INTRODUCTION &

OVERVIEW OF
CLINICAL
DOCUMENTATION
Roderick M. Napulan
Division Chief, Facility Performance Management Division, DOH
Health Facility Development Bureau
Adviser, Philippine Association of Health Records and
Information Officers
Professorial Lecturer, West Visayas State University College of
Medicine and University Medical Center
Associate Member, National Research Council of the Philippines
What is health information management (HIM)?

According to AHIMA, “Health Information Management (HIM) is the practice of

acquiring, analyzing and protecting digital and traditional medical information vital to
providing quality patient care”.

HIM in Healthcare?

HIM involves medical coding and billing, ensuring compliance with government
regulations, and handling customer requests for Personal Health
Information (PHI).

It also involves medical records retention and transition formats, as well as analysis of
health care trends and the implementation of improvements.
 ■ GOALS
○ privacy and security
Strategic Roles of HIM ○ interoperability
Professionals for
National Health ○ adoption
Information ○ collaborative governance
Infrastructure
 ■ FOCUS AREAS
1. Ensuring that patient information is secure and
protected;

Strategic Roles of HIM 2. Improving healthcare quality, reducing medical

errors, reducing health disparities, and advancing
Professionals for delivery of patient-centered medical care;
National Health 3. Reducing healthcare costs resulting from

Information inefficiency, medical errors, inappropriate care,

duplicative care, and incomplete information;
Infrastructure 4. Providing appropriate information to help guide
medical decisions at the time and place of care;
 ■ FOCUS AREAS
5. Ensuring that meaningful public input is
included in development of such infrastructure;
Strategic Roles of HIM 6. Improving the coordination of care and

Professionals for information among hospitals, laboratories,

physician offices, and other entities for the secure
National Health and authorized exchange of healthcare information;

Information 7. Improving public health activities and facilitating

the early identification and rapid response to
Infrastructure public health threats;
 ■ FOCUS AREAS
8. Facilitating health and clinical research and
healthcare quality;
Strategic Roles of HIM 9. Promoting early detection, prevention, and
Professionals for management of chronic diseases;

National Health 10. Promoting a more effective marketplace,

increased consumer choice, and improved
Information outcomes in healthcare services; and
Infrastructure 11. Improving efforts to reduce health disparities.
 ■ Collecting and securely storing medical records
and protected health information (PHI)

Role of a ■ Ensure the information is accurate, accessible

and high quality

health ■ Implement health information systems and

information
processes to ensure the complete and accurate
documentation of medical records

manager ■ Organize and analyze health information for

better utilizations, process improvement,
preparing reports and research purposes

by Xiaoming Zeng, MD, PhD; Rebecca Reynolds, EdD, RHIA; and Marcia Sharp, MBA, RHIA
 HIM is vital for every healthcare organization and
associated business. Breaches impact patient trust
in a healthcare provider and may prohibit a patient
from sharing vital information for fear of exposure.

Importance of health information management

 What is CDI?
▪ Clinical documentation is at the core of every
patient encounter.
▪ In order to be meaningful it must be accurate,
timely, and reflect the scope of services provided.
▪ Successful clinical documentation improvement
(CDI) programs facilitate the accurate
representation of a patient’s clinical status that
translates into coded data.
▪ Coded data is then translated into quality
reporting, physician report cards,
reimbursement, public health data, and disease
tracking and trending.
 What is CDI?
▪ CDI is the bridge between clinical language and coding language
▪ Concurrent review of health records for conflicting, incomplete, or
nonspecific provider documentation
▪ Reviews typically occur on patient care units or in outpatient clinics, or
can be conducted remotely via the HER
▪ Queries to providers may be utilized to gain greater specificity in
documentation
▪ CDI should be viewed as a tool and not as a hindrance to being able to
perform patient care
▪ CDI provides educational information about specificity in documentation
that supports consistency in care and supporting severity of illness and
length of stay
 Importance of CDI
▪ The convergence of clinical, documentation,
and coding processes is vital to a healthy
revenue cycle, and more important, to a
healthy patient.

