Copy of himd lecture mha

HEALTH INFORMATION
MANAGEMENT
June 3, 2011

Florinda G. Tuvillo
Development Management Officer IV
(Medical Records Adviser)
National Center for Health Facility Development

Department of Health, Philippines

Health Record Standard I

The hospital maintains health records
that are documented accurately and in
a timely manner, are readily accessible
and permit prompt retrieval of
information, including statistical data.


Health Record Standard II

The health record contains sufficient
information to identify the patient,
support the diagnosis, justify the
treatment and document the course
and results accurately.


Health Record Standard III

Health records are confidential, secure,
current, authenticated, legible, and
complete.


Health Record Standard IV

The Health Information Management
Department is provided with adequate
direction, staffing, and facilities to
perform all required functions.


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

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.


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.


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


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.


• 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 considerations

10. A sufficiently detailed report of a
relevant Physical Examination (PE),
performed by a medical practitioner,
should be included for the purpose
of admission.

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.


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.


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).


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)

18. When a patient is transferred to another
facility, a Discharge Summary should
accompany him/her.


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.


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 YES
NO Process
Physician’s
Search at: Index
•Incomplete
•Processing
•Etc… Data Collection Final Re-check
Statistics Disposal Complete?

Permanent File Retrieval
system

SYSTEMS

AND

PROCEDURES

THE MEDICAL RECORD SERVICE

1. RECORDING
2. INDEXING
3. ASSEMBLY
4. ANALYSIS
4.1 QUANTITATIVE
4.2 QUALITATIVE
5. CLASSIFICATION, CODING OF DISEASE
AND OPERATIONS
6. INDEXING OF CODED DATA
7. DATA GATHERING AND STATISTICAL
REPORT PREPARATION
8. FILING
9. RETRIEVAL

Log of all discharged patient from the
facility

“NURSING SERVICE LOG OF DISCHARGED
PATIENT” = “MRD PREPARED INDEX OF
DISCHARGED PATIENTS” = CENSUS REPORT

 Source Oriented

 Problem Oriented

 Integrated


ANALYSIS (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.

 Knowledge of Medical
Terminology
 Anatomy
 Physiology
 Fundamentals of Disease
Processes
 Medical Record Content
 Standards of Licensing,
Accreditation

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

 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


CONCURRENT ANALYSIS OF MEDICAL RECORDS

ADVANTAGES:
* 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 Review
DISADVANTAGES:
* Requires more employees to truly implement this type of
analysis
* Requires an on going technical training program.


CONCURRENT VS. RETROSPECTIVE ANALYSIS
Facilitates timely At times causes delay in the
collection of statistical timely Collection/
data/information consolidation of statistical
data/information
Pro-realistic and timely At times affects decision-
decision-making is making
achieved
Aid in the timely Utilization review has to be
performance of utilization scheduled after retrospective
review analysis to be sure of a
completely documented
record
Has the tendency of Incomplete medical records
eliminating incomplete not addressed on a timely
medical records basis


CONCURRENT VS. RETROSPECTIVE ANALYSIS
Assures timely completion of Delayed completion of
records by consultants and records by consultants
visiting physicians and visiting physicians
and records turn
delinquent.
Improves interface/interaction Interaction not enhance
between the members of the and at times create
staff involved in the creation of negative coordination
record
Aid in the prediction of daily Prediction of daily income
income as billing process is is only made possible
enhanced before or after the
discharge of the patient
and the record is analyzed

 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
defense

NOTE: = 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

 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

Poorly documented clinical record

is of Little use to a patient during his

treatment, for his future care or for

evaluation of the care rendered by the

members of the medical, nursing and

other health professionals.

Hayt, Emanuel (Atty.)

We must always stress the importance of a

complete, accurate and up-to-date documentation

because it does not only project the image of an

efficient, conscientious and reliable staff but, more

importantly, it gives the impression to patient that

he is being taken cared of properly”

Teresita Sanchez, MD., LLB.


SIGNIFICANCE 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


IN SUMMARY:
Managing the contents of the medical record
through analysis of documentation is an important
function of the HIMD/MRD.
By reviewing all medical records during or
following an occasion of service for completeness
and accuracy, the Medical Record Practitioner makes
a significant contribution to the Health Care Facility.
Completion of medical records and improved
documentation, results in improved communication
among all health care providers, contributing to
improve patient care.


CLASSIFICATION CODING OF DISEASE & OPERATIONS
ICD-9-CM & ICD-10

CENTRAL CONCEPT IN MORBIDITY CODING
At the end of an episode of care, the clinician should record all
conditions which affected the patient in the episode, starting with the
PRINCIPAL DIAGNOSIS/ MAIN CONDITION, FOLLOWED BY
THE OTHER DIAGNOSES/CONDITION

COMPLICATION
An additional diagnosis that describes a condition arising after the
beginning of hospital observation and treatment and modifying the course
of the patient’s illness other medical care required.

