Professional Documents
Culture Documents
Effective Date:
September 1, 2009
No. of Pages
Submitted by:
Medical Records In Charge
Reviewed by:
Hospital Administrator
Authorized by:
CEO/ President/Chairman
Effective
Date:
Vision
Mission
To serve AMSHI clients, by ensuring the safety and privacy of patients records.
And maintain a comprehensive recording of relevant information through time.
Section 3.
Purpose
d.
e. To provide records, upon request, for patients attendance to OPD and the
wards.
f. To help in preparing periodic reports on morbidity, birth and death,
utilization of hospital beds, rate of bed occupancy, out-patient services
rendered, as well as compilation of statistical reports on type of surgery
performed and types of diseases treated.
ARTICLE II:
ORGANIZATIONAL CHART
BOARD OF DIRECTORS
HOSPITAL ADMINISTRATOR
Section 1.
Name of Department:
General Policy:
1. The health facility appoints and allocates personnel who are suitably
qualified, skilled and/ or experienced to provide the service and meet
patients needs.
2. Each personnel is qualified, skilled and/or experienced to assume the
responsibilities, authority, accountability and functions of the position.
3. Professional qualification are validated, including evidence of
professional registration/license, where applicable, prior to employment.
4. An organized medical and nursing staff shall be responsible for the
quality of patient care and for the ethical conduct and professional
practices of its members.
Position
Medical
Records
Clerk
DOH
Minimum
Requirement
Internal
Manpower
Plan
Compliance
Status
(FT if Full
Time)
(PT if Part
Time)
Remarks
FT
ARTICLE III:
Officer In-charge
a.
b.
Checks all patients chart for proper indexing and file it to permanent
shelves.
c.
d.
e.
f.
g.
h.
i.
k.
l.
m.
Retrieves and pull-out patients chart requested for the use of:
1. study purposes of doctors and students
2. HMO/ Insurance
3. Philhealth / DOH
4. MRD
ARTICLE IV:
b.
Filing and storage areas with very humid conditions also had bad effects
on the medical records, papers absorb moisture to some extent and this
could affect the quality of the record.
3. Proper Temperature
It is fact that the temperature affects the performance of a person, it
shouldnot be too warm nor too cold, and conducive for working should be
provided.
4. Retention of records
a.
b.
DOH came up with ministry Circular 77, series 1981 which further
qualifies the 25 year retention period for all hospitals under the DOH
regardless of its category/ classification.
inactive records.
2. Active records are usually maintained for (5) years after which
they are transferred to the inactive file until they reach the required
retention period.
c. Attitude
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education).
Section 2.
Document type
Admission and Discharge
Birth Register
Correspondence Log Book for MRS
Disposal Schedule
Retain permanently
Retain permanently
Seven (7) years after date of the
last entry
In-patient Record
ADULTS
* Teaching-training and Research,
And Provincial Hospitals
* District/Community Hospitals
MINOR (All)
* Psychiatric Hospital
25 years
25 years
Retain permanently
Retain permanently
Retain as in-patient records
Retain permanently
Retain permanently
Research Request
10 years
Subpoenas
If no record
X-ray Result/Report
* If filed with the chart
* If no Record
Section 3.
Filing of Chart
2.
Final diagnosis
ICD-10 coding
Patient Index Card
Report of Operation (if any)
ECG reading (if any)
Anesthesia record (if any)
IV flow sheet complete
Correct carry out of nurses notes
complete checklists of patients chart.
3.
All charts ready for filling should be stamp by MRD Head at the
right upper portion of Medical Examination Sheet or above the
date of admission with corresponding signature of MRD in charge.
4.
5.
This is otherwise
2. Unit Numbering
Section 4.
Retrieval of Chart
a. PHIC office
PHIC office pull-out discharged charts 2 days after patients discharge for
their claims processing. Signed the daily discharge list prepared by MRD
staff for records purposes. Returned the charts borrowed 3 days after date
borrowed then counter check MRD in charge for checking of complete
charts returned.
b. HMO office
HMO Office pull-out discharged charts for claims processing purposes.
