COLLEGE OF HEALTH SCIENCEAND TECHNOLOGY NGURU,

YOBE STATE
DEPARTMENT OF HEALTH INFORMATION MANAGEMENT

STUDENT NAME:
REG NO:

LECTURE NOTE ON

HEALTH INFORMATION MANAGEMENT (HIT111)

PROFESSIONAL DIPLOMA
HEALTH INFORMATION TECHNICIAN

PREPARED BY
AHMED SULE HND, PGDE, DDPIT
08060202431. [email protected]

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DEFINATION OF HEALTH RECORD
Health record
Is a collection of data complied on a patient to assist in the clinical care of present and future
illness. By clinical care is meant treatment by doctor nurses and other in the health term, in a hospital, and
outpatient clinic or primary care by a family doctor.
Or
Health record is defined as a clinical, scientific, and administrative and the legal document relating
to patients care in which are recorded sufficient data written in the sequence of events to justify the
diagnosis and warrant the treatment an end of results.
QUALITIES AND ESSENTIAL OF A GOOD HEALTH RECORD
A good record should be:
1. Identify clearly the person about whom it is written.
2. It must to be legible and able to be understood by any one likely to use it.
3. It must to be accurate, concise and logical in its organization.
4. It must to be consistence in lay out and in the size of papers use in it.
5. It must to be able to identify the people contributing to the record so that they can be asked for
further information if necessary.
6. It must to be promptly retrievable when require.
a. Unit number
b. Name
C. Date of admission
d. Diagnosis
e. Operation index
f. Physical index
OUT-PATIENT REGISTRATION
On arrival at the hospital a new outpatient is directed to the new patients section of the desk for
registration .This is where the initial interview with the registration clerk taken place. The clerk will
initiated the medical record if this has not already taken place. He will also ensure that this record and the
referral letter if any. Precedes the patient in to the clinic.
HISTORY OF HEALTH RECORDS
The history of health records runs parallel with the history of medicine, the health record is equally
important as medicine, as medication is for effective treatment.
Development in medicine in the olden days was ascribed to notable men who contributed to health care of
the people. Their works were so important that they were defied after their death. In fact, it is now
difficult to separate mythology from reality. In essence the history of medicine and consequently of
medical records, in the early period of civilization was shrouded in mystery.
Early records were kept in pictorial form, on the walls of stone, cave, figures or objects, burnt clay wall of
tombs temples or on long rolls of papyrus dated as far back as about 25000BC. Prominent among these
papyruses was that discovered by Edwin smith, (Edwin smith papyrus), an African Egyptomologist. The
Edwin smith papyrus contained twelve rolls, each measuring 15feet, and 8inches. The rolls contained
forty-eight caser of clinical surgery and other medical cases.
Although record were kept primitively, they serve the same purpose with present method of record
keeping. This is evidence that physicians of old keep records about their patients. However, from
generation, the attitude of different medical men to records varied according to the various individuals’
perspective. We shall attempt to trace the historical of medical records using the criteria the development
from the period to period.

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THE EGYPTIAN PERIOD
In Egypt, thoth was not a god of medicine but he was important in the art of healing by virtue of being the
god of letters, (he was credited with having invented the art of writing), invention and …….he was
credited with authorship of between 36-42 books; six of which were medical cases bothering on human
body; diseases, instrument and appliances, drugs, disease of eyes and logical ailments.
Another notable physician in that period was imbotep who lived in the pyramid age about ……4000BC.
He was grand vizies, chief architect and royal medical adviser to the then pharaoh in twenty-ninecentaury
before Christ. He was defied after his death as a medical god. Both Greeks and Romans equated him with
the Aesculapius and regarded him the first physician to stand from the midst of antiquity.
GREEK PERIOD: The Greek medicine was not purely Grecian, but their success in practicing medicine
scientifically could be attributed to the contributions made by older civilizations, especially those Egypt,
Babylonia and Assyria and other various sources from which they were able to draw information.
Aesculapius, as said previously, was equated by both the Greeks and the Romans with imbotep of Egypt.
He had student that he taught the art of healing sick people with local herbs and kept records of his
patients. History has it that he had some snakes in his castle that he made use of to lick wounds of patients
in order to heal them. He was said to have cured many were ill to the point of death. He was also said to
have revived some patients who were presumed dead. After his death, sculptors depicted him with a
serpent entwined around a staff. Many medical institutions and associations up till today use this symbol
as their logo or emblem. His students also built treatment castles, which they named after him
(Aesculapius).
Hippocrates, known as the “father of medicine” was born about 460BC in the north of Cos (the birth place
of Aesculapius) and was said to have lineally descended from the Aesculapius. He used his intellectual
brilliance to develop and improved on Aesculapius methods of treatment. Although his knowledge of
human anatomy was limited because of the respects the Greeks had for the dead precluded him from
practicing dissection, his knowledge of history, symptoms, and physical sign of diseases made him an
outstanding physician.
He wrote many volumes of medical related subject and propounded many medical theories which was
regarded as being correct many years after his death; his work have been translated in to many languages.
He was the first to cast superstition aside and practice medicine scientifically. He was the author of
Hippocratic oath, which state in parts; “whatsoever in my practice or not in y practice I shall see or hear
amidst lives of men which ought not to be noised abroad; as to this, I shall keep silent holding such things
unfitted to be spoken.” With this oath the medical records per-se was record personnel is the fact that he
kept detailed case report of his patient and instructed his sons in the act of recording all findings.
GRECO-ROMAN PERIOD
Galen was bout 130-201AD, about 600 years after the time of Hippocrates. He had access to some
treatment castles built by Aesulapius graduates. He became famous after curing the emperor that lived
during his time. He had his own students too. He was the first to recognize the true function of the arteries
as blood carrying vessels, which prior to his discovery were regarded as containing air. He had some
write-ups to his credit.
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 Trallesandpaul of Aegina were noted as corny the
works of Hippocrates, Galen and many of other early physicians.
JEWISH PERIOD
The bible and Talmud are the principle sources of jewish medical information. The Talmud contains more
medical information than the bible. Some of the jewish biblical injunction bothers on diseases preventing

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measures. For instance, the book of Leviticus contain mandates as regards touching unclean objects, the
proper food to eat, purifying of women after childbirth, and mother matters of hygiene.

