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Medical record
Prepared by: Mahmoud A Abdalla
Supervised by Dr. Mahmoud Aldamaty
American university in cairo (AUC)
This work is done the course of TQM in health care reform
Medical record definition: It is an instance or event of medical care
It must contain sufficient data to identify the patient, support the diagnosis or reason for attendance at the healthcare facility, justify the treatment and accurately document the result of that treatment.
Uses:
1- to record facts about patient’s health
2- for continuing care of the patient in the future if needed
3- to communicate between attending doctors and other healthcare professionals providing care to the patient.
4- for research of specific diseases and treatment and health statistics.
Purposes:
Clinical on the patient whether admitted to the hospital or treated as an outpatient or an emergency patient..
Non clinical
1- Administrative demographic and socioeconomic data such as the name of the patient (identification), sex, date of birth, place of birth, patient’s permanent address, and medical record number
2- Legal data a signed consent for treatment by appointed doctors and authorization for the release of information
3- Financial data the patient whether admitted to the hospital or treated as an outpatient or an emergency patient.
Different forms of medical record
1- front sheet or identification and summary sheet, which covers identification, final diagnosis, disease and operation codes, and the attending doctors signature;
2- Consent for treatment is often on the back of the Front Sheet and must be signed by the patient at the time of admission. There are two parts to this form. The first half of the form is a general consent for treatment and the bottom half is consent to release information to authorized persons;
3- correspondence and legal documents received about the patient, e.g., referral letter, requests for information, …
4- discharge summary, if required by the hospital/health authority;
5- admission notes, including the patient’s family medical history, the patient’s past medical history, presenting symptoms, results of a physical examination, provisional diagnosis (the reason the patient came or was brought to hospital), proposed tests and care.
6- Clinical progress notes recording the patient's daily treatment and reaction to that treatment written by the attending doctor and other health care professionals.
7- Nurses’ progress notes recording daily nursing care including temperature, pulse and respiration charts, blood pressure charts ..
8- operation report if an operation or operations are performed;
9- other health care professional notes, e.g., physiotherapy, Social Workers, …
10- Pathology reports including hematology, histology, microbiology,…
11- other reports – X-ray, …
12- Orders for treatment and medication forms listing daily medications ordered and given with signatures of the doctor prescribing the treatment and the nurse administering it.
13- Special nursing forms for observation of head injuries.
Culling medical records
The removal of medical records from the medical record files room when they are no longer active for a specified number of years. Records may then be either destroyed, or filed in inactive or secondary storage.
Verbal and telephone order
It is an order by attending treating physician orally or prescribing physician by telephone to give service or treatment to the patient. Should be used infrequently (urgent and emergency cases). This order is given by authorized licensed personnel. The order is written in the medical record if available or written appropriate order sheet with reed back to the ordering physician. It should be signed, dated and time of order by attending treating physician or prescribing physician as soon as possible and within 24 hours of the order.
Prohibited abbreviation
JCAHO has approved a “minimum list” of dangerous abbreviation, acronyms, symbols and dose designation that must be included on each accredited organization. And this schedule contains some of these abbreviations.
JCAHO Forbidden Abbreviations
Abbreviations Potential Problem Preferred Term
U (for un it) Mistaken for zero, four or cc.
Write “unit”
IU (for international unit) Mistaken for IV (Intravenous) or 10 (ten).
Write “international unit”
Q.D., Q.O.D. (Latin abbreviation for once daily and every other day)
Mistaken for each other.
The period after the Q can be mistaken for an “I” and the “O” can be mistaken for “I.”
Write “daily” or “every other day”
Trailing zero (X.0 mg), Lack of leading zero (.X mg)
Decimal point is missed. Never write a zero by itself after a decimal point (X mg), and always use a zero before a decimal point (0.X mg)
MS
MSO4
MgSO4
Confused for one another.
Can mean morphine sulfate or magnesium sulfate.
Write “morphine sulfate” or “magnesium sulfate”
Experience shows that abbreviation, symbols and dose designation may cause medical error and some are fatal
Documentation time frame in MR
- Documentation must be legible, signed, dated and timed. Word choice and grammar are important.
- A physician written assessment should reflect a sharp medical intellect and graceful literary style.
- Do not sacrifice details for space consideration.
Time frame of documentation
Differs according to policies and procedures and level of care
- Complete physical assessment within 2 hours
- Admission history within 8 hours, reassessment of the patient within 8 hours
- Initiate pathway within 2 hours and updated every 8 hours
- Patient story updated every shift
- Pain assessment upon admission and at least every 8 hours.
- Education pages including evidence of learning reviewed every 8 hours.
- Focus notes upon admission, discharge, transfer, new finding, physician notification, and response to plane of care at least every 24 hours.
Untimely / late entries management
- Identify the new entry as late entry
- Enter the current date and time
- Identify or refer to the date and incident for which the late entry is written
- If late entry is late to document an omission, validate the source of additional information as much as possible
- Document the late entry as soon as possible
- Document the current date and time
Addendum
- Write “addendum” and state the reason for addendum referring back to the original entry
- Identify any source of information to support the addendum
- When writing an addendum, complete it as soon after the original note as possible
Clarification
- Document the current date and time
- Write “clarification” state the reason and refer back to the entry being clarified
- Identify any sources of information used to support the clarification
- When writing the clarification complete it as soon after the original entry as possible
Policy on retention of medical record
When developing a retention policy, it is important to remember that medical records should be kept by the hospital as long as required under the Statute of Limitations (retention for legal requirements) or the country’s record retention regulation. Before determining a retention policy, the hospital administrator should review the record usage after discharge. Some questions that need to be answered include:
- How long medical records should be kept after the last visit of the patient?
