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Department of Health, Philippines
HEALTH INFORMATION
MANAGEMENT
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.
Department of Health, Philippines
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.
Department of Health, Philippines
Health Record Standard III
Health records are confidential, secure, current, authenticated, legible, and complete.
Department of Health, Philippines
Health Record Standard IV
The Health Information Management Department is provided with adequate direction, staffing, and facilities to perform all required functions.
Department of Health, Philippines
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
Department of Health, Philippines
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.
Department of Health, Philippines
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.
Department of Health, Philippines
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
Department of Health, Philippines
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.
Department of Health, Philippines
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.
Department of Health, Philippines
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.
Department of Health, Philippines
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.
Department of Health, Philippines
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).
Department of Health, Philippines
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)
Department of Health, Philippines
18. When a patient is transferred to another facility, a Discharge Summary should accompany him/her.
Department of Health, Philippines
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
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.
Health Record Identification System
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
Agency Schedule No. Page ___ of __ pages
Address
Date Prepared:
# Records Series Title and Description
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
Agency Schedule No. Page ___ of __ pages
Address
Date Prepared:
# Records Series Title and Description
Retention Period Disposition Authority/Remarksa. Active b. Storage c. Total
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
Agency Schedule No. Page ___ of __ pages
Address
Date Prepared:
# Records Series Title and Description
Retention Period Disposition Authority/Remarksa. Active b. Storage c. Total
•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
Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Description
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
Agency Schedule No. Page ___ of __ pages
Address
Date Prepared:
# Records Series Title and Description
Retention Period Disposition Authority/Remarksa. Active b. Storage c. Total
•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
Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Description
Retention Period Disposition Authority/Remarksa. Active b. Storage c. Total
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.
Agency Schedule No. Page ___ of __ pages
Address
Date Prepared:
# Records Series Title and Description
Retention Period Disposition Authority/Remarksa. Active b. Storage c. Total
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.
Agency Schedule No. Page ___ of __ pages
Address
Date Prepared:
# Records Series Title and Description
Retention Period Disposition Authority/Remarks
a. Active b. Storage c. Total
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.)
Agency Schedule No. Page ___ of __ pages
Address
Date Prepared:
# Records Series Title and Description
Retention Period Disposition Authority/Remarks
a. Active b. Storage c. Total
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.
Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Description
Retention Period Disposition Authority/Remarks
a. Active b. Storage c. Total
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.
Agency Schedule No. Page ___ of __ pages
Address
Date Prepared:
# Records Series Title and Description
Retention Period Disposition Authority/Remarksa. Active b. Storage c. Total
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.
Agency Schedule No. Page ___ of __ pages
Address
Date Prepared:
# Records Series Title and Description
Retention Period Disposition Authority/Remarksa. Active b. Storage c. Total
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.
Agency Schedule No. Page ___ of __ pages
Address
Date Prepared:
# Records Series Title and Description
Retention Period Disposition Authority/Remarksa. Active b. Storage c. Total
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.
Agency Schedule No. Page ___ of __ pages
Address
Date Prepared:
# Records Series Title and Description
Retention Period Disposition Authority/Remarksa. Active b. Storage c. Total
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.
Agency Schedule No. Page ___ of __ pages
Address
Date Prepared:
# Records Series Title and Description
Retention Period Disposition Authority/Remarks
a. Active b. Storage c. Total
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.
Agency Schedule No. Page ___ of __ pages
Address
Date Prepared:
# Records Series Title and Description
Retention Period Disposition Authority/Remarks
a. Active b. Storage c. Total
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.”
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