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MODULE TITLE: HEALTH RECORDS MANAGEMENT

Introduction to the Module

The module is designed to equip the learner with the necessary knowledge, skills, and attitude

to effectively and efficiently manage health records. . The module has units as follows:

MODULE OUTCOMES

At the end of the module the learner should be able to:

UNIT 1

INTRODUCTION TO HEALTH RECORDS MANAGEMENT

The health record is a written collection of information about a patient. It originates from the

patient's first encounter or treatment at a hospital, health post or other primary health care centre.

The health record is thus a record of all the procedures carried out on that patient, while he is in

the hospital or under treatment at a clinic or centre. It should contain the past medical history of

the patient, including opinions, investigations and other details relevant to the health of the

computer; the sheets of paper scanned onto optical media or the actual sheets may be

microfilmed. (Microfilming is similar to taking a picture of the paper and storing it on a film

strip.)

Edna Huffman (1994), one of the first medical record professionals in the U.S., defined a health

record as "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. The health record must be compiled in a timely manner and contain sufficient

data to identify the patient, support the diagnosis, justify the treatment, and accurately document

the results."

The actual physical record should be of an acceptable size and standardized on suitable

forms, as far as possible to enable interchange of information, from hospital to hospital,

HISTORICAL BACKGROUND OF HEALTH RECORDS DISCIPLINE

Learning Objectives

The learner should be able to:-

Define health records

Give a historical background of health records discipline

Define a health records department

Historical Background

The history of Health Records runs parallel with the history of medicine. Records are

necessary for the practice of medicine as medications are for effective treatment, and they

seem to have been made from earliest antiquity.

The first real physician of health records in Egypt is Imhotep. He lived in the pyramid age

(about 3,000 – 2500 BC) and was grand vizier, chief architect, and royal medical adviser to a

Pharaoh of the 29

the Edwin Smith Papyrus. This papyrus is one of the most valuable ancient medical

documents that has come down to us and appears to have been copied about 1600 BC from an

earlier original. This papyrus is a roll over 15 feet by about 3 inches wide and is made up of

12 sheets of the usual size. It is written on both sides and consists of 48 cases of Clinical

Surgery.

In Greece Hippocrates, known as the “father of medicine” was born about 460 BC. He was

eventually the Health Records per see was, also considered as privileged communication.

Hippocrates kept detailed case reports of his patients.

the distinction of having a complete file of clinical records, with all cases catalogued, dating

from the day it opened.

In the 20

serious consideration by other types of hospitals and especially by hospitals and medical

associations.

In 902 the American Hospital Association discussed Health Records for the first time at a

convention.

In 1948 Health Records Association was started in Britain.

In 1978 the Health Records and Information Technician Program was started at the Medical

Training College, Nairobi.

In 1990, the Health records and information officers program was started at the medical

training college, Nairobi.

In 2003, the certificate records program was started in the KMTC Muranga campus, 2008

Siaya campus in 2010 Msambweni campus,

In 2011,Kitui campus,in 2012 Bondo,in 2013 Webuye.

In 2009, a degree program was started in both Kenyatta University and Mt Kenya University.

In conclusion, the demand for quality information in both public and private health

institutions for evidence decision making in managing health care services and resources

records are kept for:-

Communication purposes:-

Health records are kept initially for communication between

persons responsible for the care of the patients present and

future needs.

. Some of these people include:

Medical record staff will have access to the record to ensure that all documents are appropriately

filed and organized and may also perform quality audits or research as requested by the facility

or other agency.

Continuity of patient care / Treatment

The patient may be readmitted to the same or another hospital or visit a clinic where all his past

medical history should be available for assessment in the light of their current problem. It is vital

that the health care professionals, who is responsible for the patient as a whole, should receive

information about a patient's hospitalisation as soon as possible after the patient is discharged

health professional in court in case of professional negligence or

The record also, however, protects the patients by documenting all injuries and diseases or

conditions in the record so that there is no confusion about what happened to the patient.

Statistical purposes:-

Statistics are collected in hospitals, clinics and in primary health care centres. They may be used

to tabulate numbers of diseases, surgical procedures and incidence of recovery after certain

treatments; to assess areas which the hospital or clinic serves by collecting demographic details;

or for public health or epidemiology. The morbidity and mortality statistics collected are used in

planning health services activities, decision making, and day today running of the institutions.

and conditions across hospitals in the country and, in turn, will report data to the World Health

Organization for comparisons throughout the world. The facility where the data is collected

should also use the information to improve patients.

