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Copy of himd lecture mha

  1. 1. HEALTH INFORMATION MANAGEMENT June 3, 2011 Florinda G. Tuvillo Development Management Officer IV (Medical Records Adviser) National Center for Health Facility DevelopmentDepartment of Health, Philippines
  2. 2. Health Record Standard IThe hospital maintains health recordsthat are documented accurately and ina timely manner, are readily accessibleand permit prompt retrieval ofinformation, including statistical data. Department of Health, Philippines
  3. 3. Health Record Standard IIThe health record contains sufficientinformation to identify the patient,support the diagnosis, justify thetreatment and document the courseand results accurately.Department of Health, Philippines
  4. 4. Health Record Standard IIIHealth records are confidential, secure,current, authenticated, legible, andcomplete.Department of Health, Philippines
  5. 5. Health Record Standard IVThe Health Information ManagementDepartment is provided with adequatedirection, staffing, and facilities toperform all required functions.Department of Health, Philippines
  6. 6. 1. The record is sufficiently detailed to enable: - patient to receive continuing care - effective communication within the health team - Attending Physician to have available information required for the consultation - other medical practitioners and health personnel to assume the patient care - concurrent or retrospective evaluation of patient care Department of Health, Philippines
  7. 7. 1. Entries into the records are made only by duly authorized persons of the facility and are dated and signed, containing designation.3. All entries, including alterations, must be legible.Department of Health, Philippines
  8. 8. 1. Only abbreviations and symbols approved by the Medical Records Committee are to be used.5. If possible, original copies of all reports made by medical, nursing, and allied health professionals are filed in the record.Department of Health, Philippines
  9. 9. 6. Each record should at least contain the following data: - unique health record number or reference - Patient’s full name - Address - Date of birth - Sex - Person to notify in case of emergency Department of Health, Philippines
  10. 10. 7. An “ALERT” notation, for the conditions such as allergic responses and drug reactions, is prominently displayed on the face sheet of the record.8. The record contains a written admission diagnosis by the medical practitioner.Department of Health, Philippines
  11. 11. • The record contains a patient’s history, pertinent to the condition being treated, including relevant details of: − Present and past medical history − Family history − Social considerations10. A sufficiently detailed report of a relevant Physical Examination (PE), performed by a medical practitioner, should be included for the purpose of admission. Department of Health, Philippines
  12. 12. 1. Evidence that the patient has given informed consent is available.12. Drug orders are written in the record by the medical staff.13. Therapeutic orders and orders for special diagnostic test are noted in the record. Department of Health, Philippines
  13. 13. 14. There is evidence in the health record that patient care plans were made.15. 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. Department of Health, Philippines
  14. 14. 1. The Admission and Discharge Record’s ischarge data is completed at the time of discharge or as soon as the relevant information is available. It contains all relevant diagnoses and procedures using the terminology of a current revision of the International Classification of Disease (ICD). Department of Health, Philippines
  15. 15. 17. A Discharge Summary for each patient should be completed within 48 hours upon patient’s discharge, with a copy remaining in the health record. The discharge summary should at least include the following: − Discharge diagnosis − Procedures performed − Follow-up arrangements − Therapeutic orders − Patient instructions (when necessary) Department of Health, Philippines
  16. 16. 18. When a patient is transferred to another facility, a Discharge Summary should accompany him/her. Department of Health, Philippines
  17. 17. 19. When an autopsy is performed a provisional diagnosis is noted in the health record within 72 hours and the health record is completed within 15 days following the death. A copy of the autopsy report is filed in the health record. Department of Health, Philippines
