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MEDICAL HEALTH RECORD DEPARTMENT

Health Reacord

 

MRS OLUWABUNMI OPEOLUWA ADIGUN

Name



 Position:  HOD
 Department
: Health Record
 Work Rate: 24 Hours
  Email: enquiriesThis email address is being protected from spambots. You need JavaScript enabled to view it. 

   

What is Health Reacord

What is Health Record

It is a clear concise and accurate history of patient life and illness within from the Medical point of view. It is also a collection of Medical Information which are assembled together in respect of patient into a case folder.

Medical Records comprises of an orderly report of;

  • Patient Complaints
  • Family history
  • Past and present Medical history
  • Physical Examination
  • Provisional Diagnosis
  • Investigation
  • Final diagnosis
  • Treatment
  • Final Result
 
   


Content of Health Reacord

CONTENT OF HEALTH RECORD

In Health Records various types of documents make up the case notes which cater for the clinical, social and administrative needs.  The patient’s record can only be good as of quality of information contained in it.

Hospital information in the patient case note is divided into three;

  1. Identification/Social data
  2. Clinical data
  3. Administrative date

Identification/Social data:-  Consist of Names, Address, Sex Age, hospital number occupation and religion etc.

  1. Clinical date:- Consist of medical history, examination result, operation notes, prescription sheet, administration of drugs (drug chart). Diagnosis, condition on discharge and discharge summary.
  2. Administrative data:- Correspondence, consent form, authorization, consent for operation and autopsy, discharge against medical advices,hospital history on out-patient attendance, hospital history on admission  and discharge.

Our Activities

DEAPARTMENT ACTIVITIES

The department runs 24 hours services in the Emergency unit of the hospital and 2 shifts in the Out-patient clinic i.e. morning and afternoon; also it runs two shifts in Harvey Road Clinic and 1 shift in Amenity Clinic. Activities resume from 8.00a.m.–4.00p.m at the Amenity clinic.

EMERGENCY UNIT

The emergency unit operates 24 hours shift duty and is fully utilized for new patients.  All the new patients are registered at the unit including patients from Oshodi Annex.

The majority of registration takes place in emergency unit by direct enquiry with patient on his first attendance at the hospital.  The efficiency and humility of the organization will be judged by some patients on the manner of their reception on arrival, anxious about the condition which brings them into the hospital.

Registration

This is the act of maintaining an official list of all the written record, which is regularly kept in a prescribed register of all patients who have ever come in contact with the hospital.

Registered patient are usually issued with a unit number and appointment card which serves as hospital number to the record of the patient.

 Registration procedure

  • Health record staff should give prescription booklet, request form, and outpatient continuation sheet to the doctor on duty
  • Health records staff should give assessment form to the doctors on duties
  • After the payment of N2,000 (Two Thousand Naira) for registration by the new patients, health records officer will interview and check the patient names from the master name index in the computer system in order to verify if the patient has register before
  • But if he/she has not been registered, an input form will be given  to the new patient/relative in order to collect his/her data
  • The input form will be returned to health records staff by the patient/relative after filling the necessary data and all the data will be registered or transferred into the registration book
  • Health records staff will also open a case note for the new patient by using the input form and along the line an appointment card will be given to the patient/relative which contains the registration number, patients name, consultant name, department, day and time.
  • After proper documentation the case note will be passed to the nurses section for vital signs and nurses will take the case note to the doctor for consultation
  • After the consultation the doctor will write the week the patient will visit the hospital on the prescription sheet which will be taken to appointment unit of health records at the emergency
  • After the doctors must have seen the patient, the health record staff will go to the consulting rooms and pack all the seen files, outpatient continuation sheets and prescription sheets.
  • The health records officer will enter the patients information (registration number, date of registration, surname, other names, first name, title, home address date of birth, sex, age, telephone number, occupation, state of origin, local government area, town, ethnic group, marital status, religion , provisional diagnosis, first next of kin, relationship, kin’s address, second next of kin, relationship, kin address, kin telephone number and the consultant) into the computer system for easy retrieval
  • At the end of the day the health records staff on afternoon shift will sort and arrange the case note numerically for proper filling to the health records library and attend to the patient that comes while he/she follows the same procedure from above.