- Are there separate rules for children's records?
- If medical records are not kept, how are records to be destroyed?
- Are there specific diseases for which the medical record must be kept for the life of the patient?
- What penalties are provided for breaking the rules?
Who approves the destruction of medical records? In general, the retention of medical records in an active file depends on:
- the amount of filing space available; and
- the yearly expansion rate of current files.
There is NO general retention policy and individual hospitals/health care facilities or governments should determine how long medical records will be kept. When considering such a policy, the hospital/government must consider:
- the readmission rate of inpatients;
- the volume of medical research undertaken by hospital staff;
- the Statute of Limitation (legal requirement);
- cost involved in finding inactive filing space;
- cost of alternative storage e.g. microfilming, optical disk or other computerized system; and
- cost of destruction of medical records.
Policy of the Destruction of Medical Records
In many countries, when medical records are destroyed after the required retention period, basic information is retained permanently. This information includes the:
- patient's full name and date of birth;
- admission and discharge dates;
- name of the attending doctor;
- diseases treated and operations performed; and
- a discharge summary for each admission if more than one.
In addition, to leave a permanent record of the patient on file, a note should be included with the retained documents stating that the records have been destroyed according to the retention policy.
- If it is the policy to destroy inactive medical records, they should be destroyed by burning.
- To ensure that the medical records are completely destroyed, the MRO should supervise their destruction.
Function of medical record department
- Admission procedure including patient identification and development and maintenance of master patient index(MPI)
- Retrieval of medical records for patient care and other authorized use
- Discharge procedure and completion of medical records after an inpatient has been discharged or died
- Coding diseases and operation of patients discharged or having died
- Filing medical records
- Evaluation of medical record service
- Completion of monthly and annually statistics
- Medico-legal issue relating to the release of patient information and other legal matters
Responsibility of MRO
The MRO or person in charge of the Medical Record Department is delegated responsibility for the functions of that department and overall management of the medical record service. That is, he or she is responsible for the management of patient health care data on a daily continuing basis. A major responsibility of the MRO is seeing that the medical record is available at all times when needed for the continuing care of the patient. They are also responsible for:
- seeing that all forms related to the care of a particular patient are in that patient's medical record;
- seeing that staff are trained and understand the value of the medical record and importance of its availability at all times;
- making sure that the medical record has been completed by the doctor;
- making sure that diseases and operations are coded accurately and within a specified time period; and
- seeing that all information produced for statistics is accurate and readily available when required by the administration, Ministry of Health or other government agency.
The MRO is also responsible for the development and maintenance of policies and procedures relating to the medical record services of the hospital.
The MRO should be responsible for the numbering system used for patient identification as it is also used for filing the medical record.
Complete
a) Component of medical record are
1- medical record forms,
2- a clip or fastener to hold the paper together
3- dividers between each admission and outpatient notes
4- a medical record folder
b) The order of forms after discharge is not the order used on the ward; on the ward the clinical progress notes and nurse notes are usually kept in the front for ease access with all forms kept in a loose-leaf binder
c) Documentation inside medical record must be legible, signed, dated and timed (LSDT)
d) The automation of the MR procedures can improve the efficiency and effectiveness of medical record departments.
e) Medical record completion procedures include:-
Check the doctor has completed the lower part of front sheet. That is a principle diagnosis,
Check if an operation or other surgical were performed then they are recorded and the doctor has signed the front sheet.
F) MRO is responsible for function of medical record department and overall management of the medical record services
g) Responsibility of medical record personnel includes management of patient healthcare on daily continuing basis and the medical record is available at all times when needed for the continuing care of the patient,
1- Basic medical record department procedures
Procedures are a detailed course or mode of action. It should be done in particular action according to the established policies. MRO is responsible for developing the department procedures in most countries. There should be a written copy of procedures with employees. These procedures include
A) Admission procedure
Routes of admission
- Through emergency room
- General outpatient clinic
- Specialist outpatient clinic
- And in some countries doctors in general practice may refer patients to the hospital for admission; in this case, patients are usually referred to emergency department for assessment and subsequent admission or referred to specialist clinic.
Types of admission
- Inpatient ward
- ICU
- One-Day
- Observation
The admission of patients to the hospital is ordered by doctors and carried out by an admission clerk
B) Discharge procedure
Medical record staff responsible for the discharge procedure should be trained to ensure that the medical records are completed promptly and correctly.
Discharge procedure begins with the receipt of the medical record of the discharged patients.
The medical record of the discharged patients or patients who have died should be sent to the medical record department by the ward staff the day of discharge or death, or the next morning
C) Disease classification and clinical coding
Clinical coding is the translation of diseases, health related problems and procedural concepts from text to alphabetical/numeric codes for storage, retrieval and analysis of healthcare data.
Staff responsible for coding should be formally trained by attending clinical coding courses offered at a local or regional level.
D) Medical record filing procedure
- The file area clean, tidy and good lightening.
- Plenty of space must be available for filing medical record.
- There should security procedure to protect medical record from fire, water damage, pest damage and unauthorized access.
- File area should have desks for the medical record clerk to sort the medical record and make out tracers.
- Space for records awaiting filing or completion.
The goals of medical record procedures are:-
- All forms are in the medical record.
- Sort the forms in the correct order.
- Check if the doctor completed the lower part of the front sheet.
- Check if an operation or other surgical procedures were performed then are recorded and the doctor has signed the front sheet.
- Ensures that diseases and operation are coded.
- Ensures that information produced for statistics is accurate and readily available.
- Seeing the medical record is available at all times when needed for the continuing care of the patient.
1- Correct and incorrect methods for patient identification and its importance
Correct methods include
- A national identification number.
- A social security number.
- Date of birth.
- Health insurance number.