  18. 18. START Charts from Unit NEEDED LOANED RECORD RECORDS Med. Record Release to Returned Record •Request Borrower Recording/ •Accomplished Pre-sort Indexing Search: Assembly •Forwarded Accomplish Remove from Trucking Records Trucking System System •Un-filed MPI NO Analysis •Record of Adm. In MPI File? •Etc… YES Disease Coding/Indexing YES In File? NO Operation Coding Complete? Routing YESNO Process Physician’s Search at: Index •Incomplete •Processing •Etc… Data Collection Final Re-check Statistics Disposal Complete? Permanent File Retrieval system
  19. 19. SYSTEMS AND PROCEDURES
  20. 20. THE MEDICAL RECORD SERVICE1. RECORDING2. INDEXING3. ASSEMBLY4. ANALYSIS 4.1 QUANTITATIVE 4.2 QUALITATIVE5. CLASSIFICATION, CODING OF DISEASE AND OPERATIONS6. INDEXING OF CODED DATA7. DATA GATHERING AND STATISTICAL REPORT PREPARATION8. FILING9. RETRIEVAL
  21. 21. Log of all discharged patient from thefacility“NURSING SERVICE LOG OF DISCHARGEDPATIENT” = “MRD PREPARED INDEX OFDISCHARGED PATIENTS” = CENSUS REPORT
  22. 22.  Source Oriented Problem Oriented Integrated
  23. 23. A N A L Y S I S
  24. 24. THE MEDICAL RECORD SERVICEANALYSIS (QUANTI AND QUALI) Basis in doing analysis: The medical record must contain sufficient information to : IDENTIFY the patient SUPPORT the diagnosis JUSTIFY the treatment, and RECORD the fact accurately.
  25. 25.  Knowledge of Medical Terminology Anatomy Physiology Fundamentals of Disease Processes Medical Record Content Standards of Licensing, Accreditation
  26. 26. THE MEDICAL RECORD SERVICE COMMON CAUSES OF INCOMPLETE MEDICAL RECORDS* Ineffective systems and procedures and policy guidelines regarding record completion.* Non-implementation of existing standards regarding the timely completion medical records.* Lack of administrative policies to address the problem.* Lack of supervision and control on the part of top management, specifically the Chief Operating
  27. 27.  Negativeattitude of some members of the medical staff and other paramedical staff on the timely completion of medical records Weak interface between the staff of the medical records service and those involved in the creation of quality record Staffinvolved in the creation of records are not fully oriented on the negative effects of maintaining poorly documented medical records
  28. 28. THE MEDICAL RECORD SERVICECONCURRENT ANALYSIS OF MEDICAL RECORDSADVANTAGES: * Hastens Billing Process * Improves the quality of medical records * Shortens Time of Completing a record * Is the foundation for working DRG which is used as reference for Utilization ReviewDISADVANTAGES: * Requires more employees to truly implement this type ofanalysis * Requires an on going technical training program.
  29. 29. THE MEDICAL RECORD SERVICECONCURRENT VS. RETROSPECTIVE ANALYSISFacilitates timely At times causes delay in thecollection of statistical timely Collection/data/information consolidation of statistical data/informationPro-realistic and timely At times affects decision-decision-making is makingachievedAid in the timely Utilization review has to beperformance of utilization scheduled after retrospectivereview analysis to be sure of a completely documented recordHas the tendency of Incomplete medical recordseliminating incomplete not addressed on a timelymedical records basis
  30. 30. THE MEDICAL RECORD SERVICECONCURRENT VS. RETROSPECTIVE ANALYSISAssures timely completion of Delayed completion ofrecords by consultants and records by consultantsvisiting physicians and visiting physicians and records turn delinquent.Improves interface/interaction Interaction not enhancebetween the members of the and at times createstaff involved in the creation of negative coordinationrecordAid in the prediction of daily Prediction of daily incomeincome as billing process is is only made possibleenhanced before or after the discharge of the patient and the record is analyzed
  31. 31.  Cost hospitals reimbursement pesos when there is no documentation of the services that were given Hamper quality assurance and risk management efforts Force hospitals and physicians to settle suits out of court or to lose cases because lawyers cannot prepare a solid defenseNOTE: = 85% of malpractice cases that could be dismissed for lack of evidence end up in court because the patient record is too poor to defend the hospital
  32. 32.  1. Patterns of poor documentation * Identify a need for more focused peer review by Med. Record Committee Quality Assurance Committee, Education & Training. 2. Statistics of physician with incomplete medical records 3. Statistics on the number of incomplete vs. complete records
  33. 33. Poorly documented clinical recordis of Little use to a patient during histreatment, for his future care or forevaluation of the care rendered by themembers of the medical, nursing andother health professionals. Hayt, Emanuel (Atty.)
