Medical Records

Prepared By
Assist.Prof.Dr.Awatef Hassan kassem
Assist.Prof.Dr. Gamal Helmy
Mansoura University

Second Year
2018-2019
 Acknowledgment
This two-year curriculum was developed through a participatory and collaborative approach
between the Academic faculty staff affiliated to Egyptian Universities as Alexandria University, Ain
Shams University, Cairo University , Mansoura University, Al-Azhar University, Tanta University, Beni
Souef University , Port Said University, Suez Canal University and MTI University and the Ministry of
Health and Population(General Directorate of Technical Health Education (THE). The design of this
course draws on rich discussions through workshops. The outcome of the workshop was course
specification with Indented learning outcomes and the course contents, which served as a guide to
the initial design.

We would like to thank Prof.Sabah Al- Sharkawi the General Coordinator of General Directorate of
Technical Health Education, Dr. Azza Dosoky the Head of Central Administration of HR
Development, Dr. Seada Farghly the General Director of THE and all share persons working at
General Administration of the THE for their time and critical feedback during the development of
this course.

Special thanks to the Minister of Health and Population Dr. Hala Zayed and Former Minister of
Health Dr. Ahmed Emad Edin Rady for their decision to recognize and professionalize health
education by issuing a decree to develop and strengthen the technical health education curriculum
for pre-service training within the technical health institutes.

2
 Contents

Course Description .............................................................. vii

Chapter 1: History of Medical Records ....................................... 6

Chapter 2: What is Medical Records? ………………………………………………….10

Chapter 3: Types of Medical Records....................................... 17

Chapter 4: Components of Medical Records……………………………………….36

Chapter 5: Patient Identification and Registration ...................... 41

Chapter 6: Role of Admission office in Medical Records.……………………45

Chapter 7: Master Patient Index……………………………………………………………49

Chapter 8: Responsibility of medical record department………………….57

Chapter 9: Retention and Destruction of Medical Records………………..72

Chapter 10: Retrieval Data…………………………………………………………………..74

References and Recommended Readings……………………………………………...82

Appendixes……………………………………………………………………………………………..86
 Medical Records

‫توصيف مقرر دراسى‬

‫ بيانات المقرر‬-1

‫المستوى‬/ ‫الفرقة‬ Medical Record : ‫اسم المقرر‬ : ‫الرمز الكودى‬

Second Year: ‫السجالت الطبية‬

12 :- ‫عملى‬ ‫ ساعة نظرى‬24 : ‫عدد الوحدات الدراسية‬ : ‫التخصص‬

‫ساعة‬

This course aims to:- :‫ هدف المقرر‬-2

Provide students with knowledge and skills of
medical record which serves as a communication
link among care-givers. Also help students to
identify basic types and component of medical
record. Documentation in the medical record also
serves to protect the legal interests of the patient,
health care provider, and health care facility and
learn how use retrieval data of patient s to answer
certain query .

: ‫ المستهدف من تدريس المقرر‬-3

A.1 Explain history of medical record.
A.2 Define medical record concept. ‫ المعلومات‬.‫ا‬
A.3 Identify importance of medical record in health : ‫والمفاهيم‬
field.
A.4 Describe types of medical record.
A.5 Explain medical record as source of information.
A.6 Explain history of medical record.
A. describe components of medical record.
A.8 Discuss patient's identification.
A.9 Describe role of admission office.
A.11 Explain destruction and retention of medical
record.
A.11 Define retrieval and availability of data.
A.12Enumerate common error and problems occur
when writing documentation
B.1Illestrate characteristics of medical record
B.2Differentiate between different types of medical ‫ المهارات‬-‫ب‬
record.

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Medical Record Management

Medical Records

B.3Analyze role of admission office in formulating : ‫الذهنية‬

medical record.
B.4Determine consequences when enter master
patient index number incorrect.
B.5 Criticize medical record papers to. and identify
possible problem areas
B.6Evaluate reason for using Identification patient
band.
.

C.1Assess information available sources for patients ‫ المهارات‬-‫ج‬

and others health professional workers. ‫المهنية‬
:‫الخاصة بالمقرر‬
C.2Applying tool to assess the condition of medical
record.
C.3Prepare a diagram of the flow of medical/health
care data in your health care facility.
C.4Apply guide line to implementing standard patient
identification Band.
C.5 Plan regulation requires to keep medical records for
time periods
C.6 Apply to identify common problems in medical
record
C.7 Assess retrieval data of patients in different formts.

D.1Mange paper medical record effectively

D.2Estimate the adequacy of information available ‫ المهارات‬-‫د‬
source . : ‫العامة‬
D.3 Respect patient confidentiality and privacy of
information.
D.4 Keep communication skills among patient and
professional heath team.
D.4 Establish team working collaboration effectively
among patients and professional heath.

:‫ محتوى المقرر‬-4

2
 Medical Records

Lecture ‫ أساايب التعليم والتعلم‬-5

Group Discussion
Self-Learning

‫ أساليب التعليم والتعلم‬-6

------------------------------------------------------------- ‫للطالب ذوى القدرات‬
‫المحدودة‬

: ‫ تقويم الطالب‬-7

Continuous evaluation through participation in ‫ األساليب المستخدمة‬-‫أ‬

discussion -Quiz- Assignment- Written Final exam –
Oral exam –

Formative assessment: quizzes throughout the course ‫ التوقيت‬-‫ب‬

Continuous assessment: home assignments, self
learning tasks,
Summative assessment: Final exam Written (Essay,
MCQ)

‫ توزيع الدرجات‬-‫ج‬
: ‫ قائمة الكتب الدراسية والمراجع‬-8

‫ مذكرات‬-‫أ‬
Course Notes (paper and / or electronic) provided by
course coordinators and teaching staff

Medical Record Manual .A Guide ‫ كتب ملزمة‬-‫ب‬

For developing Countries.
World Health Organization
2002
Spooner,L.M &Pesaturo.k.A.Pdf . ‫ كتب مقترحة‬-‫ج‬
Medical Record .Chapter 2

‫ دوريات علمية‬-‫د‬
...... ‫أو نشرات‬
‫الخ‬

3
Medical Record Management

Medical Records

Course Description

Core Knowledge

By the end of this course, students should be able to:

 Provide students with knowledge and skills of medical record which serves
as a communication link among care-givers.
 Help students to identify basic types and component of medical record.
Documentation in the medical record
 Serve to protect the legal interests of the patient, health care provider,
and health care facility.
 Learn how use retrieval data of patient s to answer certain query

Core Skills

By the end of this course, students should be able to:

 Explain history of medical record.
 Define medical record concept.
 Identify importance of medical record in health field.
 Describe types of medical record.
 Explain medical record as source of information.
 Explain history of medical record.
 Describe components of medical record.
 Discuss patient's identification.
 Describe role of admission office.
 Explain destruction and retention of medical record.
 Define retrieval and availability of data.
 Describe common error and problems occur when writing documentation

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 Medical Records

Course Overview

Methods of Teaching/Training with

Number of Total Hours per Topic

Assignments
Field Work
Interactive

Research
ID Topics

Lecture

Class

Lab
1 Introduction to course 4 1

2 History of Medical Records 2 1

3 Meaning of Medical Records 2 1

4 Types of Medical Records 2 1 1

5 Component of Medical Records 2 1

6 Patient Identification 2 1
7 Role of Admission office in Medical
2 1
Record
8 Master Patient Index 2 1

9 Responsibility of medical record

2 1
department
10 Retention and Destruction of Medical
2 1
Records
11 Retrieval Data 2 1

36 24 4 8

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Medical Records

Historical Perspective of Medical Records?

Objectives

At the end of this chapter, the student should able to:-

a) Discuss History of medical Record.

b) Discuss medical record development.

c) Explain who medical record changed from paper to electronic record.

Historical Perspective:-

A patient medical record is required to record patient information and communicate

with other as health problem, diagnosis and treatment.

So historical development of the medical record parallels the development of

science in clinical care. The development of automated systems for dealing with
health care data parallels the need for data to comply with reimbursement
requirements. Early health care systems focused on inpatient-charge capture to
meet billing requirements in a fee-for-service environment. Contemporary systems
need to capture clinical information in a managed care environment focusing on
clinical outcomes in ambulatory care.

Health professionals. Patient medical records have been developed to record patient
information such

A) Early Hospital Focus:-

The Flexner report on medical education was the first formal statement made about
the function and contents of the medical record (Flexner, 1910). Mayo clinic had
begun to record the diagnoses for every admitted patient 3 years earlier (Melton,

6
 Medical Records

1996).

In advocating a scientific approach to medical education, the Flexner report also

encouraged physicians to keep a patient-oriented medical record. The contents of
medical records in hospitals became the object of scrutiny in the 1940s, when
hospital-accrediting bodies began to insist on the availability of accurate, well-
organized medical records as a condition for accreditation. Since then, these
organizations also have required that hospitals abstract certain information from the
medical record and submit that information to national data centers. Such discharge
abstracts contain (1) demographic information, (2) admission and discharge
diagnoses, (3) length of stay, and (4) major procedures performed. The national
centers produce statistical summaries of these case abstracts; an individual hospital
can then compare its own statistical profile with that of similar institutions.

In the late 1960s, computer-based hospital information systems (HISs) began to

emerge. These systems were intended primarily for communication. They collected
orders from nursing stations, routed the orders to various parts of the hospital, and
identified all chargeable services. They also gave clinicians electronic access to
results of laboratory tests and other diagnostic procedures. Although they contained
some clinical information (e.g., test results, drug orders), their major purpose was
to capture charges rather than to assist with clinical care. Many of the early HISs
stored and presented much of their information as text, which is difficult to analyze.
Moreover, these early systems rarely retained the content for long after a patient’s
discharge.

The introduction of the problem-oriented medical record (POMR) by Lawrence Weed

(1969) influenced medical thinking about both manual and automated medical
records. Weed was among the first to recognize the importance of an internal
structure of a medical record, whether stored on paper or in a computer. He
suggested that the primary organization of the medical record should be by the
medical problem; all diagnostic and therapeutic plans should be linked to a specific
problem.

Morris Collen (1972) was an early pioneer in the use of hospital-based systems to
store and present laboratory test results as part of preventive care. He also wrote an
extensive history of the field (Collen, 1995). Use of computers to screen for early
warning signs of illness was a basic tenet of HMOs. Other early university hospital-
based systems provided feedback to physicians that affected clinical decisions and
ultimately patient outcomes. The HELP system (Pryor, 1988) at LDS Hospital, the
CCC system at Beth Israel Deaconess Medical Center (Slack and Bleich, 1999), and
the Registries System (Tierney et al., 1993; McDonald et al., 1999) at Wishard

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Medical Record Management

Medical Records

Memorial Hospital continue to add more clinical data and decision-support

functionality.

B) Influence of Managed Care and the Integrated Delivery System

Until recently, the ambulatory care record has received less attention from the
commercial vendors than the hospital record because of differences in financing and
regulatory requirements. The status of ambulatory care records was reviewed in a
1982 report (Kuhn et al., 1984). Under the influence of managed care .The
reimbursement model has shifted from a fee-for-service model (payers pay providers
for all services the provider deemed necessary) toward a payment scheme

Where providers are paid a fixed fee for a specific service (payers pay a fixed
amount for services approved by the payer). Information management tools that
facilitate effective management of patients outside of the hospital setting help
providers manage patients’ disease more cost-effectively. The emphasis on
ambulatory care brought new attention to the ambulatory care record.

Thirty years ago, a single family physician provided almost all of an individual’s med-
ical care. Today, however, responsibility for ambulatory care is shifting to teams of
health care professionals in outpatient clinics. Ambulatory care records may contain
lengthy notes written by many different health care providers, large numbers of
laboratory test results, and a diverse set of other data elements, such as X-ray
examination and pathology reports and hospital discharge summaries. Accordingly,
the need for information tools in ambulatory practice has increased.

Medical Record development:-

Change 1:-

Increase workload led to introduction to several machines as typewriter ,

Dictaphones and computers in medical record department.

Change11:-

Maintenance medical records for all patients encounters such as admission,

outpatient, emergency room, etc. As opposed to earlier where only medical record
in house patient prepared and maintained.

Change111:-

Changing medical record from paper record to electronic records.

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 Medical Records

Computer replaces to keep, maintain, and store medical reports of patients.

Comparison period from 1968 to2000year:

1- The medical records used in 1968 were unstructured as the records did not
have a pre-formatted listing (Weed 2).Doctor lawrence weed is father of
problem –oriented medical record. Weed introduce the SOAP format as the
following:

 S Stands for subjective

 O mean objective

 A refer to assessment and

 P means planning.