- Mother’s maiden name.
- Mother’s first name.
- Father’s first name.
- New born infant fingerprint or footprint.
Incorrect methods include
- Age of the patient because it does change
- Where a person lives as it can change
- Place of birth as most of people opposed that the place where they “come from” as the place they “are born”
Importance of patient identification
- Positively identify the patient.
- For patient safety as correct procedure , correct medication, …
- For short time to get the medical record when attending to the healthcare organization.
- For accuracy of billing and payment.
- For legal purposes as in the court.
- For claims of insurance company.
- For providing a high quality services.
- For overall patient satisfaction on attending or receiving services.
- For accurate finding patient’s medical record.
- Link patient’s previous admission or outpatient attendance.
2- Number register:
Is the origin of patient identification numbering system and is a numerical list of numbers issued to patient. And also the medical record numbers are issued from number register. Number register is important for patient identification number control.
3- Master Patient Index (MPI)
MPI is a database that maintains a unique index (or identifier) for every patient registered at a healthcare organization. MPI is considered an important resource in a healthcare facility because it is the link tracking patient, person, or member activity within an organization and across patient care settings.
Master patient index card: it is a card contains information necessary to identify the patient and locate that patient’s medical record. It should contain no medical information. It is prepared by medical record staff. The information on the card includes
- Patient full name; family name and given name
- Patient’s full address
- The hospital’s identification number; that is the medical record number
- Patient date of birth and sex
- Patient’s maiden name and or other unique patient characteristics
4- Admission register
It is a chronological listing for maintaining admission statistics. The admission listing is done at time of admission to the hospital and this list is daily of all admission. Its contents are:-
- Family name and given name
- Reason for admission
- Date of admission
- Date of discharge if discharge register is combined
- Discharged dead or alive if discharge register is combined
- Some other details as doctor’s name, sex’ date of birth, ward, …
5- Death register
This is a list in date order of all inpatient that died in the healthcare organization during their stay. The death register does not include person who are dead on arrival (DOA) at the healthcare organization as they are not formally admitted and does not include patients who die in outpatient or emergency. Its contents are:-
- Family name and given name
- Age and sex
- Home address
- Treating doctor and ward
- Underlying cause of death as recorded by attending doctor on the death certificate
6- Discharge summary:
Is a summary of a patient’s stay at the hospital by the attending doctor with the minimum details in the following:-
- The reason for the admission
- Any diagnosis made
- Investigations
- Significant findings
- Procedures performed
- Medications and/or other treatment
- Patient’s condition at discharge
- Discharge instructions including diet, medications and follow up
- The name of the physician who discharged the patient
7- Difference between indices and registers
Indices: are permanent topical collections of medical record data required by laws and logic to locate cases for record maintenance, statistics and researches as MPI, surgery indices …
Registers: are permanent chronological listings for maintaining certain statistics; as admission register, death register…
8- Importance of daily discharge list
Daily discharge lists are usually used to prepare the healthcare organization statistics and copy is sent to accounting for billing, for catering, inquiries and medical record department.
9- ATD system
ATD system is one of the most computerizes systems involving medical record. It enables staff to maintain a file on all patients currently in hospital; awaiting admission, transferred and recently discharged.
- It provides an inpatient booking services for patient awaiting admission.
- Keep records of the bed state and bed allocation.
- Trace patients for inquiries
- It provides daily patient census reports and related statistics.
- It provides information for the MPI ( directly linked to the MPI system)
- It provides complete data base for all authorized users of patient identification and location of information.
10- Disease classification and clinical coding
Coding also referred to as clinical coding or disease coding, involves the allocation of a code for each relevant diagnosis/condition/disorder/health status and a code for each relevant procedure and treatment that a patient encounters during their inpatient stay. These codes are allocated from the ICD-10-AM classification system. Non-admitted emergency presentations and non-admitted attendances are not coded.
In the coding process, the Health Information Manager (HIM) reviews the contents of the medical record pertaining to the inpatient stay. From the medical record the conditions and procedures the patient experiences are converted into the representative ICD-10-AM alphanumerical characters. These alphanumerical characters are recorded within the medical record and entered into the computerized hospital management system.
- It enables the retrieval of information on diseases and injuries
- For planning healthcare facility
- For determining the number of healthcare personnel required
- For educating the population on health risks within their country
- It is used at an international level to compare health status of countries in a region or globally
As with all classification systems, ICD-10-AM enables the translation of diagnosis and procedures and other health problems from words into an alphanumeric code. This permits easy storage, retrieval and analysis of the data.
The coding standards clearly emphasize that "the responsibility for recording accurate diagnosis and procedures, in particular, principal diagnosis, lies with the clinician, not the clinical coder."
“An effort between the clinician and clinical coder is essential to achieve complete and accurate documentation, code assignment and reporting of diagnoses and procedures.”
11- Decentralized medical record system;
Inpatient and outpatient departments have their own individual medical record and should file them independently. There is usually no connection between the services if a patient has two medical record, they are not combined
12- Medical record filing system and methods
A) Centralized medical record system the medical record number is allocated at first admission or attendance of a patient to a healthcare organization and is used for all subsequent services
B) Decentralized medical record system the inpatient and outpatient departments have their own individual medical record and should file them independently. There is usually no connection between the services if a patient has two medical record, they are not combined
Each file room should have a set of shelves for records waiting to be filed; this is usually called a sorter. Medical records should be sorted in a manner which will enable them to be found if required, while waiting to be filed.
Methods of medical record filing system
A) Alphabetical filing; medical record should not be filed alphabetically
B) Straight numeric filing; the best filing system in developing countries. In this method the medical records are filed in strict numeric order according to MRN starting with the lowest number and ending with the highest number. In this method the training time for the staff is short.