  34. 34. We must always stress the importance of acomplete, accurate and up-to-date documentationbecause it does not only project the image of anefficient, conscientious and reliable staff but, moreimportantly, it gives the impression to patient thathe is being taken cared of properly” Teresita Sanchez, MD., LLB.
  35. 35. THE MEDICAL RECORD SERVICESIGNIFICANCE IN DOING MEDICAL RECORD ANALYSIS Quality *Complete Quantitative *Accurate Medical Qualitative Documented *Adequately Record Analysis Med. Record Documented Quality Committees: •Correct Statistics Quality Assurance * Professional Risk Management •Valid Performance Infection Control •Reliable * Quality of Care •Policy Tool used in: Formulation Research/Studies Decision Support Training •Better Hosp. System Operation Teaching/ For Better Education •Patient Care Court Management
  36. 36. THE MEDICAL RECORD SERVICEIN SUMMARY: Managing the contents of the medical recordthrough analysis of documentation is an importantfunction of the HIMD/MRD. By reviewing all medical records during orfollowing an occasion of service for completenessand accuracy, the Medical Record Practitioner makesa significant contribution to the Health Care Facility. Completion of medical records and improveddocumentation, results in improved communicationamong all health care providers, contributing toimprove patient care.
  37. 37. C O D I N G
  38. 38. THE MEDICAL RECORD SERVICE CLASSIFICATION CODING OF DISEASE & OPERATIONS ICD-9-CM & ICD-10CENTRAL CONCEPT IN MORBIDITY CODING At the end of an episode of care, the clinician should record allconditions which affected the patient in the episode, starting with thePRINCIPAL DIAGNOSIS/ MAIN CONDITION, FOLLOWED BYTHE OTHER DIAGNOSES/CONDITIONCOMPLICATION An additional diagnosis that describes a condition arising after thebeginning of hospital observation and treatment and modifying the courseof the patient’s illness other medical care required.ADDITIONAL DIAGNOSES: All conditions that coexist at the time of admission, or developsubsequently, which affect the treatment and/or management received bythe patient and the length of stay.
  39. 39. THE MEDICAL RECORD SERVICE PRINCIPAL DIAGNOSIS The condition established after study to be chiefly responsible for occasioningthe admission of the patient to the hospital for careDIAGNOSIS A word or phrase used by a physician to identify a disease from which anindividual patient suffers or a condition for which the patient needs, seeks, orreceives medical careFINAL DIAGNOSIS INCLUDES 1. ADMITTING DIAGNOSIS The condition stated on the entry (prior to entry) to the health care facilityas the reason for hospitalization. 2. INTERIM DIAGNOSIS Is an additional diagnosis that describes a condition arising afteradmission that modifies the course and treatment of the patient’s illness or thehealth care required
  40. 40. THE MEDICAL RECORD SERVICE3. DISCHARGE DIAGNOSIS - is the condition stated at the time of an episode of care/dischargeFORMAT IN WRITING DIAGNOSIS I. Main condition : Primary diagnosis : Principal Diagnosis: ________________________ II. Other condition : Secondary diagnosis: Minor condition (s) : ________________________ ________________________ ________________________ ________________________
  41. 41. THE MEDICAL RECORD SERVICEEXAMPLE:PATIENT A: 1. RIGHT INGUINAL HERNIA (Admitted for Surgery) 2. DIABETES MELLITUS 3. EMPHYSEMA, PULMONARY 4. DISRUPTION OF OPERATIVE WOUNDPATIENT B 1. CARCINOMA OF CERVIX UTERI 2. CHRONIC CYSTIC DISEASE OF THE BREAST
  42. 42. No. of No. of ErrorPhilHealth & Total RTH Error Assigned Total Rate Other No. of ICD-10 Rate Codes Codes Based Insurance Coded (Phil- (ICD-10 Assigne on Total Claims Records Health) ) d CodesICD 10 ICD- % ICD-10 ICD- Assigne 9-CM 9C d M %10,979 1,057 6 12,036 (code) 0.054 25,170 5,75 30,92 0 0.049 0 47 (OR) 0.42 22 (others 0.20 )