Historical purposes

all information is recorded in the record, those treating

to verify dates of visits and treatments they have received.

Complete health records mean increased and deficient to the

ORGANIZATIONAL STRUCTURE OF A HEALTH RECORDS DEPARTMENT

Registration is thedocumentation of bio data of individual patients/client needed for his/her

attendance

3. ADMISSION

Admission is the process of taking a patient to the ward for in-patient care and management,

the registration details are used for admission. The admission details includes:-Names of the

patient, sex, date of birth, marital status, physical address, occupation, name of next of

kin/address, name of the ward, name of the admitting doctor, mode of payment,diagnosis.

Duplication in the use of unit numbers can be prevented:-

In addition to the above the patient can be asked whether he has attended the hospital

previously during registration. Whether the patient says yes or no across checking can be

done through the patient master index to ascertain this.

The unit number register

From the foregoing comments the importance of the unit system will be appreciated if the

unit number register is maintained. In the unit number register the following information will

be included:-

The contents of the unit health record

The folder should be made of tough manila with a gusset and single or double fold inside,

through which are threaded metal or plastic prongs with which the loose sheets may be

fastened into the folder.

2. The front sheet of identification sheet

This is the area where all the patients’ social details are transcribed from the pre-registration

form. The inside front cover of the folder is sometimes used for this purpose. Space should be

provided to record several changes of address and change of a doctor.

It is important that all these facts should be readily visible to the doctor who is in charge of

the patient, and who may wish to remind himself at a glance at the personal facts about the

patient without hunting through sheaves of documents. Is also important that the information

should be complete and accurate so that the person writing a letter to the doctor will address

this correctly, or anyone writing to the patient will send the letter to the correct address.

3. Clinical history sheet

Two types of clinical history are in common use. In one, each consultant has his individual

history sheets on which he only will write. A patient currently attending three different clinics

will have three separate history sheets although these are likely to be filled next to each other.

4. Continuation sheet

one history sheet. This is not very usual, and continuation sheets are similar to history sheets

treating the patient can see what previous medication has been prescribed.

6. Surgical operation sheet

Special forms are provided on which operations may be recorded. They normally contain

sections in which the names of all surgeons and anaesthetists taking part in the operation are

to be recorded, and special remarks about drainage, blood loss, special recovery treatment etc.

7 Anaesthetic record

As aesthetic techniques become increasingly sophisticated and complicated, the need for a

special form on which to record the relevant facts has been rendered ineffective. Most

There are two usual versions of this chart. One is the b.d twice daily chart for the recording of

the routine observations. Urine and stool details are usually recorded at the foot of the T.P.R

chart. A separate chart is often used for 4 hourly recordings for more seriously ill patients.

This is frequently printed on coloured paper, or in coloured ink, to make it noticeable.

9 Report mount sheets

Many reports which are smaller that the size of most forms have to be filed in the folder.

They are usually mounted on a report mount sheet. These mount sheets vary in designs and

methods of gumming. There are two possibilities, all reports may have a gummed edge and

be stuck on the mount sheet itself, or may have a series of gummed strips on to which all

reports will be stuck. Several versions of the mount sheet with gummed strips are available.

the other, but with approximately one quarter inch or one third inch of the lower edge left

visible so that the date and type of report can immediately be seen. In this way, a dozen or

more reports will be file on one mount sheet.

other report forms.

11. Report Forms

All investigations-laboratory (Haematology, biochemistry, bacteriology, histology)

cardiology, radiological results in some sort of report form that will have to be fastened into

patients’ notes. These reports are becoming rapidly a very special problem, as they swell the

bulk of the folders in rapidly increasing numbers. Some laboratories issue cumulative report

forms each on which in turn replaces all the reports that have been issued previously but

unless the previous reports are conscientiously removed there is no reduction in bulk.

When a patient has an unusually interesting condition, a clinical photograph may be taken. In

plastic surgery, where the patient may pass through several stages of treatment, a photograph

is often taken at intervals to record progress. Photographs may be kept centrally in the

Medical Photograph Department, but they are frequently filed in the case folder, either

mounted on card or in a special plastic folder with pockets for the storage of a series of

smaller photographs or slides.

