KATSINA STATE COLLEGE OF HEALTH SCIENCES &

TECHNOLOGY, KATSINA
SCHOOL OF HEALTH TECHNOLOGY DAURA
DEPARTMENT OF HEALTH INFORMATION MANAGEMENT

LECTURE NOTE

ON

HEALTH INFORMATION MANAGEMENT I (HIT

HIM 100 LEVEL STUDENTS

BY

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ABDURRASHID SANI

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INTRODUCTION
HEALTH: according to (WHO), Health is a complete state of physically,
mentally and socially well-being of an individual not merely the absent of a
disease or infirmity.
INFORMATION: This can be defined as a raw fact, it can either be inform
of numbers, letters or symbols.
MANAGEMENT: This can be defined as getting things done through
efficient use of resources; man money, material and time.
HEALTH RECORD: This can be defined as a compilation of patient
information to assist in the clinical care of present and past illness.
In other words, can be defined as written document of all services
provided to the patient from the first day of arrival in to the hospital through
the progressive consultation until final discharge.
MEDICAL RECORD: It is an orderly written report of patient history,
physical, laboratory finding, treatment and hospital course. It contains
sufficient data to justify the diagnosed and also to describe the result of the
care rendered.
CLINICAL RECORD: It’s a basic medical decument compiled for every
patient who applied to a medical treatment and preventive centre. It contains
the information on family status, previous disease and present illness.
HEALTH INFORMATION MANAGEMENT: is a collection and analysis
of health care data to provide information for health care decisions, involving
patient care, institutional management, health care policies, planning and
research.
PRIMARY AIMS OF HEALTH RECORD
1. To initiate health record
2. To preserve health record
3. To retrieve health record

