Modul Pelatihan Praktisi rekam Medis : Planning Health Record Departement

Education Module for Health Record Practice

Based On IHFRO modul

UNIT 5  ‑ PLANNING A HEALTH RECORD DEPARTMENT

Health information management/health record professionals are acutely aware of the need for proper facilities for the efficient and effective operation of the health record department.  In fact, it has been recognized for some time that architects, health facility planners, administrators and heads of departments, should plan for construction of specialty areas together, as a team.  Although in many instances this has in fact happened, for a number of departments there has been little participation by health information management/health record professionals.  The reasons for non‑participation are varied and range from the health information management/health record professionals not being consulted or involved because the planning authorities do not realize their ability in this area, or the health information management/health record professionals has not been interested or has felt incapable of involvement in such a daunting task.

OBJECTIVES:

At the conclusion of this unit participants should be able to:

1.      explain the functions of a health record department for planning purposes

2.      identify the most suitable place for a health record department

3.      calculate space required for defined functions, staff and health record storage

4.      communicate effectively with architects and hospital administration to ensure departmental needs are recognized.

INTRODUCTION:

The hospital administration is responsible for seeing that the health record department of their institution have adequate facilities and equipment for the efficient day‑to‑day operation of the service.  The criteria to meet this standard includes:

1.      the health record department/office should be located in such a place as to facilitate the rapid retrieval and distribution of health records

2.      the Office and work space should be sufficient for health record staff to perform their duties and for other authorized personnel to work with health records, including records on microfilm or computer

3.      there should be sufficient storage space for health records to allow for future storage needs. This includes:

a)   an active storage area with sufficient space to include all health records currently in use by hospital staff, and

 

b)   available space to provide for both active and inactive health records being stored under statutory guidelines

4.      areas for active and inactive health record storage should be sufficiently secure to protect records against loss, damage, or use by unauthorized persons (ACHS, 1992).

The planning of a health record department, whether for a new hospital or relocation within an existing hospital, should develop from the interaction of three people: the health information management/health record professional, the facility’s planning co‑ordinator and the architect.  The health information management/health record professional contributes ideas especially on the detailed functions of the proposed department; the planning co‑ordinator has an understanding of the total requirements within the facility and co‑ordinates all departmental planning and the architect is responsible for defining, both verbally and graphically the building or complex to meet   specified objectives.

To design a department that will offer both efficient and effective services, the planning team must clearly define the functions of the department and the inter‑relationships of the proposed department with other departments/areas of the facility. For example, will the health record department be responsible for transporting health records, for ordering and storing health record forms, or will these functions be the responsibility of another department. This involves looking at procedures to be performed, staff requirements for the performance of these procedures, the flow of work planned for the department and the hours of services offered. This information should be stated in clear, logical writing, with sufficient detail for an architect to understand what is required. 

The six phases determined by the architects which they believe should be observed when designing a new hospital department are as follows:

A.      Definition phase, is the definition of the precise need the design of the department is to meet

B.      Brief phase, is a detailed nomination of the estimated facilities to meet the defined need

C.      Department phase, the integration of one specific area or department into the greater complex of the total facility.  In this phase the key people in the facility along with the architect and planning co‑ordinator establish ideal working relationships with other departments

D.      Total facility phase, which looks at wants, as compared to needs, compared to available resources.  A total hospital proposal is prepared to enable the selection of the most viable scheme for the department

 

E.      Process phase ‑ at this stage attention is focused on the actual function of the individual departments.  This means that each proposed procedure to be performed in a department is thoroughly analysed and assessed.  Diagrams illustrating the various processes and procedures, most of which were completed in the definition phase, are extremely useful as graphic expressions of physical requirements and associated services.  It is at this phase that attention must be paid to the welfare, comfort and health of workers in the proposed requirements for the department.

F.      Department design phase is the stage where the architect prepares final proposals to enable an optimum design to be prepared and selected.  Detailed drawings of each department are prepared, including all special requirements. There must be a systematic means of assessing and comparing the various schemes to enable the planning team to reach a final decision.

In this Unit we will concentrate on the first two phases since these require the greatest participation by the health information management/health record professional and also have the greatest applicability in improving the layout of an existing department.

A.    DEFINITION PHASE

When preparing for this first phase in the planning of a health record department, there are five major points to be considered.  These are:

1.      location of the department in regard to services and inter‑relationship of service areas

2.      space requirements for records, for personnel and for equipment

3.      functional design and logical placement of key work areas

4.      system of communication within the health record department and between the department and other areas of the facility

5.       systems to be used to transport health records within the department and to other departments and wards.

1.      Location

When determining location consideration must be given to the need for the department to be centrally located where it will provide:

  • prompt service for all patients ‑ inpatients, outpatients and emergency

 

  • ready accessibility for medical officers and other users, and

 

  • easy availability for administrative use.

 

 

That is it should be:

  • adjacent to the Admission Office, the Emergency Department (ED), the Outpatient Department (OPD)

 

  • close to medical staff office, entrance, or lounge

 

  • close to the administrative and business offices

 

  • close to other service departments, e.g. x‑ray, pathology, etc.

 

While it is desirable to have the health record department centrally located, it is accepted that this is not always possible.  If this is the case and the department cannot be logistically situated near all these areas, the first three should have top priority and, in most situations, the proximity to the outpatient and accident and emergency departments would have the highest priority, as these two areas usually have the greatest utilization of records with speed of access often essential.

2.      Space

Regardless of the type of facility, when planning for space requirements for records, personnel and equipment, the health information manager/health record administrator must consider the following:

  • population of the district served by the hospital
  • hospital services proposed
  • number and type of beds
  • current and projected number of discharges/deaths and outpatient and emergency registrations and visits
  • major functions to be performed in the department
  • number of personnel required to perform proposed functions
  • equipment most suitable for the work to be done
  • extent of computerization anticipated
  • type of filing system to be used
  • the numbering system
  • whether the record services are to be centralized or decentralized
  • whether emergency/casualty records are to be included in the main record
  • number of years of active storage
  • length of time original records are to be retained and whether inactive records will be selectively purged or microfilmed,
  • type of secondary storage required
  • special services to be offered by the department.

 

a)   Space for records

Before calculating file space required, decide how many years of health records should be kept in active filing and estimate the number of records generated per year.

The retention schedules for health records recommended by the local health authority (or national retention schedules where appropriate) should be considered when determining record activity.  These retention schedules usually take into consideration:

  • the statute of limitations for legal protection, and
  • state or national regulations

 

Retention for longer periods than determined by health authorities or national retention schedules, however, could be influenced by:

  • available storage space, and
  • the clinical and/or research value of the records.

 

Once the proposed numbers of records and the activity rate have been determined the estimated number of medical records over the number of years of active filing can be calculated.  The steps required are as follows:

  1. Given the number of annual discharges/deaths and OPD registrations (+ ED/A&E new patients if to be filed in main health record) and the number of years required for active storage, e.g. 7 years, you can determine the number of records to be generated over a 7 year period, e.g.

 

Annual OPD registrations                       3000

Annual discharges/deaths                   2,3000

(No ED/A&E)                                                _____

26,000 records per year

26,000 per year for 7 years = 26,000 x 7 = 182,000 health records in 7 years

It should be noted that these figures overestimate the number of actual records, as discharges will include readmissions. However, this is a better figure to use as it allows space for the expansion of the file with each re‑admission plus the workspace needed for efficient filing and retrieval.

  1. The next step is to determine the average size of each health record e.g. one record = 2cms of linear shelf space

 

  1. Determine how many records to 1 meter of linear shelf space,

i.e.  100 = 50 records to 1 meter

  1. The total filing space required, therefore, for these health records can be calculated as follows:

 

annual discharges/deaths + OPD reg  x storage years required

records per meter

e.g.  using the above example:

23,000 + 3,000    x    7          =          182,000  =     3,640

                        50                                               50

Therefore for 182,000 health records, 3,640 meters of shelving is required.

  • As well as determining what is adequate to meet the needs of the present, the needs of the future, i.e. in 10 or even 20 years, should also be considered.  This can be achieved by an estimate, for example a 10% increase in discharges/deaths and OPD registrations over the next 10 years.  This will change the filing space required to:

 

10% of 3640 = 3640 + 364 = 4004 meters required.

  • To calculate the total number of units required:

 

determine the number of meters of storage per unit,

e.g. each unit      = 6 shelves high x 2 meters wide

= 12 meters of storage per unit

4004  = 333.66 or 334 units of 6 shelves

       12

  • For terminal digit filing, to calculate the number of meters of shelving required for each primary digit the following formula should be used:

 

meters of shelving required

number of sections in file

4004

100     = 40 meters per primary section

Each terminal digit will therefore occupy 20 full shelves.  Should, however, the calculations show that each terminal digit will occupy only a portion of a shelf one might want to adjust the number of shelving units to be acquired (or reduce the space allotted to each terminal digit).

b)  Secondary storage

If a secondary storage area is considered it should ideally be located within the department, or immediately adjacent to it, or directly underneath with its own stairway. There are a number of advantages for keeping non‑active health records readily accessible and available, two of which are that:

  • it is time saving for staff, and
  • offers easy access for refiling.

 

If storage space is a problem and microfilming of inactive records is being considered a special room for microfilming will need to be planned.

To calculate the space required for secondary storage, divide the total number of records to be stored by the number of records to 1 metre, i.e. 150,000 inactive records to be stored and there are 50 records to 1 metre divide 150,000 by 50. Health records, however, are generally filed in serial order in secondary storage allowing for shelves to be packed to capacity, and this could allow for 80 records to 1 meter.  The reason you can get more records/meters is (i) no need to allow for growth of individual record and (ii) no need for working space since there will be little movement.  The calculation would then be:

150,000  = 1875 meters of shelving required for secondary storage

   80

c)  Master Patient Index (MPI)

Consideration must be given to the space the patients’ master index will occupy. When all or part of the MPI is on cards, the space requirements can be considerable. The steps to be followed in calculating the space needed to file the index cards and guides are the same as those for the health record files.

d)  Planning space for personnel and equipment

When planning for personnel and equipment requirements, consideration must be given to the functions to be performed within the department and the services offered by the department to other areas.

The number of staff determines the floor space; desks, files and other equipment necessary, and ample room must be provided for each employee.  Huffman (1994) recommends that the minimum space allocated for each office worker should be 5.57m2 (16 sq ft), although this estimation may vary, it is still a good guideline.

It is generally accepted that the staff of a medical record department are responsible for the initiation, completion and maintenance of a medical record for every person attending the facility as an inpatient, outpatient or accident/emergency patient.  The major functions of a health record department usually include:

  • the initiation of health record documentation and the design and control of all record forms

 

  • initiation and maintenance of a unique patient identification system and master patient index (MPI)

 

  • preparation of new outpatient and emergency department health records and the update of records of returning patients

 

  • assembly, completion and control of incomplete records for discharged/deceased inpatients

 

  • classification of diseases and the collection of morbidity/ mortality statistics for all hospital discharges/deaths

 

  • collection of health facility statistics relating to discharges/deaths, length of stay, occupancy rates for administrative and health department use

 

  • filing and retrieval of all inpatient and outpatient health records with an inbuilt record control system

 

  • transcription services covering discharge summaries, operation reports, outpatient letters and medico‑legal correspondence (using word processing facilities)

 

  • services to medical and other health professionals for the retrieval of health records for research and teaching purposes

 

  • in some situations the functions of the health record services includes patient reception and processing in the outpatient department, admission office and accident and emergency centres.

 

3. Staff required

Once the functions of the department have been determined, consideration should be given to the number of staff required. Hospital policy regarding the number of hours in the work week and the hours of service for the health record department (24 hours a day, seven days a week versus some other schedule) will be a major factor in this determination along with the functions to be performed, the number of annual discharges/deaths, OPD and ED/A&E visits (if ED/A&E reports are incorporated in the unit record), and research undertaken by medical staff.

(a)  Forecasting:

Once the health information management/health record professional has:

  • determined the predicted number of discharges/deaths, and OP/ED visits, and predicted specialised work, e.g. research, quality assurance, etc.

