Professional Documents
Culture Documents
INFORMATION
SYSTEM
DEVELOPMEN
T
(Medical
Records)
HEALTH INFORMATION SYSTEM
DEVELOPMENT (MEDICAL RECORDS)
Organizational Chart
Objectives
Standards
Record Completion
Release of Information
Policies for:
Doctors Release Of Information
Nurses On Release Of Information
Other People Concerned
Objectives
General Policies
Patients Record Fill
Retrieval of Patient Chart
Death Certificate
Reports
Hospital Records
Section Head
Recording and Analysis Clerk
Receiving, Filing, And Retrieval
Appendix
ORGANIZATIONAL CHART
(Medical Records)
PRESIDENT/ CHIEF
EXECUTIVE OFFICER
SECTION HEAD
OBJECTIVES:
STANDARDS:
RECORDS:
1. Prepares the patients index based on the list of admission and check the
patient’s assigned number.
RECORD COMPLETION:
RELEASE OF INFORMATIONS:
1. Nurses may borrow/ sign-out medical records per doctor’s instruction for
ward use.
2. In the ward, student nurses shall have access to the records of patients
assigned to them.
3. Private nurse shall only be allowed to review records of patients assigned
to them.
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 Medical Records Section.
5. Ward nurses should always see to it that charts are in a secured place away
from the patients or the patient’s relative.
OBJECTIVES:
GENERAL POLICY:
1. Patient’s chart from ER & nurse station upon discharged, must be forwarded
to the medical record section for recording.
2. Check all charts received against the list of discharges as reflected in the Daily
Census Report.
3. Records all chart received to the logbook.
4. Prepares the patients index based on the list of admission and check the
patient’s assigned number.
5. Rearranges the record according to the standard format.
6. Analyze data on patient’s chart.
a. If the data are incomplete (from ER & ward), fill up the deficiency
sheet, attach it to the chart and return it to the ward or unit
concerned;
b. Upon receipt of incomplete chart and deficiency sheet, fill up the
required data and sign it.
c. Return completed chart and deficiency sheet to the Medical
Record Section.
d. Once the data are already completed the medical record in-
charge will sort our according to filling system and prepare folder
with corresponding terminal digits.
1. The requesting party must submit duly accomplished request form to the
medical record in-charge.
2. The medical record in-charge verifies patient’s name, number from the patient
index card.
3. The medical record in-charge will retrieve the chart from the file and record
the said chart in the logbook, indicating the patient’s name, the requesting
party, the date when borrowed and the name of the recipient of the patient’s
chart.
4. The medical record in-charge will release patient chart to the requesting party
and the latter will sign the logbook.
DEATH CERTIFICATE:
1. If the patient dies the medical record in-charge will prepare four (4) copies of
death certificate and let the attending physician signed the certificate.
2. The attending physician will check, completes and signs death certificate and
return it to the medical record section.
3. The medical record in-charge will check the accuracy and completeness of
data and forwards it to the releasing/ information clerk.
4. The information clerk will record the death certificate in the official logbook
and releases four (4) copies of the death certificate to the patient’s relative.
5. The patient’s relative acknowledges acceptance of the death certificate and
sign the logbook.
6. Medical record in-charge files the annotated Death Certificate copy from the
Local Civil Registrar.
BIRTH CERTIFICATE:
1. The medical record in-charge will provide a birth certificate draft form to the
parent.
2. The parent fills-up the draft form.
3. The medical record on duty will interview the parent and verifies data.
4. The medical record in charge advises the parent to sign a preliminary blank
official certificate form.
5. The medical record will advise the parent to submit the following documents
that requires in the submission of the birth certificate to the Local Civil
Registrar (LCR).
FOR MARRIED
a. Marriage contract (Xerox copy)
b. Two (2) valid ID namely: SSS, Passport, company ID, Voter’s ID
& etc. (Xerox copy).
c. c. Latest Residence Certificate (Xerox copy)
UNMARRIED
a. Affidavit of paternity signed & notarized by lawyer
d. Two (2) valid ID namely: SSS, Passport, company ID, Voter’s ID
& etc. (Xerox copy).
e. Birth Certificate of the parents (Xerox copy)
f. Latest Residence Certificate (Xerox copy)
REPORTS:
Section Head
RESPONSIBILITIES:
3. Gathers and receives medical records problems and reports to medical records
consultant for immediate action and solution.
5. Re-echo the said activity to the personnel of the Medical Record Section.
RESPONSIBILITIES:
6. Retrieves and pull out patient’s record requested for the use of
a. Medicare or PHIC
b. Insurance
c. ECC
d. SSS
e. Study purpose of Doctors, Students and health personnel.
RESPONSIBILITIES:
1. Collects daily census reports and discharged patient’s charts from the nurse’s station.
6. Makes a list of incomplete patient’s chart for completion and place into the pigeon
holes provided.
8. Retrieves and pull out charts requested for the use of PHIC claims. Processing, ECC,
Study purpose of students, doctors and other health personnel.
9. Attends & prepares client request, this is the birth certificate, death certificate,
medical certificate & insurance.
10. Files complete patient’s chart to permanent shelves following the terminal digit
filing.
Section Head
Reports to : Director of Administrative Services
Unit/ Department : Medical Records
RESPONSIBILITIES:
11. Provides adequate training of Medical Records personnel and supervise daily
activities.
13. Gathers and receives medical records problems and reports to medical records
consultant for immediate action and solution.
14. Represents the Medical Records Section in meetings, seminars and other
related activities.
15. Re-echo the said activity to the personnel of the Medical Record Section.
18. Compile data and produce statistical reports required by Department of Health
and PHIC.
RESPONSIBILITIES:
13. Maintains the patient’s master file.
18. Retrieves and pull out patient’s record requested for the use of
a. Medicare or PHIC
b. Insurance
c. ECC
d. SSS
e. Study purpose of Doctors, Students and health personnel.
RESPONSIBILITIES:
11. Collects daily census reports and discharged patient’s charts from the nurse’s station.
12. Records admission in the computerized logbook.
16. Makes a list of incomplete patient’s chart for completion and place into the pigeon
holes provided.
18. Retrieves and pull out charts requested for the use of PHIC claims. Processing, ECC,
Study purpose of students, doctors and other health personnel.
19. Attends & prepares client request, this is the birth certificate, death certificate,
medical certificate & insurance.
20. Files complete patient’s chart to permanent shelves following the terminal digit
filing.