List all borrowed chart at logbook countersigned by HMO staff for record
purposes.
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received the chart. Returned the chart immediately at MRD, in charge will
note the logbook for the chart returned.
d. MRD in charge pull-out chart for personal insurance claims and patient
requesting for clinical summary, laboratory results, Xray, operating report,
etc.
1.
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ARTICLE V:
IN-PATIENT
Section 1.
completion.
d. Medical Certificate should be release immediately within 10-20 minutes
depending on physician availability.
e. In case, attending physician is not available/ out of town, patient is
scheduled to comeback 2-3 days after date of requisition.
f. In case patient send a representative to get his/her medical certificate,
patient should make an authorization letter and bearer should present
Identification Card for verification and records purposes.
g. MRD in charge should explain to patient/ any representative the
confidentiality of patients record.
h. MRD in charge should logbook all patients request forms and released of
medical certificates.
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Section 2.
Section 3.
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e. Medical Certificate should be in two (2) copies, one for the patient and
one for the medical records for proper records purposes.
f. Duplicate file should be filed, together with the copy of the Affidavit of
Desistance.
g. All request and released Medical Certificate should be in logbook for
records purposes and signed by patient/ representative for confirmation of
the released certificate.
Section 4.
a. DR Nurse will pick-up daily the newborn footprint at delivery room and
endorses it to MRD for issuance of MBFH (Mother Baby Friendly
Hospital certificate.
b. MRD in charge will give the parents a Birth Certificate Information
Sheet.
c. Information Sheet should be properly filled-up by parent with Signature
over printed name below noted by MRD in charge.
d. MRD in charge then will fill up the final Birth Certificate Form as
provided by National Statistic Office.
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e. Parent should check first the data encoded before signing the birth
certificate.
f. A certificate of confirmation should be properly filled-up and signed by
the parent of the baby for confirmation of records of the baby.
g. MRD in charge , is the one assigned to complete the forms with:
a. signature of OB-Gyne
b. receiving and processing at local civil registrar.
h. Parent must receive the Birth Certificate as soon as possible or before
discharged.
i. Original copy will be given to the parent and a duplicate file will be left to
the hospital for record purposes.
j. In case an error or changes in any data given after typing/printing birth
certificate, a corresponding charge of the form will be implemented.
k. For strict compliance, all released Birth Certificate must be complete and
received by the LCR.
l. All request and released certificates should be in logbook with
corresponding signature of any representative for records keeping
purposes.
Section 6.
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f. Families of the deceased will be the one to finished all the signatures
needed for the form, with the following:
a. funeral/ embalmer
b. city health officer
c. receiving at the local civil registrar
g. All request and released death certificate should be in logbook with
corresponding signature of any representative for records purposes.
ARTICLE VI:
2.
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3.
Any person making an entry in the medical record must date and
sign his entry or properly authenticate the entry made.
The
To correct:
a.
b.
c.
Section 2.
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f. In case ECG strips had no reading upon discharge, MRD will forward the
chart to at OPD section for completion.
g. Operating report/technique if possible should be properly filled up and
attached at the patients chart before or upon discharge.
h. All discharged charts should be forwarded daily by NS Head nurse or the
head of the shift in the absence of the head nurse.
i. All discharged chart should be properly checked by NS head nurse or
supervisor before endorsing at MRD office.
j. NS will make a logbook for all patients endorsed to MRD and MRD will
also make separate logbook for records purposes and verification of chart
received.
k. Medical Records must be maintain the privacy, accuracy and prevent loss
and destruction of patients record.
l. All errors of patient identification data during admission must be notarized
and a joint affidavit should be presented to the Medical records Department
for changing of data.
Section 3.