C) Terminal digit filing; this method is used in many developed countries in medical record department with a large volume of medical records a six digit number is generally used and divided into three parts as 11-22-33 ; this means
11 (sequence; on the shelf)- 22 (secondary; shelf)- 33 ( primary; cabinet or sorter)
This method is not recommended in counties where the number of records is small and when clerks are not trained in its implementation and use.
13- Sorter or pre-filing system;
Each file room should have a set of shelves for records waiting to be filed; this is usually called a sorter. Medical records should be sorted in a manner which will enable them to be found if required, while waiting to be filed.
14- Medical record committee
It should be made up of people who are interested in good medical record and who are prepared by their own example; to provide incentives to others, particularly junior doctors.
It is responsible for all matters relating to the content of medical records and the provision of medical records services in the healthcare organization
Medical record committee meets every month in large healthcare organization and less frequently in smaller ones. It should be meet at least four times per year.
Medical record committee consists of
- Representative of doctors from both medicine and surgery
- Representative of nursing administration
- Representative of healthcare organization (management)
- Representative from allied health staff; physiotherapy, social worker…and the MRO
Functions and responsibility of medical record committee
- Review of medical records to ensure that they are accurate, complete clinically pertinent and readily available for continuing care of the patient, medico-legal requirements and medical research
- Ensure that the medical staff complete all the medical records of patients
- Determine the standard and policies for medical record and the medical record services
- Recommend action when a problem arise in relation to medical record and medical record services
- Determine the format of the medical record and approve and control the introduction of new medical record forms used in the healthcare organization.
- Assist and support the MRO in liaising with other staff/departments in healthcare organization.
- It is important that rules and regulations for the completion of the medical records are developed and approved by medical staff and adhered to by all.
- The MRO should prepare a summary for each medical record committee meeting; this summary should include the numbers of medical records awaiting completion by doctors.
15- Instances in which medical record are used as legal evidence
- Accident cases
- Insurance cases
- Worker’s compensation
- Personal injury claims
- Malpractice claims
- Will cases
- Criminal cases; assault cases, violent or unexplained death and sexual assault cases
- Mental competency
16- Who owns the medical records?
The medical records are considered the property of the healthcare organization and are compiled and kept primarily for the benefit of the patient
17- HIPAA
HIPAA is Health Insurance Portability and Accountability Act
Title I: of HIPAA regulates the availability and breadth of group health plans and certain individual health insurance policies. It amended the Employee Retirement Income Security Act, the Public Health Service Act, and the Internal Revenue Code.
Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform
Per the requirements of Title II, the Department of Health and Human Services has promulgated five rules regarding Administrative Simplification: the Privacy Rule, the Transactions and Code Sets Rule, the Security Rule, the Unique Identifiers Rule, and the Enforcement Rule
18- Informed consent
Adequate information is provided to the patient or legal representative in order to make a rational, informed decision to permit medical/surgical treatment and it is of two types
- A general admission or treatment consent
- A special consent for a highly technical testing, medical or surgical treatment; it must include - the full extent of the treatment plan - the extent of the side effects and risks - alternative treatment available - the risks of non-treatment.
19- Release of patient information
The MRO should develop a policy for approval by the medical record committee for the release of patient information
There are four methods for releasing information
- Direct access to the medical record
- Supply of an abstract giving details requested
- Verbal release
- Photocopying
The medical record department should have specific policies governing each type of release.
If a request is made for a release of information; the request should contain the following
- Full name of the patient, address and date of birth
- Name of person or institution
- Purpose and need of the information
- Extent and need of the information to be released, including dates
- A recent dated authorization signed by the patient or authorized representative.
Areas in which MRO can evaluate medical record procedures
1- Are medical records filed promptly?
2- Is the file room clean and tidy?
3- Are Master Patient Index cards filed promptly?
4- Are all discharges returned to the Medical Record Department the day after discharge?
5- Are medical record forms filed in the correct order?
6- Are all medical records completed within a specified time after discharge?
7- Are medical records coded correctly?
8- Are all discharges for last month coded by the middle of the next month?
9- Are the monthly and yearly statistics collected within a specified time?
The content of the medical record can be evaluated by reviewing to see if the following has been done:
1. the consent form for treatment has been signed by the patient;
2. patient identification details (name and medical record number) are correct and entered on all forms;
3. doctors have recorded all essential information;
4. doctors have signed and dated all clinical entries;
5. the front sheet has been completed and signed by the attending doctor;
6. nurses have recorded and signed all daily notes regarding the condition and care of the patient;
7. all the orders for treatment have been recorded in the medication form and signed;
8. medication administration has been recorded and signed;
9. the anesthetic form (if any) has been completed and signed;
10. the operation form (if any) has been completed and signed;
11. the main condition/principle diagnosis has been recorded on the front sheet;
12. operations and/or procedures have been recorded on the front sheet; and
13. the MRO or staff member responsible for coding has accurately coded the main condition/principle diagnosis and any other condition listed (if required).
14. a study questionnaire should be prepared and a standard determined, e.g., 100% compliance.
Medical record delinquency
Delinquent Medical Record: A medical record that remains incomplete more than 30 days after the discharge, or outpatient encounter. The specific documentation elements that are tracked for delinquency status include admission H&P, operative report, discharge summary, and clinic note.