MUHAMMADAN PERIOD
It is on records that Christian scholar, verse in the knowledge of both greek and Arabic translated the
work of Hippocrates and galen into Arabic languages and thus stimulated medical studies among the
Arabs.
Rhazes lived in 865-925D. He was the greatest Muslim and 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
smallpox and measles. He was credited with using twisted intestine of sheep for suturing and using
alcohol in wound cleaning
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 has been used to improve on
present method of treatment.
MEDIVAL PERIOD
St. Bartholomew’s hospital, London, England is the onlyhospitalstill in existence from medieval times.
The hospital still has some records of its past patients from its inception in March 1123 it is significant to
note that, this hospital took a lead in establishment a medical library and what correspond to our medical
records department. The hospital was founded by Rahere who later died in September 21, 1144. It was
believed that st. Bartholomew appeared to him in vision instructing him to go the subbarbis where he
founded a church; (which is now known as St. Bartholomew hospital).
The records keeping of those days was so similar to that of today to the extent that is was discovered that
the book of the foundation, published by the early English text society and edited from the original
manuscript by sir Norman more, contained about 28 original case histories.
RENAISSANCE PERIOD
With the renaissanance of European civilization and of king Henry who lived between 1509-1547
conditions in St. Bartholomew hospital improved and rules were drawn up for its management. These
rules bother principally on privacy of records and importance of keeping the records the hospital took lead
in establishingwhat would correspond to our medical records of today.
In 1821, the famous Massachusetts general Hospital in boston was established. The hospital was the first
to have medical records personnel in the name of Mrs. Grace whiting Myers 1859 1957; she was the first
present of the association of record librarians of North America.
As time went on, nationalhealth record practitioners were formed; United States of America took the lead
by forming its American medical records association in 1928, followed by Great Britain which formed
her own association of medical records officers of Great Britain in1948. Australia followed soon in 1949
with two associations of medical records. In1952; they united and founded the united Australian record
librarians.
HISTORY OF HEALTH RECORDS MANAGEMENT IN NIGERIA
There is no significant difference, as regards to the history of medical records in Nigeria with the rest of
the world; it all started in the same manner. In Nigeria before the advent of colonial masters and
missionaries, traditional and faith healers treat the sick and injured and kept the records of their patients to
themselves.
In fact, those days quite number of the traditional practioners, did not allowed anybody access to the
records of their patient, of the wealth of knowledge and experience except their children, other relations
or through companion, which they might like to take over their wealth.
MEDICAL RECORD
Is a written document of a patient in a hospital set up about a state of health of a particular patient.
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HEALTH RECORD
Can be defined as documentation of the history of one person injury or illness either outpatient or
inpatient made to preserve information on medical scientific, administration, planning research on a legal
value.
HEALTH INFORMATION
Is the application of computer technology to manage patient information in a hospital set up or
health care institution which maintains standard and high level of security of patient information.
CLINICAL RECORD
This is a written documentation of the patient by medical doctor or clinician which comprises
history taking physical examination of clinician or observation of patient state of health.
HEALTH INFORMATION MANAGEMENT H
Is the process of managing and reporting patient information through an electronic means which
can also enable clinical research, teaching and other clinical comparison of a health care institution.
USES OF HEALTH RECORD
There are two (2) ways in which health record can be used:
1. As a personal documentation
2. Impersonal documentation
PERSONAL DOCUMENTATION
This is a record of a patient who identify a particular patient as an individual it is use in the
following:
1. On admission: this can be used when a patient is about been admitted in the hospital. Health record
personal or health record officer should produce existing record of that patient which can assist in
his/her treatment.
2. On admission to another hospital: a copy of discharge patient summary can be prepare and be given
to a patient on referral to another hospital which can help his subsequent consultant in knowing his
disease history.
3. On attendance: this is the record of patient which is used by the consulting physician when patient
attend outpatient clinic.
IMPERSONAL DOCUMENTATION
As impersonal documentation health record became as impersonal document when it does
not identify patient as an individual.
The major use here is for basic research
1. Planning purpose: the management of health care institution use patient record for planning and
budget.
2. Research: an impersonal record of a patient can be used for a clinical research purpose
3. Training purpose: medical and para medical staff and student are being train by the use of patient
record in the hospital set up.
VALUES OF HEALTH RECORD
- To the patient
- To the hospital
- To the doctor
- To the community
TO THE PATIENT
 It is used for patient’s health care planning.
 It is used for patient’s identification.
 It is used for further treatment on the patient’s.
 It is used for reference for treatment of other patient’s.
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  It is used as proof for insurance claims.
TO THE DOCTOR
* It is used as a remainder – doctors forgot, records remember the doctor used it to identify his patients.
* Doctors used it to teach medical students.
* It is used to prove the degree of professional practice.
*The health records can also help in court case.
* It is used as legal protection.
* It is used for issuance of certificate (birth discharge death)
* It is used to treat other patients
* It is used for treatment claim from the patient.
*It is used to communicate with other professional
TO THE HOSPITAL
 It is used for patient’s care.
 It is used for hospital planning services.
 It is used for teaching other professional e.g Doctors students nurses Health information
management students etc.
 It is used for legal protection to the hospital
 It is used for research purpose.
 It is used to evaluate health care delivery.
 It is used to furnish information to the 3rd party( payee employer)
TO THE COMMUNITY
Health records of a facility of particular community provide a basic information diagnosis for felt
need to the community.
THE ROLE OF HEALTH INFORMATIONMANAGEMENT.
1. PATIENT CARE: Health information management is important as how medication is important in the
treatment of a patient it plays a vital role in documenting the clinical history of the patient care which
assist in the treatment of present and future illness of the patient.
2. HEALTH CARE PLANNING AT THE FACILITY:
The community and local level. Resources material for planning effecting services to the patient at the
facility level is health information management, because it show all the types of disease coming to the health
facilities and also a certain number of patient turn over, in the health facility which health administrators
used as a guiding principles in planning and budgeting the activities of the health facility.
ii. At the same vein existing patient information at the health facility help to diagnose the community and
locality felt need which is used for planning and controlling the infectious disease in the facility as well as
the community level.
iii. MEASURING AND IMPROVINGQUALITY HEALTH CARE SERVICE:
Diseases surveillance health information management department are responsible for designing disease
notification form which can be used in monitoring the occurrence of the diseases in human population as
well as the causative factors.
iv. EPIDEMIOLOGY:
is a science of study of the distribution of disease within the population as well as the factors that
determine such distribution. The epidemiological study of diseases in a particular community can only be
successful with aid of existing record of the patients in that community health facility.
v. BIO-ETHICAL REASERCH:
Health information management is used for bio-ethical/clinical research purpose in health care delivery
system patient information immensely, assist in conducting research work.

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 vi. LITIGATION:
Health information management is the wetness in the court of law for or against the health facility
because it contains all transaction of patient encounter in the hospital.
UNIT/SECTION IN HEALTH RECORD DEPARTMENT
1. reception and registration officer G.O.P.D
2. appointment section
3. admission office
4. filling and the library office
5. statistic coding and indexing office
6. central record office filling library office
7. Sectarian services office, registration and the admission office.
8. reception registration and admissions officers
FUNCTION OF HEALTH RECORD
1. Reception and the registration of patient
2. Appointment booking and the follow up procedure
3. Waiting list admission and the discharge/death procedure
4. The collection, compilation and representation of hospital statistic
5. Provision of medical secretarial transcription services to the medical staff
6. The planning record and conduct of surveys and research in medical records
7. Training of staff, procurement forms card and equipment.
DESCRIBE THE PHYSICAL LAY OUT OF DEPARTMENT

H.R.D
A&E E.P.U CRL medical record
GOPD
corresponding
Statistic
Admission and Medical retainer ship
NHIS
discharge office
Coding
and

Ophthomology Dental
Pediatric Clinic ENT ANC Other special clinic

RELATIONSHIP BETWEEN THE UNIT / SECTION

The relationship of the section and unit of health record is how record is been initiated from the GOPD
back to the central library for falling, the patient health record is first started from .G.O.P D where health
record clerk document the social identification data of the patient, from there the patients case folder
should be send to nursing officers for vital sign and then to consulting room where by friendly discussion
between doctor and the patient take place to assist the biological condition of disease episode. If the
condition warrant admission the patient folder will be send to admission officer, to find out any of the
ward with a vacant bed. After discharge a ward clerk will convey the case folder to the discharge officer
from there if there is appointment the folder will be forwarded to appointment office which date time and
venue will be given to the patient for next visit from there to statistics unit for quantitative and qualitative
analysis, then coding and indexing office after the diagnosis of a patient has been coded & index the
folder will finally be send back to the central library for falling.