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 HISTORICAL DEVELOPMENT OF HEALTH RECORD
The history of health records runs parallel with the history of medicine.
Health record is equally as important as medicine as medication for effective
treatment.
Early records were kept in pictorial form. On the walls of stone, cave,
figures or object burnt clay, wall of tombs and temples as on long rolls of
Papyrics dated as far back as about 25,000BC
EGYPTIAN PERIOD:
It was the first period of historical time naturally that contribute by many
people, the first person named THOT, who was credited with having invented
wisdom and written. He was credited with authorship of HAEMATIC BIC
between 36 – 42 books, six were related to medicine, discussing on human
body diseases, instrument and appliances, drugs, diseases of the eyes and
gynecology ailment.
Another notable physician in that period was IMHOTEP who lived in
the pyramid ages about 3,000 – 2500BC. He was the first physician of anti-
royal medical adviser of Pharaoh and first worship as demigod as was
Aesculapius.
The third person named Edwin Smith: One of earliest student of
Egyptian language to discovered Edwin Smith papyrus, which recognized as
medical treatise. It was the oldest of six Egyptian papils dealing with surgical
subject. The Edwin Smith Papyrus contained twelve (12) rolls, each
measuring 15 fact by 13 inches. The rolls contained 48 cases of clinical
surgery and other medical cases.
Although, records were kept primitively they serve the same purpose
with present method of records keeping. This is the evidence that physicians
of old kept records about their patients.
GREEK PERIOD:
Saw the introduction of scientific spirit into the art of healing but merely
identify the various sources of there were to draw the information.
Aesculapius was equated with Imhotep as Greek god medicine who was
believed to have the cured of ill. During his treatment he would use herbs,
alcohol & serpent.
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Second person in this period was HIPOCRITE (a father of medicine) was
born about 460BC at cost lived during the period of intellectual awakening.
He was the first to cast superstition aside and practice medicine and scientific
spirit. He was the author of Hypocrite Oath, pledge by physician “ I swear by
Apollo the physician, by Ausculapius and by Hygeia by panacea, and by all
the gods and goddesses, making of them by with witnesses, that I will carry
out according to my ability and judgment, this Oath and this indenture. To
hold my teacher in this art equal to my own parents; to make him partner in
my livelihood; when he is in need of money to share mine with him; to
consider his family as my own sons, the sons of my teacher and pupils who
have taken physician’s Oath, but nobody else. What so ever in my practice or
not in my practice I shall see or hear in midst. The life of main which ought
not been nonsense abroad to this, I shall keep silent holding such thing
unfamiliar to be spoken.
Thus, the originated the privacy of all information giving to the physician by
the patient eventually the medical record persists was also considered in
privilege communication. In his written to describe observation acknowledge
as correct even today.
GRAECO – ROMAN PERIOD (150BC – 575AD)
In this period came Galen, born in Pargamea in Asia Minor in 131 A.D. he
regarded the body as a merely the vehicle of the soul, and this met with the
approval of the early Christians. He was very dogmatic, but he followed the
Hippocratic methods. It is surprising that at a time when the writing of books
was such more difficult than now, he wrote upwards of having hundred
books. Unfortunately, the majority of these were destroyed by a fire in his
house, and only eighty of them remain today, Galen was the first recognized
true functions of arteries and described the pain felt by the gall stone, the
symptoms used constantly for diagnostic purpose today.
The second contributor JEROME: he credited to be the first to
mentioned the word hospital from the Latin hope, host and guest.
BYZANTINE PERIOD
Although this period lasted over 1000 years not much was achieved in
medical history however, medical authors as Oribasius, Aetius of Amida,
Alexander of Tralles and Paul of Aegina were noted as copy the works of
Hippocrates, Galen and many other physicians.
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MUHAMMAD PERIOD
The use of Islam and near cost came in the 9 th century when Rhazez (865 –
925 AD) practiced in a hospital in Persia and Bagdad, he was the greatest
Muslim physician and clinician of the middle ages. He wrote many books,
half of which were on medical subjects. He was the first to distinguish
between small pox and measles, and first to carry out accurate study of
infectious diseases, he credited with using alcohol in wound cleaning and
first suture with twisted intestine of sheep.
Avicenna (980 – 1037) he combined the work of Hippocrates and
medical information gathered during his journey as an itinerary doctor. This
clearly shows that previous clinical notes have been used to improve on
present method of treatment.
MEDIEVAL PERIOD (A.D 1096 – 1438)
The first hospital ever to be founded in England was founded by a Courtier
who later turned Monk, named Rahere. After having gone to Rome on
pilgrimage. He is said to have seen a vision of ST. Bartholomew telling him
to go back and found a priory and hospital on the out skirts of London. He
found the hospital of ST. Bartholomew. In 1123, just outside the wall of
London, opposite sith field, then known as smooth field. Being outside the
walls of London city, its fortunately escaped being burned down in the great
fire of London. The hospital had meager founds, and was attached to the
prior. ST. Thomas’s hospital was founded a little later in 1215, and other
hospitals sprang up in later years.
RENAISSANCE (AD – 1453 – 1600
In the renaissance, Henry Vill closed down the monasteries and desecrated
the churches, but he gave ST. Bartholomew’s Royal charter, in which he laid
down that the hospital should keep records of the patients and certain other
details. This charter is still preserved – an enormous scroll with large seal on
it bearing Henry Vill’s signature. Thus ST. Bartholomew’s took the lead in
keeping medical records and was again in the lead when its established a
medical library in 1667.

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SEVENTEEN CENTURY
The writing of case record was established during this period and that
was the responsibility of the doctor to write his order as was the incharge
given William Starvey when he became physician to ST. Bartholomew
hospital on October 14, 1609. In 1661 Captain John Graunt, first study vital
statistics and published his observation on bills of mortality list of burial
(dead) marriage and pointed out two (2) facts that the urban death state is
higher than the rural, two though the male birth exceed the female, there are
approximately equal number of both sex in population due to greater
proportion of male death.
EIGHTEEN CENTURY
The period was establishment of Penncy Larvia hospital in Philadelphia
in 1752, Benjamin Frankling served as the secretary, the medical records of
the first 50 years well those in the registered which contains names, address,
disorders, date of admission and date of discharge and result of discharge. In
1873, the hospital began to keep history and patient index started, but was not
kept on cards until 1906, New York hospital opened in 1771 and started its
first register in 1793, many history dealing back to 1808 are similar to one
followed disease and condition where made in 1862 not until 1914 a disease
nomenclature was adopted.
NINETEEN CENTURY
On 3rd September 1821, the famous Massachustte general hospital in Baston
opened, it has distinction of having complete file of clinical record with all
cases catalogues, it was until 1873 that the need for a card catalogues became
a patient, the hospital seems to be the first to have medical record librarian by
name Mrs Grace Whitins Myre (1857 –1859) the first president of ARC of
North American and honourably.
President of AARMC the first record written in ink made at the hospital
are eligible to this day and discovery of 164 patients submitted to surgery and
487 patients that were operated upon proved the values of keeping medical
record for research and statistical purposes.