 

  • determined the functions of the department and services to other departments

 

  • determined the hours of service eg 24 hours x 7 days per week or less

 

  • defined each function and determined the tasks to be performed

 

  • defined how each task is to be divided into manageable work units or jobs

 

  • analyzed each job to determine the content, skills, knowledge and responsibilities, and

 

  • prepared a job description and job specification for each job,

 

The next step is to forecast the number and type of staff required to perform each job. That is, the health information management/health record professional needs to be able to predict the number of direct employee hours required to cover the jobs outlined in each job description. There are a number of forecasting techniques used to cope with the problems involved with human resource forecasting. For our purposes, traditional statistical projection could be used by using the correlation of staff to patient discharges/deaths and attendances. The time to process one health record of a discharged patient can be estimated as suggested in the following hypothetical example:

  • Collection of records from designated collection area             3 minutes
  • Pulling of work cards from the hospital box                               1    “
  • Assembling record into correct order                                            3    ”   
  • Checking record for deficiencies and retrieval

                        of loose sheets                                                                                 3    ”

  • In case of re‑admission, retrieval of old records or

                        if new patient, preparation of new folder                                     3    ”

  • Assigning record to appropriate doctors for completion            2    “
  • Filing record in incomplete file area                                             2    “
  • Filing work card in work box                                                          1    “
  • Filing outguide on file                                                                       “

            20 minutes

By the above calculations, it is estimated that the discharge procedure for each record takes 20 minutes.  If there were 70 discharges/deaths per day for seven days, the total time to process these records would be:

70 x 20 x 7 = 9800 minutes or 163.3 hours

If each clerk worked 7.5 hours per day for five days, the number of staff required for this process would be:

163.3  = 4.35

37.5

That is, 4.5 full-time equivalent staff members would be required to complete the discharge procedure in a hospital with approximately 25,480 annual discharges/deaths.

A similar procedure could be undertaken for each job within the department using the prepared job descriptions.

Alternatively, another method would be to use a work distribution chart as illustrated below.  By this method, previous information relating to departmental functions and jobs can be used to estimate the time each job takes.  That is, by listing the work activities performed and the estimated time it takes to perform them, we can estimate the number of staff required.

  Hours                                               Hours

Activity                         per week      Activity                       per week

Record assembly           106           Retrieval of

Record analysis               50              records for Clinics               76

Admissions                       57            Transcription                         114

Filing recent discharges   18         Release of Information         40                 

Telephone/enquiries        16          Filing                                        38

Statistics                            19            Research                                 36                    

Coding                              13                                                304

Indexing                            25           

                                              304                                                          

Based on a 37.5 hour week, calculate staff as follows:

608   = 16.2

37.5

The health information management/health record professional could then indicate the actual staff required for each job, e.g.

Record retrieval & filing                                 3

Transcription                                                   3

Release of Information                                   2

Separations & Enquiries                                5

Coding & Indexing                                          1

Admissions & Statistics                                  2

                  16

Relief staff based on estimated absences such as recreation leave, sick leave, etc. should also be determined, as should supervisory and professional staff requirements.

e)  Health information management/health record professional’s office space

Since privacy is desirable for the health information management/health record professional (for talks with personnel, doctors, lawyers, administrators); a private office may be necessary.  However, in smaller hospitals the director may prefer to be with the staff in the main department area.

f)   Other special areas

  • A section of the health record department should be provided away from the flow of traffic for the medical staff so that they can complete their records or review records for research in reasonable quiet and comfort.

 

  • A special area is often required for transcription. Medical transcription should be confined to one area because of noise ‑ sound proof booths or partitions help reduce the noise of computer equipment and printers.

 

4.      Equipment

The number of staff and the functions of the department will determine the equipment required.

As well as planning space requirements for records and personnel, consideration must also be given to the allocation of sufficient space for the equipment required to cover the defined functions of the department.

The major areas for consideration are:

a)   Filing

Type of shelving to be used is important and it is generally accepted that open shelving is the most practical. It utilizes less floor space than other forms of filing equipment, allows for faster filing and retrieval and lends itself to any type of filing system used. Once the amount of shelving required is calculated, the amount of floor space required for the shelving can also be calculated using the width and length measurements of each bay of shelving.

The space should also be allocated for aisles and it is generally accepted that main aisles should be 150‑155 cms wide and secondary aisles 90‑95 cms wide.

b)   Computer facilities

The level of initial computerization would have been defined in the determination of functions and job analysis and sufficient space must be planned for terminals and ergonomically sound work areas.  If the entire department is not air conditioned, provision should be made to protect the computers from excessive heat and dust.

c)   Dictation/transcription

Appropriate space for dictation and transcription services needs to be carefully planned to allow for ergonomically sound facilities and work areas.  The use of a dictating service with a central receiving unit encourages doctors to dictate reports and discharge summaries promptly. Computers for word processing are now widely used in health care facilities and appropriate space must be allocated to ensure efficiency and also the health and well-being of the staff.

d)   General

The number and therefore, space requirements, of desks, chairs, typewriters, telephones, filing cabinets and other office equipment will be based on the jobs to be performed and the number of personnel required. Staff working different shifts can occupy the same work area.

Department personnel should have a place to store their belongings (handbags, umbrellas, coats, etc) safely.  A tea or lunchroom should be available for staff to take their break so that they do not eat and drink at their desk.  Convenient access to hand-washing and toilet facilities is needed.

e)   Special space

Space requirements for a photocopier, storage cabinet (for supplies and folders, etc), bookshelves, and any other special equipment should also be defined at this stage.  If microfilming is planned, space for the necessary equipment, e.g. microfilm camera, reader‑printer, jacket‑filler, filing cabinets and work area must be considered in the planning stage.

The predetermined departmental functions, job descriptions and number of proposed staff, however, will enable the health information management/health record professional to determine the equipment and furniture needed and the approximate space required for the work area.

5. Functional design and logistical placement of key work areas

When considering functional design and layout, a key consideration is workflow.  At this stage of definition, the health information management/health record professional should prepare work flow diagrams   to indicate the workflow from procedure to procedure or desk to desk.  Keeping in mind that:

  • desks should be arranged so that paper moves in a straight line and only a short distance at a time

 

  • desks should be next to each other for procedures performed in sequential steps

 

  • amount of floor space required will depend largely on record activity and whether or not data processing or microfilm programs are established, and

 

  • equipment should be chosen for reasons of both efficiency and appropriateness.

 

The use of a layout diagram or flowchart, sometimes called or movement diagram (LaTour 2002), which is a diagram of the flow of work through the layout, can assist with determining that furniture and equipment are placed effectively.

When preparing a layout for the architect, the health information management/health record professional should be able to use appropriate terminology and blueprint symbols to illustrate the essential features such as columns, lifts, doors, windows, furniture and equipment, etc.  This will give everyone including the health information management/health record professional, a visual image of the proposed department. 

6.      System of communication

During the definition stage, consideration must be given to the communication system to be used within the department and between the health record department (HRD) and other departments or areas.

Most health record departments require numerous telephones placed at strategic points within the department. In addition, some hospitals may use intercom systems between the ED/A&E and the HRD, or the OPD and the HRD.

If computer terminals are to be used, both as communication devices between the HRD and other areas and for the input and output of data, the cabling for such devices is an important part of the planning process.   If the entire department is not air conditioned, consideration must be given to air conditioning the area where the terminals are located not only to prevent them from overheating but also to protect them from excessive dust.

7. Transport

Consideration must be given to how the health records are to be transported both within the HRD and to other areas. If carts are to be used within the department they have to be able to be pushed freely between desks and files. If a dumb waiter or pneumatic tube or other automated device is to be used, special space provision in the appropriate place must be made.  Some hospitals use motorized trolleys, which need to be stored in the HRD when not in use. Provision for all these needs must be considered in the definition phase of planning.

8. Layout

In determining the physical layout the following points should also be considered (LaTour, 2002 and Huffman, 1994).

  • it is important that full use be made of available space. Desks and files must be arranged to provide maximum efficiency, light and air

 

  • to eliminate the hazard of electrical cords, attention should be given to the most convenient placing of electrical outlets for the use of any electrical equipment

 

  • temperature control and circulation of air, i.e. adequate ventilation, fans, windows

 

  • adequate lighting ‑ i.e. well positioned lighting (experts should be consulted as to levels required and correct placement). Workers should not face glaring lights

 

  • use of colour ‑ walls, floors, furniture and equipment (light colours for walls ‑ bright for accents and trims)

 

  • to keep traffic flow in the medical record department to a minimum, it may be desirable in many hospitals to have a reception and/or waiting area where an employee may attend to requests

 

  • employees handling enquiries should be placed near the main entrance

 

  • equipment should be near users and the doors wide enough for record carts

 

  • desks should face the same direction with 1 to 1 ½  meters between desks

 

  • supervisors should be at the back of the people she/he is supervising ‑ should be able to see all employees without leaving desk

 

  • two desks placed side by side in the same direction is a compact arrangement

 

  • it is best to place the file space to the back of the department ‑ it should not be placed near the main entrance (for safe keeping)

 

  • sufficient space for workers to stretch and move around.

 

B.    THE BRIEF PHASE

At the completion of the definition phase the health information management/health record professional should be ready to prepare a brief for the architects, which will include the proposed functions and services of the department, the preferred location, and the capacity with regard to space, staff and equipment, relationship to other departments, and any other design features to be considered. Requirements may be illustrated by drawing a plan.

The brief should include work flow diagrams, and a proposed layout with specific reference to ergonomic consideration in all aspects of the design. If the health information management/health record professional does not feel confident in making determinations on ergonomic issues an expert in this area should be consulted.

SUMMARY

Effective planning of a health record department for a new facility or in an existing one is an important responsibility, which should be readily accepted by the health information management/health record professional. As discussed previously, the planning process should begin with clarification of the functions to be performed and services to be offered. The health information management/health record professional is the best person to undertake this important step and should be prepared to do so.

REFERENCES

1.         Davis, Nadinia, and LaCour, Melissa.  Introduction to Health Information Technology.  Philadelphia, PA:  W.B. Saunders, 2002.

2.         Huffman, Edna K. Health Information Management.  10th ed. Berwyn, IL: Physicians Record Company, 1994.

3.         Johns, Merida, ed.  Health Information Management Technology: An Applied Approach.  Chicago: AHIMA, 2002.

4.        LaTour, Kathleen M., and Eichenwald, Shirley.  Health Information Management:  Concepts, Principles and Practice.  Chicago:  AHIMA, 2002. (A good source for a flowchart for loose chart filing can be found in this book in Figure 22.1 page 528.  Also a movement diagram in Figure 22.2 page 530.)

5.         Skurka, Margaret.  Health Information Management:  Principles and Organization for Health Information Services.  San Francisco, CA:  Jossey- Bass, 2003.

 selesai@hak cipta dr Iwan Suwandy 2010

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Modul Pelatihan Praktisi Rekam Medis unit 4 c “The key of Question Answer”

Appendix 2 – Answer Key to Appendix 1

Education Module 4 – Healthcare Statistics

 based on IFHRO modul

EXERCISE 1 – Patient Care Unit CENSUS

1.    Using the information from the left of the page, complete the daily census for patient unit A.

UNIT A                                                                        DAILY CENSUS FOR DATE 6.3.06

 

John Smith adm. from                                    a.         No. on unit last report              40

O.P.D. (Dr. Richard)

Adam James adm. Dr. Maurice                                 No. admitted                             5

Stanley Paul adm. G.P.                                              No. transfers in                         1

Anthony Greech trans.                                   b.         Total                                          6

from other hospital

Patrick Sterling trans.                                                 No. discharges                          5

from Med. (Ward B)

Gordon Thompson died 10.30 a.m.                            No. Deaths                                2

Wayne Johnson emerg. adm.                                    No. transfers out                       1

Brett Arnold disch. O.P.D.                              c.         Total                              8

Michael Stephens disch. G.P.           

Adam Carpenter trans.                                               Today’s census

to Psych. (Ward D)                                                     a + b ‑ c           =  40 + 6 – 8 = 38

John Trip trans. to

other hospital

Wayne Johnson died 4.30 p.m.

John Smith disch. O.P.D.

Thomas Adams disch. O.P.D.

2.    Number of patient days for patient unit A on 6-3-06:   40

38 + 2 patients admitted and discharged on 6-3-06  =  40

 

                                    EXERCISE 2 ‑ HOSPITAL CENSUS REPORT

Date:        6-3-06    

Complete the data for Unit A from Exercise 1.

Complete the Hospital Census report.

What checks for accuracy can you use?

 Unit  Prev.

Day

Census

 Admi-

ssions

 Transfers

In

 Discharges  Transfers

Out

 Today’s

Census

 Alive  Deaths
 A   40  5  1 from B  5  2  1 to D  38
 B   35   4  2 from C      1 to A  41
 C   23   8     4     2 to B  25
 D   28   3  1 from A   2   1    28
 E   30   6     3      33
 TOTAL  156  26  4  14  3  4     165

 

Accuracy checks:

1.    Total transfers in equal total transfers out

2.    Today’s hospital census is result of adding total admissions and transfers in to previous day census, and subtracting from this the total discharges and transfers out.

156 + 26 + 4 – 14 – 3 – 4 = 165

 

                                             EXERCISE 3 ‑ HOSPITAL CENSUS

Complete today’s hospital census report

HOSPITAL CENSUS REPORT 

 

August 27, 2006.

 Unit  Prev.

