MODULE TITLE: HEALTH RECORDS MANAGEMENT

Introduction to the Module

The module is designed to equip the learner with the necessary knowledge, skills, and attitude
to effectively and efficiently manage health records. . The module has units as follows:

UNIT 1 Introduction to Health Records Management

UNIT 2 Receiving, Registration, and Initiation of Health Records
UNIT 3 Creating and Maintaining Health Records Indices
UNIT 4 Scheduling and Follow-Up; Preparing of In/Out Clinic, Patients
UNIT 5 Admitting and Discharging Patients/Clients
UNIT 6 Storage and Retrieval of Health Records
UNIT 7 Acquiring and Maintaining Health Records Equipment
UNIT 8 Legal Aspects of Health Records
UNIT 9 Managing Special Records
UNIT 10 Managing a Health Records and Information Office
UNIT 11 Establishing a Health Records Department In a Health Care Facility
UNIT 12 Developing and Designing Health Record Forms
UNIT 13 Ensuring Quality Assurance in Health Care Services
UNIT 14 Introduction to Electronic Health Records

MODULE OUTCOMES
At the end of the module the learner should be able to:
1. Give an overview of the health records discipline and its organisation
2. Describe the procedures used in reception, registration, and initiation of patient/client
records
3. Describe the appointment systems
4. Describe the various methods of creating and maintaining health records indices
5. Display ability to create and maintain health records
6. Explain the various procedures of clinic preparation
7. Describe the admission and discharge procedures
8. Maintain an efficient system of storage, retrieval, and control of health records
9. Explain the various systems of storage and retrieval of health records
10. Describe different methods of acquiring and maintaining health records equipment,
health records forms, and office stationery
11. Demonstrate ability to acquire health records forms and equipment and office
stationery and supplies
12. Describe legal aspects of health records
13. Enumerate the various notifiable diseases
14. Describe various types of special records
15. Describe how to establish a Health Records Department
16. Educate the community and other health workers on the importance of health records

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 17. Describe how to design and develop health record forms
18. Appreciate the importance of quality assurance in health care
19. Display thoroughness and efficiency in managing health records
20. Appreciate the importance of confidentiality in dealing with health records
21. Definition of electronic health records and electronic medical records system
22. Explain the concepts of electronic health records system

UNIT 1

INTRODUCTION TO HEALTH RECORDS MANAGEMENT

The health record is a written collection of information about a patient. It originates from the
patient's first encounter or treatment at a hospital, health post or other primary health care centre.
The health record is thus a record of all the procedures carried out on that patient, while he is in
the hospital or under treatment at a clinic or centre. It should contain the past medical history of
the patient, including opinions, investigations and other details relevant to the health of the
patient. You might also hear patients referred to as “clients” in certain settings. Sometimes these
words are used interchangeably.

As a document it may appear in many shapes and sizes with varied information related to the
care of the patient recorded by many health care professionals in many ways. In physical
appearance, it consists of a number of sheets of paper or cards and may be placed in a cover or
envelope. In more advanced health care facilities, the information may be recorded digitally in a
computer; the sheets of paper scanned onto optical media or the actual sheets may be
microfilmed. (Microfilming is similar to taking a picture of the paper and storing it on a film
strip.)

Edna Huffman (1994), one of the first medical record professionals in the U.S., defined a health
record as "a compilation of pertinent facts of a patient's life and health history, including past
and present illness (es) and treatment(s), written by the health professionals contributing to that
patient's care. The health record must be compiled in a timely manner and contain sufficient
data to identify the patient, support the diagnosis, justify the treatment, and accurately document
the results."

The actual physical record should be of an acceptable size and standardized on suitable
forms, as far as possible to enable interchange of information, from hospital to hospital,
hospital to health centre, hospital to general practitioner or other primary health worker. The
record must contain forms approved by the facility and the folder itself should be of a
standard weight.

HISTORICAL BACKGROUND OF HEALTH RECORDS DISCIPLINE

Learning Objectives

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The learner should be able to:-
Define health records
Give a historical background of health records discipline
Define a health records department
Enumerate the functions of a health records and information department.
Explain the various functions of a health records and information department.

Definition
A health record is any written document about a patient in a professional relationship with a
doctor.

Historical Background
The history of Health Records runs parallel with the history of medicine. Records are
necessary for the practice of medicine as medications are for effective treatment, and they
seem to have been made from earliest antiquity.

The first real physician of health records in Egypt is Imhotep. He lived in the pyramid age
(about 3,000 – 2500 BC) and was grand vizier, chief architect, and royal medical adviser to a
Pharaoh of the 29th century before Christ. Imhotep has been credited with the authorship of
the Edwin Smith Papyrus. This papyrus is one of the most valuable ancient medical
documents that has come down to us and appears to have been copied about 1600 BC from
an earlier original. This papyrus is a roll over 15 feet by about 3 inches wide and is made up
of 12 sheets of the usual size. It is written on both sides and consists of 48 cases of Clinical
Surgery.

In Greece Hippocrates, known as the “father of medicine” was born about 460 BC. He was
the first to cast out superstition and to practice medicine on scientific principles. He was the
author of the Hippocratic Oath, which is pledged by physicians and which states in part:
“whatsoever in my practice or not in my practice, I shall see or hear amid the lives of men
which ought not be noised abroad- as to this I shall keep silence, holding such things unfitted
to be spoken”. Thus originated the privacy of all information given to physicians by patients,
eventually the Health Records per see was, also considered as privileged communication.
Hippocrates kept detailed case reports of his patients.

In the 18th Century, Benjamin Franklin was one of the first leaders in the movement to
establish the first incorporated hospital within the United States. This institution was known
as Pennsylvania in 1751. Franklin served as secretary of the hospital, and many of its earliest
records are in his handwriting.
In the 19th Century in 1821 the famous Massachusetts General Hospital Boston opened. Is has
the distinction of having a complete file of clinical records, with all cases catalogued, dating
from the day it opened.
In the 20th Century, it was not until the beginning of this era that medical records received
serious consideration by other types of hospitals and especially by hospitals and medical
associations.

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In 902 the American Hospital Association discussed Health Records for the first time at a
convention.
In 1948 Health Records Association was started in Britain.
In 1967 the Department of Health Records was started in Kenya at Kenyatta National
Hospital, Nairobi.
In 1978 the Health Records and Information Technician Program was started at the Medical
Training College, Nairobi.
In 1990, the Health records and information officers program was started at the medical
training college, Nairobi.
In 2003, the certificate records program was started in the KMTC Muranga campus, 2008
Siaya campus in 2010 Msambweni campus,
In 2011,Kitui campus,in 2012 Bondo,in 2013 Webuye.
In 2009, a degree program was started in both Kenyatta University and Mt Kenya University.
In conclusion, the demand for quality information in both public and private health
institutions for evidence decision making in managing health care services and resources
prompted the increase of qualified personnel to run health information systems in Kenya.

PURPOSE OF THE HEALTH RECORD

As indicated above a good complete health record should encompass all information about a
patient's health, ill health, treatment over a period of time and patient status at discharge . Health
records are kept for:-
1. communication purposes
2. continuity of patient care/ treatment

3. evaluation of patient care

4. monitoring and evaluation of health systems

5. medico-legal purposes

6. statistical purposes

7. research

8. Education.

9. historical purposes

Communication purposes:-

Health records are kept initially for communication between

persons responsible for the care of the patients present and
future needs.

. Some of these people include:

 consultants, physicians, surgeons, obstetricians

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  nurses
 physiotherapist
 occupational therapists
 medical social workers
 laboratory technologists
 dieticians
 medical students
 radiologists, etc.

Medical record staff will have access to the record to ensure that all documents are appropriately
filed and organized and may also perform quality audits or research as requested by the facility
or other agency.

Continuity of patient care / Treatment

The patient may be readmitted to the same or another hospital or visit a clinic where all his past
medical history should be available for assessment in the light of their current problem. It is vital
that the health care professionals, who is responsible for the patient as a whole, should receive
information about a patient's hospitalisation as soon as possible after the patient is discharged
from [Link] main function of the health record department in a hospital or clinic, in this
context, is as a service area, that is, medical records should be produced for patient care at all
times and as quickly as possible. Also, discharge summaries and letters must be processed so
that people outside the hospital may be informed of the patient's progress and their continued
management after discharge.

Evaluation of patient care

In any setting in which an individual puts the responsibility for their health and well-being into
the hands of others, there should be some mechanism that enables evaluation of the standard of
care being given. In some countries, hospital medicine is evaluated by an 'accreditation' system.
Surveys of each hospital are made and hospitals given 'accreditation' by a Board for a limited
number of years, depending on the standard which they reach. Also, in some countries, the
health record services of a hospital must meet predetermined standards.
The health records are first and foremost of value in the present and future treatment of the
patient.
Medico-legal aspects:-
Occasionally, health or medical records are used to substantiate
substandard care and are then used to bring a lawsuit against a
health professional in court in case of professional negligence or
malpractice

The record also, however, protects the patients by documenting all injuries and diseases or
conditions in the record so that there is no confusion about what happened to the patient.

Statistical purposes:-

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Statistics are collected in hospitals, clinics and in primary health care centres. They may be used
to tabulate numbers of diseases, surgical procedures and incidence of recovery after certain
treatments; to assess areas which the hospital or clinic serves by collecting demographic details;
or for public health or epidemiology. The morbidity and mortality statistics collected are used in
planning health services activities, decision making, and day today running of the institutions.
Research
In the past, accurate recording of observation in the health record would lead to accurate
information required for research, but demographic and epidemiological information contained
in the record is more often used today for purposes. The MOH (Ministry of Health) will use data
reported from medical records through the current HMIS reporting structure to compare diseases
and conditions across hospitals in the country and, in turn, will report data to the World Health
Organization for comparisons throughout the world. The facility where the data is collected
should also use the information to improve patients.
Education
Health records can be used as an education tool or instrument. When the quality of health
records is high the task of a learner is simplified and verse visa when the quality is poor the
learners task is made more difficult and his progress is there for impended . The physician
interested in a case may use the information from the records teach his students.
Historical purposes
The record acts as a sample of the type of patient care and method of treatment used at a
particular point in time. Because all information is recorded in the record, those treating the
patient can go back to earlier visits to see previous methods of treatment. Patients themselves
can also access their records to verify dates of visits and treatments they have received.

Administrative Purposes
Complete health records mean increased and deficient to the patient and to the public, these
will help to avoid vexation, litigation, fair settlement of claims and capacity to answer
enquiries on how the institution work. Equally complete health records will assist the
administrators in the smooth running of the institution.

ORGANIZATIONAL STRUCTURE OF A HEALTH RECORDS DEPARTMENT

Since the department has a variety of functions, it is necessary to organize the department into
functions with employees assigned to each function. In small facilities, several of the functions
may be performed by one or two employees. However, an organization chart for a medical
record department may look like this:

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 Medical Records Org Chart

c
The person in charge of the department may be called a “director,” “manager,” or “an assistant
manager.” The number of staff or employees in each department will vary by the size of the
facility and the numbers of patients seen in the facility. Some departments may have thirty (30)
employees including managers and supervisors and others may have ten (10) or even fifty (50).
Some large hospitals in other countries have as many as 100 employees. The number of
employees may also vary based on whether the facility has a computer system or is using paper
medical records. In a computerized system, manual retrieval of records is not necessary.
Organization charts will also look different in different facilities but it is recommended that the
director or manager of the department report to the chief executive officer. It is also
recommended that patient/client registration function report to the Director of Health records
&information officer in charge.

FUNCTIONS OF A HEALTH RECORDS AND INFORMATION DEPARTMENT:-

THE VARIOUS FUNCTIONS OF HEALTH RECORDS DEPARTMENT ARE:-

(1) Reception
(2) Registration
(3) Admission
(4) Discharge
(5) Appointments
(6) Filing
(7) Tracing
(8) Follow-up of patients

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 (9) Clinic preparation
(10) 9 Coding and indexing of diseases
(11) Collection, tabulation, analysis and dissemination of information (statistics)
(12) Maintenance of health records equipment
(13) Maintenance of the confidentiality of health records
(14) Manage special health records
(15) Design medical forms
(16) Ensure quality assurance of health records
(17) Develop and implement electronic health records systems
(18) Attending National, county and health facility meetings

1. RECEPTION
This is the reception of patients when they arrive in a health care facility. In this area the
patient/ client is greeted and welcomed to the hospital.
2. REGISTRATION
Registration is the documentation of bio data of individual patients/client needed for his/her
attendance

3. ADMISSION
Admission is the process of taking a patient to the ward for in-patient care and management,
the registration details are used for admission. The admission details includes:-Names of the
patient, sex, date of birth, marital status, physical address, occupation, name of next of
kin/address, name of the ward, name of the admitting doctor, mode of payment, diagnosis.
4. DISCHARGE
This is a procedure carried out when a patient is supposed to leave the hospital after
treatment, which is contained in the in-patient discharge summery sheet which indicates the
mode of discharge(abscondees, dead, alive, transfers in, transfer out, paroles).
5. APPOINTMENTS
This is a scheduling and follows up procedure given to the patient indicating the venue, date
and time of clinic. Patients are asked to report to the various clinics on certain time and dates
ready to be seen.
6. FILING
This is a procedure which either manual or electronic used to arrange the documents in a
prescribed order or in systematic manner.
7. TRACING
This is a system with procedures for documenting maintains the movement of movements of
all the documents pertaining to the health care which has been given to the patient/client.
8. CLINIC PREPARATION
This is a process of getting ready all the documents – 48 hours in advance before a patient
attends a clinic.
9. FOLLOW-UP OF PATIENTS
There are some patients who need follow-up after they have been discharged from the
hospital such as cancer cases.
10. CODING AND INDEXING

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Diseases and operations and other procedures in medicines need to be coded and indexed
using the international classification of diseases, ICD/EICD and the international
classification of procedures in medicine ICP (WHO).
11. COLLECTION, TABULATION, ANALYSIS, INTERPRETATION AND
DISSEMINATION OF DATA
Raw data collected form health records are put in tables, analysed interpreted and forwarded
to the users.
12. MAINTENANCE OF HEALTH RECORDS EQUIPMENT
All the equipment used in a health records department must be maintained by the health
records and information manager/assistant.
13. MAINTAIN CONFIDENTIALITY
All the information in a health records document is confidential and should not be handled by
unauthorised persons or disclosed without due consent from the patient/client. All employees
should be bonded by signing the secrets declaration form to undertake not to release any
information concerning a patients/client to unauthorized person. The case records should be
kept in a secure storage system.

14. MANAGE SPECIAL HEALTH RECORDS

Special health records are a type of health records for patients/clients that are initiated and
handled differently from other records, due to the nature/conditions of the ailments/diseases
such as :-
1. Psychiatric records
2. Tuberculosis records
3. Maternity records
4. Sexually Transmitted diseases records
5. STI/HIV/AIDS
6. Accident & emergency records
7. Gender based violence Records
8. Medco legal Records
15. DESIGN OF DATA COOLECTION TOOLS&DATA SETS
All data tool/data sets are supposed to be designed by the health records and information
managers in consultation with the information users. Data tools /Sets should be geared
towards the measurement 0f a specific health indicator.
16. MAINTENANCE OF QUALITY ASSURANCE OF HEALTH RECORDS: -
Quality assurance is the process of monitoring and maintaining the timeliness, consistency,
reliability, accuracy, accessibility and completeness of data.
The quality of the record will reflect the type of health care being rendered to the patient/
client. In order to maintain data quality
The following should be ensured:-
 Protect data generated by the database systems from deliberate bias, manipulation
and/or falsification.
 Take appropriate security measures.
 Collect data using established and consistent protocols and procedures.

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  Respect time schedules for data entry and reporting.
 Set goals for entering data within a set period of time.
 The health records documents are complete and accurate.
1. Routin1. Routine data quality Methods and process of Methods and process of conducting th
conducting the 2. Data quality review meetings Frequency
and structure of forums
3. Data quality supportive supervision Recommended
steps
4. Data quality improvement teams Role and
proposed team compositions data quality audits
2. Data quality review meetings Frequency and structure of forums

3. Data quality supportive supervision Recommended steps

4. Data quality improvement teams Role and proposed team composition

.
RELATIONSHIP BETWEEN A HEALTH RECORDS DEPARTMENT AND OTHER
DEPARTMENT IN A HEALTH FACILITY.
The medical records officer in a health facility is expected to co-ordinate the day
administrative functions with other departments in a hospital. Some of the departments in a
health facility are listed below:-
(1) Laboratory
(2) Radiography
(4) Orthopaedic
(5) Dental
(6) Physiotherapy
(7) Occupational therapy
(8) Department of Nursing
(9) ENT
(10) Supplies
(11) Accounts
(12) Transport
(13) Maintenance
(14) Nutrition
(15) Pharmacy
(16) Community oral health
(17) Patient support Centre
(18) VCT
(19) Youth centre

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All this co-ordination is done to enhance the treatment of the patient. Therefore the patient
stands in the middle and all these activities revolve around the patient/client. No one
department is more important than the other; they should work together towards the
achievement of this common goal.

QUALITIES OF A GOOD HEALTH RECORDS AND INFORMATION

MANAGER/ASSISTANT MANAGER: -
Most of these qualities apply to all professionals in a health care delivery service. A trained
health records and information manager/assistant manager should have the following
qualities: -
(i) Integrity – Honest and upright
(ii) Adaptability – Should be flexible to the circumstances in an environment
(iii) Discretion – Ability to use his own knowledge to make decisions
(iv) Politeness - Humility / humbleness
(v) Calmness – A state of not being emotional in an emergency situation
(vi) Neat appearance – Smart and acceptable appearance in his work
(vii) Consistent efficiency – Effective and exceptional performance in his/her work.
(viii) Personal sense of vocation and service to the other health workers and thence the
patient/client.
Health Records Ethics.
In Greece, Hippocrates, known as the “father of medicine” was born about 460 BC. He was
the first to cast out superstition and to practice medicine on scientific principles. He was the
author of the Hippocratic Oath, which is pledged by physicians and other health workers
including health records personnel. It states in part: “whatsoever in my practice or not in my
practice I shall see or hear amidst the lives of men which ought not to be noised abroad- as to
this I will keep silence, holding such things unfitting to be spoken”. That is how
confidentiality of health records originated and should be maintained until today.

DUTIES AND RESPONSIBILITY OF HEALTH RECORDS INFORMATION

MANAGER/ASSISTANT MANAGER:-
The health records technician should be able to: -
1. Manage and organize health records and health information services.
2. Manage and maintain health records and information systems:

(a) Initiate, collect, store and retrieve health records

(b) Collect, tabulate analyse, interpret and store health information.
(c) Disseminate health information and provide feedback
(d) Establish good public relations
(e) Plan, supervise, co-ordinate work in health records services
(f) Maintain legal aspects and security of health records
(g) Maintain health records equipment
(h) Maintain health records indices
(i) Classify, code and index diseases
(j) Schedule patients appointments

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(k) Edit records and provide quality assurance
(l) Provide first aid
(m) Receive, register and admit and discharge patients
(n) Establish mechanism for patients’ follow-up
(o) Handle disaster and special records conduct/ participate in basic
operational research.
(p) Participate in teaching health records and information students
and other health workers and community on health records.
(q) Design various health/ clients forms
(r) Control client forms and finance
(s) Budget and control health records equipment, supplies and
medical stationery.

UNIT 2
THE UNIT HEALTH RECORDS SYSTEM
INTRODUCTION
This is a Health Records system where one patient is given one number for the rest of his stay
or attendance in one hospital, otherwise known as a unique identifier, where the unit is the
patient/client.
Learning objectives
Students should be able to:-
1. Define the unit systems
2. Describe the health unit system
3. Initiate the unit record
4. Prevent the duplication of the unit number
5. Describe the contents of the unit health records.

Definition: -
The unit system is a health records system in which all health records notes relating to one
patient are contained in one case folder- the patient is the unit.
Initiation of the unit system: -
The change from the old system of numbering to the unit system presents no difficulties.
From any given day it is simply necessary to assign a unit number to every patient attending
for the first time. Thereafter, a six digit range of numbers is normally used ranging from 1 to
999,999. Some health records officers prefer to insert zeros at the beginning i.e. 000,001 but
this arrangement is quite optional. When an old patient attends or is admitted at the first time
his old notes are filed at the back of his new unit folder under the new unit number. Only the
old records of the patients who present themselves after the appointed day are brought
forward in this way the others, remaining in the old file under their original identification

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number. A tracer card should be replaced where the old record was indicating the new unit
number.
Prevention of duplication
Duplication in the use of unit numbers can be prevented:-
a) Either by not giving the same number to two patients
b) Not giving the same patient more than one number
In addition to the above the patient can be asked whether he has attended the hospital
previously during registration. Whether the patient says yes or no across checking can be
done through the patient master index to ascertain this.
The unit number register
From the foregoing comments the importance of the unit system will be appreciated if the
unit number register is maintained. In the unit number register the following information will
be included: -
a) Full names of patients
b) Addresses
c) Dates of birth
d) Registration dates
e) Specialty to which they have been referred

The contents of the unit health record

1. The folder
When selecting a folder the following points should be noted:-
i. Strength of manila
ii. Method of fastening documents
iii. Clarity of numbering on the outside cover
iv. Cost of the folder
The folder should be made of tough manila with a gusset and single or double fold inside,
through which are threaded metal or plastic prongs with which the loose sheets may be
fastened into the folder.
2. The front sheet of identification sheet
This is the area where all the patients’ social details are transcribed from the pre-registration
form. The inside front cover of the folder is sometimes used for this purpose. Space should be
provided to record several changes of address and change of a doctor.
A section is often provided here to list the consultants whose clinics the patient has attended
or to whose wards he has been admitted.
It is important that all these facts should be readily visible to the doctor who is in charge of
the patient, and who may wish to remind himself at a glance at the personal facts about the
patient without hunting through sheaves of documents. Is also important that the information
should be complete and accurate so that the person writing a letter to the doctor will address
this correctly, or anyone writing to the patient will send the letter to the correct address.