13 In-Patient Summary

After a patient has been discharged from hospital, it is usual for the registrar or consultant to

patient’s progress while as an in-patient carried out operations or other treatment and

and from hospital to the general practitioner must be returned. These will include copies of

the discharge note, which is traditionally written by the junior hospital doctor on the day of

the patient’s discharge, to keep the doctor informed of the most important points about the

DIFFERENT TYPES OF HEALTH RECORDS-THEIR VALUES, USES

Learning objectives

The learner should be able to:-

VALUES AND USES OF HEALTH RECORDS

Health records have various uses:-

1. Treatment

The health record is the first and foremost of value in the present and future treatment of the

patient. The individual record is a reminder to the physician, surgeon, clinician, nurse, social

workers or health records technicians of what he/she has personally observed during the

patient’s illness. It contains information of what has been observed by others. It provides or

should provide the whole previous hospital record of the patient, so that every fact that may

be very accurate and disseminated promptly to users:- inadequate records mean incomplete

statistics leading to improper planning of various activities in the health service.

3. Research

Health records can be used as an educational tool or instrument. When the quality of the

records is high, the task of the student is simplified conversely when the quality is poor the

student’s task is made more difficult and his progress is impeded.

5. Administration

Complete health records mean increased and efficient services to the public, avoiding

vexations, litigations and fair settlement of claims and capacity to answer queries about how

hospitals work.

For the record to meet and be useful for the above purposes it should designed for the

complete the records to meet should be complete. To be complete the records should be

analysed quantitatively by the health records officer and qualitatively by the clinician.

RECEPTION, REGISTRATION AND INITIATION OF PATIENTS/CLIENTS

RECORDS

INTRODUCTION

This chapter explains reception registration and how the patients/clients records are created.

Learning Objectives

The students should be able to:-

1. Define Reception, registration and initiation of a health record.

work, because he is the one who will interview the patient. He or she should have ease,

assurance of manner and a pleasant appearance. He has to convey to the anxious patient that

there is nothing to worry about; the hospital is smoothly run, created for his care. This is not a

registration should be carried out before the patients attends the clinic. The environment

should be conducive and the patients should be interviewed individually and in privacy. The

patient is registered, a file opened and an appointment is given prior to the clinic day.

Another important factor that should be noted is that the patient should only be given one unit

number and the patient should be asked whether he has attended the hospital before. If the

answer is no is when a new number should be given to prevent duplication of numbers.

Whether the answer is yes or no, this should be cross checked with the patient master index.

This includes all the cards that are used in the Out-Patient Departments, for example the

Casualty Wards, Ante-Natal Wards, Immunization cards and any other card that may be used

in the outpatient departments.

Diagnostic Records

These include notes on Radiography, Pathology, Electrocardiography and other investigations

available in all consultation rooms both in the Out-patient and In-patient departments in a

health care facility. They could be different colours for quick identification.

3. INITIATION OF PATIENTS RECORD

The identification details that are taken during the registration time are used to create the

This form when returned will be used to create the patients/clients health records. The use of

stay in the hospital. The master index cards should also be created during the time that the

record is being created and filed immediately. This will help to answer enquiries in case the

patient happens to lose the attendance card.

CREATING MAINTAING HEALTH RECORDS INDICES:-

Learning Objectives

The learner should be able to:-

1. Define various health record Indices

2. Explain the importance of health records indices

3. Describe the procedures used in creating health records indices

4. Describe various equipment used in storage of health record indices

5. Describe the techniques used infilling health record indices.

1. The Patient Master Index

2. The Diagnostic Index

3. The Operations Index

4. The Waiting List Index

1. The Patient Master Index

Definition

The Patient Master Index is the alphabetical key to the numerically file case records.

Importance

This is a very important index in the case where a patient has lost his attendance cards. The

A typical layout of the card which measures 3” x 2½” or 5” x 3” would be

3”

Creation of the Patient Master

The Master Index card is created when the patient is being registered.

Equipment used for filing the Master Index Cards

Cards

Cards will be the basic record document in most master indexes. Generally a card must be of

good quality for endurance

Drawer filing

Cards may be filled “blind” in drawers-filed one behind the other in an upright position.

Strip Index

A strip index as its name indicates consists of a series of thin wooden strips coated with paper

on which details required for the master index are filed on metal panels. The strips are filed

on metal panels with a fold of metal down each edge which holds the strips in place. The

like a large metal cabinet which may be up to five feet high and up to ten feet wide, with an

opening at the top. In this opening two or three shelves with their trays of cards are visible.