2- Health professionals used paper records in 1990s to record patient information.

The medical records in 1990s were structured differently from medical records
used in 1960s. The medical record contains patient's medical history. The
temperature list mapped various variables against time in the x- axis (Berg and
Bowker).

3- Consequently, Wager, Lee and Glaser examine the transition from paper-based
medical records to electronic medical records. The authors provide a detailed
analysis of the electronic medical record. Medical records have evolved
considerably in terms of constraint according to Wager, Lee and Glaser.
Electronic medical records were developed to overcome the constraints
associated with paper medical records and ensure patient information is
organized effectively for easy comprehension and interpretation (Wager, Lee
and Glaser).

4- The electronic medical record is well structured, unlike paper-based medical

records. Hence, health professionals are supposed to fill the patient
information based on the pre-formatted listings. They are not required to
provide the information in a narrative form, but enter the information in a
precise manner based on the acceptable codes (Wager, Lee and Glaser).
Electronic medical records can be used by both physicians and nurses to record
patient information about his or her condition, treatment and diagnosis.

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Medical Record Management

Medical Records

What is Medical Records?

Objectives

At the end of this chapter the student should able to:-

a) Defined medical record.

b) Identify purposes of medical record.

c) Describe main uses of the medical record.

d) Explain medical record as source of information.

e) Illustrate characteristics of medical record.

Overview to Medical record:-

Medical record documentation is required to record pertinent facts, findings, and

observations about a veteran’s health history including past and present illnesses,
examinations, tests, treatments, and outcomes Also the medical record documents
the care of the patient and is an important element contributing to high quality
care. Medical record is a powerful tool that allows the treating physician to track the
patient’s medical history and identify problems or patterns that may help determine
the course of health care

Definition of medical record:-

Medical record defined as collection of information concerning a patient and his or

her health care that is created and maintained in the regular course.

Or systematic documentation of information about patient's past medical history and

treatment. Finally, medical record can be defined as an instance or event of medical

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 Medical Records

care.

Other terms are the same meaning of medical record are as followed:-

 Medical report

 Patient chart

 Health record

 Medical chart

Purposes of medical record:-

• Record information from the patients.

 Record caregivers findings and (planned) treatments.

 Communicate information to other (subsequent caregivers).

 Coordinate the activities of caregivers.

 Serve as a formal (legal/financial) record.

 Provide data for studies and research.

Help to provide information through report example:-

 Mortality and morbidity rate.

 Malnutrition index

 Infectious or communicable disease

 Population census Fertility rate

The main uses of the medical record are:

• To document the course of the patient's illness and treatment.

• To communicate between attending doctors and other health care

professionals providing care to the patient.

• For the continuing care of the patient.

• For research of specific diseases and treatment.

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 Medical Record Management

Medical Records

• The collection of health statistics.

Medical Record as Source of Information:-

Figure 2.1 Medical Records as Source of Information

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 Medical Records

Figure 2.2 Medical Records As Source of Information (cont.)

THE PATIENT’S MEDICAL RECORD

Sole source of health information
Direct patient
care Doctors
nurses, others

The Patient’s Government

Planning, Legal Health care
Medical record -
issues, agencies, Health
source of
protection insurance
information

Indirect care
House, keeping,
Business office,
etc.

Figure 2.3 The Patient's Medical Record

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Medical Record Management

Medical Records

Definition of Patient record: Repository of information about a single patient and

generated by health care professionals and this information from direct interaction
with a patient.

Characteristics of medical record:-

With documentation of medical records, particular emphasis must be placed on the

five factors that improve the quality and usefulness of charted information:-

1. Accuracy

2. Relevancy

3. Completeness

4. Timeliness

5. Confidentiality

1- Accuracy:

• Each individual medical record MUST be correct.

• Information in the medical record is relied upon for accuracy throughout the
veteran's lifetime.

• Inaccuracies (either commission or omission) lead to improper medical advice

being provided in error and may result in adverse healthcare outcomes or in
legal proceedings.

2- Relevance:-

• It is important that medical records contain only information relevant to the

patient’s healthcare.

• Inclusion of inappropriate and irrelevant information could result in damaging

legal action.

3- Completeness:-

• All documentation, including that from the clinics and hospital must be
included in medical record.

• Every document should be free from omissions.

• Documentation is sent to CPRS, which maintains a complete record for each

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 Medical Records

patient.

• The Joint Commission requires continuous review of medical record

documentation throughout the year.

4- Timeliness:-

There are specific time requirements for completion of the medical record:

• History and Physical –completed and signed within 24 hours of admission

• Post-Operative Note –written immediately following surgery

• Operative Note –dictated and signed within 24 hours of operation/procedure

• Medical Record –must be completed within 7 days of discharge or outpatient

visit

5- Confidentiality:-

• Medical records are confidential and protected by authority of the Privacy Act
of 1974.

• Do not leave patient-identifiable information on your computer screen or

exposed in your work area.

• Shred papers containing patient information that is not relevant to medical

documentation.

• Do not talk about patients or families in hallways, elevators, or in other public

places.

• Do not release medical record information without the patient’s consent.

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Medical Record Management

Medical Records

Figure 2.3 attributes of a Universal patient Record

16
 Types of Medical Records?

Objectives

At the end of this chapter the student should able to:-

a) Discuss types of medical record.

b) Advantage and disadvantage of different type.

Three are three types of medical record which are:-

a) Paper based medical record

b) Electronic medical record

c) Hybrid medical record

a) Paper based medical record:-

Information about a patient health treatment produced, stored and accessed in

paper format within a healthcare institution.

Paper-based record management systems have been the traditional and primary
method of storing business records and other documents until the later part of the
20th century. Usually, it includes the processes of maintaining and storing physical or
hard-copy documents.

Advantage:

1. Easy

2. Simple

3. Not cost

4. Not require training

5. Available

17
 6. No downtime

Disadvantage:-

1- Content:-

Data:-Missing, Never acquired, not recorded, lost, Illegible, Inaccurate, incomplete

2- Format

1- Data fragmented and not designed for dealing with multiple problems over
time.

2- Usually organized chronologically NOT problematically

3- Access, Availability and Retrieval

1- Records unavailable 10-30% of the time record movement

2- Simultaneous use impossible

4- Linkages and integration:- Discontinuity

b) Electronic medical record:-

An electronic medical record (EMR) is a digital version of the traditional paper-based

medical record for an individual. The EMR represents a medical record within a
single facility, such as a doctor's office or a clinic.

Electronic components of the Medical Record consist of patient information from

multiple Electronic Health Record source systems.

18
 Figure for EHR Concept Overview

Figure 3.1 Electronic Health Record- Concept Overview

Advantages of Electronic medical record:-

1. Providing accurate, up-to-date, and complete information about patients at

the point of care

2. Enabling quick access to patient records for more coordinated, efficient care

3. Securely sharing electronic information with patients and other clinicians

4. Helping providers more effectively diagnose patients, reduce medical errors,

and provide safer care

5. Improving patient and provider interaction and communication, as well as

health care convenience

6. Enabling safer, more reliable prescribing

7. Helping promote legible, complete documentation and accurate, streamlined

coding and billing

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 8. Enhancing privacy and security of patient data

9. Helping providers improve productivity and work-life balance

10. Enabling providers to improve efficiency and meet their business goals

11. Reducing costs through decreased paperwork, improved safety, reduced

duplication of testing, and improved health.

Disadvantages of electronic health record:-

There are also several disadvantages of electronic medical records, such as:

 Potential Privacy and Security Issues: As with just about every computer
network these days, EHR systems are vulnerable to hacking, which means
sensitive patient data could fall into the wrong hands.

 Inaccurate Information: Because of the instantaneous nature of electronic

health records, they must be updated immediately after each patient visit
— or whenever there is a change to the information. The failure to do so
could mean other healthcare providers will rely on inaccurate data when
determining appropriate treatment protocols.

 Frightening Patients Needlessly: Because an electronic health record

system enables patients to access their medical data, it can create a
situation where they misinterpret a file entry. This can cause undue alarm,
or even panic.

 Malpractice Liability Concerns: Issues associated several potential liability

with EHR implementation. For example, medical data could get lost or
destroyed during the transition from a paper-based to a computerized EHR
system, which could lead to treatment errors. Since doctors have greater
access to medical data via EHR, they can be held responsible if they do not
access all the information at their disposal.

Key components of an Electronic Health Record :-

1- Administrative System Components

Registration, admissions, discharge, and transfer (RADT) data are key

components of EHRs. These data include vital information for accurate patient
identification and assessment, including, but not necessarily limited to, name,
demographics, next of kin, employer information, chief complaint, patient
disposition, etc. The registration portion of an EHR contains a unique patient

20
identifier, usually consisting of a numeric or alphanumeric sequence that is
unidentifiable outside the organization or institution in which it serves. RADT
data allows an individual’s health information to be aggregated for use in
clinical analysis and research.

This unique patient identifier is the core of an EHR and links all clinical
observations, tests, procedures, complaints, evaluations, and diagnoses to the
patient. The identifier is sometimes referred to as the medical record number or
master patient index (MPI). Advances in automated information systems have
made it possible for organizations or institutions to use MPIs enterprise wide,
called enterprise-wide master patient indices.7

2- Laboratory System Components :-

Laboratory systems generally are standalone systems that are interfaced to

EHRs. Typically, there are laboratory information systems (LIS) that are used as
hubs to integrate orders, results from laboratory instruments, schedules, billing,
and other administrative information. Laboratory data is integrated entirely with
the EHR only infrequently. Even when the LIS is made by the same vendor as the
EHR, many machines and analyzers are used in the diagnostic laboratory process
that are not easily integrated within the EHR. For example, the Cerner LIS
interfaces with over 400 different laboratory instruments. Cerner, a major
vendor of both LIS and EHR systems, reported that 60 percent of its LIS
installations were standalone (not integrated with EHRs).8 Some EHRs are
implemented in a federated model, which allows the user to access the LIS from
a link within the EHR interface.

3- Radiology System Components:-

Radiology information systems (RIS) are used by radiology departments to tie

together patient radiology data (e.g., orders, interpretations, patient
identification information) and images. The typical RIS will include patient
tracking, scheduling, results reporting, and image tracking functions. RIS
systems are usually used in conjunction with picture archiving communications
systems (PACS), which manage digital radiography studies.9 The RIS market is
considered to be mature by industry analysts, with 80 percent market
penetration by 2001. This means that most AMCs have RIS systems.10 However;
it does not guarantee that the RIS systems are integrated with the EHRs.

21
 4- Pharmacy System Components:-

Pharmacies are highly automated in American Medical center and in other large
hospitals as well. But, again, these are islands of automation, such as pharmacy
robots for filling prescriptions or payer formularies, that typically are not
integrated with EHRs. Ondo, et al, report, in 2005, that “in inpatient settings,
an average of 31 percent of all [electronic] pharmacy orders … are re-entered in
a pharmacy system. While re-entry is not desirable, this is a 35 percent
improvement overall since 2003, and a 14 percent improvement from that
reported in 2004.”11

5- Computerized Physician Order Entry:-

Computerized physician order entry (CPOE) permits clinical providers to

electronically order laboratory, pharmacy, and radiology services. CPOE systems
offer a range of functionality, from pharmacy ordering capabilities alone to
more sophisticated systems such as complete ancillary service ordering, alerting,
customized order sets, and result reporting.

According to Klas Enterprises, a data provider for the hospital informatics

industry, only four percent of U.S. hospitals reported that they are using CPOE
systems.12 Ondo, et al, report that 113,000 physicians are using CPOE regularly
and 75,000 of these physicians are using CPOE in teaching hospitals.13 Forty
teaching hospitals reported in 2005 that 100 percent of their physicians were
using CPOE for placing orders, an increase from eight teaching hospitals in 2004.
The uptake among teaching hospitals may be happening because, Ondo reports,
“…teaching sites typically have employed—as opposed to privileged—physicians
as well as a significant number of residents and interns, it’s easier to gain
physician buy-in for the system.”

This slow dissemination rate may be partially due to clinician skepticism about
the value of CPOE and clinical decision support. There have been some major
CPOE successes and some notable failures. Handler, et al, in an overview article
concerning CPOE and clinical decision support systems, stated “that CPOE has
been well demonstrated to reduce medication-related errors. However, CPOE
and dosing calculators do not entirely eliminate error and may introduce new
types of error. It has been shown that weight-based drug dosing calculators are
faster for complex calculations and may be more accurate than hand
calculations. Many CPOE systems have dosing calculators. However, the net
effect of CPOE can be to slow clinicians.”14.