Day

Census

 Admi-

ssions

 Transfers

In

  Discharges  Transfers

Out

 Today’s

Census

 Discharges  Deaths
 A   40   3     2    2 to B   39
 B   26     2 from A   4  1  1 to D   22
 C   31   8  2 from D   5  1     35
 D   45     1 from B  10    2 to C   34
 E   12   6           18
 TOTAL  154  17  5  21  2  5  148

 

 

                                                                EXERCISE 4

1.    Compute the length of stay of 10 patients who were discharged from hospital on October 6, 2006.  Their dates of admission were as follows:

(a)        September 12                     24                 (f)        September 11 ­   25

(b)        September 28                  ­­­     8                 (g)        October 5                        1

(c)        September 30                       6                  (h)       September 16    20

(d)        September 26                     10                  (i)        October 6                          1

(e)        October 4                  2                              (j)        August 13                        54 

(k) What was the average LOS?     15.1  151 divided by 10

2.    In a 200 bed hospital, the patient days for 2006 were 62,050.   The 6,495 patients who were discharged or died had a total of 61,930 days care.  Using the above figures, compute the following averages and rates, showing formulae used.

(a)        62050 divided by 365 = 170 patients

(b)        (62050 x 100) divided by (200 x 365) = 85.0%

(c)        61930 divided by 6495  =  9.54 or 9.5 days

 

EXERCISE 5

1.    A Coronary Care Unit in a large teaching hospital had a total bed count of 20 beds in 2006.  During the year the patient days for the unit were calculated at 5,260 days.  The 1,255 inpatients who were discharged from the unit during 2006 spent a total of 5,066 days there.

(a)   5260 divided by 365 =  14.41 or 14 patients

(b)   5066 divided by 1255 = 4.03 or 4.0 days

(c)   (5260 x 100) divided by (20 x 365) = 72.054 or 72.1%

2.    The following data have been collected from a 700 bed general hospital during 2006:

Patients admitted                                                          14,117

Total discharges/deaths                                                14,086

Total discharge days                                                   137,202

Total inpatient patient days                                         226,842

Total registered outpatient attendances                      192,846

From the information above, calculate the following, showing formulae:‑

(a)        137202 divided by 14086 = 9.74 or 9.7 days

(b)        226842 divided by 365 =  621.48 or 622 patients

(c)        (226842 x 100) divided by (700 x 365) =  88.78 or 88.8%

3.    In a local hospital, the average length of stay in January 2006 was 10.4 days.  The number of patient days care rendered to discharged patients in the same period was 5,460.  How many discharges were there in January?

                             5460 divided by 10.4  = 525 discharges/deaths

4.    A 460 bed general hospital assigned 215 beds for general medical service, 125 beds for general surgery including Orthopedics, the remainder, 120, were divided among the other services.  For the past 12 months (2004) the number of patient days within the three major categories were:

Pt. days                            Beds                       Bed days

A.  General medicine       59,059                         215      x 365                 78690           

B.  General surgery          43,070                         125      x 365                 45750

C.  Other services                        35,040                         120      x 365                 43920

Using the above information calculate the following for each of the three categories:

 

General Medicine                           General Surgery                  Other Services

(i)     5905900/78690= 75.1%         4307000/45750 = 94.1%       3504000/43920 = 79.8%

(ii)   59059/365 = 161.36 or 161    43070/365 = 117.67 or 118   35040/365 = 95.73 or 96

 

 

 

 

 

EXERCISE 6

A 477 bed general hospital had 15,746 patients discharged/died in 2006.  Total deaths for the year were 487.  There were 81 cases reported to the Coroner, and 351 autopsies were performed.

Total patient days were 136,995 and the total length of stay of discharged/died patients was 136,540. 

Give the formulae, and using the above information, compute the following:

1.    (487 x 100) divided by 15746 = 3.09 or 3.1%

2.    15746 divided by 477 = 33.01 or 33.0

3.    (351 x 100) divided by (487 – 81) = 86.453 or 86.5%

(The 81 Coroner’s cases were NOT autopsied at the hospital)

4.    136450 divided by 15746 = 8.67 or 8.7 days

 

EXERCISE 7

1.    The following data have been collected from a local hospital.  The average length of stay in June was 5.2 days.  The total length of stay of discharged/died patients in the same period was 2,730.  There were 18 deaths, including 2 unautopsied Coroner’s cases and 12 autopsies were performed.

a.          Number of patients discharged/died = 525

(18 x 100) divided by 525 = 3.43 or 3.4%

b.          (12 x 100) divided by (18 – 2) = 75.0% (.0 for uniformity with other indicators)

2.    The following data have been collected from a 700 bed general hospital during 2006.

Patients admitted                                                             19,957

Total discharges/deaths                                                   19,933

Patients remaining in hospital midnight

Dec.31, 2005                                                           632

Patients remaining in hospital midnight

Dec.31, 2004                                                           656

Total length of stay of discharged/died patients           218,515

Total patient days                                                         236,842

Total deaths                                                                         615

Total autopsies performed                                                   485

Coroner’s cases (unautopsied)                                              43

Number of anaesthetics administered                             6,925

Number of operations performed                                    7,700

Total registered outpatients                                           192,846

From the information above, calculate the following:

a.         236842 divided by 365 =  648.88 or 649 patients

b.         (615 x 100) divided by 19933 = 3.08 or 3.1%

c.         (700 x 365) – 236842 divided by 19933 = 0.93 or 0.9 days

d.         (485 x 100) divided by 615 =  78.86 or 78.9%

e.         (485 x 100) divided by (615 – 43) = 84.79 or 84.8%

f.          (236842 x 100) divided by (700 x 365) = 92.69 or 92.7%

g.         218515 divided by 19933 = 10.96 or 11.0 days  (.0 added for uniformity)

 

EXERCISE 8

The following information was collected from a 500 bed hospital and includes the census figures for the 30th September, 2006 and the monthly figures for the month of September, 2004.

(a)  September 30

Patients in hospital at midnight                             418

Patients discharged 30th September                     17

Patients admitted 30th September                        24

(6 patients were admitted and discharged

the same day.)

(b)  September  2004

Total number of discharges/deaths                     1088

Total deaths                                                               43

Coroner’s Cases (unautopsied)                                  4

Total number of autopsies performed                       28

Total number of anaesthetics administered            467

Total number of outpatient attendances              16203

Total patient days during September                   12332

Total length of stay of discharged/died   

patients                                                     10943

From the above figures, calculate the following:‑

1.    Census for the 30th September                           418 – 17 + 24   =  425

2.    Patient days for 30th September                         425 + 6  =  431           

3.    12332 divided by 30 =  411.06 or 411 patients

4.    (12332 x 100) divided by (500 x 30) = 82.21 or 82.2%

5.    10943 divided by 1088  =  10.06 or 10.1 days

6.    (28 x 100) divided by 43  =  65.12 or 65.1%

7.    1088 divided by 500 =  2.18 or 2.2

8.    (43 x 100) divided by 1088  = 3.95 or 4.0%

9.    (28 x 100) divided by (43 – 4)  =  71.79 or 71.8%

 

EXERCISE 9

1.    In an obstetric hospital there were 310 live births in June 2004; of this number 7 died within the early neonatal period.  The hospital also registered 8 fetal deaths for the same month.  What rates were calculated below?

a.  (8 + 7) x 100 divided by (310 + 8) = 4.72 or 4.7%                 Perinatal death rate

b.  8 x 100 divided by (310 + 8) = 2.52 or 2.5%                          Fetal death

2.    An obstetric hospital published the following figures in 2004.

Obstetrical discharges

  • delivered                                      2288
  • undelivered                                  327
  • aborted                                            39

Total infants discharged/died                         2255

Total births (live)                                                2309

Infant deaths (early neonatal)                            56

Fetal deaths                                                            36

Maternal deaths                                                          3

Using the above information, calculate the following:

a.  3 x 100 divided by (2299 + 327 + 139)  =  0.1%

b.  56 x 100 divided by 2255  =  2.48 or 2.5%

c.  36 x 100 divided by (2309 + 36)  =  1.54 or 1.5%  

d.  (36 + 56) x 100 divided by (2309 + 36) =  3.92 or 3.9%

3.    A 320 bed obstetric hospital had 10,220 obstetric separations in 2006. There were 7,016 live births; 139 fetal deaths; 523 caesarean sections were performed with a total of 6,968 deliveries for the year and 2 maternal deaths.  There were 4 infant deaths classed as early neonatal.  Using the above information, calculate the following:

a.  139 x 100 divided by (7016 + 139)  =  1.94 or 1.9%

b.  523 x 100 divided by 6968  = 7.51 or 7.5%

c.  (139 + 4) x 100 divided by (139 + 7016) = 1.99 or 2.0%

It is not reasonable to have only 4 infant deaths.  The medical record professional should investigate to be sure that infants who die minutes after birth are not being classified as fetal deaths.

 

 

 

EXERCISE 10

You have received the following medical statistics for review prior to their publication in the Annual Report of a General Hospital.  What comments do you have regarding the accuracy of the data?

Available beds (Bed complement)                                                                             430

Total admissions                                                                                                    11,285

Total discharges/deaths                                                                             11,123

Total deaths                                                                                                                521

Patients in hospital at midnight on 31 December 2003                                              344

Patients in hospital at midnight on 31 December 2004                                              371

Autopsies performed (including 2 autopsied Coroner’s Cases)                                 378

Coroner’s cases                                                                                                            44

Total patient days                                                                                                 128,954

Total length of stay of discharged/died patients                                                  126,872

Out‑patient visits                                                                                                  106,750

There is an inconsistency in the inpatient data.  If there were 344 patients in hospital at the beginning of the year and 11,285 admissions and 11,123 discharges/deaths, there would be 506  patients remaining at the end of the year which is impossible given that the hospital has 430 beds.   344 + 11285 – 11123 = 506

Average daily census                         352                  Divided by 365 rather than 366

Percentage of Occupancy                 81.9%

Turnover rate                                      25.9

Hospital death rate                              46.8%              Multiplied by 1000 rather than 100

Gross autopsy rate                             0.73%              Did not multiply by 100

Net autopsy rate                                 0.79%              Did not multiply by 100

 selesai @hak cipta Dr iwan suwandy 2010

Modul Pelatihan Praktisi Rekam Medis Unit 4 ”

Education Module for Health Record Practice

based on IFHRO  Modul

UNIT 4a – HEALTHCARE STATISTICS

 

In this unit participants are introduced to the collection of statistical data in hospitals, community health centers and primary health care areas.

The various rates and percentages generally calculated in health facilities are discussed along with the formula for their computation and definitions relating to statistical collections.

OBJECTIVES:

At the conclusion of this unit participants should be able to:

1.   state the uses of health care statistics

2.   list the type of statistical information routinely collected in hospitals on a monthly and annual basis

3.   state the formulae used for the calculation of rates and percentages used in the collection of statistical data

4.   calculate rates and percentages used in the collection of statistical data in hospitals

5.   describe the process of statistical collections in an ambulatory setting

6.   prepare appropriate statistical reports.

INTRODUCTION:

The collection of meaningful statistics is an important function of a hospital or clinic.  Health records are the primary source of data used in compiling health care statistics. The medical record department staff, therefore, may be responsible for the collection, analysis, interpretation and presentation of statistical data wherever possible.  Today, computerized systems automatically collect and calculate many of the statistics that were once previously done manually.

Statistics are only as accurate as the original sources from which they are taken.  The health information management/health record professional should see that medical records and other source documents are complete and readily available to meet the requirements for the production of useful statistics.  Health service statistics are used for:

·     comparison of present and past performance of the hospital or clinic

·     guide for planning future development of the hospital or clinic

·     appraisal of work performed by the medical, nursing and other staff

·     hospital or clinic funding if government funded

·     research

When deciding to collect statistical data, or if reviewing existing collection systems, the hospital administrator and health information management/health record professional should ask:

 

  • Why are the data being compiled?

 

  • What use is being made, or will be made, of the information?

 

Before proceeding, we should become familiar with some definitions relating to terms used in statistical collections.

A.  DEFINITIONS

Definitions used for the collection of statistical data on hospital utilization vary from country to country.  To enable you to recognize the terms used in this Unit, the following is a list of definitions used in some countries.  If your country has a different definition for an item, or if the item is known by a different term, change the one in this Unit to the one used by your hospital/country.

1.   Admission

The formal process whereby a person is accepted by a hospital for the purpose of hospital treatment as an inpatient. If an inpatient is formally discharged from the hospital and then returns for further treatment, the admission process is repeated and a second admission is recorded in the statistics.

Live births in the hospital are considered inpatient admissions, but are always recorded separately as newborn admissions whether or not they require, during their continuous stay in the hospital since birth, special medical care in the nursery or in another clinical service of the hospital (for example, neonatal intensive care unit).  A newborn admission is deemed to occur at the time of birth in the hospital.

Typically, a patient should be admitted as an inpatient if treatment and/or care is provided by hospital staff over a period of 24 hours.

2.   Visit (also called Attendance)

A visit is a single encounter with a healthcare professional that includes all of the services supplied during the encounter.  (Horton)  This term is usually used to refer to non-inpatient services, such as outpatient.  An outpatient is one who receives ambulatory care services in a hospital based clinic or department.  A visit occurs each time an outpatient attends a hospital, nursing home or community health center and receives one or more occasions of service.