The largest elevator file would probably hold 900,000 index cards. The large files are

electrically driven. If the card is wanted, the filing clerk presses a button indicating the

shelves; the cards rotate until the correct one arrives at hand level. The clerk then looks in the

appropriate tray for the card. Smaller elevator files are manually controlled.

The advantage is that there is speedy access to all cards while the clerk is comfortably sitting

on a chair.

The disadvantage is that the machine is expensive and may not be afforded by some of the

health facilities.

UNIT 5

ADMISSION PROCEDURES

Patients/clients should be supplied with a booklet containing information about the hospital

before they are admitted. If they are emergency patients then they should be supplied with the

patients/clients should be guided to the ward by a member of staff to the sister or nurse

responsible for reception and documentation of patients in the ward. This will ensure a

feedback of information to the health records/information department.

SOURCES OF ADMISSION

Admissions can come from different sources:-

DISCHARGE PROCEDURES

Definition:

A hospital bed bureau is a system used to manage the availability, allocation and utilization of

beds by the hospital to admit patients from the waiting list. It shows the location of the bed in

list of such beds as and when they fall vacant or even project when beds are most likely to fall

vacant. This is done by keeping a notice board with the location of all the wards and their bed

capacity. The notice board has two colour strip cards which are put in pocket bags, red for

occupied beds and green for vacant beds.

The electronic aspect is more user friendly because the patient waiting list is automatically

integrated and interfaced (the whole process is on line and data is available to all at real-

time)with the admission and discharge modules and bed availability can be accessed

automatically as and when a bed falls vacant, the officer in charge of bed placement can

Auditing of the record is the arrangement of all the forms inside the unit folder in a prescribed

manner. This can be decided by the hospital concerned. It can either be done chronologically

or in order of speciality. This can be done by the ward clerks if they are available.

After the record has been edited it should be returned to the health records department. In the

department the records should be cross checked with the daily bed returns to ensure that all

records have been received in the records department.

After this, the records will be coded and then indexed ready for filing back to the library. The

health records and information officer should complete all the information that is supposed to

be contained in it is there. The discharge procedure cannot be complete until the record

returns back to the file.

quality of professional performance.”

It is the method of evaluating quality of medical care given to a patient. It is a tool to enable

the administrator and the medical staff to uncover inefficient service and to point away to an

After a patient has been seen at the health centre he may be having some ailment which needs

immediate and urgent attention. Definitely the doctor will refer him to a hospital for

immediate attention. He will find himself in an accident and emergency department. Also

patients with any type of accident will be brought to this department directly.

Records to be kept.

Register

Firstly a register must be maintained at the Accident and Emergency department. The

following information should be included in this register; name of patient, address, age,

must be recorded in the register. The register may be in loose leaf form or in bound volumes.

From the register statistics of attendance will be compiled.

Clinical record

For an R.T.A (Road traffic accident) patient, time and place of accident must be given and the

space left for the clinician to write on.

(ii) Two part card

A card with carbonized part made from N.C.R material. The card is made up in an envelope

from so that x- ray reports and any other correspondence may be filled in it.

(iii) Thick paper envelope four and an eighth by five and three quarters inches (half the size

the patient’s attendance card.

(ii) Pre-printed appointment cards for each day and time may be given to the patient. A

different colour of the card could be kept for each day of the week and when a patient arrives

(c) Referred to an out-patient consultant clinic.

(d) Referred to a consultant clinic in another hospital.

(e ) Admitted to the wards for further treatment. Here full documentation for admission will

be carried out before the patient goes to the ward.

(f) Transferred to another hospital for further treatment.

( g) In the case of patient who has been brought dead (B.I.D) the doctor just goes to certify

the death and the body is conveyed straight to the mortuary.

4. Legal requirements

filed numerically or alphabetically depending on the number of records created annually. At

the beginning of the year, 1

lock because most of these records are usually required in court and as much details as

possible should be recorded. Most patients who have been involved in road traffic accidents

need some claims in future. Therefore statistics for these patients may be sent to finance

department so as to issue the necessary claims.

WAITING LIST FOR IN-PATIENT AND DAY CASE TREATMENT

A waiting list is an index of all patients waiting admission to hospital or waiting treatment on

a day case basis.

able to make full use of the available beds in a health institution.

2. Types of waiting list

The waiting list may be maintained in various ways:-

secretary, or an individual wards or individual departments.