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CENTRALIZED FILLING SYSTEM
Centralized refers to the filling of patient inpatient and outpatient record in one location under this
system the patient has only one folder in the hospital, always located in the same place on the filling
shelves in one central location within the medical record department in this system personnel method,
policies equipment, material and all the component involved in an effective filling system are located and
the operational in one place.

DECENTRALIZED FILLING SYSTEM

In a decentralized filling system, files are usually located very close to the source of their use. A
large medical complex consisting of several health care unit which are physically separated from each
other might need to adopt such a decentralized system.
DESCRIBE ORGANIZATIONAL CHART IN HEALTH RECORD DEPARTMENT

Head of dept. program

coordinator

Admin. office Confidential sec.

Deputy head of
department

Unit Head out patient Form designed Unit head in patient

dept distribution

Clinic

Transcript Corresponding
Community health

Processing File

Indexes Research

Emergency room
record office Disease operation Master Physician Registries
index card

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 POSITION IN HEALTH RECORD DEPARTMENT

Director health records

Deputy Director Health records
Assistant Director Health records
Chief Health records
Assistant Chief Director health records

Principal Health Record’s officers

Health records officers I

Senior Health records officers

Health records Officers II

Assistant Health technician

Health record assistant

RESPONSIBILITIES IN HEALTH RECORD DEPT
1. Director health record: he planned and implements policies, guide lines of activities of the
department and also supervise principal officer of the department.
2. Deputy/ Assistant director:- he assistant the director in carry out day to day administrative
function
3. Chief health record officer this is an officer in health record department of whose has received
training and also undergo practical experience to monitor a particular clinic eg outpatient clinics in
patient service.
4. Assistant chief record officers: - he assists the chief health record officers in carry out the activities
of his / her unit.
5. Principal health officers: Has responsibilities of directing and supervisor health record officer and
technician and carry out certain departmental function.
6. Senior health record office:- he is responsible of summarizing statistical report of various
outpatient and inpatient services with other administration function.
7. Health record officer these are officers that are responsible of compiling monthly return statistical
form of patient turn over and disease episode.
8. Health record technician he is responsible in documentary case folders and other clinical services.
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 9. Health assistance: - this is on officer who assist record technician in discharging his
responsibilities.
10. Health record clerk: he works in the reception unit of the record department where documentation
of social identification data of the patient is place.
HEALTH RECORD DEPARTMENT
A publisher of local magazine “pulse magazine once describe health record department in October
1980 as follows:
Of all the numerous department of a large modern hospital, a least understood in term of functions
by the public, the most maligned and yet the pay to the efficiency or other wise of what hospital is, is the
health record department.
It is the public first point of call and in the most Nigeria teaching hospital the scene of fight, high
temperature and seemingly in surmountable obstacles or problems in health care.
There for, going by description summed of the position of an average health record department in
Nigeria hospital today we know that health record started with introduction of medicine that mean the
more scientific the modern medicine the greater sophistication of the system of health record
Health record department is a branch that specialized in keeping of medical records and the
provision of health information services. Its function also includes all clerical/ clinical services effective
to both outpatient and inpatient.
FACTORS TO BE CONSIDER IN HEALTH RECORD DEPARTMENT
1. Human resources (train personal)
2. Library for filling
3. Filling cabinet or shelves
4. Cross ventilation
5. Coding tool and equipment
6. Accessibility to the patient
FUNCTION OF HEALTH RECORD DEPARTMENT
1. Reception and registration of a patient
2. Waiting list admission and discharge death procedure
3. Care and the guidance of medical record including its competence, componential, accuracy
4. Appointment booking and follow up procedure
5. Planning and the conducts surveys and research in medical record.
6. The collection and presentation of hospital statistic
ORGANIZATION OF HEALTH RECORD DEPARTMENT IN THE FOLLOWING
1. G.O.P.D: in the unit health record reception is the first point of call to the patient and mostly
allocated at in-trance of the unit
2. CONSULTATIVE
In all the outpatient clinic the site library of record department is located folder of outpatient attending the
clinic are filled by the record officers. In this unit record officer are given appointment to the outpatient
for subsequent visit.
3. ACCIDENT AND EMERGENCY
Side libraries of A&E of the record unit are properly design to keep the patient records that need
immediate attention.
4. PHYSIO-THEREPY
This is clinic where record of physical challenge patient is kept.
5. RADIOLOGY
This is the unit all the photographic image of internal body system are been kept.
RELATIONSHIP BETWEEN HEAITHS RECORD AND OTHER DEPARTMENT.
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 The relationship between health record and other department is to produce the existing record of the
patient by the record department to all others department that need it,also record consumable to other
department.
HEALTH RECORDS OFFICERS REGISTRATION BOARD OF NIGERIA
HRORBON was inaugurated on Tuesday December 29, 1992. The ceremony was performed by the then
honorable minister of health and social service professor Olikoye ransom Kuti.
The relevant instrument [LAW] establishment the board is decree no.39, titled health record officers
[ Registration etc] decree 1989 as published under government notice N0.693 the federal republic of
Nigeria [extraordinary] official gazette N0.71 vol 76 Lagos 11th December, 1989.
THE BOARDS FUNCTION INCLUDE:
a. Regulating standards for the accreditation of training institutions and from time to time ensuring the
maintenance of such standard
b. Regulation of standard for the training programmed and examination for person seeking to practice the
profession and improving such standard from time to time as circumstances may permit.
c. Regulating of forms and formats for the maintenance of the register of qualified and approved
members, the modes of application for registration as well as updating and publication of register.
d. Regulating the standard of health information practice in all institution.
e. Ensuring professional discipline if the health information practitioners.
Reference is hereby made to the provisions of decree N0 39 of 1989 part TWO section12 civil service
[re-organization] decree N043 of 1988 paragraphs II and 12 page A794 and volumes I and ii of the
explanatory notes for guidance on important of the civil service reforms [ie, vol 1 part v1,vol II part xi
[Vi] staff list and professionalism and [viii] 8 staff nomenclature.
Accordingly employers of health records labour in the civil service of the federal, state and local
government authority [LGA] and parastatals public or private establishment body or institution are
particularly urged to note and ensure that effective from the inception of the board on December
29,1992 all names, addresses and or titles hitherto used in the profession e.g;
Medical record officers
Card issued.
Medical records assistant
Medical record technician
Ceased to be applicable to the practice and member of the profession.
NIGERIAN HEALTH RECORDS ASSOCIATION [NHRA]
The author has done enough justice as regard the history of NHRA in the earlier chapter. So, it is not
worth mentioning here.
The NHRA which is the second organ of the health information management is saddled with the
following responsibilities/functions;
a.To provide a forum through which persons practicing the profession can discuss problem affecting
the practice of their profession.
b.To serve as a body for promoting the development of health information management techniques
and practices, and to disseminate among its members and other interested persons.
c. to foster a high sense of value for systematic and correct health information management and to
encourage a degree of efficiency in those engage in such service.
d. To provide opportunities by means of lecture discussion or other media among its members and
other interested and to encourage the publication and distribution of books, journals etc for the
benefits of members.
e. To originate and promote improvements in the law in any way affecting the administration of health
information management and to guard jealously, the interest of such law.
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f. To check the influx of quacks into the profession.
INTERNAL FEDERATION OF HEALTH RECORDS ORGANIZATION [I.F.H.R.O]
The IFHRO was officially formed in 1968 [5 th congress]. The formation of the internal organization for
medical record personal was the culmination of the work of many people from many countries. However
the concept and final development was due to the visit and drive of one person. Mrs. Elsie roylemansell of
United Kingdom [UK]
The international movement actually began with the first international congress held in London in 1952,
but the congress was largely and informal one. At the London meeting held in 1952 306 participants were
recorded from nine countries. This was followed by the second congress in Washington in 1956 at this
stage of the international development it was decided that representatives of the USA Canada and UK
should draft a constitution for an international body which would ultimately assume responsibility for
developing international liaison.
Twelve countries were represented at the second congress in 1956. Australia become the fourth nation to
be a member of the IFHRO
The third international congress was hosted by UK in 1960. All these period an interim committee was
charge with the responsibility of working toward the formation of an international federation. the fourth
congress was planned for in 1969 in USA the fifth congress washed in 1968 in Sweden and nineteen
member nation with official representation were present it was at this fifth congress that an agreement was
officially reached, and international medical records organization came into being with the following
objectives;
a.To provide a means of communication between person working in the field of health record in all
countries.
b. To advance the standard of health records in the hospital dispensaries other health and medical
institution and in all primary health care institutions.
c. To promote and/develop techniques for efficient use of health records for patient care statistics research
and techniques etc.
d. To provide means for the exchange of information on education requirement on training programmed
for health records personnel in all countries.
The four years between the fifth sixteen congresses were busy ones for the formed federation. The
constitution was circulated and minor alteration noted. A set of guidelines for conduct of business meeting
were prepared.
IMPORTANCE
It was during this period, just before the six international congresses that the constitution of Venezuela and
Nigeria were received for consideration by the board of managers.
In 1972 the six international congresses was held in Sydney at Sydney 420 participants from 24 countries
were present and Venezuela and Nigeria were given active membership.
In 1976 the seventh international congress in medical records was held in Toronto, Canada, two thousand
participants from 25 countries attended the Toronto congress. After the seventh international congress,
India, Italy, Kenya, 3est Germany and the association of health records.
FUNCTION OF HEALTHS RECORD OFFICERS
1. Set the policy relating to maintenance of the medical record system throughout the hospital or health
care center.
2. Design plans and administrative policies of medical record services including:
1. Planning staff space and the equipment requirement
2. Establish procedure of content retrieval and retention of medical record.
3. Controlling and organizing the typing of medical summaries, patient letters and operation report or
distribution.
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4. Processing correspondences relating to the list of information under the authorization of the patient
and the subpoena.
5. Designing form of inclusion in the medical or health’s record.
6. Developing method of the collection and the representation of statistic or morbidity, mortalityand
administrative.
7. Assisting medical officer in research, project and study and determining method of data linkage.
8. Classify disease and operation to enable the retrieval of medical information for research and teaching.