3. Clinical history sheet

Two types of clinical history are in common use. In one, each consultant has his individual
history sheets on which he only will write. A patient currently attending three different clinics

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will have three separate history sheets although these are likely to be filled next to each other.
An alternative way is the continuous history sheet on which each doctor writes as he sees the
patient. This achieves a chronological statement about the patient which would seem to have
many advantages. If the continuous history sheet is used, it is important that different clinics
that the patient has attended should be easily identifiable – perhaps by using different
coloured rubber date / clinic stamps.
4. Continuation sheet
Some patients’ attendance may be so short that their entire hospital episode is contained on
one history sheet. This is not very usual, and continuation sheets are similar to history sheets
but without any special printed identification of consultant or clinic which enables them to be
used by all consultants.
5. Prescription chart
This chart makes formal provision for the doctor to prescribe drugs for in or out-patients. The
form must always find its way back to the case folder from the pharmacy so that the doctor
treating the patient can see what previous medication has been prescribed.
6. Surgical operation sheet
Special forms are provided on which operations may be recorded. They normally contain
sections in which the names of all surgeons and anaesthetists taking part in the operation are
to be recorded, and special remarks about drainage, blood loss, special recovery treatment
etc.
7 Anaesthetic record
As aesthetic techniques become increasingly sophisticated and complicated, the need for a
special form on which to record the relevant facts has been rendered ineffective. Most
anaesthetic record forms contain considerable amount of detail, filled in by the anaesthetist
during the operation and immediate post operative period
8. Temperature, pulse and respiration (TPR) chart
There are two usual versions of this chart. One is the b.d twice daily chart for the recording of
the routine observations. Urine and stool details are usually recorded at the foot of the T.P.R
chart. A separate chart is often used for 4 hourly recordings for more seriously ill patients.
This is frequently printed on coloured paper, or in coloured ink, to make it noticeable.
9 Report mount sheets
Many reports which are smaller that the size of most forms have to be filed in the folder.
They are usually mounted on a report mount sheet. These mount sheets vary in designs and
methods of gumming. There are two possibilities, all reports may have a gummed edge and
be stuck on the mount sheet itself, or may have a series of gummed strips on to which all
reports will be stuck. Several versions of the mount sheet with gummed strips are available.
The most popular and the most expensive has strips of self adhesive gum protected with
greased paper. The protective paper is peeled off and the edge of the report pressed on to the
exposed gum. This procedure is so much agreeable than having to moisten the edge of a form
as is usually done, unhygienic ally, with the tongue-that its introduction is extremely popular
with all members of staff who have fasten reports into notes. The forms are filed one above
the other, but with approximately one quarter inch or one third inch of the lower edge left
visible so that the date and type of report can immediately be seen. In this way, a dozen or
more reports will be file on one mount sheet.

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10 Consent Forms
Written consent has to be obtained for all operative procedures (which are technically an
assault on the patient). For sterilization procedures, for post mortem examination-the consent
has to be obtained from the patient, relative or parent (if the child is under 16). These forms
are usually fastened onto a mount sheet, often separate one from those used for laboratory or
other report forms.
11. Report Forms
All investigations-laboratory (Haematology, biochemistry, bacteriology, histology)
cardiology, radiological results in some sort of report form that will have to be fastened into
patients’ notes. These reports are becoming rapidly a very special problem, as they swell the
bulk of the folders in rapidly increasing numbers. Some laboratories issue cumulative report
forms each on which in turn replaces all the reports that have been issued previously but
unless the previous reports are conscientiously removed there is no reduction in bulk.
Computerized laboratory reports have not yet provided an easy answer to this problem as
storage space is within the folder.
12 Clinical photographs
When a patient has an unusually interesting condition, a clinical photograph may be taken. In
plastic surgery, where the patient may pass through several stages of treatment, a photograph
is often taken at intervals to record progress. Photographs may be kept centrally in the
Medical Photograph Department, but they are frequently filed in the case folder, either
mounted on card or in a special plastic folder with pockets for the storage of a series of
smaller photographs or slides.
13 In-Patient Summary
After a patient has been discharged from hospital, it is usual for the registrar or consultant to
dictate a “summary’ (though this is frequently a substantial document ) of salient points of
the patient’s progress while as an in-patient carried out operations or other treatment and
condition on discharge are always included. A copy of this summary is often used as the
hospital’s full report to the general practitioner. The summary usually forms the document on
which diagnostic coding is carried out.
14 Correspondences
Copies or originals of all communications from the general practitioner to the hospital doctor,
and from hospital to the general practitioner must be returned. These will include copies of
the discharge note, which is traditionally written by the junior hospital doctor on the day of
the patient’s discharge, to keep the doctor informed of the most important points about the
patient’s stay in the hospital until he receives full discharge summary.
These are some of the more important documents normally included in the case folder, but
there will be literally hundreds more in use in most hospitals, their number and use depending
on the type of hospital. Students will become familiar with these forms as with the case notes.

DIFFERENT TYPES OF HEALTH RECORDS-THEIR VALUES, USES

Learning objectives
The learner should be able to:-
1. Identify different types of health records
2. Explain the uses and value of health records in:-

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 (i) Treatment
(ii) Planning
(iii) Research
(iv) Teaching
(v) Administration
(vi) Monitoring and Evaluation

3. Explain the qualities and responsibilities of a Health Records/Information Technician

TYPES OF HEALTH RECORDS
There are different types of health records:-
 Case records
 Outpatient records
 Diagnostic records

Case Records
These are records initiated for patients who get admitted into the wards or who continuously
attend the various consultant clinics. The information that is contained in the case can be
expressed verbally, graphically, diagrammatically or in a tabular form. This depends on the
person taking in the information. The range of documents to be included in the case record
also depends on the local requirements although certain documents are common in all
hospitals.
Out-Patient Records
This includes all the cards that are used in the Out-Patient Departments, for example the
Casualty Wards, Ante-Natal Wards, Immunization cards and any other card that may be used
in the outpatient departments.
Diagnostic Records
These include notes on Radiography, Pathology, Electrocardiography and other
investigations that are usually initiated by report forms. These forms are usually 6” x 4” in
size and are available in all consultation rooms both in the Out-patient and In-patient
departments in a health care facility. They could be different colours for quick identification.

VALUES AND USES OF HEALTH RECORDS

Health records have various uses:-
1. Treatment
The health record is the first and foremost of value in the present and future treatment of the
patient. The individual record is a reminder to the physician, surgeon, clinician, nurse, social
workers or health records technicians of what he/she has personally observed during the
patient’s illness. It contains information of what has been observed by others. It provides or
should provide the whole previous hospital record of the patient, so that every fact that may
be important is permanently available for reference at any time. A complete record prevents
duplication of work and effort and facilitates future care of the patient (patient follow up).
2. Planning

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Health statistics and information gathered from the health records will definitely be very
useful in the planning of health care services. It is very necessary that these statistics should
be very accurate and disseminated promptly to users:- inadequate records mean incomplete
statistics leading to improper planning of various activities in the health service.
3. Research
Accurate recording of observation in the health records will lead to accurate information
required for research. They should contain that basic information that is required of them to
meet the purposes for which they are intended, one being research. The methods of filing and
retrieving should be systematic and simple.
4. Teaching
Health records can be used as an educational tool or instrument. When the quality of the
records is high, the task of the student is simplified conversely when the quality is poor the
student’s task is made more difficult and his progress is impeded.
5. Administration
Complete health records mean increased and efficient services to the public, avoiding
vexations, litigations and fair settlement of claims and capacity to answer queries about how
hospitals work.
For the record to meet and be useful for the above purposes it should designed for the
purposes for which it is to be used. It is important for the record to meet the requirements of
both the clinician and the records personnel. The records also should be complete. To be
complete the records to meet should be complete. To be complete the records should be
analysed quantitatively by the health records officer and qualitatively by the clinician.

UNIT 5: RECEPTION, REGISTRATION AND INITIATION OF PATIENTS/

CLIENTS RECORDS
INTRODUCTION
This chapter explains reception registration and how the patients/clients records are created.
Learning Objectives
The students should be able to:-
1. Define Reception, registration and initiation of a health record.
2. Receive patients/clients
3. Register patients/clients
4. Initiate patient/client records
1. RECEPTION OF PATIENTS/CLIENTS

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 Reception is the art of greeting and welcoming. The right person should be selected for this
work, because he is the one who will interview the patient. He or she should have ease,
assurance of manner and a pleasant appearance. He has to convey to the anxious patient 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.
2. REGISTRATION OF PATIENTS
Is the completion of a documentation of personal and health data before a patient is treated.
 Registration falls into two procedures – that for out-patients and the consultative clinics the
registration should be carried out before the patients attends the clinic. The environment should
be conducive and the patients should be interviewed individually and in privacy. The patient is
registered, a file opened and an appointment is given prior to the clinic day.
 Another important factor that should be noted is that the patient should only be given one unit
number and the patient should be asked whether he has attended the hospital before. If the
answer is no is then a new number should be given to prevent duplication of numbers. Whether
the answer is yes or no, this should be cross checked with the patient master index.

Types of Registration:-
There are two types of registration, namely-
 Centralised-this is where registration is done one area
 Decentralized-Registration is done in several service delivery points
***assignment(advantages and disadvantages of centralised and decentralised appointment
systems)

3. INITIATION OF PATIENTS RECORD

The identification details that are taken during the registration time are used to create the
patient’s file. The registration details are:- patient’s full names, date of birth, hospital
number given, address, occupation, marital status, religion, name of next of kin, address
of next of kin.
Many hospitals have formed formal systems 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 the 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 cards should also be created during the time that the
record is being created and filed immediately. This will help to answer enquiries in case the
patient happens to lose the attendance card.

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UNIT 6
CREATING MAINTAING HEALTH RECORDS INDICES: -

Learning Objectives
The learner should be able to: -
1. Define various health record Indices
2. Explain the importance of health records indices
3. Describe the procedures used in creating health records indices
4. Describe various equipment used in storage of health record indices
5. Describe the techniques used infilling health record indices.
INDICES
There are various health records indices used and maintained in a health records department
namely:-
1. The Patient Master Index
2. The Diagnostic Index
3. The Operations Index
4. The Waiting List Index

1. The Patient Master Index

Definition
The Patient Master Index is the alphabetical key to the numerically file case records.
Importance
This is a very important index in the case where a patient has lost his attendance cards. The
following details must appear on any index card:-
 Surname
 First names
 Sex
 Hospital number

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  Address
 Space left for change of address.

A typical layout of the card which measures 3” x 2½” or 5” x 3” would be

5”
Name of patient 3” Hospital No:

D.O.B

Address Sex 2½

Space for change

Figure 2-PATIENT MASTER CARD
Of address

Creation of the Patient Master

The Master Index card is created when the patient is being registered.
Equipment used for filing the Master Index Cards
 Cards
 Strip Index
 Elevator files
 Cartwheel
 Carousel type files
 Guide cards
Cards
Cards will be the basic record document in most master indexes. Generally a card must be of
good quality for endurance
Drawer filing
Cards may be filled “blind” in drawers-filed one behind the other in an upright position.
Strip Index
A strip index as its name indicates consists of a series of thin wooden strips coated with paper
on which details required for the master index are filed on metal panels. The strips are filed
on metal panels with a fold of metal down each edge which holds the strips in place. The
panels are hanged on a central revolving spindle so that they fan out like leaves on an open
book. They may also be wall mounted. This is recommended for the waiting list and not the
master index.
Elevator Files
In an elevator file the cards are usually filed in trays about a foot long and several trays about
a foot long and several of these trays are files on a shelf in the machine. The machine looks
like a large metal cabinet which may be up to five feet high and up to ten feet wide, with an
opening at the top. In this opening two or three shelves with their trays of cards are visible.
The largest elevator file would probably hold 900,000 index cards. The large files are
electrically driven. If the card is wanted, the filing clerk presses a button indicating the
shelves; the cards rotate until the correct one arrives at hand level. The clerk then looks in the
appropriate tray for the card. Smaller elevator files are manually controlled.

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The advantage is that there is speedy access to all cards while the clerk is comfortably sitting
on a chair.
The disadvantage is that the machine is expensive and may not be afforded by some of the
health facilities.
Cartwheel type files
In this type the cards are attached to a large upright central wheel which is rotated until the
required section comes on top. This type of file is probably not suitable for a very large
hospital.
Carousel type files
In this type the cards are housed in open metal boxes which are attached to a central upright
spindle. The boxes can be swung out for use and then folded back towards the spindle when
finished with. Because the boxes are attached right round the stem, several clerks can have
access at once. The equipment is space saving considering the number of cards that can be
housed.

The notes carrying a unique hospital number

There are always one or two departures from the unit system in hospitals which use this
system. To maintain confidentiality, some of the departments like Psychiatry may keep
detailed notes about their patients. But the Tunbridge report of 1965 and the Walker report
published in Scotland in 1967 advocates the inclusion of all the patients’ notes even if he
attends any other speciality put together in one folder. We only need to mention this although
this should not be the case.
Guide Cards and back stops
All the equipment described above except the strip index will need some guide card or back
stop. The function of the guide card is to sub divide the file into reasonable sections, so that
little time is spent hunting through several hundred cards before finding the precise section of
the file that is needed. Whatever type of guide card chosen, clear, bold lettering will aid both
filing and finding of cards. Back stops are the pieces of metal that stop the cards in a drawer
that is not full from sliding down. Back stops should be firm enough to stay in place when the
drawer is closed too roughly, but mobile enough to be readily adjustable as the cards have to
be expanded backwards.
Filing Techniques used in filing Master Index Cards
(a) Sorting
The most important step in filing is sorting-which means putting the cards into good order
before being filed.
There are two methods of sorting most appropriate to a master index:-
(i) Use of sort-file –This is series of flaps each bearing a letter of the alphabet-arranged
in a solid base.
(ii) Pigeon Holes- each lettered for the initial sorting of the index cards.

(b) Filing
This requires a lot of concentration. It easy to file in a card when the files in front and behind
have been checked. This should be allocated to an experience clerk.
( c) Checking

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It is obvious that mistakes do occur when one is filing the cards and therefore constant
checking of file cards is required.
Reference to Index
Once cards have been filed and checked they should only be removed when the address needs
to be changed. Cards should never be so packed as to prevent checking and filing. The most
important thing to note here is that the master index cards should be filed strictly
alphabetically and only one member of staff should work on the cards at any one time to
prevent cards from being misfiled.
Diagnostic Index
The diagnostic index is to provide access for study purposes to the clinical data contained in
the hospital records. A health personnel wishing to carry out a study on any particular disease
can obtain from the index the case folder number of those patients who have been admitted or
have attended an out-patient department with a particular disease in which he is interested.
The disease index will provide the number of the relevant case records and may also provide
some minimal data about the patient’s age, sex, and outcome of the episode of treatment.

Equipment used to maintain the diagnostic index

(i) Vertical Index Card
(ii) Visible Edge Card
(iii) Computers
Operations Index
It will be possible for the Health Records and Information Officer to maintain an operations
index besides the diagnostic index. Operative procedures need to be coded, just as do
diagnoses. The code used is the classification of surgical operations.
Equipment used to maintain the operations Index
The information is recorded on the same media as the disease index. Identification factors
records on the operations index: case record, number, sex, age, surgeon, outcome of episode
and date of discharge.

Waiting list index

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 UNIT 4
SCHEDULING AND FOLLOW UP; PREPARING OF IN AND OUT PATIENT
CLINIC, PATIENTS
Learning Objectives
The learner should be able to:-
1. Define scheduling and follow up
2. Describe concept of scheduling and follow up
3. Explain the purpose of scheduling and follow up.
4. Describe the types of appointment systems
5. Describe different sources of appointments
6. Describe the equipment used to maintain appointments
7. Explain how to prepare a clinic
Definition:-
Appointment system is a systematic way pf giving a specific date, time and venue of the
clinic to an individual patient/client.
Concepts of scheduling:-
1. Patients should be distributed evenly to various clinics depending on the number that
the consultants will be able to see.
2. The staff manning the clinics should ensure that they are in time so that patients are
not kept waiting for long before they are seen.
3. overloading of clinics should be avoided.
4. There should be a laid down policy on how to schedule current cases.
5. Staff working in the appointment area should be familiar with the layout of the
hospital so that they can give proper directions to the patients/clients.
Follow-Up
Care given to a patient over time after finishing treatment for a disease. Follow-up care
involves regular medical check-ups, which may include a physical exam, blood tests, and
imaging tests. Follow-up care checks for health problems that may occur months or years
after treatment ends, including the development of other types of cancer. Follow-up care is
given after positive screening test results, such as a positive Pap test result. In cancer
patients, one purpose of follow-up care is checking to see if the cancer has come back or has
spread to other parts of the body.
Importance of patient follow-up

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Participating in follow-up care helps many survivors feel in control as they transition back
into their everyday lives. Keeping a medical support system in place is essential for
maintaining physical and emotional health

You and your health care team will work together to develop a personalized follow-up care
plan. This plan will serve as a guide for monitoring your health for the months and years that
follow. Your care plan may include regular physical examinations and medical tests. This
plan is usually based on medical guidelines for a specific diagnosis. Your doctor will also
consider your individual needs and preferences.

Participating in follow-up care helps many survivors feel in control as they transition back
into their everyday lives. Keeping a medical support system in place is essential for
maintaining physical and emotional health.

Purpose of Scheduling and Follow up

1. To reduce patients’ waiting time.
2. To provide an even spread of work over the whole clinic session. An appointment
provides for even spread of work among the medical staff running the clinic.
3. To allow the hospital to prepare each and every patient in an advance so that delay for
registration at the time of the clinic can be reduced.
4. To provide special clinic arrangements, for example recording of social history,
weighing of patients, removal of plaster, pathological and radiological examinations.
5. To allow for distance and known transport difficulties.
Allowance should be made by health records staff for such factors as the distance a patient
has to travel, train and arrival and departure times, rural transport difficulties, availability of
local ambulance to the health care facility. All these can consistently ease burden of attending
the hospital.
6. To provide for teaching arrangements. A consultant may wish to select an interesting
case to present to the medical students. This is simplified if an appointment system is
well organized in the health institution.

Type of appointment systems

There are 3 types:-
1. Centralized
2. Decentralized
3. Combined.
Centralized
This means that all appointments for the various clinics are made in one central place.
Advantages
1. The Master Index will be near the area for quick reference.
2. Control of staff, stationery and equipment by the health records/information officer is easy.
3. Each of the appointment clerks become familiar with the working systems of the various
consultants.

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4. All Enquiries concerning appointments are referred to one place.
5. Urgent cases are channelled quickly to the respective clinics.
6. When one clerk is sick or goes on leave the other clerks continue with the work since they
are all familiar with the work.

Disadvantages
1. Too much workload on the staff
2. Congestion
3.

Decentralized
This is an appointment system which is carried on in different clinics.
Disadvantages
1. The Master Index is far from the appointment area.
2. Control of available resources is difficult.
3. When the clerk who mans the clinic becomes sick or is on leave the work come to a
standstill.
4. Enquiries concerning appointments are directed to different places.

Advantages
1. The clerk dealing with the appointments becomes familiar with the patients and knows
them by name.
2. The consultant in charge of the clinic will know the number of patients on his list without
having to walk or ring the central area.

Combined System
Some of the hospitals have the two systems combined. Return appointments being made in
the various clinics and new bookings being done in the central area. It is the duty of health
records/information officer to look at these systems critically to decide on which suits his
hospital or health institution.
Advantages of a combined System
1. …
2. …..
3. ……

Disadvantages of a combined System

1. …..
2. …….
3. ………

Sources of request for appointments

1. Patients telephoning personally to make appointments.
2. Physicians on private practice wanting to book appointments for their patients
through telephone or writing.

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 3. Letter from other health institutions given to patients to come and book their own
appointments.
4. Patients already discharged from the hospital making return appointments.
5. Patients referred from one clinic to another.