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 6- Clinical Documentation:
Electronic clinical documentation systems enhance the value of EHRs by
providing electronic capture of clinical notes; patient assessments; and clinical
reports, such as medication administration records (MAR). As with CPOE
components, successful implementation of a clinical documentation system must
coincide with a workflow redesign and buy-in from all the stakeholders in order
realize clinical benefits, which may be substantial—as much as 24 percent of a
nurse’s time can be saved.15

Examples of clinical documentation that can be automated include:

 Physician, nurse, and other clinician notes

 Flow sheets (vital signs, input and output, problem lists, MARs)

 Peri-operative notes

 Discharge summaries

 Transcription document management

 Medical records abstracts

 Advance directives or living wills

 Durable powers of attorney for healthcare decisions

 Consents (procedural)

 Medical record/chart tracking

 Releases of information (including authorizations)

 Staff credentialing/staff qualification and appointments documentation

 Chart deficiency tracking

 Utilization management

Medical devices can also be integrated into the flow of clinical information and
used to generate real time alerts as the patient’s status changes. Haugh reports
that “At Cedars-Sinai Medical Center, Los Angeles, for example, intravenous
medication pumps connected to the clinical information system provide
automatic dosage verification and documentation for medication management.

23
All of Cedars-Sinai’s physiologic monitoring systems are networked, and data on
patients is viewable on other clinical information systems in the hospital. From
his office, Michael Shabot, M.D., can monitor patient EKGs using a Web-based
viewing system created at Cedars-Sinai that incorporates a vendor product that
provides live waveforms from ICU and monitored bedsides.

Functional Components of an Electronic Health Record System

Electronic Health Record System (HER) system and illustrate functionality with
examples from systems currently in use. The five functional components are:-

a) Integrated view of patient data

b) Clinical decision support

c) Clinician order entry

d) Access to knowledge resources

e) Integrated communication and reporting support

a) Integrated view of patient data:-

Clearly, providing integrated access to all patient data is the primary purpose of
an EHR. Although this task may seem relatively simple, acquisition and
organization of these data are major challenges because of the complexity and
diversity of the data— ranging from simple numbers to graphs to images to
motion images—and the large number and organizationally distributed sources of
patient data such as clinical laboratories, radiology departments, free-standing
magnetic resonance imaging (MRI) centers, community pharmacies, home health
agencies. Furthermore, no unique national patient identifier exists in the United
States for linking patient data obtained from many sites.

Figure (1) shows an example of architecture to integrate data from multiple

source systems. The database interface depicted not only provides message-
handling capability but can also automatically translate codes from the source
system to the preferred codes of the receiving EHR. However, human labor is
needed to define the mappings that drive this automatic translation. The
interface engine provides a technical and translation buffer between systems
manufactured by different vendors. In this way, organizations can mix different
vendors’ products and still achieve the goal of integrated access to patient data
for the clinician.

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The idiosyncratic, local terminologies used to identify clinical variables and their
values in many source systems represent major barriers to integration of medical
record data by EHRs

Figure 3.2 Database Interface

A block diagram of multiple-source-data systems that contribute patient data

ultimately reside in a CPR. The database interface, commonly called an
interface engine, may perform a number of functions. It may simply be a router
of information to the central database. Alternatively, it may provide more
intelligent filtering, translating, and alerting functions. as it does at Columbia
presbyterian Medical Center. (Source: Courtesy of Columbia Presbyterian
Medical Center, New York.)

Clinicians need more than just integrated access to patient data; they also need
various views of these data (e.g., in chronologic order by report date) so
providers can easily find the newest individual results, in a flow sheet format to
highlight changes over time across multiple variables, and in focused views
tailored to specialties and settings An example of such a snapshot for general
medicine in an outpatient setting visit is shown in Figure 12.2. This summary
view of patient data shows the active patient problems, active medications,
medication allergies, health maintenance reminders, and other relevant
summary information. Such a view presents a current summary of patient con-
text that is updated automatically at every encounter; such updating is not
possible in a paper record.

Web browsers for finding and viewing information on the Internet also provide
health care workers with tools to view patient data from remote systems.

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Advanced security features are required to ensure the confidentiality of patient
data transmitted over the public Internet. Figure (2) shows an integrated view of
a flow sheet of the radiology impressions with the rows representing all kinds of
radiology examinations and the columns representing Web dates. Clicking on the
radiology image icon 8 brings up the radiology images, e.g., the quarter
resolution PA and lateral chest X-ray views in Figure 12.3b. An analogous

Figure 3.3

Quick access to summary information about a patient. The patient’s active

medical problems, current medications, and drug allergies are among the core
data that physicians must keep in mind when making any decision on patient
care. This one-page screen provides an instant display of these core clinical data
elements as well as reminders about required preventive care. (Source: Courtesy
of Epic Systems, Madison, WI.)

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 Figure 3.4 an Example (1)

Figure 3.5 An Example (2)

Web resources. (a) Web-browser flow sheet of radiology reports. The rows all
report one kind of study, the columns one date. Each cell shows the impression
part of the radiology report as a quick summary of the content of that report.

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The cells include two icons. Clicking on the report icon provides the full
radiology report. Clicking on the radiology image icon S provides the images. (b)
Shows the chest X-ray images on radiology images obtained by clicking on the
“bone” icon. What shows by default is a quarter-sized view of both the PA and
lateral chest view X-ray. By clicking on various options, users can obtain up to
the full (2,000 x 2,300) resolution and window and level the images over the 12
bits of a radiographic image, using a control provided by Medical Informatics
Engineering (MIE), Fort Wayne Indiana. (Source: Courtesy of Registries Institute,
Indianapolis, IN.)

b) Clinical Decision Support

Decision support is thought to be most effective when provided at the point of

care, while the physician is formulating his or her assessment of the patient’s
condition and is making ordering decisions. The most successful decision-support
intervention makes complying with the suggested action easy (e.g., simply
hitting the “Enter key” or clicking “Accept” with the mouse), while still allowing
the physician to control the final decision. Providing access to a brief rationale
with the recommendation may increase acceptance of reminders and at the
same time educate the care provider.

Figure 12.4 shows the suggestions of a software module in a large HIS. The
patient diagnosis uses sophisticated treatment protocols that consider a wide
spectrum of clinical information to recommend antibiotic choice, dose, and
duration of treatment. Clinicians can view the basis for the recommendations
and the logic used. A notable part of this program is its solicitation of feedback
when the clinician decides not to follow the recommendations. This feedback is
used to improve the clinical protocol and the software program. Providing online
advice on antimicrobial selection has resulted in

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 Figure 3.6 The Adult Antibiotic Assistant& Order Program

Figure 12.4. Example of the main screen from the Intermountain Health Care
Antibiotic Assistant program. The program displays evidence of an infection-
relevant patient data (e.g., kidney function, temperature), and
recommendations for antibiotics based on the culture results. (Source: Courtesy
of R. Scott Evans, Stanley L. Pestotnik, David C. Classen, and John P. Burke, LDS
Hospital, Salt Lake City, UT.)

Significantly improved clinical and financial outcomes for patients whose

infectious diseases were managed through the use of the program

Reminders and alerts can be raised during outpatient encounters as well. Indeed
the outpatient setting is where the most formal reminder studies have been
performed (Garg et al., 2005). Figure 12.5 shows how alerts and reminders are
included on a preprinted encounter form for use during an outpatient visit. The
system searches for applicable decision-support rules and prints relevant
reminders on the encounter form during batch printing the night before the
scheduled visit. Figure 12.6 shows computer-based suggestions regarding health
maintenance topics from the Veterans Administration EHRS. These suggestions
were derived from rules that examine the patient’s problems

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 Figure 3.7 old medical example

This figure shows :Pediatric encounter form. The questions on these forms vary
by age. Reminders for routine immunizations appear at the bottom. (Source:
Courtesy of Registries Institute, Indianapolis, IN.) Administration computer-
based patient record system (CPRS)—released as VISTA open source system (web
reference accessed sep 17, 2005 http://www.vistasoftware.org/).

c) Clinician order entry:-

If the ultimate goal of an EHR system is to help clinicians make informed

decisions, then the system should present relevant information at the time of
order entry. Several systems have the capability of providing decision support
during the order-entry process.

For example, a clinical team in the medical intensive care unit (ICU) at
Vanderbilt University Hospital can use an electronic chart rack to view active
orders and enter new orders. The WIZ Order screen integrates information about
a patient’s active orders, clinical alerts based on current data from the
electronic patient record, and abstracts of relevant articles from the literature.
Clinical alerts attached to a laboratory test result can also include suggestions
for appropriate actions
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Once a physician order-entry system is adopted into the practice culture, simply
changing the default drug or dosing based on the latest scientific evidence can
significantly change the physician’s ordering behavior. Clinical quality and
financial costs can be changed virtually overnight.

d) Access to Knowledge Resources:-

Most queries of knowledge resources, whether they are satisfied by consulting

another human colleague or by searching through reference materials or the
literature, are conducted in the context of a specific patient (Covell et al.,
1985). Consequently, the most effective time to provide access to knowledge
resources is at the time decisions or orders are being contemplated by the
clinician. Today a rich selection of knowledge sources ranging from the National
Library of Medicine’s free literature search site, PubMed to full-text resources
such as OVID and online references such as Up-To-Date are available for perusal.
Consequently, it is relatively easy for physicians to get medical knowledge while
reviewing results or writing notes or orders online. However, active presentation
of literature relevant to a particular clinical situation, such as an “Info button”
would increase the chance that the knowledge will influence clinicians’
decisions

e) Integrated communication and reporting support

As the care function becomes increasingly distributed among multidisciplinary

health care professionals, the effectiveness and efficiency of communication
among the team members affect the overall coordination and timeliness of care
provided. Most messages are associated with a specific patient. Thus,
communication tools should be integrated with the EHR system such that
messages (including system messages or laboratory test results) are
electronically attached to a patient’s record, i.e., the patient’s record should
be available at the touch of a button. Geographic separation of team members
creates the demand for networked communication that reaches all sites where
providers make decisions on patient care. These sites include the providers’
offices, the hospital, the emergency room, and the home. Connectivity to the
patient’s home will provide an important vehicle for monitoring health (e.g.,
home blood-glucose monitoring, health status indicators) and for enabling
routine communication. Communication also can be “pushed” to the user via e-
mail and or pager service ort.

Ways in Which an Electronic Health Record Differs from a Paper-Based

Record:-

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In contrast to a traditional patient record, whose functionality is tethered by the
static nature of paper—a single copy of the data stored in a single format for
data entry and retrieval—an EHR is flexible and adaptable. Data may be entered
in a format that simplifies the input process (which includes electronic
interfaces to other computers where patient data are stored) and displayed in
different formats suitable for their interpretation. Further, the EHR can
integrate multimedia information such as radiology images and
echocardiographic video loops that were never part of the traditional medical
record. Data can be used to guide care for a single patient or in aggregate form
to help administrators develop policies for a population. Hence, when
considering the functions of an EHR, we do not confine discussion to the uses of
a single, serial recording of provider-patient encounters. An EHR system extends
the usefulness of patient data by applying information-management tools to the
data.

Inaccessibility is a common drawback of paper records. In large organizations,

the traditional record may be unavailable to others for days while the clinician
finishes documentation of an encounter. For example, paper records are often
sequestered in a medical records department until the discharge summary is
completed and every document is signed. During this time, special permission
and extra effort are required to locate and retrieve the record. Individual
physicians often borrow records for their convenience, with the same effect.
With computer-stored records, all authorized personnel can access patient data
immediately as the need arises. Remote access to EHRs also is possible.

When the data are stored on a secure network, authorized clinicians with a need
to know can access them from the office, home, or emergency room, to make
timely informed decisions. At the same time that EHR systems make data more
available to authorized users for legitimate uses, they also provide the tools
needed to control and track access to patient records to enforce the privacy
policies required by the Health Insurance.

Documentation in an EHR can be more legible because it is recorded as printed

text rather than as handwriting, and it is better organized because structure is
imposed on input. The computer can even improve completeness and quality by
automatically applying validity and required field checks on data as they are
entered. For example, numerical results can be checked against reference
ranges. Typographical errors can be detected via spell checkers and restricted
input menus. Moreover, an interactive system can prompt the user for additional
information. In this case, the data repository not only stores data but also
enhances their completeness.

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Paper based Record VS Electronic Heath Record:-

HICH SYSTEM IMPROVES EFFICIENCY AND FINANCIAL PERFORMANCE?