ADMISSION AND PROCEDURE

A hospital admission is the formal acceptance by a hospital of a patient by service. Occupy hospital bed
and the receive physicians dental or alive services while lodged in the hospital and will have a medical
record maintain for him.
It is important that arrangement for patients admission should be clearly the file and know to
professional and the lay staff working in the area of the hospital concerning clinic word etc if all this
patients are filling aware of the agree admission procedure, the patient will be admitted to the hospital.
SOURCE OF ADMISSION
1. Via Accident and Emergency: patients arrive in one or other of the following circumstance.
a. By their own volition.
b. Sent by their relatives, friend or employer after filling unwell or after an accident, after initial
treatment and the clinical decision to admit, the patient
2. Via Outpatient Department
A clinician seeing a patient as either a routine or urgent, may decides that patient condition warrant
either unlimited or a plan admission.
3. Via request by other government or hospital or private hospital, clinic
Patient seeing at the above areas might needs to be sent to a particular hospital to complete the
treatment. This might be due to the fact that, there were no facilities to treat the patient at where they
were originally seeing or treated.
4. Inter ward admission
Patients transferred from on ward (consultant) are regarded as discharged by the transferring
consultant and admitted by the receiving consultant.
5. Via waiting list
Where one is maintained
SPECIAL POINT TO NOTE
1. The decision to admit or not admit is a clinical responsibility. Not for health records.
Health record staff i.e. Admission officer is given recognition, the admission officer therefore can advise
as to bed availability and may affect the decision, but the decision is not his.
1. Admission of patient cannot be postponed without the appropriate health authority and if all possible
a new date should be given at the time of the postponement.
2. Where and admission officer is involved in patients admission in all the time have a clear up to date
Picture of bed availability. To ensure this he must be told at once of all admission and transfer and
discharge.
3. In the case of place of where waiting list is maintained the admission officer can influence the health
staff into providing bed of their own, the health staff having undertaken when sending for the patient
that beds will be available.
CENTRALIZED ADMISSION SYSTEM
This is where all admission are channeled through the admission office I,e all admission from the clinic
both within and outside the hospital gets through a focal point- admission office.
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 DECENTRALIZED ADMISSION SYSTEM
This where admission. Are made directly at the wards by the ward clerk. Ward clerks would be
responsible for informing the central admission office or during the course of their ward round of new
admissions.
ADMISSON PROCEDURE
When the patients arrive, the identification details are checked and any missing items are completed. The
patient should be escorted to the ward it may be possible for the staff of admission officer to take patient.
In most well developed health record system various department need to be notified in the hospital. The
department is;
a. Ward
b. Health record department
c. The main reception desk of the hospital
d. Medical social workers department
e. The chaplains most hospital will have resident or visiting clergy in the main denomination
f. Catering
If admission register is maintained, it will be created this moment. Hospital has to maintain record of
the patient as in-patient and will normally contain hospital number discharge. Next of kin.
Sex
Occupation
Marital status
There are two ways of compiling any register of this type.
a. The entries are made in letter order i.e. the names of all patients whose surnames start with a are
entered in one section. This is carted a self-indexing register if an emergency have to be made it is
relatively easy to look through all the entries under a certain letter until the correct one is found.
b. The entries are made in chronological order i.e the name of each patient admitted is entered in
sequence.
c. BED BOARD
This is a displaying board showing the names of the patient’s occupying beds in the hospital which are
the same time displaying vacant beds in the hospital. It should be constantly kept up to date. Color code
can be used to indicate vacant beds and condition of patients. Maintained i.e not merged with the
admission officer.
HEALTHS RECORD PERSONNEL IN THE WORD
Whether a centralized or decentralized admission system in operation, it becomes inevitable to have a
record staff the ward. This record staff is the one who represent health record department in the ward.
The following are the various duties of record staff would perform for the health records department;
1. Documentation of admissions.
2. Filling of investigation reports
3. Filling of documents in the prescribed order in the case folder.
4. Control of all cases of discharge patient by ward register.
5. Making tracer cards of cases borrowed from the ward against the name of the borrowers.
6. Forwarding of summarized case notes promptly to the records department for further action.
7. Liaison with the appointment office on return appointment to the patients.
8. Tracing of case folders for further admission and follow up cases.
9. Checking for accuracy and collection of the daily ward statement.
10. Keeping of the bed board up to-date.
11. Supplying of relevant in-patients forms to the wards.
12. Helping to complete ward registers.
14
13. Notification of infection diseases through the ward register kept in the record department.
14. Helping to complete admission and discharge register kept in record department.

