Him

Department of Health, Philippines

HEALTH INFORMATION

MANAGEMENT


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


2. 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.


4. 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.


9. 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.


11. 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.


16.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).


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.

The simplest form of record identification, using the patient’s name to identify and file the patients’ health record.

Alphabetic System

Health Record Identification System


Numerical System

•has a direct influence on the filing system

•use of a Master Patient Index (MPI) to cross-reference the patient’s name with his or her HRN is required.


Unit Number

•unique identification number is assigned on first contact with the health care facility, whether:

◘admission ◘ER attendance ◘out-patient ◘includes health care facility

newborn babies

After receiving the inpatient health records from the Nursing Service, the HIMD performs essential procedures prior to filing and storage.

1. Assembly of Health Record

The forms are arranged in the order upon admission of the patient.

2. Analysis of Health Record •The most important function of the HIMD is the health record analysis to ensure maintenance of quality documentation.

•Analysis is the process of evaluating and/or checking health records to ensure completeness, accuracy and adequacy of documentation.

•In cases where the patient wants some data corrected especially on the demographic/sociological data, it shall not be done in the original entry, but should appear as an amendment only.

•The health records shall contain all original copies of examination results, operations, and other required forms.

•Anesthesia record

•Report of operation

•Nurses' notes

3.Coding

•It is a process of assigning numbers to represent diagnosis or problems and surgical procedures.

4. 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.

5. Collection of data for hospital statistics

5. Filing of Health Record

A filing area that will ensure the rapid location and retrieval of health records must be maintained.

Alphabetical filing system

•All records of discharged patients are filed in strict alphabetical order from A to Z.

Numerical filing systemThere are two systems of filing records numerically:

• Straight Numeric • Terminal Digit For terminal digit, a six-digit number is used and divided into three (3) parts.

MEDICAL RECORDSDISPOSITION

SCHEDULE

Agency Schedule No. Page ___ of __ pages

Address

Date Prepared:

# Records Series Title and Description

Retention Period Disposition Authority/Remarksa. Active b.

Storagec. Total

1 Emergency Room Records /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

25 years

25 years


Address

Date Prepared:


Retention Period Disposition Authority/Remarksa. Active b. Storage c. Total

2 Certificates•Birth (Not Official Copy)

•Death (Not Official Copy) Medical

Medico- legal Non Medico- legal

15 yrs. 15 yrs.

Retain until patient reaches the age of maturity (18 yrs.)All Health Care Facilities, irrespective of its category and classification shall dispose of medical records beyond (15 yrs.)Health Care Facilities attached to teaching training/research institutions may keep medical records beyond fifteen yrs. (15 yrs.) if deem necessary


Address

Date Prepared:



3 Consent to involvement in Medical Trials

1 year Dispose 1 yr. after 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 Basic Medical Records• Clinic and Graphic Record/Graphic Chart/TPR Chart •Consent to Hospitalization•Cover sheet/Face sheet/Admission-Discharge Record•Discharge Summary•Laboratory Record •Nurses Notes/Nursing Records

15 years

All Health Care Facilities, 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


Address

Date Prepared:



•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


Address Date Prepared:


Retention Period Disposition 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


Address

Date Prepared:



•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• Disease• Master Patient• Operation• Physician

PERMANENT For agency reference.

Requirement from all tertiary hospitals and in some secondary hospitals w/teaching/training/research components.

6 Registers• Electrocardiogram (ECG)• Family Planning (Sterilization)• Laboratory 1. Bacteriology 2. Blood Chemistry 3. Clinical Microscopy 4. Hematology 5. Hispathology 6. Specimens

PERMANENT PERMANENT

For agency reference.For agency reference.Dispose 2 yrs. After the last entry provided to item is subject of a medico legal case.


Address

Date Prepared:



6 • Live/Still Birth• Medical Records Service (Incoming Medical Records from Wards)• Medico- legal• Radiology 1. C-T Scan 2. Ultrasound 3. X-Ray (Routine/Special Procedure)• Surgical Cases

PERMANENT

PERMANENTPERMANENT

PERMANENT

For agency reference.Dispose 1 yr. after the last entry.

For agency reference.For agency reference.

For agency reference.

7 Medical Records of Employees Working in a Health Care Facility

Dispose 10 yrs.after separation/voluntary resignation or retirement from the facility.


Address

Date Prepared:




8 Out- patient Records (Ambulatory Service)

Dispose 10 yrs. After last consultation/visit.

9 Psychiatric Records 25 yrs. 25 yrs.

10

Records of Infants Delivered in a Health Care Facility

Retain until patient reaches the age of majority (18 yrs.)


Address

Date Prepared:




11

Registers• 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)

PERMANENT For agency reference.






12 Reports• Census 1. Daily 2. Monthly

• Consumption and Inventory of supplies Incident (Nurses and others)

1 yr.

2 yrs.

1 yr.

2 yrs.

Dispose 2 yrs. After preparation of annual report.

All Health Care Facilities, 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.


Address

Date Prepared:



12 • Notifiable Diseases• Statistical 1. Annual 2. Monthly 3. Semi-Annual

1 yr. 1 yr.

Permanent1 yr. 1 yr.1 yr. 1 yr.

13 Results/Reports of Examinations/Procedures/ Tests • ECG Report/Result and Tracing

All Health Care Facilities, irrespective of its category and classification shall dispose of medical records beyond fifteen (15 yrs.)Health Care facilities attached to teaching/training/research institutions may keep medical records beyond 15yrs. If deem necessary.


Address

Date Prepared:



13 • Laboratory 1. Bacteriology 2. Blood Chemistry 3. Clinical Microscopy 4. Hispathology 5. Parasitology

For all laboratory, X-Ray, ECG and other examinations requested as a product of hospitalization/ confinement, the original 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.


Address

Date Prepared:



14 Requests• Access to Clinical Information from Medical Records

•ECG

Attach to Medical Records, all Health Care Facilities, 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.

Dispose 1 yr. from date/ release of official report/ result.


Address

Date Prepared:



14 • Laboratory 1. Bacteriology 2. Blood Chemistry 3. Hispathology 4. Parasitology 5. Urinalysis• Release of Information

•Research

•X-Ray 1. C-T Scan 2. Routine 3. Special Procedures 4. Ultrasound

Dispose 1 yr. from date/ release of official report/ result

Attach to Medical Records and follow disposition authority under Item No. 14Dispose 1 yr. after date of receipt.

Dispose 1 yr. from date/ release of official report/ result.


Address

Date Prepared:




15 X-Ray Films• With Court Case

All Health Care Facilities, 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.


Address

Date Prepared:




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.

Department of HealthMemorandum Circular No. 2005-0081dated November 17, 2005

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)

• 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.

B. Death Certificates

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 assaultinflicting injuries upon a person resulting to death, or any otheracts or violence upon a person resulting to death and or suddendeath of undetermined cause.

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.

4. World Health Organization’s International Statistical Classification of Diseases and Related Health Problems Version 10 (ICD-10) Volume 2

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.”

THANK YOU!

Health & Medicine

Him