 

3.   Bed count (also called available beds or bed complement)

The number of beds (both occupied and unoccupied), set-up and staffed in an inpatient area of a hospital, which are immediately available to be used by inpatients.  In statistical returns the number of beds should always be shown as a whole number.

Bassinets used by normal newborns are counted and reported separately from other hospital beds.  Recovery room beds and labor beds are not counted as hospital beds if patients who occupy them for brief periods are assigned to another bed in the hospital.

4.   Bed count day

A unit of measure denoting the presence of an inpatient bed (occupied or unoccupied) set-up and staffed for use in one 24-hour period.

5.   Census

A count of inpatients at a given time.  The census is always taken in a hospital at the same time each day, usually midnight. The census provides the number of inpatients at census taking time

      6.   Daily census (daily inpatient census)

The daily census is the number of patients present at census taking time, plus any patients who were admitted after the previous census-taking time and discharged before the next census-taking time.

 

7.   Delivery

The act of giving birth to either a living child or a dead fetus. A pregnant woman who delivers may have multiple births.  For example, a woman who gives birth to twins will have one delivery but two births.

7.   Discharge (Separation)

The formal process whereby an inpatient leaves the hospital at the end of an episode of care.

The number of discharges includes discharges to home, transfers to other hospitals, nursing homes or other institutions, and deaths of persons who were inpatients at the time of death.

     8.    Encounter

The direct contact between a patient and a physician or other licensed independent practitioner, to order or furnish healthcare services for the diagnosis or treatment of a patient. (Horton)

      9.   Fetal death

 

“Fetal death is death prior to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy; the death is indicated by the fact that after such separation the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord or definite movement of voluntary muscles.”

WHO ICD 10: Vol.1, p. 1235-1236

 10.      Health facility

A health facility refers to any of the following:

  • State, public, general or country hospitals
  • Private hospitals
  • Psychiatric hospitals
  • Hospices
  • Nursing homes
  • Community health centers
  • Ambulatory care centers
  • Primary health care centers

 

  11.     Hospital patient

An outpatient or an inpatient to whom a hospital provides comprehensive care, including all necessary medical, nursing and diagnostic services and, if they are available at the hospital, dental and allied health services, by means of its own staff or by other agreed arrangements.

  12.     Inpatient

       A person who occupies a bed in a hospital for the purpose of hospital treatment.  

Where a patient is admitted on the expectation that he or she will remain overnight, but the patient dies or is discharged before the midnight census, the patient should still be regarded as an inpatient, whether or not a hospital bed is occupied or treatment is provided.  For example, the patient may die in the operating room or the recovery room, or may be discharged because surgery cannot be performed for medical or administrative reasons.

Patients who are held for observation in the Emergency Department or other observation areas, pending a decision whether to admit or not to admit to an inpatient bed should NOT be regarded as inpatients.  However, if a decision is taken to admit such a patient, the time of admission should be regarded as the arrival time at the Emergency Department or observation area.

A hospital newborn inpatient is an infant born in the hospital at the beginning of the current inpatient admission.  These infants are may be classified as normal newborns, or as those requiring special care because of prematurity, congenital malformations, etc., and are admitted to the neonatal intensive care unit (NICU).   Well newborns staying in the regular nursery are listed separately from those in the NICU.  Some countries include the special care newborns with regular inpatients; others group them with the well newborns.  In both instances the special care newborns should be listed separately.

Policies also vary from country to country regarding certain short-stay cases.  In some countries, for example, the following are classified as inpatients (patients may have to meet minimum length of stay criteria); in other countries they are considered outpatients, day patients or day cases.

  • outpatient or same day surgery

 

  • chemotherapy patients

 

  • renal dialysis patients

 

  • endoscopic procedures

 

  13.     Length of stay (discharge days)

The total number of patient days for an inpatient episode.  The duration of an inpatient’s hospitalization is considered to be one day if he is admitted and discharged on the same day and also if he is admitted on one day and discharged the next day.  The day of admission should be counted but not the day of discharge.

  14.     Live birth

       “The complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached; each product of such a birth is considered live born.”

                                                                                              WHO, ICD 10, Vol.1, page 1235

  15.     Maternal death

Death of any woman while pregnant, or within 42 days of termination of pregnancy, irrespective of duration and site of pregnancy, from any cause related to or aggravated by the pregnancy, or its management, but not from accidental or incidental causes.

Maternal deaths should be divided into two groups:

(1) Direct obstetric deaths

 

Those resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above.

(2) Indirect obstetric deaths

Those resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by physiological effects of pregnancy.

                                                                                              WHO, ICD10, Vol. 1, page 1238

 16.      Neonatal death

The neonatal period commences at birth and ends 28 completed days after birth.  Neonatal deaths (deaths among live births during the first 28 completed days of life) may be subdivided into early neonatal deaths, occurring during the first seven days of life, and late neonatal deaths, occurring after the seventh day but before 28 completed days of life.

                                                                                              WHO, ICD10, Vol. 1, page 1237

  17.     Occasion of service

An occasion of service is a specified, identifiable service involved in the care of patient that is not an encounter, such as a lab text ordered during an encounter.  (Horton)  Any examination(s), consultation(s) or treatment(s) or other service(s) provided to a patient by a functional unit of a health service facility.  On each occasion such service, each specimen, or simultaneous set of specimens for the one patient, referred to a hospital department, constitutes one occasion of service.

  18.     Outpatient

An outpatient is a patient who receives care without being admitted to inpatient or resident care.

  19.     Patient day (inpatient service day)

A unit of measure denoting the services received by one inpatient during one 24-hour period.  

  20.     Perinatal death

A perinatal death is one occurring during the perinatal period, which commences at 22 completed weeks (154 days) of gestation (the time when birth weight is normally 500 g), and ends seven completed days after birth.

                                                                                              WHO, ICD10, Vol. 1, page 1237

 

NOTE:  In ICD9 it was recommended that countries should present, solely for international comparisons, “standard perinatal statistics” in which both the numerator and the denominator of all rates are restricted to fetuses and infants weighing 1000 g or more (or, where birth weight is unavailable, the corresponding gestational age (28 weeks).

                                                                                                    WHO, ICD9, Vol.1, page 766

  20.     Surgical procedure (Surgical operation)

Any single separate systematic manipulation upon or within the body which can be complete in itself, normally performed by a licensed practitioner or dentist, either with or without instruments, to restore disunited or deficient parts, to remove diseased or injured tissues, to extract foreign matter, to assist in obstetric delivery or to aid in diagnosis.

Although surgical procedure and surgical operation are considered synonymous here, a surgical operation is defined as one or more surgical procedures performed at one time for one patient via a common approach or for a common purpose.  (Horton)

  21.     Total length of stay (total discharge days)

The number of days of care rendered to a group of inpatients from admission to discharge. The sum of the length of stay of any group of inpatients discharged during a specified period of time.

  22.     Total patient days (total inpatient service days)

The sum of all inpatient service days for each of the days during a given period. This is taken from the census forms. Every inpatient receives one inpatient service day each day he/she is hospitalized. 

  23.     Transfer

The movement of a patient from one medical care unit to another within a hospital.  Transfers to another health care institution are classified as discharges.

  24.     Underlying cause of death

  • the disease or injury which initiated the train of morbid events leading directly to death; or

 

  • the circumstances of the accident or violence, which produced the fatal injury.

                                                                                              WHO, ICD10, Vol. 1, page 1235

 

B.   INPATIENT STATISTICAL DATA COLLECTION AND CALCULATIONS

Inpatient statistical data routinely collected and calculated in hospitals on a monthly and annual basis include:

  • number of admissions – total hospital and by service
  • number of patient days
  • number of discharges (live and expired) – total hospital and by service
  • number of deaths – total hospital and by service
  • total length of stay (total discharge days)
  • number of autopsies
  • number of Coroner’s (medical examiner’s) cases
  • number of deliveries (obstetric patients)
  • number of live births
  • number of fetal deaths
  • number of obstetric discharges
  • number of maternal deaths
  • number of perinatal deaths
  • number of surgical procedures
  • number of anaesthetics administered

 

       The above information is used to calculate the following rates and percentages:

 

(a)   Hospital utilization

  • daily census
  • average daily census
  • average length of stay of inpatients
  • percentage of occupancy of hospital beds
  • turnover interval
  • turnover rate

 

(b)   Death rate

  • hospital death rate
  • net death rate
  • postoperative death rate
  • anesthesia death rate

 

(c)  Autopsy rates

  • hospital autopsy rate
  • net autopsy rate

 

(d)  Obstetric and perinatal rates

  • caesarean section rate
  • maternal death rate
  • fetal death rate
  • perinatal death rate

 

The above rates and percentages may be calculated using the following

formulae:

1.    Hospital Utilization

  • Daily Census (Daily Bed Occupancy) 

 

Formula 

 

Census    =    Inpatients                 Admissions up       Discharges/deaths

remaining at              to the next                  between census

midnight the    +        census hour ‑           taking hours

previous night

  • Average Daily Census (Average Daily Bed Occupancy) 

 

The average number of inpatients present each day for a given time period.  This figure is derived by dividing the sum of patient days for a period by the number of days in the same period.


Formula 

 

Total number of patient days for a period (except newborn)          

Total number of days in the same period

 

Example

In May a hospital rendered 4,280 patient days (excluding newborn babies).  May has 31 days. Using the above formula the average daily census is calculated as follows:

4280

 31  =          138.06 or 138.1

This would be rounded to give the average daily inpatient census during May of 138 patients.

NOTE:  This indicator is calculated separately for newborns.

  • Average length of stay (ALOS) of discharged patients 

 

The average number of days that inpatients (exclusive of newborn) remained in the hospital.

Formula 

 

Total length of stay of discharged patients for a given period 

Total number of discharges and deaths in the same period

Example

In June a hospital discharged 2,086 patients (including deaths, but excluding newborns). Their combined length of stay was 13,654 days. Using the above formula the average length of stay of these patients was:

13654

 2086         = 6.54 or 6.5 days

  • Percentage of occupancy of inpatient beds 

 

The percentage of inpatient beds occupied over a given period.

 

Formula 

 

Total number of patient days for a given period x 100 

Available beds (bed complement) x the number of

days in the period

Example

A hospital with 210 available beds (excluding newborn bassinets) rendered 4,780 patient days in June.  June has 30 days.  The percentage of  occupancy for the hospital in June was:

4780 x 100           =          78000 =

          210 x 30                             6300              75.87 or 75.9%

  • Bed Turnover Interval 

 

Average period in days that an available bed remains empty between the discharge of one inpatient and the admission of the next.

Indicates the time that available beds are free.

Indicates a shortage of beds when negative, and under-use of the hospital or an inefficient admission system, if positive.

Formula 

 

Available beds x days in the period ‑ patient days for the period 

Number of discharges, including deaths, in the period

Example

A hospital with 210 available beds in June rendered 4,780 patient days and had 736 discharged/died patients.  The turnover interval rate using the above formula is:

210 x 30 ‑ 4780    =          1520

736                             736     =          2.06 or 2.1 days

  • Bed Turnover Rate

 

The mean number of patients “passing through” each bed during a period.

Indicates the use made of available beds.

Formula 

 

Number of discharges (separations) in the period 

Available beds

Example

During the month of June there were 736 discharges (including deaths) from a hospital with 210 beds.  The turnover rate for June was:

736  =

210                        3.50 or 3.5

2.    Death Rates

Note:       Patients who are dead on arrival (DOA) at a hospital are not included when calculating these rates.

  • Hospital Death Rate 

 

A ratio of all inpatient deaths for a given period to the total number of discharges and deaths in the same period.

 

Formula 

 

Total number of deaths of inpatients in a given period x 100 

Total number of discharges and deaths in the same period

Example

A hospital had a total of 15 deaths during the month of June.  A total of 540 patients were discharged (including the 15 deaths) during the month.  The hospital death rate according to the above formula is:

15 x 100

  540          =          2.77 or 2.8%

  • Net Death Rate 

 

 

A death rate, also known as the institutional death rate, that does not include deaths, which occur within 48 hours of admission (24 hours of admission in some countries).  Previously, it was that those deaths that occur within 48 hours of admission should not be counted because not enough time had lapsed to allow the health care providers adequate time to directly affect the patient’s condition.  However, with today’s technology, this concept is no longer thought to be valid.  Therefore, it is recommended that net death rates not be calculated unless there is a special order to do so.