DISCHARGE PROCEDURE (INCLUDING TRANSFER OUT ANDDEATH)

1. DEFINITION OF DISCHARGE
The formal termination of treatment of a patient by a hospital. An inpatient discharge is the termination of
the granting of lodging and formal release of a patient by the hospital.
It is the termination of the grant of lodging and formal release of an in-patient by the hospital this implied
by entries in the discharge register. This would not include a patient, who is temporarily absent,
But in psychiatric department the term discharge is often reserved by psychiatrics for patient being
discharge to the community because of their peen lair problems. Bedis reserved by for him pending his
return.
Just a sequence must be established and followed for admission so a sequence will be needed for various
steps that have to be taken when a patient has to be discharged the health records department is likely to
be involved in the following aspects.
PROCEDURE: APATIENT is either discharged home (no further appointment required) or discharged
to continue treatment as an outpatient in which case an appointment for consultation will have to be
arrange by the ward staff before he leaves the hospital or the patients is transferred to other hospital for
further treatment or a patients is discharged to the mortuary if he is dead.
Daily Ward Statement/ Ward Return.
a. Content and layout.
The daily ward statement is a return made by each ward at the same time each day, relating to the
movement of patients into and out of the wards.
B. STATISTICS: The daily ward statement provide a figures that are the basis for hospital economics
management as for as inpatients. Are concerned. It is the sources document for many financial and
administrative returns and will give the statistics. On which planning of resources will be based. E.g the
number of beds likely to be needed in any future development for patients in certain specialty. It indicate
the used which is being made of the beds- for example, whether beds are lying empty for several day
before the next patient is admitted.
2. DISCHARGE LISTS: The same section wished to know when a patient was admitted to hospital will
also wish to know that he has discharged. Lists of patients discharge will probably have to be prepare to
notify at least the health records department.
Daily word statement provides figures that are the basis for hospital economics and might discuss.
3. Follow-up appointment:
a. each hospital will have its own way of making follow up appointment for patient leaving the ward. It
must be functioning if the appointment card can be given to the patients before he leaves the hospital. The
ward should hold stock of special request forms on which appointment can be requested. One of these
forms plus the patient’s appointment card, if he had brought this into hospital with him, it should be sent
down to the appointment sections preferably the afternoon before the patient is being discharge.
b. check by ward clerk/ discharge clerk
Who over is responsible for putting the patients note in order after he had left the ward should
check that if a further appointment is needed it has been made.
4. Collection and the procedure of note
It is desirable that there should have been discharged list in each ward from which the ward from
which the note of patient who have been discharge can be collected if there is a ward clerk, desk is the
obvious place, where those supposed to be, otherwise it may be the sisters desk or office.

15
 a. Collection by daily ward statement
The health record department may be responsible for collecting notes and x-ray films from the wards. If
so, the officer concerned should take with her the daily ward statement and check that she has a set of
notes for each patient who is no longer on the ward. This is to safe guide against not being retained in
error, so delaying of case further procedures.
b. Collection: collection of case notes must be done by health record officer concern and investigations
and report relative to the admission have to be filed in the agreed order in the folder and any transitory
documents. That do not have to be retained by law, such as 4 hurt temperature charts, may discharged
at this stage/ if the hospital policy.
c. Discharged summary: the ordered notes are than taking to the health secretary where one is
maintained who will be responsible for typing the discharge summary or formal report.
d. Coding: the notes how containing a list of the diagnosis made while the patient was in hospital will be
passed to the coding and indexing section so that he relevant details may be carried out by a trained
health record technician.
e. File: only after these multiple procedures have been completed the note is retained to library for filling
COMPLETION OF ADMISSION/ DISCHARGE REGISTER
This process is likely to be carried into two stages one after the collection of notes from the wards and the
other after the notes have been coded.
If an admission register is kept, the date of discharge will have to enter again original entry of each
patient as it is know from the daily ward statement. If this register is also used to trace the note that has
been returning to file after patient discharge they may often be final column not returning to file.
TRANSFER
Transfer is appear in the daily ward statement they may be patient moving from one place to another in
the same hospital or if two hospital in a group are regard as. (One administrative unit for various purpose.
If a patient is discharged from the point of view of the ward statement) to another hospital together his
relatives will probably be told that he has been transferred to another hospital this is a little confusing for
the purpose of this.
INTERWARD TRANSFER
a. Inter ward transfer- The bed board if there is one will need to be altered, so that the patient plate or
card appears in the new ward.
b. Inter Hospital Transfer (Discharge- It is possible that the case folder will be taken with the patient
to the new hospital. When this fact is discovered, either by the ward notifying the record department, or by
the clerk who collects notes from the ward, the library tracer card will have to be amended.
It is also useful to record the fact that a patient has gone to another hospital in the admission/discharged
register. Both these actions will be helpful in locating the notes when they are next needed
Death - When a death occurs in hospital it is of course the duty of the ward staff to notify relatives, if they
are not present. The health record department is likely to be involved in several ways, according to
practice in the hospital.
Death registration- This can be done in the admission office or the health record department. The deaths
certificate book is composed of pages of certification and cause and time of death are entered registration
should take place within five days of death occurring. The order of information is:
1. The nearest relative present at death
2. A relative in the area
3. A person present at the death
4. The occupier or the person responsible for burial.