Equipment used to record appointments

The choice of the equipment used will depend on whether the appointment is being made
centrally or de-centrally.
(a) Loose leaf binders
Books vary in size and it is recommended that they be in loose leaf form to facilitate
additions and removal of the sheets. The type used depends on local circumstances.
(b) Visible edge sheets
Sheets are cut out and by the use of cardex these sheets are fixed on the cardex and the
information written on them can easily be seen when the cardex is open.
(c) Diaries.
Books that are bound can be used to write all the appointments for one consultant. The
disadvantage is that one keeps cancelling the list the diary becomes untidy. Another
disadvantage is that one cannot photocopy the diary direct. He has to write out other list from
the dairy.

Clinic Preparation
It is done Two days prior to the clinic all the clinic lists should be sent to the appropriate
sections:- one to the clinic, one to the filing area, another to the consultant in charge of the
clinical area. All the records and documents should be pulled out, all the pathological reports
inserted in the correct files and kept in the pigeon holes for the clinic receptionist to come and
collect. The clinic receptionist should make sure that all the documents such as x- rays are
ready for each and every patient attending the clinic. The clinics are prepared two days in
advance to reduce the patients waiting time before he is seen by the physician.
At the end of the clinic the receptionist should ensure that all the files are returned to the
central library ready for filing.

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 UNIT 5
ADMITTING AND DISCHARGING PATIENTS/CLIENTS
Learning Objectives
The learner should be able to:-
1. Describe admission and discharge procedures and their sources.
2. Edit and audit the record
3. Collect, compile, analyze, disseminate and verify returns.
4. Code and Index
1. Identify the types of records to be kept.
2. Describe how appointments are made in this department
3. Describe how patients are disposed of from this department
4. Describe the legal requirements to be observed in this department.
1. Define a waiting list
2. Describe the functions of a waiting list.
3. Explain the types of waiting lists
4. Describe how to maintain a waiting list
5. Explain the methods of filing to be used.
6. Describe the procedures used in admitting patients.
7. Maintenance of bed bureau.
Admission :- Is The Procedure followed when accepting a client for inpatient care and
treatment in the ipatient department after4 conmpletionn of all registration prcedures

Discharge:- is a formal procedure where a patient after treatment to finality leaves the
inpatient department while adherening to all discharge procedures

ADMISSION PROCEDURES
Patients/clients should be supplied with a booklet containing information about the hospital
before they are admitted.
If they are emergency patients then they should be supplied with the booklet after admission.
The book should contain the layout of the hospital, visiting times for relatives and visitors.
The wards should be easily be identified. Accommodation for relatives of very ill
patients/clients, mothers, ill babies should be available.
After admission patients/clients should be guided to the ward by a member of staff to the
sister or nurse responsible for reception and documentation of patients in the ward.
This will ensure a feedback of information to the health records/information department.

SOURCES OF ADMISSION
Admissions can come from different sources:-
(i) Accident and Emergency department
(ii) Outpatient clinic
(iii) Other hospitals
(iv) In-patient waiting list

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DISCHARGE PROCEDURES
Admissions and discharge registers should be maintained in all health institutions. The
register should provide for full name of the patient, date of birth, admission date, discharge
date, diagnosis and the length of stay at the hospital.

Written order by doctor

Discharge form
Informing other departments
Check payments of the bill
Hospital glossaries taken back
Returning of the personal belongings
Arrangement for transport
Documentation

MAITENANCE OF A BED BUREAU:-

Hospital bed bureau:-
Definition:
A hospital bed bureau is a system used to manage the availability, allocation and utilization
of beds by the hospital to admit patients from the waiting list. It shows the location of the bed
in the ward, and when a bed will fall vacant for the next admission.
Maintenance of a bed bureau:-
A hospital bed bureau could either be managed manually or electronically. In the manual
environment, the officer in charge of bed allocation monitors both admissions and discharges
routinely in order to report on available beds and inform the officer maintaining the waiting
list of such beds as and when they fall vacant or even project when beds are most likely to
fall vacant. This is done by keeping a notice board with the location of all the wards and their
bed capacity. The notice board has two colour strip cards which are put in pocket bags, red
for occupied beds an
d green for vacant beds.
The electronic aspect is more user friendly because the patient waiting list is automatically
integrated and interfaced (the whole process is on line and data is available to all at real-
time)with the admission and discharge modules and bed availability can be accessed
automatically as and when a bed falls vacant, the officer in charge of bed placement can
therefore admit patients on the waiting list as beds become available .

EDITING AND AUDITING OF THE HEALTH RECORD

Editing of the record is the arrangement of all the forms inside the unit folder in a prescribed
manner. This can be decided by the hospital concerned. It can either be done chronologically
or in order of speciality. This can be done by the ward clerks if they are available.
After the record has been edited it should be returned to the health records department. In the
department the records should be cross checked with the daily bed returns to ensure that all
records have been received in the records department.

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After this, the re
cords will be coded and then indexed ready for filing back to the library. The health records
and information officer should complete all the information that is supposed to be contained
in it is there. The discharge procedure cannot be complete until the record returns back to the
file.
The patient is then given a return appointment to a consultative clinic and this is recorded on
his attendance card. When the patient comes back to the clinic his record should be available
in the clinic.

THE MEDICAL AUDIT

The Medical Audit has been defined as an “objective method for applying a yardstick to the
quality of professional performance.”
It is the method of evaluating quality of medical care given to a patient. It is a tool to enable
the administrator and the medical staff to uncover inefficient service and to point away to an
improvement of standards in the health facility- a tool of management. It is important to
evaluate the care rendered to the patients in terms of lives saved, avoidable deaths and
patients rehabilitated back to society. This evaluation is carried out by health records
committee.
Medical audit is a systematic, critical analysis and quantified comparison against explicit
standards, of the quality of current medical practice, including the procedures used for
diagnosis and treatment, the use of resources, and the resulting outcome and quality of life
for the patient in order to improve the quality f patient care.
The motivation to carry out audits arise from the desire of providers of care to know the
level of quality of the services they provide and to improve it to a higher level.

The main objectives of carrying out an audit is to:

a) know whether the provider of care individually or as a group has achieved the desired
quality characteristic of its service
b) provide comparison with previous and future performance
c) allow comparison with others
d) know the degree of inadequacy or shortcoming
e) provide feedback for quality improvement

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Items to be audited

ACCIDENT AND EMERGENCY RECORDS PROCEDURE

After a patient has been seen at the health centre he may be having some ailment which needs
immediate and urgent attention. Definitely the doctor will refer him to a hospital for
immediate attention. He will find himself in an accident and emergency department. Also
patients with any type of accident will be brought to this department directly.
Records to be kept.
Register
Firstly a register must be maintained at the Accident and Emergency department. The
following information should be included in this register; name of patient, address, age,
doctor referring him, time of arrival, brief description of injury, brief details of treatment, and
the mode of disposal. The particulars of the person who has brought this patient to the
accident and emergency departments must be taken also. If it is a police officer his number
must be recorded in the register. The register may be in loose leaf form or in bound volumes.
From the register statistics of attendance will be compiled.
Clinical record
(i) Single card measuring 8” x5” or 6” x 4” on which the identification details are recorded.
For an R.T.A (Road traffic accident) patient, time and place of accident must be given and
the space left for the clinician to write on.
(ii) Two part card
A card with carbonized part made from N.C.R material. The card is made up in an envelope
from so that x- ray reports and any other correspondence may be filled in it.
(iii) Thick paper envelope four and an eighth by five and three quarters inches (half the size
of A4 paper). The envelope will serve as a card and a pocket for reports.
2. Appointments
Most patients attending this department rarely come back for return appointment. For those
patients that need return appointments this can be carried out in two ways:-
(i) Appointment register may be retained by the receptionist and the appointment written on
the patient’s attendance card.

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(ii) Pre-printed appointment cards for each day and time may be given to the patient. A
different colour of the card could be kept for each day of the week and when a patient arrives
seeking an appointment a card is simply pulled out and given to him.
3. Disposal of patients
Disposal of patients attending this department could be in one of these categories:-
(a) Treated to finality and discharged.
(b) Treated initially and referred back to the nearest health centre.
(c) Referred to an out-patient consultant clinic.
(d) Referred to a consultant clinic in another hospital.
(e ) Admitted to the wards for further treatment. Here full documentation for admission will
be carried out before the patient goes to the ward.
(f) Transferred to another hospital for further treatment.
( g) In the case of patient who has been brought dead (B.I.D) the doctor just goes to certify
the death and the body is conveyed straight to the mortuary.

4. Legal requirements
It is important to note that the same legal requirements that are applicable to other health
records as far as retention is concerned still apply in accident and emergency records. They
may be retained for a minimum of six years after the last attendance. The records may be
filed numerically or alphabetically depending on the number of records created annually. At
the beginning of the year, 1st January, a new file is started. The records should be kept o\in
lock because most of these records are usually required in court and as much details as
possible should be recorded. Most patients who have been involved in road traffic accidents
need some claims in future. Therefore statistics for these patients may be sent to finance
department so as to issue the necessary claims.

WAITING LIST FOR IN-PATIENT AND DAY CASE TREATMENT

A waiting list is an index of all patients waiting admission to hospital or waiting treatment on
a day case basis.
1. Functions of a waiting list.
The waiting list must be organized that enquiries can be answered from individual patients
wanting to know when they are supposed to be admitted in the health institution. Individual
consultants would like to know how many patients are on their waiting list should
immediately be furnished with such information. The main function of the waiting list is to be
able to make full use of the available beds in a health institution.
2. Types of waiting list
The waiting list may be maintained in various ways:-
(i) Centralized waiting list
This waiting list is held in one office and contains the names of all patients awaiting
admission under all the consultants in the hospitals.
Advantages of centralized waiting list
1. Gives a fair representation of all the demands being made on the in-patient facilities.
2. All enquiries are referred to one place.

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 3. Staffs dealing with the waiting list develop skills in dealing with enquiries, and in the
maintenance of the waiting list.
4. Updating procedures such as change of address, death are easily carried out.
5. Checking admissions and discharges from the daily returns is easier.
6. When one staff falls sick or goes on leave another staff can carry on with the work.
Disadvantages of centralised waiting list
1. Consultants need to walk to the central office to select their patients from the waiting
list.
2. The list become so big so that some patients may be left out of the waiting list

(ii) Decentralized waiting list

The decentralized waiting list will be maintained in several places possibly each consultant’s
secretary, or an individual wards or individual departments.
Advantages of decentralised waiting list
1. Consultants need not go to the central office to select their patients from the waiting
list.
2. The secretaries get familiar with the patients and can call them by name.
Disadvantages of decentralised waiting list
1. Several staff will be deployed in the maintenance of the waiting list in different areas.
2. It will be very expensive since each department will need to use its own equipment.
3. A clerk will have to walk to the central records department to check for admissions
and discharges from the daily returns.

3. Creation of the waiting list record

Most of the waiting list records are initiated at the out-patient clinics. Some other patients
may come from another hospital and be put in the waiting list for another different
hospital, where there are more beds or facilities. There are four ways in which
information can be conveyed to the waiting list:-
(a) Card – The card is created for every patient who is to be put on the waiting list. This
card will be filed and form part of the waiting list.
(b) The nurse or doctor may send a list of patients to be included in the waiting list to the
records department for action.
(c) Letter – A consultant in one hospital may wish to include his patient’s name in his
waiting list, in another hospital for his name to be included in that waiting list. In this
letter he will in clued diagnosis, and priority for admission. A case folder will then be
created for this patient. The information to be included in this record are: the patient’s
name, address, title, telephone number, holiday dates, diagnosis, operation to be
carried out, duration of stay in the hospital, name of the surgeon, or consultant.
4. Method of filing
A waiting list contains dozen names and needs two files:-
1. Alphabetical index of the names of all patients on the waiting list. These cards should not
be removed until the patient is admitted.
2. Consultants list will make provision for date, time, and ward. These lists will have
priorities indicated – routine, soon, and urgent.

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These two files should be able to answer an enquiry from a patient and consultant.
5. Filing equipment
The type of filing to be used will depend on the size of the list.
(a) Visible edge card filed in trays
When this is used to maintain a waiting list may be in the form of manila flaps, with a rigid
bar at the top and a transparent plastic pocket about half an inch deep at the lower edge of
each flap. A card is inserted into this pocket and the flap is held in a metal tray in such a way
that all the information in the plastics is visible. Date is put on the list, diagnosis, operation
and admission priority is put to allow the consultant to select his patients.
(b) Strip index
A strip index is limited in space so that no space is left for change of address. It can only be
used if the list is not too long. It has already been mentioned as one of the equipment used in
the maintenance of the patient master index card.
(c) Diaries
Each consultant could have a diary for his patients put on the waiting list according to dates.
Its danger is that a patient can easily be missed or overlooked on date which passed.
(d) Colour coding
Colour coding could be used to indicate soon, urgent and routine case.
6. Procedures for admitting patients from list
1. The patient is selected from the waiting list by the consultants
2. The clerk writes to the patient or telephones him inviting the patient to the hospital
3. The records are got out from the files and sent to the documentation office.
4. The waiting list card is sent to the admission office so that the patient is expected on
the day he comes in. the admission office checks the record before the patients comes.
When he comes his details are checked and confirmed by the admission office.
5. Patient is admitted and sent to the ward.
6. When the patient has been discharged his name is removed from the waiting list.
7. Certain checks are made on the waiting list to remove the names of the patient who
have died to remove their names from the waiting list.
7. Statistics
Regular returns are compiled from the waiting list for hospital activity analysis. The
procedures described above also apply to patients who come for day case treatment. Special
letters are sent to these patients because of preparations needed if general anaesthesia is to be
given.

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 UNIT 6
STORAGE AND RETRIEVAL OF HEALTH RECORDS
Learning Objectives
The learner should be able to:-
1. Define filing
2. Describe the three main filing systems.
3. Explain how to convert sequential filing to terminal digit filing system.
4. Describe the filing equipment use to file case records and X ray films.
5. Describe the ancillary equipment.
6. Define tracing
7. Describe different types of tracing health records.
8. Explain the advantages and disadvantages of each tracing system.

FILING SYSTEMS FOR CASE RECORDS AND X RAY FILMS

Filing is a systematic way of arranging documents to enable those documents filed to be
maintained in good order. The library from which notes are readily available is a threat to the
patient’s treatment.
Filing Methods
There are three main filing methods used in an organized health records department.
(i) Alphabetical
(ii) Chronological
(iii) Numerical

(i) Alphabetical filing system

It is the arrangement of files in alphabetical order
Alphabetical filing really has little place in any discussion of the filing of case notes. The
main disadvantage of using this method of filing is that it grows very unevenly ((sdepending
on the names of the clients )and spreading of notes or x- ray files can be very difficult if the
file is used for many years and the number of files becomes very large.

Disadvantages
Slow-takes a long time to locate files especially in large organisations systems
Difficulties may arise due to misspelling of the names.
Difficulty in estimating how much space is required for each letter of the alphabet when
setting up a new system.

Advantages

(ii) Chronological filing system

This is a method of filing where records are filed using dates when the record was created. It
cannot be used to file case records except that it can be used to arrange records inside the case
folder. It is not recommended for filing in a big library.
 Chronological filing is not useful for large scale business units.
 It is very difficult to locate the documents if the date is not known.

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(iii) Numerical filing system
In this system two ways of filing can be adapted:-
(a)Straight numerical
(b) Terminal digit filing system.

(a) Straight Numerical filing system(sequencial)

This is probably the filing system that comes automatically into people’s mind:-12 3 4 5 6, 1
2 3 4 5 8. It is probably the most suitable method of filing for small records library where
there is no necessity to go into the fairly elaborate detail needed to install a terminal digit
system.

(b) Terminal Digit filing system

The filing system was first used in the United States hospitals and has been the standard
method of filing in that country. Anyone starting a new records department would be well
advised to start with it from the beginning. The main difficulties experienced with the
traditional sequential filing system are:-
(i) Growth is at one end of the file because this is the busiest section of the
library.
(ii) Gaps are usually left after weeding of notes
(iii) Transposition of figures occurs whenever one is dealing with big numbers.
(iv)

Terminal digit filing system overcomes these difficulties. Its main principles are as follows:-
i. The library is divided into 100major sections numbering from 00 to 99. Each major section is
again divided into 100 sub-sections. This means that the library is now divided into 10,000
sections. Each section should be labelled properly.
ii. The hospital number should be thought of as three pairs of digits e.g. 1 2 3 4 5 6 as 12-34-56.
56 is the terminal digit, 34 is the middle digit, and 12 is the primary or first digit.

a) The record will be filled in the major section appropriate to the terminal digit (last
two numbers in section 56.
b) Within major section 56, it goes behind the sub-section guide appropriate to
middle digit (middle two numbers) 34.
c) It is then filed in he order of primary digit 12.

(c) Advantages of terminal digit filling system are:-

i. New and old records are evenly distributed throughout the
records library.
ii. Chance ensures that an equal number of records and loose filing returns each day to
each major section. Trials have shown that where 1,500 records are filled daily, 150
records will be returned to each section daily
iii. There is no annual shift-back or closing up of notes after weeding, to make room for
new records.

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 iv. Sorting notes is simpler.
v. New staff find the system very much easier to learn than sequential filing-probably
because the library is much more static and the 00s are always in the same place.
vi. Fever misfiles occur. This is because the filing clerk is concentrating on only two
digits at a time.
vii. Tracer cards can be written in advance when preparing a clinic.

(d) Conversion of straight numerical filing to terminal digit order

Before one changes from straight numerical filing system to terminal digit filing system, one
should make sure that there is enough:-
 Space
 Manpower – trained
 Shelves constructed
 Medical forms
 Pre-printed folders
One day should be set on which to start the system. The first patient who comes should be
issued with a unit number 00 and the second patient who comes next 01. This should
continue until the number 999999 is reached. When an old patient has been issued with a
number in the previous years comes, his record should be pulled out and brought forward to
the new unit number. If a patient does not turn up, his record should be left in the old file.

(e) Filing equipment used to file case records and x-rays

(1) Shelf filing
This is the most used filling equipment and probably more suitable for filing large quantities
of notes or x-ray films than any else. Metal is more suitable than wood. There are some
advantages and disadvantages of shelf filing.
(i) Advantages
(a) Records can easily be filed and pulled quickly since the shelves are open.
(b) More records can be filed on the shelves than in the cabinets.
(ii) Disadvantages
(a) If the shelves are constructed high light cannot penetrate the lowest shelves
(b) If shelves are constructed high the shortest clerk has to climb the ladders or the kit stools
(c) Shelves are not dust proof
(d) Shelves are not fire proof
(e) Shelves are not water proof

Filing cabinets
Filing cabinets are recommended for smaller libraries. They provide ideal filing conditions:-
a) Good access
b) Dust-proof
c) Convenient height
d) Provide attractive appearance
Disadvantages

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 1. They take up ore space
2. More expensive than shelves

Suspended filing
This form of filing is never suitable for a large number of case records and x-ray films on the
ground of cost and amount of space taken up. Basically it consists of manila pockets hanging
from two metal bars and providing a v-shaped space into which notes can be filed. The metal
hanging bars have flat tops to indicate the unit numbers filed in each pocket. Suspended filing
can be installed in filing cabinets, with addition of special framework on which to hang the
pockets or it can take place of the shelves in horizontal units.

Disadvantages
1. Provide less filing space
2. It is expensive to install
Advantages
It is ideal for filing administrative records where files are slim.

Mobile racking
This is the most economical filing method as far as space is concerned. A series of shelves,
contained in a rigid frame with backing, are run on rails. One set of shelving is fixed and then
there maybe three mobile sets
It will be immediately obvious from this that if all five sets of racking were static, far more
room would be taken up by the gangways necessary to gain access to both sides of the racks.

Disadvantages
1. No gangways which could cause hold ups.
2. Access may not be possible by more than two clerks at a time.
3. The pushing of the racks could be a formidable task.
4. It is expensive
Advantage
It saves space
Circular, carousel filing
These units consists of a series of shelves or suspended files rotating round a fixed spindle- a
large version of the carousel described in the section dealing with the master index. Their
great virtue is that the files can be placed against a wall and rotated to bring the files that are
needed to the front- they are therefore space saving. This type of installation is undoubtedly
more expensive than many others. It should be looked at last for interest and for the space
saving principle.

Elevator files
These are very large relatives of the elevator files described in the master index section. They
are extremely expensive and quite out of the financial range of most records departments.
However, they should be recognised as a possible form of filing.

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The records are stored in boxes, on trays, as in the smaller index card elevator files. The
difference is that elevator files for notes probably extend upwards for twenty feet or more. As
the operator presses the correct button, the shelves will rotate until the correct one presents
itself at filing level. The argument for their installation apart from the convenience of never
having to walk, bend or stretch to pull file records is that valuable ground floor space no
longer needs to be allotted to the records library as most of the notes are stored on one or two
floors above while still being available at the most convenient point. It is not possible to use
this method in a busy library.

