Health Care Records in health care service management

Health care records in health care services management

1. QUESTION 10 Describe health care records in details GROUP 10 HEALTH CARE RECORDS

2. Group participants NAME REGISTRATION NUMBER DAVID SSEMBUYA 2021-04-03410 DOROTHY ANIRWOTH 2021-04-03482 JOSHUA OGWANG OGWANG 2021-04-03540 HASANA ADAM ABUBAKAR 2021-04-03551 NGOBI BENARD 2021-04-03604 AARON BWAMIKI 2021-04-03649 FREDRICH HERBERT OCHEN 2021-04-03684 ALFRED ETOMET 2021-04-03786 KIIZA ROMEO 2018--08-03787 JUSTUS MUKIRANIA ASINJA 2021-04-04272

3. Definition A health care record is a written account of a person’s health history. It includes past and present illnesses, medications, treatments, investigations and review notes from visits to a health care provider It is an important compilation of facts about a patient’s life and health The medical record; “ must contain sufficient data to identify the patient, support the diagnosis or reason for attendance at the health care facility, justify the treatment and accurately document the results of that treatment” (Huffman, 1990)

4. T he main purpose of the medical record is; to record the facts about a patient’s health with emphasis on events affecting the patient during the current admission or attendance at a health care facility, and for continuing care of the patient when they require health care in the future . A patient’s medical record should provide accurate information on: Who the patient is and who provided the health care What, when, why and how services were provided The outcome of the care and treatment

5. The medical record has 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 including a signed consent for treatment by appointed doctors and authorization for the release of information; financial data relating to the payment of fees for medical services and hospital accommodation; and clinical data on the patient whether admitted to the hospital or treated as an outpatient or an emergency patient

6. Importance of health care records They are used to track events and transactions between patients and health care providers They offer information on diagnoses, procedures, investigations and other services offered to the patient Medical records help us measure and analyze trends in health care use, patient characteristics and quality of care Accurate medical records help in easy insurance claims or medi -claim settlements They act as legal documentary evidence in medico legal cases when there is necessity to be presented in courts of law

7. Importance of health care records cont’n Health care records avail proof that the physician provided right treatment to the patient in defense against medical negligence allegations They are used for ongoing record review or closed record review by health care providers These records are useful in compilation of various kinds of reports and statistical information such as Morbidity and Mortality rate, Malnutrition index, infectious disease reports, etc

8. Importance of health care records cont’n Medical records are required for accurate billing to the patients They are audited by government agencies to review the hospital certification and medical care providers’ credentials Help administrators to plan for the availability of future health care services Important for research purposes and quality management They protect the legal interests of the patient, health care personnel and the hospital Records help in informed decision making so as to meet the patients’ needs

9. Preparation of proper medical records cont’n A health care record begins with the patient’s first admission as an inpatient or attendance as an outpatient to the health care facility This begins with collection of identification information which is recorded on the front sheet or identification and summary sheet The responsibility for correctly identifying the patient rests with the clerk who interviews the patient in the admission office or outpatient department It should be made sure that the questions asked are clear and understandable by the person being interviewed.

10. In order to identify patients we need a unique patient characteristic. Some unique patient characteristics are: a national identification number, a health insurance number, date of birth, mother’s first name, father’s first name Where the patient lives and the patient’s age are not unique characteristics because they can change Once the patient is identified the next step is identifying their medical record. This is done by assigning a patient a particular Medical record number(MRN) It can be referred to as hospital number, patient identification number or unit record number

11. 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 the particular patient If the patient has been an inpatient previously the admission clerk must look for and find the old number in the master patient record A medical record number should be issued on the first attendance and retained for future admissions or attendance at the hospital or clinic The already assigned number should not be pre-assigned

12. Components of a medical record Medical record forms A clip or fastener to hold the papers together Dividers between each admission and outpatient notes Medical record folder

13. Medical record forms 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 records includes: Front sheet or identification and summary sheet; which covers identification, final diagnoses, disease and operation codes and attending doctor’s signature Consent for treatment signed by the patient at time of admission Correspondence and legal documents received about the patient, e.g., referral letter Discharge summary, if required by the hospital

14. Admission notes including patient’s family medical history, patient’s past medical history, presenting symptoms, results of physical examination, provisional diagnosis, proposed investigations and care Clinical progress notes recording patient’s daily treatment and reaction to the treatment Nurses’ progress notes recording daily nurse care including temperature, pulse and respiratory charts, etc Operation notes if an operation or operations are performed

15. pathology reports including hematology, histology, microbiology, among otherts other reports – X-ray, CT scan; 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 .

16. Types of medical records Depending on the way the patients are reviewed in a medical facility ; Inpatient medical records : when a patient is admitted into the hospital for treatment Outpatient medical records : when the patient is not hospitalized but receives treatment as they return to their residences

17. Based on the area of usage of the medical records; Patient’s clinical records : these contain information about patient’s illness, treatment given, progress to recovery, etc Individual staff records : they entile each staff’s sickness, the absences, carrier and developmental activities and a personal note 3. Ward records : these are for particular wards including round books, duty roasters, staff patient assignment etc. 4 . Administrative records with educational value : these include treatment registers, admission and discharge registers, job description, personal performances, etc.