There are medical record delinquency total
= total number of medical record which are delinquent (not completed within the numbers of days)
Medical record delinquency timeframe
The number of days within which a medical record must be completed as specified within the medical staff rules and regulation these days not more than 30 days
Medical record delinquency rate
= number of medical record which are delinquent X100
Average monthly discharges
Case mix
The basic concept or idea was to identify the output of hospitals, i.e. patients treated, as classes of patients, with each “class” receiving a similar amount of goods and services associated with their diagnosis and treatment. The ultimate goal being to include flexible budgeting, cost and quality control
DRGs:
A scheme for billing for medical and especially hospital services by combining diseases into groups according the resources needed for care arranged by diagnostic category. A dollar value is assigned to each group as the basis for payment for all cases in that group without regard to the actual cost of care or duration of hospitalization of any individual case as a mechanism to motivate healthcare providers.
Electronic medical record
A digital instance or series of instances of medical care
Medical record procedures commonly computerized in many countries include the
• Master patient index (MPI);
• Admission, transfer and discharge/death(ATD) system;
• Disease and procedure index; and
• An automated record tracking system.
• Medical record completion system; and
• Discharge summary abstracting system;
Medical Record Completion System
• A computerized medical record completion system provides an efficient tool for tracking incomplete medical records and provides a list of the number of incomplete records awaiting completion by individual doctors.
• Such a program would be linked to the ATD system on discharge of the patient.
With this system, staff can call up by doctor and by patient name all medical records awaiting completion. Deficiencies would be entered and stored in the computer memory. The system would then generate a number of reports, listing the number of records awaiting completion by the doctor, grouped by service, and the number of records waiting to be coded.
Discharge Summary Abstracting System
• With the establishment of a central data base of patient information linked to an ATD System, a summary of the patient’s stay in hospital can be produced. The summary would include identifying information about the patient, admission and discharge dates, final diagnosis, and treatment on discharge, and follow-up details.
Linked to the ATD system, health care statistics are also collected and processed via the computer thus enabling the hospital/health care facility to produce them in a more efficient and timely manner.
This gives only a brief indication of some of the available computer applications relating to medical record procedures of a hospital. Specifications for any computerized system should be developed following discussions with the computer planning team at a time when a decision has been made as to type and capacity of the computer to be installed.
JCI hospital accreditation standard (2008) for managing communication and information (MCI)
General Focus of the Standards
- The healthcare provider generally needs to have information management processes in place to assure that the information systems and content are available to meet the needs of their programs and services
- That information privacy and confidentiality of patient information is upheld
- That the security and integrity of information is enabled
- That availability and continuity of information is supported
- That appropriate systems and mechanisms to properly capture, report, process, store, retrieve, disseminate, and display clinical and non-clinical information are enabled
- That information required for decision making is provided
- That significant medical reference libraries and resources are available to staff and practitioners
- That patient medical records are complete and accurate and contain the necessary information for the provision of care
- That the patient record contain a summary of all significant diagnosis, procedures, drug allergies, and medications to support continuing or recurring ambulatory care
Admission clerking Performa
It is software for Performa and is an example of an implantation of the structure and content standards. The standards are high level headings and are highlighted
Additional subheadings have been added so that the Performa can be easily used. The subheading can be freely modified to suit local practice, specialized services and particular clinical settings.
RCP approved generic medical record keeping standards
1- The patient’s complete medical record should be available at all times during his stay in the hospital.
2- Every page in the medical record should include the patient’s name, identification number (NHS number) and location in the hospital.
3- The contents of the medical record should have a standardized structure and layout.
4- Documentation within the medical record should reflect the continuum the patient care and should be viewable in chronological order.
5- Data recorded or communicated on admission, handover and discharge should be recorded using a standardized Performa.
6- Every entry in the medical record should be dated, timed, legible and signed by the person making the entry. The name and designation of the person making the entry should be legibly printed against their signature. Deletions and alterations should be countersigned.
7- Entries to the medical record should be made as possible after the event to be documented and before the relevant staff member goes off duty. If there is a delay, the time of the delay of the event should be recorded.
8- Every entry in medical record should identify the most senior healthcare professional present (who is responsible for decision making) at the time the entry is made.
9- On each occasion the consultant responsible for the patient’s care changes, the name of the new responsible consultant and the date and time of the agreed of care, should be recorded.
10- An entry should be made in the medical record whenever the patient is seen by a doctor. When there is no entry in the hospital record for more than four (4) days for acute medical care or seven (7) days for long stay continuing care, the next entry should be explained why?
11- The discharge record/ the discharge summary should be commenced at the time a patient is admitted to the hospital.
12- Advanced decision to refuse treatment consent, cardio-pulmonary resuscitation decisions must be clearly recorded in circumstanced where the patient is not the decision maker; the person should be identified (lasting power of attorney).
Heavy hitter that must be included while conducting tracers
1- Nursing assessment and reassessment.
2- Timely history and physical reports.
3- Updates to history and physical reports.
4- Presence of advance directives.
5- Pain management
6- Verbal/telephone orders and critical test values.
7- Time out before procedures.
8- Anesthesia assessments.
9- Timely operative reports.
10- Timely post-operative progress notes
11- Informed consents
12- Prohibited abbreviations.
13- Legibility
14- Anything to do with the national patient safety goals that require documentation in the medical record.
Information technology
The acquisition, processing, storage and dissemination of vocal, pictorial, textural and numeric information by a micro-electronics based combination of computing and telecommunications.