 Simultaneous Access to Records: Operational efficiency is increased when

information can be simultaneously accessed by multiple users. Paper files
must be retrieved or tracked down and shared desk-to-desk in order for a
paper-based system to function.

 Lost or Misplaced Records: Which form of record keeping mitigates

problems from misplaced records or damaged documents? Does your staff
lose productivity searching for files that could easily be viewed on a cloud-
based system?

 Billing Accuracy: Which system strengthens the billing and collections

process? Which system provides the optimal record keeping, and ability to
produce reports?

 Sharing Records with Third Parties: Which form of record keeping presents
a more professional image of your practice? Is it easier to take time and
cost to copy and fax, or simply email information?

 Ease of Use: Accuracy is critical. Which form of record keeping provides

the most legible and organized information? Which system makes it easier
for a person to quickly go to the exact information they need?

WHICH SYSTEM IS MOST LIKELY TO IMPROVE PATIENT CARE?

 Intelligent Alerts: The best EMR systems contain a patient’s medications

and known allergies. This information supports the capability for automatic
interactions with newly prescribed pharmaceuticals and existing
medications.

 Emergency Response Capability: Information gathered by a primary care

provider and recorded in an EHR tells a clinician in the emergency
department about a patient’s life-threatening allergy, and emergency staff
can adjust care appropriately, even if the patient is unconscious.

 Organized Patient Care Details: An EMR / EHR provides a well-organized,

searchable system for all patient information. From physician care to
insurance billing, everything is organized and easy to find.

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  Identify and Correct Problems: An EMR / EHR can enable clinicians to
quickly identify and manage operational problems. With paper-based
records finding problems is generally left to chance, and correcting errors
can be a difficult and time-consuming process.

 Reduce Potential Dangers: An EMR / EHR can actively reveal potential

safety in a timely manner, thereby enabling clinicians to avoid detrimental
outcomes or severe consequences for patients.

WHICH SYSTEM REDUCES LIABILITIES AND RISKS YOUR PRACTICE MAY

ENCOUNTER?

 Compliance Chaos: It’s easier to make a change when you have control
and time on your side. What would happen within your practice if total
EMR compliance became law this year? Would the ensuing urgency be
something you could manage while smoothly running your front office?

 Liability Issues and HIPAA Violations: Which system would benefit you the
most if you faced a legal situation? Which system best supports your
adherence to evidence-based practices, informed consent and
reconstructing events during the time of care?

 Natural Disaster: What would happen to your practice in the event of a

tornado, hurricane, catastrophic fire or flood? Could you maintain
continuity of business? Do you have up-to-date copies of medical records
stored off-site?

 Criminal Sabotage: Criminal Sabotage: Which system protects your

practice’s ability to function in the event of criminal activity? What if a
burglar or disgruntled employee destroyed or stole records?

 Inability to Collect: In the event of a disaster, can your system enable you
to manage your billing and receivables? Can you reconstruct records in
order to maintain collections, meet timely filing, view current ledgers, and
reference active billing?

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Imagine Gaining More Office Space When Paper Records Become EMR/EHR

Figure 3.8

a) Hybrid medical record

Hybrid record consisting of both electronic and paper documentation.

Documentation that comprises the Medical Record may physically exist in
separate and multiple locations in both paper-based and electronic formats.

Advantages of Hybrid medical record:-

• Attractive option for hospitals to avoid huge costs of conversion of paper

medical records into digital record.

• Provide alternative to professionals to use both paper and electronic

medical record.

Disadvantages of Hybrid medical record:-

 It’s difficult to use both paper and electronic for professional health

 Cost needs extra staff to maintain both manual and electronic record.

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 Components of Medical Records
Objectives

At the end of this chapter the student should able to:-

a) Identify frame of medical record.

b) Discuss forms of medical record.

When a patient has been admitted to hospital, they become an inpatient and
the front sheet is the beginning of the inpatient medical record.

The physical medical record will eventually consist of the following:-

• A clip or fastener to hold the papers together;

• Dividers between each admission and outpatient notes; and

• A medical record folder.

• Medical record forms

A clip or fastener to hold the papers together:-

Forms should be held in the medical record either by a clip or fastener. Staples
should NOT be used as they tend to rust and additional forms cannot be easily
added. It is best to use plastic rather than metal clips. Metal clips can cut
fingers or rust. Dividers between each admission and outpatient notes;

Dividers between each admission and outpatient notes:-

It is good practice to separate each admission by a divider; the divider will be

slightly wider than the forms in the medical record and have a tab on which to
write “1st Admission”, “2ndIn addition Admission”, etc.

If combined with the inpatient notes, all outpatient notes can be stored behind
an outpatient divider.

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 The medical record has divided into four major sections:

• Administrative:-Which includes 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;

• Legal data:- Which including a signed consent for treatment by appointed

doctors and authorization for the release of information;

• Financial data: - Which relating to the payment of fees for medical

services and hospital accommodation.

Finally clinical data: - on the patient whether admitted to the hospital or

treated as an outpatient or an emergency patient. Sample of medical records
forms

A medical record folder:-

All medical record forms should be kept in a medical record folder. This should
be a manila folder and, if possible, stronger cardboard folders should be
purchased

The basic set of forms in the inpatient medical record includes:

The medical record is made up of a number of forms, which are all used for a
specific

Purpose. The basic set of forms in the inpatient medical record includes:

 Front sheet or identification and summary sheet, which covers

identification, final diagnoses, disease and operation codes, and the
attending doctor's signature.

 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;

 Correspondence and legal documents received about the patient, e.g.,

referral letter, Requests for information, etc.;

 Discharge summary, if required by the hospital/health authority;

 Admission notes, including the patient’s family medical history, the

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 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;

 Clinical progress notes recording the patient's daily treatment and reaction
to that Treatment written by the attending doctor and other health care
professionals;

 Nurses’ progress notes recording daily nursing care including temperature,

pulse And respiration charts, blood pressure charts etc.;

 Operation report if an operation or operations are performed;

 Other health care professional notes, e.g., physiotherapy, Social Workers,

etc.;

 Pathology reports including hematology, histology, microbiology, etc.;

 Other reports – X-ray, etc.;

 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; and special nursing forms for observation of
head injuries etc.

Order of Forms in the Medical Record

There should be a specified order in which all forms are placed within the
medical record after discharge/ death of the patient.

Description Examples of certain forms of medical record:-

1-Front Sheet:-

During the admission procedure, identification data are collected and recorded
on the

FRONT SHEET, which is the first form in the medical record. The information is
also Recorded d on an admission slip or notification. In the past, this task was
performed at the same time using carbon paper to save duplication and
subsequent errors. Today in many countries, the Front Sheet is generated via a
word processor and a second copy of the top section produced as the Admission
Slip/notification. If a word processor is not available, a written copy should be
made. The FRONT SHEET goes with the patient to the ward (with the old

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medical record, if any) and the admission slip/notification is sent to the Medical
Record Department to enable the preparation of the MASTER PATIENT INDEX
CARD. The business/accounts office where the patient’s accounts are prepared
may also require this information and the ADMISSION SLIP/NOTIFICATION may be
sent there first for processing before being sent to the Medical Record
Department.

2.Clinical examination sheet:-

A physical examination is an evaluation of the body and its functions using inspe
ction, palpation (feeling with the hands),
percussion (tapping with the fingers), and auscultation (listening). A complete h
ealth assessment also includes gatheringinformation about a person's medical his
tory and lifestyle, doing laboratory tests, and screening for disease. Recorded by
physician.

3.Treatment sheet:-

It includes the course of action and conducted by doctor who responsible to

patient's. The doctor responsible for plan of care. All order are signed and noted
date and time of this order can be verbal or telephone , All order responsibility
of doctor and should be signed.

4.Clinical progressive note:-

The part of a medical record where healthcare professionals record details to

document a patient's clinical status or achievements during the course of
a hospitalization or over the course of outpatient care. Reassessment data may
be recorded in the Progress Notes,. Progress notes are written in a variety of
formats and detail, depending on the clinical situation at hand and the
information the clinician wishes to record. Progress notes are written by
both physicians and nurses to document patient care on a regular interval during
a patient's hospitalization.

Progress notes serve as a record of events during a patient's care, allow

clinicians to compare past status to current status, serve to communicate
findings, opinions and plans between physicians and other members of the
medical care team, and allow retrospective review of case details for a variety
of interested parties. They are the repository of medical facts and clinical
thinking, and are intended to be a concise vehicle of communication about a
patient’s condition to those who access the health record.

The majority of the medical record consists of progress notes documenting the

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care delivered and the clinical events relevant to diagnosis and treatment for a
patient. They should be readable, easily understood, complete, accurate, and
concise. They must also be flexible enough to logically convey to others what
happened during an encounter.

5.Nurses note sheet:-

A nursing note is a medical note into a medical or health record made by a nurse
that can provide an accurate reflection of nursing assessments, changes in
patient conditions, care provided and relevant information to support the
clinical team to deliver excellent care.

Complete and accurate nursing notes are crucial to make good decisions for
patient care. Nursing notes should provide a clear and accurate picture of the
patient while under the care of the healthcare team. Federal, state, and
institutional regulations require that nursing notes follow broad guidelines to
determine if a nurse’s action was reasonable and prudent addition, to the type
of information found on the medical note page.

Nursing notes should follow these guidelines:

 Always include interventions initiated and the patient response when

documenting an acute abnormality found during assessment

 Always elaborate when documenting a body system abnormality with each

assessment

 Always include if an assessment was visual, audible, and/or tactile

 Reconcile mismatched objective and subjective assessment findings

 Document the patient’s baseline mental status

 Always assess the patient at the time of discharge or transfer.

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 Patient Identification & Registration

Objectives

At the end of this chapter the student should able to:-

a) Identify patient identification concept.

b) Explain patient registration

c) Important aspects of patient registration

d) Identify registration number in medical record

Patient Identification:-

The identifying information is an important part of a patient's health record. It

should include enough information to uniquely identify an individual patient.
Most facilities will ask to view and/or copy the patient’s driver’s license or
identification card in order to verify this data.

Patient misidentification is increasingly being recognized as a widespread

problem within healthcare organizations. Failure to correctly identify patients
constitutes a serious risk to patient safety. Correct patient identification starts
with the patient’s first contact with the service audit is the responsibility of all
staff involved in the admission process, clinical and administrative to ensure
correct details are obtained and recorded and that any inaccuracies or queries
are highlighted and dealt with.

It is essential that patients are registered on the Trust’s Patient Administration

System (PAS) and wherever possible checks must be made as to whether the
person is already registered PAS, as this will minimize the risk of duplicated
records being created.

The patient identification data that is collected during the patient registration
process is used to populate the Master Patient Index (MPI which will discuss
later).

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Patient number identification and Medical record number

The medical record begins with the patient’s first admission as an inpatient or
attendance as an outpatient (if a combined medical record) to the health care
facility.

This begins with the collection of identification information, which is recorded

on the FRONT SHEET or IDENTIFICATION AND SUMMARY SHEET. The name of the
first form in the medical record varies from hospital to hospital and country to
country.

The responsibility for correctly identifying a patient rests with the clerk who
interviews the patient in the admission office or outpatient department.

The data collected must be written clearly on the correct form.

Correct patient identification enables hospital staff: -

• Help to find a particular patient's medical record whenever they come to

the health care facility. Once a patient has been identified the next step
is to be able to identify their medical record. The collection of patient
identification data and the assignment of a medical record number or
verification of an existing medical record number should be the first step
in every admission procedure.

• The term used for this number varies from hospital to hospital and
country to country. It can be referred to as the hospital number,
patient identification number, unit record number or medical record
number. We will call it the MEDICAL RECORD NUMBER (MRN). The MRN
is a permanent identification number assigned in STRAIGHT
NUMERICAL
• SEQUENCE by the admission staff and is recorded on all medical record
forms relating to that particular patient.

• An important point is that THIS NUMBER IS THEN USED TO FILE THE

MEDICAL RECORD. Thus, it is important to make sure that the number is
correctly assigned and recorded on all forms in the patient's medical
record

Remember

• ONE PATIENT→ ONE MEDICAL RECORD NUMBER = ONE MEDICAL RECORD

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This section of the medical record should contain at least the following
information:

1) The full legal name of the patient, including the surname (or family
name), first name, middle name or initial, suffixes (e.g., Jr.) and prefixes
(e.g., Doctor). It is also important to collect the patient’s alias, previous
name, or maiden name, as the patient may have been seen at the facility
under another name.

2) Internal identification number or hospital registration number. This is the

number used to identify and file a health record, also called the patient’s
health record number. (This number is may be assigned at the patient’s
first inpatient admission or outpatient encounter at this facility, or a new
number is also assigned for each subsequent visit.)