18. Formats of medical records Different forms of medical records exist in health care systems. These include: Paper-based records : they constitute medical records which are stored on paper Electronic medical records : here medical records are stored electronically or digitally Hybrid medical records : medical records are stored partly on paper and partly on digitally

19. Formats of paper medical records Source oriented medical records(SOMR) Problem oriented medical records(POMR) Integrated medical records(IMR)

20. Source oriented medical records Medical information is grouped together based on the point of origin. For example the physician’s notes are filed together, the nursing records are kept together, etc. advantages Enables health care providers from various disciplines to quickly locate use forms specific to their role Facilitates efficient and effective health care service provision

21. Disadvantages Patient’s data is fragmented making it difficult to tract the exact health need with input from different groups of health professionals It encourages excessively detailed documentation making it difficult to separate relevant information from the irrelevant one

22. Problem oriented medical records In this medical record approach all the detailed information is focused on the most important health problems a patient is facing. It consists of a standard data base, a problem list, problem oriented plans and problem oriented progress notes. Here medical records are organized basing on the diagnoses For example: an elderly, lonely female who is admitted with a fractured hip and whose physical examination is normal except for the hip fracture and whose review of other systems is unremarkable; the physician could list the problems:1-fracture of hip 2-unremarkable review of systems

23. Advantages It is the most efficient in documenting chronic diseases Keeps records uniform Gives the document writer direction by focusing on the problem and solution Disadvantages Documentation using this methodology is time consuming There is repetition of medical information related to more than one problem

24. Integrated medical record (IMR) It integrates reports from all the available sources. It can be arranged in chronological order or reverse chronological order. Advantages It is less time consuming while filing a report. In this all instances of specific diagnosis and treatment are filed together so easily accessible .

25. Disadvantages It is difficult to compare information related to same subject and time consuming. Retrieval of the related information is hard and time consuming

26. Types of electronic health care records Electronic Medical Record (EMR) Electronic Health Record(EHR) Personal health record(PHR )

27. Electronic Medical Record (EMR) Electronic medical records (EMRs) are  digital versions of the paper charts  in clinician offices, clinics, and hospitals. EMRs are computerized medical information systems that collect, store and display patient information. They are means to create legible and organized recordings and also access clinical information about individual patients

28. . EMRs have been described as an important tool to reduce medical errors and improve information sharing among physician ( Kubben , 2019). EMRs are more valuable than paper records because they enable providers to track data over time, identify patients for preventive visits and screenings, monitor patients, and improve health care quality.

29. Electronic Health Record(EHR EHRs contain information from  all the clinicians involved in a patient’s care  and all authorized clinicians involved in a patient’s care can access the information to provide care to that patient. EHRs also share information with other health care providers, such as laboratories and specialists. EHRs follow patients – to the specialist, the hospital, the nursing home, or even across the country.

30. Personal health record(PHR ) Personal health records (PHRs) contain the same types of information as EHRs—diagnoses, medications, immunizations, family medical histories, and provider contact information—but are designed to be set up, accessed, and  managed by patients . Patients can use PHRs to maintain and manage their health information in a private, secure, and confidential environment.

31. Access Health care records should be available at the point of care or service delivery. Health care records are only accessible to: a) Health care personnel currently providing treatment to the patient. b) Staff involved in patient safety, the investigation of complaints, audit activities or research

32. c) Staff involved in urgent public health investigations for protecting public/population health, consistent with relevant legislation. d) Patient to whom the record relates, or their authorized agent. e) Other personnel / organisations in accordance with a court subpoena, valid search warrant, or other lawful order authorised by legislation

33. Retention and durability Health care records must be maintained in a retrievable and readable state for their minimum required retention period. Entries should not fade, be erased or deleted over time . . EMRs have been described as an important tool to reduce medical errors and improve information sharing among physician ( Kubben , 2019). Electronic records must be accessible over time, regardless of software or hardware changes, capable of being reproduced on paper where appropriate, and have regular adequate backups.

34. conclusion “In conclusion, health records are the lifeline of patient care. From Electronic to paper records, their types may vary, but their importance remains unwavering. For patients, it’s a personal health narrative; for hospitals, a road map to informed decisions; and for health professionals, a tool for precise care. Guided by strict guidelines, these records are safeguarded, with defined protocols for destruction, secure storage, controlled access, and clear ownership, ensuring a continuum of care and accountability in the health care landscape.”

35. references Canadian Health Information management Association Medical records manual: a guide for developing countries WHO 2006 Electronic Medical and health record http://health.kaiserpermanente.org/ . American Institute for Healthcare Management health service standards and recommended practices for healthcare records management QPSD-D-006-3 V3.0