Information technology
Three levels
1- Corporate
2- Team, division, business unit,…
3- Individual
Types of networking
1- Wide area network (WAN)
2- Local area network ( LAN)
3- Metropolitan area network (MAN)
4- Internet; global information network
5- Intranet; corporate information network
6- Extranet; network of business partners
1- Administrative safeguard
2- Physical safeguard
3- Technical safeguard
Encryption
Is the process of encoding information in such a way that only the person or (computer) with the key can decode it
DATA dictionary
Is a structure definition defining data objects and the relationship between them together with attributes, and acceptable values
It acts as a catalogue of all data elements containing their names and structures and information about their usage
DATA warehouse
It stores data extracted from various database
It is a central source of data that has been cleaned, transformed and catalogued
Ready to be used in different operations or organizational transaction
DATA mining
Information is stored in enormous database
To make meaning of all that data; a process is used known as data mining
Data is further analyzed to enable advanced level analysis for further projection based on historical data
Formulating patterns between various data elements and developing trends
Support tools for strategic decisions taken by business managers
Database management system
Is a set of computer programs that controls the creation, maintenance and use of databases of an organization and its end-users
Healthcare information system (HCIS):
It is an information system used within a healthcare organization to facilitate communication, to integrate information, to document healthcare interventions, to perform record keeping, or otherwise to support the communication functions of the organization.
HCO’s information needs
1- Operational requirements.
2- Planning requirements.
3- Communication requirements
4- Documentation and reporting requirements.
Role and responsibilities of chief information officer (CIO)
Is a senior level executive responsible for leading the strategic information system, planning process and for helping the leadership team use information system in support of strategic planning and management.
RFP
1- Introduction; why are we issuing this RFP?
2- Objectives; what are the objectives which we are trying to achieve?
3- Hospital profile; a brief history about the hospital
4- Current operational system; a brief description of the current system
5- Problems; what are the deficiencies in the current system?
6- Required system; detailed description of the required system.
7- Functionality required; why are we issuing this RFP?
8- General terms and condition;
- Delivery
- Installation
- Warranty
- Maintenance
- Training
- Acceptance criteria
9- Enclosures; any technical reports of attachment related to the hospital to be enclosed for more clarification if required.
Hospital information system
An integrated system used in healthcare setting to manage patient information.
COPE
- Give the prescriber options to change the order by constantly performing checks in the background.
- Whether the patient is allergic to the drug
- Whether there are interactions with other drugs the patient is taking.
- Whether the dosage ceiling for the drug is being exceeded
Barcoding
In 2002 JCI announced six national patient safety goals. The first goal positive patient identification, is amenable to bar-coded patient wrist-bands
The BPOC system provides much needed safety net at the bed side to avert potentially injurious medication error; by
- Viewing the near miss data in spreadsheet
- Eliminating omitted doses through the warning “ dose omitted”
- Cost avoidance
Concentrate on
Purposes of medical record:
Clinical, on the patient whether admitted to the hospital or treated as an outpatient or an emergency patient..
Non clinical
1- Administrative demographic and socioeconomic data such as the name of the patient (identification), sex, date of birth, place of birth, patient’s permanent address, and medical record number
2- Legal data a signed consent for treatment by appointed doctors and authorization for the release of information
3- Financial data the patient whether admitted to the hospital or treated as an outpatient or an emergency patient.
Legal documentation include:-
A signed consent for treatment by appointed doctors and authorization for the release of information
A written consent; it is for; 1- operation. 2- Invasive procedure. 3- Experimental chemotherapeutic medication use. 4- Blood transfusion 5- contraceptive method 6- research 7- organ donation
Forms of legal documentation
1- Authorization for release of information
2- Operation reports anesthesia and procedural notes
3- Patient leaving against medical advice
Order of the forms in the medical ward
The order of forms is not the order used in the ward
Forms should be in the same size usually A4
The patient’s name and the medical record number, and the name of the form should be in the same place on every form
Medical information should not be recorded on the folder
In clarification; for every entry, identify the time date and signature
Computerization of medical record
It is important to develop a simple, effective, and efficient manual medical record service before considering computerization
Computerization will not solve all problems if manual record is not properly developed and maintained
Who is responsible for?
The quality of care top manager,
Direct patient care and documentation in the patient’s medical record hospital administrator
The accuracy and completeness of this documentation doctors and nurses
The availability of medical record at all times who is recording the data
The hospital administration is legally responsible the quality of care given to patients
Responsibility of direct patient care and documentation in the patient’s medical record is delegated to doctors, nurses and other healthcare professionals.
The accuracy and completeness of this documentation is the responsibility of those who are recording the data.
Basic medical record department procedure
3- Disease classification and clinical coding
2- Discharge procedure
4- Medical record filing procedure
1- Admission procedure
Types of admission
1- Inpatient ward
2- ICU
3- One-Day
4- Observation
The admission of a patient to the hospital is ordered by doctor and carried out by an admission clerk
In order to identify patients, we need unique patient characteristics. (Full name and age false)
Number register is the origin of the patient identification numbering system and is a numerical list of number issued to patients.
Master patient index “MPI” card contains only information necessary to identify the patient and locate that patient’s medical record
If the patient has an inpatient previously, the admission clerk must look for and find the old number in the master patient index MPI
Inpatient admission; the patient is send to the ward with front sheet and that is the beginning of medical record
What kind of register is this?
Q1: a register where a number is given to each patient on his/her first admission to the hospital to identify the patient, and to identify his/her medical record and to file the medical record number register
Q2: a register listing all admission, readmissions as well as new admissions. It is used to produce admission statistics admission register
Death register is a list in date order of all inpatients that died in the hospital/healthcare center.
The death register does not include persons who are dead on arrival “DOA” at the hospital as they are not formally admitted.