Formula 

 

                        Deaths minus those w/in 48 hours of admission in a given period x 100

Total number of discharges and deaths, minus

Deaths w/in 48 hours of admission w/in the same period

 

Example 

Taking the above example, of the 15 deaths, 4 patients died under 48 hours, leaving 11 patients who died 24 hours or more after admission.  The total discharges, including deaths were 540. According to the formula the deaths under 48 hours of admission are deducted.  Therefore, the calculation of the net death rate would be as follows:

15 ‑ 4 x 100          =          11 x 100

     540 ‑ 4                               536                 =          2.09% or 2.1%

  • Postoperative Death Rate

 

The ratio of deaths within 10 days after surgery to the total number of patients operated on during that period.  Some healthcare providers question the usefulness of this rate, as it is questioned how ten days is considered the “magic number.”

Formula

 

  Total number of deaths(within 10 days of surgery)    X    100

Total number of patients who were operated on for the period

Example

During the month of November a hospital performed 275 operations, and 269 patients were operated on.  There were 2 deaths that occurred within 10 days of surgery, and 1 that occurred after 10 days.  The postoperative death rate according to the above formula is:

              2 X 100  = 0.74%

              269

Note:  it is recommended with small percentages of this nature, that the percentage be left at two decimal places.

  • Anesthesia Death Rate

 

The ratio of deaths caused by anesthetic agents during a specified period of time to the number of anesthetics administered. This formula includes those deaths that occurred within 10 days of surgery.

Formula

 

  Total deaths caused by anesthetic agents   X    100

         Total number of anesthetics administered

Example

During the month of August a hospital performed 750 operations, and 750 anesthetics were administered.  There was 1 death due to anesthesia.  The anesthesia death rate according to the above formula is:

              1 X 100    =    0.13%

              750

3.    Autopsy Rates

  • Hospital autopsy rate

 

The ratio of all autopsies performed in the hospital to all inpatient deaths in the hospital.  Patients who are dead on arrival (DOA) at the hospital and fetal deaths are excluded from both the numerator and the denominator

 

Formula

 

Total number of autopsies for a given period  x   100

Total number of inpatient deaths for the same period

Example

In a hospital with 15 deaths during the month of June, 7 autopsies were performed on hospital patients whose bodies were available for hospital autopsy.  The hospital autopsy rate is calculated as follows:

7 x 100

  15             =          46.66 or 46.7%

  • Net autopsy rate

 

A hospital may be prevented from performing an autopsy because the death is a coroner’s or medical examiner’s case and must be sent to the coroner’s court for autopsy.  It would not reflect the scientific interest of the doctors to include such cases in a measure of unautopsied hospital cases. Cases, which are not available for autopsy, are not included in the net autopsy rate.

Formula

 

Total number of autopsies for a given period x 100

Total number of deaths minus unautopsied

Coroner’s cases for the same period

Example

In the above example, of the 15 deaths and 7 autopsies in June 2 deaths were reported to the coroner/medical examiner and the bodies removed from the hospital and no hospital autopsy was performed.  The net autopsy rate, therefore, was:

7 x 100      =          700

15 ‑ 2                     13       =          53.84 or 53.8%

4.    Obstetric and Perinatal Rates

  • Cesarean section rate

 

A ratio of the number of cesarean sections performed to total deliveries.

Formula

 

Total number of cesarean sections performed in a period x 100

Total number of deliveries in the period

Example

During the month of May, 310 deliveries occurred.  Of this number 5 deliveries were by cesarean section.  Using the above formula, the cesarean section rate is calculated as follows:

5 x 100

   310         =          1.61 or 1.6%

  • Maternal Death Rate

 

The ratio of maternal deaths to total obstetric discharges, including deaths.  NOTE:  Deaths due to abortions are maternal deaths even though the patient may have been hospitalised on a gynaecology ward.

 

Formula

 

  Total number of maternal deaths for a given period    x   100

    Total number of obstetric discharges, including deaths,

                               for the same period

 

Example

During May an obstetric hospital discharged 230 obstetric patients, of this number, 1 patient died.  Using the above formula the maternal death rate would be:

1 x 100

230                        =          0.43 or 0.4%

  • Perinatal Death Rate

 

The ratio of perinatal deaths to live births and fetal deaths.         

Formula

 

Total number of perinatal deaths in a given period x 100

Total number of live births and fetal deaths in the same period

 

Example

In the month of May, there were 294 births, including 4 fetal deaths, and 2 babies subsequently died within seven days of birth.  The perinatal death rate for May, therefore, was:

6 x 100

   294         =          2.04 or 2.0%

  • Fetal Death Rate

 

A ratio of fetal deaths to the total number of live births and fetal deaths in a period.

                   Formula:

 

Total number of fetal deaths for a given period x 100

Total number of births and fetal deaths for the same period

Example

The fetal death rate, using the perinatal death rate example above, is calculated as follows:

4 x 100

   294         =          1.36 or 1.4%

C.   OUTPATIENT STATISTICAL DATA COLLECTION AND CALCULATION

 

  • number of outpatient visits
  • number of outpatient visits for each clinic
  • number of emergency department visits
  • occasions of service (i.e., number of special services, e.g. Ultrasound, X‑ray, pathology tests)

 

Most of the above are collected to assess the workload of each department or clinic, and plan for future needs. It may be found that the Wound Clinic staff see twice as many patients than other clinics, therefore more staff will be required in the clinic area on the wound clinic days; or, patient waiting time may be too long and the administration decides to look at the statistics for each clinic to see if it is because too many patients are given appointments when sufficient medical staff are not available.

This data may be manually tallied each day and totalled at the end of the time frame, or if a computerized patient registration system is used, the computer may automatically count these statistics.  Therefore, no formulae are necessary to calculate this information.

1.    Outpatient Visits (per day or per clinic session)

The average number of patients seen per day or per clinic session.

 

                   Formula

 

 Total number of visits in period     

Total number of days in the time period (or clinic session held)

Example

During the month of September the Wound Clinic was held 12 times and there were 287 visits.  Using the above formula, calculate the number of visits per clinic session.

287            =          23.92 or 23.9

 12

D.   REPORTS

Quite frequently, the health facility’s administrator, accreditation agency, or a government agency establishes various reports that must be presented. It is important to ensure that these reports are prepared in a timely and accurate manner since, directly or indirectly, this is one of the ways the health record department is evaluated.

The data collected and reports prepared should be reviewed and evaluated on at least an annual basis to determine if they are be used. Data that are collected for no apparent reason or reports that are prepared that no one uses are a waste of staff time and resources.

Sometimes reports prepared only present the work accomplished during the reporting period, and may not be particularly useful for problem identification or for decision-making. A report that compares selected data and indicators over different time periods may prove useful. 

For example, the data and indicators for a month and the year to date can be compared with data for the same month and year to date of the previous year.

                                                                        Current year                          Previous year

                                                                        Month    YTD                         Month     YTD

Admissions

Discharges

Deaths

Patient days

Average daily census

Average length of stay

Percentage of occupancy

Turnover rate

Outpatient visits            

 

E.   QUALITY CONTROL

Health record professionals are evaluated on the timeliness, completeness, and accuracy of the statistical reports they are responsible for preparing.  It is therefore important to have policies and procedures that help ensure that reports meet these criteria.

Policies and procedures should include the following points:

1.  Monitor that the Health Record Department receives all reports within the established time period (e.g., unit census reports received daily; operating room reports received within 5 work days following end of the month).

2.  Follow-up immediately on delinquent reports.

3.  Check each unit census daily to be sure that:

  • ·    every patient listed as a transfer in or transfer out appears as a transfer on the census report of another ward;

 

  • ·    the number of patients remaining at the end of the day agrees with the number obtained by adding to the patients remaining the previous day the number of entries to the ward (admissions and transfers in) and from this total subtracting the number of departures (live discharges, deaths, transfers out) from the ward.

 

4.  Verify that for the hospital as a whole the number of transfers in agrees with the number of transfers out.

5.  At the end of each day, month, and year (or other time period), check the hospital inpatient statistical report as outlined in point 3 above.

6.  Check all indicators for accuracy and to be sure that they make sense.  For example, the number of patients remaining at the end of the time period should be lower than the number of beds unless, of course, more than one patient occupies a bed.

7.  Proofread all reports before distribution to be sure that they contain no typographical errors.

SUMMARY:

Before proceeding to collect or compute any statistical information, the health record professional must find out what is needed and how and when it is to be used.

The reports generated are also very important and are used as a tool of communication.  All presentations should be simple and readable with important facts highlighted.  Although most reports will be in tabular form, they would be easier to read if visual aids such as graphs, bar charts and pie diagrams were used to illustrate clearly what the figures indicate.

In addition, reports should be clear and concise, and leave no doubt as to what the figures represent.

Many health facilities around the world today use computers to analyze and present their statistical data.  This often results in the collection of more than basic data, which is readily retrievable and useable.

To assist in your understanding, complete the following exercises in Appendix 1.  Answers are included in Appendix 2, but please work through each exercise before checking your answers.  If any of your answers are incorrect, work through them again to find out where you went wrong.

REFERENCES:

1          Davis, Nadinia, and LaCour, Melissa.  Introduction to Health Information Technology.  Philadelphia, PA:  W.B. Saunders, 2002.

2.         Horton, Loretta A.  Calculating and Reporting Healthcare Statistics.  Chicago, IL:  AHIMA, 2004.

3.         Huffman, Edna K. Health Information Management.  10th ed. Berwyn, IL:    Physicians Record Company, 1994.

4.         Johns, Merida, ed.  Health Information Management Technology: An Applied Approach.  Chicago: AHIMA, 2002.

5.         Skurka, Margaret.  Health Information Management:  Principles and Organization for Health Information Services.  San Francisco, CA:  Jossey- Bass, 2003.

6.         World Health Organization (1994). International Classification of Diseases and Related Health Problems, 10th Revision, Volumes 1, 2 &3.  Geneva: WHO.

Appendix 1 – Excercises

Education Module 4 – Healthcare Statistics

 

 

 

EXERCISE 1 – Patient Care Unit CENSUS

 

1.  Using the information on the left of the page, complete the daily midnight census for Unit A.

UNIT A                                                           BED RETURN FOR DATE 3/6/2006

John Smith adm. from                                 a.         No. in ward last report         40

O.P.D. (Dr. Richard)

Adam James adm. Dr. Maurice                             No. admitted               ______

Stanley Paul adm. G.P.                                          No. transfers in           ______

Anthony Greech trans.                               b.         Total                            ______

from other hospital

Patrick Sterling trans.                                              No. discharges            ______

from Med. (Ward B)

Gordon Thompson died 10.30 a.m.                      No. Deaths                  ______

Wayne Johnson emerg. adm.                               No. transfers out          ______      

Brett Arnold disch. O.P.D.                          c.         Total                             ______

Michael Stephens disch. G.P.      

Adam Carpenter trans.                                            Today’s census

to Psych. (Ward D)                                                        a + b – c     =             ______

John Trip trans. to

other hospital

Wayne Johnson died 4.30 p.m.

John Smith disch. O.P.D.

Thomas Adams disch. O.P.D.

2.    Calculate the number of patient days for Ward A on 03/06/2006:

EXERCISE 2 ‑ HOSPITAL CENSUS REPORT

 

            Date:  ____________

Directions:         Complete the data for Unit A from Exercise 1.

                             Complete the Hospital Census report.

                             What checks for accuracy can you use?

 

Unit

 

Prev.

Day

Census

 

Admi-

ssions

 

Transfers

In

 

Discharges

 

Transfers

Out

 

Today’s

Census

 

Alive

 

Deaths

 

A

 

 40

           
 

B

 

 35

 

 4

 

2 from C

       
 

C

 

 23

 

 8

   

 4

   

 2 to B

 
 

D

 

 28

 

 3

   

 2

 

 1

   
 

E

 

 30

 

 6

   

 3

     
 

TOTAL

 

156

           

 

                                          EXERCISE 3 ‑ HOSPITAL CENSUS

Complete today’s hospital census report

HOSPITAL CENSUS REPORT

 

August 27, 2006.

 

Unit

 

Prev.

Day

Census

 

Admi-

ssions

 

Transfers

In

 

 Discharges

 

Transfers

Out

 

Today’s

Census

 

Discharges

 

Deaths

 

A

 

 40

 

 3

   

 2

   

2 to B

 
 

B

 

 26

   

 2 from A

 

 4

 

1

 

1 to D

 
 

C

 

 31

 

 8

   

 5

 

1

   
 

D

 

 45

   

 1 from B

 

10

   

2 to C

 
 

E

 

 12

 

 6

         
 

TOTAL

 

154

           

 

 

                                                               EXERCISE 4

1.    Compute the length of stay of 10 patients who were discharged from hospital on October 6, 2006.  Their dates of admission were as follows:

(a)        September 12                ______           (f)        September 11           ­______

(b)        September 28                ­______           (g)       October 5                   ______

(c)        September 30                ______           (h)       September 16           ______

(d)        September 26                ______           (i)         October 6                   ______

(e)        October 4                        ______           (j)         August 13                  ______

(k)        What was the average LOS?   ________

2.    In a 200-bed hospital, the patient days for 2006 were 62,050.   The 6,495 patients who were discharged or died had a total of 61,930 days care.  Using the above figures, compute the following averages and rates, showing formulae used.

