Health Sciences Records Management

LIS 219

Ms. Joenabie A. Encanto, MLIS

COURSE DESCRIPTION

Principles behind the administration and organization of records, the technology and systems used in the health sciences

COURSE OBJECTIVES
1. To identify and explain the principles and policies needed in understanding, organizing and administration of patients medical records such as defining patients medical records, medical records flow, qualitative and quantitative information analysis, release of information and medical staff organization 2. To discuss medical records management processes which involves, procedures of filing, forms control and design, records disposition, indexes and registers, clinical coding and indexing and regulatory and accrediting agencies

COURSE OUTLINE
I. Overview: Patients medical and health records A. Definition and history B. Contents of medical records C. Uses/value of medical records D. Ownership of medical records

II. Responsibility for the patients medical records A. Governing body and administrator B. Medical records department C. Medical and nursing staff D. Medical records committee

COURSE OUTLINE
III. Development and organization of medical records A. Data collection and assembly B. Medical Records Flow and health information systems C. Filing and storage systems D. Release and control of medical information IV. Qualitative and Quantitative analysis A. Quantitative analysis B. Qualitative analysis C. Medical terminologies D. Classification of diseases and indexing

COURSE OUTLINE
V. Medical Medical records policies and standards (local and international) A. Forms control and design B. Retention and disposition of medical records C. Registry and statistics D. Regulatory and accrediting agencies

COURSE REQUIREMENTS
Attendance Quizzes Reporting Exams (Midterms and Finals) Benchmarking Final project 10% 10% 15% 30% 15% 20%

References

http://www.scribd.com/collections/ 3989912/LIS-219-2nd-AY12-13

What is a medical record? Who owns a patient's medical record? Who can have access to a medical record? Is it available to the public or is it confidential?

What is a Patients Medical Record?

A medical record is

a compilation of facts about a patients life and health a documented data on past and present illnesses, treatment written by health care professionals while caring for a patient

WHO (2006)

must contain sufficient data to identify the patient, support the diagnosis or reason for attendance at the health care facility, justify the treatment and accurately document the results of that treatment (Huffman, 1990)

HISTORY
Early medical records were used to measure plagues, epidemics and even hostile attack from enemies 1700 - Formans and Napiers casebooks (used to map celestial bodies, astrology and medicine are cognate disciplines) (magicandmedicine.hps.cam.ac.uk) 1800s admission and discharge records 1821 used for care research and statistics 1900 standardization of medical records Mid 1990s - standardization was replaced with accreditation - emerging electronic medical records

Purpose to record the facts about a patient's health with emphasis on events affecting the patient during the current admission or attendance at the health care facility, and

for the continuing care of the patient when they require health care in the future

Medical Records Content

Information about the patient Data that support the diagnosis or the reason for attendance in health care facility Justification for the treatment Accurate documentation of the results

Examples of Content
Birth records Delivery records Reports of physical examinations and illnesses Medicinal intake Treatments performed and justification for the treatment

Actual Parts of PMR

Admission reports Initial Diagnosis and Final Diagnosis Consent to treatment Physicians orders Physical examinations Progress notes Operative report Discharge summary