Revised and updated 2006 - WPRO

1 Revised and updated 2006 WHO Library Cataloguing in Publication DataMedical Records manual : A Guide for Developing CountriesISBN 92 9061 005 0 World Health Organization 2002 All rights designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organizationo concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimination of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned.

2 Errors and omissions excepted, the names of proprietary products are distinguished by initial capital World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: Requests for permission to reproduce WHO publications, in part or in whole, or to translate them -- whether for sale or for noncommercial distribution -- should be address to Publication, at the above address (fax: +41 22 791 4806; email: For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, 2932, 1000, Manila, Philippines, Fax.))

3 No. (632 521-1036, email: named author/s alone is/are responsible for the views expressed in this Records ManualA Guide for Developing CountriesACKNOWLEDGEMENTWHO Regional Office for the Western Pacific acknowledges the contribution made by Professor Dr. Phyllis J. Watson, Head of School of Health Information Management (formerly), Faculty of Health Sciences, University of Sydney, to this publication. Med cal Records manual A Guide for Developing CountriesTABLE OF CONTENTS 1. INTRODUCTION ..1 Aim of the Workbook ..1 Objectives ..1 National and international support ..2 Name changes and definitions ..32. THE medical record ..7 Patient identification and medical record numbering ..8 medical record numbering ..11 Components of a medical record ..13 medical record forms ..14 Clip or fastener ..16 medical record dividers ..16 medical record folder.)

4 17 Responsibility for medical records ..183. THE medical record DEPARTMENT ..21 Support for medical record Department and staff ..21 Functions of a medical record Department ..21 Development of medical record policies and procedures ..23 Writing procedures ..24 4. BASIC medical record DEPARTMENT PROCEDURES ..27 Admission procedure and the Master patient Index ..27 Admission register ..28 Computerization of the Master patient Index ..36 Discharge procedure ..38 medical record completion procedure ..40 Discharge summary ..41 Computerized admission, transfer and discharge system ..42 Disease classification and clinical coding ..43 Clinical coding procedure ..45 Disease and procedure index ..47 Computerization of the disease and procedure index ..48 medical record filing procedure ..49 Filing systems and Methods ..51 Terminal Digit Filing.

5 53 Med cal Records manual A Guide for Developing Countries Removing medical record from file and record control ..55 Locating misfiled medical records ..56 Culling medical records ..56 Computerized record tracking system ..57 5. COLLECTION OF HEALTH CARE STATISTICS ..59 Statistical definitions ..60 Hospital inpatient monthly/annual statistical collection ..616. MEDICO-LEGAL ISSUES AND POLICIES ..67 The medical record as a legal document ..67 Privacy, confidentiality and release of patient information ..68 Patient access to their medical records ..70 General medico-legal principles ..71 Procedure for the release of medical information in a legal Other important medico-legal issues ..77 7. OUTPATIENT RECORDS ..79 General outpatient clinic ..80 Specialists outpatient clinics ..81 Counting outpatients ..82 Outpatient statistics.

6 83 Emergency patients ..848. medical record COMMITTEE ..87 Terms of reference ..87 Functions and responsibilities ..889. QUALITY ISSUES FOR medical record SERVICES ..91 Areas in which the MRO can evaluate medical record procedures ..91 Evaluating the content of the medical record ..9210. CASEMIX MEASUREMENT AND DRGS ..95 The formation of DRGs ..96 11. COMPUTERIZED HEALTH INFORMATION SYSTEMS AND THE ELECTRONIC HEALTH record ..99 Electronic health records ..100 Med cal Records manual A Guide for Developing Countries12. CONCLUSION ..105 Annex 1. Pre-employment Test for medical record Clerks/Officers ..107 Annex 2. International federation of Health record Organizations ..109 Annex 3. Glossary ..111 REFERENCES ..114 Med cal Records manual A Guide for Developing CountriesLIST OF ILLUSTRATION A large teaching hospital ..1 Sample medical record forms.

7 7 The top section of a front sheet ..8 Samples of X-ray, pathology, and other investigation forms ..15 The Patient s medical record : Sole source of health information ..19 A typical medical record department with manual systems ..21 A typical computerised medical record department ..22 A medical record officer coding a medical record ..27 A sample identification form ..31 Removing a medical record and replacing it with a tracer ..32 A master patient index ..35 Clerical staff working on the discharge A bay of filing shelves ..51 A sorter in a large medical record Department ..54 A colour coded Terminal Digit Folder ..54 A tracer being removed on the return of a medical record ..55 A medical record officer working on the monthly statistics report ..59 A diagram showing the flow of data from the patient s admission to the return of the medical record to file.

8 65 A terminal digit folder marked Confidential ..67 An emergency department attached to a large teaching hospital ..79 A typical medical record Committee meeting ..87 An MRO checks the information records with a doctor ..91 Staff working in a computerised medical record Department ..99 Med cal Records manual A Guide for Developing CountriesINTRODUCTIONM edical/health records form an essential part of a patient s present and future health care. As a written collection of information about a patient s health and treatment, they are used essentially for the present and continuing care of the patient. In addition, medical records are used in the management and planning of health care facilities and services, for medical research and the production of health care statistics. Doctors, nurses and other health care professionals write up medical /health records so that previous medical information is available when the patient returns to the health care facility.

9 The medical /health record must therefore be available. This is the job of the medical record worker. If a medical record cannot be located, the patient may suffer because information, which could be vital for their continuing care, is not available. If the medical /health record cannot be produced when needed for patient care, the medical record system is not working properly and confidence in the overall work of the medical /health record service is of the ManualThe aim of this manual is to help medical /health record workers in developing countries to develop and manage the medical record /health information service in an effective and efficient manner. It has been written for clerical staff with a basic understanding of medical /health record procedures. It has NOT been designed as an introductory text to medical record /health information management, rather as an aid to medical record officers (MROs) and medical record clerks by describing appropriate systems for medical record Departments.

10 The emphasis is on manual systems but includes some discussion of computerized applications and may be used as an adjunct when considering the introduction of some basic computerized systems. It does not provide all of the options for medical record management, but it does provide one option in each area for the management of medical records in developing countries. For the interest of readers, a small segment on some more advanced applications such as electronic health records and DRGs have been included. The reference list at the end of this manual lists some textbooks that provide detailed information on medical record you have reviewed the manual , you should be able to: identify the major functions of a medical record Department and carry out basic procedures;A large teaching hospital.