(a)        Average daily census for 2006

(b)        Percentage of occupancy for 2006

(c)        The average length of stay of discharged patients during 2006

 

EXERCISE 5

1.    A Coronary Care Unit in a large teaching hospital had a total bed count of 20 beds in 2006.  During the year the patient days for the unit were calculated at 5,260 days.  The 1,255 inpatients that were discharged from the unit during 2006 spent a total of 5,066 days there.

       a.         How many patients, on the average, were cared for in the unit per day?

       b.         How long, on the average, did patients remain in the unit?

       c.          What percentage of beds were occupied during the year?

2.    The following data have been collected from a 700-bed general hospital during 2006:

Patients admitted                                                       14,117

Total discharges/deaths                                           14,086

Total discharge days                                               137,202

Total inpatient patient days                                    226,842

Total registered outpatient attendances              192,846

From the information above, calculate the following, showing formulae:

a.         Average length of stay

b.         Average daily census

c.          Percentage of occupancy

3.    In a local hospital, the average length of stay in January 2006 was 10.4 days.  The number of patient days care rendered to discharged patients in the same period was 5,460.  How many discharges were there in January?

4.    A 460 bed general hospital assigned 215 beds for general medical service, 125 beds for General surgery including Orthopedics, the remainder, 120, were divided among the other services.  For the past 12 months (2006) the number of patient days within the three major categories were:‑

A.         General medicine         59,059

B.         General surgery                        43,070

C.         Other services               35,040

Using the above information, calculate the following for each of the three categories:

  • Percentage of bed occupancy
  • Average daily census

 

 

EXERCISE 6

A 477-bed general hospital had 15,746 patients discharged/died in 2006.  Total deaths for the year were 487.  There were 81 cases reported to the Coroner, and 351 autopsies were performed.

Total patient days were 136,995 and the total length of stay of discharged/died patients was 136,540. 

Give the formulae, and using the above information compute the following:

1.    Hospital death rate

2.    Bed turnover rate

3.    Net autopsy rate

4.    Average length of stay

 

EXERCISE 7

1.    The following data have been collected from a local hospital.  The average length of stay in June was 5.2 days.  The total length of stay of discharged/died patients in the same period was 2,730.  There were 18 deaths, including 2 unautopsied Coroner’s cases and 12 autopsies were performed.

a.         What was the hospital death rate?

b.         What was the net autopsy rate?

2.    The following data have been collected from a 700 bed general hospital during 2006:

Patients admitted                                                                      19,957

Total discharges/deaths                                                           19,933

Patients remaining in hospital midnight

Dec.31, 2005                                                                                              632

Patients remaining in hospital midnight

Dec.31, 2006                                                                                             656

Total length of stay of discharged/died patients                218,515

Total patient days                                                                 236,842

Total deaths                                                                                               615

Total autopsies performed                                                           485

Coroner’s cases (unautopsied)                                                     43

Number of anaesthetics administered                                    6,925

Number of operations performed                                            7,700

Total registered outpatients                                                192,846

From the information above, calculate the following:

a.        Average daily census

b.        Hospital death rate

c.         Turnover interval

d.        Gross autopsy rate

e.        Net autopsy rate

f.         Percent of occupancy

g.        Average length of stay

 

EXERCISE 8

The following information was collected from a 500-bed hospital and includes the census figures for the 30th September, 2006, and the monthly figures for the month of September, 2006.

(a)  September 30

Patients in hospital at midnight                        418

Patients discharged 30th September                 17

Patients admitted 30th September                     24

(6 patients were admitted and discharged

the same day.)

(b)  September, 2006

Total number of discharges/deaths                 1088

Total deaths                                                                                     43

Coroner’s Cases (unautopsied)                             4

Total number of autopsies performed                 28

Total number of anaesthetics administered     467

Total number of outpatient attendances       16203

Total patient days during September             12332

Total length of stay of discharged/died        

patients                                                    10943

From the above figures, calculate the following:

1.    Census for the 30th September

2.    Patient days for 30th September

3.    Average daily census

4.    Percentage occupancy

5.    Average length of stay

6.    Gross autopsy rate

7.    Bed turnover rate

8.    Hospital death rate

9.    Net autopsy rate

EXERCISE 9

1.    In an obstetric hospital there were 310 live births in June 2006; of this number 7 died within the neonatal period.  The hospital also registered 8 fetal deaths for the same month.  What rates were calculated below?

a.        (8 + 7) x 100 divided by (310 + 8) = 4.72 or 4.7%

b.        8 x 100 divided by (310 + 8) = 2.52 or 2.5%

2.    An obstetric hospital published the following figures in 2006:

Obstetrical discharges

  • delivered                                      2288
  • undelivered                                  327
  • aborted                                            39

Total infants discharged/died                         2255

Total births (live)                                                2309

Infant deaths (early neonatal)                            56

Fetal deaths                                                            36

Maternal deaths                                                         3

Using the above information, calculate the following:

a.  Maternal death rate

b.  Infant death rate

c.  Fetal death rate

d.  Perinatal death rate

3.    A 320 bed obstetric hospital had 10,220 obstetric separations in 2006. There were 7,016 live      births; 139 fetal deaths; 523 caesarean sections were performed with a total of 6,968 deliveries for the year and 2 maternal deaths.  There were 4 infant deaths classed as early neonatal.  Using the above information, calculate the following:

(a)       Fetal death rate

(b)       Cesarean section rate

(c)       Perinatal death rate                     

 

EXERCISE 10

You have received the following medical statistics for review prior to their publication in the 2006 Annual Report of a General Hospital.  What comments do you have regarding the accuracy of the data?

Available beds (Bed complement)                                                                                    430

Total admissions                                                                                                 11,285

Total discharges/deaths                                                                                    11,123

Total deaths                                                                                                              521

Patients in hospital at midnight on 31 December 2005                                                 344

Patients in hospital at midnight on 31 December 2006                                                371

Autopsies performed (including 2 autopsied Coroner’s Cases)                     378

Coroner’s cases                                                                                                                      44

Total patient days                                                                                              128,954

Total length of stay of discharged/died patients                                          126,872

Out‑patient visits                                                                                               106,750

Average daily census                                             352

Percentage of Occupancy                         81.9%

Turnover rate                                                25.9

Hospital death rate                                      46.8%

Gross autopsy rate                                         0.73%

Net autopsy rate                                             0.79%

 selesai @ hak cipta dr Iwan suwandy 2010

Modul Pelatihan Praktisi rekam Medis Unit 3 ” Record Identification syatem,Filing and Retention Of Health Record”

Education Module for Health Record Practice

based on IFHRO Modul

UNIT 3 ‑ RECORD IDENTIFICATION SYSTEMS, FILING AND RETENTION OF HEALTH RECORDS

This unit introduces the participant to different record identification and filing systems used in health record management.  Record identification may be either alphabetic or numeric, and the filing system used is dependent upon the type of record identification system employed.  Although some health care facilities have electronic health records,  most health care facilities still maintain patient records in a paper-based format.  

This unit deals with the various methods to identify and file paper-based patient records.

The record identification and filing systems form the first step in a series of procedures in the management of health record services.  A medical record has no value if it cannot be found once it is stored somewhere in the file area.

Careful planning of the record identification and filing systems to be used is of great importance.  The choice of the system, however, also depends on the specific type and circumstances of the health care facility for which it is selected.

Planning of filing activities should also include a policy on record retention.  Storage space is generally a scarce commodity, so usage of it has to be maximised.

OBJECTIVES:

Upon the completion of this unit, the participant should be able to:

1.     compare and contrast the different methods of record identification and list the advantages and disadvantages of each

2.     give specific examples of serial and unit numbering

3.     explain what is meant by a unit numbering system

4.     compare and contrast filing systems for health records.

5.     explain relational numbering with advantages and disadvantages

6.     define record linkage and explain how it is used

7.     demonstrate an understanding of terminal digit filing and cite the advantages and disadvantages of its use.

8.     define what is meant by a centralized filing system and delineate the advantages of this system

9.     describe the methods that may be used to assign patient healthl record numbers

        10.     explain the various control methods used to facilitate the location of health records

        11.     state the general rules for record control in a hospital or clinic and the specific filing rules required to maintain an efficient health record service

        12.     identify and compare the different types of filing equipment used to file health  records

        13.     delineate characteristics which should be considered in choosing folders, guides and outguides

        14.     outline criteria which must be evaluated when establishing record retention policies

        15.     explain the storage options for health records with advantages and disadvantages.

A.      RECORD IDENTIFICATION SYSTEMS

It is important that each record has a unique identifier, either alphabetic or numeric. The collection of patient identification data and the assignment of a record number or verification of an existing record number should be the first step of every admission or visit to a hospital or health center.  It is the only way to ensure properly identified health records.

          1.     Alphabetic Identification

The simplest form of record identification is alphabetic, using the patient’s name to identify and file the patient’s health record.  And because only the patient’s name is used to identify the record, it is also the easiest method of record retrieval, as the master patient index (MPI) is not needed to cross-reference the patient’s name to the health record number.  The accurate spelling of the patient’s name is of extreme importance.  It is also important to create a system to track name changes, such as from marriage or divorce.  It is necessary to thoroughly train staff to verify patient names and spellings, and to accurately and consistently file the health records.

One concern with this type of record identification is patient confidentiality.  Since the outside of the record is identified only with the patient name, and not a number, the patient’s identity is not protected.

This type of record identification system is most practical in smaller health care facilities with stable patient populations.  Larger patient populations would result in multiple patients with the same name, leading to possible mix-ups of patient files.  It is also most practical for facilities with little or no computerization. 

2.     Numerical Identification

A numerical record identification system requires that a unique health record number be assigned.  It requires the use of a MPI to cross-reference the patient’s name with his or her health record number.

There are two main systems of numbering patient records:

  • ·Serial numbering
  • ·Unit numbering

 

a.  Serial numbering

With this method the patient receives a new health record number on every inpatient admission or outpatient visit to the hospital or clinic.  That is, the patient is treated as a new patient each time with a new number, new index card and new record, filed totally independently from previous records.

Serial numbering is not used extensively today and is only useful in small hospitals with a low rate of readmission.

b.  Unit numbering

The patient is assigned a unique identification number on his first contact with the hospital, whether it is for an admission, emergency room or outpatient clinic visit.

The same health record number is kept and used on all subsequent visits, whether as an inpatient, outpatient or emergency patient. A unit health record number results in the creation of one, central health record for the patient.

This number is normally related to one single record, where all the information on the patient is brought together.  These data can originate from different clinics or units, at different time periods. If a unit record is not possible, the unit numbering system can be used to link health records that are physically located in different places.

      1) The advantages of using a unit number for filing are:

  • the number is unique to the individual and therefore distinguishes him/her from any other patient in the hospital or clinic

 

  • the number does not change regardless of how often a person is admitted to hospital or attends a clinic

 

  • patients’ health records are centralized in a single folder

 

  • this system provides the medical staff with a complete picture of the patient’s medical history and treatment received over a number of admissions and attendances.

 

  • health records are filed in one place.

 

      2)    The disadvantages of using a unit number for filing are:

  • health records may become quite thick and additional folders may be required

 

  • space needs to be allocated to allow for the expansion of records as more admissions are added to a folder.

 

It is important to note that when a unit record is used, it is essential for all staff to check the patients’ master index before issuing a new record folder.  This ensures that a duplicate health record is not produced.

  1. Serial-unit numbering

 

Serial-unit numbering is an adaptation of the serial and unit numbering systems that combines both systems.  With this system, the patient receives a new number on every contact with the hospital, but previous records are brought forward and filed under the latest number, so only one record will remain in the files.

It is necessary to leave either the old health record folder or an outguide (or tracer card), referring to the new record number, in the place from where the old records are removed.

1) The advantages of serial‑unit numbering and filing are:

  • §a unit record is created

 

  • §record retention is easier as records with lower numbers automatically remain in the old file.

 

2) The disadvantages of serial-unit numbering and filing are:

  • §gaps are left in the file area when medical records are brought forward.

 

  • §time is needed for back shifting and for cross‑reference from old record and record number to the newest one. (Huffman 1994)

 

d.  Conversion to a unit system

The change from one system to another should not be underestimated.  It implies an increased workload, since two filing systems have to be used for an undetermined period of time.  Many records have to be controlled and shifted, especially in the first months.

      The steps proposed for a conversion are:

      1)    Select a date to make the change, and begin issuing patients new unit numbers on that day.

      2)    Check if the patient already has a record (or records).  Bring forward these previous records and file them under the new number.

      3)    It is best to convert the records of old patients to the new system as they come back to the health care facility, rather than attempt to convert the entire file at one time.

      4)    The Master Patient Index has to be adjusted or a new MPI started from day one of the changeover.   As a dual control, empty folders of previous records or out guides (tracers) should be left at the original places in the old file, with cross‑reference to the new unit record number.

