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Him

  1. 1. HEALTH INFORMATION MANAGEMENTDepartment of Health, Philippines
  2. 2. Health Record Standard IThe hospital maintains health records thatare documented accurately and in a timelymanner, are readily accessible and permitprompt retrieval of information, includingstatistical data. Department of Health, Philippines
  3. 3. Health Record Standard IIThe health record contains sufficientinformation to identify the patient, supportthe diagnosis, justify the treatment anddocument the course and resultsaccurately. 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 to performall 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 discharge 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.   Health Record Identification SystemAlphabetic SystemThe simplest form of recordidentification, using the patient’s nameto identify and file the patients’ healthrecord.
  19. 19. Health Record Identification SystemNumerical System•has a direct influence on the filing system•use of a Master Patient Index (MPI) tocross-reference the patient’s name with hisor her HRN is required.
  20. 20. Health Record Identification SystemUnit Number•unique identification number isassigned on first contact with thehealth care facility, whether: ◘admission ◘ER attendance ◘out-patient ◘includes health care facility newborn babies
  21. 21. After receiving the inpatient health recordsfrom the Nursing Service, the HIMDperforms essential procedures prior to filingand storage.1. Assembly of Health RecordThe forms are arranged in the orderupon admission of the patient.
  22. 22. 2. Analysis of Health Record•The most important function of theHIMD is the health record analysis toensure maintenance of qualitydocumentation.•Analysis is the process of evaluatingand/or checking health records toensure completeness, accuracy andadequacy of documentation.
  23. 23. •In cases where the patient wants somedata corrected especially on thedemographic/sociological data, it shall notbe done in the original entry, but shouldappear as an amendment only.
  24. 24. •The health records shall contain alloriginal copies of    examination results,operations, and other required forms. •Anesthesia record •Report of operation •Nurses notes
  25. 25. 2. Coding •It is a process of assigning numbers to represent diagnosis or problems and surgical procedures.
  26. 26. 1. Indexing• Disease Index is a listing on a card for specific disease based on standard classification/nomenclature, arranged according to code number.• Operation Index is a listing on a card for a specific operation according to standard classification/nomenclature, arranged according to code numbers.
  27. 27.  5. Collection of data for hospital statistics
  28. 28. 5. Filing of Health Record A filing area that will ensure the rapid location and retrieval of health records must be maintained.
  29. 29. Alphabetical filing system •All records of discharged patients arefiled in strict alphabetical order from Ato Z.
  30. 30. Numerical filing systemThere are two systems of filing recordsnumerically:• Straight Numeric                            • Terminal Digit For terminal digit, a six-digitnumber is used and divided intothree (3) parts.
  31. 31. MEDICAL RECORDS DISPOSITION SCHEDULE
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. Agency Schedule No. Page ___ of __ pagesAddress Date Prepared:# Records Series Title and Retention Period Disposition Description Authority/Remarks a. Active b. Storage c. Total •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 4. Summary of Parturition
  36. 36. 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
  37. 37. 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
  38. 38. 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
  39. 39. 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.
  40. 40. 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.)
  41. 41. 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)
  42. 42. 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.
  43. 43. 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.
  44. 44. 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.
  45. 45. 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.
  46. 46. 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
  47. 47. 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.
  48. 48. 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.
  49. 49. Department of HealthMemorandum Circular No. 2005-0081dated November 17, 2005 REITERATING COMPLIANCE WITH VARIOUS ISSUANCES REGARDING POLICIES ON ADMISSION AND DISCHARGE OF PATIENTS
  50. 50. 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.
  51. 51. 2. Instruction Manual: Civil Registry Forms (Accomplishment & Coding)Date and place of marriage of parents (Item 18)• Enter the exact date and place of marriage, if parents are legally married at the time of birth.• If the 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.
  52. 52. B. Death Certificates1. 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.
  53. 53. 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
  54. 54. 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.
  55. 55. 3. DOH Adm. Order No. 55 s.2001 - Muslim Deaths “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.
  56. 56. 1. World Health Organization’s International Statistical Classification of Diseases and Related Health Problems Version 10 (ICD-10) Volume 2 Item 4.1. Causes of Death In 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 Death It 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.”
  57. 57. THANK YOU!

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