Discharge summary: is a summary of a patient’s stay at the hospital by the attending doctor with the minimum details in the following:-
1- The reason for the admission
2- Any diagnosis made
3- Investigations
4- Significant findings
5- Procedures performed
6- Medications and/or other treatment
7- Patient’s condition at discharge
8- Discharge instructions including diet, medications and follow up instructions
9- The name of the physician who discharged the patient
In a centralized medical record system the MRN is allocated at the first admission or attendance for a patient to hospital and is used for all subsequent services
Decentralized medical record system; inpatient and outpatient departments have their own individual medical record and should file them independently. There is usually no connection between the services if a patient has two medical record, they are not combined
Alphabetical filing: medical record should not be filed alphabetically
Straight numeric filing and terminal digit filing
Removing medical record from file and record control
To ensure proper record control whenever a medical record is removed from file for any purpose, it should be replaced by a tracer, which indicates where the medical record has been sent. A tracer is also called outguide in many countries
Tracers or outguides enable medical record to be traced when not on file
For admitted emergency patients, it is important to remember to not to count the patient twice; once as emergency patient and once as an admission
Terms of reference “TOR” = FUNCTIONS:
The medical record committee is responsible for all matters relating to the content of medical records and supervision of medical record services in the hospital
The medical record committee in large hospital meets every month and less frequently in smaller hospital; it should meets at least four times per year
Bed Day: unit of measure denoting the presence of an inpatient bed “occupied or unoccupied” set-up and staffed for use in one 24hours
Length Of Stay “LOS”: the duration of an inpatient’s hospitalization considered to be one day; if he/she is admitted and discharged in the same day and also; if he/she is admitted on one day and discharged the next day
Exceptions of this rule include the use of the information:
1- By doctors and other health professionals for continuing care of the patient.
2- For medical research where the patient is not identified.
3- For collection of healthcare statistics when the individual patient is not identified.
4- For medical record personnel.
Choose the suitable answer using one word (availability, integrity, accountability, confidentiality)
1- Data has been altered or destroyed in an unauthorized manner = integrity
2- Information is not made available or disclosed to an unauthorized parties = confidentiality
3- Information is accessible and usable on demand by an authorized entity = availability
4- The action of an entity can be traced = accountability
DRGs: a scheme for billing for medical and especially hospital services by combining diseases into groups according the resources needed for care arranged by diagnostic category. A dollar value is assigned to each group as the basis for payment for all cases in that group without regard to the actual cost of care or duration of hospitalization of any individual case as a mechanism to motivate healthcare providers.
Sampling criteria: select the minimum number of the medical record that must be audited based upon the population size;
- For population size less than 30, sample of 100% of your medical record
- For population size up to 100, sample 30 medical records
- For population size 101 to 500, sample 50 medical records
- For population size over 500, sample 70 medical records
Full name of the patient, MRN and the ward should be written on the forms
Tracer: which indicate where medical file has been sent for any purpose and enables medical records to be traced when not on the file.
Centralized
Decentralized
Property of the medical record
Electronic medical record all of the above
Handover= endorsement
Who has the authority to see the medical record except all physicians and nurses?
Exercise 1) in one of the internal medicine departments there were 40 bed set-up and staffed for use. 600 patients were admitted in the second quarter of the year 2008.
The inpatient service days for the same period was 2400
Find the bed days and the occupancy rate of the department?
Bed day =
Occupancy rate of the department =
Exercise 2) if a number of patients in hospital at midnight on august 25 = 160 and the number of patient admitted on august 26 = 30 and the discharged including deaths on august 26 = 20 & patient both admitted and discharged including deaths on august 26 = 5
Find the inpatient census on august 26
If the inpatient service days for august were 4800; find the average daily census of august
Inpatient census for august 26 =
The average daily census of august =
Exercise 3) in June; a hospital discharged 6700 patients including deaths but excluding newborn. The combines service days were 26800 days find the average length of stay of inpatient during June
The average length of stay of inpatient during June =
Exercise 4) in January there were 310 deaths a total of 7500 patient were discharged including deaths
Find the hospital death rate for January?
The hospital death rate for January =
Bed day: unit of measure denoting the presence of an inpatient bed (occupied or unoccupied) set-up and staffed for use in one 24 hours (bed/day)
Daily inpatient census: the total number of inpatient at a given time
= the number of patients in hospital at midnight the previous night + all admissions for next day – the total discharges/deaths for the same day + patients both admitted and discharged including deaths (patient)
Inpatient service day: a unit of measure denoting the services received by an inpatient during one 24 hours period = patient day = patient service day = occupied bed day (days)
Total inpatient service days: the sum of all daily inpatient census for each of the days in the period = inpatient days of care
Average daily census: the average number of inpatients present each day for a given time period = inpatients service days/ number of days (patients/day)
Length of stay: the number of days of care rendered to an inpatient admission to discharge (days)
Average length of stay: the average number of day that the inpatients stayed in the hospital (days)
Bed occupancy rate: total inpatient service days / bed days (%)
Hospital death rate: the proportion of inpatients that die in hospital (number of deaths of inpatients in period number of discharges) X100 (%)
Handover documents: is one of the high risk transactions in clinical practice
There are two principle types of handover document suggestion
1- Handover to hospital at night or week-end teams
2- Handover where ongoing care will be with a different consultant team.
Handover is strongly recommended that formal handover documents are used when handing over patients who will require attention or who at clinical risk
It can be used “as is” and are unlikely to require significant amendments.
Not all handovers justify completion of paper documentation in busy clinical practice
Sampling criteria: select the minimum number of medical records that must be audited based upon the population size
1- Population size less than 30; a 100% of your medical records
2- Population size 30 to 100; a sample 30 medical records
3- Population size 101 to 500; a sample 50 medical record
4- Population size over 500; a sample 70 medical record
Information technology
The acquisition, processing, storage and dissemination of vocal, pictorial, textural and numeric information by a micro-electronics based combination of computing and telecommunications.