ADDITIONAL DIAGNOSES:
All conditions that coexist at the time of admission, or develop
subsequently, which affect the treatment and/or management received by
the patient and the length of stay.


PRINCIPAL DIAGNOSIS
The condition established after study to be chiefly responsible for occasioning
the admission of the patient to the hospital for care
DIAGNOSIS
A word or phrase used by a physician to identify a disease from which an
individual patient suffers or a condition for which the patient needs, seeks, or
receives medical care
FINAL DIAGNOSIS INCLUDES
1. ADMITTING DIAGNOSIS
The condition stated on the entry (prior to entry) to the health care facility
as the reason for hospitalization.
2. INTERIM DIAGNOSIS
Is an additional diagnosis that describes a condition arising after
admission that modifies the course and treatment of the patient’s illness or the
health care required


3. DISCHARGE DIAGNOSIS
- is the condition stated at the time of an episode of care/discharge
FORMAT IN WRITING DIAGNOSIS
I. Main condition :
Primary diagnosis :
Principal Diagnosis: ________________________
II. Other condition :
Secondary diagnosis:
Minor condition (s) : ________________________
________________________
________________________
________________________


EXAMPLE:
PATIENT A:
1. RIGHT INGUINAL HERNIA
(Admitted for Surgery)
2. DIABETES MELLITUS
3. EMPHYSEMA, PULMONARY
4. DISRUPTION OF OPERATIVE WOUND
PATIENT B
1. CARCINOMA OF CERVIX UTERI
2. CHRONIC CYSTIC DISEASE OF THE BREAST

No. of No. of Error
PhilHealth & 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 Codes
ICD 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
)

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;

• 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”


GOOD RECORDING AND DOCUMENTATION
PRACTICES
• Evidence of timely recording of entries

• Legibility

• Authentication of all entries

• Use of approved abbreviation

• Avoidance of extraneous remarks

• Medical Record should contain no unexplained time
gaps.

e.g. E.R. record

• Do not “Skipped Spaces” (consecutive lines)

• Correct spelling

• Ethical


STEPS TO EFFECTIVE MEDICAL RECORD
DOCUMENTATION
1. A complete history and physical exam including baseline
lab values, pap smear, breast examination and rectal
examination are required. Provisional diagnosis must be
documented.
2. Daily progress notes must reflect findings, assessment and
plan 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 condition
for which the patient was admitted or which develops
subsequently. If ancillary tests or medical therapies are ordered
which are not consistent with the current diagnosis or condition,
they should be justified in the progress notes.


4. Note all abnormal test findings in the progress
notes, along with an assessment of the findings’
impact on the patient’s current condition. A plan for
treatment or follow-up must be included.

5. If antibiotic ordered do not conform with
sensitivity results, document the reason for the
choice.
6. If the patient must undergo unplanned surgery,
document indications clearly.
7. Nosocomial infections, transfusion reactions or
errors, or trauma suffered in the hospital should be

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

MEDICAL RECORDS
DISPOSITION SCHEDULE

Agency Schedule No. Page ___ of __ pages

Address Date Prepared:

# Records Series Title and Retention Period Disposition
Description Authority/Remarks
a. Active b. Storage c. Total
1 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



2 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



3 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 records
4 In- Patient Chart 15 years All Health Care Facilities,
Basic Medical Records irrespective of its category
• Clinic and Graphic
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



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



• 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



•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



5 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



Description a. Active b. Storage c. Total
Authority/Remarks

6 • 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 Cases
7 Medical Records of Employees Dispose 10 yrs.after
Working in a Health Care Facility separation/voluntary
resignation or retirement
from the facility.




8 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.)




11 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)




12 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
yrs.)
attached to
fifteen yrs. (15 yrs.) if
deem necessary.




12 • 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
15yrs. If deem necessary.




13 • 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.




14 Requests Attach to Medical Records,
• Access to Clinical Information all Health Care Facilities,
from Medical Records irrespective of its category
yrs.)

attached to teaching/
training/ research
15 yrs. If deem necessary.
•ECG
Dispose 1 yr. from date/
release of official report/
result.




14 • 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




15 X-Ray Films All Health Care Facilities,
• With Court Case irrespective of its category
yrs.)

attached to teaching/
training/ research
15 yrs. (15 yrs.) if deem
necessary.




15 • 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.

REITERATING COMPLIANCE
WITH VARIOUS ISSUANCES
REGARDING POLICIES ON
ADMISSION AND DISCHARGE
OF PATIENTS

Republic Act No. 3753
Law on Registry of Civil Status
Sec. 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.

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.

1. Presidential Decree No. 856
“The Code of Sanitation of the Philippines”
Chapter XXI – Disposal of Dead Persons
Section 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.

2. Implementing Rules & Regulations of Chapter XXI – Disposal
of Dead Persons of the Sanitation Code of the Philippines

Item 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

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.

“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.

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.”

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