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5. TPR Sheet
no. Records all medicines given by NOD to patient with date ordered, name of
medicines & treatment, time given, signature of NOD and date/time discontinued
with signature of patient/representative at the right lower portion of the form.
10. Nurses Notes - contain the notes of all nurses who tended the patient. These
include their observations of the patient, the treatment given, the response to the
treatment, and unusual occurrence. The first page shall always contain a record of
checking the patient in the unit and recording his physical condition at the time.
The admission portion is completed when the patient first admitted to a particular
nursing unit; while the discharge portion if completed when the patient is
discharged from the unit. The discharged notes should include basic information
such as time of discharge with signature over printed name of NOD and condition
upon discharge.
11. Discharge Instruction Sheet - summarizes the significant findings and events
occurring during patients hospitalization, final diagnosis, date of discharge, home
medication with complete dosage, time and duration of intake, recommendation
and arrangement of future care (OPD follow-up treatment), special instructions (if
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any), NOD signature over printed name, signature over printed name of any
representative and name of attending physician
12 Anesthesia Report Sheet (if any)
13. Report of Operation Sheet - record and authenticate a pre-operative diagnosis
before surgery. The record should contain a report of all findings, a description of the
technique used, description of any tissue removed, and a post-operative diagnosis,
date of operation and signature of the surgeon.
14. Birth and Death Certificate , if either of these events occurred.
15. Other Sheets - OB-gyne History form, Physical Therapy Note form, consent for
operation(if any) and Trauma Form.
16. Consultation Reports - adequately record the consultants findings on physical
examination of the patient, as well as his opinion and recommendations.
17. Birth and Death Certificate , if either of these events occurred.
18. Other Sheets - Medication and treatment, vital sign sheet, graphic chart sheet,
referral form and ETC.
19. Information Sheet- for preparation of birth and death certificate. Patient must
fill up this sheet with correct and complete data.
ARTICLE VII:
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b. Indicate the persons name requesting it, date, purpose and numbers of copies in
the charge slip.
c. Approved charged slip must be presented to MRD before it will be
performed by the in charge.
d. All sales from the photocopy service for the day must be remitted to the cashier
with corresponding official receipt.
e. Photocopier in charge must provide a logbook for all sales and charge photocopy
including the errors for proper control system.
f. This report must be verified by the accounting officer and with an actual checking
on the machine to confirm the accuracy of the report.
ARTICLE VIII:
SERVICE STANDARDS
Antipas Medical Specialist hospital, Inc believes that the best way to give quality
care to patient is by satisfying their needs. And begin this by caring for ourselves
and each other. The way we treat each other within AMSHI sets the way on how
we treat our patients and guests. We need to treat each other with courtesy, respect
and kindness. All employees are therefore expected to pledge to provide and
uphold the following service standards.
1. Smile
allow patients and visitors the right of way in the ramp, stairs, hold door open
for those trying to enter the room
politely ask others to wait for the next wheelchair or stretcher if transporting
patients on beds.
always practice patient confidentiality including clinical discussions in the
hallway, ramp and all public areas.
acknowledge with a nod or smile to patients/watchers guests.
4. No Waiting
acceptable waiting time for a scheduled appointment is 30 minutes. For a nonscheduled visit, every effort will be made to see the patient within an hour.
apologize if there is a delay, offer to reschedule the appointment if possible.
if delay is over an hour, update patient about their status at least every 30
minutes.
update family members at least hourly while patient is still on procedure.
5. Dress Professionally
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address patient by name, maam , sir, nay, tay or any comforting name/address
to patient.
do not leave the floor until patients requests have been conveyed to
appropriate nurse/attendant.
appropriate nurse must respond to patient call or request within 3 minutes.
before leaving the patient, ask. is there anything else I can do for you
maam / sir?
check patients an hour before shift change to minimize patients requests
during endorsement.
before leaving the floor for breaks or meals, notify patients of when you will
return, inform patient who will cover in your absence.
8. Direct Communication
9. Speak positively
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