Ways of protecting information: firewall is either a program or computer it runs on, usually an internet gateway server; that protect the resources of one network from users from other networks
Your forces; an enterprise with an intranet that allows its workers access to the internet will want a firewall to prevent the outsiders from accessing its own its own private data resources
Encryption
Is the process of encoding information in such a way that only the person or (computer) with the key can decode it
DATA dictionary
It is a structure definition defining data objects and the relationship between them together with attributes, and acceptable values
It acts as a catalogue of all data elements containing their names and structures and information about their usage
DATA warehouse
It stores data extracted from various database
It is a central source of data that has been cleaned, transformed and catalogued
Ready to be used in different operations or organizational transaction
Healthcare information system (HCIS)
It is an information system used within a healthcare organization to facilitate communication, to integrate information, to document healthcare interventions, to perform record keeping, or otherwise to support the communication functions of the organization.
HCO’s information needs
5- Operational requirements.
6- Planning requirements.
7- Communication requirements
8- Documentation and reporting requirements.
Enumerate 3 examples of role of information communication technology
1- Barcoding
2- Electronic medical record (EMR)
3- Physician order entry
4- Nursing services
5- Patient care management
Hospital information system
An integrated system used in healthcare setting to manage patient information.
COPE
- Give the prescriber options to change the order by constantly performing checks in the background.
- Whether the patient is allergic to the drug
- Whether there are interactions with other drugs the patient is taking.
- Whether the dosage ceiling for the drug is being exceeded
Barcoding
In 2002 JCI announced six national patient safety goals. The first goal positive patient identification, is amenable to bar-coded patient wrist-bands
The BPOC system provides much needed safety net at the bed side to avert potentially injurious medication error; by
- Viewing the near miss data in spreadsheet
- Eliminating omitted doses through the warning “ dose omitted”
- Cost avoidance
EMR: increase availability
It keeps track of medical information such as practice management system.
Systematic random sampling: also called Quasi-random sampling
Like picking every third name of the list, drawing every nth element from the population
Data
Analysis
Information
Experience
Knowledge
Accumulation
Decision making
Coefficient variation: it measure the variability of the observation around its mean
In histogram: if data
20 – 50 6 cells (minimum)
51 – 100 7 cells
101 – 200 8 cells
201 – 500 9 cells
501 – 1000 10 cells (maximum)
Range = highest value - lowest value
Cell width = range / N0 of cells
HCIS: An information system used within a healthcare organization to facilitate communication, to integrate information, to document healthcare interventions, to perform record keeping, or otherwise to support the communication functions of the organization.
CASE MIX: classification of bundles of patients by disease, diagnostic or therapeutic procedure performed, method of payment, duration of hospitalization and intensity and type of service provided
(The basic concept or idea was to identify the output of hospitals; patients treated as classes of patient with each class receiving a similar amount of services associated with their diagnosis and treatment. The ultimate goal is being to include flexible budgeting, cost and quality control.
Information technology: The acquisition, processing, storage and dissemination of vocal, pictorial, textural and numeric information by a micro-electronics based combination of computing and telecommunications.
Information system (IS): an organized combination of people, hardware, software, communication, networks and data resources that collects, transforms and disseminates information in an organization
Management information system (MIS): a system to convert data from internal and external sources into information and communicate that information in an appropriate form to managers at levels of all functions to enable them to timely and effective decisions for planning, direction and controlling the activities for which they are responsible.
Data mining: Information is stored in enormous database
To make meaning of all that data; a process is used known as data mining
Data is further analyzed to enable advanced level analysis for further projection based on historical data
Formulating patterns between various data elements and developing trends
Support tools for strategic decisions taken by business managers.
DRGs: a scheme for billing for medical and especially hospital services by combining diseases into groups according the resources needed for care arranged by diagnostic category. A dollar value is assigned to each group as the basis for payment for all cases in that group without regard to the actual cost of care or duration of hospitalization of any individual case as a mechanism to motivate healthcare providers.
Firewall: is either a program or computer it runs on, usually an internet gateway server; that protect the resources of one network from users from other networks
Your forces; an enterprise with an intranet that allows its workers access to the internet will want a firewall to prevent the outsiders from accessing its own its own private data resources.
Data dictionary: Is a structure definition defining data objects and the relationship between them together with attributes, and acceptable values
It acts as a catalogue of all data elements containing their names and structures and information about their usage.
Encryption: Is the process of encoding information in such a way that only the person or (computer) with the key can decode it.
Order information
1- Strict numeric numbers (number register)
2- Alpha-numeric (ICD-10)
3- Alphabetical (master patient index)
4- Date order (death register)
Sampling technique:
Random/probability Nonrandom/non probability
1- Simple random sample 1-convenience sample
2- Systematic random sample 2-purposive or judgment sample
3- Cluster sampling 3-snowball sample
4- Stratified random sample 4-quota sample
5- Multi-stage sampling 5-expert sample
6- Others
Standard deviation: it measures how far each number in a set of data is from their mean.
Simple frequency distribution
Control chart: special cause variation
1- 1 data point falling outside the control limit (violation of the 3 sigma level).
2- 6 or more points in a row steadily increasing or decreasing (trend).
3- 8 or more points in a row on one side of the centerline (shift).
4- 14 or more points alternating up and down (zigzag).
Control chart for variebles
x-chart
s-chart
R-chart
Control charts for attributes
C-chart
p-chart
Statistical quality control
1- Process control: detect occurrence of assignable (identifiable) causes of quality variation in the production process through technique of control chart
2- Product control: ensures that lots of manufactured products do not contain large proportion of defective items through technique of acceptance sampling inspection plans
Product is said defective if it has one or more defects which is serious enough to restrict its effective use
Particular instance of nonconformity is called defect
Medical record completion procedure include 4 items
1- insure that all forms are in MR 2- put all forms in correct order 3- confirm presence of doctor principle diagnosis on front sheet 4- check that if a surgical procedure has been done is recorded and doctor signed in
front sheet ...