  43. 43. THE HIMD/MRD DOCUMENTATION GUIDELINES• Documentation should be complete;• Documentation should be objective and non-judgmental;• Documentation must be legible and written in ink;• Entries must be dated and signed;• Documentation of volunteers must be reviewed and initialed by a regular hospital staff prior to the filling of the medical records;
  44. 44. • Documentation should be completed shortly after the service was provided;• No form may be removed or destroyed once it is filed in the Medical Records Office;• Errors should be corrected in the proper manner.• FACTUAL = OBJECTIVE ENTRY = WHAT YOU SEE and HEAR, WHAT YOU WRITE• Never “DOCUMENT” for “SOMEBODY ELSE”
  45. 45. THE MEDICAL RECORD SERVICE GOOD RECORDING AND DOCUMENTATION PRACTICES• Evidence of timely recording of entries• Legibility• Authentication of all entries• Use of approved abbreviation• Avoidance of extraneous remarks
  46. 46. • Medical Record should contain no unexplained timegaps. e.g. E.R. record• Do not “Skipped Spaces” (consecutive lines)• Correct spelling• Ethical
  47. 47. THE MEDICAL RECORD SERVICE STEPS TO EFFECTIVE MEDICAL RECORD DOCUMENTATION 1. A complete history and physical exam including baselinelab values, pap smear, breast examination and rectalexamination are required. Provisional diagnosis must bedocumented. 2. Daily progress notes must reflect findings, assessment andplan of care. Avoid use of such phrases as “status quo”.Progress notes should reflect the acute condition of the patient. 3. Physician orders must reflect treatment of the conditionfor which the patient was admitted or which developssubsequently. If ancillary tests or medical therapies are orderedwhich are not consistent with the current diagnosis or condition,they should be justified in the progress notes.
  48. 48. THE MEDICAL RECORD SERVICE4. Note all abnormal test findings in the progressnotes, along with an assessment of the findings’impact on the patient’s current condition. A plan fortreatment or follow-up must be included.5. If antibiotic ordered do not conform withsensitivity results, document the reason for thechoice.6. If the patient must undergo unplanned surgery,document indications clearly.7. Nosocomial infections, transfusion reactions orerrors, or trauma suffered in the hospital should be
  49. 49. 8 Document early efforts to arrange an adequate discharge plan for the patient.9. The final note should reflect the medical stability of the patient on discharge. Blood pressure and temperature within normal limits, wound status if surgery was performed, and any abnormal ancillary findings should be addressed with a plan for follow-up after discharge.10 The final summary should be a meaningful recapitulation of the patient’s course of illness, hospital management, discharge plan/instruction and include a plan for follow- up care. At discharge, final diagnosis which relate to the current hospitalization should be
  50. 50. MEDICAL RECORDSDISPOSITION SCHEDULE
  51. 51. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description Authority/Remarks a. Active b. Storage c. Total1 Emergency Room Records 25 years 25 years /Blotters and other records of prospective medico-legal significance •Gun Shot Wounds •Mauling of any Nature •Poisoning Cases •Stab/Hacking Wounds •Sudden Death of Unknown & Suspicious Causes •Vehicular Accidents