▪ To that end, CDI has a direct impact on

patient care by providing information to all
members of the care team, as well as those
downstream who may be treating the patient
at a later date.
 High Quality Documentation
1. Legible – clear enough to be read and easily deciphered
2. Reliable – trustworthy, safe, yielding the same result when repeated
3. Precise – accurate, exact, strictly defined
4. Complete – has the maximum content, thorough
5. Consistent – not contradictory
6. Clear – unambiguous, intelligible, not vague
7. Timely – performed at the time of service
 Why CDI?
1. Perform gap analysis of current documentation
○ Identify points of pain
○ Biggest impact

2. Determine areas of focus

○ Specific service lines
○ Specific physician specialties
○ Specific payers
○ Inpatient, Outpatient, Emergency Room,
Clinic
CDI Goals
1. Achieving coding compliance

2. Increase case mix index (CMI)

3. Quality performance improvement

4. Patient satisfaction

5. Reduction in denials

6. Streamlining communication between HIM/Coding, CDI and Physicians

7. Other goals
 CDI Tools and Technology
▪ Software Packages ▪ Query Forms
❑ Build your own ❑ Paper
❑ Electronic
❑ Purchase from vendor
❑ Integrated
❑ Integrated with EHR ❑ Templates
❑ Standalone platform ❑ Free text
❑ Retention
 CDI Tools and Technology
▪ Resources ▪ Other Tools
❑ Encoder ❑ Quality assurance (QA)
❑ Coding books audit tool
❑ Coding guidelines ❑ Computer-assisted
❑ Coding references coding (CAC)
o Coding Clinic ❑ Data analysis and report
o CPT Assistant generating software
❑ Pharmacology reference (e.g., MS Excel)
❑ Anatomy reference
❑ Medical Dictionary
CDI Implementation Essentials: Step 1
▪ Determine key CDI stakeholders
❑ HIM and coding departments
❑ Case management and utilization review
❑ Medical staff and provider leadership (including Physician Advisor)
❑ Executive leadership
❑ Patient financial services or billing
❑ Finance and revenue cycle
❑ Quality and risk management
❑ Nursing
❑ Compliance and ethics
 CDI Implementation Essentials: Step 2
▪ Provide Targeted Education
❑ Determine the education needs of each
stakeholder and develop specific
training based on needs
❑ Build a collaboration between
HIM/coding, CDI, and physicians
❑ Ongoing education
❑ Open communication
 CDI Implementation Essentials: Step 3
▪ Ongoing Maintenance and Updates
❑ Software updates (e.g., encoder, EHR)
❑ Quarterly Coding Clinic
❑ Annual coding updates
❑ Continual gap analysis
❑ CMI trending
❑ Addition of new services
❑ Expansion to new setting
❑ New staff training
❑ Quality initiatives
 Summary
▪ To select the appropriate CDI tools and technology for your organization,
you must do the following:

❏ Determine the type of CDI program you have, or want to create,

within your organization
❏ Establish CDI goals for your organization
❏ Review all available features of CDI tools and ensure that all of your
program needs are met
❏ Once the tools are implemented, continually evaluate your CDI
program as a whole and determine additional needs/education/tools
 Objectives and Plan
of Activities
Learning Outcomes