3) Place and date of birth (MM/DD/YYYY or DD/MM/YYYY), gender, race,

ethnicity, marital status, address, phone numbers, and any unique
identifying number, such as a national identification number or social
security number.

4) Name, address and telephone number of nearest relative (next of kin) or

friend.

5) Name and address of attending doctor, and name and address of referring
doctor, if applicable.

6) Occupation, name and address of patient's employer.

7) Date and time of admission or encounter, and name of unit or clinic.

8) Details of health insurance and medico-legal information if appropriate.

The above information should be obtained from the patient, if possible, or

otherwise from the person accompanying the patient to the hospital or clinic.

B. PATIENT REGISTRATION:

The complete and accurate collection of patient identification information is an

important part of the patient registration process. For statistical purposes, a
method for counting all outpatient encounters and hospital admissions each day
is essential. There are a variety of methods in use, which are separate from the
allocation of new health record numbers

Important aspects of patient registration are:

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 1- When a patient presents at a hospital or clinic for the first time, they
should be registered as a new patient. However, to make sure that the
patient is, in fact, a new patient they should be asked if they have been to
the hospital or clinic previously. Even if they say no, the admission or
clinic staff should still check in the facility’s computerized patient
database, the manual master patient index or with the health record
department, depending upon the level of computerization at the facility.
This step is necessary to make sure that the patient does not already have
a health record number at that hospital or clinic; and to ensure that
duplicate records are not created.

2- If the patient does not have an entry in the MPI or a health record number,
the identifying information is collected and either entered into the
computerized database, or recorded on the front sheet of a new record.
The patient is registered and a patient identification number is assigned.
In most hospitals and health care centers, this registration number is used
as the patient’s health record number. In a manual system, an Admission,
or Patient Register is maintained at the point where the number is issued,
and should contain the following information:

Table 1: Patient Register's Information

Number Name Date Where issued Doctor/Clinic

Admission Mohamed
300 Mohamed Ali Ahamed 12.1.2001
office fathy

Admission Ahamed
301 Adel Elsyeed Ahamed 12.1.2001
office Hassan

Liala Ahamed Admission Mohamed

302 13.1.2001
AbdElrhaman office fathy

Admission Ahamed
304 Aaad Mahamod Ali 13. 1.2001
office Hassan

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 Role of Admission Office in Medical Records

Objectives

At the end of this chapter the student should able to:-

a) Define meaning of admission.

b) Explain when a decision admitted a patient to hospital.

c) Identify ways of patients admitted to hospital

d) Clarify process of admission of patient to hospital.

e) Enumerate contents of the Admission Register

f) Explain role of admission clerk officer

 Admission :

• Admission means permission given to a person to enter organization.

Or A patient accepted for inpatient service in a hospital.

 The decision to admit a patient to hospital is a clinical decision.

Patients may be admitted when at least one of the following criteria
apply:

• The person’s condition requires clinical management and/or facilities

not available in their usual residential environment;

• The person requires continuous observation in order to be assessed or

diagnosed;

• The person requires at least daily assessment of their medication needs;

• The person requires a procedure(s) that cannot be performed in a

stand-alone facility, such as a doctor’s room, without specialized
support facilities and/or expertise available (for example cardiac

45
 catheterization); or There is a legal requirement for admission, for
example under the Mental Health (Treatment and Care)

Ways of patients admitted to hospital through:-

a) Emergency

b) Outpatient clinic

c) Specialist outpatient clinic

d) General practice

Admission Process:-

 The admission of a patient to hospital is ordered by a doctor and carried

out by an admission clerk.

 At the time of admission, a patient may already have a medical record

number and a medical record.

 ALL patients admitted, whether admitted for the first time or the second,
third or fourth time, are listed in the daily admission list.

 The admission register is kept in the Admission Office and, as mentioned,

is a list of all admission patients.

 Admissions to the hospital/health care Centre in date order. In some

countries, the discharge date is also included in the admission register. It
is better to have one register that has all

 Admission and discharge details in the one place. In this case a separate
discharge register is NOT required

Contents of the Admission Register

 Family name and given name.

 Reason for admission (presenting disease/illness).

 Date of admission.

 Date of discharge.

 Discharge alive/dead.

46
  Other details may include doctor's name, sex, date of birth/age, ward,
etc…. Include date of discharge and alive/dead if admission and discharge
register are combined.

 A copy of the admission list is sent to the medical record department to

check that a Master Patient Index card has been made for all new patients.
This is why it is best that the Medical Record Department.

 A copy of this list is also sent to the Accounts Office and Inquiry Desk

Coming
Name of patient Address Phone &E-mail
Yes No

------------------------- ---------------------- --------------------------

------------------------- ---------------------- --------------------------
------------------------- ---------------------- --------------------------
------------------------- ---------------------- --------------------------
------------------------- ---------------------- --------------------------
------------------------- ---------------------- --------------------------
------------------------- ---------------------- --------------------------
------------------------- ---------------------- --------------------------
------------------------- ---------------------- --------------------------
Figure show Admission list sheet

The entire above are usually carried out in the Admission Office and ideally,
there should be a formal link between the Medical Record Department and the
admission office if they are separate. The admission clerk must be able to access
the information about a patient’s previous admission and this is done through
the master patient index, which is kept in the medical record department.

Role of Admission clerk officer:-

 Provides an excellent and professional customer service, giving assistance

to all internal and external customers of the department.

 Follows and maintains an efficient booking process for all patient

admissions which includes financial, privacy, transport and patient
contact elements.

 Notifies Bed Management/Afterhours Clinical Nurse Managers of any

Patients with special requirements e.g. Isolation for possibly infective
patient admissions.

47
 Notifies Admission Services Manager, Bed Management and Executive of
any pending VIP patient admissions.

 Performs courtesy calls prior to patient admissions to ensure all admission

details are correct and patients are fully informed of their financial
obligations to the hospital.

 Provides an efficient and courteous front desk reception/patient admission

role for all elective and acute patient admissions.

 Maintains the integrity of the hospital’s computer patient management

system using the PMI index and corrects any data entry errors.

 Completes all admission paperwork required for each patient at admission

with no omissions and within 24hrs for all acute admissions.

 Ensure that all patient records are accessed, utilized and returned in
accordance with the hospital policies and procedures.

 Provide a patient location report and access to the daily theatre list for
every consultant attending the department.

 Assist wards with ward secretary duties afterhours e.g. patient discharges
/ transfers.

 Produce specific patient related computer reports as required.

 Undertakes typing, photocopying, faxing and filing as directed

48
 Master Patient Index

Objectives

At the end of this chapter the student should able to:-

a) Identify meaning of master patient index

b) State importance of master patient index

c) List the items, which should be included in a master patient index

d) Develop and implement a master patient index (MPI)

e) Trace the flow of a patient's index card from admission to discharge

f) Use alphabetical or phonetic filing rules to correctly file cards in a manual

master patient index

g) State the types of supplies and equipment commonly used for maintenance
of a manual master patient index (MPI).

Master Patient Index (MPI):

Indexes are a must for any hospital, health clinic, or primary health care
facility. They serve as a guide to the location of an item. An index can be a
table, file, or catalogue, listing an item and furnishing information for easy
access to that item. Data base of all patients ever treat at a given health care
facility. MPI is an electronic archive system that holds the data of every patient
treats or registered at health care service. It may include data on physician,
other medical staff and facility employees.

The Master Patient Index (MPI) is a permanent listing, containing the names of
all patients who have ever been admitted to or treated in a hospital or clinic
(also called Patients' Index, Master Person Index, Patient’s Master Index, or
Master File). Because the Master Patient Index is the key to locating a patient's
health record, it is considered to be one of the most important tools

49
maintained.

The MPI card is prepared by the medical record staff responsible for the
admission procedure in the Medical Record Department and is the key to
locating the medical record. In manual systems, it is a card index.

Importance of MPI:

• Ensure that every patient is represented

• Only once and with constant demographic identification, within all systems
of hospital data .by keeping this data well organized, hospital can provide
more efficient and accurate care for their patients.

• MPI was used to avoid duplication at patient registration in order to

provide connection to one authentic record. MPI are often create by and
accessible from electronic health record(EHR) system

Element of MPI:

In the health record department, clinic or primary health care center. Since
health records are filed numerically in most healthcare facilities, the MPI is used
to identify a patient’s health record number and locate the record. Typically, a
manual MPI is maintained using individual index cards for each patient that are
filed alphabetically. In a manual MPI, each patient who is registered in the
facility has an index card in the MPI that is maintained in the health record
department.

The information contained in this index varies with the needs of the hospital or
clinic. Whether the MPI is computerized or manual will determine the amount of
data that will be maintained, based on space limitations. In a manual system,
only information of an identifying nature necessary for prompt location of a
particular health record should be recorded on the patient’s MPI card. A
computerized MPI will allow the facility to maintain additional information.
Typically, the MPI contains two basic types of data: demographic level and visit
level. The privacy necessary for maintaining confidential information should be
considered when thinking of recording diagnoses and procedures on a MPI card,
and should be avoided. The information recorded should include:

a) Demographic Level:

 Internal identification number – number assigned at the time of hospital

registration, also called the health record number. It is the number used to

50
 file the health records.

 Patient’s full name - family name, given name, middle name or initial, and
pertinent suffixes and prefixes

 Date of birth (MM/DD/YYYY or DD/MM/YYYY) - in cases where patients

have the same name, the age and date of birth provides additional
information for identifying and obtaining the correct health record

 Complete address – street, city, state, zip code/post code, country

 Gender

 Race/Ethnicity

 Other unique identifying information, which will assist the identification of

the patient, such as the mother's maiden name, national identification
number or social security number. (This information is limited by the
amount of space available, i.e., computerized database or index card.)

b) Visit Level :

The following additional information may also be listed on the patient's

master index card if there is a need and adequate storage available:

 Account number – the billing number used to identify admission or

encounter charges

 Admission and discharge dates - for inpatient hospitalizations

 Type of service – inpatient, emergency, outpatient surgery, etc.

 Encounter date or date of service – for outpatient visits

 Disposition – discharged, transferred, or died

 Admitting and/or attending physician's name

The following is an illustration of a MPI card used in a manual master patient

index. The information at the top is collected at the time of the first encounter
of the patient with the hospital or clinic. If the entries on the card must be
handwritten, a pre-printed card will help ensure that the required data
elements are recorded and made in a uniform place on the card.

51
 Table 1 Example of Patient Master Index

Last name First name Middle name Gender Age race Patient
number

Pace of birth Social Security number

Admission Discharge provider type

date date

2. Manual Master Patient Index

A. For inpatients, the procedure for a manual master patient index could be
as follows:

1. Each day the admission registration staff notifies the health record
department of all patients registered in the facility. This may be done by
sending copies of the admission slips for all patients admitted to hospital,
which are usually the carbon copies or computer printouts of the
registration forms or face sheets.

2. The MPI is checked to see if any of the patients whose names appear on
the admission slips have been previously admitted and if they have an
index card. If yes, these cards are pulled out and the current admission
information is recorded. The demographic information on the index card
must also be checked for any changes in name, address, etc.

3. If the patient has had no previous admission and therefore no card in the
MPI, a new index card is prepared.

4. In some hospitals the completed cards of inpatients are filed in a separate

file, called the "in-hospital" or “in-house” file, and remain there until the
patient is discharged.

5. At discharge, the MPI card is removed from the "in-hospital box" and the
52
 discharge date is recorded. If a death occurred the date may be recorded
in red. The patients' index cards are then filed into the MPI. Given the
importance of the integrity and accuracy of this index, many hospitals
have a second person check the filed card for accuracy.

B. Organization of the MPI :-

In the absence of a computerized MPI, special index cards or books or may be

used for the listing of patients' names, with index cards being the most
preferred.

The most popular and efficient method of maintaining the MPI is on index cards
arranged alphabetically in a vertical file with a separate card for each patient.
Using this method a single index card can be located readily in one search.

If using a book, it is divided into alphabetical sections. Names are listed under
the first letter of the surname in chronological order by date of admission. This
method is only feasible for a small facility, but retrieval becomes cumbersome
and increasingly difficult for large hospitals, or where the volume of patient
admissions or encounters is great, because a strict alphabetical order is
maintained. This method is NOT generally recommended for a MPI.