Advantages of centralized waiting list

Advantages of decentralised waiting list

Disadvantages of decentralised waiting list

may come from another hospital and be put in the waiting list for another different

hospital, where there are more beds or facilities. There are four ways in which

information can be conveyed to the waiting list:-

4. Method of filing

A waiting list contains dozen names and needs two files:-

1. Alphabetical index of the names of all patients on the waiting list. These cards should not

These two files should be able to answer an enquiry from a patient and consultant.

5. Filing equipment

The type of filing to be used will depend on the size of the list.

(a) Visible edge card filed in trays

When this is used to maintain a waiting list may be in the form of manila flaps, with a rigid

bar at the top and a transparent plastic pocket about half an inch deep at the lower edge of

each flap. A card is inserted into this pocket and the flap is held in a metal tray in such a way

that all the information in the plastics is visible. Date is put on the list, diagnosis, operation

and admission priority is put to allow the consultant to select his patients.

(b) Strip index

Its danger is that a patient can easily be missed or overlooked on date which passed.

(d) Colour coding

Colour coding could be used to indicate soon, urgent and routine case.

7. Statistics

Regular returns are compiled from the waiting list for hospital activity analysis. The

UNIT 6

STORAGE AND RETRIEVAL OF HEALTH RECORDS

Learning Objectives

The learner should be able to:-

FILING SYSTEMS FOR CASE RECORDS AND X RAY FILMS

Filing is a systematic way of arranging documents to enable those documents filed to be

maintained in good order. The library from which notes are readily available is a threat to the

(i) Alphabetical filing system

Alphabetical filing really has little place in any discussion of the filing of case notes. The

main disadvantage of using this method of filing is that it grows very unevenly and spreading

of notes or x- ray files can be very difficult if the file is used for many years and the number

of files becomes very large.

(ii)Chronological filing system

(iii) Numerical filing system

In this system two ways of filing can be adapted:-

(a)Straight numerical

(b) Terminal digit filing system.

(a) Straight Numerical filing system

This is probably the filing system that comes automatically into people’s mind:-12 3 4 5 6, 1

2 3 4 5 8. It is probably the most suitable method of filing for small records library where

there is no necessity to go into the fairly elaborate detail needed to install a terminal digit

system.

traditional sequential filing system are:-

(c) Advantages of terminal digit filling system are:-

records library.

each major section. Trials have shown that where 1,500 records are filled daily, 150

records will be returned to each section daily

new records.

(d) Conversion of straight numerical filing to terminal digit order

Before one changes from straight numerical filing system to terminal digit filing system, one

One day should be set on which to start the system. The first patient who comes should be

issued with a unit number 00 and the second patient who comes next 01. This should continue

until the number 999999 is reached. When an old patient has been issued with a number in

the previous years comes, his record should be pulled out and brought forward to the new unit

number. If a patient does not turn up, his record should be left in the old file.

management tools, disposal of stores and equipment by Public Entity

workplace

/facility plan and/or priority project

Unit 6: overview

Current classification of procurement entities

Class A are Ministries and State Corporations

Class B are City Councils, Universities, Judiciary, Commissions, Colleges, Cooperative

Application of the Regulations.

These Regulations apply to public entities as enlisted under Section 3(1) of

the ACT that is-

Within a Public Entity the procurement contracting functions should hence be separated.

Incompetence

Schedule

Approve list of persons qualified to submit proposal pursuant to Section 80 of

the Act

Categories of Tender committees in Second Schedule cover Procuring entities

Line with Section 3 of the Act- Definition of Procuring Entities

The committee shall cause to be prepared the minutes of the meetings

The minutes shall include:

Evaluation Committee

Inspection & Acceptance Committee

- issue interim or completion certs or GRNs

MEASURES FOR REDRESSING GRIEVANCES

To redress meritorious grievances of candidates and correct system failures.

An Administrative Review Board may grand or recommend the following

remedies:

surplus

Disposal methods

The records do not belong to the patient even if fees have been paid. The records belong to

the various health institutions which created them. In the case of government institutions they

belong to the government. Case records of private institutions belong to the institutions

because they have contributed to the creation of the records.

Retention

The Public Records Act stipulates that authorities responsible for public records have a duty

to make proper arrangements for selecting those records which should be permanently be

preserved and for disposal of the rest. There are some records that were spelled out by that

Act and they should not be destroyed.

be destroyed depending on the institution’s demands.

Security

It is the responsibility of each and every health institution to ensure that there is security in