  52. 52. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description Authority/Remarks a. Active b. Storage c. Total2 Certificates •Birth (Not Official Copy) Retain until patient reaches the age of maturity (18 yrs.) •Death (Not Official Copy) 15 yrs. 15 yrs. Medical All Health Care Facilities, irrespective of its category and classification shall dispose of medical records Medico- legal beyond (15 yrs.) Non Medico- legal Health Care Facilities attached to teaching training/research institutions may keep medical records beyond fifteen yrs. (15 yrs.) if deem necessary
  53. 53. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description Authority/Remarks a. Active b. Storage c. Total3 Consent to involvement in 1 year Dispose 1 yr. after Medical Trials completion of medical trial. If product of confinement, follow the disposition schedule under Item No. 2 for Non- Medico-legal records4 In- Patient Chart 15 years All Health Care Facilities, Basic Medical Records irrespective of its category and classification shall • Clinic and Graphic dispose of medical records Record/Graphic Chart/TPR Chart beyond fifteen yrs. (15 •Consent to Hospitalization yrs.) •Cover sheet/Face sheet/Admission-Discharge Health Care Facilities Record attached to •Discharge Summary teaching/training/research •Laboratory Record institutions may keep •Nurses Notes/Nursing Records medical records beyond 15 yrs., if deem necessary
  54. 54. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description a. Active b. Storage c. Total Authority/Remarks •Personal History • Physical Examination •Physicians/Doctors Order Sheet •Progress Records/Progress Notes/Doctor’s Progress Notes Supplemental Records • Anti-Coagulant Therapy Record •Autopsy Report •Blood Transfusion Record •Consultation Report •Delivery Block 1.Labor Room Record 2. Newborn Record 3. Pre-natal Record
  55. 55. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description Authority/Remarks a. Active b. Storage c. Total • Diabetic Record • Dialysis Record • Dietary Record/Report • Discharge against Medical Advice • Electrocardiogram (ECG Block) 1. Report 2. Tracing • Fluid Intake and Output Chart • Inhalation Therapy Record • Intravenous Fluid Sheet • Medication Board
  56. 56. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description Authority/Remarks a. Active b. Storage c. Total •Operation Record 1. Anesthesia 2. Informed Consent for Surgery, Anesthesia and other Procedures 3. Operating Room Record 4. Operative Technique 5. Recovery Room Record 6. Tissue/Biopsy Record • Parenteral Fluid Sheet • Pulmonary Laboratory Blood Gas Analysis • Radio Therapy Record • Referral Slip • Rehabilitation Record • Tissue/Organ Donation • Vital Signs Record
  57. 57. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description Authority/Remarks a. Active b. Storage c. Total5 Indexes PERMANENT For agency reference. • Disease • Master Patient Requirement from all • Operation tertiary hospitals and in • Physician some secondary hospitals w/ teaching/training/research components.6 Registers • Electrocardiogram (ECG) PERMANENT For agency reference. • Family Planning (Sterilization) PERMANENT For agency reference. • Laboratory Dispose 2 yrs. After the last 1. Bacteriology entry provided to item is subject of a medico legal 2. Blood Chemistry case. 3. Clinical Microscopy 4. Hematology 5. Hispathology 6. Specimens
  58. 58. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description a. Active b. Storage c. Total Authority/Remarks6 • Live/Still Birth PERMANENT For agency reference. • Medical Records Service Dispose 1 yr. after the last (Incoming Medical Records from entry. Wards) • Medico- legal For agency reference. PERMANENT • Radiology For agency reference. PERMANENT 1. C-T Scan 2. Ultrasound 3. X-Ray (Routine/Special Procedure) For agency reference. PERMANENT • Surgical Cases7 Medical Records of Employees Dispose 10 yrs.after Working in a Health Care Facility separation/voluntary resignation or retirement from the facility.