It is not recommended to maintain the master patient index by year of

admission or encounter. This is not a good method as patients often forget the
date of their last visit, or if they were ever admitted to a particular hospital at
all. Much time is lost searching through several sections of the index for the
appropriate index card. Nor is it recommended to separate the MPI by sex, that
is, to file the cards of male patients in one file and the cards of female patients
in another

C. Methods used for filing:-

1. Alphabetical - The MPI cards are arranged in the file like the words in a
dictionary, following letter by letter of the family name first, then by the
given name, and last by the middle name or initial.

• If there are two or more patients with the same family name, cards should
be filed alphabetically by the given name. If given names are the same,
the middle name or initial should be used to arrange the cards. If the
entire name is identical the cards are filed by date of birth, filing the
earliest birth date first (the card of the patient who was born first is filed
first).

53
 • If an initial is given for a patient's first or middle name, the rule is to "file
nothing before something" (Huffman, 1994). Thus, SMITH, P. would come
before SMITH, PETER.

• Last names beginning with a prefix or containing an apostrophe are filed in

strict alphabetical order, ignoring any spaces or apostrophes. For example,
the name O’Leary would be filed as Oleary, and the name Mac Dougal
would be filed as MacDougal.

• Compound or hyphenated names are filed letter by letter, as one word;

thus Ai-Min would be filed A-I-M-I-N.

2. Phonetic - in phonetic filing systems the patients' master index cards

are arranged in the file by the first letter of the surname, and then
according to sound rather than spelling. Thus all surnames that sound
alike, but are spelled differently, are filed together. For

Example:

SMITH P. LEA S. GREENE, JAMES EDGAR

SMYTH P. LEE S. GREEN, JAMES EDWARD

SMYTHE P. LEIGH S. GREENE, JAMES EDWIN

 While an alphabetical filing, system uses 26 letters the "Soundex" system

uses only six code numbers.

 Names, which sound alike, but are spelled differently are grouped together
in a phonetic patient index, rather than filed letter by letter as in an
alphabetical patient index.

 Grouping similar sounding names together lessens the chance of lost index
cards due to misspellings and index cards having misspelled names can be
more easily located. d.

General filing rules for a Master Patient Index :-

1. Rules for filing MPI cards must be very detailed. It is not easy to locate
medical records if you cannot locate the correct MPI card. Filing rules
should be posted near the patients' master index for easy reference.

2. Use of the MPI and filing of the cards should be by authorized personnel
only. Careful orientation of new employees to the proper filing procedures

54
 is necessary, as is periodic follow-up on the accuracy of these procedures.

3. The MPI should be a continuous file that is not divided into years.

4. A MPI card should be removed from the file only for updating or placing in
the in-hospital box.

5. Occasional auditing of the MPI is recommended to monitor filing accuracy.

This can be done by having the file clerk place a slightly higher card of a
different color behind each individual card at the time it is filed. A second
person, known as the auditor or checker, removes the audit card after
checking that each card has been correctly filed. It is useful to audit the
filing done by new personnel to ensure that they are applying the rules
correctly.

6. A patient whose name has changed since a previous admission will need a
new index card. The new index card should be cross-referenced to the
original index card. All information recorded on the original card should be
entered on the new card. The original card should be cross-referenced to
the new card.

3. Supplies and equipment for a manual Master Patient Index:-

Index cards, index guides and filing equipment are needed for maintaining a
manual MPI.

a. Index cards - 3 x 5 inch cards (7.5 x 12.5 cms) are generally used, but the
size may vary depending on the amount of information to be recorded.

Since the MPI is a permanent file, the card must be durable to withstand
much handling. Remember, however, that the heavier the card, the more
space required in the file.

b. Index guides - Index guides for an alphabetical or phonetic MPI file

facilitate the location of an individual patient's card. Being slightly larger
than the patient's card, the top of the guide with an initial letter of
common surname is extended above the other cards, thus serving as a
guide. Phonetic index guides will require, in addition to guides with initial
letters or surnames, sub guides indicating basic code numbers. The size
and activity of the index will determine the number of guides needed.
Sturdy construction of guides is also essential.

c. Filing equipment - Patients' index cards may be filed in cabinets suitable to

55
 the card's size. If 3 x 5 inch (7.5 x 12.5 cms) cards are used, they are
usually filed in vertical, eight-drawer, triple compartment file cabinets. A
power file is considered feasible when the MPI has more than 500,000
actively used cards. At the touch of a button, a power file delivers the
required section of the index to the front of the file for easy access.

4. Computerized Master Patient Index

It is also possible to maintain the MPI in a computer. At the time of admission to

a facility, the registration staff searches the computer database for a particular
patient. If the patient has been in hospital or attended a clinic previously, the
patient’s information is displayed on the computer screen. The registrar then
updates any demographic information that has changed since the previous
admission or visit. If the patient has not been to the hospital previously, the
registrar collects the patient demographic information and the system
automatically assigns a new registration, or medical record number, and stores
this information in its memory. At the time of the patient’s discharge, the date
of discharge is entered into the system, thereby completing the current MPI
entry.

Consequences of incorrect master patient index-

There are three problems occurs which are:-

1. Overlap occur when a person have more than one medical record number.

2. Overlay occur when two patient have the same number of medical record.

3. A duplication occur when one patient have two or three number of medical
record in the same organization

N.B:- When there are two center in the organization use the same data it call
Enterprise Master Patient Index (EMPI)

56
 Responsibility of Medical Record Department
Objectives

At the end of this chapter the student should able to:-

a) Discuss Responsibility of medical record department.

b) Describe main function of medical record department.

Medical record department:-

The medical records department (MRD) must be organized and managed upon
the concept that it exists for the benefit of the patients. The medical record
department benefits the patient by being responsible for the completeness,
accuracy and availability of the medical records at all times. Organizing the
work of the medical record department in order to attain the planned objectives
should be done on the basis of the departments functions. The functions of the
department are the processing of outpatient and inpatient records, retrieval,
record storage, disease and procedure wise coding & indexing. In a smaller
department which may have only a few workers, it is better for all the staff to
be familiar with all aspects of the medical record department, so that the
department functions smoothly.

57
 Figure 8.1

Support for Medical Record Department and Staff:-

Because of the vital nature of the work of the department, it is important to

obtain support from the hospital administration and medical staff. The hospital
administration, medical

And nursing staff, and allied health professionals should also be made aware of
the work of the Medical Record Department and problems that may arise in
relation to the inaccurate recording of patient care data. This can be achieved
by:

 The MRO liaising with clinical staff and hospital administration about the
content of medical records, and procedures required in the management
of medical record Services.

 Having adequate stationery (medical record forms, folders, and office

stationery) Available to enable basic medical record functions to be
carried out.

 Having sufficient trained staff to complete all basic medical record

procedures.

To maintain an effective medical record service, medical record officers also

need the support of a Medical Record Committee. pThey need to be able to

58
bring important issues relating to medical record services to the Committee for
discussion. In doing so, they also need to ensure that the issues are carefully
recorded and presented to the Committee in a clear and objective manner.

Nature of medical record department:-

Departmental layout: Proper layout of the medical record department adds to

its efficiency and attractiveness. The key consideration in layout is workflow
i.e.: the flow of record from desk to desk. Desks should be arranged so that, as
far as possible, records move in straight lines and only a short distance at a
time.

Departmental coloring: The proper use of color is another important

consideration in office design. Effective use of color not only gives a good and
bright appearance of an office, but also improves working conditions. White
color will have a favorable psychological effect; others a negative effect. White
color gives a lift; others can either hasten or depress mental action.

Departmental lighting: Lighting is another environmental factor, which cannot

be over looked. Light sources on the ceiling can usually provide enough light for
the entire office area at a prescribed level of illumination.

Location Requirement:-The medical record department is in constant

communication with the registration departments of the out-patient and in-
patient care units. Every day, many doctors visit the medical records
department for completion of medical records or for records reference. The
medical records department must be located in an area near the new and review
registration counter and admitting and discharge office.

Space requirement

Space allocation should be determined by the departmental services to be

provided, the equipment and computer systems to be used and the daily
workload to be handled. Although services vary somewhat from hospital to
hospital, services and tasks to be considered when allocating space include
record filing cabins, coding and indexing desk, medical records sorting and
arranging desk, outpatient registration area, and admitting and discharge office.

The medical record service requires adequate space, which is generally not
available and presents a universal problem. Therefore, the medical records
technician should review space requirements frequently to overcome the highly
common filing problems in medical records department.

59
The medical records technician should anticipate in advance the growth of MRD
and make arrangements for the future requirements and to procure the required
space.

Equipment requirement

Open-shelf filing units are the most commonly used storage system for medical
records. They are less expensive. Medical records assistant can file or retrieve
records faster. Most importantly open shelves are space savers, accommodates
more records in a given floor area. Open-shelf filing equipment may consist of 7
or 10 shelves with a height of 9 to 10 ½ feet depending upon the NO. of shelves
(Fig.3.2). 7 open shelves having 3 feet long and 1 feet width each with dividers
can house an average of 750 outpatient records in one compartment, thus
housing 5250 records in a single open-shelf filing unit. If a unit-numbering
system is used, adequate shelf space must be provided for growth of records as
a result of readmission and repeat clinic visits.

A review of records from the past several years is the best source of information
for working estimates of the amount of space required. One approach is to
tabulate the average number of sheets per medical record of repeat clinic visit
and discharged patient over two or three months. This can be achieved by
counting the sheets per current episode of care and the sheets for previous
episodes of inpatient or outpatient care. This tabulation indicates the size of an
average medical record for the hospital.

Figure 8.2

60
Record dividers between files

Record dividers should be placed throughout the files to speed up the retrieval
and filing process and finding of records. The number of dividers needed
depends upon the thickness of the majority of the medical records in the
shelves. For medical records of medium thickness, a divider for every hundred
and fifty records is adequate. When purchasing dividers, durability and quality
should be the primary concern. To determine the total number of dividers
needed, the following formula may be used:

Total number of dividers

Total number of records =
Number of records between dividers

If the total number of records is not known, an estimate may be made by

multiplying the filing inches by the average number of records per inch. Several
shelves of records should be counted to determine the average number of
records per inch. Storage and retention of medical records should be done in the
most efficient manner for retrieval of requested records in a health care
facility. The medical record file area may either be centralized or
decentralized.

Climbing devices

Open shelf filing unit is designed to reach the maximum height of medical
records filing room in order to save the space available. When medical records
are placed at more than the height of 5 feet or 6 feet, it may be difficult to
retrieve them. Hence, hospitals use various types of climbing devices to reach
the medical records kept at a height of up to 8 or 9 feet.

61
 Figure 8.3

An aluminum ladder with rubber bush at the bottom of the leg or a step type
ladder will be of greater use to the retriever to file or retrieve the records
easily. Aluminum ladder will be less in weight and easy to carry inside the
medical records room. The rubber bush avoids ladder from slipping down.

The step type steel ladder will be easy to climb exclusively for female (Fig.3.3).
Thus, climbing device will be much more helpful for the filing assistants to place
or to retrieve medical records much quickly avoiding unnecessary accidents.

62
Organizational chart of medical record department:-

Responsibility of medical record department

The Medical Record Department is a busy department and the work of medical
record clerks are highly demanding. Although staff are not directly involved in
patient care, the information recorded in the patient’s medical record is an
essential part of that care.

The Medical Record Department staff is, therefore, required to perform an

essential service within the hospital. Sometimes, the nature of this work is not
understood by the medical staff, hospital administrators and other hospital
personnel, and medical record clerks and medical record office is often feeling
isolated.

In addition, in many countries, funding is inadequate, making the effective

running of the medical record service difficult.

63
Functions of a Medical Record Department:-

The Medical Record Department staff, under the leadership of the medical
record office or medical record clerk in-charge, is responsible for the
maintenance of medical records service. Medical record office is also
responsible for the development and maintenance of policies and procedures
relating to the medical record services of the hospital.

Main Functions of medical record department:-

The main functions of medical records department are:-

Out-patient service:-

 Registration of new and revisit patients

 Guiding patient to units and specialties

 Coding of out-patient and in-patient medical records

 Collecting, processing, sorting and arranging of medical records

In-patient service:-

 Admitting patients

 Discharging patients

Out-patient service

The purpose of the out-patient service area is to register new and revisit
patients and direct them to the concerned units or specialties for consultation
and treatment.

1. New and revisit registration

This section functions throughout the week from Monday to Saturday. The
medical records assistant employed in the new registration area performs the
following function:

I. Procedure for New Registration

 Before registering the new patients the medical records assistant checks
for the sociological data form, outpatient records, and plastic pouch to
keep ID card, staplers and bell pin in the new registration counter.

64
  The medical records assistant checks the system and other tools to assure
they are working properly.

 The New Registration counter starts functioning in the morning.

