Scribd Logo
Upload

Welcome to Scribd!

  • 55 views

    Medical Records Reporting B17

    Uploaded by

    MAYBELINE OBAOB
    The document summarizes the functions and processes of a medical records department. The department is responsible for safekeeping patient medical records, assisting healthcare providers in chart management, and ensuring confidentiality and security of records. Key processes include gathering charts from wards, sorting contents, scanning documents, ICD coding, indexing, color coding, and filing records. Medical records serve important clinical, legal, research, and administrative purposes for both patients and healthcare organizations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Medical Records Reporting B17

    Uploaded by

    MAYBELINE OBAOB
    55 views16 pages
    The document summarizes the functions and processes of a medical records department. The department is responsible for safekeeping patient medical records, assisting healthcare providers in chart management, and ensuring confidentiality and security of records. Key processes include gathering charts from wards, sorting contents, scanning documents, ICD coding, indexing, color coding, and filing records. Medical records serve important clinical, legal, research, and administrative purposes for both patients and healthcare organizations.

    Original Title

    MEDICAL RECORDS REPORTING B17

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document summarizes the functions and processes of a medical records department. The department is responsible for safekeeping patient medical records, assisting healthcare providers in chart management, and ensuring confidentiality and security of records. Key processes include gathering charts from wards, sorting contents, scanning documents, ICD coding, indexing, color coding, and filing records. Medical records serve important clinical, legal, research, and administrative purposes for both patients and healthcare organizations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    55 views16 pages

    Medical Records Reporting B17

    Uploaded by

    MAYBELINE OBAOB
    The document summarizes the functions and processes of a medical records department. The department is responsible for safekeeping patient medical records, assisting healthcare providers in chart management, and ensuring confidentiality and security of records. Key processes include gathering charts from wards, sorting contents, scanning documents, ICD coding, indexing, color coding, and filing records. Medical records serve important clinical, legal, research, and administrative purposes for both patients and healthcare organizations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 16

    MEDICAL

    RECORDS
    DEPARTMENT

    By: Group 2
    BSN2-B17
    Sept. 4-8, 2023
    (2-10pm shift)
    MEDICAL RECORDS DEPARTMENT
    -The Medical Records Department is in charge of safekeeping and
    safeguarding the medical records of all patients admitted at The
    SWU med. The department assists the physicians and other
    healthcare team members in the management and completion of
    patient charts and makes sure that the medical records are
    secured and are treated confidentially.
    PHYSICAL FACILITIES
    MEDICAL RECORDS STAFF

    HEAD
    STAFF
    Haidee Ornopia
    Richel Ugbaniel SCANNING STAFF

    Margie Ortiz Jennilyn Amoguis


    MEDICAL RECORD
    • A clinical, scientific, administrative, and legal
    document relating to patient care.
    • It records sufficient data written in the sequence of
    events to identify and locate the patient and justify the
    diagnosis, the treatment given, and the final out
    • To meet legal requirements & to avoid complications
    medical record must fulfill the following criteria:

    complete adequate acurate eligible


    PURPOSE OF MEDICAL RECORDS

    For the patient Medico Legal

    medical record
    -documentation of clinical - claiming insurance & tax
    history benefit
    -continuity of treatment -malpractices and negligence
    -claiming insurances -evidence in court of law
    -issue of Med. Certificate -certification of birth & death
    Hospital -certification of mental status
    -legal evidences
    -certification of invalid
    -quality, quantity, and adequacy pension
    of treatment
    For the doctor -medical audit
    Research & Training
    -future planning & decision
    -medical review of making
    -administration & management -education & training
    treatment -clinical, epidemiological
    -research & publication -medico legal protection
    -disease surveillance research
    -assist in legal proceedings -health system rsearch
    -epidemiological studies
    REPUBLIC ACT NO. 10173
    An act protecting individual
    personal information and
    communications systems in the
    government and the private
    sector, creating for a purpose of
    this purpose a national privacy
    commission and for other
    purposes.
    CHART PROCESS
    FLOW

    01 GATHERING OF PATIENT
    CHARTS FROM THE WARD

    02 SORTS THE CONTENT OF THE PATIENTS CHART


    IN PREPARATION FOR THE SCANNING PROCESS

    03 DIGITALIZATION PROCESS
    / SCANNING PROCESS
    CHART PROCESS
    FLOW

    04 ICD 10 CODING - INTERNATIONAL


    CLASSIFICATION OF DISEASES

    05 INDEXING

    • MASTER INDEX
    • PATIENT INDEX
    • PHYSICIAN INDEX
    • DISEASE INDEX
    • OPERATION INDEX
    CHART PROCESS
    FLOW

    06 COLOR CODING

    1 2 3 4 5

    61 27 38 9 5 0

    05 FILING
    CHARTS ARRANGEMENT
    I. FRONT PAGE
    II. GATE PASS
    III. DOCTORS ORDER FROM CLINIC
    IV. MEDICAL ABSTRACT
    V. DISCHARGE SUMMARY
    VI. TEMP, PR, RR, CHART
    VII. DOCTORS ORDER SHEET
    VIII. LAB RESULTS AND IMAGES
    IX. INTERNAL MEDICINE, OB/GYNE
    PEDIA/NEWBORN, SURGERY RECORDS
    CHARTS ARRANGEMENT
    IX. OB PATIENT:

    • CESAREAN SECTION- OPERATIVE RECORD


    -ANESTHESIA RECORD
    -ANESTHESIA PRE-OPERATIVE EVALUATION NOTES
    -PRE-OPERATIVE CARE CHECKLIST
    -RECOVERY ROOM/ POST-ANESTHESIA CARE RECORD AND OTHER
    RECORD

    • NORMAL DELIVERY- OB RECORD


    CHARTS ARRANGEMENT

    X. HISTORY: RESIDENT’ HISTORY


    -PGI’S HISTORY
    -CLERK’S HISTORY
    XI.PROGRESS NOTES
    XII.PROBLEM LIST
    XIII.LABORATORIES SUMMARY
    XIV.DOCTOR’S ASSESMENT
    CHARTS ARRANGEMENT

    XV. DIALYSIS FLOW CHART(FOR DIALYSIS PATIENT)


    XVI. BLOOD GLUCOSE SHEET
    -MONITORING SHEET
    -FLUID INTAKE AND OUT MONITORING RECORD
    -MEDICATION ADMINISTRATION RECORD
    XVII. NURSES NOTES
    XVIII. GUARANTOR SHEET
    XIX. DISCHARGE INSTRUCTION SHEET
    CHARTS ARRANGEMENT

    XX. ATTESTATION
    XXI. RELEASE AND ASSUMPTION OF RISK
    XXII. PATIENT TRANSFORM FORM
    XXIII. AMBULANCE TRANSPOSRT RECORD
    XXIV. DNR RECORD
    XXV. BREAST FEEDING FORM
    XXVI. KARDEX
    XXVII. EMERGENCY ROOM
    THANKYOU!

    You might also like