  59. 59. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description Authority/Remarks a. Active b. Storage c. Total8 Out- patient Records Dispose 10 yrs. After last (Ambulatory Service) consultation/visit.9 Psychiatric Records 25 yrs. 25 yrs.10 Records of Infants Delivered in Retain until patient a Health Care Facility reaches the age of majority (18 yrs.)
  60. 60. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description Authority/Remarks a. Active b. Storage c. Total11 Registers PERMANENT For agency reference. • Admission and Discharges • Birth • Death • Delivery Room • Emergency Room • Labor Room • Operation Room • Out- patient Service/Department • Prescription of Patients (Prohibited Drugs) • Tumor (Special Registry Book)
  61. 61. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description Authority/Remarks a. Active b. Storage c. Total12 Reports • Census 1. Daily 1 yr. 1 yr. Dispose 2 yrs. After 2. Monthly preparation of annual report. • Consumption and Inventory of supplies Incident (Nurses and 2 yrs. 2 yrs. All Health Care Facilities, others) irrespective of its category and classification shall dispose of medical records beyond fifteen yrs. (15 yrs.) Health Care Facilities attached to teaching/training/research institutions may keep medical records beyond fifteen yrs. (15 yrs.) if deem necessary.
  62. 62. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description Authority/Remarks a. Active b. Storage c. Total12 • Notifiable Diseases 1 yr. 1 yr. • Statistical 1. Annual Permanent 2. Monthly 1 yr. 1 yr. 3. Semi-Annual 1 yr. 1 yr.13 Results/Reports of All Health Care Facilities, Examinations/Procedures/ irrespective of its category Tests and classification shall • ECG Report/Result and dispose of medical records Tracing beyond fifteen (15 yrs.) Health Care facilities attached to teaching/training/research institutions may keep medical records beyond 15yrs. If deem necessary.
  63. 63. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description Authority/Remarks a. Active b. Storage c. Total13 • Laboratory For all laboratory, X-Ray, 1. Bacteriology ECG and other 2. Blood Chemistry examinations requested as a product of 3. Clinical Microscopy hospitalization/ 4. Hispathology confinement, the original 5. Parasitology copy must be incorporated in the medical records. The first duplicate must be maintained by the service concerned as “Official File”. If the result is a product of an OPD Consultation, then the original must be incorporated with the OPD Record.
  64. 64. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description Authority/Remarks a. Active b. Storage c. Total14 Requests Attach to Medical Records, • Access to Clinical Information all Health Care Facilities, from Medical Records irrespective of its category and classification shall dispose of medical records beyond fifteen yrs. (15 yrs.) Health Care Facilities attached to teaching/ training/ research institutions may keep medical records beyond 15 yrs. If deem necessary. •ECG Dispose 1 yr. from date/ release of official report/ result.
  65. 65. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description Authority/Remarks a. Active b. Storage c. Total14 • Laboratory Dispose 1 yr. from date/ 1. Bacteriology release of official report/ result 2. Blood Chemistry 3. Hispathology 4. Parasitology 5. Urinalysis • Release of Information Attach to Medical Records and follow disposition authority under Item No. 14 •Research Dispose 1 yr. after date of receipt. •X-Ray 1. C-T Scan Dispose 1 yr. from date/ 2. Routine release of official report/ result. 3. Special Procedures 4. Ultrasound
  66. 66. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description Authority/Remarks a. Active b. Storage c. Total15 X-Ray Films All Health Care Facilities, • With Court Case irrespective of its category and classification shall dispose of medical records beyond fifteen yrs. (15 yrs.) Health Care Facilities attached to teaching/ training/ research institutions may keep medical records beyond 15 yrs. (15 yrs.) if deem necessary.