      5)    After a predetermined period of time, the records still in the old file can be considered as inactive and eventually removed to inactive storage.  This also applies to old MPI cards, if a new MPI was started.

2.     Types of numbers

a.  Sequential numbering

Records are assigned a sequential number in chronological sequence commencing at 1.  For example, if the last number to be assigned was 010524 the number issued to the next patient would be 010525.  This method is simple, easy to assign, and easy to control.

This is the way numbers are issued in both serial and unit numbering systems.

Often when using a serial numbering system, some hospitals connect  this sequential numbering system with the year as a prefix, for example:

     05‑0024, represents the 24th patient of 2005

Other types of numbering are described below.  They are not generally considered to be better than a straight numbering method, nor as commonly used.

b.  Alphanumeric numbering

This is a combination of letters and figures, for example:

     AA 99 99 instead of 99 99 99

This method has the advantage of a greater capacity with the same number of characters, for example, letters:  A‑Z (26); figures: 0 to 9 (10).

This method, however, is not extensively used.

c.   Relational numbering

Relational numbers are numbers that, totally or partially, have a certain significance in relation to the patient.  There are various types of relational numbering systems that may be used, including:

   1)    Birth number

This number is derived from the date of birth.  That is, the number is based on six of the eight digits of the birth date.

To these digits other digits may be added.  For example, two, three (or even more) digits for the serial number (can be odd for males and even for females), a digit for gender, or digits representing a geographical code, for example:

    50            06                24            1                  05                    2

  Year      Month             Day         Gender       Serial       Geographic

Number          Code

In addition, one or two check digits may also be included, particularly, in computerized systems.  The total number, therefore, could consist of 9 to 12 digits.

           a) The advantages of using a relational number include:

  • The record number has built‑in information (age and sex)

 

  • Easy to remember, because of date of birth.  If difficulties occur in retrieving information from the MPI (misspellings, husband’s name, common names, etc.) the date of birth gives enough information to find the record.

 

   b) The disadvantages, however, must be taken into consideration, and include:

  • Long number, increasing the risk of transcribing errors, particularly in non‑automated systems.

 

  • A limited capacity, since a maximum of 31 numbers can be used for the day digits and a maximum of twelve numbers for the month.  Only the year digits have a range of 00 to 99.

 

  • If the birth date is unknown pseudonumbers (eg. 99 99 99) have to be used, and conversion procedures must be developed once the birth date is available.

 

  • Folders and MPI cards cannot be prenumbered.

 

 Although useful for identification, it is not generally considered a 

 good number for filing purposes.

   2) Social security numbering

Social security numbers are used, mainly in the USA and in some countries where the social security administration operates health facilities, but are also not recommended for filing purposes.

        a) Advantages of using a social security number are:

  • It is a unique identification number.
  • No reference to the Master Patient Index is necessary, and therefore faster retrieval.

 

  b) The disadvantages, however, outweigh the advantages and 

       include:

  • Some patients do not have or cannot give a social security number at the time of their admission or visit (eg. newborns, children, patients from abroad). Pseudonumbers must be assigned if no actual social security number is present, and again conversion procedures are needed, once the real social security number is available.

 

  • Threat of identity theft.

 

  • Control and verification of the number is out of the hands of hospitals using it.

 

3)  Family numbering

Another type of number used is a family number.  This type of numbering system is most appropriate for primary care clinics where all members of a family may receive health care.

With this system one unit number is issued to a household, and extra digits are added to indicate every individual in the household.

Example:       01        =          head of household

                02        =          spouse

                03        =          children and other family members (con’t)

                04

                05

                 06

Examples:

Mrs. Mary Smith            01 6436          Pamela Smith           03 6436

Mr. Donald Smith         02 6436          John Smith               04 6436

All health records are then grouped numerically by families, but separate folders can be maintained for each individual patient.

a)    The advantage of this method is that it is useful for ambulatory care centers, which emphasise the family as a unit (eg. family counselling).

b)    The major disadvantage is that families change.  Marriage and/or divorce cause changes of household number and/or extra digits.

When it is important to link family numbers a combination of a family number with another individual number is suggested.  It is safer and easier to use.

3.     Assignment of numbers

As previously mentioned, whatever method of numbering used it is important to have a unique identifier (medical record number) as soon as possible. The gathering of patient identification data and the assignment of a medical record number to new patients should be the first step of every admission or visit to a hospital or health center. 

How health record numbers are assigned is dependent upon if the registration process and MPI are computerized or manual, and if unit or serial numbering is used.

a)  Manual system

In a manual system that uses unit numbering, the responsibility for number allocation is retained in one place, usually the health record department. This ensures that controls are in place to prevent more than one patient from having the same number, or that a patient will have more than one number.  If a new patient arrives at a registration area, the health record department is contacted in order to get a new number.

The procedure for assigning numbers should be clearly recorded and monitored.

In a manual system that uses serial numbering, either the health record department may issue the numbers or the registration staff may be responsible.  If the registration staff assign the health record numbers, predetermined blocks of numbers are often issued to patient registration areas having a high volume of new patients.  The amount of numbers in each “block” should be determined by the activity of each area and should be limited and carefully controlled.  Since each area is allocated a specific block of numbers, duplicate numbers should not be assigned.

b)  Computerized system

The best system for number assignment exists in facilities having computerized registration and unit numbering.  With computerized registration, number assignment in every registration area is possible because computer systems are available to check the MPI and to verify that the patient does not have an existing medical record number.  As the patient is registered, the staff searches the computerized MPI database to determine if the patient has already been assigned a unit number.  If so, the demographic information is updated as necessary and the current visit information is entered.  It is important to note, however, that if more people are responsible for assigning numbers, the risk of duplication will increase.

4.     Number control

It is important in both manual and computerized systems to have an established method of number control.  Numbers should not be pre‑assigned unless good control processes are in place.

In a manual system, this can be a permanent number index, or master control book, where all assigned and unassigned numbers are held.  As a number is allocated the name of the patient is immediately entered beside that number.  Date of issue is also recorded.

For example:

Number                Name                         Date                Where issued

102642                Brown, John             09/27/2004    Outpatient Department

102643                                                    Miles, Andrew           09/27/2004    Outpatient Department

102644                West, Julia                09/27/2004    Admission Office

In computerized systems, a check digit is determined by performing some calculations on the basic number.  Thus, check digit verification is a way of detecting errors, caused by transcription of a data field or transposition in the use of the number.  It contains information about the magnitude and the position of each digit in the field.  Transcription (a wrong digit) or transposition (two digits reversed) errors lead to a calculation result, different from the check digit, and therefore an error message will be printed.

The way a number is presented also adds to the efficiency of the system. For example, an all-numeric number, presented in a fragmented form (eg, 10 26 42) or in boxes helps to reduce the misquotation rate.

5.     Record linkage or longitudinal records

The main goal of record linkage is the centralization of all medical data about a particular patient to enable essential information, about that patient, to be more readily accessible, and thereby creating a longitudinal record.  This type of system requires the use of electronic health records in order to share patient information.

Hospitals and governments, concerned with an expanding volume of medical information, are developing systems, designed to link all health records belonging to one patient that are physically located in different buildings or hospitals, within a city, state or province or across a country.

In order to link records or data within or between hospitals, accurate and fast patient identification and number assignment are of prime importance. As mentioned previously, in many countries a unique number, often based on the birth date, is assigned at birth, and remains the standard identifier during the individual’s lifetime.  This system readily enables record linkage.

 

The perfect standard identifier, and thus the perfect record linkage number, should be:

  • §    unique (assigned to one person only)
  • universal (covering the population involved, eg. hospital or nation)
  • §    permanent
  • §    available (it must be present on each of any pair of records to be linked)
  • §economical (it should consist of no more characters of information than necessary, as each character creates additional computer storage space).

 

It should also be noted that controversy exists surrounding the use of unique personal health identifiers because of the possible security issues, and many view it as a means of invasion of privacy

 

B.      FILING SYSTEMS

Record identification systems and filing must go hand‑in‑hand, as the filing system depends on the identification system used.  Filing is the systematic arrangement of records in a specific sequence so that reference and retrieval is fast and easy.

Daily procedures in many areas of a clinic or hospital can be severely affected by poor management of health record services.  It is therefore the responsibility of the health information professional/health record administrator to establish systems and procedures to ensure the efficient production of health records for patient care, medico‑legal purposes, statistics, teaching and research.

The health record department is judged on the efficient service it provides to the rest of the hospital or clinic. That is, health records must be readily available when required for patient care.  Departmental efficiency and record control are therefore two of the most important things to consider in the management of the health record services.

1.     Alphabetical filing                   

When no health record number is assigned, and the patient’s name is the only identifier, then alphabetical filing is the only possible method to use.  Filing is by patient surname first, then given name, and finally middle name or initial.  Records of patients with exactly the same name should then be filed according to their date of birth date.

This type of filing is time consuming and the risk of errors (change of name, misspelling) is extremely high.  Moreover, there is no way to control the use of the file area as it is not possible to know beforehand where the next new record will be filed.  Since names are not equally distributed, it is extremely difficult to avoid congestion areas and back shifting to open new file space.

Alphabetical filing is not recommended, and is only useful for facilities with a limited patient population and a small files area, with a very low patient turnover rate.

 

2.     Numerical filing systems

If a numerical record identification system is used, then a numerical filing system is used.  There are two main systems of filing records numerically:  straight numeric and terminal digit.

a.  Straight numerical filing

In this system, health records are filed in straight numeric sequence as follows:

8984                   108264

8985                   108265

8986                   108266

8990                   108267

This filing method reflects exactly the chronological order of the creation of records.  Straight numeric filing is typically used when serial health record numbers are assigned, however, a unit health record number may also be filed in straight numerical order.

1)    The advantages of straight numeric filing include:

  • people are used to this “logical” order and training is easy

 

  • easy to retrieve consecutive numbers for research or inactive storage.

 

2)    The disadvantages, however, outweigh the advantages, particularly in large hospital health record departments.  The disadvantages include:

  • easy to misfile, one must consider all the digits of the number in order to file the record

 

  • easy to transcribe numbers where one digit is wrongly written or read, for example: 1 for 7

 

  • easy to transpose numbers (reverse digits), for example, record number 194383 is filed as 193483

 

  • the highest numbers represent the newest, and therefore most active records, causing a concentration of record activity in one particular area of the file room, where these records are filed

 

  • it is not feasible to assign filing responsibility to one clerk since most of the records and loose sheets are filed in the same area.

 

b.  Terminal digit filing

1)    Whether using a serial, unit, or serial‑unit numbering system, the actual method used for filing is most important.  In place of straight numerical filing, other methods have been designed to improve retrieval and filing efficiency.  The most popular method in use today is the terminal digit filing system.

In terminal digit filing a six or seven digit number is used and divided into three parts.

Part 1 ‑    The primary digits, which are the last two digits on the right hand side

Part 2  ‑   The secondary digits, which are the middle two digits

Part 3 ‑    The tertiary digits, which are the first two or three digits on the left hand side

                                For example, the number 14 20 94 is divided as follows:

14                ‑             20                  ‑              94

Tertiary                   Secondary                     Primary

      2)    In the terminal digit file there are one hundred (100) primary sections ranging from 00 ‑ 99. When filing, the clerk considers the primary digits first, for example, the number 14 20 94 will be filed in the “94” primary section.  Within each primary section there are 100 secondary sections, also ranging from 00 ‑ 99.  The number 14 20 94 is filed in the 20 ‑ 29 secondary part of the “94” primary section.  Within the 20 ‑ 94 section the record is then filed in numerical order by the tertiary number.  The sequence of the file is as follows:

13 20 94             02 21 94                     11 21 94

14 20 94             03 21 94                     12 21 94

15 20 94             04 21 94                     13 21 94

16 20 94             05 21 94                     14 21 94

17 20 94             06 21 94                     15 21 94

18 20 94             07 21 94                     16 21 94

19 20 94             08 21 94                     17 21 94

00 21 94             09 21 94                     18 21 94

01 21 94             10 21 94                     19 21 94

      3)    The file clerk considers the record number in parts, going from the right to the left.  For the number 142094 he first locates the primary section (94). Within section 94 he looks for the secondary or subsection (20). There he files in numerical order, using the tertiary digit 14.

Adaptations can be made when more or less than six numbers are used.

 

        For example:

02               ‑                   44                    ‑           87

107          ‑           09                    ‑           14

      4)    The advantages of terminal digit filing include:

  • Records are equally distributed throughout the 100 primary sections.

 

  • Only every 100th new medical record will be filed in the same primary section of the file.

 

  • Congestion of personnel in the filing area is eliminated.

 

  • Clerks may be assigned responsibility for certain sections of the filing area.

 

  • The work can be evenly distributed among file clerks.

 

  • Inactive health records may be pulled from each terminal digit section as new ones are added, thus eliminating the need to backshift records.