 The sociological form filled up by the patient contains the patient’s name,
age, sex and relatives name, address of the patient with city, Patient’s
telephone number, mobile number and fax number.

 The filled up sociological data form is collected at the new registration

counter and checked for any correction, omissions and additions.

 The medical records assistant then enters the data in the system.

 The amount that may be due for the new registration is collected from the
patient.

 The currency notes are then checked in the fake note identifier machine
to confirm good notes.

 The medical record assistant checks with the patient for any referral
letters from outside doctors.

 The data is then printed in the outpatient main card.

 The identification card along with the receipt is given to the patient
bearing his medical records number.

 The patient is well informed about the likely duration of his consultation
and treatment with the doctor.

 The patient is then taken to the doctor along with his outpatient record
for consultation.

II. Procedure for Revisit Registration:-

 Patients visiting the hospital from the next day of their new registration
are subsequently called as revisit patients.

 The medical records assistant checks the system and other tools at the
counter to assure they are working properly.

 The revisit registration counter starts functioning in the morning.

65
  The revisit patient produces the identification card to the revisit
registration counter

 The medical records assistant then enters the medical record number in
the system to register the patient

 The money that is due for the revisit registration is collected from the
patient

 Tracer card is prepared for record retrieval by entering the date of

registration and medical records number

 The purpose of the tracer card is to help the retriever to trace the medical
records when it is not found in its place

 The tracer card is then taken by the medical records assistant to retrieve
the medical record.

 After retrieving the medical record by M.R. Number, the tracer card is
kept in place of the record.

 In case if the medical record is missing, the tracer card will help to find
out the location of the medical record.

2. Procedure for patient guides:-

 During the course of training in medical records, the medical record

trainees are assigned the role of the patient guides.

 The role of the patient guides is to guide the patients to the concerned
units from the new and revisit registration area .

 After registration, the new and revisit patients waiting in the lounge are
called through the public address system.

 After confirming the name and city of the patients called, the patient
guides will guide them to the concerned units and specialties.

3. Processing and filing of out-patient and in-patient medical records:-

The main functions of this area are:

 Collection of medical records from the out-patient clinics, specialty clinics

and discharge counter

66
  Checking for deficiencies in outpatient and inpatient records

 Coding of completed records in the system

 Sorting and serially arranging medical records

Collection and sorting out of disposed of records for filing:-

 The patient medical records are collected from the dispose box of each
out-patient clinics, specialty clinics and discharge counter by the patient
guides.

 The collected medical records are checked for deficiency in outpatient and
inpatient records. The medical records are checked for any
incompleteness, final diagnosis and, doctor’s signature.

 The collected medical records are sorted out according to units and
specialty for coding.

 Each medical record is coded according to the diagnosis and treatment

given.

 The coding is done in computer software designed for this purpose.

 After coding is done, all the medical records are arranged serially in
ascending order according to the medical records number(Fig.3.5).

 The medical records thus sorted out and arranged in ascending order are
placed in different medical record boxes for filing.

 Each medical record box is assigned with serial numbers in a continuous

sequence from 1 to 10000 and from 10001 to 20000 and so on.

 Each medical record box is allotted to a medical records assistant for filing
in relevant racks.

67
 Figure 8.4 Sorting and arranging Medical Records

In- patient service

The in-patient medical record services are classified into two sections. They are
Admission and Discharge counter and Accident and Emergency (casualty) service.

a) Admission counter

This admission counter functions 24 hours a day throughout the year. Staff are
posted in two shifts (morning and night) to perform the following functions.

 The patients are guided by the counselors to the admission counter after
counseling is done for the type of lens and room they prefer.

 The admission counter staff collects the money for the surgery and an
advance receipt is generated in the system.

 The receipt is signed by the staff and handed over to the patient.

 The inpatient record is prepared with patient name, age, sex and a rubber
stamp is stamped to write the type of lens and the amount paid by the
patient.

 Signature of the patient or his attendant is obtained in the operation

consent form.

 A color folder is attached to hold all the relevant medical record forms of
the patient. This folder denotes the speciality to which the patient is
admitted.

68
  Patient is then taken to the ward or theatre by the nursing staff along with
the case sheet for surgery.

In-patient coding assistant:

 After surgery is performed in the theatre, the medical records are sent to
the inpatient coding assistant.

 Each medical record is coded for the surgery performed in the theatre,
which automatically updates the charges for the surgery in the system.

 If patient is supported by monitor or any other additional procedure is

done during the course of the surgery, they are also charged and updated
in the system.

b) Discharge counter:-

 The case sheet is received from the ward through the nursing staff to the
discharge counter

 The final receipt is generated according to the number of days stay and for
the surgery performed

 The final receipt along with the discharge summary is handed over to the
patient

 The follow-up date of patient’s revisit is explained to the patient by the

discharge counter staff

Monthly duty rosters (schedules)

For effective utilization of personnel, a monthly duty roster must be prepared.

Every month the staff should be rotated from one section to another, with the
exception of the specially trained and supervisory staff. The supervisory and
specially trained should be rotated once every three to six months. The monthly
duty schedule should include name of the staff, his or her designation, place of
work, main duties and responsibilities, and the person to whom he or she should
report.

Departmental meetings:-

There should be weekly general meeting with all departmental staff to review
the day-to-day work carried out by the medical records department. Any new

69
innovations brought for the better improvement of the department can be
shared with the staff members. The problems and issues related to the staff and
the department can be discussed among the staff with the medical records
technician and proper solution should be evolved for the smooth functioning of
the department.

Others function of the medical records department:-

Training of new staff

Every new staff must be clearly informed in writing of hospital and departmental
policies, rules and procedures. A supervisor cannot hold a staff accountable for
his / her actions unless the staff has a clear understanding of his responsibilities.

Provide on Job Orientation and Training

All staff are entitled to thorough training for the job to which they are assigned.
An intensive training of three to four weeks should be given to all new
departmental staff before they are independently put to work.

The new staff member should first be introduced to all the personnel of the
department and later to the hospital’s important units, which maintain a close
relationship with the medical record department. In the initial training stage,
staff members should be placed under an experienced medical records
supervisor who in turn must impart “on job training” and instruct the new staff
in observing the correct policies and procedures.

Evaluate performance

Every staff wants to know where he stands with his/her supervisor.

Evaluations of performance should take place on a regular basis. Point out to the
staff his/her strengths and weakness.

The medical records technician should assist the staff in correcting poor
performance. The medical records technician and the supervisor should share in
a process of goal setting. This provides a staff with direction for development
and creates job satisfaction and improves his/her self-confidence. Verbally
scolding a staff in presence of others is not acceptable.

Supervisors should strive to maintain two way communications with staff, and
staffs should be encouraged to make suggestions. Supervisors in turn should be

70
sympathetic when listening to staff’s problems. Finally, a supervisor will at
times have to give priority to get a job done by the staff or to untie a problem.

71
 Retention and Destruction of Medical Record

Objectives
At the end of this chapter the student should able to:-

a. Define meaning of Retention and Destruction of medical record.

b. The Regulation requires keeping medical records.
c. Putting schedule to retention medical records.
d. Describe The hospital/government must consider when putting policy for
retention of medical record.
e. Explain process of destruction medical records.

Retention of medical record:-

Archiving and storing of medical record is the act of physically moving

inactive or other records to a storage location until the record retention
requirements are met or until the records are needed again.

Retention period – The period of time during which medical records must be
maintained by an organization because the records have administrative, fiscal,
legal, medical or other value. 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 should medical records has 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?

72
• 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.
Record retention schedule:- A schedule of standard and/or legally required
retention periods for each type of record, taking into account the
administrative, fiscal, legal, medical and historical value of those records.

The Regulation requires that physicians keep medical records for the following
time periods:
• Adult patients: records must be kept for 10 years from the date of the last
entry in the record.
• Patients who are children: records must be kept until 10years after the day on
which the patient reached or would have reached the age of 18 years.
• Physician ceases to practice medicine: records must be retained for the
periods outlined above unless:
1) Complete custody and control of the records has been transferred to another
person who is legally authorized to hold them.
2) Each patient has been notified that records will be destroyed two years after
the notification and that they may obtain the records or has them transferred
to another physician within the two years.

The hospital/government must consider when putting policy for retention of

medical record:-
 Readmission rate of inpatients.
• Volume of medical research undertaken by hospital staff.
• 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.

Destruction of records:- Any action that prevents the recovery of information

from the storage medium on which it was recorded. Method of destruction must
be appropriate to the medium on which it is stored.

Records that have satisfied their legal, fiscal, administrative and archival
requirements may be destroyed in accordance with retention as outlined in the
State Records Retention Schedule. No entire medical record shall be destroyed
on an individual basis. Final approval by the Public Records Administrator and
the State Archivist must be obtained before any records can be destroyed.
Medical records will be destroyed in a manner that does not allow for the
information to be retrievable, recognizable, reconstructed or practically read.
All destruction of medical records should be done in accordance with policy of
hospital.

73
a)Identify meaning of data.
b) Describe kind of data.
c) Discuss data management.
d) Examples of collecting data in medical record department.
e) Identify Retrieval data, data availability and data security,

Data meaning

Data, information, knowledge and wisdom are closely related concepts,

but each has its own role in relation to the other, and each term has its own
meaning. According to a common view, data is collected and analyzed; data
only becomes information suitable for making decisions once it has been
analyzed in some fashion. Knowledge is derived from extensive amounts of
experience dealing with information on a subject. For example, the height
of Mount Everest is generally considered data. The height can be recorded
precisely with an altimeter and entered into a database. This data may be
included in a book along with other data on Mount Everest to describe the
mountain in a manner useful for those who wish to make a decision about
the best method to climb it. Finally Data – a collection of facts (numbers,
words, measurements, observations, etc.) that has been translated into a
form that computers can process

74
Structure of data:-
a) Personal data: Personal data is anything that is specific to you. It covers your
demographics, your location, your email address and other identifying factors.
b) Transactional data: Transactional data is anything that requires an action to
collect

c) Web data: Web data is a collective term which refers to any type of data
you might pull from the internet, whether to study for research purposes or
otherwise.

Data management:- Includes all aspects of data planning, handling, analysis,

documentation and storage, and takes place during all stages of a study. The
objective is to create a reliable data base containing high quality data.

Data management is a too often neglected part of study design and includes:
• Planning the data needs of the study
• Data collection
• Data entry
• Data validation and checking
• Data manipulation
• Data files backup
• Data documentation
Each of these processes requires thought and time; each requires painstaking
attention to detail.

The main element of data management are database files.

Database files:-Contain text, numerical, images, and other data in machine

readable form. Such files should be viewed as part of database management
systems (DBMs) which allows for a broad range of data functions, including
data entry, checking, updating, documentation, and analysis.

Data Management Software: - Many DBMSs are available for personal

computers. Options include:
• Spreadsheet (e.g., Excel, SPSS datasheet)
• Commercial database program (e.g., Oracle, Access)
• Specialty data entry program (e.g., SPSS Data Entry Builder, EpiData)
Spreadsheet are to be avoided for all but the smallest data systems since
they are unreliable and easily corrupted (e.g., easy to type over, lose track
of records, duplicate data, miss-enter data, and so on. ).

75
-Data Entry and Validation3
Data processing errors: Are errors that occur after data have been
collected.2 Examples of data processing errors include:
• Transpositions (e.g., 19 becomes 91 during data entry)
• Copying errors (e.g., 0 (zero) becomes O during data entry)
• Coding errors (e.g., a racial group gets improperly coded because of
changes in the coding scheme)
• Routing errors (e.g., the interviewer asks the wrong question or asks
questions in the wrong order)
• Consistency errors (contradictory responses, such as the reporting of a
hysterectomy after the respondent has identified himself as a male)
• Range errors (responses outside of the range of plausible answers, such as a
reported age of 290)
To prevent such errors, you must identify the stage at which they occur and
correct the problem.

Methods to prevent data entry errors include:

• Manual checks during data collection (e.g., checks for completeness,
handwriting legibility)
• Range and consistency checking during data entry (e.g., preventing
impossible results, such as ages greater than 110)
• Double entry and validation following data entry
• Data analysis screening for outliers during data analysis EpiData provides a
range and consistency checking program and allows for double entry and
validation, as demonstrated in the accompanying lab.
Data Backup and Storage A well-known computing saying goes:-
There are two kinds of computer users. Those that have lost a major chunk
of data, and those who are going to lose a major chunk of data. Data loss can
be due to natural disasters, theft, human error, and computer failure.

