
UNIT NUMBER
VERBALORDERS
- a change in medical care unit, medical staff
unit, or responsible physician ofan in-patient
during hospitalization
- a new admission will be given the next
sequential number fromthe admissionlog,which
will be retained no matter how many times h(f"
shemaybere-admitted to thefacility Areadmitted
patient will be given his/her admission number
from his/her first admission.
- orders given verbally, to the unit clerkor nurseby
the physician in person or on the telephone
[
REFERENCES
Amatayakul, Margareth K. & Schraffenberger, Lou Ann. (1988).
Productivity: A Handbook for Health Record Departments.
Chicago: American Medical Record Association Pub.
American Hospital Association Resource Center.(1986). Hospital
Administration Terminology Chicago: American Hospital Pub. Inc.
Azurin, Jesus. (1981). Approved Agency's Medical Record Disposition
Schedule. Manila: Department of Health
Bashook, Philip G & Sandlow, Leslie J. (1974). Problem Oriented Medical
Records: Instructor's Manual for Teaching Physicians. Chicago:
Michael Reese Hospital & Medical Center.
Davis, Elwyn. (1987) Notes on Information Systems for Medical Record
Administration Students. Cumberland College of Health Sciences.
Department of Education, Culture, and Sports. (1988). Guidelines on
the Decentralized Disposal ofValueless Records on Government
Agencies. Manila: D.E.C.S.
Donabedian, A. (1982). The Criteria and Standards ofOuality. An Arbor;
Health Administration Press.
Epstein,Jerome. (1%8). Medical Record Analysis. Medical Terminology
- An Individualized Approach. California: Westinghouse Learning
Press.
Esley, Carole E. (1973). Implementing the POMR System - Guidelines
for Medical Record Personnel. Chicago: American Medical Record
Association.
Fox, Leslie Ann. (1983). The Role of Medical Record Service in Risk
Management. Chicago: A.M.R.A.
Graham, N.0. (1982). Ouality Assurance in Hospitals: Strategies for
Assessment and Implementation. Maryland: Aspen Systems
Corporation.
Haytt, Emanuel. (1964). Legal Aspects of Medical Records. Illinois:
Physician's Record Company.
Huffman, Edna K. (8"'Ed.)(1985). Medical Record Management. Illinois:
Physician's Record Company:
International Federationof Health Record Organizations. (1992). Learning
Packages for Medical Record Practice. Sydney: LF.H.R.O.
Lang, Gerald S. & Dickie, Kenneth J. (1978). The Practice - Oriented
Medical Record. Maryland: Aspen Systems Corporation.
Luke, R.D., et. al (1983). Organization and Cbange in Health Care
Ouality Assurance. Maryland; Aspen Systems Corporation.
f
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Miller, M. C. & Knapp, R.G. (1979). Evaluating Quality of Care.
Maryland: Aspen Systems Corporation.
Miller, Susan C. A Medical Record Handbook for Hospice Programs:
Assuring High Quality Care Through High Quality
Documentation. Chicago: AMRA
Ministry of Health. (1980). Manual of Medical Record
Manila: Bureauof Medical Services.
Officeof the Civil Registrar General. (1975). Manual ofCivilRegistration.
Manila: Office of the Civil Registrar General.
Robinson, Kerin Mary. (1978). Consent to Treatment Forms for
Hospitals - With Guidelines. Chicago: lincoln Institute of Health
Sciences.
Waters, K.A. & Murphy, G.F. (1979). Medical Record in Health
Information. Germantown: Aspen Systems Corporation.
World Health Organization. (1978). International Classification of
Diseases - Manual of the International Statistical Classification
of Diseases Injuries and Causes of Death. Geneva: WHO. (Vols. I
& II)
World Health Organization. (1978). International Classification of
Procedures in Medicine. Geneva: WH.O.
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H108.45 records'management manual

Hospital Medical Records Management Manual

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CRITERIA FOR AN EFFECTNE MRS ORGANIZATION