There are two other filing methods which must be referred to, but purely on a historical basis
because they are unlikely ever to be used in modern records departments. They are:-

Bound volumes
These have been referred to already in the description of the unit system. As items of
historical interest, and sometimes for clinical purposes, the bound volumes must be stored
carefully but note will never again be kept in this form.
Box filing on shelves
When records are finished with, they are sometimes packed into cardboard boxes and filed on
shelves. It is hardly necessary to point out that access to a set of notes that is packed in one
cardboard box at the bottom of a pile of several such boxes is not easy to get at.
Dividers
Documents as heavy and at the same time as flexible as case folders and x-ray films need
plenty of support. This is provided by dividers for any sort of shelf filing. Ideally these
dividers are metal, and reach from the bottom of one shelf to the top surface of the shelf
below, being firmly attached to both shelves. They thus provide support not only for the files
but also for the actual shelf unit, by adding rigidity. The metal dividers can be supplied with a
rolled edge similar to that used for the shelf units. Notes should be divide every 12” and x-ray
films divided after 6” otherwise they soon “droop” and become permanently misshapen.
Colour coding
Colour coding can be applied to both notes for a variety of purposes. It is traditional that ten
colours should be used for the ten main divisions of terminal digit filing. Thus each number
1-9 has a different colour. Colour can be used to identify a particular number except that a
few individuals suffer colour blindness. Colour coding can also be used to indicate the year
when the record was created. This can be affected by the use of coloured cello tape or
adhesive levels.
Ancillary equipment
The efficiency of a well laid out, carefully filed records or X ray records library can be
significantly increased if certain basic items are provided in addition to the most suitable type
of shelving.
(a) Filing Trolleys
If clerks are to walk round the filing area with armfuls of notes, putting them down each time
they withdraw or file a record they will be very tired by the end of the day. Trolleys should be
strong and large enough to be able to carry heavy loads of case records and X ray films.
(b) Kik stools/ladders

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These are necessary for the shortest clerk to climb on to reach of shelf as high as 7 feet. Any
ladder or Kik-stool should be light and easily moved.
(c) Sorting equipment
Sorting equipment for case records and X ray films will certainly be some form of pigeon
hole. It is usually very important that this vital task is not attempted with inadequate
equipment.
Where terminal digit is used, it is desirable to have one hundred pigeon holes, one for each
terminal digit. These should be clearly numbered. As the files come back to the library, form,
clinics, secretaries, wards, they can be filed straight into the appropriate pigeon hole of the
sorting unit. The filing clerk responsible for each section of the library will ten take on
pigeon hole numbers, sort them out and file them.
(d) Preparation tables
These tables can be used for sorting the notes for filing for preparing the clinics. There should
be enough space for each clerk and the table should be large enough.

TRACING AND RETRIVAL OF HEALTH RECORDS:-

Tracing is the act of keeping track of movement of medical records during its use in the
care of patient.
To be able to keep track of the case files /medical records. The health records and
information department came up with tracer systems for the medical records library.

There are three systems of tracing most commonly used in a records library.
(a) The common tracer card
Enough supply of tracer cards is kept in the library. When a record is removed from the filing
area it is replaced by a tracer card. When the record is returned to the file the tracer card is
removed and the notes filed back. The tracer card is cancelled and reused for another set of
records-hence the adjective “common’. The common tracer card should be made of strong
card as it may be used up to eighty times before it is full. The information to be recorded on
the tracer card should be as follows:
Date
Destination (ward or clinic)
Hospital Number
Patient’s full names
Reasons for extraction
Borrower’s signature.
Some special mention should be made about the date. Where the notes are being extracted for
an outpatient clinic the date recorded on the tracer card should be the date of the clinic not the
date of extraction.
When the patient is being admitted, the date of admission should be included on the tracer
card. If the notes are for research or for a letter to be written, the date should be the date of
extraction. The tracer card should be one quarter inch larger that the notes so that it can guide
the filing clerk of where the notes should be inserted.

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Advantages of the common tracer card
1. It can be used 80 times for different patients.
2. A clerk can prepare a whole clinic in advance while seated.
If tracer cards are used for x- rays envelopes size 15” x 18”, the tracer card should be more
than the envelope so that it can act as a guide to locating the correct place and filing the films
back. The same information will be recorded as on the cases for record tracer cards.

(b) Library tracer system

Each case record has a small pocket inside the cover in which is held a small card with the
patients name and the hospital number at the top, and a series of lines below on which
borrower and date may be entered, very much on the principle still being used by public
libraries. When the notes are withdrawn from the file the card is marked with date and name
of the borrower and filed in a small tracer card index. When notes are returned to file, the
card is extracted from this index, the entry cancelled and the card filed into the pocket in the
folder which is itself then re-filed.
Disadvantages
1. This system is recommended only for a small library.
2. There is no object left in place of the file to show where the record is.
3. Misfiling is likely to occur.

Advantage
Because the card is created permanently when the folder is created, the facts are always right.
(c) Personal Tracer Card
This card is created the same time as the case folder and identified with the patient’s name
and hospital number. It is filed inside the folder and is only taken out of file when the notes
are taken out of the file. The same details as the common tracer card are entered onto it.
Advantages
1. When the record cannot be traced the details of the previous destination may give a
clue as to the destination of the record.
2. No transposition of numbers since the number is created permanently on the card.

The importance of the tracer systems cannot be overstressed. It is no excuse that notes cannot
be found because the tracer is out of date. This will not help the patient. Like any other
procedure, the tracer must help to achieve instant availability of the patients’ notes when they
are needed.

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 UNIT 7
ACQUISITION AND MAINTAINANCE OF HEALTH RECORDS EQUIPMENTS
Management of Health Resources. Supply Chain Management
Unit Objective-
• Appropriately apply the steps in procurement procedure and guide implementation of these
procedures in procuring goods and services
• Describe the Supply Chain Management including inventory and distribution management
tools, disposal of stores and equipment by Public Entity
• Identify and address challenges related to supply chain management at the workplace
• Apply knowledge and skills to design a procurement plan for the investment /facility plan
and/or priority project
• Rationale and principles of procurement
• Procurement regulations and ethical guidelines for good procurement practices
• Roles and responsibilities of various bodies and actors in the procurement procedure
• Procurement procedures and variations at each stage based on the type of goods and
services
• Procedures for contracting
• Supply Chain management tools for inventory, management, disposal of stores and
equipment
• Investment plan application – designing a procurement plan for goods and services
• Challenges to supply chain management in health systems

Assignment
Define procurement, acquisition, bond, bidder, lead time, forms used iin procurement
Steps in the procurement procedure
This is a procedure and it entails the following:-
 Needs identifications
 Specifications
 Requisition of quotations
 Opening of the quotations
 Selection of the qualified bidder
 Supply of the goods by the bidder and receipt of the goods by the hospital supplies
department
 Authentication of the goods by the concern department
 Acquisition of the goods by the department by use of S11
 Installation of the machines in the department after they have been entered into their
inventory.
 Finally, maintenance of the equipment is put in place and observed(see the public
procurement act)

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Current classification of procurement entities
Class A are Ministries and State Corporations(KNH, MTRH, KEMSA)
Class B are City Councils, Universities, Judiciary, Commissions, Colleges, Cooperative
Societies, Parliament, Districts, Provincial Hospitals and SAGAs (Semi Autonomous
Government Agency)
Class C are Municipalities, County Councils, Urban Councils and Schools, District
Hospitals, Sub District and Dispensaries, CDF

Anatomy of Kenya’s Public Procurement and Disposal Act

The purpose of the Act
 To establish procedures to achieve the following objectives:
 To maximize the economy and efficiency
 To promote competition and ensure that the competitors are treated fairly
 To promote the integrity and fairness of those procedures
 To increase transparency and accountability in those procedures
 To increase public confidence in those procedures
 To facilitate the promotion of the local industry and economic development

Application of the Regulations.

These Regulations apply to public entities as enlisted under Section 3(1) of the ACT that is-
• Any body using public assets in any form of contractual undertaking.
• Companies owned by public entity
• Any body in which the Government has a controlling share

Acquisition of goods and services not classified as procurement according to the Act
(Section 4(2)
• Retaining of services of an individual for a period of term if the individual works as
though one was an employee.
• Acquiring stores and equipment disposed by a public entity.
• Acquiring of services provided by Government or a department of the Government.

Conflict with other Acts

• This act prevails on matters of pro -In relation to donor funds Conflict with
international agreements
• The Act prevails except in instances of negotiated grants and loans. Conflict with Donor
conditions
• Donor conditions to prevail with respect to procurement

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BODIES AND ACTORS INVOLVED IN PROCUREMENT PROCESS: ROLES AND
FUNCTIONS
Key Bodies and Actors: Membership, roles and functions
• Public Procurement Oversight Authority (PPOA)

• Public Procurement Oversight Authority and the Director General

• Public Procurement Oversight Advisory Board (PPOAB)

• Public Procurement Administrative Review Board

Internal Organization of Public Entities

• Procurement Unit
• Procurement committee
• Tendering committee
• Roles of Heads of Departments
• Evaluation committee
• Inspection and acceptance committee
• Disposal committee

There ought to be separation of roles to ensure that procurement contracting process is

accountable. Within a Public Entity the procurement contracting functions should hence be
separated. Why?:
 To avoid conflicts of interest.
 To promote the integrity and fairness of the procedures {(Sub-Section 2(c) of the
Act}
 To increase transparency and accountability in the procedures {(Sub-Section 2 (d) of
the Act}
Hence- A Public Entity shall establish a tender committee ,procurement unit and other
bodies required under the regulations for making procurement decisions {(Subsection26 (4)}

Bodies involved in Regulation of Public Procurement

Public Procurement Oversight Authority (PPOA) – Functions
• Monitoring the performance of the public procurement system and report to the
Minister (M&E)
• Assisting in the implementation of an efficient and effective public procurement
system
• Preparation of manuals
• Providing advice and assistance to procuring entities
• Issuing directions to procuring entities
• Offering other functions provided under this Act.

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Promotion of Professionalism
• The Authority to assist in the establishment of an examination body and professional
association for procurement professionals.
• Training and professional development
• Ensuring engagement of procurement professionals
The Director General
• The Chief Executive of the Authority.
• Appointed by the Advisory Board
• Term of office – 5 years, renewable once.
• Conditions for termination by the Advisory Boards:
Incompetence
Infirmity
Conviction
Corruption
Employed in other public office
Bankruptcy.

Sources of Funds of the authority

 Money appropriated by Parliament
 Loans/grants
 Revenue/fees for services rendered
 Capacity building levy

Public Procurement Oversight Advisory Board (PPOAB)

Composition – 9 members appointed by the Minister from persons nominated by prescribed
(private and public) organizations. (First schedule for prescribed organizations), and the
Director-General.
Functions:
• Approve estimates of revenue and expenditures of the Authority.
• Advise the Authority
• Recommend appointment or termination of Director- General in accordance with this
Act.
• Other functions and duties provided within the Act

Public Procurement Administrative Review Board

Continued from the previous. Public Procurement Regulations. -Legal Notice No 51 of
March 2001. Composition of the Board shall be as prescribed in the regulations.. The
Authority shall provide administrative services to the Review Board.

The Internal Organization of Public Entities Relating to Procurement- Significance

Decision making process:- in a systematic and structured manner.
Decision making structure
• Oversight function by the Accounting officer/CEO at PE level
• Establishment of Tender Committee, Procurement Committees and Procurement Unit

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 • Head of Departments participation in the procurement process.
• Coordination and Secretariat services offered by the Procurement Unit
• Establishing and staffing Procurement Unit with procurement professionals.
Planning.-Planning Procurement annually within approved budgets
Compliance Responsibilities:-Accounting officers to ensure that the Act is complied with
Outsourcing of procurement by the PE or by the Authority
• To a Procuring agent who shall comply with the Act, Regulations and the Authority’s
circulars
• To another Procuring Entity
• NB: Authority to register procuring agents

THE TENDER COMMITTE

The Roles- Sub-section10 (2) of the Regulations
• To review, verify and ascertain that all procurement and disposal has been undertaken
in accordance with the Act, Regulations and terms set out in the tender document.
• To approve, select, award contracts to successful bidders where value exceeds
threshold in 1st Schedule
• To ensure availability of funds for procurement under consideration
• To ensure intended payment not to exceed prevailing market prices
• Pre- adjudication action: Procurement Unit to carry out periodic market surveys
{(Reg.8 (3) (z)}.

The Tender Committee: roles

 Review selection of procurement method (most preferred-open tender)
 Ensure any other procurement method is in line with the Act and Regulations.
Pre- adjudication action:
 Selected procurement method is to be included in the Procurement Plan
(Reg.21 (1) (h) and
 Complying with conditions for use of “Alternative Procurement Procedures “
Part VI of the Act.
 Review and approve aggregations of procurement, packaging or use lots if proposed.
Approve list of tenderers in case of restricted tendering pursuant to Reg.54 (3)
 Invitation of tenders from at least 10 persons selected Sub-Reg.54 (3)
(a)
Fulfilling the conditions for use of Restricted Tendering Section 73 (2) of the Act.

Approve list of persons qualified to submit proposal pursuant to Section 80 of the Act
Pre- adjudication action: Examination and evaluation of Expressions of Interest to
determine qualification for invitation to submit proposal
Approve negotiation under Section 75 and 80 of the Act
Pre- adjudication action:
 Negotiation is allowed in respect of Direct Procurement (Section 75 of the Act) and
 In respect of Selection of the most advantageous proposal determined with regards to
Section 80 of the Act.

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  NB: Requirements for negotiation should be stipulated in Bid document or of Letter
of Invitation as appropriate.
 Approve: Amendments of contracts previously awarded by the Tender Committee in
accordance with terms and conditions in the Regulations
 Approve list of persons to be given Request for Quotation pursuant to Reg.59 (3)
 Pre- adjudication action:
 Selection of qualified persons from maintained list and/or
 From knowledge of the market.
 NB: Selected list of qualified persons can be supplemented by other known sources
in the market
 To review the quarterly reports on quotations that has been awarded by
procurement committee.
 NB: This is in accordance with Reg 10 (2) (a) which states that Tender Committee
shall review, verify that ALL procurements and disposals have been undertaken in
accordance with the Act and the Regulations
 To undertake any other functions and duties as are provided under the
Regulations or as may be stipulated by the Authority.

The Tender Committee: Composition

Established in the manner set out in Second Schedule to the Regulations to consist of:
 Not less than FIVE members
 Have as its secretary, the procurement professional in charge of procurement unit.
Categories of Tender committees in Second Schedule cover Procuring entities in

The Tender Committee: Procedures for meetings

Line with Section 3 of the Act- Definition of Procuring Entities
Tender committees’ membership to include alternate members
Only alternate member to attend meetings whenever the member is unable to attend
Quorum to be FIVE including the Chairman
Decision of the Committee shall be by consensus
In case of no consensus decision shall b Members may be paid honoraria
The committee shall cause to be prepared the minutes of the meetings
The minutes shall include:
 A register of attendance
 Date of the meeting
 List of all matters considered and decision made, reasons for rejections,
clarifications, minor amendments
 A notes regarding evaluation
 Conflicts of interest declared and any dissenting opinion among members
 Such other records as may be necessary.
e made through voting by simple majority
Where there is a tie during voting ,the Chairman shall have a second and a casting vote

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A member with interest ( direct or indirect) in the matter being deliberated upon shall
declare the interest and shall not participate in the deliberation
Procedures for meetings
Members may be paid honoraria
The committee shall cause to be prepared the minutes of the meetings
The minutes shall include:
 A register of attendance
 Date of the meeting
 List of all matters considered and decision made, reasons for rejections,
clarifications, minor amendments
 A notes regarding evaluation
 Conflicts of interest declared and any dissenting opinion among members
 Such other records as may be necessary.
 Committee may also invite two more observers for contract with estimated value
above Kshs 50 Million
 At leased one observer to come from a recognized private sector organization or
discipline relevant to the procurement under consideration
 Failure of an observer to a meeting shall not nullify the procurement proceedings .

The Tender Committee

Adjudication of evaluated bids to ensure:
 Compliance with product specifications
 Delivery /Lead-Time.
 Supplier’s economic standing
 Supplier’s legal standing-whether qualified to operate as supplier/vendor of the
proposed goods services or works or not.
Adjudication of evaluated bids to ensure:
 Supplier’s relevant experience
 Supplier’s technical capability to perform the proposed contract
 Supplier’s responsiveness to the tender technical requirements
 Price for delivering the goods or rendering the services
 Total cost
Procurement Committee
Roles
• Responsible for procurement below the threshold for Tender Committee
• May approve or reject submissions with reasons.
• May approve submission subject to minor clarification by procurement unit
• Shall not modify any submission or reject submission without justified reasons
• Any rejected submission maybe resubmitted (with further clarity or details)
• Committee to provide explanations and justifications of its decisions.
Composition
• An official delegated the role of being a Chairman by the Head of the Procuring
Entity
• The Finance officer or an officer carrying out related functions

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 • Three members appointed by Accounting Officer
• Secretary-an officer appointed by Head of Procurement Unit.

Procedures for Meetings

Quorum-Chairman and at least two other members
A member unable to attend a meeting may delegate authority to a appropriate official
The committee to ensure that the delegated authority is to an official with appropriate skill
and experience
Decisions of the committee shall be by consensus; otherwise the decision shall be through
voting by simple majority
In case a of a tie in voting the Chairman’s vote shall have as second or casting vote.
• A member with interest (direct or indirect) in the matter being deliberated upon shall
declare the interest and shall not participate in the deliberations.

• The Committee may invite independent observer or member of procurement unit to

explain submission or provide technical advices.

The Procurement Committee to adjudicate evaluated bids to ensure:

 Compliance with product specifications
 Delivery /Lead-Time.
 Supplier’s economic standing
 Supplier’s legal standing-whether qualified to operate as supplier/vendor of the
proposed goods services or works or not.

The committee shall cause to be prepared the minutes of the meetings

The minutes shall include:
 A register of attendance
 Date of the meeting
 List of all matters considered and decision made, reasons for rejections, clarifications,
minor amendments
 A notes regarding evaluation
 Conflicts of interest declared and any dissenting opinion among members
 Such other records as may be necessary.
Evaluation Committee
• Established for each procurement within threshold of TC
• May comprise separate technical & Financial evaluations or Combined
• At least 3 members recommended by Proc. & appointed by CEO
• Technical evaluation in strict adherence to compliance & evaluation criteria as set out
in tender docs
• Performed with due diligence within 30 days
• Independent evaluation by each member before sharing the ratings
• Financial evaluation within 5 days of completion of technical evaluation

Inspection & Acceptance Committee

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 • Composed of 3 members recommended by Proc. & appointed by CEO Shall:
- inspect & test goods received
- ensure compliance with terms & conditions of contract
- accept or reject the deliveries
- ensure correct quantity is received
- goods meet technical stds
- timely deliveries or note the delays
- all manuals are received
- issue interim or completion certs or GRNs

MEASURES FOR REDRESSING GRIEVANCES

Appeal Right
To redress meritorious grievances of candidates and correct system failures.
An Administrative Review Board may grand or recommend the following remedies:
 Declare the legal rule or principle that govern the subject matter
 Prohibit the procuring entity from acting or deciding unlawful
 Annul in whole or part an unlawful act or decision of a procuring entity.
 Revise an unlawful decision or substitute it with its own decision
 Administrative Review Board may grand or recommend the following remedies:
 Order that the procurement proceedings be terminated
 Review Board to make decision in stipulated timeframe.
• The decision to be final unless successfully reviewed by court.

Disposal of Stores and Equipment

What to be disposed of .
Stores and Equipment that are :
 unserviceable,
 obsolete or
 surplus

Disposal methods:- As recommended by Disposal Committee subject to technical report

Disposal Committee:- To be established in accordance with the regulations
Disposal Methods
 transfer to another entity
 sale by public tender
 sale by public auction
 destruction, dumping or burying
 trade-in
There shall be a time limit for acceptance of recommendations of disposal committee by the
Accounting Officer.
Restriction on disposal to employees unless as prescribed in the regulations.

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 MANAGING STORES
Items stored include:
a) Consumables – used within a short time( cotton wool, sutures, syringes etc)
b) Non-consumables – permanent and can be used for years
Procedure for equipment: deciding what to buy, ordering equipment, storing
(recording, labeling and holding), issuing, controlling, maintaining and
repairing

Store Management = Avail goods and equipment - in time -at the right place
- at minimal costs

ASSET MANAGEMENT RE_CAP

Benefits
Transparency
Reduces costs
Optimal use
Optimal volume
Optimal value
Saves time
Known location

86

TO DRAW IN WORD

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 Stores Management Cycle

Strategic Planning Review

Stores
Management
Cycle

Implementation Information

90

Stores Management Cycle Strategic Planning ¼

Strategic decisions on principles:
Stock levels policy
Stock storage system (Centralisation level)
Registration system
What finance is needed /available?
Stock validation method (e.g. at cost price, depreciated, etc.)
Outsourcing or in-house
Institutional organisation
Stores Management Cycle Strategic Planning 3/4
Based on an assessment of:
• What goods and/or equipment are needed?

• Legal and regulatory requirements

• How does a store impact performance? How measured?

• Organisation set-up

• Human resource requirements

• Risks and costs

• In-house or outsourced?

Stores Management Cycle Strategic Planning 4/4

Stores design

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Decide location(s)
• Based on type stock (cold, size, climate, hazardous, sensitive)

• When needed and where?

