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Medical Records Reporting B17

The document summarizes the functions and processes of a medical records department. The department is responsible for safekeeping patient medical records, assisting healthcare providers in chart management, and ensuring confidentiality and security of records. Key processes include gathering charts from wards, sorting contents, scanning documents, ICD coding, indexing, color coding, and filing records. Medical records serve important clinical, legal, research, and administrative purposes for both patients and healthcare organizations.

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MAYBELINE OBAOB
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231 views16 pages

Medical Records Reporting B17

The document summarizes the functions and processes of a medical records department. The department is responsible for safekeeping patient medical records, assisting healthcare providers in chart management, and ensuring confidentiality and security of records. Key processes include gathering charts from wards, sorting contents, scanning documents, ICD coding, indexing, color coding, and filing records. Medical records serve important clinical, legal, research, and administrative purposes for both patients and healthcare organizations.

Uploaded by

MAYBELINE OBAOB
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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MEDICAL

RECORDS
DEPARTMENT

By: Group 2
BSN2-B17
Sept. 4-8, 2023
(2-10pm shift)
MEDICAL RECORDS DEPARTMENT
-The Medical Records Department is in charge of safekeeping and
safeguarding the medical records of all patients admitted at The
SWU med. The department assists the physicians and other
healthcare team members in the management and completion of
patient charts and makes sure that the medical records are
secured and are treated confidentially.
PHYSICAL FACILITIES
MEDICAL RECORDS STAFF

HEAD
STAFF
Haidee Ornopia
Richel Ugbaniel SCANNING STAFF

Margie Ortiz Jennilyn Amoguis


MEDICAL RECORD
• A clinical, scientific, administrative, and legal
document relating to patient care.
• It records sufficient data written in the sequence of
events to identify and locate the patient and justify the
diagnosis, the treatment given, and the final out
• To meet legal requirements & to avoid complications
medical record must fulfill the following criteria:

complete adequate acurate eligible


PURPOSE OF MEDICAL RECORDS

For the patient Medico Legal

medical record
-documentation of clinical - claiming insurance & tax
history benefit
-continuity of treatment -malpractices and negligence
-claiming insurances -evidence in court of law
-issue of Med. Certificate -certification of birth & death
Hospital -certification of mental status
-legal evidences
-certification of invalid
-quality, quantity, and adequacy pension
of treatment
For the doctor -medical audit
Research & Training
-future planning & decision
-medical review of making
-administration & management -education & training
treatment -clinical, epidemiological
-research & publication -medico legal protection
-disease surveillance research
-assist in legal proceedings -health system rsearch
-epidemiological studies
REPUBLIC ACT NO. 10173
An act protecting individual
personal information and
communications systems in the
government and the private
sector, creating for a purpose of
this purpose a national privacy
commission and for other
purposes.
CHART PROCESS
FLOW

01 GATHERING OF PATIENT
CHARTS FROM THE WARD

02 SORTS THE CONTENT OF THE PATIENTS CHART


IN PREPARATION FOR THE SCANNING PROCESS

03 DIGITALIZATION PROCESS
/ SCANNING PROCESS
CHART PROCESS
FLOW

04 ICD 10 CODING - INTERNATIONAL


CLASSIFICATION OF DISEASES

05 INDEXING

• MASTER INDEX
• PATIENT INDEX
• PHYSICIAN INDEX
• DISEASE INDEX
• OPERATION INDEX
CHART PROCESS
FLOW

06 COLOR CODING

1 2 3 4 5

61 27 38 9 5 0

05 FILING
CHARTS ARRANGEMENT
I. FRONT PAGE
II. GATE PASS
III. DOCTORS ORDER FROM CLINIC
IV. MEDICAL ABSTRACT
V. DISCHARGE SUMMARY
VI. TEMP, PR, RR, CHART
VII. DOCTORS ORDER SHEET
VIII. LAB RESULTS AND IMAGES
IX. INTERNAL MEDICINE, OB/GYNE
PEDIA/NEWBORN, SURGERY RECORDS
CHARTS ARRANGEMENT
IX. OB PATIENT:

• CESAREAN SECTION- OPERATIVE RECORD


-ANESTHESIA RECORD
-ANESTHESIA PRE-OPERATIVE EVALUATION NOTES
-PRE-OPERATIVE CARE CHECKLIST
-RECOVERY ROOM/ POST-ANESTHESIA CARE RECORD AND OTHER
RECORD

• NORMAL DELIVERY- OB RECORD


CHARTS ARRANGEMENT

X. HISTORY: RESIDENT’ HISTORY


-PGI’S HISTORY
-CLERK’S HISTORY
XI.PROGRESS NOTES
XII.PROBLEM LIST
XIII.LABORATORIES SUMMARY
XIV.DOCTOR’S ASSESMENT
CHARTS ARRANGEMENT

XV. DIALYSIS FLOW CHART(FOR DIALYSIS PATIENT)


XVI. BLOOD GLUCOSE SHEET
-MONITORING SHEET
-FLUID INTAKE AND OUT MONITORING RECORD
-MEDICATION ADMINISTRATION RECORD
XVII. NURSES NOTES
XVIII. GUARANTOR SHEET
XIX. DISCHARGE INSTRUCTION SHEET
CHARTS ARRANGEMENT

XX. ATTESTATION
XXI. RELEASE AND ASSUMPTION OF RISK
XXII. PATIENT TRANSFORM FORM
XXIII. AMBULANCE TRANSPOSRT RECORD
XXIV. DNR RECORD
XXV. BREAST FEEDING FORM
XXVI. KARDEX
XXVII. EMERGENCY ROOM
THANKYOU!

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