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c. Discharge register- it is often found useful to make some distinguish mark in the admission/discharge
register to indicate who has died are usually sent to the postmodern room, and this mark will be an
indication of their where absents if they cannot be found with health secretary if there is one.
d. Death notification form- its creation as a result of the daily ward statement is essential, so that the
checks may be carried out by the various department or sections that attended to the patient.
COLLECT COLLATE INTEGRATE ANALYZE AND DISSEMINATION VITAL AND
HEALTH DATA.
This is a method How to use in collecting the patient health data or information in the Hospital.
MAINTENANCE OF ACCURATE BED CENSUS
Census can be define as a counting of a patient who are occupy Hospital, bed, bed census is normally
conducted or carry out around 12:59pm in the night the reason is that by, 12 mid night every patient is on
his/her bed, also patient that came in the night would be counted.

CONFIDENTIALITY
1 MEDICAL RECORD: including extracts from medicals. Are highly confidential and the greatest care
and secrecy must be maintained regarding their contents.
2 Staff should not discuss the content of patients, record with any person except as necessary for training
purposes and in the essential courses of their duty.
3 Extracts from medical, bearing the name of the patient, must be regarded in the same way as unit
records. Complete security and confidentiality must be maintained even though information may be in
the form of a routine return (e.g. identification sheet, FHS2 used for Hospital Activity Analysis)
RELEASE OF INFORMATION
The patient health record, which is part of the doctor patient relationship is considered a confidential
document, all employees in the ECF or nursing home are responsible for ensuring that no unauthorized
person ever takes any of these record out of a files, read, copies or otherwise tampers with them. Some
people are authorized to get this information and the health records personnel should be ready to make it
available to them since legal requirement and restrictions about release of medical information vary from
state to state, the facility should have a local attorney for outline basic rules to follow. The attorney should
review the regulation of the state administrative agency responsible for regulating health facilities
(generally the department of health). The attorney should also study federal and state judicial decisions
about medical record and inform the staff of its legal responsibility concerning health record he should
advise all health record personnel of the liabilities of the extended care facility or nursing home if health
record information is improperly released.
DISCLOSURE OF INFORMATION
Information may be released under certain circumstance without the consent or authorization of the
patient. The health facility may allow physicians and other qualified personnel to consult its record for
purposes of study, statistical evaluation, research, utilization review and education. Department and
agencies of the government may also consult these records, according to the applicable legal regulations.
It is important to note that if information from a record disclosed without the consent of the authorized
parties; released for no legitimate purpose, and if the disclosure results in some kind of injury to the
patient (being expose to ridicule, shame humiliation, or suffering etc.) the patient may have the right to
sue the health facility and collect damages.
PREPARING A WRITTEN POLICY TO COVER RELEASE OF INFORMATION,
The following steps needs to be taken
a. Request from doctors, hospital social agencies and institutions concerned with the care of patient,
may be honored according to institution policy.

17
 b. Written authorization from the patient should be secured before releasing of any information to press,
radio, television, or other news agencies.
c. Where there is doubt about the released of any medical information from records, theauthorization of
the patient should be obtained.
REMOVAL OF RECORDS FROM HOSPITAL (POLICIES TO FOLLOW)
1. Any information of a medical nature in possession of the hospital must not be revealed by an
employee of the hospital except as herein after outline.
2. Information may be released to other hospital without signed authorization by the patient upon receipt
of a request from the hospital stating that the patient is now under their care.
3. Request by patient for information concerning their own records shall be referred to the attending
physician in charge e of the case.
MEDICAL CARE EVALUATION
The health record committee of a modern hospital may also carry out an evaluation of medical care
rendered to the patients (using the health record) the aim of programming this evaluation is to improve the
quality of patient care
a) An evaluating search may reveal
i. Post-operative infection
ii. Disagreement between provisional and final diagnosis
iii. Administration of a drug or therapy contra indicated by some aspect of the patient condition.
iv. Removal of tissue at operation, which is later, proved his to pathologically to be normal. The
medical officers concerned should be asked to correct error or fill in omissions found in the health
record. Errors in clinical method may be letter considered by a selected committee of the medical
staff.
PROCEDURE IN CONDUCTING A MEDICAL CARE EVALUATION
1. Study of record patient records discharged the previous month, giving special attention to cases
discharged as “undiagnosed” death and any health records showing discrepancy between
diagnoses.
2. Making use of appropriate statistical report (discharge analysis statistics), they should study the
trend of clinical work in the hospital. Whether it is improving or getting worse in the various
clinical services. If a facility area is found, steps should be taken to remedy the situation.
3. The chief health information manager must be well trained and be able to select inadequate health
record for the committees attention in addition, the committee should check 10% of records which
the chief health record officer, has passed as adequate, either choosing at random from the record
for all discharge patient for the month, or taking the whole 10% from one service. E.g.
OTHOPAEDICS until health record showing the work of all the clinical services have been so
scrutinized (over a period of months).
Quality Control: qualification control for the purpose of this lecture is defined as those evaluation
procedures that are performed systematically to ensure that established policies and standards are being
met. These procedures include the Quantities and qualitative review of health record, the evaluation of
health record services and the evaluation of patients care or medical audit. The evaluation of patient care
is mentioned because of the great dependence, this types of evaluation has on the availability of complete
and accurate health records.
REVIEW OF HEALTH RECORD
Quantities analysis is the review of health record to ensure that they are complete and accurate and meets
the standards established for them (either by national group, the health records committee or both). It is
the responsibility of health records personnel to perform this analysis on inpatients and outpatient records

18
 in Centre’s that are staffed by only one person, this type of analysis may be a function of the supervisor
who visits the center periodically.
QUALITATIVE ANALYSIS IS THE REVIEW OF THE RECORD TO ENSURE THAT
1. It contains sufficient information to justify the diagnosis, the treatment and the end result.
2. There are no discrepancies or errors. The responsibility of this review falls on physicians (or other
health care professionals) and on the health record committee.
Policies should specify what records are to be reviewed, what points are too included in the review and
who is responsible for the review.
3. All opinions supported by the finding
QUANTITATIVE ANALYSIS

Patient. Name: Hospital No

Health Record Rec. Completeness No

Addiction Of Miscellaneous Report

Notification Of Responsible Parties

Discharged Analysis
Completing Information

Coding and Indexing

Filling for permanent files Final Analysis

THE SOCIAL IDENTIFICATION DATA OF PATIENT

1. Age –use for drug prescription
2. Name-use for identified of the patient
3. Address-use for contact of the patient.
4. Sex-is for diagnosis of disease gender different.
5. Date-to know when a patient comes and leaves the hospital.
6. Hospital no- for filling patient record.
7. Next of kin-is use for claiming the interest of the patient in hospital.
8. Tribe-this is use in getting some disease that has due .tradition face.
ALPHABETICALNUMBERINGSYSTEM
Placing surname first, middle name and other names. In the case of more persons bearing the same name,
the cards are arranged according to date of birth or date of registration e.g master index card this system is
ideal for a small hospital especially specialist hospital like psychiatric hospitals where the volume of
records involved is small. It does not required master index cards as back up for the system.
SERIAL NUMBERING:
This is the method or type of numbering whereby the patient is assigned a new number at every visit to
the health care facility. If the patients visit the hospital on five (5) different occasions, he/she will have
five (5) different numbers assigned to him/her accordingly and such records would be filed in their