• Legal and regulatory requirements

• Access

• Security and safety (hazardous goods, fire, accident, health)

Decide Storage/stockyard lay-out & equipment

• Legal and regulatory requirements

• Conditions for storing goods and equipment

• Access and efficiency of movement

• Energy supply - emergency back-up needed?

• Security measures to be installed

Human Resource Management

• Detailed organogram and job descriptions

• Recruit and manage staff (Number, qualifications, motivation, training,

supervision, monitoring)

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 UNIT 8
LEGAL ASPECTS OF HEALTH RECORDS AND VARIOUS ACTS RELATED TO
THEM
Legal- established by or founded upon law or official or accepted rules
Ethics:- moral principles that govern a person's behaviour or the conducting of an activity.
Learning Objectives
The learner should be able to:-
I. Familiarize with medical records ethics
II.

Medical Records Ethics

Concepts of professional ethics &legal aspect of health Records.
Confidentiality
Disclosure
Ownership
Retention
Security
Consent of Operations

Confidentiality(see government official secrets act)

“(Cap 187))Any person who receives any code word, plan, article, document or information,
knowing or having reasonable grounds for believing at the time when he receives it, that the code
word, plan, article, document or information is communicated to him in contravention of this Act,
shall be guilty of an offence, unless he”))
Information concerning a patient is confidential and should not be released to any
unauthorized persons. If a member of the hospital staff improperly discloses ay information
concerning a patient whereby that patient suffers material loss, the patient can easily sue the
hospital and the officer who is in breach of his duty had made any improper disclosure. If a
hospital authority is to minimize its risk in the matter, it is suggested that it should have a rule
for strict secrecy about all information regarding patients, their diseases, their affairs, and the
affairs of their families obtained by any officer in the course of his duties. Further it is
recommended that:-
 No unauthorized information should be given concerning patients or former patients.
 Apart from normal replies, and enquiries concerning the progress of a patient’s illness
is not to be given except from instruction of the consultant.
 Case notes are not produced to unauthorized members of staff.

Disclosure of information
There are five main categories under which contents of patients records can be disclosed;-
(1) Consent by the patient which could be expressed or implied.
(2) If there is a court order.
(3) If the interest of the doctor or hospital cannot be otherwise safeguarded.
(4) If transference between hospitals, clinics or doctors in the interest of the patient.

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 (5) If there exists a higher duty than the private duty e.g. notification of infectious
diseases, notification of births and deaths registration, and notification of poisons.

(a) Disclosure with patient’s consent

A patient can give his consent for disclosure either expressly or implicitly. Implies consent
arises only in certain limited circumstances as, for instance, when records are disclosed to
another medical agency for purpose of continued treatment. Express consent is obtained
when the patient signs a document authorizing the hospital to disclose his medical history for
some specific purpose.
In general the consent form should always indicate the reasons for disclosure, and no
disclosure should be made except for that reason. If the reason and purpose change, specific
consent should again be obtained. Where a consent form reaches the hospital, the hospital is
at liberty to disclose and the patient would have no ground for complaint if the disclosure was
wider than he intended.
In cases where requests for clinical information are received from solicitors claiming to be
acting on behalf of the patient, care should be taken to make sure that the solicitors really are
acting on behalf of the patient, and not, in fact against him.
Requests from insurance companies and similar bodies should only be acceded to with the
patient’s written consent but should be referred to the hospital authorities.
(b) Disclosure by an order of court
A court in the pursuit of justice may make an “Order for Discovery” or a Subpoena to
produce case records. There is no question but that such an order must be obeyed. Generally
the appropriate person to attend court and produce the appropriate record would be the
Records officer.
It is the original document that should be produced in court but if the original document
cannot be traced then the court may accept the photocopies but photocopies must be certified
to be the true copy of the original document.

(c) Disclosure to safeguard the interests of a doctor or hospital

If an action is brought against a hospital or doctor, then the disclosure of a patient’s record
may be done. Of equal importance is the fact that disclosure is permissible if the hospital is to
work effectively. Disclosure of the contents of a medical record is necessary between
departments or between members of medical staff in the hospital and this is justifiable of
course, as being in the patient’s interests. Such disclosure if made publicly by any member of
the hospital staff, resulting in the patient’s interest being adversely affected could result in
action for damages.
(d) Disclosure in transfer of information between authorized medical agencies
A doctor dealing with a patient has full rights of access to any clinical data made at the time
(except of course, where patient has been referred for treatment who is acting for a third
party). When a patient is seen subsequently by another, strictly speaking that doctor has no
legal right of access to the notes made by the previous doctor.
(e) Disclosure as a ‘higher” duty
The existence of the higher duty may be said to apply when the interests or needs of the
public are better served if there is some relaxation of the private duty and in some cases there

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is a clear legal duty to give information which supersedes the doctrine of confidentiality.
More common instances are in the following circumstances:-
(i) Notification of infectious diseases by medical doctors to local medical officers of
health under the Public Health Act (1936).
(ii) Notification of the cause of death under the Births and Deaths registration Acts1836-
1926.
(ii) Notification of the industrial poisonings under the Factory and Workshop
Act 1901.
(iii) Radiation protection act
(iv) Mental health act
(v) Criminal procedure code( completion of P3 forms,post-mortems,consent
for operation release of information)
(i) to (iii) above represent statutory obligations, whereas (iv) below are good causes. A
statutory obligation must be complied with, whereas although a good cause should be there,
there is no breach of law if it is not.
(IV Claims for sickness benefits under the National Insurance Acts and work men’s
compensation act
(v) Exchange of records between doctors for research purposes.
(vi) Disclosure to a central body for collective statistical purposes e.g. hospital activity
analysis.
In the foregoing instances, it is plain that the disclosure is in the public’s interest.

Ownership
The records do not belong to the patient even if fees have been paid. The records belong to
the various health institutions which created them. In the case of government institutions they
belong to the government. Case records of private institutions belong to the institutions
because they have contributed to the creation of the records.
Retention
The Public Records Act stipulates that authorities responsible for public records have a duty
to make proper arrangements for selecting those records which should be permanently be
preserved and for disposal of the rest. There are some records that were spelled out by that
Act and they should not be destroyed.
(a) Post Mortem books
(b) Summaries of clinical notes
(c) Discharge registers containing diagnosis

The rest of the health records in the folder may be destroyed. This should be done six years
after the patient’s last attendance. Each hospital should be able to decide on which records to
be destroyed depending on the institution’s demands.

Security
It is the responsibility of each and every health institution to ensure that there is security in
storage and handling of health records. This security could be maintained by:-
(a) Providing adequate security in the departmental procedures and use of equipment.

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 (b) Instructing lay staff on the confidentiality of health records.
(c) Require all lay staff to sign a declaration of secrecy.
(d) Health records staff accepting responsibility for disclosure of contents of health
records in their possession.
Consent for operations
It is legal requirement that a health institution should obtain consent from patient/ client
before an operation or anaesthesia is administered to him in order to safeguard it.
 This only becomes difficult in the case of children and unconscious patients.
 In the case of unconscious patient, the surgeon should carry on with the necessary
procedures. In case of somebody under 16 years it is necessary for parent or guardian to
give consent.
 In case of emergency, consent should not delay the procedure because this could increase
the risk. In case the operation is to be done on the child the father is the right person to give
the consent but if the father is not accessible, the mother’s consent would be acceptable.
Failing that of the father, mother and then, a legal guardian would be obtained.

Married women would give consent on their own right just as single women. It is wise to
obtain the husband’s consent particularly where sterility may follow an operation. For
mentally disordered patient the consent of the nearest relative should be obtained.

ASSIGNMENT
Write shrt notes on the following:-
Various acts related to health records,
a) (public health act,
b) records and archives act,
c) radiation protection act,
d) mental health act,
e) government official secret act,
f) civil registration act,
g) workman compensation act,
h) criminal procedures code,
i) records disposal act,
j) public archives and national documentation service act.)

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 UNIT 9
MANAGEMENT OF SPECIAL HEALTH RECORDS
Learning objectives
The learner should be able to:-
1. Define special health records.
2. Describe types of special health records.
3. Describe the security and control of special health records.
The special health records are:-
1. Psychiatric records.
2. Infectious diseases records.
3. Accident &emergency records.
4. Tuberculosis records
5. Radiotherapy records.
6. HIV/ AIDS records
7. Maternity records.
8. Maternal &child health/family planning records.
9. Gender based violence Records
1. Psychiatric records
The way psychiatric records are maintained is different from the way the general records are
maintained. This is prescribed in the Mental Health Act. The admission of psychiatric
patients may be “informal or formal”. Informal means a patient is admitted without legal or
other formalities and the hospital has no right to detain him in the hospital against his will.
Admissions are carried out in reference to the Mental Health Act. Discharge procedures are
also carried out in the same act.
The records officer must ensure that the information inside the record is accurate. The same
responsibility being carried out by the health records officer in a general hospital are the same
ones carried out in a psychiatric hospital except for the addition to the special statutory work
arising from the operation of the mental health act.
2. Infectious diseases.
There are many infectious diseases e.g. Tuberculosis, STI/HIV/AIDS, POLIO MYLITIS,
MEASLES for each of these diseases, surveillance programs are put in place to identify that
population and it requires complete documentation of cases. Since these are infectious
diseases notification must be made to the “Medical Officer of Health. A register is
maintained for this notification. Copies of the notification of new cases are sent to the various
specific programs. A unit record is opened for this patient and the information contained in it
should be very comprehensive.
The records belonging to these patients are supposed to be kept for long periods and therefore
the case folder must be made of sturdy material to resist wear and tear. The notes should be
written in foolscaps instead of a4 size papers.
3. Radiotherapy records
Radiotherapy department present a special records problem. All radiotherapy cases are
supposed to be registered nationally for perpetual follow-up. These records could be filed in a
separate area but given the unit number, and copies of the notes for the same patient from
other units in the hospital incorporated in the same unit file. This should be a radiotherapy

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number given to each patient to be used for National Cancer Registration. This number is
prefixed by the year of first registration and is used in all follow-up correspondences, until
the patient dies. The prefix to the year of registration number is a precaution against
confusion with unit number which will be used for treatment and all other occasions in the
hospital.
Security and control of special health records
The special health records should be if possible locked in cabinets and the keys kept by the
health records/ information officer.

Maternal &child health/family planning records.

The data from MCH/FP is very important since it is used to measure the following Global&
national health indicators:-
 Child mortality rate
 Maternal mortality rate
 Child growth monitoring
 Family planning contraceptive consumption rate
 National planned hood growth rate.
Gender Based violence Records:-
These type of records are sensitive they contain serious personal and purely highly emotive
and private information and are used for medico legal purposes; they also contain social
cultural information which in some aspect are viewed as taboo and a source of cultural
conflicts. The management of these records should therefore be handled strictly on the basis
of the laid down rules and regulations in place for medico legal purposes.

UNIT 10
MANAGING A HEALTH RECORDS AND INFORMATION OFFICE
Planning
Organizing
Coordination of activities

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 UNIT 11
ESTABLISHMENT OF A HEALTH RECORDS DEPARTMENT IN A HEALTH
CARE FACILITY
Learning objectives
The learner should be able to:-
1. Carry out a needs assessment.
2. Describe the procedures in establishing a health records department.
3. Organize various sections.
4. Describe commissioning procedures.
5. Monitoring and Evaluation.

1. Needs assessment
A study should e carried out to know what is required in the building of a new department,
the staff required, the equipment and the stationery that will be needed. This will require a lot
of funds and therefore a lot of caution will be needed in carrying out this study. The only
person to do this is the health records/ information officer because he is the one conversant
with the layout of the department and what to put in the department. It important once the
needs assessment is ready a corresponding budget be prepared for cost analysis prior to
acquisition of resources.
2. Design and layout
The layout of the department should take care of:-
1. Working space for all the clerks.
2. Storage space for equipment and files
3. Lighting and air circulation

The layout of an office can either hinder or promote the work. Consider the amount of work
to be done, number of staff to work in it, placing the filing clerks where the files are. Ensure
enough gangways at least 3 ft apart. Take into consideration telephone points, mail collection,
electric sockets. Weigh out the pros and cons of private or open offices remembering that a
supervisor needs an open office to co-ordinate and check the work being done. Look at all
these with an open mind from the point of view of staff and the system.

Procedures in establishing a health records department

Before one establishes a health records and information depart he should consider two
factors:-
1. The line of command
2. The number of staff and jobs needed to achieve the desired results

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The most important function of a health records and information office is to store information
when needed by medical and administrative staff.
In view of this a list of jobs and staff to carry the out can be made. The line of commandment
must be specified. The sections of the records department must be organized to fit one with
another:-
(a) The objective should be efficiency, accuracy and speed.
(b) The function is to store and provide information.
(c) Line of command should be understood and known by all.
(d) Staff should have initiative and scope to suggest improvement.
(e) There should be co-ordination of sections and departments
(f) There should be continuity in the system so that work continues in the absence of
some staff.
(g) Mobility- for staff to change and learn other jobs.
(h) Incentive – to know why the job is being done to satisfy achievement on completion.

Fire precautions
All offices should comply with fire precautions. Fire escapes and extinguishers should be
labelled clearly. The health records and information officer should ensure that his staff
understand and comply with implications of fire regulations. Lectures on fire drills and
precautions should be attended by his staff.

Security of information and property

The library must be secure during office hours and after hours. Only authorizes persons
should have access during the night. It should not be a through way to other offices.
Equipments like typewriters, Dictaphones, or machines that are very expensive and the
records office should be under lock.

Proximity of Rooms
Rooms with related functions should be near each other.
Fittings
Telephones, electric socket outlets, hoists between floors, lighting acoustic filing on walls
and ceiling should be fitted properly.
Special sound proofing
If the machines like those ones for mechanical documentation are to be used they should be
installed on rubber pads.
Storage.
Enough storage equipment should be installed if the rooms are to remain tidy. Store
cupboards should be lockable. Shelves should be at least I feet part and 7 feet high. Ancillary
equipment should be added to the library.
Space
Detailed analysis of the following must be carried out before space can be allocated.
1. The nature of the function of the records department

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Main functions being registration, appointments, medical secretariat, waiting lists, statistics,
bed bureau, microfilming, mechanical documentation, library, storage for notes and X ray
films.
2. The volume of work
This can be estimated by knowing the number of admissions, number of outpatient
attendances, number of consulting staff, any special departments.
3. General operational policies
Is it a seven day health records services?
What type of secretarial services will be chosen?
How long are the records to be retained?
4. Internal communication
This is internal communications between records departments and other departments in the
institution. The possibilities of physical communications are:-
(a) Any member can transport any item from one part of the department to another.
There could be a messenger to be sent from one department to another in the
institution.
(b) A vertical hoist may be installed between one floor and another and by pressing a
button to indicate the floor the hoist will stop.
(c) Intercom installed between sections
(d) Pneumatic tube systems are installed. It is important that they should be between the
records library and the registration area and they are sited at convenient areas on the
floors that are going to be served.

5. The Architect’s Plan

The Health Records and Information officer should know the architect’s plan and advise
accordingly.
6. Detailed planning of sections.
 The “nerve centre” of the department is the library and should be allocated enough space.
Retention period of the records department should be clearly laid down. The space for
shelving must be properly calculated.
 The type of filing equipment must be known-cabinets, shelf-filing.
 The registration and appointment areas must be easily accessible to all out patients. It
should be attractive to patient/clients for comfort and privacy. Open counters is agreeable
to the patients.
 The secretarial section may be centralized or decentralized depending on the requirements
of the institution.
 The master index may be sited near the registration or appointment areas.
 An intercom can connect other distant areas of the department.

7. Planning individual rooms.

Individual rooms should be planned depending on the functions to be carried out in each unit.
Furniture, lighting, telephones and electrical sockets should be fitted in appropriate positions
in each room.

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Monitoring and evaluation:-
Establishing a new Health Records and Information department should be viewed as a
project, thus the need to monitor every aspect and stage of the implementation to ensure that
the plan does not go off track.
At the beginning of the implementation the modalities on monitoring should be put in place
as well as an end of establishment evaluation protocol to inform on how well the resources
were utilised and whether all the activities planned were done to specifications.(see project
implementation concept and protocols)

UNIT 12
DEVELOPING AND DESIGNING HEALTH RECORDS FORMS
Learning Objectives
The learner should be able to:-
(1) Describe the basic principles of form design.
(2) Describe various medical forms used in a health records department.
(3) Explain procedures of pre-testing medical forms.
(4) Describe reproduction and costing of medical forms.
(5) Describe control procedures of medical forms.

Basic Principles of Form Design

Before one designs a form he should ask himself some questions as:-
(a) Is the form necessary?
(b) Is it the best form for its purpose?
(c) Is it easy to use?
(d) Are the instructions clear and unambiguous?
(e) Is there any unnecessary duplication with another form?
(f) How can be improved?
(g) Is it economical in terms of paper, printing and equipment required for its use?
(h) Can it be combined with any other form or forms, making it a multipurpose
document?
There are basic principles of form design that should be in one’s mind before he designs a
form. These are:-
(1) Simplicity
(2) Uniformity of size and style- in particular the “standard’ location of basic information
on the form is important.
(3) Clear instructions on the form
(4) Information requested should be minimized, by pre-printing and multiple choice
questions and answers.
(5) Layout should be eye catching (drawing attention) to special areas of interest) and
easy to read.

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Various medical forms used in health records departments are:-
Case folder
Should have the name of the hospital, the patient’s name, the hospital number, and the
information “highly confidential” enclosed printed on top of the folder.
In-Patient summary sheet
Contains complete clinical summary of the individual’s stay and treatment given during the
stay.
Letter of referral
This is a letter given to a patient by a doctor referring to a hospital or health institution for
further management.

Prescription sheet
This is used for recording treatment and drugs given by the medical staff.
Mount sheet
This is for mounting x- rays, laboratory and other reports. It should be A4 size and made of
heavy material.
History and continuation sheet
The physician continues to write the history of the patient’s illness, the continued treatment.
Operation and anaesthetic record.
There could be special operation forms used for different operation purposes. The name of
the surgeon and the anaesthetist should be recorded on this form.
Temperature, pulse, respiration and blood pressure charts
These may be destroyed after the patient’s discharge; they are transitory records unless one is
marked for retention by the Medical officer of Health. Fluid and Diabetic charts. These once
could also be destroyed unless otherwise stated.
Nursing Record
Should be included in the unit record.
Notification of discharge and discharge letter
A letter of discharge from a health institution should be given to him and his doctor notified
as well. In this letter the drugs prescribed to him should be recorded.
Report forms
The report forms should be gummed onto the mount sheets.
Post-Mortem reports
This should be the final document and should be filed in the unit file.
Medical social workers’ report
This should be inserted in the case folder.
Pre-testing of medical forms
Before the form is used it may be tested by the users to see whether it has been appropriately
been designed for the work it is going to be used for.
Reproduction and costing of medical forms
Very often “document reproduction’ is interpreted as “photocopying’. This is only one
method of document reproduction. When a machine is hired photocopying becomes more
expensive than when it is bought.

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Photocopying
Manufacturing are now supplying new models of photocopying machines at ever increasing
rates.
Spirit and wax stencil reproduction
This is a very special yet versatile method of reproduction. The actual medium of
reproduction is a sheet of paper with fine clay-like coating on the reverse side. This sheet is
placed over the sheet of hectograph paper, the clay-like coating on the first sheet actually in
contact with the carbon surface of the second sheet. These sheets are typed with the
information or handwritten. From the master sheet copies are made clamping to a revolving
drum moistened by a spirit solvent. As the machine and the dampened carbon impression on
the master sheet is reproduced in mirror form on each sheet. From a well prepared master
sheet 300 copies can be produced. Mechanical documentation uses this method also.
Other means of document reproduction
Other means of document reproduction are offset litho and typeset plates. Offset litho
depends on reproduction by either metal or paper (plate). The plate is placed on the rotary
press and copies are made. Typeset duplication equipment is the same as most professional
printers still in use. It is expensive to install.
Before equipment for document reproduction is bought the following points should be
considered:-
(a) What kind of documents need to be reproduced?
(b) Is the material likely to be done single or double sided?
(c) How many copies are required?
(d) At what speed are copies required?
(e) What quality of copy is required?
(f) What will be the capital and the running cost-(important to consider)

CONTROL PROCEDURES FOR MEDICAL FORMS

There should be strict control of all forms and records routine to prevent wasteful duplication
in inefficient procedures. Obsolete and redundant forms should be removed from circulation
and unsatisfactory forms amended where necessary. There should not be duplication of any
forms. Forms used for ad hoc investigations should be withdrawn as soon as investigation is
over.
The records officer should maintain a list of all the forms with a similar function to be kept
together. This will give the records officer an opportunity periodically to examine, combine,
simplify or eliminate the forms if necessary.
MODERN METHODS OF DEVELOPING AND DESIGNING MEDICAL FORMS:-
The current technological advancement especially in the field of ICT has made it possible to
design, develop and produce health records and information forms (tools) for data capture
electronically using computers. There are also software’s that are specifically designed for
this purpose. IN computerised environment, where EMR /EHR or HIMS/IMS is used, data
tools are predesigned and available for use, however, In a situation where one is needed to
convert manual forms into electronic format, the health Records and Information manager
should liaise with the software developer to ensure that all the data sets are availed in the data
forms.