1. Discuss the importance of the

standards for patient health records
documentation
2. Demonstrate clinical documentation
improvement
3. Conduct Qualitative and Quantitative
Analysis of records
4. Apply Continuous Quality
Improvement on HHIM
REGULATIONS
OVERVIEW
HEALTH INFORMATION
MANAGEMENT
Roderick M. Napulan
Division Chief, Research and Performance Management Division,
DOH Health Facility Development Bureau
Adviser, Philippine Association of Health Records and
Information Officers
Professorial Lecturer, West Visayas State University College of
Medicine and University Medical Center
Associate Member, National Research Council of the Philippines
Doh rules and regulation on hospitals
Policy Objective: To protect and promote the health of the public by ensuring a
minimum quality of service rendered by hospitals and other regulated health
facilities and to assure the safety of patients and personnel
Standard: The organization informs the community about the services it provides and the hours of their
availability
Criteria: All patients are correctly identified by their patient charts, incl newborn
Indicator: The contents of patient‘s charts are the following:
1. Summary or face sheet
2. Informed Consent
3. History and Physical Examination
4. Doctor's order
5. Nurses Notes
6. TPR Sheet
7. Laboratory report
8. Imaging reports
9. Maternal Record with Partograph (if warranted)
10. Newborn record and maturity rating (if warranted)
11. Medication and/or treatment record
12. Operative and anesthesia record (if warranted)
13. Record of interdepartmental referral/consultation to other physicians, including notes
14. Record of referral or transfer of patient to other facility/service/doctor including notes
15. Discharge summary
16. Clinical abstract
17. Advance directive, whenever applicable
Standard: Each patient's physical, psychological and social
status is assessed
Criteria: An appropriate comprehensive history and physical examination is
performed on every patient within 48 hours from admission. The history
includes present illness, past medical, family, social and personal history

Indicator: All patients have comprehensive history and PE within 48 hours from
admission
Standard: Appropriate professionals perform coordinated and sequenced
patient assessment to reduce waste and unnecessary repetition

Criteria: Previously obtained information is reviewed at every stage of the

assessment to guide future assessments

Indicator: All patient charts have progress notes by doctors and other health
professional
Standard: The discharge plan is part of the patient's care plan
and is documented in the Patient’s chart
Criteria: Discharge plans for patients to ensure continuity of care.

Indicator: All charts have discharge plans.

Standard: Clinical records are readily accessible to facilitate patient care, are
kept confidential and safe, and comply with all relevant statutory
requirements and codes of practice.

Criteria: Electronic Medical Records

Indicator: All general and specialty hospitals are mandated to comply with the EMR
implementation

*EMR implementation includes, but is not limited to, e-claims, primary care benefits,
maternal and neonatal deaths, injury, and confirmed cases of diagnosis
Standard: The organization has a planned systematic organization-wide
approach to process design and performance measurement, assessment and
improvement.

Criteria: Continuous Quality Improvement Program

Indicator: Presence of Quality Improvement Program

Standard: Appropriate professionals perform coordinated and sequenced
patient assessment to reduce waste and unnecessary repetition.

Criteria: Nurses make use of Nursing Process in the care of patients

Indicators: Charts have nurses’ notes

Presence of Nursing manual and properly utilized Kardex

Standard: Medicines are administered in a standardized and systematic
manner. Diagnostic examinations appropriate to the provider organization’s
service capability and usual case mix are available and are performed by
qualified personnel
Criteria: Medicines are administered in a timely, safe, appropriate and
controlled manner
Indicator: All medicines are administered observing the five (5) R’s of medication which
are:
1. Right patient
2. Right medication
3. Right dose
4. Right route
5. Right time
Personnel- medical records Officer

■ Bachelor’s Degree
■ Training in ICD-10
■ Training in Medical Records Management
HEALTH RECORD
STANDARDS AND
POLICIES

Roderick M. Napulan
Division Chief, Research and Performance Management Division,
DOH Health Facility Development Bureau
Adviser, Philippine Association of Health Records and
Information Officers
Professorial Lecturer, West Visayas State University College of
Medicine and University Medical Center
Associate Member, National Research Council of the Philippines
PHILIPPINE HEALTH RECORDS STANDARD INCLUDE:

1 2
Licensing Standards as defined International Health Record Standard
in Administrative Order No. as defined by the Joint Commission
2012-0012 International Accreditation Standards

3 4
International Organization for
PhilHealth Benchbook Standardization (ISO
9001:2015)
PHILIPPINE HEALTH RECORDS STANDARDS INCLUDE:
(8,030,585)
Other regulatory / mandatory policies;

01 02
RA 10173 RA 11223
DATA PRIVACY ACT OF 2021 UNIVERSAL HEALTH CARE ACT

03 04
AO 2013-005 RA 9470
NATIONAL POLICY ON THE
NATIONAL ARCHIVES ACT OF
UNIFIED DISEASE REGISTRY
THE PHILIPPINES 2007
SYSTEM OF DOH
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 1. HEALTH RECORD CREATION
SPECIFIC STANDARDS

The health facility shall initiate and maintain a standardized health record for
1 every patient assessed or treated and determine the record’s content, format
and location of entries.