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20TH CENTURY
Teaching hospitals were keeping records after fashion period to 20 th century
the beginning of this era saw the serious consideration given to medical
records. In 1902 American Hospital Association for the first time discussed
medical record at consentation and highlights some problems which were
uniformity in method. No single types of person incharges of record and in
different on the part of all doctors was responsible for failure to obtained
good record. In 1905 Dr. Wilson pointed out the necessity for the complete
records for the progress of the patient. In the hospital both for reference and
for medico-legal need and emphasized the difficulties encountered in getting
the doctor to write records because they did not like details and clerical work.
After 60 years, the majority of the physicians still don’t like this phase
of their responsibility even through the acknowledge the necessity for
accurate medical records and accept their completion as parts of their routine
daily cure of the patient.
ESSENTIALS OF A GOOD HEALTH RECORD
A good Health Record should:-
1. Identify clearly the person about whom it is written.
2. It must be legible and able to understand by anyone likely to use it.
3. It must be accurate, concise and logical in its organization
4. It must be consistence in lay-out and in the size of papers used in it.
5. It must be able to identify the people contributing to the record so that
they can be asked for further information if necessary.
6. It must be promptly retrievable when required.
PURPOSES / USES OF HEALTH RECORD
 To the Patient:
i. For continuation of patient care
ii. For better treatment
iii. For detailed analysis of past and present state of health and
present illness in terms of diseases and prognosis (expectation).
iv. For review present illness and treatment and make judgment as to
course of treatment to follow.
 To the Hospital:
i. Justification of result of treatment is tied to accurate keeping of
health record.
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 ii. To evaluate the standard of health care rendered by the staff.
iii. It protects the hospital clinic for medico-legal purposes.
iv. For planning and equipment used.
 To the Doctor:
i. It refreshes the memory of the medical officer about the patient
past medical treatment.
ii. The knowledge gained in treating a patient is still useful for
patient with similar disease.
iii. For future references
iv. For review of certain disease treatment and response to treatment
v. For legal protection.
 To the Nation:
i. It provides health information for science, research and collection
of health statistical data.
ii. It is useful for all categories of medical/paramedical teaching
programmes.
iii. Present interpreted and utilize health statistical data for decision
making progress.
 To the Public:
i. Identification the physiological and sociological data contained in
the medical record such as Name L ups to distinguish the medical
record of one patient from another.
ii. Education is useful for the teaching or given instruction to
medical students and other professional.
iii. Medical research is useful in seeking out aetiological factors in a
diseases or compare progress and result of different forms of
treatment for patient with similar disease.
iv. Legal uses serve as written in court.
v. Insurance claims for damaging result from accidents.
GENERAL OBJECTIVES OF HEALTH RECORD
1. Organized and managed health record services in a health care delivery
system.
2. Organized and control health record personnel
3. Coordinate the collection, storage and retrieval of health information.
4. Present, interpreted and utilize health statistical data for decision
making progress.
5. Plan and conduct in-service training programmes for staff development
6. Control the movement of health records
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 7. Organized the preservation of health record.
8. Apply computer system to health care information.
9. Plan health record department and prepare budget for its running.
10. Participate in planning quality control and evaluation of health care
delivery.
11. Participate in conduct of medical research.
12. Advise on legal aspect of Health release of information from record etc.
13. Standardize Health records forms; design and control.
14. Plan and implement renewal concept in the Health record.
GENERAL IMPORTANT OF HEATH RECORD IN HEALTH CARE
DELIVERY
The important of health record to the development of health care
delivery will not be over emphasis, but mean while health record supply
services and health information system, so that health care institution can
provide adequate health care treatment to all individual.
Below are the lists of some importance of health records in the health care
delivery.
1. Control and develop and efficient patient identification system which
control the identification of all department or health care.
2. Classify disease and operation and prepare related indexes for retrieval
of medical information.
3. Collect and compiled hospital statistics for the evaluation of patient
care, administrative purpose planning of health care facilities and to
perform demographical surveys relating to health care delivery.
4. Appraising the quality of care in groups of patients selected for their
similar status and common interest.
5. It cost benefits analysis in which the quality of care is determined by
balance of benefit and specified patient or procedures over their cost.
6. Provision of information on result of care for use in modifying future,
health care performance.
7. To protect patient right of privacy by securing the information from
unauthorized person and ensure that full record is provided for all level
of health care delivery.