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 UNIT 13
ENSURING QUALITY ASSURANCE IN HEALTH CARE SERVICES
The learner should be able to:-
1. Define Quality assurance
2. Explain the importance of quality assurance
3. Describe the procedures in ensuring quality assurance.

Quality assurance is defined as the customer satisfaction process.

The importance of quality assurance is to be able to:-
1. Identify cases of patients who may be discharged from a health institution before
being diagnosed.
2. Identify those patients who may have died and why.
3. The types and results of health care rendered.
4. The frequency of consultations.
5. The occurrence of infections on all cases.
6. Any other trends in the work performed.

Procedures in ensuring quality assurance

It is accepted that there are professional and consumer components in quality care. The six
dimensions of quality that need to be recognized separately and each requiring assessment
skills are:-
I. access to service:- What is our response to emergencies?
II. Relevance to need. Do we adequately provide for the need of our community as a whole?
III. Effectiveness- Do individual patients receive an adequate standard of treatment?
IV. Equity Do all members of our community have access to facilities and services?
V. Social acceptability- Do we provide for patients’ privacy in wards and clinic?
VI. Efficiency and Economy
VII. Have we developed adequate measures of cost and performance?

The assessment of quality is both complicated and multi-dimensional involving the news to
individuals and the much under questions of community need. Patients should be allowed to
air their views on the services provided to them. How do we come across to our patients?

I. Do we show concern about their feelings and about their need to be kept informed about what
is happening to them?
II. Do we provide even the basic amenities to ensure that they are reasonably comfortable when
waiting for treatment?
III. Do we provide adequate reassurance about the progress of their treatment?

Procedures in ensuring quality assurance in health records.

The health records department may carry out its evaluation of the services rendered to the
patients through the Health Records Committee. The committee should see that the health
records are complete. The committee should meet regularly and report regularly to the Senior
Medical committee in the health institution.

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The functions of the health records committee are;-
1. To recommend to the Senior Medical committee in the format of the health record.
2. To recommend policies for maintenance of the health record.
3. To ensure that proper filing, indexing, storage and availability of patients’ records.
4. To advice and guide the Health Records officer, Medical staff and administration of
the institution on the release of information from the records.
In order to evaluate the quality of the record, the Medical Records officer brings to the notice
of the Senior Medical committee all records which do not meet the level of quality. The
committee analyzes these cases carefully, and check a sample of those analyzed by the
Medical Records officer as adequate. There will be selected at random from the discharges
for the period, or specific types of cases, varying from month to month so that all types will
eventually be analyzed.

The Medical Audit.

This has been discussed fully in the previous chapters. This is an “objective method for
applying a yardstick to the quality of professional performance’. It is a method of evaluating
quality of medical care given to the patient and it is used as a tool of management to enable
the administrator and the medical staff to uncover inefficient service and try to raise the
standards of care in health care institutions.

Ensuring Quality Assurance in Health Care Services

Definition of Quality Assurance

Over recent years, the quality of documentation in the medical record has become an important
issue, not only with the need to promote better health care, but also, the need by governments to
reduce health care costs. In some countries, when funding began to be based on medical record
data, it was found that more attention should be paid to the quality of the medical record and
documentation of the original health care data.

In many countries, some problems facing administrators and government authorities include:
Poor medical record documentation;
Large backlogs of medical records waiting to be coded;
Poor coding quality; and
Poor access to, and utilization of, morbidity data.

To address these problems and improve the quality of data collected, and the information
Generated from that data, quality control measures need to be implemented.

The Medical Record Department is often the first department in a hospital to introduce
quality assurance. As the Medical Record Department has connections with most other
departments within the facility, the medical record is the best place to check the medical care and

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treatment of the patient. It should be noted that quality checking of the medical record often
results in action being required by staff outside the Medical Record Department.

One approach to quality checking is for the MRO to ask staff from other departments to
check the services of the Medical Record Department using a check-list. The results of these
quality checks (or audits) are kept on a chart (or graph) in the Medical Record Department.
They should also be presented to the Medical Record Committee for review. As the results
improve, the figures on the chart are a source of pride for the Medical Record Department
staff. This process is often the beginning of a reciprocal quality-checking program with other
departments, which could result in an improvement in the quality of procedures throughout
the health care facility.

Areas in which the Health Records Officer can Evaluate Medical Records Procedures

There are a number of procedures in the Medical Record Department that can and should be
evaluated. Some study questions that could be used to evaluate the work of the Medical Record
Department staff could include:
 Are medical records filed promptly?
 Is the file room clean and tidy?
 Are Master Patient Index cards filed promptly?

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 Are all discharges returned to the Medical Record Department the day after
discharge?
Are medical record forms filed in the correct order?

Are all medical records completed within a specified time after discharge?
Are medical records coded correctly?
Are all discharges for last month coded by the middle of the next month?
Are the monthly and yearly statistics collected within a specified time?

To conduct an evaluation study, the MRO should select a time period for the study
(e.g., one-month), prepare a questionnaire, and determine the standard or acceptable level
of compliance considered appropriate for the work to be studied. The results can be used
to improve the services in areas below the required standard of performance.

Evaluating the Content of the Medical Records

The content of the medical record can be evaluated by reviewing to see if the following
has been done:

the consent form for treatment has been signed by the patient;
patient identification details (name and medical record number) are correct and
entered on all forms;
doctors have recorded all essential information;
doctors have signed and dated all clinical entries;
the front sheet has been completed and signed by the attending doctor;
nurses have recorded and signed all daily notes regarding the condition and
care of the patient;
all the orders for treatment have been recorded in the medication form and signed;
medication administration has been recorded and signed;
the anaesthetic form (if any) has been completed and signed;
the operation form (if any) has been completed and signed;
the main condition/principle diagnosis has been recorded on the front sheet;
operations and/or procedures have been recorded on the front sheet; and
the MRO or staff member responsible for coding has accurately coded the main
condition/principle diagnosis and any other condition listed (if required).

Again, a study questionnaire should be prepared and a standard determined, e.g., 100%
compliance.

Sample check-list or audit form:

Yes No N/A* Comments
1. Patient's first name present
2. Patient's family name
present
3. Patient's medical record number
written
4. Patient's address written

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 5. Etc.
TOTAL

*N/A = not applicable

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CONCLUSION
The on-going process of care delivery must not be disturbed by the quality assurance activities
such as intensive observations of physician’s behaviour.
No simple measure of the quality of care given to the patient is available. We have to live with
the often unproved casual relationship between process and outcome measures.
Health records officers and clinical epidemiologists acting as health accountants should play an
active role in quality assurance programmes without losing their neutrality.
More good health care trials and more efforts are needed to improve the effectiveness of the
existing quality assurance programmes.

APPRAISAL ARCHIVAL, DISPOSAL

Records can be defined as information captured by individual, organization or institution in
whatever media and form for carrying out business.
 Or Recorded information of any kind and in any form, either originated or received by an
organization. Include papers, correspondence, forms, books, photographs, films, sound
recordings, maps, drawings, and other documents.

Therefore records are recorded information regardless of form or medium, created, received and
maintained by an institution or individual in the transaction of business

 Records management Is the systematic control cords in their entire lifecycle i.e. from creation
up to the disposition of records. It ensures that records is available at the right time, in proper
way and in an authorized person

 Records Manager A person assigned primary responsibility for the records management
program.

 Records keeping A process of maintaining, distributing, indexing and storing records for their
proper use. The processes of creating and maintaining complete and accurate records of business
activities

 Public records record created or received and maintained in any public sector agency.

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 Private records. Records created or received and maintained in any private or non-
governmental organization such as organizations, families, or individuals relating to their private
and public affairs.

 Information can be defined as the processed data which have complete meaning for decision
making

 Data is incomplete information collected for interpretation. Or refers to the collected facts to
be analyzed.

 File An organized physical assembly of documents grouped together for current use. Or an
organized physical assembly (usually within a folder) for current use because they relate to the
same subject, activity or transaction.

 Records Centre a low-cost facility for the controlled maintenance, retrieval, and disposal of
inactive records. A commercial records centre, operated by a private company, houses records of
many organizations on a fee basis.
A building or part of a building designed for the low-cost storage, maintenance, and
communication of semi-current records pending for their ultimate disposal.

 Active/current Records Records regularly used in day to day operation of an organization and
are kept in the records office/ place of origin. Records providing current or most recent
information.

 Semi-current records Records required infrequently in the conduct of current organizational

activities, are kept to the records centre.

 Non-current records Records no longer needed for current business. Are destroyed or
transferred to the archive.

 Administrative Records Records documenting the daily operation and administration of an

office.

 Archival Records Records of enduring value, documenting the history and the development of
the organization.

 Archives Are records usually but not necessarily noncurrent records, of enduring value
selected for permanent preservation. Refers to place or building/ room/ storage area where
archival materials are kept.
It refers to the organization responsible for appraising, acquiring, preserving and making
available archival material.
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 Appraisal is the process of determining the value of records for further use, for whatever
 Disposal The final removal, whether for destruction or formal transfer to another agency, e.g.,
records storage centre or archives, of records that have reached the end of their retention period.

 Disposition Refers to the action that are associated with implement decisions about the
retention or destruction of records. Any means of changing the location or physical format of the
records. Includes destruction by shredding or recycling, digitizing, microfilming, duplication, or
transfer.

 Vital(Essential) Records Records essential to resume or continue operations of the

organization, including records necessary to recreate the organization’s legal and financial
position, and to fulfill obligations to the organization, its students and employees, and to outside
parties.
 Format The physical form in which material appears – books, slides, photographs, film,
recordings, etc.

 Legal Value The usefulness of records as evidence supporting an organization’s transactions,

activities, claims, and obligations.
 Life Cycle of Records the records management premise (argue) that records pass through three
stages: creation, maintenance and use, and disposition.

 Medium(Media) The physical form of recorded information. Includes paper, film, magnetic
tapes and disks, CDs, etc.

 Non-Record Material Material that does not need to be filed or that can be destroyed after a
short retention. Includes drafts, worksheets, routine replies, and extra copies of documents
created for convenience.

 Record Office The office assigned responsibility for custody and maintenance of specific
records. Generally the office in which they were originally created and filed.
 Official Files Original records, including official copies of outgoing correspondence, that
document policy, operations and programs, property, financial transactions, and legal obligations
of the organization.

 Records Retention Schedule A comprehensive schedule of record series (by office or

department), indicating for each series the length of time it is to be maintained in office areas, in
a records centre, and when and if such series may be digitized or microfilmed, destroyed, or
transferred to the Archives.
 Records Values: The usefulness of records for operating, administrative, legal, fiscal, and
historical purposes.
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 Retention Period
The length of time records must be kept before they are eligible (qualified) for destruction or
archival preservation. The retention period begins at a cut-off date (e.g., the end of the fiscal,
calendar, or academic year) or is triggered by a cut-off event, such as a termination of
employment, contract closure, etc.

 Subject File a file in which documents are arranged by subject. Not to be confused with a
case file.
 Transfer, the change in physical custody of records from one organization or unit to another,
e.g., from an office to a records center.

APPRAISAL
Records appraisal brings about a lot of benefits if properly planned and implemented, such as
compliance to legislations, easy destruction of ephemeral records to keep only enduring value
records, and the smooth running of an organisation.
Proper records appraisal requires consideration of five key principles, which are
 Timing,
 Methodology,
 Engagement,
 Documentations
 Guidelines.

This means appraisal needs to be done in time so that the records may also be disposed of in line
with the set retention period

In the process of appraisal, several things need to be considered.

 There are needs to have a way or mode of conducting appraisal.
 There should also be a consultation with the creators of records and end-users to understand
the need and use of the records concerned.
 There should also be a recording taking place during the appraisal to keep record of each record
regarding the value and retention period for future implementation of appropriate disposal.
 Finally, a guideline should be developed to assist officials in the whole process of appraisal
throughout to disposal.

Appraisal Procedure
a) Records identification for disposal
b) Records separation per archival and ephemeral value
c) Records sorting and registration for disposal
d) Disposal permission application from the Archivist

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 e) If disposal authority is granted, records disposed off
f) Disposal certificate issuing by the records manager
g) Disposal register creation and safe keeping for future reference and accountability

Appraisal, Disposal, And Destruction Of Health Records Procedures

6.1 Appraisal
The process to appraise a record begins with validating the timeframe against the retention
period to calculate if the record is suitable for destruction.
 The content of the health record is to be checked to ensure that the date of last attendance is
correct.
 Any reference to “conclusion of treatment” should be taken to include all follow-up checks and
action in connection with the treatment.
 All health records identified for disposal will be checked against electronic health record systems
and the relevant tracking systems, where appropriate, by another member of staff to ensure
there are no current episodes of care in progress and that the year of the last attendance is
correct.
 If it is found to be incorrect the year of last attendance on the health records will be amended
and returned to archive in line with procedure documented in separate policy on retention and
archive.

6.2 Disposal
 An inventory of all records that have been destroyed will be maintained.
 This inventory will record details of what has been disposed of.
 Once the inventory has been fully updated, those records identified for destruction will be
placed in confidential waste containers to await destruction.
 The Committee will then authorize destruction of the records by an approved contractor.
 This will be carried out under secure conditions and a certificate of destruction will be issued to
Hospice at Home.
 The Chief Executive will ensure that this contractor meets the IG requirements laid out in the IG
Toolkit.
 When the health records have been crosschecked against electronic health records systems and
thereby verified for destruction, the electronic health records systems, where appropriate,
should be updated to indicate that the paper records have been disposed of.

Disposal policies and schedules

Organisations are accountable for the way in which they use and dispose of their assets and this
includes disposal of their records. They also need to be in a position to explain the absence of
records that were once held. For these reasons it is recommended that disposal decisions are
clearly documented in disposal policies and schedules.

A disposal policy can be either part of the overall records management policy or a separate
document. The policy usually provides an overview and serves as an introduction to a more

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detailed document, the disposal schedule or, for large organisations, disposal schedules. (Some
authorities use the term retention schedule instead of disposal schedule)

A disposal schedule is a set of rules identifying classes of records and specifying their retention
periods and what should happen to them at the end of that period.

Disposal class is the term used in this guide for the set of records to which a disposal decision
applies. This set is an aggregation of individual records which are similar in nature and result
from the same activity, either in a particular business unit or throughout the authority.
Aggregating these records into disposal classes ensures consistency and also cuts down on the
time and resources needed to make and apply disposal decisions.

Benefits of disposal schedules

The main benefits of disposal schedules are:
● records of continuing value are identified and can be managed appropriately
● records which cease to have any value to the organisation or as archives can be disposed of
efficiently
● clear instructions on what happens to records when they are no longer needed to support the
business
● definitive periods of time for which records should be kept and remain accessible
● consistency in retention of records across the organisation
● evidence of compliance with legal and regulatory requirements for the retention of records
● evidence of what records were created but subsequently destroyed.

Retirement of records
 The retirement of records from the office or registry to the storeroom or strongroom is an
absolute must for the better functioning of any records system. Unless it is done the system
becomes burdened and over loaded by information that should not be there. The removal and
retirement of this information and its eventual transfer to Records Centres is the pivotal
justification behind the Records Centre concept which aims at unburdening offices and registries
by receiving and storing in lowcost storage areas records that would otherwise be stored in
expensive office accommodation and even more expensive filing equipment.
 The retention of semi-current and non-current records in offices and registries slows down the
rate of retrieval of information.
 A guiding principle in retrieval is that the more the number of items that must be retrieved from
the slower the rate of retrieval. Put simply, it is faster to retrieve a file from a cabinet that has
fifteen files than it is to retrieve a file from a cabinet with one hundred and fifty f
 The retirement of records from the office and registry to the storeroom or strongroom has important
implications for the decision makers. If the transfers are done systematically with appropriate and
requisite controls and documentation, then there is no period during which decision makers find
difficulties in retrieving information that is needed. The use of such tools as transfer/transmittal lists
also means that information is available on what was transferred and is in the storeroom, on what has
subsequently been disposed of and on what has been transferred to the Records Centre.

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 The transfer/transmittal lists also serve as the basis for the making of disposal - retention decisions
since they will identify and isolate the records coming out of active use thereby requiring decisions as
to their disposal or retention. While the disposal and retention of records should be controlled by the
archival authority in the country to ensure that records with archival value are identified and
preserved, it is nevertheless necessary that after such consultation, mechanisms be introduced for the
automatic disposal at creating agency level of records that have outlived their usefulness. it is futile
and wasteful to retain records whose usefulness will have expired.

 The point that has repeatedly been emphasised above is that it is necessary to have a transitional
period between active use and storage of records in offices and registries and their transfer to Records
Centres. In this transitional period the records should be transferred and kept in storerooms and strong
rooms within the premises of the record creating agency. During this period, the archivist must of
course have an interest to ensure that no unauthorised destruction takes place and to ensure that the
records are organised. in a way that will make transfer to the Records centre easy. It is interesting to
note that of those archival institutions that indicated involvement in the management of semi-current
records

6.3 Permanent Preservation

 The identification of clinical records for permanent preservation and retention of clinical records
beyond the minimum retention period is the responsibility of the individual clinician in charge of
the care for the patient, following discussion with either the Caldicott Guardian and/or Chief
Executive.
 The decision for the retention of documents/information will be recorded on a standard form
“Retention of Documents past Schedule” (form) which includes implications of both retaining
and destroying that information.
 The form must be filed and retained within the health record.

6.4 Incidents
The destruction or permanent loss of any document/information that occurs requires the
completion of an Incident Form.

TRAINING Training relating to records management will be provided as appropriate.

APPRAISAL, DISPOSAL AND ARCHIVING OF HEALTH RECORDS

APPRAISAL

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Appraisal is the process of evaluating records to determine how long to keep them, including to
decide if the records have sufficient long term value to warrant the expense of preservation in
an archives

Characteristics of a good appraiser

 Personal and professional integrity.
 Has a career, not just a job
 Objective can overlook personal biases.
 Talented. Is able to take conflicting information and pieces of a puzzle, and make a good
reconciliation. Get “hunches” that something isn’t quite right, and are able to find out
what’s really happening (or at least make a very good effort to find out).
 Can get “out of the box.” Flexible, willing to try new ways of analyzing, researching, or
reporting.

RECORDS TRANSFER PROCEDURE

Every hospitals and programs should regularly transfer inactive records to the secondary filling
area or the archive area. The place should offers a free, secure, and environmentally friendly
storage facility for your important patient records. The following procedures are provided to
assist offices in transferring records to the archive.

Step One: Organize and Arrange Files for Transfer

 The files are normally arranged in an alphabetic, numeric, or alphanumeric filing system.
It may be necessary to meet with records management staff to review records and
create a more organized plan for arrangement and transfer to the archive

Step Two: Appropriate Boxes for Transfer

Look for a suitable box where you can place/put your file before transfer or during transfer.
Ensure that the box is strong enough to carry good number of files

Step Three: Proper Box Etiquette

Once you have arranged and acquired the appropriate record center boxes, it is time to
properly fill inventory, and label the boxes. All documents should be in a standard manila
folder (no loose papers or hanging folders), and each folder should be labeled and dated. You
are strongly encouraged to weed or discard documents as dictated by each record Guideline. If
you are unsure of whether or not to discard something, please contact records management
staff before moving forward.

Proper labeling of boxes helps staff distinguish between different series when transferred at the
same time. Using a pencil, and pencil only, please mark the box number in the upper right hand
corner on the front of the box.

STEP FOUR Records Inventory Creation

Create a Records [Link]

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• indicating and filling all field thats are required
.•List each description in its designated area.
•Add all files to the Inventory in the same order as they are in the boxes.
•File titles listed on the Inventory should identically match the titles on the physical files
•Enter dates as MM/DD/YYYY
•Use the Retention Schedule to determine the: o Series code (ex. SA0001) o Final status or
disposition (Destroy, Archival Selection, Permanent) o Eligible disposal date

Step FIVE: Transfer to the archive Center

When new record transfers are processed at the archive each unique series receives its own
accession record in our internal database. Therefore, it is imperative that if transferring
multiple record series at the same time, each record series receives its own Record Transmittal
Form. This not only helps archive staff process the boxes, but it also prevents any confusion as
to which boxes belong to which record series.

Records Appraisal
Records appraisal is the process of determining the archival value and ultimate disposition of
records. Appraisal decisions are informed by a number of factors including the historical, legal,
operational and financial value of the records.

When deciding on the retention and disposition of a medical records the following questions
must be considered:
 Is the record needed and referred to on a day to day basis?
 Is the record required for legal purposes
 Is there any legislation which affects how long the record should be kept?
 Is the record likely to be of enduring public interest?
 Is there guidance or precedent (practise or standard) available on retention of this type
of record elsewhere in the sector?

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The answers to these questions will inform how long records will be kept.

Selecting Records for Permanent Retention

Records are likely to be designated as 'archival' and selected for permanent retention where:

 they are essential to the continued functioning of the hospital and enable it to assert its
legal position and rights e.g. title deeds

 They provide evidence and accountability of the hospital policies, activities and
decisions.