2 Health records of patients should meet the education, research and statutory
requirements as provided by law.

Each patient confined and consulted in a health facility has a sufficiently

3 detailed health record that correctly identifies the patient, supports the
diagnosis, justify the treatment, and documents the course and results if
treatment.
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 1. HEALTH RECORD CREATION
SPECIFIC STANDARDS

4 Collection of personal information is accompanied by a Data Privacy Consent

form to be signed by the patient or his/her authorized representative.

5 Authorized personnel to make entries in the health record are clearly defined
as per Hospital Policy.

The health facility uses standardized diagnosis and procedure codes and
6 ensures the standardized use of approved symbols and abbreviations across
the hospital.
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 1. HEALTH RECORD CREATION
SPECIFIC STANDARDS

The health records of patients receiving emergency care include the time of
7 arrival and departure, the conclusions at termination of treatment, the
patient’s condition at discharge, and follow-up care instructions

Relevant, accurate, quantitative and qualitative data are collected and used
8 in a timely and efficient manner for delivery of patient care and management
of services.

9 Data in the patient charts are coded and indexed to ensure timely production
of quality patient care information and reports to PhilHealth.
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 1. HEALTH RECORD CREATION
SPECIFIC STANDARDS

10 The hospital has a process to address the proper use of the copy and paste
function when electronic health records are used.

11 Standard Health Record Arrangement:...............

 STANDARD HEALTH RECORD ARRANGEMENT:
A B C

Clinical Cover Sheet Admission Slip Triage Slip

D E F

Informed Consent for History and Physical

Data Privacy Consent Form
Admission or Examination
Confinement
 STANDARD HEALTH RECORD ARRANGEMENT:
G H I

Discharge Summary Clinical Laboratory Test Doctor’s Order and

Result Forms Progress Notes

J K L

Nurses Notes (FDAR) Monitoring Sheet Intravenous Fluid Sheet

 STANDARD HEALTH RECORD ARRANGEMENT:
M N O

Medication Sheet Pharmacist’s Nutrition Care Plan

Notes/Pharmacist
Intervention Form ● TPR
● Pain Monitoring Sheet
● Input and Output
● Vital Signs
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 1. HEALTH RECORD CREATION
SPECIFIC POLICIES

1 HIMD shall use standardized forms to ensure overall quality care, at the same
time, serve as an effective cost control measure.

A Forms Committee should be established to help the Head of the Health

2 Information Management Department in determining the forms needed by
the hospital, as well as in the proper design of the forms.

All forms in the health record must be reviewed and approved by the Patient
3 Health Records Committee and shall be registered with the Document
Controller before it is officially used.
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 1. HEALTH RECORD CREATION
SPECIFIC POLICIES

Health record forms consist of standard/basic and supplemental/special

4 forms. Standard or basic forms are those that are fundamental to or essential
portions of all health records.

A consent form from the health facilities shall be incorporated in the

5 admission/confinement form of hospitals, treatment/ health facilities which
shall be accomplished prior to the patient’s admission or management.