19
 respective position. In this case time is saved, but there is waste of stationeries and the patient’s records
are scattered.
TYPE OF HOSPITAL THAT USES SERIAL NUMBER ING SYSTEM
This method can be used to number causality/ emergency records, or in a small hospital without
ambulatory services it might be used to number health records.
This method is also in use in a small hospital with few readmissions clinics.
a. TB Hospital
b. Mental Hospital
c. Terminal patient hospital
ADVANTAGE OF SERIAL NUMBERING SYSTEM
The following are the advantage of serial numbering system
1. Easy to control numbers accurately
2. File expand easily for small hospital
3. Easily adaptable o to microfilm
4. More filing space – 100% capacity.
DISADVANTAGE OF SERIAL NUMBERING SYSTEM
Here is the disadvantage of serial numbering system
1. All charts are in different location
2. Time consuming to pull/file health records
3. Researcher are more difficult and costly to do
4. Transfer of inactive files are difficult to implement
5. Is not economical, printing of stationery etc.
UNIT SERIAL NUMBERING:
This is the type of numbering whereby the patients is assigned a new number at every visit and the
previous records which he has in the facility are brought forward and are filed under the current number.
In this case there is waste of stationeries even though the records are filed in one place.
TYPES OF HOSPITAL THAT USES SERIAL UNIT NUMBERING.
1. Small hospital with a few admissions or re admission.
2. Clinics
3. TB hospital.
4. Mental hospital.
5. Terminal patient Hospital.
ADVANTAGE
1. It is easier to control member issued out.
2. All health record put together help in research done individual cases.
3. Creation of more filling space-100%.
4. It is well suited for micro film.
DISADVANTAGE
1. There will be uneven fill expansion.
2. It necessitates back shifting of health records.
3. Bringing of charts forward is a time consuming.
4. It makes studies difficult and confusing with the numbers.
UNIT NUMBERING SYSTEM
This is a system in which one number is assigned to a patients records that patient retains that one
number forever. Regardless of the number of times that the patients enters or leaves the system. That one
number is retained and entered on the master patients’ index to identify the patient’s records,

20
 Unlike the serial numbering system provides a single record which composite of all data gathered on a
given patient, whether as an inpatient, ambulatory care or emergency patients. The patient is assigned a
number on his first admission, and treatment. His entire health record will be in one folder under one
hospital number with unit numbering, e.g. each time Ibrahim arrive to the hospital doors for treatment, he
would receive the first number he had been assigned 17-20-4
TYPES OF HOSPITAL THAT USES UNIT NUMBERING A SYSTEM.
1. University teaching Hospital because of high admission and read mission and research activities.
2. Specialized hospital
ADVANTAGES OF UNIT NUMBERING
1. All patient records are together and best suited for health records personnel to handle.
2. No confusion in the system
3. It eliminates the task of gathering separate parts of a patients record together,
DISAVANTAGE OF UNIT NUMBERING.
1. It is difficult to estimate space for readmission (filling space)
2. Hard to control numbers.
3. Removal of inactive records from the file for purging or micro filming is difficult when using unit
numbering system.
NUMERICAL FILLING SYSTEM
The filling method under which files and folders are arranged in order of number is called numerical
classification. All files and folders are given separate number. It is indirect method of class, function of
filling.
In this filling alphabetical index is required. It include: name, address, phone number, subject and other
information along with file number.
If a numerical record identification system is used, then a numerical filling system is used. There is main
system of filling record numerically.
ESSENTIAL OF A GOOD FILLING SYSTEM
1COMPACTNESS: To take cognizance of the value and cost of storage space, and also the need to
reduce physical effort in working the system.
2 ACESSIBILTY: For speed of location and means of identification items, the records must be readily
accessible.
SIMPLICITY: Whatever the system or methods adopted must be simple to understand and to operate.
4 ECONOMY: The filling system must not be excessive costly in cost either to install or to operate.
5 ELASTICITY: The system should be able to expand and contract according to future requirements and
to ensure extraction and disposal of dead matter without much disturbance.
CROSS REFFENCE: This facilities must be considered so that a folder can be fund under difference
heading
.
7 TRACER CARD: A tracer card must be placed in position of a folder to show the location of the folder
document in circulation.
8 A method of classification
9 Retention: Current Note must be kept for the requisite length of time.

MIDDLE DIGIT: Is the types of filling were the record number is divided into three (3) pairs of digit.
The two middle digits stand as primary number, the first two digit stand as the secondary numbers while
the last two digits stand as the tertiary numbers and filling is done considering the numbers in that order.
21
 05 32 41
Secondary primary tertiary
ADVANTAGES
From the example given one can see that blocks 100 files (i.e 56-78-60-567-899) are in straight
numerical order. This has advantage of
1. Simple to pulling to 100 can consecutively number files for study purposes.
2. Conversion form a straight numerical system to a middle digits system is much simpler than is
conversion to terminal digits.
3. Block of 100 files pulled from a straight numerical file are in exact order for middle digit filling.

DISADVANTAGE
1. Training is more involved than training for straight numerical filling.
2. Gaps result in the file when large groups of records are pulled for in activities storage.
3. Unlike the terminal digit filling system, middle digit filling does not lend itself well to numbers
with more than six digits.
TERMINAL DIGIT
Usually 6 digits number is utilized and divided into three part, each part containing two digits. The
primary digits are last two digits on the right hand side of the number: the secondary digits are the middle
two. The tertiary digits are first left side of the number. Eg

Tertiary Digits- secondary digits- primary digits

46 93 27
46 93 27
In terminal digit file, there are 100 primary sections, ranging from 00 to 99 when filling. A clerk
considers the primary digits first, taking the record to the corresponding primary section. Within each
primary section, groups of records are matched according to secondary digits. After locating the correct
secondary section, the clerk files in numerical order by the tertiary digits which changes with very record.
Note the under listed sequence in a terminal digits.
46-52-02 98-05-26 98-99-30
47-52-02 99-05-26 99-99-30
48-52-02 00-66-26 00-00-31
49- 52-02 01-06-26 01-00-31
56 78 98
56 78 97
56 78 98
ADVANTAGES OF TERMINAL
1. Even distribution of record throughout the 100 primary sections.
2. The congestion that results when several clerk file active records in the same area of the file is
eliminated.
3. Clerk may be assigned the responsibility for certain section or the files. E.g. oo-24, 25-49, 50-74 and
75-99 even distribution of duties.
4. Annual shifting of record is prevented.
5. It is possible to estimate.
6. It aids confidentially.
7. Misfiling is substantially reduced.
DISADVANTAGES
1. Training period necessary unlike the straight numerical.
22
STRAIGHT NUMERICAL
Consist of filling the records serially, in the sequence they were assigned to the patients from smaller to
bigger number. E.g. 328782, 328783,328784
E.g. Diagnostic index cards and the system in the central library. It has the advantage of.