In most cases this will mean retaining records which provide evidence of:

 High level decision making

 The structure, organisation and remit of the University (including any changes to these)
 Policy formulation
 Significant interactions between the hospital, its stakeholders, external bodies and the
wider community.

Destruction of Patient Health Information

Destruction of patient health information by an organization or provider must be carried out in

accordance with federal and state law pursuant to a proper written retention schedule and
destruction policy approved by appropriate organizational parties. Records involved in any open
investigation, audit, or litigation must not be destroyed until the litigation case has been closed.

As with record retention, there is no single standard destruction requirement. Some states require
organizations create an abstract of the destroyed patient information, notify patients when
destroying patient information, or specify the method of destruction used to render the
information unreadable. Organizations should reassess the method of destruction annually based
on current technology, accepted practices, and availability of timely and cost-effective
destruction services.

In the absence of any state law to the contrary, organizations must ensure paper and electronic
records are destroyed with a method that provides for no possibility of reconstruction of
information.

Examples of destruction methods are provided below:

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  Paper record methods of destruction include burning, shredding, pulping, and
pulverizing.
 Microfilm or microfiche methods of destruction include recycling and pulverizing.
 Laser discs used in write once-read many document-imaging applications are destroyed
by pulverizing.
 Computerized data are destroyed by magnetic degaussing.
 DVDs are destroyed by shredding or cutting.
 Magnetic tapes are destroyed by demagnetizing.

Organizations must maintain documentation of the destruction of health records permanently and
include the following (see appendix D for a sample form):

 Date of destruction
 Method of destruction
 Description of the disposed records
 Inclusive dates
 A statement that the records were destroyed in the normal course of business
 The signatures of the individuals supervising and witnessing the destruction

Under the HIPAA privacy rule (45 CFR, Parts 160 and 164), when destruction services are
outsourced to a business associate the contract must provide that the business associate will
establish the permitted and required uses and disclosures and include the following elements:

 The method of destruction or disposal

 The time that will elapse between acquisition and destruction or disposal
 Safeguards against breaches
 Indemnification for the organization or provide for loss due to unauthorized disclosure
 Require the business associate to maintain liability insurance in specified amounts at all
times

STEPS FOR DESTRUCTION

Assessing records

Organisational units need to determine and document records that are eligible for destruction.

To assist with determining the eligibility of records for destruction a ‘Criteria Matrix’ resource
is appended (refer to 7.1).

The ‘Criteria Matrix’ summarises the conditions referenced in the approved retention and
disposal schedules to:

 determine whether the records are categorised as temporary records, and to

 understand the retention trigger conditions in order to calculate and confirm that the
minimum retention requirements have been served.

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RMAS(Remote Memory Administration System) provides advice and support to organisational
units to assist with the correct translation of the requirements stated in the approved retention and
disposal schedules.

3.3 Create evidence of destruction process

Regardless of the format the time expired records are in, under legislation it is mandatory to keep
a record (log) of destruction activities.

 Organisational units must document the records eligible for destruction and receive local
organisational unit endorsement and delegated manager approval prior to carrying out
destruction. Liaison with the RMAS team is also required and templates to assist are
available in Section 7.2.
 The destruction logs, must always be kept and captured

3.4 Destruction of Records

3.4.1 Carrying out the destruction of physical source records

The destruction of physical source records must be carried out using a secure process unless the
record had a security classification approved as ‘public’.

The RMAS team provide advice to organisational units on preferred confidential destruction
services. These include:

 For small volumes of paper records, local shredding equipment can be used.
 For sizeable volumes of paper records or records on small portable recording devices
such as USB’s or compact disks, there are third-party providers for:
o Medium volumes – supply and removal of in-office confidential destruction bins,
and
o Large volumes – through an on-site mobile destruction service or via an off-site
destruction plant.

3.4.2 Destruction of digital records

As is the case for physical source records (refer to 3.4), the destruction of digital records must
also be carried out using a documented, authorised and secure process. Organisational units can
contact RMAS if they require assistance.

NATIONL ARCHIVE

Archives, which reflect the entire scope of significant governmental activity, have a broad range
of research values. They serve, first of all, as the collective institutional memory of the
government and its component parts. As such, archives are an essential tool for achieving
administrative and historical , as they provide ready access to the government's past experience,

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including its successes and failures. They furnish and help when challenges arise that are similar
to those faced earlier. Archives can also contribute significantly to economic and social
development, particularly in developing countries, because they are a unique source of
information on earlier development initiatives. They contain demographic, economic and social
information useful in planning and development on a local, regional, or national scale. Archives
also contain vital documentation of the identity, rights, privileges, entitlements, and
responsibilities of individuals and organizations. Most of these research values relate, in greater
or lesser degree, to the purposes for which the government created the records in the first place.

Roles of Archives

 Identify, appraise, preserve, and make available documentary materials of long-term

value (essential evidence) to the organization or public that the archives serves
 Ensure the accountability of government by preserving public records and making them
available to the citizenry as is legally and ethically appropriate
 Ensure the accountability of nongovernmental institutions to their shareholders, boards,
and other constituents
 Preserve unique or collectible documents
 Serve as memory institutions for a culture
 Support scholarly, administrative, and personal research

Records retention

A records retention schedule is a policy that defines how long data items must be kept and
provides disposal guidelines for how data items should be discarded. ... They often outline the
business reason for retaining specific records, and designate what should be done with the data
when it is eligible for disposal.

Retention Scheduling
What is a Records Retention Schedule?
A Records Retention Schedule is a control document that sets out the recommended periods
for which an organization’s/ hospital records should be retained to meet its operational needs
and to comply with legal and other requirements.

Why is a Records Retention Schedule necessary?

A Records Retention Schedule is an essential component of an efficient and effective records

management system. Properly developed and consistently implemented, a Records Retention
Schedule protects the interests of the organization and its stakeholders by ensuring that records
are kept only for as long as they are needed for operational and legal purposes and are then
disposed of appropriately.

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What does the Schedule Cover?
Records Retention Schedules apply to records in all media and formats including:

 Paper
 Microfilm
 Electronic records held on magnetic or digital media

Photographs, film and video

Records Disposal Schedule?

A records disposal schedule sets out the minimum amount of time specific types of records
must be kept. Disposal is not all about destruction - in a records management context,
'disposal' is an umbrella term for the ultimate fate of a record (its 'sentence'), which could be
that it is kept OR destroyed.
Disposal is an important part of records management. Properly done, it ensures that the
organisation retains records for as long as they are needed and then, when they are no longer
needed, destroys them in an appropriate manner or disposes of them in some other way, e.g.
by transfer to an archives service. A managed disposal process has several benefits :
● It avoids unnecessary storage costs incurred by using office or server space to maintain
records no longer needed by the organisation
● It supports compliance with the 5th data protection principle if records contain personal
information (this principle requires organisations not to keep personal information for longer
than necessary)1
● Finding and retrieving information is quicker and easier because there is less to search
● responding to Freedom of Information (FOI) requests is more efficient

Benefits of disposal schedules

The main benefits of disposal schedules are:
● Records of continuing value are identified and can be managed appropriately
● Records which cease to have any value to the organisation or as archives can be disposed of
efficiently
● Clear instructions on what happens to records when they are no longer needed to support
the business
● Definitive periods of time for which records should be kept and remain accessible
● Consistency in retention of records across the organisation
● Evidence of compliance with legal and regulatory requirements for the retention of records
● Evidence of what records were created but subsequently destroyed

WEEDING OF RECORDS
Weeding is the act of removing unnecessary files from the active records. The result is
significant savings in storage space and faster and more efficient retrieval of information for
research purposes.

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 UNIT 14

INTRODUCTION TO ELECTRONIC HEALTH RECORDS

Any countries now have a number of computerized applications as part of a Health
Information System (HIS) within the health care facility. The aim of health care authorities around
the world is for the development of an automated patient information service that will increase the efficient
retrieval of information for patient care, statistics, research and teaching. Health Information
Systems are designed to integrate data collection, processing, reporting, and the use of

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information necessary for improving the effectiveness and efficiency of the health service through
better management at all levels of health care (WHO, 2000).
An important point to remember, however, is that the use of a fully computerized system may
improve the effectiveness and efficiency of a Medical Record Department, but ONLY
where the basic manual procedures are already in place organized. and well

The development and implementation of computer applications require detailed planning and
cooperation between the medical record officer, computer staff and the hospital
administration. The first step in such an undertaking would be to review the existing manual
system to define the data needs and determine the proposed data flow. Once this has been
accomplished, the next step would be to design the data collection and reporting tools and
develop procedures. These would be followed with a detailed program of education for all
staff, particularly the persons who will use the system.
Medical record procedures commonly computerized in many countries include the

Master patient index (M PI);

Admission, transfer and discharge/death (ATD) system;

Disease and procedure index; and

An automated record tracking system.

Devise strategies in preparation for an EHR

When determining strategies in preparation for the introduction of an EHR system, it must be
kept in mind that the institution/country is in the process of introducing a major change within
the healthcare delivery system and managing that change effectively and efficiently will be
crucial to a successful outcome.

Strategies should include the identification of critical factors to success.

They could include, but may not be limited to, a strategy for:
a) Patient identification
b) Documentation standards – for the exchange of information
c) Incorporation of provider signatures
d) Education and training of all staff – medical, nursing, administration, and clerical
e) Storing electronic health records
f) Risk management
g) Quality assurance

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h) Personal Health Records – with the current trend for patients to be more involved in their
own healthcare personal healthrecords are playing a greater role in healthcare in many
countries
The Steering Committee will also need to determine how they will communicate the planned
changes and market them to providers and consumers. In addition, work practice issues need to
be addressed as well as possible issues and challenges that may cause problems and delay in
implementation such as lack of available personnel with technical expertise to operate the
system; lack of data processing facilities; and staff lacking computer skills.

a) Patient Identification
As mentioned many times, an essential step to be taken when preparing for the introduction of an
EHR is to ensure that all patients are uniquely identified at all times. Some form of Unique
Patient Identifier is essential to provide the linking mechanism that underpins the EHR. In many
countries, national patient identification numbers are already being used. If this is the case in
your country, you are already on the first rung of the ladder to implementing an EHR. If it is not
possible to have a national identification number, the current system used for patient
identification should be used and adapted if required but if there are problems with patient
identification that need to be solved before moving forward. As previously mentioned,
identifying information should be stored ina Patients’ Master Index (PMI) and would include
demographic information such as:

 a unique patient identification number

 medical record/hospital number
 date of birth
 sex
 address
 And other specific demographic information.
Currently, many institutions have already automated their PMI. If this is not the case, an
electronic patients’ master index system is essential when considering implementing an
electronic health record. Automation would require a group of programs, accessed by users via
display terminals, and/or printing terminals. The programs would be designed to enable access to
the information held on the PMI file, and to build or modify the file information as required by
the institution.

b) Documentation Standards for Information Exchange

Just as there are a set of standards for manual medical records and medical record services, there
also need to be standards in electronic health records systems. The Steering Committee needs to
ensure that standards are in place to address definitions of data to be exchanged, the timing of the
exchange, the management and integration of data to support patient care, and the evaluation of
healthcare services.

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There are several accredited standard-developing organizations operating in the international
healthcare industry, the most well-known being Health Level 7. This organization and the
standards they develop are known as HL7. These standards are developed to provide a structure
that defines data and data elements and specifies how data is coded. Specifications developed by
HL7 include the widely used messaging standard that enables disparate healthcare applications to
exchange key sets of clinical and administrative data. Such standards have been developed
specifically to create flexible, cost-effective approaches, standards, guidelines, methodologies
and related services for interoperability between healthcare information system (HL7 2005).
Theuseofinternationallyacceptedstandardsinindividualapplications will improve the integration
of the application with other applications in the system. A decision needs to be made as to which,
if any, standards organization the institution/government will use. In many commercial EHR
systems standards are already imbedded within the program.

c) Incorporating Provider Signatures

In an electronic health record, as in manual records, treatment and medication orders must be
signed. The authenticity of an electronic signature is extremely important particularly when the
record is used for documentary evidence in legal cases. In an electronic system, authenticity is
often easier with documents automatically stamped with date, time, and user identification. Some
systems use the provider’s password as verification of their signature. This is accomplished by
requesting that the password be entered a second time for verification.
Some countries do not see this as sufficient and plan to use a digital signature created
cryptographically. Cryptography keeps data secret through mathematical or logical functions that
transform intelligible data into seemingly unintelligible data and back again so as to authenticate
the user and provide non-repudiation. That is, it is a process that enables positive identification
of the sender of a computer message so that the sender cannot deny sending the message

d) Education and Training

One of the most crucial issues when preparing to introduce a major change in any organisation is
the training and education of users of the system. The change from a manual medical record
system to an electronic health record system is a major change and many people – healthcare
professionals, administrative, clerical staff – need to be thoroughly trained if the change is to be
successful. Resistance to change or hesitancy in electronic documentation needs to be addressed
and although some staff may still be hesitant, they may be willing to become involved. It is
extremely important to gain the confidence of all staff particularly medical and nursing staff. As
the major users of the system, doctors and nurses need to understand how the system will
function and be confident that all legal and ethical issues will be safeguarded.

e) Storing Electronic Health Records

A strategy needs to be in place to address the storage of electronic health records. As for manual
medical records, the electronic health record needs to be maintained in an accessible media for
future retrieval for patient care and other uses such as research and teaching. The Steering
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Committee should identify whether previous health records will be scanned and included as part
of the system, how they will be stored, and if the system will include emergency attendances.
The strategy should include what type of media will be used to store the HER Primary storage is
usually maintained in the central processing unit (CPU) with information readily available
online. When developing a strategy for storage, it is important to remember that speed and
backup are important considerations as it must fully support continuous and instantaneous access
to data. Secondary storage also needs to be considered. An EHR system stores huge amounts of
data and decisions need to be made on the type of storage device to be used. The better-known
devices are magnetic tape, hard disk systems, and optical disks. The latter are well suited for
storing multiple media including images such as x-rays. It may be on-line to the CPU for real
time access or off-line requiring on-line loading.
Other questions and issues on storage to be addressed would include:
• What are the environmental conditions? Are there any physical hazards?
• What control will there be for equipment and media? Whomay have access?
• What contingency plans are in place if the system is down – secondary or back-up copy?
• What will the storage period for each record type be? – local laws need to be taken into
consideration; and
• A plan is in place for the transfer of electronic health records to new media before degradation
occurs.

f) Risk Management
A risk management strategy should be in place to address any foreseeable barriers to the
implementation of an EHR. Elements of this strategy should include plans to:
• Ensure adequate funding is available to provide the source applications, hardware infrastructure
and implementation resources with a funding/financial management plan in place to incorporate
ongoing needs
• Ensure sufficient skilled resources, both human and technical, are available to provide program
management during implementation and to give on-going support
• Develop and implement a marketing strategy to promote the benefits of the proposed EHR to
consumers and healthcare providers such as brochures or a newsletter to keep personnel up-to-
date with developments

g) Quality Assurance
This strategy should set out the aims of an EHR, which should include improving health
outcomes, population health, and the management of health resources and services by:
• Providing better information for clinicians to make decisions about treatment and care planning
• Supporting a best practice, evidence-based health system
• Increasing access to information for medical audit purposes
• Providing decision-support to allow clinicians to make the best treatment decisions for their
patients

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• Ensuring the availability of medical alert and prescription decision-support to reduce adverse
events
• Providing information to support an understanding of service utilization patterns and better
service planning

h) Personal Health Records

A decision as to whether a personal health record (PHR) will be an integral part of the EHR plus
the form it will take should be determined during the planning stage. In some countries a
personal health record is provided via a smart card, like a plastic credit card. It is used to store
patient information including identification and demographic details, allergies, and blood type, as
well as current health problems and medications. They may also include the patient’s photograph
for positive identification. Patients carry their smart card with them when they attend a
healthcare facility and present it to the provider who processes it via an electronic card reader.
The card is not part of an electronic network and provides detailed accurate information that is
readily available. Such personal health records are popular in some countries and contain varying
levels of information.

Develop policies for use in an electronic health record system.

Policy development is essential to ensure that existing policies have been revised and
redeveloped to address the implementation of an electronic health record system. A policy is a
basic guide of action that prescribes the boundaries within which activities are to take place. It is
important to identify how the proposed automation of health records will affect existing policies
and procedures and revise them accordingly. Some policies required may include:

a.) Information Flow

In a simple EHR system the information flow for inpatients should be the same as for a manual
system except that data will be entered at the nurses’ or doctors’ station in the ward via an
electronic device with other data transmitted electronically from other departments where the
patient has received tests, treatment, etc. An existing policy on information flow should be
reviewed and revised to incorporate electronic data entry. The actual entering of clinical data at
the time the provider visits a patient has been an important factor that has restricted the
implementation of a fully electronic health record in many institutions.
To overcome this problem, data entry has been improved by using a structured format that
prompts the provider.

b.) Work Flow

Current work-flow policy needs to be reviewed and revised to meet the demands of the
electronic system as there will be many changes particularly in the MRD. Work-flow varies from

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one healthcare setting to another and needs to be clearly understood and documented before
implementation.

c.) Content and Format of the Health Record

The current paper record content and format should be assessed to see if they are suitable for
adaptation to the electronic system. Forms may need to be redesigned to enhance data entry. The
record format needs to be of a kind that will ensure efficient retrieval of needed data. In a manual
system, procedures should be in place to enable correction and amendments to data entry in
health records with strict guidelines for correcting data and reports. The same will apply to
electronic data entry. In paper records, corrections in a record entry are easily identified. This
may not occur in an electronic record and the computer program should provide an audit trail
that shows when changes were made and by whom. Policies on how data is to be validated also
need to be in place as well as rules for the completion process following the discharge of an
inpatient (that is, how clinicians complete their records). Completion of a health record by the
attending physician should be done at the time of discharge.
A standard form of patient consent for treatment needs to be designed with detailed policies and
guidelines for its use, including how the patient’s signature will be incorporated. In many cases
the signed Consent Form is scanned and included in the EHR.

d.) Downtime Policy

A policy and procedure needs to be in place to address issues relating to downtime and backup.
How the system is to be backed up is an important issue and implementation cannot take place
until this has determined.

e.) Printing Policy

There needs to be a policy on printing documents. It must be determined for what purposes a
record will be printed. Ideally, for patient care, all entries and retrieval of data would be via
thecomputer. Copies will be printed and will be traced by an audit trail to identify users who
have printed reports from the system. This is to ensure that the patient’s privacy has been
maintained.

f.) Retention Policy

It is critical to determine the length of time documents and data is to be retained. Information
will need to be culled and a policy needs to be developed to cover what data will be retained and
for how long. Other policies and procedures that may be unique to your institution and should be
in place before proceeding to implementation should be identified and addressed.

Next Steps in the Planning Process

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The next steps in planning for the introduction of an EHR would be to appoint a team to oversee
implementation and establish a number of working groups to assist with the development of
policies relating to specific tasks.

1. Appointment of an implementation coordinator and an implementation team

Skilled information management personnel and a well-trained technology workforce are essential
for successful implementation of an EHR. An appropriate organisational structure also needs to
be in place and key users made ready.
The institution/country should determine whether the Steering Committee will be given the task
of implementation or a team of dedicated staff delegated for the purpose. Some members of the
Steering Committee may be ready to move on as their specific task has been completed; some
may not feel able to be part of the implementation team, while others may be both willing and
competent to participate in the implementation. Given the critical nature of the implementation
phase, however, two groups may be required – the
Steering Committee to see to the overall implementation and a dedicated team to undertake
specific tasks as outlined in the plan. An implementation coordinator will lead the
implementation team and may have a title such as Program Coordinator or Project Manager. This
person may be a member of the Steering Committee, someone already on staff, or someone
specifically employed for the task. Alternatively, the institution/country may wish to employ a
consultant or outside advisor with abroad range of experience in health information management
and electronic health record implementation to assist the Steering Committee.
The implementation team leader will be responsible for coordinating the implementation of the
new system. The person appointed or contracted for this role must be respected and valued by his
or her peers, be a good communicator, a strong leader with good negotiation and problem-
solving skills.
The implementation team (whatever its form) should include a skilled workforce with the
expertise to support the Steering Committee, implementation coordinator, and potential users.
Remember that it is extremely important that all potential users are involved in the formulation
of policies and guidelines to foster participative decision-making – vital to the successful
introduction of the new system.

2. Establishing a number of working groups for specific tasks

A number of working groups need to be identified and appointed for each specific responsibility
such as a/an:
a.) Information Security Group – to deal with medico-legal aspects including privacy and
confidentiality issues
b.) Education and Training Group
c.) Quality Assurance Group
More groups may be required and the Steering Committee, in conjunction with the
implementation coordinator and team, need to identify areas needing special attention.