All registered information are checked at every attendance and updated where and when necessary.

 Referral Letter: the health record officer at the emergency unit will file the patient referral letter into the case note before passing it to the nurses section, record in the register for future purpose.


Out-Patient Clinic

OUT-PATIENT CLINIC

This is a place where patients come in for follow-up of their treatment after they have been given appointment at the emergency unit and outpatient clinic.

The health record officer usually gives health talk to the patient on Monday to Friday which usually takes place within 8am to 8:30 am

  1. The patient will make payment to the account section and the records staff on duty will collect the card to retrieve the files on the table which is already arranged in alphabetical order
  2. After the collection of the appointment card, a number is given to the patient and  their names, registration numbers and sex are documented on a separate clinic list which comprises of batches
  • The case file is arranged according to the number allocated to them. e.g 1 to 160 which gives 4 batches list ( i.e first 40 patients, second 40 patients, third 40 patients and fourth 40 patients.). This has been of help to reduce waiting time and also create a sense of orderliness among the patients
  1. For patients that have appointment date, their files would be retrieved from the sorting table and passed to the stamping table.
  2. The patient’s appointment card will be used to tick the patient’s name from the clinic of appointment list in order to indicate the number of patients that attended the clinic.
  3. The appointment clinic list helps to indicate the particular number of patients booked for a particular clinic day.
  • The stamping table is where patient’s files will be arranged and outpatient continuation sheets will be added into the case note which contains names, registration number, date and clinical note space
  • Then the case note will be transferred to the Nursing section for vital signs and from nurses to the consulting rooms for consultation.
  1. After consultation, the patient will come back to health record department with the prescription sheet to book next appointment date. This will be documented in the appointment jacket according to the consultant in order to reduce waiting time.
  2. At the end of the clinic the records staff will pack the patient’s files from the consulting rooms and it will be sorted and arranged numerically for easy filing at the library unit.

MEDICAL REPORT

Medical report is normally dispatched by health records officer to the patient/relatives at out-patient clinic according to the patient’s consultant and it is always documented in the register which consists the following.

  • Date of collection
  • Destination,
  • Reference no
  • Names of the patient
  • Registration number
  • Signature of the patient/relative.

A copy of the medical report is filed into the patient’s case note for future purpose and original copy is given to the patient/relative to his/her destination.

WARDS

* The health Record staff goes to the wards to changes the entire torn patient case note.

*  We do arrange the content of patient case note in an orderly manner.

*  Patient case note that are bulky is change and label volume 2 while the new one is created with latest diagnosis and it is label volume 1

* The label volume 2 case note is filled back into the health records library which can be access to at any point in time by doctors or health professionals.


CAMHSC Unit

CHILD AND ADOLESCENT UNIT

 band treated, the Record Officer, register, retrieve and book appointment at the end of each day. The patient case note are kept in the library and arranged numerically.  

ADULT CLINIC IN OSHODI

The department runs three (3) shift in the unit i.e. Morning, Afternoon and Night. The clinic serves the staff, staff relatives, patients and the community around the hospital. The same method applies in this unit.