ADVANTAGES
1. Easy to understand.
2. To pull say fifty case notes for study.
3. To pull record for secondary storage.
DISADVANTAGE
1. Because a clerk must consider all digits of the record number at one time it is easy to misfile.
2. Transposition of number is common.
3. Several clerks file at the same time are bound to get in each other’s way.
FAMILY UNIT NUMBERING
Family numbering is a type of unit numbering system. In this system, the entire family is assigned one
number and all information on visit by any family member is filed in one location. This system may be
appropriate for use in family practice settings, but care must be taken to preserve patient privacy.
SOURCES OF NUMBER FOR PATIENT REGISRATION
1. Accident and emergency age.
2. General outpatient dept GOPD.
3. POPD
4. GYNAE.
PATIENT NAME INDEX CARD.
The master patient index is a permanent list of all patient names who ever been admitted or treated in the
hospital or health facilities. The information contain in this card varies with the size and needs of the
health or hospital institution.
The information contain in this varies but the following are common.
-Patient name.
- Sex and age.
- Date of birth.
-Address telephone number.
- Hospital number.
- Date of admission& discharge.
-Treatment date.
- Name of services unit.
-Attending physician.
- Ethic group. U I.T.H ILORIN (MNI CARD)
- Occupation
-Change of address Surname……………………………………. Unit
MASTER PATIENT INDEX CARD. no…………………………….………

First name(s)…………………………………………………..

Date of birth sex M F

Age………….

23
 THE PRIMARY PURPOSE OF MASTER PATIENT INDEX CARD

Primary purpose of master patient index card is to provides entry into the filling system but it can be
extended without prejudice to perform other function according to demand. The recorded information for
its function should be kept to minimum and should comprise of the basic patient identification.
USES OF THE PATIENT MASTER INDEX
1. It helps in coding &indexing
2. It helps to locate the patient record if the patient lost his/her hand card.
3. Is also use in term of research?
STEPS IN PATIENTS REGISTRATION.
1. The patient must come with receipt evidence of payment.
2. Health record officer will upon the folder for patients.
3. The patient will asked to Wait at GOPD.
4. The folder will be taking to nursing station for triaging.
5. From nursing room to be sent to consulting room for consultation.

MATERIAL USE OF REGISTRATION OF A PATIENT.

1. Pen
2. Table
3. Register
4. Ruler
5. Chairs
6. Computer accessories
7. Pencil
8. Eraser
METHODE OF DELIVERING PATIENT RECORDS FOR CONSULTION
The patient health records are initiated by health records office, after that, he would forwarded to
consultant in the consulting room
INDIVIDUAL UNIT RECORD: This is a types of record which are kept individual example the
principal which is the father, spouse which is the wife, the dependent which are the children have
individual record.
Advantage
1. One patient one record
2. Easy for research & education
3. Easy for retrieval
Disadvantage
1. Very bulky
2. Consume the space
1. Family unit records (family folder)
This kind record is used by more than one person in the same family is meant to see the doctor, the name,
age and sex of the patient is written on the history sheet for continues of treatment.
Advantage
1. It reduces cost of material.
2. It allows space for other files to be field.
DISADVANTAGES
1. It can become cumbersome to access the last treatment in the file.
24
 PATIENT HELD RECORD
These records are initiated primary to be handed by the patient and to be brought to the hospital when
he/she wants to see the health officer on duty at the health center. These records are usually will protected
and simple to understand by any health worker, it is also able to with stand continuous handing example
of such record is the immunization card.
ADVANTAGE
1. The records can be used at any health center if the need arises.
2. It is noticeable because of its distinct features, i.e color and largeness which remain the patient the need
to see the doctor or the health worker.
3. Because of the protection i.e lamination of the record, it is able to withstand handling by the patient and
getting destroyed by liquid i.e rain.
DISADVANTAGE
1. It can get missing.
2. 2. It might be damages as a result of rough handling by patient.
HOME BASED RECORDS
These are records that are given to the patient to carry at home.
This is done because of either the nature of the condition and their usage.
These include:
-Certificate of fitness
-Immunization records.
-Record of cases like, Asthma.
Mental illness.
Diabetes etc.
ADVANTAGES
1. It ensures continuity of care.
2. Patient can be seen and assisted anywhere.
3. Reduces wasted of time.
4. It Stimulate patient co-operation and attendance.
DISADVANTAGES
1. Record is exposed to damage.
2. Do not enhance confidentially.
3. Record can get missing.
1. FILLING SYSTEM: in health care can be defined as a set of document convenience reference and
preservation.
The primary responsibilities or health records department is to initiate presence and make timely retrieval
of records possible. The department under takes the custody, classification and presentation. Maintain
confidentially and retrieval of patient case history.
SHELVING: is a place in the library where patient case folder is kept for future use.
3. MISFILING
This is where by a patient case folder is being arrange in the shelve wrong position
4. MISLAYING: this is a situation where by the Health records officer does not kept patient case folder
where is support to be kept in the hospital.
TRACER SYSTEM
A tracer system is a system, which is introduced into the unit system, which a unit health record, is
initiated so that the where about or the movement of patient case note can be easily as curtained.
25
Operational
A transfer card issued at the same tie the unit health records is initiated while the patient is still physically
present in the hospital for health care, the transfer card is send to the record library and is filled away in
the space on the shelf for that ease folder when the face returned it is the duty of the fillings staff to ensure
that the trace card is put inside the case folder and to record the date of return on the trace card.
CONTENT OF TRACER CARD
1. Date issue.
2. Identification of the records issue (Hospital Number)
3. The name of borrower or department
4. Purpose
KIND OF TRACER CARD SYSTEM
a. Personal tracer system
b. Common tracer system
c. Library tracer system
(a) Personal tracer system
The personal tracer card is best suitable for the immediate location of health records (case note)

ADVANTAGE
The great advantage of personal tracer system library tracer system and the requisition holder s that every
time a patient note is taken out of fill the destination is entered on the same card and that card becomes a
very brief history of that patient hospital life.
Another advantage is that names and hospital number one penalty written on the card from the beginning.
COMMON TRACER SYSTEM
The common tracer system is a system where a single tracer card is used to record the movement of health
record (case folder) of many patient this means that one of the case note are borrowed and recorded on a
common tracer card and it return the entry is crossed of from that card, with the result that when some
health records are borrowed again and record on a common tracer card the staff in charge may forget to
cross off. One or two of such return case note- make common tracer system very unsuitable.
LIBRARY TRACER SYSTEM
Tracing system of document in circulation to avoid lost misplacement
Filing procedure
1. The record should be sorted before filling
2. Only record personnel should be allowed to handle the records and to the filling
3. Records with torn covers those with loose papers should be repaired to prevent further damage or
loss of valuable documents.
4. The person supervising the file area should keep a report of activities in the area.
This system contains similar information like the personal tracer. The size library tracer card is not as
large as personal tracer card, with the result the when some Health records is being borrowed, the library
tracer card box provided for the purpose. At the same time: the personal tracer card is taken out and field
on the shelf in the space for the borrowed Health Records.

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