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 CLASSIFICATION OF HEALTH RECORDS
The classifications are broadly classified in to (2) main group as
follows:-
1. GENERAL TYPES
2. SPECIAL TYPES
GENERAL TYPE CONTAINS
1. Obstetric record
2. Newborn record
3. Ambulatory record
4. Admission summary sheets record
5. Clinical record
6. Nurses record
7. Anesthetic record e.t.c
SPECIAL TYPES CONTAINS
1. Laboratory record
2. Pharmacy record
3. X-Ray record
4. Family planning
5. Nutritional record
6. Physiotherapy record etc.
ORGANIZATION OF HEALTH RECORD
The organization of Health records are characterized by the following
1. Out-patient Department.
2. Accident and Emergency (casualty) services
3. In-patient (ward)
4. Medical Record Library.

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 FUNCTIONS OF OUT-PATIENT DEPARTMENT
Out-patient medical record services are classified in to two (2) sections.
 Central registration and appointment.
 Out-patient clinic.
The central out-patient appointment is a section function around the
clock throughout the year with three shifts in operation. The personnel
employed in the services perform the following functions.
 Control the Hospital numbers.
 Preparation of re-numbered folders.
 Registration of new cases.
 Maintenance of patient master index.
 Registration of follow up appointments cases.
 Supply of records to out-patient services
Out-patient clinic:-The medical record staff posted in this unit performs
the following functions:
 Collection of new and follow up registered patient record including x-
ray.
 Maintenance of account of patients treated in the clinic.
 Maintenance of account of patient referred to received from clinics,
investigations and admission.
 Collection and returns of record to the medical record library.
ACCIDENT AND EMERGENCY (CASUALTY) SERVICES
This unit function around the clock throughout the years with three (3) shifts
in operation: personal employed in this services perform the following
function:-
 Control the casualty number
 Preparation of pre-numbered folders.
 Registration of casualty cases
 Referral patient for follow up appointments, admission and so on
 Registration of medico-legal cases
 Collection and mounting of investment reports
 Collection of satistics and filing of A and E record

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IN-PATIENT SERVICES
The in-patient service are classified in two (2) section
i. Admission office
ii. Ward
Admission Office:- The office functions around the three (3) shifts in
operation throughout a year staff are posted to perform the following function
but in small hospitals, the work of the third shift can be transferred to
casualty section .
 Maintenance of waiting list of patient
 Registration of admission and discharges
 Maintenance of bed occupancy secure
 Serves patient property
 Medical record library
Ward:- The work relating to medical record in the ward will be performed by
the ward nurses, or ward clerks the following are function :-
 Registration of admission and discharges.
 Receipt and mounting of investigation report in the appropriate records
 Maintenance of account of bed position
 Scheduling of appointment for follow-up cases
 Preparation and submission of ward daily census reports.
MEDICAL RECORD LIBRARY
This is a library that (especially filing and tracing or retrieving unit) function
around the clock, the throughout the year, the staffs are posted (3) shifts in
operation and broadly perform the following functions.
 Processing of out-patient record
 Processing of in-patient record
 Collection of analysis of hospital statistics
 Filing and retrieving the record $ x-ray
 Performance of general medical record
 Receiving the case record from out-patient clinic and arrangement of these
record in prescribed order
 Receiving and monitoring the investigation report.
CONTENTS OF A COMPLETE PATIENT HEALTH RECORD
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 Identification which contains patients social data such as full name,
address, sex, ages, occupation e.t.c
 Referral or transfer statement
 Admission and diagnosis statement
 Admission evaluation /history sheet/ medical/and social history, physical
examination and treatment plan.
 Treatment sheet :-Treatment test, medical and diet
 Progress note:-shows the condition of patient from time to time.
 Report mount sheet:-special reports from laboratory, X-rays,
physiotherapy and other clinical reports which should be filed
chronologically.
 Final diagnosis:-The actual disease affected.
 Summary sheet:-usually completed by physician after discharged the
patient.
 Consent form:-This is a form before any operation and anaesthesia is
carried out on the patient.
ARRANGEMENT OF THE CONTENT OF CASE FOLDER/RECORD
The arrangement of health record for permanent policy in the hospital and
health care delivery are as follows
1. Discharge Summary Sheet
2. Referring Letter
3. Clinical History Sheet
4. Laboratory Report
5. Report Mount Sheet
6. X-ray report sheet
7. Continuation sheet or prescription sheets
8. Treatment sheet or prescription sheets
9. Consent form
10. Operation note
11. TPR (temperature, pulse and respiration chart)
12. Fluid chart