STATISTICS UNIT

Collection of statistics are done on weekly, monthly and quarter basis for the purpose of planning, research and budgeting

  1. HRO collect and collate the numbers of patient attended to at outpatient clinic, Harvey road clinic, amenity clinic, oshodi outpatient clinic and C/A clinic from Monday to Friday using clinic list from appointment jacket
  2. HRO collect and collate the numbers of patient that registered at emergency unit from Monday to Sunday using the registration book
  3. After the collection and collation of the weekly statistics, a copy of the statistics is submitted to Head of clinical service

Booking Appointment

PROCEDURE FOR BOOKING APPOINTMENT

  • A calendar date is usually prepared by the health records officer at the appointment unit before the arrival of the patient  from the consulting rooms
  • When a patient finish is through with the consultant he/she goes straight to the appointment unit to book the next visiting date
  • The health record officer will collect the prescription sheet and  the appointment card from the patient in order to give the the correct appointment date
  • The appointment date is documented in to the consultant jacket according to the days of their clinic.
  • After the booking of appointment and documentation, the patient will be directed to the pharmacy to buy their drugs
  • Sometimes, patients ask for transfer of treatment to oshodi annex and the records officer will book the patient under the consultant at oshodi according to the day the patient usually comes to the clinic. The consultant’s name will be changed from the system to oshodi consultant

Library

HEALTH RECORD LIBRARY

  1. This is also known as the custodian of patient case note where all patients case notes are filed and kept for easy access,
  2. The numbering system in health records library is straight numerical and also a centralized filing system is maintained
  3. Case notes are retrievable on a 24 hours/7 days arrangement to allow prompt treatment of out-patient attendance
  4. The filing, retrieval, sorting, arranging, clinic preparation and research are  done here to ensure strict confidentiality of unauthorised staff
  5. If any case note is  requested from the doctors or health professional a permission form for releasing of files must be obtained from the health records departmental secretary
  6. The form will be taken to health records library for retrieval and documentation inside the movement register which helps to reduce missing case note/misfiling. The moving register consists of the following: File no, Name of the patient, Sex, Destination, Consultant/HOD and Signature

 

Clinic Procedures

CLINIC PREPARATION PROCEDURE

  1. HRO will pick up the clinic list of a week interval from the appointment unit to the library to prepare weekly clinic case notes
  2. The patient’s name, registration number, destination, appointment date and signature are entered into the tracer cards which will indicate the movement of the case note.
  3. After the necessary documentation on the tracer card they are sorted and arranged numerically for easy filling
  4. While retrieving the case notes from the shelf, the tracer card will replace the position of the case note  immediately on the cabinets/shelves
  5. The tracer cards serve as a mirror to locate the case note movement and destination
  6. the retrieved case notes are sorted and arranged in alphabetical order  on the sorting table
  7. The case notes are moved to clinic area by the health records staff on night duty, arranged on the clinic table at the out-patient clinic for easy retrieval on clinic hours
  8. The appointment clinic list will be returned to out-patient clinic, which will serve as attendance to the patients that keep to their appointment  on their clinic days

PROCEDURE FOR ADMISSION AND DISCHARGE

 ADMISSION

  • Admission section is concerned with effective and efficient acceptance of the patient into the hospital or formal acceptance of patient into the hospital ward.
  • When a patient comes for admission the HRO will direct the patient to pay for consultation fee, and the appointment card will be submitted to the health record unit.
  • The patient’s case note is retrieved from the health record library and outpatient continuation sheet is added with the date, patient names registration number written on it, then the case note will be transferred to nurses unit for vital signs and from the nurses to the consulting room. This is where the doctor will endorse the admission to the ward
  • Admission unit is where the patient’s information about the admission is being documented before  patient can be moved to the words
  • The admission section originates the identification portion of the health record such as: Patient Name, Hospital number, Address, phone number, birth place, diagnosis, Consultant, sex, age, marital status, religion and Next of kin etc.

Discharge

* Proper discharge summary form must be written by the consultant or doctor in the ward.

* The Nurses must discharge the patient from their register which will be signed by Health Record Officer at the out-patient clinic.

* The health record officer will calculate the number of days the patient spent on hospital bed.

* The case file will be discharged to out-patient clinic from the admission and discharge register for follow up.

* Appointment will be given to patient for continuity of treatment.

* Finally the file will be taken to the Library for proper filing.

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