You’ve worked to hard to collect and enter data, and you must now take care
of it. The most common loss of data among students is due to “loss” of data
somewhere on the computer.

The best way to prevent such loss is to know the physical location of you
data (local drive, removable media, network) and to use logical file names.

All too often students save files to unknown locations (usually the default set
up by the program) but never find saved files or have the saved files deleted
by the local area network as a part of routine data cleanup.
Importance of Data collection:
76
 Data collection differs from data mining in that it is a process by which data
is gathered and measured. All this must be done before high quality research
can begin and answers to lingering questions can be found. Data collection is
usually done with software, and there are many different data collection
procedures, strategies, and techniques. Most data collection is centered on
electronic data, and since this type of data collection encompasses so much
information, it usually crosses into the realm of big data.

So why is data collection important? It is through data collection that a

business or management has the quality information they need to make
informed decisions from further analysis, study, and research. Without data
collection, companies would stumble around in the dark using outdated
methods to make their decisions. Data collection instead allows them to stay
on top of trends, provide answers to problems, and analyze new insights to
great effect.

Examples of collecting data in medical record department:-

1-Statistics:-
Collecting data for no obvious reason is a waste of time and should be
avoided. The statistics collected in each hospital should be reviewed
regularly to make sure that they are still needed and are still used.

In addition to the daily census patient (also called the daily bed census),
statistical Information routinely collected on inpatients on a monthly and
annual basis include:
• Total no. of admissions - total in hospital and by service, e.g., medical,
surgical, etc.;
• Total no. of discharges (including deaths) – total in hospital and by
service;
• Total no. of deaths - total in hospital and by service;
• Total no. of deliveries (obstetric patients);
• Total no. of live births;
• Total no. of foetal deaths;
• Total no. of obstetric patients (discharged including deaths);

77
• Total no. of maternal deaths; and
• Total no. of patient days

This information is used to calculate patient-related rates and percentages.

Some rates and percentages collected include:
• Average daily census
• Average length of stay of discharged patients
• Percentage of occupancy of hospital beds
• Hospital perinatal death rate
• Hospital maternal death rate
• Foetal death rate; and
• Hospital death rate

2) Disease and procedure index:-

In some countries, data are also collected at hospital and State/Province
level for medical research. This is done by hospitals developing and
maintaining a Disease and Procedure Index.

• A disease index: Its lists diseases, conditions and injuries by the specific
code number for each disease, condition or injury according to the coding
system used in a hospital.
• A procedure index: lists operations and procedures performed in a hospital
by the specific code number for each operation or procedure. Both are
simple indexes usually maintained by the code number of the disease,
injury, or operation on a card system (except when computerized).

3) Computerization of the Disease and Procedure Index:-

Computerized disease and procedure index has been developed in many
hospitals to enhance the retrieval of medical information for research. As
with a manual system, it would contain information relating to diagnoses
and procedures, in coded form, to enable the retrieval of individual cases for

78
medical research. It could use the ATD system as the base records to which
disease and procedure codes are added following the completion of the
medical record at discharge or death of a patient.

• Such a system could also accommodate information relating to tests

performed during hospitalization for later review of the utilization of
hospital services.
• The program would process the "discharge" area of the ATD master file. In
such a system, relevant records in the discharge area are accessed. A specific
time limit, however, should be determined regarding transfer from the
discharge area to the disease/procedure index. Seven days is the suggested
minimum transfer time.

Coding
The main condition/principal diagnosis and procedure is coded by the MRO or
person given this responsibility. The diagnosis/procedure and code numbers
are entered into each individual patient’s admission record via a computer
terminal.

Retrieval:-
The system would be designed to enable the retrieval and report generation
of information on the types of diseases/ procedures treated within the
hospital. It should enable retrieval by disease/procedure and also
sex/age/doctor/associated diseases and hospital number.
Reports from a computerized Disease/Procedure Index could include:
• a list of all discharges not coded;
• a list of all patients with a particular code or range of codes;
• a list of last month's discharges by ICD code; and
• a list of discharges by notifiable disease code.

79
Retrieval Data:-
In databases, data retrieval is the process of identifying and extracting data
from a database, based on a query provided by the user or application.
It enables the fetching of data from a database in order to display it on a
monitor and/or use within an application.

Retrieval data means obtaining data from a database management system. In

this case it is consider that data is represented in a structured way and there
is no ambiguity in data.
In order retrieve the desired data the user present a set criteria by a query.
Then the database Management System (DBMS ) , software for managing
database. The retrieved data may be stored in file , printed or viewed on the
screen .Structured query language (SQL) is used to prepare the quires. SQ|L
is an American national standards institute .Standardized query language
developed specifically to write database quires. Each DBMS may have its own
language but most relational.

Availability of data:-

Data availability is the process of ensuring that data is available to end users
and applications when and where they need it. It defined the degree or
extent to which data is readily usable along with the necessary it and
management procedures, tools and technology required to enable , manage
and continue to make data available .
What is Data Security?

Data Security concerns the protection of data from accidental or intentional

but unauthorized modification, destruction or disclosure through the use of
physical security, administrative controls, logical controls, and other
safeguards to limit accessibility. Ways of securing your data include:

80
Data Encryption - converting the data into a code that cannot be easily read
without a key that unlocks it.
Data Masking – masking certain areas of data so personnel without the
required authorization cannot look at it.
Data Erasure – ensuring that no longer used data is completely removed and
cannot be recovered by unauthorized people.
Data Backup – creating copies of data so it can be recovered if the original
copy is lost.

81
 References

1. Medical Record Manual .A Guide For developing Countries. World Health

Organization 2002

2.Spooner,L.M &Pesaturo.k.A.Pdf . Medical Record .Chapter 2

1. https://www.medipro.com/electronic-medical-records-vs-paper-records/ https://2018
2. www.igi-global.com/dictionary/paper-based-patient-record/33400 .2018
3. www.recordnations.com/2016/04/developing-paper-record-management/2018
4. https://www.healthit.gov/faq/what-are-advantages-electronic-health-records,2018
5. NIH NCRR 6 MITRE April 2006 Electronic Health Records Overview Key
Components of Electronic Health Records
6. IFHIMA Education Module 2: Patient Identification, Registration & the Master
Patient Index (2012)
http://www.aurosiksha.org/ebook/medical_records_chapter3.html
7. Medical record management PDF

8. LHS Transfusion Fillable Informal Consent .PDF

9. https://en.wikipedia.org/wiki/Data

10.https://www.import.io/post/what-is-data-and-why-is-it-important/

11.https://www.edq.com/uk/glossary/data-security/

82
 Appendixes
Patient file

Personal data model

Name…………………………………………………………………………
Age: …………………………………………………………………………
Address: ………………………………………………………………

The national figure room number

Entry number

Final diagnosis
.. Doctor on the.......................................................................................................

Date of entry: / / History of gardening /

/

Department of
/

83
 Entry / Exit Form
-:patient. No. -: Gender -:DOB :Name
.................... .......................... ............................……………………………

-:code -:work administration … -: job -:religion -:Social status

......................................... ...…: ............
Phone. No. Gov.: City:………….. ............................................................-: Address
-: ....................... Village.:……….. ……….………………………...……………………
...................
Phone No. Address...................................-: relation -: -: ‫اسم من يمكن الرجوع إلية‬
-: ...................................................... ........................................ .....................................
................... ..
Prev. entry Police referral Accident : Referred from -:
Yes Yes No road  work  home Hall  clinic 
No other
level: room: Entry dep.: Treating / admitting doctor -:
............ ......................... .................................... ..............................................................................
.....
-: Provisional diagnosis
................................................................................................................................................
...........................................................................................................................................................................
Stay duration-: Exit Date‫ م‬02 / / : Entry date‫ م‬02 / / :
......................... Exit Time: ................................... Entry Time .................................... :
days
Admission ................................-: ........................-: Entry Employee:...............................-
FINAL DIAGNOSIS:-……………………………… ....................................................-:‫التشخيص النهائي‬
……………………………………………………….. .............................................................................
……………………………………………………….. ...........................................................................
ASSOCIATED DIAGNOSIS :-……………………….
………………………………………………………… ..............................................-:‫التشخيصات المصاحبة‬
………………………………………………………… .............................................................................
.............................................................................
OPERATIONS OR PROCEDURES :-………………
…………………………………………………………..
………………………………………………………….. ...............................................................-: ‫العمليات‬
............................................................................
COMPLICATIONS :- ...........................................................................
Infections ( Type , Site , Organism )
…………………………………………………………..
………………………………………………………….. -: ‫المضاعـفــات‬
ALLERGY ( Specify ) :-……………………………… .............................................................................
………………………………………………………… ............................................................................
......................................................-: ‫الحســـاســـــية‬

Exit status
death No improvement  improvement Cure 

: Exit to
Escape Home Exit upon request Another hospital Clinic

Exit Approval
Name: ……………………………..…………
Signature: ……………………………….………
Date:02 / /

84
 Lab Request Forum
name .: .................... : AGE .................SEX
Date of entry . . ..:File number department:
Diagnosis

Type of Request : Routine Emergency

) ‫( نوع الفحص‬ ) ‫( روتينى‬ ) ‫( عاجل‬

Signature of the treating DATE Req. Lab.

physician

85
 Radiological Request

name .: .................... : AGE ................. SEX...........................

Date of entry department,..............: .......File number.:

Diagnosis ……………………..…
Type of Request : Routine Emergency Portable

pregnancy?.--------- NO YES
---

Signature of the date Req. Rad.

treating physician

86
 Radiological report

NAME......: .................... : AGE ................. SEX..................................................................:

Department:……….. .File number:-................... Date of entry :…………………
Diagnosis ……………………..…
------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------ ----------- -----------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------
------------------------------------

Date-------------------------- Sign ----------------------------- Radiologist------------------------------

87
 (Physician Progress Notes )

date time Physician progress notes Sign

Patient name ................ : Section.................. : File number................................................

Room number ...............................................Doctor's name ..............

88
 (Physical Examination )
Patient name ............. ... : Section.................. : file number Age date
Height:…… Weight :.......….. Temperature :…... B.P :……...Pulse :…….… R.R :
Yes No Specify : ……………………………

Normal Abnormal
General Appearance   Mention
Skin   Mention
Head & Neck
Eyes   Mention
Ears   Mention
Nose   Mention
Mouth & Pharynx   Mention
Tongue & Teeth   Mention
Thyroid   Mention
L.N   Mention
Chest
Inspection   Mention
Palpation   Mention
Percussion   Mention
Auscultation   Mention
Heart
Inspection   Mention
Palpation   Mention
Percussion   Mention
Auscultation   Mention
Abdomen
Inspection   Mention
Palpation   Mention
Percussion   Mention
Auscultation   Mention
Neurological Findings
Cranial Nerves   Mention
Motor System   Mention
Sensory System   Mention
Reflexes   Mention
Gait   Mention
Musculoskeletal
Muscles & Bone   Mention
Joints   Mention
Extremities   Mention
Nutritional Status   Mention
Psychological   Mention
Status

Provisional diagnosis: ……………………………………………………………………...........................................

……………………………………………………………................................……………………………………….
Associated Risk Factors: ……………………………………………………................…………………………….
……………………………………………………………………..................................................................................
*Plan of Care : ………………………………………………………………………........................………………...
....name Doctor's ...............................................Sign date / /
……………………………….………………………………………………….............................................................

* Add in the care plan management is any of the following present:

1- Lost weight unintentionally 3- inability to eat > 5 Days
2- Looks poorly nourished 4- pregnant / Lactating with medical complications

89
 (Personal History)
Patient name ............. ... : Section.................. : file number a
Date…. Time……………..sex ................... working.
Marital History :  M S W D Children  Yes  No 
Special Habits :  Smoking  Coffee  Alcohol
Allergy :  Yes  No Comment : ……………………………………
Adverse drug reaction:  Yes  No Comment : …………………………………...
Complaints : ………………………………………………………………………………………………….…
………………………………………………………………………………………
Present History :
……………………………………………………………………….…………………………………………………
……………………………………………………………………………….
…………………………………………………………………………………………………………………………
………………………………………………………………………………
Past History (hospital admission &surgery) :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
Family History :
…………………………………………………………………………………….…………………
………………………………………………………………………………………………………
Psychosocial History : …………………………………………………………………………...

History by Systems Normal Abnormal

General   Mention
Pain   Mention
Respiratory System   Mention
Cardiovascular System   Mention

Gastrointestinal System   Mention

Genitourinary System   Mention
Endocrine System   Mention
Neurological System   Mention
Present medications ( before admission )
Drug Strength Dosage / frequency Duration of therapy

90
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