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 SCOPE OF HEALTH RECORD
 Documentation and Registration
 Out-patient record (Ambulatory record)
 In-patient record
 Appointment system
 Unit system of Health record
 Master alphabetical name index
 Tracing system
 Filing system
 Arrangement of the content of health record
 Accident and emergency record
 Confidentiality of health record
 Authorized discharged of the health record
 Release of health record
STRUCTURE AND FORMAT OF HEALTH INFORMATION
These include the following:
 Identification:-contains names, Address, Age, Sex tribe, Occupation etc.
 Medical History:-These are normally concern in the history of patient
illness pertaining his present medical history of disease family history to
determine the types of care given to patient.
 Progress note:-This similar as clinical sheet but not clinical identification
stem. Record observation during care in ecological order and justify the
final diagnosis. This includes subjective information, objective
information, assessment and plan.
 Discharge and summary:-The term contains essential information
regarding the patient illness, investigation and treatment. Discharge
summary should be written by physician after patient discharged.
ANALYSIS AND COMPLETION OF THE HEALTH RECORD
Analysis of health record is the art review of health record for completeness,
adequacy and accuracy the record however can be analyze in the following
ways:-
 QUALITATIVE ANALYSIS
 QUANTITATIVE ANALYSIS

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QUALITATIVE ANALYSIS:-This is the type of record analysis that the
patient record must be checked by medical staff for omission error
discrepancies by the clinical staff in completing any part of the current paper.
When such items are found, a deficiency slip must be put inside the front
cover of the folder.
QUANTITATIVE ANALYSIS:-This is the types of record analysis where
by the record of patient is checked to ascertain the presence of all forms that a
basic health record should contain i.e the diagnosis record, progress note,
operating form, summary sheet. If the medical officer is not satisfied with
any entries in it, he has it returned to the attending physician for updating and
regulation.
FUNCTIONS OF THE HEATH RECORD
1. Formulate the rule governing the practice of health record profession
2. Co-ordinate the collection and analyses internal statistical data
3. Create forum for publication, seminar and workshop
FUNCTIONS OF HEALTH RECORD DEPARTMENT IN HEALTH
CARE DELIVERY
The Health record department is the pivot with all other hospital services
revolved whatever the size of hospital whatever large teaching hospital or
rural hospital, the main point of emphasis is the record care and the following
functions are perform:
 Primary function is creating care, storage, issue and retrieval patient
health record and continuity of patient care.
 Provision of statistical information from health record accurate and
meaningful.
 Identification of patent record, physiologically and sociologically.
 To operate and association service.
 Numbering controlled.
 Cording and indexing.
 Maintenance the confidentiality of patient to protect record forum.
 Continue patient care and bucking subsequent appointment.
 For Administrative purpose and development.

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 PURPOSE OF ANALYSIS
The analysis ensured that the medical record compiled with the policy of
standard establish by hospital administration, medical staff and various
hospital accrediting agency.
GROWTH AND DEVELOPMENT OF HEALTH RECORD
Medical record practiced has past many various stages in its development
from the old stage generation. These developments has been as a result of
improvement in quality and quantity of patient care and information services,
despite the various stages of development and the creation and maintenance
the significant purpose of medical record study is almost the same throughout
the history.
STAGE 1:- Use of pictograph
2:- The use papyrus
3:-the use notebook
4:-Introduction of unit system (on registration belong to
person one code number)
5:-Introduction of automated equipment
6:-Introduction of micro filming
7:-Introduction of machine.
CODE/RULE OF HEALTH RECORD PROFESSION
 Put services before material gain, honor of the professional before
personal advantage, the health welfare of patient above all personal and
financial iterance.
 Preserve and protect the medical record custody all hold in violence
the privilege contain of record and any other information of a
confidential nature often in his official capacity.
 Refuse to participate on ethical practice or procedure.
 Preserve the confidential nature of profession determination made by
the staff committee which he serves.
 Serve your duty trustfully, honesty and honorable by discharged