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a.) Information Security Group – medico-legal aspects including privacy and confidentiality
The Steering Committee should appoint a team to develop and maintain a medico-legal checklist,
incorporating government regulations, to guide the implementation and on-going use of the
EHR. Remember that measures need to be directed at ensuring appropriate security and storage
of information to prevent improper disclosure.
Within the institution/country an Information Security Policy should Executive Steering
Committee Providers and users Implementation Coordinator Working groups Implementation be
in place, with standards, implementation guidelines, and an action plan. Compliance with such a
policy will safeguard the accuracy and completeness of information and ensure that:
• Only authorized persons have access to healthcare information
• Dependant privacy policy and related legislation are upheld
• Information is stored and handled in a secure manner
Implementation of an Information Security Policy will ensure that information related to health
encounters will be protected from unauthorized access when the EHR is operational. It is
important to remember that for a manual health record system the privacy and confidentiality of
patient information in an electronic health record must be protected at all times.

b.) Education and Training Group

A training team needs to be in place to develop education and training programs. As previously
discussed, on-site training is required to address work practice issues and develop a group of
competent users, confident in their knowledge of the proposed system and ready to accept the
change. The Steering Committee may identify the need to have more trainers than staff on-site
during early preparation for the introduction of an EHR system.
Systems have been known to fail because individuals required to use the system have not been
adequately trained and do not understand and the system. They also may not have been involved
from the beginning of discussions and negotiations. Training, however, should commence with
the more interested users with keyboard skills and a better knowledge of computers who will
subsequently be used to promote to the less interested, motivated or skilled persons.
Remember, a key ingredient for successful implementation is user-involvement from the
beginning. It is critical to success so too is training.
The first step would be to conduct a needs assessment to determine the level of training required
for all data providers and data users. From this assessment, the Education and Training Group
will be able to identify the training needs of users, determine content of the training program and
methods of teaching and set up a schedule for classes. When the above has been completed the
group needs to determine the location where training will take place and what hardware and
software will be needed. It is also important to estimate the costs of training and how the
programs are to be evaluated.
From the needs assessment it may be found that not all users need training at the same level and
that different levels of classes need to be conducted. The first group to be trained should be the
trainers and a program (specifically to “train the trainers”) needs to be designed and

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implemented. This group will then take on the responsibility to train the rest of the providers and
other users.
Training will be an on-going function and will not stop when the system is up and running. There
will always be new providers and users requiring training before using the system.
It may be wise to consider some one-on-one training sessions for clinicians who may be reluctant
or too busy to attend group sessions.
The training group would need to:
•Prepare a training program with clearly stated learning objectives. The program should aim at
not only educating staff but also ensuring that the value of the EHR in healthcare delivery is
understood.
•Start training sessions with a “train the trainers” program to enable the development of a
training workforce.
•Present the programs clearly and enthusiastically enabling hands on experience.
•Encourage members of the health services to commit to reviewing work practices and endorse
the changes required to implement the EHR for maximum efficiency gains.
•Prepare staff to participate in defining the new work practices and developing policies and
guidelines to promote user-ownership and increase compliance.

c.) Quality assurance group

A quality assurance coordinator and team should be established to oversee that data collected and
processed are accurate, reliable, and organized in such a way that they are both readily
understood and available when needed by healthcare providers. To ensure that documentation
meets the required standards, quality assessments must be undertaken beforehand and continued
on an on-going basis.
Poor quality data is a major hindrance to planning and decision making and data quality is an
important concern for healthcare institutions and governments, regardless as to how data is
recorded and processed.
As shown in the following diagram the working groups will be responsible to the Steering
Committee and should report back to the Committee on a regular basis.
Remember that an essential requirement for the successful implementation of an electronic
health record system is the cooperation and commitment of all staff to the new system, including
administration, medical and nursing staff, other healthcare professionals, and computer and
clerical staff. It also must be remembered that just selecting an electronic health record system
that has been implemented elsewhere and expecting it to work for your institution /country could
cause disappointment if it does not meet your perceived needs or available resources

Factors to be considered when developing an EHR Implementation Plan

When the type of EHR system has been determined, goals identified, issues and challenges
recognized and addressed, some strategies devised and documents relating to policies and
procedures covering the proposed EHR System prepared the next step is the development of an
implementation plan.
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Some factors for consideration when developing a plan for implementation are outlined in this
chapter.
The implementation plan should show all steps required to move from a manual medical record
system to an electronic health record system. A successfully implemented HER system should
promote and meet the specific, stated EHR goals of the institution/country. Most importantly, it
should also improve the overall performance of the institution and the services it provides.
A sound implementation plan can mean the difference between success and failure
A factor to be Considered It is extremely important when planning for a change to an EHR to
anticipate the impact of the introduction of work-flow, productivity, users, and patients.
There are many factors to be considered when developing a plan for implementation for
example:
1. What computer systems does the institution currently have?
2. What form will the implementation take? Will it be phased in? How?
3. How will past data be integrated and old data retained?

1.) What computer systems does the institution currently have?

Determine if the proposed system would be compatible with electronic data systems (if any)
already in use by the institution/country. They may include:
• Electronic Patients' Master Index (PMI) –As outlined previously, an electronic patients’ master
index system is essential and, if not already in place, should be the first step undertaken when
changing to an electronic health record system.
• An Automated Patient Administration System (PAS) – This would also be critical for the
effective operation of the proposed system. An admission, discharge, and transfer system enables
staff to maintain a file on all patients awaiting admission, currently in hospital, transferred within
the hospital, recently discharged or diseased. It enables authorized users to have direct access to
the patient’s information. It also automatically generates the bed census and other daily statistics
required by the administration.
• Clinical Systems – In many institutions/countries, systems are already in place that are capable
of reporting results – laboratory, pathology, radiology, treatment orders and medications,
surgical reports, discharge summaries, etc. Some specialized units offer forms of clinical
documentation may have already been implemented.
• Automated clinical coding and disease and procedure indexing – in many institutions/countries
computer-assisted coding of diseases and procedures is conducted on-line. If this is not the case
in your institution/country this is another important area to be developed and implemented. With
such a system the use of a standard medical vocabulary is essential. With the use of automated
clinical coding, data quality will be monitored automatically.

2.) What form should the implementation take?

The Steering Committee needs to determine whether they want to move into full implementation,
have phased implementation, or start with implementation at a pilot site. The readiness of the

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site, readiness of all users to accept change, and the availability of funds for implementation are a
few of the issues that may influence the
Committee in its decision on the form implementation should take.
• Full Implementation - In an environment with a strong technical infrastructure, the tendency
may be for full implementation. This would require detailed preparation with all technical
requirements in place and working telecommunication infrastructure fully operational, the
system tested thoroughly, and all staff ready and fully trained. If this is the desired
implementation, data for all active patients must be uploaded immediately before the cut-off –
that is, identification and demographic details of all patients currently in hospital uploaded into
the new system. Decisions need to be made as to whether the electronic system will run parallel
to the manual system for a trial period or take over completely from the manual one. Running
parallel systems would ensure backup, but sometimes when systems running parallel it’s often
difficult to cut-off later. If the above issues have been addressed and the institution/ government
see a possibility of successful implementation, it may be best to have a complete cut-off from the
manual system upon full implementation of the EHR.
• Phased Implementation - The second option is to phase-in implementation unit-by-unit. This
appears to be preferred by many institutions/countries that realise the introduction of an EHR
system is an enormous task with significant change required. It may also be the most appropriate
plan for developing countries. With limited resources, both technical and human, phased
implementation could help to manage the impact of the change. Initially, some
institutions/governments may prefer limited implementation with a pilot program. A pilot
program could enable the institution/government to determine the project’s potential, assess its
value, and determine the institution’s readiness for the system, or buy time to gain user
acceptance.
Other reasons for conducting a pilot program may include difficulty in managing a major change
due to inexperience of the workforce and users, limited staff and technical support, insufficient
funds for such a change, or uncertainty as to whether the new system will actually work.
The Steering Committee’s decision on the form of implementation needs to be based on all the
relevant facts and considerations, including costs, the readiness of the site, users and the system.
If the decision is to phase-in implementation the first site should be carefully selected. The first
site should be one that is self- contained with fully trained staff to test the system. The unit
should not be too big or too small. Interest of users is another factor to consider when selecting
each site and the order the EHR will be implemented. When the first unit has completed
implementation the committee and implementation coordinator should be able to assess the
impact on users and patients, work-flow, and productivity before the next phase is implemented.
Once it is determined that the system is working well, the next unit or units should be phased in
one-by one until all departments/units are online.

3.) How will past data be integrated and old data retained?
By this stage, the Steering Committee needs to have decided how past data will be integrated
and old data retained. Questions and suggestions to consider include:
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• Will all old records be scanned and made part of the electronic record when the patient first
presents for care after the new system is introduced?
• Will old records be scanned and kept in a secondary storage device and brought into the new
system if and when needed?
• Old records will not be scanned but summary information of a patient will be entered into the
electronic health record when the patient attends for the first with the new system in place.
• Old records will be scanned and remain in manual storage for a prescribed time before being
destroyed. It is important to note that scanning past records could be very costly and that there
are other options stated above. If all old records are scanned, a percentage of them will be
records of patients who will never return to the facility.

Development of a Comprehensive Implementation Plan

When the form of implementation has been determined, the Steering Committee and
implementation team need to ensure that the institution/government is ready to move forward.
The next steps would be to:
a) Select the best system to meet the needs of the institution government
b) Determine that the required technological infrastructure is in place
c) Determine what clinical data capture and data retrieval is required and what current data
collection is redundant
d) Ensure that important policies and procedures are clearly documented

a.) Select the Best System

Know what you want. There are many commercial systems available but individual
institution/country requirements are different and the system MUST be able to meet local needs
or be able to be adjusted to do so. That is:

• Select the EHR system that is right for your institution/country

What system will best meet the needs of the institution/government? The institution/government,
through the Steering Committee, needs to determine whether they want to build their own EHR
system, or buy or lease one from a reputable computer systems vendor. All have a significant
cost attached. Building one’s own system could be time-consuming and expensive but should
enable the organisation to design one to meet their specific needs. This, however, would require
a high level of expertise that may not be available in the institution/country.
Purchasing a system already developed and implemented elsewhere would have an initially high
financial outlay. As there are many EHR systems on the market selecting the one most suitable
would require detailed investigation to ensure that it will meet the anticipated definition, needs,
and goals of your institution/country.
Leasing the EHR system would enable access to software applications managed off-site. The
initial costs would be less than for the other two options but may prove more costly over a long
period of time. Whatever system is determined must be compatible with systems already

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installed and also with other institutions with whom the institution wishes to share information
and needs to interface with.
A thorough cost-benefit analysis should be conducted to compare the options against each other
and the costs of any proposed system against the perceived benefits, so as to determine the value
of the system to your institution/government.

• Look at the total picture before committing to a specific system

What you also need to know in selecting a system are the clinical information needs of your
institution/country. That is, determine what is to be captured, stored, and viewed to support the
EHR objectives. Developing a framework defining how clinical information is to be captured
and represented such as lists, views, or reports in the proposed EHR is essential. The purpose of
the framework is to help people developing or selecting the system to decide:
• What information should be recorded?
• How this information is to be described and classified; and
• What are the collection and retention priorities for information?

b) Technological Infrastructure
The technological infrastructure is how hardware and software work together. There are
many types of computer system infrastructure and the Steering Committee should review the
current (if any) infrastructure and determine what is needed to ensure that the right technical
infrastructure is available for the proposed EHR system. Briefly, it should include:

•A Central Processing Unit or operating system – The central computer performs all
processing and storage functions and sends and receives data to and from terminals and printers.

• Input/ Output devices – Current devices, if any, need to be assessed to see if they will meet
the needs of and are compatible with the proposed system. There are numerous devices available
and the type to be used must be compatible with the proposed system
• Network – If the institution already has a set of computers, ensure that they are linked to
enable the sharing of software and data. It may be a Local-area Network (LAN), a Wide-area
Network (WAN), or a Wireless Local-area Network (WLAN). An efficient EHR system depends
on linking information from many sources. With an EHR system, two other network
configurations using internet technologies are used, intranets and extranets:
An intranet uses Internet technology that enables users to find, use, and share documents.
Extranets are used to connect a given institution to its users and business associates outside the
physical location of the institution – these would be necessary if a longitudinal health record was
planned.
Supporting software – These are programs or instructions that direct the processing of data in
computers.
Operating system software identifies input from external devices, sending output to terminal
screens, keeping track of files, and controlling peripheral devices such as printers.
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Application software makes applications perform their functions.
Application integration/interface is software designed to work together without any external
intervention. Interface facilitates the exchange of information across different systems.
Messaging standards are also called interoperability standards or data exchange standards.
c) Clinical Data Capture and Data Retrieval
What is required and what current data collection is redundant.
• Clinical Data Capture
This is where findings and actions are documented by providers healthcare and data obtained
about a patient in real-time. How the data is to be captured is important and must not be
complicated or time-consuming. Decisions need to be made as to how data will be entered and
could include free-text entry or structured data entry from pull-down menus. Most clinicians
would prefer ‘free text’ by keyboard, dictation, voice recognition, or handwriting recognition.
Technology is available for all these methods but there are a number of issues involved with their
use and the Steering Committee/implementation team will need to investigate all possibilities
and make a decision that will best suit the needs of the institution/government.

• Clinical Data Retrieval

When obtaining healthcare data in real-time, access menus and navigational devices are used,
such as a mouse, keypad, and scroll keys and so on, used to move data through parts of a
computer screen. They are important as they enable a healthcare provider to retrieve data directly
from the system. This is another area that needs to be fully investigated so as to ensure that the
system selected or developed will enable data to be readily retrieved for patient care.
d) Policies and Procedures
As mentioned previously, policies and procedures may need to be revised to encompass the
change to an electronic system. The readiness of the institution/country for the change is
extremely important and a change management strategy must be in place to ensure a smooth
transition. Change management techniques should be used to help health professionals adopt a
different form of documenting and using health information.
• Confidentiality and Security setup
As mentioned previously, security must be in place to ensure that all medico-legal issues
including privacy, confidentiality, and security are addressed. Security arrangements should be
clearly documented and communicated to all potential users.
• Education material prepared and training programs for users commenced
Education programs should start as soon as possible, but not too early that information is
forgotten before it can be applied, to ensure that all users are adequately trained by the time the
system is ready to ‘go-live’.
It is important to remember:
The administration needs to plan, advice, and educate staff, and work with providers and patients
to ensure a smooth transition. All the above factors need to be considered along with others that
may identified and unique to your institution/country. The decision to go aheadcannot be rushed.
The institution/country needs to ensure that all issues and challenges are addressed, policies
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revised, and staff trained. They also need to be clear as to where they are heading and confident
that they are ready to move forward.

Implementation Plan
The Steering Committee, implementation coordinator, and team should now have a thorough
understanding of the environment in which the system will be functioning; the information needs
of the institution, functional requirements to ensure the system will work, and most importantly
be confident in their ability to effect change. They should understand the overall scope of the
proposed system and have decided what information will be loaded into the system before going
live.
The decision to convert to an EHR all at once or in stages will also have been made. Assuming
the decision was made to phase-in the system by unit or department a timeframe for
implementation for each unit should be prepared. The first unit may take longer to implement the
system than subsequent units. As the first implementation will be a trial, the plan may need to be
modified before proceeding to other units. It is important for the implementation team to ensure
each phase is functioning well before moving to the next unit or department.
There may be some unit managers who are ready and very keen to start while others may not be
fully confident and wish to see how it works in other places before implementing. This should be
taken into account when determining the sequence of units for implementation. When overall
phasing has been determined and timeframes established, detailed tasks should be plotted on a
plan. Remember that the plan could cover hundreds of tasks. It is a huge undertaking so
successful implementation is particularly important. Thoroughly addressing all the relevant
issues beforehand will help guarantee success.
Timeline for Implementation
The timeline for implementation will vary from institution to institution and will be dependent on
whether the institution/country has decided to implement the EHR system all at once with a “big
bang” or phase it in by unit/department over a longer period of time.
Each step of the implementation plan should have its own timeline to coincide with the overall
project plan for implementation. The timeline or project plan should be mapped out on a large
board. Quite often white boards are used to enable changes to be made if or when required. Items
would include a detail list of EHR project tasks with a timeframe for each task. Implementation
may take days, weeks, months or even years. A realistic timeline should be prepared if possible
but everyone should be prepared for changes if problems or unidentified issues arise which may
cause a delay in implementation
The plan should contain the steps previously discussed such as the:
Review of current medical record system
Identification and addressing of issues and challenges to be addressed prior to implementation
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Establishment of a Steering Committee
Preparation of a clearly defined statement of the type of EHR to be implemented
Identification of perceived benefits to the institution with the introduction of an EHR system
Preparation of a list of clearly stated goals and strategies for implementation
Review of current medical record policies and procedures and develop them to cover proposed
changes
Appointing of an implementation co-ordinator and team
Establishment of working groups
Security and Confidentiality Group
Prepare a confidentiality, security and privacy policy
Education and Training Group
Prepare education programs
Prepare the education site
Identify participants
Commence training
Quality Assurance Group
Prepare quality assurance guidelines and policies
Determine record structure and content
Ensure a patient identification system is in place
Determine an effective means of obtaining the patient’s informed consent
Introduce data standards and the use of a common terminology
Other
Determine technology infrastructure required
Cabling
Terminals
Other
Determine telecommunications infrastructure required
Determine how system will be phased in
In addition the plan should also include:
Site preparation; and
System testing.
1. Preparing the Site
The sites for implementation need to be prepared. The extent of the system will determine the
number of areas needing preparation. For example, will there be terminals for data entry and
retrieval in all wards in the hospital, all outpatient rooms, and other patient service areas? Before
the system can “go live”, the technological infrastructure needs to be in place with data entry
facilities in all point-of-care areas. For inpatients, they would include the admission office,
wards, and other areas at the point-of care. For outpatients, they would require the reception area
and all consulting and treatment rooms. All required cabling for all devices need to be in place
and operable.

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If a longitudinal health record is planned, data entry facilities need to be in place in all
community care centres and outlying clinics. A detailed plan showing the infrastructure needs to
be prepared and displayed.
2. Pre-test the System
When the site has been prepared with the appropriate infrastructure, the software in place, all
issues relating to confidentiality and security addressed, and all users trained (including
healthcare professionals, technicians and clerical staff), it is time to install and pre-test the
system at a point-of-care area in conditions that closely reflect actual situations.
The decision as to where the system will be pre-tested should have been made using a set of
selection criteria which include technical factors such as the level of expertise of the staff,
infrastructure support, and staff support (WHO, 2004). In addition, different levels of staff need
to participate in the pre-testing, especially health professionals who will be both providers and
users of data. The length of time the system will be pre-tested needs to be determined. Finally,
the system needs to be monitored during pre-testing to identify any problems and to enable
informed decisions to be made with regard to further implementation.

Determine Readiness
Questions which should have been asked to determine readiness include:
• Are there any barriers still to be overcome?
•Has everyone who will be involved been trained and are they ready?
• Have any problems identified in the pre-test of the system been reported and corrected?
• Are we ready?
If all these questions are answered positively the system is now ready to implement.
System Start-up
The day selected to “go live” should be on a weekend or a day when there are few patients
expected. The institution may be able to re-organise admissions and close some outpatient areas.
This would need to have been decided much earlier. In addition, it is important that on the day all
staff is available and ready with support personnel available to provide assistance as needed. If
the system was purchased from a computer company, key members of their staff also need to be
onsite. When all pre-requisites have been addressed, a detailed implementation plan in place, the
site ready, all users and support staff trained and ready, and the system pre-tested, the next step is
implementation.
It is now time to ‘go live’! Correct course if needed, and enhance the system. As mentioned
many times, a major change such as the implementation of an electronic health record system is
an enormous task and the staffs needs to be on the alert for any problems which may arise. That
is, expect the unexpected. When the first unit/department has gone live it is important to review
and correct any identified problems or issues as soon as possible. If it is not what was expected,
it is a signal for course correction. When problems are addressed and expectations met, the
results can justify further enhancements to the system.
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Conclusion
The principal benefits identified for the introduction of an electronic health record system are:-
Supporting patient care and improving the quality of that care.
Accurate and timely health information, which is accessible when needed by both
providers/users and consumers has great advantages for the healthcare of all individuals and
would enhance the health and welfare of the community.
It will also enhance the productivity of healthcare providers in the delivery of care, and be a
strong support to clinical and health service research.
Implementation of EHRs has been said to revolutionise how we collect, store, and use health
information. Patients are expected to become more involved in healthcare decisions when
electronic systems provide them with easily accessible and accurate information about their
health problems and care. It is often advocated that healthcare practitioners tend to deliver better
healthcare by being able to more efficiently provide up-to-date details of a patient’s healthcare to
others involved in treating the patient and by having better access to best practice and the latest
research findings.

BIBLIOGRAPHY

1. Benjamin, Bernard 1980, Medical records William Heinemann Medical Books Ltd.
2nd Edition London, UK.

2. Huffman, E.K, Medical Records Management

3. , MEDICAL RECORDS JOURNALS BRITAIN

Learning Objectives
Students should be able to:-
1. Define a waiting list
2. Describe the functions of a waiting list.
3. Explain the types of waiting lists
4. Describe how to maintain a waiting list
5. Explain the methods of filing to be used.
6. Describe the procedures used in admitting patients.

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