The health facility identifies members of the staff who are authorized to make
6 entries in the patient health record. Thus, every patient health record entry
identifies its author and shall indicate when the entry was made.
 PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 1. HEALTH RECORD CREATION
SPECIFIC POLICIES

7 All health records shall contain all relevant and complete demographic data
of the patient at least but not limited to the following:

FOR OPD RECORDS + FOR INPATIENT RECORDS

●Patient Hospital Number ● Contact Number ●File Number

● Patient’s full name ● E-mail Address ● Room Number
● Address ● Name of Spouse ● Admission date / time
● Date of Birth ● Father’s name ● Discharge date / time
● Place of Birth ● Mother’s name ● Length of stay
● Age ● Next of Kin to whom to ● Social Service Classification
● Gender notify ● Admitting Diagnosis
● Civil Status - Address ● Alert notation for Allergies and Adverse Drug Reaction
● Religion - Relationship to patient
● Nationality - Contact Number
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 1. HEALTH RECORD CREATION
SPECIFIC POLICIES

A health record with pending diagnostic results shall be completed in the

8 HIMD within 15 days after the patient’s discharge; otherwise, it shall be
considered a delinquent health record.

The Attending Physician (AP)/nurse on duty and other authorized staff to

document in the health record has the final responsibility for the
completeness and accuracy of the data entry in the health record.
9 The discharging nurse on duty shall be responsible in counter checking the
completeness of the health record as to documentation and quantity before
endorsing the same to the HIMD.
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 1. HEALTH RECORD CREATION
SPECIFIC POLICIES

The accomplishment of History, Physical Examination, and Discharge

10 Summary may be delegated to the interns. However, these records shall be
reviewed, corrected and countersigned by the attending physician.

The HIMD staff shall assist the attending physician in reviewing records for
11 completeness by checking for omissions and discrepancies to ensure that
health records comply with set standards and policies.
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 2. HEALTH RECORD DOCUMENTATION
SPECIFIC STANDARDS

The health record is a legal document. No form may be detached once it is

A filed at the HIMD.

The health record contains a complete and accurate set of information to

B facilitate effective and efficient patient care management.

C All documentation must be legible and written in ink or typewritten.

Decision makers and other staff members are educated and trained in the
D principles of information use and management.
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 2. HEALTH RECORD DOCUMENTATION
SPECIFIC STANDARDS

E Written documents, including policies, procedures and programs, are

managed in a consistent and uniform manner.

A health record number is assigned to the patient on his/her first encounter

F and will serve as his/her permanent unique identification number for future
visits in the health facility.
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 2. HEALTH RECORD DOCUMENTATION
SPECIFIC POLICIES

The health record shall contain all original copies of examination results,
A operations and other required forms.

There shall be a standard format for health record documentation which must
B include demographic and assessment data.

Each form in the health record shall contain at least two (2) of the following
C unique identifiers: Health Record Number (HRN), Patients Name, Date of Birth,
and Date of admission/consultation.

Collection of personal data shall include a Patient Information Sheet accompanied

D by a Data Privacy consent form to be signed by the patient/authorized
representative, the latter to form part of the health record.
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 2. HEALTH RECORD DOCUMENTATION
SPECIFIC POLICIES

All required forms shall be properly filled out. If not applicable, NA or None shall
be placed. For skipped and blank spaces, a single slanting line from bottom to
E top shall be drawn and the person responsible shall affix signature over printed
name.

All consent forms shall be properly filled out and accomplished to be attached
F to the health record as needed.

All entries in the health record shall be made only by duly authorized staff of
G the health facility with the print name, signature and designation of the author,
and date and time such entries were made.
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 2. HEALTH RECORD DOCUMENTATION
SPECIFIC POLICIES

The health record shall contain an Admitting Diagnosis by the medical

H practitioner who admitted the patient.

The health record shall contain the patient's history pertinent to the condition
being treated, and relevant details of family history, present and past medical
I history and physical examination accomplished by the AP within 24 hours from
date and time the patient was first seen.

The health record as a legal document must have no erasures of any sort.
J Entries made in error shall be immediately corrected in a legal way.
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 2. HEALTH RECORD DOCUMENTATION
SPECIFIC POLICIES

Correction and additional entries in the health record shall be made while the
K patient is still admitted and while the health record has not been processed.

If the patient requests for correction of personal data and demographic

information, the patient shall accomplish an amendment form and attach a
L Valid Identification (ID) Card/ Identity document listed under PSA Memo
Circular No. 2019-16 dated June 11, 2019, a birth certificate or a marriage
contract.