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  Stride the advance knowledge of medical record science include
continuity self improvement in order to contribute the first possible
medical care.
FUNCTIONS OF HEALTH RECORD PROFESSION
1. Set the policy relating to maintain health record system throughout the
hospital or health care center
2. planning staff space and equipment requirement
3. developing method for the collection and presentation of statistics for
morbidity, mortality and administration purpose
4. assist in training medical record student and personal
5. give lecture on medical health record service to nurses, residence,
medical officer and other member of the health team
6. plan and conduct in-service training programmers for the all grades of
personal and prepare teaching materials
PLANNING AND ORGANIZATION OF HEALTH RECORD
Organization of health record pre-support and effective and adequate
planning and structure facility that made the health record services more
convenient and comfortable for the health record personal to deliver efficient
services to the patient and community.
The planning of health record department the following point should as
follows:
1. The site and location:-on the site and location of health record
department, the following up to be taken into consideration.
 Convenient of the patient
 Convenient of the medical staff
 Nearest of the related office of health record department
2. Available space (accommodation) Available space is the major
problem passing health record office; officer should be observed the
following principles.
 The flow of work:- the objectives is to make the flow of work as
regular as possible, the straight line ,circle , or U-sharp , estrict the
movement of people and paper to the minimum and give the
maximum control.
 Floor space: - should be as free as possible from petition, other
impediment of free movement and observation the number and
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 location of chairs, table shelves would depend on the number of
staff and desk evolved. Each staff should have the minimum of
working space for such allowances, efficient and make for a health
staff.
3. Equipment Communication and Working Condition.
 Good building which high ceiling for good ventilation and
lightening sanitary facility and adequate.
4. Staff of Department:-
 Medical record administration officers
 Medical record technician staff supervision
 Medical record assistance
5. List of Department :-
 G.O.P.D.
 Consultative clinic (S.O.P.D) MOPD.
 Central record
 Accident and emergency A&E
6. Administrative Tools
 Job description
 Procedure manual
 Organization chart of flow chart
DECUMENTATION IN HEATH RECORD
Health record department is the very first point of contact or first place of
call for all patients; therefore the health record staffs are responsible for
reviewing each patient’s personal data. This done by asking to know from
the patient or his/ her next-of-kin, if there had been any changes in name,
address, social status or occupation.
The health records staff must always ensure that a patient had been to the
hospital previously before documentation can be done for him/her.
Decumentation is a process by which sufficient personal identification
particular or clinical nursing and other diverse professional details are
obtained from each an every patient or the next of kin during the patient first
attendance at each particular hospital or clinic visit. The data are recorded in
order of event and on prescribed forms to provide guidance for all future
reference and updating.

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 TYPES OF DECUMENTATION
In health records practices, there are two (2) types
1. Manual documentation
2. Mechanical documentation
Manual decumentation: - this is the layman will call registration by
hand. It’s the system where all the data as regard the patient who call at the
hospital or clinics are written by hand in the registration book and also in all
essential documents pertaining to the patient.
Mechanical Decumentation :-this is the system by mechanized system is
used for decumentation of patient health record. This may be done before or
very day of clinics to the patients.
SOME ITEMS OF IDENTIFICATION INFORMATION REQUEST
FROM PATIENT DECUMENTATION /REGISTRATION
1. Name of patient
2. Address of patient
3. Ages
4. Tribe
5. Sex
6. Religion
7. Next of kin
8. occupation
9. phone number
10. date of birth
11. address /phone number of next kin e.t.c
NUMBERING SYSTEM
Numbering system is basically an identifying factor used to label the
record and facilitate its being filed in systematic manner for easy retention
and retrieval. In most health care institution, health record and filed
numerically according to patient’s admission numbers. In the past some
health care institutions have filed records according to patient name
discharge, numbers or diagnostic code number.