  67. 67. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description Authority/Remarks a. Active b. Storage c. Total15 • Without Medico-legal Case 5 yrs. 5 yrs. 10 yrs. NOTE: X-ray Films of interesting cases with teaching and research significance may be maintained beyond 10 yrs. Depending on the decision of the hospital management.
  68. 68. REITERATING COMPLIANCEWITH VARIOUS ISSUANCESREGARDING POLICIES ONADMISSION AND DISCHARGEOF PATIENTS
  69. 69. Republic Act No. 3753 Law on Registry of Civil StatusSec. 5. Registration and Certification of Birth – The declaration of the physician or midwife in attendance at birth or, in default thereof, the declaration of either parent of the newborn child, shall be sufficient for the registration of a birth in the civil register. Such declaration shall be exempt from the documentary stamp tax and shall be sent to the local civil registrar not later than thirty days after the birth, by the physician, or midwife in attendance at the birth or by either parent of the newly born child. It is the duty of the hospitals to prepare the Birth Certificates and transmit to the Local Civil Registrar (LCR). The Registered Birth Certificates should be released by the Local Civil Registrar to the parents and not by the hospitals. The hospitals are not authorized to collect registration fees on behalf of the LCR.
  70. 70. 2. Instruction Manual: Civil Registry Forms (Accomplishment & Coding)Date and place of marriage of parents (Item 18) Enterthe exact date and place of marriage, if parents are legally married at the time of birth. Ifthe parents have forgotten the exact date of their marriage, enter the approximate year. If they cannot approximate the year, enter “Forgotten”. Enter “Unknown”, “Don’t Know” or “D.K.” if the informant could not supply the information.
  71. 71. 1. Presidential Decree No. 856 “The Code of Sanitation of the Philippines” Chapter XXI – Disposal of Dead PersonsSection 91: Burial Requirements – The burial remains is subject to the following requirements: • No remains shall be buried without a death certificate. • This Certificate shall be issued by the attending physician. • The death certificate shall be forwarded to the local civil registrar within 48 hours after death.
  72. 72. 2. Implementing Rules & Regulations of Chapter XXI – Disposal of Dead Persons of the Sanitation Code of the PhilippinesItem 2.1 Death Certificate Requirements 2.1.1 In extreme cases, where no physician in attendance, it shall be issued by: a) City/Municipal Health Officer b) Mayor, or c) The secretary of the municipal board, or d) A councilor of the municipality where the death occurred. The basis of the death certificate shall be an affidavit duly executed by a reliable informant stating the circumstances regarding the cause of death
  73. 73. 2.1.2 If the local health officer who issues a Death Certificate has reasons to believe or suspect that the cause of death was due to violence or crime, he shall notify immediately the authorities of the Philippine National Police or National Bureau of Investigation concerned. There is violence or crime when the cause of death was due to but not limited to the following: stab wounds, suicide of any kind, strangulation, accident resulting to death, actual physical assault inflicting injuries upon a person resulting to death, or any other acts or violence upon a person resulting to death and or sudden death of undetermined cause.
  74. 74. “Formulation of a Standard Operating Procedure in Releasing Muslim Cadavers from DOH Hospitals”All government hospitals are mandated to facilitate the release of cadavers belonging to the Muslim Group, within 24 hours. All existing policies pertaining to the release of cadavers must be revised and/or modified in accordance thereof.
  75. 75. Item 4.1. Causes of DeathIn 1967, the Twentieth World Health Assembly defined the causes of death to be entered on the medical certificate of cause of death as “all those diseases, morbid conditions or injuries which either resulted in or contributed to death and the circumstances of the accident or violence which produced any such injuries.Item 4.2 Underlying Cause of DeathIt was agreed by the Sixth Decennial International Revision Conference that the cause of death for primary tabulation should be designated the underlying cause of death….For this purpose, the underlying cause has been defined as “(a) the disease or injury which initiated the train of morbid events leading directly to death or (b) the circumstances of the accident or violence which produced the fatal injury.”
  76. 76. THANK YOU!

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