If there is a need for additional entries and the space would not be enough, a
separate blank sheet shall be properly labelled with patient’s name, hospital
M number, birth date, date of consultation/admission. It will be called an
addendum as part of the chart.
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 2. HEALTH RECORD DOCUMENTATION
SPECIFIC POLICIES

No abbreviations shall be used in writing the final diagnosis of the patient in

the clinical cover sheet, discharge summary, clinical abstract, operative record
N and medical certificates. Only abbreviations and symbols approved by the
World Health Organization (WHO) and the medical center chief upon the
recommendation of the Patient Health Records Committee (PHRC) are allowed.

Documentation using forms specific/ unique to use for clinical departments,

nursing service and other allied services shall follow the standards in
O completion as agreed upon by their specific departments/units/ special areas
that utilize the forms. As such HIMD staff shall evaluate the form as to
completeness and legibility and not to relevance of content.
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 2. HEALTH RECORD DOCUMENTATION
SPECIFIC POLICIES

Drug orders shall be clearly written in the health record by the attending
P physician.

Therapeutic and special diagnostic test orders shall be reflected in the health
Q record.

Progress notes, observations, and consultation reports shall be written by the

R physician, as well as by the nursing and allied staff of the health facility.

When a patient is transferred to another facility, a certified copy of discharge

S summary and an accomplished original copy of referral notes shall be issued.
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 2. HEALTH RECORD DOCUMENTATION
SPECIFIC POLICIES

A discharge summary for each patient shall be completed upon patient

discharge and shall include but not limited to discharge diagnosis, procedures
T performed, follow up arrangements, therapeutic orders (home medications), and
patient home instruction/s.

In the processing of Certificate of Live Birth, the health facility shall be

U responsible for its transfer to the Local Civil Registrar within 30 days.
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 2. HEALTH RECORD DOCUMENTATION
SPECIFIC POLICIES

When an autopsy is performed, a provisional diagnosis is made. Final diagnosis

V shall be noted in the health record within 72 hours after the occurrence of
death.A copy of the autopsy report shall be filed in the health record.

The health facility shall develop an ongoing review of health records to assure
W quality documentation. This shall be one of the major duties of the Patient
Health Records Committee (formerly known as Medical Records Committee.)
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 6. Continuous Quality Improvement
SPECIFIC STANDARDS

Data from the patient charts are routinely collected, aggregated and reported
1 for use in quality improvement activities and for administrative purposes
enhancement and mandatory reporting to the DOH and PhilHealth.

As part of its monitoring and performance improvement activities, the

2 hospital regularly assesses patient health record content and completeness.
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 6. Continuous Quality Improvement
SPECIFIC POLICIES

Quality improvement activities shall be evidence-based and shall utilize the

1 risk-based approach.

HIMD shall pursue CQI to:

● Strengthen the implementation of the existing SOPs of HIMD;

2 ● Provide quality health records for the continuity of care and for research
purposes; and
● Assess and determine the quality of service delivered and to identify the areas
that need improvement to attain excellent service.
PHILIPPINE HEALTH RECORD STANDARDS AND POLICIES
STANDARD 6. Continuous Quality Improvement
SPECIFIC POLICIES

The results of the implementation of QI activities and continuous monitoring

3 using relevant indicators by HIMD shall be integrated in iHOMIS or their
existing hospital information system, and utilized in decision-making.

The health facility’s Integrated Hospital Operations Management Program shall

4 extend full assistance to HIMD to coordinate continuous improvement efforts.

HIMD shall undertake a continuous improvement of its processes to improve

5 quality of service to patients.
Roderick M. Napulan
Division Chief, Research and Performance Management
Division, DOH Health Facility Development Bureau
Adviser, Philippine Association of Health Records
and Information Officers
Professorial Lecturer, West Visayas State University
College of Medicine and University Medical Center
Associate Member, National Research Council of the
Philippines