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 Alphabetic filing by patient name is more and subject to more error than
numerical filing.
However, filing by numerical sequence involves the additional choice of
maintaining a separate alphabetical name index this numbering of health
records offers several advantages.
 It facilitates the identification of document pertaining to
individual; feature which is an importance where name are
identical or similar
 Filing is more efficient
 Confidentiality is enhenced
TYPES OF NUMBERING SYSTEM
i. Serial numbering system
ii. Unit numbering system
iii. Serial unit numbering system.
SERIAL NUMBERING SYSTEM:-This is one method of numbering
health record. In this method the patient receives a new number each time is
admitted to or visited the hospital for treatment. If he or she is registered five
times he or she acquired five different numbers.
ADVANTAGES OF SERIAL NUMBERING SYSTEM
 Easy to control number accurately
 Easy when totally yearly admission
 Patient index is easily to assemble
 File shelves using record can be file capacity
 Its good system where readmission rate is low
DISADVANTAGES OF SERIAL NUMBERING SYSTEM
 Time consuming to pull all the record
 It’s not economically
 Numbers increased quickly after prefixed in the year
 Decentralized system of filing must be used with this system
 All chart are in different location
 Research may suffer as all record may not be found

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 UNIT NUMBERING SYSTEM:-
This system in which one number is assigned to a patient’s record that
patient retains that one number for ever, regardless of the number of time that
the patient enters or leaves the system, that one number is retained and
entered on the master patient index to identity the patient record. Its provides
the single records which composite of all data gathered on a given patient
whether as an in- patient, ambulatory care or emergency patient. Numbers are
especially 6 six digit (that is one patient, one record, one number)
ADVANTAGE OF UNIT NUMBERING SYSTEM
 All patient information are fond in one place
 It is convenient and easy to operate
 It is economically
 One number on the patient index
 One record to be pulled out
 No confusion in the system
DISADVANTAGES OF UNIT NUMBERING SYSTEM
 It is difficult to estimate space for readmission (filing space )
 It is difficult to control numbers
 Time consuming
 Removal of in- active record from the file for purging or micro filing is
difficult when using system
 About 75% of shelves are fills
SERIAL –UNIT NUMBERING SYSTEM
This numbering system is an aggregation of a serial and unit numbering
system. Although each time the patient is registered system and receives a
new hospital number, his previous record are continually brought forward
and filed under the latest issued number. This system is used in small hospital
with few admission or readmissions clinic, TB hospitals, Mental hospital etc.
ADVANTAGES OF SERIAL-UNIT NUMBERING SYSTEM
 Its easy to control number issued out.
 All health record put together help in research done.
 Creation of more filing space-100%
 Its fairly well suited for microfilm
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  Easy to detect active record.
DISADVANTAGES OF SERIAL-UNIT NUMBERING SYSTEM
 There will be uneven file expansion
 It necessitating back shitting of health record
 Bringing of charts forwards is a time consuming
 It makes studies difficult; and confusion with the numbers.
CHANGING TO A UNIT NUMBERING SYSTEM
Changing from serial or a serial-unit to unit numbering is easily
accomplished by following steps below:-
i. Select a date to make the change preferably the first day of the
calendar or fiscal year.
ii. Begin issuing unit number on the selected day (last un-used serial
numbers can be used to begin in the unit system or an entirely new
series if desired).
iii. Assign readmitted patient a new unit numbers, bring forward the
previous records and file under the number. Leave empty folder
previous record in their original place in the file. Cross reference on
the folder to the new unit number.
iv. Leaves in the file under their original number, all records of patient not
re-admitted. After a specified time, all medical records remaining in
the original file area may easily be removed from the active file area
and taken to inactive storage.
FILING SYSTEM IN HEALTH RECORD
Filing health records system can be defined as a set of documents
arranged in a prescribed order for convenience of reference and preservation.
This has a method or plan of classification designed to perform a particular
function, which for health records is to provide an information and retrieval
services.
It is to remind ourselves that the prime responsibility of health records
department is to undertake the custody, classification and preservation,
maintain confidentiality and retrieval of patients case history, including
radiographs, furthermore, the procedures within the filing unit, the method
and the accuracy will reflect in the efficiency or otherwise of all the various

