Chapter three continuation
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CHAPTER THREE …..CONTINUATION DUTIES AND RESPONSIBILITIES OF A HEALTH RECORDS TECHNCIAN / OFFICER The health records officer should be able to:-
Manage and organize a health records and information service. Manage and maintain a health records and information system. The other responsibilities include; Initiate , collect, store ,and retrieve health records Collect, tabulate, analyze, interpret and store health information. Disseminate health information and provide feedback. Establish good public relation. Plans supervise coordinate work in a health records services. Maintain regal aspect and security of health records. Maintain health records equipment. Maintain health records indices. Classify code and index diseases. Schedule patient’s appointment. Edit records and provide quality assurance. Provide first aid Receive, register, admit and discharge patient. Establish mechanism of patient follow-ups Handle disaster and special records / participate in basic operational research. Participate in teaching health records and information students and other health workers in the community on health records. Design various health /client forms Control client forms and finance. Budget and control health records equipment, supplies and medical stationary. CHAPTER FOUR FUCTIONS OF A HEALTH RECORDS AND INFORMATION DEPARTMENT Introduction This chapter explains briefly the functions of a health records department and the relationship with other departments in the health care capacity. Learning objectives The student should be able to:-
Define health records department. Enumerate the various functions of a health records and information department. Explain the various functions of a health records and information department. Def.; The health records department is where health records / information are kept. THEVAROUS FUCTIONS OF HEALTH RECODS DEPARTMENT ARE:- Reception Registration Admission Discharge Appointment Filing Tracking Follow-up of patient Clinic preparation Coding and indexing Collecting, tabulation, analyzing and dissemination of health information (statistics) Maintenance of health records equipment. Maintenance of the confidentiality of health records Manage special health records Designing medical forms Ensure quality assurance of health records RECEPTION This is the reception of patients when they arrive in the facility. In this area the patient/ clients are greeted and welcomed to the hospital REGISTRATION This means recording of identification details mostly social on documents needed for any attendances. ADIMISSIN The same identification details recorded during registration is used and the ward number added on the form. DISCHARGE This is a procedure followed when a patient is supposed to leave the hospital after treatment. APPOINTMENT Patients are asked to report to the various clinics on certain time and dates ready to be seen FILING. It’s a systematic way of arranging documents in a prescribed order or manner. TRACING. This is the tracing the movement of all the documents and their whereabouts. CLINICAL PREPARATION It is getting ready of all documents within 48 hours in advance before a patient attends a clinic. FOLLOW-UP OF PATIENTS. This are patients who require follow up after they have been discharged from the hospital such as cancer cases. CODING AND INDEXING Diseases and operations other and other procedures in medicine need to be coded and indexed using the international classification of diseases, ICD and international classification of procedures in medicine ICPM according to WHO. COLLECTION, TABULATION, ANALYSIS, INTERPRETATION AND DISSEMINATION OF DATA ( statistics ) Raw data collected from health records are put in tables, analyzed, interpreted and forwarded to the users. MAINTAINACE OF HEALTH RECORDS EQUIPMENT All the equipment used in a health records department must be maintained by a health records and information officer / technician. MAINTAIN CONFIDENTIALITY. All information in health records document is confidential and should not be handled by unauthorized person. MANAGE SPECIAL HEALTH RECORDS. There are special health records that are initiated and handled differently from other records, Namely:-
Psychiatric records Tuberculosis records Maternity records Sexually transmitted diseases records HIV/ AIDS DESIGN MEDICAL FORMS All medical form are supposed to be designed by the health records and information technician in consultation with the users. ENSURE QUALITY ASSURANCE OF HEALTH RECORDS The quality of the records will reflect the type of health care being rendered to the patient / client. The relationship between a health records department and other department in a health facility. The medical records officer in the facility is expected to co- ordinate the day administrative functions with other department in a hospital. Some of the department in a facility is listed below.