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patients services throughout the organization, whether it be hospital or other
health institution.
ESSENTIALS OF A GOOD FILING SYSTEM OR FUNDAMENTAL
REQUIREMENT
An effective filing system should contain a number of fundamental features:-
1. Compactness to take the account of the value and cost of storage space
and also the need to reduce physical effort in working system.
2. Accessibility for speed of location and positive means of identification
of the items contained in the system.
3. Simplicity to operation to ensure that the method is understood by those
who normally control it.
But also by those who require occasional access
4. Economy; both in cost of installation and operation
5. Elasticity providing an ability to extend and contract according future
requirements and to ensure extraction and disposal of dead matter without
much disturbance.
6. Cross referencing facility when required.
7. Tracer system of documents in circulation
8. A method of classification e.g. Terminal digit or middle digit e.t.c.
9. The requirements in use must be effective and efficient to the system
10. The personal operating the system must be well trained as health record
practitioner.
METHOD OF FILING SYSTEM
There are three filing system commonly used for medical records, these
are;
ALPHABETICAL; PLACING surname first, middle name and others
names. In the case of more persons bearing the same names, the cards are
arranged according to date of birth or date of registration e.g. master index
cards. This system is ideal for a small hospital especially specialist hospital
like psychiatric hospital where the volume of records involved is small. It
does not require master index cards as back up for the system.
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STRAIGHT NUMERICAL; this refers to the filing of record in exact
chronological order according to the hospital numbers; example 78492 –
784922—784923 etc diagnostic index cards and the system in central library.
It has the advantage of:
i. Easy to understand
ii To pull say fifty case notes for study
iii. To pull records for secondary storage.
DISADVANTAGES
i. The clerk must consider all the digit of the record number at the time, it is
easy to misfile.
ii. Transposition of number is common.
iii. Heaviest filing activity is concentrated in areas with the highest hospital
numbers—representing the newest or most recent records.
iv. Quality control of filing is difficult with the system
v. Several clerks filing at the sometime are bound to get in each other’s way.
TERMINAL DIGIT; usually a six digit number is used and divided in to
three part each normally containing two digit
Viz:
50 93 26
Tertiary Digit Secondary digit primary digit
Under the system there are 100 primary system sections ranging.
ADVANTAGES
i. Even distribution of records throughout the 100 primary section
ii. The congestion that results when several clerks file active record in the
same area of the file is eliminated
iii. Clerk may be assigned to responsibility for the certain section of the file
e.g. 00 – 24, 25 -49, 50 – 74, 75 – 99 even distribution of duties.
iv. Annual shifting of record is prevented.
v. It is possible to estimate
vi. It aid confidentiality
vii. Misfiling is substantially reduce
viii. The use of color coding is possible

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DISADVANTAGES
i. Training period necessary unlike the straight numerical.
FILING SYSTEM WITH REFERENCE TO LOCATION
There are four currently used system of locating files which are:
1. Centralized
2. Decentralized
3. Satellite
4. Controlled – decentralized
CENTRALIZED: - Centralized refers to the filing of patient’s in-patient and
out-patient records in one location, under this system the patient has only one
folder in the hospital.
ADVANTAGES OF CENTRALIZED FILING SYSTEM
I. There is less duplication of efforts with regard to creation
maintenance and storage of records
II. There is less overall expenditure on space and equipment
III. A unit record with all its advantages is possible
DECENTRALIZED: - In a decentralized filing system, files are usually
located very closed to the source of their active use. A large medical complex
consisting of several health care Units which are physically separated from
each other might need to adopt such as decentralized system.
SATELLITE:- In a satellite filing system, the majorities of the records are
filed in one major location but some, records travel to clinic or other areas as
needed and stay in those areas for a certain period of time to be returned to
the central file room only for permanent filing on patients discharge
CONTROLLED DECENTRALIZED— In the controlled decentralized
system all forms requisition filing procedures, methods and processes are
standard
So that records in the various areas are maintained identically

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 FILING EQUIPMENTS:-
Equipment should be chosen for reason of both efficiency and
appropriateness. The amount of storage space for records depends largely or
record activity and whether or not data procession or microfilm programs are
established.
TYPES OF EQUIPMENTS
i- Open shelves
ii- Cabinets
iii- Elevator
FACTORS AFFECTING CHOICE
i- Volume of records
ii- Available space
iii- Retention period
iv- Confidentiality
v- Available money
AIDS TO ACCURATE FILING
i- Color coding
ii- Introduction of efficient tracer system
iii- Introduction of terminal digit filing system
iv- Legibility in numbering case folders.
v- Adequate ventilation
vi- Introduction of centralized filing system
vii- Large storage of medical record library
viii- Good spacing between filing shelves as well as good dividers
ix- Length and height of shelves should be minimized
x- Adequate security measures
xi- Constant supervision of filing clerks
xii- Division of labor
xiii- Provision of ancillary equipment e.g. sorting, ladder, stool guide
card e.t.c.

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