Laboratory X- Ray Radiography Orthopedic Dental Physiotherapy Occupation therapy Department of nursing Department of oral health Supplies Accounts Transport Maintenance Nutrition Pharmacy All this co-ordination is done to enhance the treatment of the patients. Therefore the stands in the middle and all these activities revolve around the patient. No one department is more important than the other , they should work together towards the achievement of this common goal. CHAPTER FIVE RECEPTION, REGISTRATION AND INITIATION OF PATIENTS / CLIENTS RECORDS Introduction This chapter explains the reception registration and how the patients / clients records are created. Learning Objectives The students should be able to:-
Define reception, registration and initiation of health records. Receive patients / clients. Register patients / clients. Initiate patients / clients records RECEPTION OF PATIENTS / CLIENTS Reception is the act of greeting and welcoming the patients / clients. The right person should be selected for that work because he will be the one who will be interviewing and welcoming the patient. He or she should have ease assurance of the manner and a pleasant appearance. He has to convey to the anxious patients that there is nothing to worry about; the hospital is smoothly run, created for his care. This is not a job for a neurotic or anxious person. It requires cool efficiency, the ability to convey confidants, patience and compassion- a very demanding combination of qualities. REGISTRATION OF PATIENTS I t is a completion of personal and health data before a patient is treated. Registration falls into two procedure- that for two out patients and the consultative clinics the registration should be carried out before a patient attends the clinic. The environment should be conducive and the patients should be interviewed individually and in private. The patient is registered, a file opened and an appointment given prior to the clinic day. Another important factor that should be noted is that the patient should be given one unit number and the patient should be asked whether he has attended the hospital before if the answer is no is whe a new number should be given to prevent duplication of numbers. Whether the answer is no or yes, this should be cross checked with the patient master index. INITIATION OF PATIENT RECORD The identification that details that tare taken during patient registration time is used to create patient file .The registration details are:- The patient full names , date of birth, hospital number given, address, occupation, marital status, religion, name of the next of kin, address of the next of kin. Most of hospital has got formed formal system of pre- registration- This is sending the patient a simple form to be completed. This form will ask for all identification details to be confirmed. Any form used should be simple as possible to make it easy for patients for patient to complete it. This form when returned will be used to create the patients / clients health records. The use of mechanical documentation ensures continuing use of the same data throughout the patient’s stay in the hospital. The master index card should also be created during the time that the record is being created and filled immediately .This will help to answer enquiries in case the patient happens to lose the attendance card. Referencing A referencing system helps to provide a means of identifying and retrieving records. This can be used when creating a register or index of records or in the actual file and folder naming. Several types of referencing can be used: 1. Alphabetical 2. Numeric 3. Alphanumeric 4. Keyword The use of a referencing system for electronic files can help to keep information relating to one area/topic grouped together e.g. 1. By preceding all distribution lists in Outlook with DL all distribution lists will appear together in the Address Book 2. The use of numbers at the start of a folder/file can help keep then in a specific order Filing Structure A filing structure provides a framework for organising records. Within the Trust records should be filed within a functional filing structure determined by and depending on their relevance within the individual directorates / services. This ensures that records can be efficiently filed, retrieved and archived or, eventually, disposed of. Ideally, the electronic filing structure should reflect the way in which paper records are filed to ensure consistency. The filing structure could follow the actual the Trust functional organisational structure as below: Corporate Corporate DDiriiereccotoraratete
Service
FFFuunnctcciotionn Individual Individual
PPCTCT Organisational Structure It is recommended that Directorates / Services / Departments / Teams use shared network folders or libraries so that all individuals can access and share relevant information relating to their roles. These network folders should be named from an organisation business perspective and to reflect the role and / or working practices of that area and not a named individual e.g. a folder named Records Manager rather that the Alan F. Access permissions can be set so that only those who need to access these folders can. The IT Service Desk can give further advice and guidance on setting these up. Backing up Data It is important that and electronic data is backed up on a regular basis. In particular staff who use remote computers and / or laptops should ensure the data held on them is backed up to an appropriate location e.g. a network server. For further advice and guidance contact the IT Service Desk. Tracking of Records It is important that records are tracked to ensure they can be located quickly and efficiently are not misplaced or lost. One of the main reasons why records get misplaced or lost is because their next destination is not recorded anywhere. It is good practice to e-mail the intended recipient of the record(s) to advise them the record(s) are being sent and for the recipient to confirm receipt. Using e-mails provides an audit trail but also a means of flagging any follow ups required. Tracing / tracking cards should be used to record if a record is taken out of its primary filing location e.g. to be sent to another location for a clinic. This means someone looking for that record is able to trace it as required. Download 71.83 Kb. Share with your friends:
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