 

  • Misfiles are substantially reduced with the use of terminal digit filing

 selesia@hak cipta Dr iwan Suwandy,MHA 2010

Modul Pelatihan Praktisi Rekam Medis Unit 2 : “Patient Identification,Registration Index & The Master Patient Index”

Education Module for Health Record Practice

 

UNIT 2 – PATIENT IDENTIFICATION, REGISTRATION AND THE MASTER PATIENT INDEX

This unit is designed to enable the participant to discuss methods of patient identification and registration and identify processes required to develop, use and maintain an effective patient identification system in a hospital, clinic or primary health care centre.

OBJECTIVES:

At the conclusion of this unit the participant should be able to:

            1.         Discuss the importance of complete and accurate patient identification

            2.         State the purpose of a master patient index (MPI)

                        3.         List the items, which should be included in a master patient index

            4.         Develop and implement a master patient index (MPI)

            5.         Trace the flow of a patient’s index card from admission to discharge

            6.         Use alphabetical or phonetic filing rules to correctly file cards in a manual master patient index

            7.         Discuss the need for cross‑referencing names in a master patient index

            8.         State the types of supplies and equipment commonly used for maintenance of a manual master patient index (MPI).

A.        PATIENT IDENTIFICATION

            The identifying information is an important part of a patient’s health record.  It should include enough information to uniquely identify an individual patient.  Most facilities will ask to view and/or copy the patient’s driver’s license or identification card in order to verify this data.  

            The patient identification data that is collected during the patient registration process is used to populate the Master Patient Index (MPI), which will be discussed later in this unit.  The patient identification data may be entered into a computerized database, or manually typed onto a registration form. 

            This section of the medical record should contain at least the following information:

            1.   The full legal name of the patient, including the surname (or family name), first name, middle name or initial, suffixes (e.g., Jr.) and prefixes (e.g., Doctor).  It is also important to collect the patient’s alias, previous name, or maiden name, as the patient may have been seen at the facility under another name.

            2.   Internal identification number or hospital registration number.  This is the number used to identify and file a health record, also called the patient’s health record number.  (This number is may be assigned at the patient’s first inpatient admission or outpatient encounter at this facility, or a new number is also assigned for each subsequent visit.)

            3.   Place and date of birth (MM/DD/YYYY or DD/MM/YYYY), gender, race, ethnicity, marital status, address, phone numbers, and any unique identifying number, such as a national identification number or social security number.

            4.   Name, address and telephone number of nearest relative (next of kin) or friend.

            5.   Name and address of attending doctor, and name and address of referring doctor, if applicable.

            6.   Occupation, name and address of patient’s employer.

            7.   Date and time of admission or encounter, and name of unit or clinic.

            8.   Details of health insurance and medico‑legal information if appropriate.

            The above information should be obtained from the patient, if possible, or otherwise from the person accompanying the patient to the hospital or clinic.

            Care must be taken to ensure the correct spelling of names and that all names are recorded accurately and in full.  Patients should be asked how they spell their names (both surname and given names) as names that sound alike may be spelled quite differently. Names should be recorded in the manner used for all official documents of the state or country.

B.        PATIENT REGISTRATION

            The complete and accurate collection of patient identification information is an important part of the patient registration process.  For statistical purposes, a method for counting all outpatient encounters and hospital admissions each day is essential.  There are a variety of methods in use, which are separate from the allocation of new health record numbers and will be discussed in Unit 7. 

            Important aspects of patient registration are:

            1.   When a patient presents at a hospital or clinic for the first time, they should be registered as a new patient.  However, to make sure that the patient is, in fact, a new patient they should be asked if they have been to the hospital or clinic previously.  Even if they say no, the admission or clinic staff should still check in the facility’s computerized patient database, the manual master patient index or with the health record department, depending upon the level of computerization at the facility. This step is necessary to make sure that the patient does not already have a health record number at that hospital or clinic; and to ensure that duplicate records are not created.

            2.   If the patient does not have an entry in the MPI or a health record number, the identifying information is collected and either entered into the computerized database, or recorded on the front sheet of a new record.  The patient is registered and a patient identification number is assigned.  In most hospitals and health care centres, this registration number is used as the patient’s health record number.  In a manual system, an Admission, or Patient Register is maintained at the point where the number is issued, and should contain the following information:

                  Health Record    Patient’s Name         Date of Issue                        Doctor/

                  Number                                                                                       Clinic

                  10 26 42              John Doe                  01/01/2004                Dr. Lee

                  This register is maintained as a control to avoid duplication of numbers and the issuing of the same number to two people.

            3.   If the patient has an existing file in the MPI and a health record number, the current identifying information should be checked with previous data and changes noted.

C.        MASTER PATIENT INDEX (MPI)

            Indexes are a must for any hospital, health clinic, or primary health care facility. They serve as a guide to the location of an item.  An index can be a table, file, or catalogue, listing an item and furnishing information for easy access to that item.

            The Master Patient Index (MPI) is a permanent listing, containing the names of all patients who have ever been admitted to or treated in a hospital or clinic (also called Patients’ Index, Master Person Index, Patient’s Master Index, or Master File).  Because the Master Patient Index is the key to locating a patient’s health record, it is considered to be one of the most important tools maintained in the health record department, clinic or primary health care centre.  Since health records are filed numerically in most healthcare facilities, the MPI is used to identify a patient’s health record number and locate the record.

            Typically, a manual MPI is maintained using individual index cards for each patient that are filed alphabetically.  In a manual MPI, each patient who is registered in the facility has an index card in the MPI that is maintained in the health record department.  However, an increasing number of health facilities are maintaining computerized Master Patient Indexes and this is described in more detail in Unit 6, Hospital Medical Record Computer Applications.  A computerized MPI is maintained using specialized database software. Reference to the computerized MPI will be made in this Unit, when applicable.  The basic principles are the same, whether the data collection is done manually or by computer.

            1.   Content of the master patient index

                  The information contained in this index varies with the needs of the hospital or clinic. Whether the MPI is computerized or manual will determine the amount of data that will be maintained, based on space limitations.  In a manual system, only information of an identifying nature necessary for prompt location of a particular health record should be recorded on the patient’s MPI card. A computerized MPI will allow the facility to maintain additional information.  Typically, the MPI contains two basic types of data:  demographic level and visit level.  The privacy necessary for maintaining confidential information should be considered when thinking of recording diagnoses and procedures on a MPI card, and should be avoided. The information recorded should include:

                  Demographic Level

  • Internal identification number – number assigned at the time of hospital registration, also called the health record number.   It is the number used to file the health records.
  • Patient’s full name – family name, given name, middle name or initial, and pertinent suffixes and prefixes
  • Date of birth (MM/DD/YYYY or DD/MM/YYYY) – in cases where patients have the same name, the age and date of birth provides additional information for identifying and obtaining the correct health record
  • Complete address – street, city, state, zip code/post code, country
  • Gender
  • Race/Ethnicity
  • Other unique identifying information, which will assist the identification of the patient, such as the mother’s maiden name, national identification number or social security number.  (This information is limited by the amount of space available, i.e., computerized database or index card.)

 

                  Visit Level

                  The following additional information may also be listed on the patient’s master index card if there is a need and adequate storage available:

  • Account number – the billing number used to identify admission or encounter charges
  • Admission and discharge dates – for inpatient hospitalizations
  • Type of service – inpatient, emergency, outpatient surgery, etc.
  • Encounter date or date of service – for outpatient visits
  • Disposition – discharged, transferred, or died
  • Admitting and/or attending physician’s name

 

                  The following is an illustration of a MPI card used in a manual master patient index.  The information at the top is collected at the time of the first encounter of the patient with the hospital or clinic. If the entries on the card must be handwritten, a pre-printed card will help ensure that the required data elements are recorded and made in a uniform place on the card.

                                                Master Patient Index Card                      

                   ________________________________­_______________________

                  | DOE, John William                                          MR#  17‑28‑42              |

                  |                                                                                                                     |                               | 17 Western Avenue                                          DOB 02/17/1949          |

                  | Anytown, Indiana  46321                               Sex:  M                           |

                  | 219-555-3083                                                                                           |

                  |                                                                                                                     |

                  | Adm Date         Dis Date       Service       Physician       Account #              |

                  |                                                                                                                     |

                  |  02/14/2004       02/17/2004    IP              Smith              04-3332112  |

                  |  05/16/2004                               OPS          Jones            04-3332866  |

                  |                                                                                                                     |

                  |                                                                                                                    |

                  |                                                                                                                     |                               |                                                                                                               |

                  |_______________________________________________________|

           

            2.   Manual Master Patient Index

                  a.   For inpatients, the procedure for a manual master patient index could be as follows:

            1)         Each day the admission registration staff notifies the health record department of all patients registered in the facility.  This may be done by sending copies of the admission slips for all patients admitted to hospital, which are usually the carbon copies or computer printouts of the registration forms or face sheets.

            2)         The MPI is checked to see if any of the patients whose names appear on the admission slips have been previously admitted and if they have an index card.  If yes, these cards are pulled out and the current admission information is recorded.  The demographic information on the index card must also be checked for any changes in name, address, etc.

            3)         If the patient has had no previous admission, and therefore no card in the MPI, a new index card is prepared.

            4)         In some hospitals the completed cards of inpatients are filed in a separate file, called the “in‑hospital” or “in-house” file, and remain there until the patient is discharged.

            5)         At discharge, the MPI card is removed from the “in‑hospital box” and the discharge date is recorded. If a death occurred the date may be recorded in red. The patients’ index cards are then filed into the MPI.  Given the importance of the integrity and accuracy of this index, many hospitals have a second person check the filed card for accuracy.

                  b.   Organization of the MPI

                  In the absence of a computerized MPI, special index cards or books or may be used for the listing of patients’ names, with index cards being the most preferred.

                  The most popular and efficient method of maintaining the MPI is on index cards arranged alphabetically in a vertical file with a separate card for each patient.  Using this method a single index card can be located readily in one search.

                  If using a book, it is divided into alphabetical sections.  Names are listed under the first letter of the surname in chronological order by date of admission.  This method is only feasible for a small facility, but retrieval becomes cumbersome and increasingly difficult for large hospitals, or where the volume of patient admissions or encounters is great, because a strict alphabetical order is maintained. This method is NOT generally recommended for a MPI.

                  It is not recommended to maintain the master patient index by year of admission or encounter.  This is not a good method as patients often forget the date of their last visit, or if they were ever admitted to a particular hospital at all.  Much time is lost searching through several sections of the index for the appropriate index card. Nor is it recommended to separate the MPI by sex, that is, to file the cards of male patients in one file and the cards of female patients in another.

                  c.   Methods used for filing

                        1)         Alphabetical ‑ The MPI cards are arranged in the file like the words in a dictionary, following letter by letter of the family name first, then by the given name, and last by the middle name or initial.

  • If there are two or more patients with the same family name, cards should be filed alphabetically by the given name.  If given names are the same, the middle name or initial should be used to arrange the cards.  If the entire name is identical the cards are filed by date of birth, filing the earliest birth date first (the card of the patient who was born first is filed first).

 

  • If an initial is given for a patient’s first or middle name, the rule is to “file nothing before something” (Huffman, 1994).  Thus, SMITH, P. would come before SMITH, PETER.

 

  • Last names beginning with a prefix or containing an apostrophe are filed in strict alphabetical order, ignoring any spaces or apostrophes.  For example, the name O’Leary would be filed as Oleary, and the name Mac Dougal would be filed as Macdougal.

 

  • Compound or hyphenated names are filed letter by letter, as one word; thus Ai‑Min would be filed A‑I‑M‑I‑N.

 

                        2)         Phonetic ‑ in phonetic filing systems the patients’ master index cards are arranged in the file by the first letter of the surname, and then according to sound rather than spelling. Thus all surnames that sound alike, but are spelled differently, are filed together.  For example:

                        SMITH P.       LEA S.                        GREENE, JAMES EDGAR

                        SMYTH P.     LEE S.                        GREEN, JAMES EDWARD

                        SMYTHE P.   LEIGH S.                   GREENE, JAMES EDWIN

           

  • While an alphabetical filing system uses 26 letters the “Soundex” system uses only six code numbers.

 

  • Names, which sound alike, but are spelled differently are grouped together in a phonetic patient index, rather than filed letter by letter as in an alphabetical patient index.

 

  • Grouping similar sounding names together lessens the chance of lost index cards due to misspellings and index cards having misspelled names can be more easily located.

 

                  d.  General filing rules for a Master Patient Index

            1)         Rules for filing MPI cards must be very detailed.  It is not easy to locate medical records if you cannot locate the correct MPI card.  Filing rules should be posted near the patients’ master index for easy reference.

                        2)         Use of the MPI and filing of the cards should be by authorized personnel only.  Careful orientation of new employees to the proper filing procedures is necessary, as is periodic follow‑up on the accuracy of these procedures.

                        3)         The MPI should be a continuous file, that is, not divided into years.

                        4)         A MPI card should be removed from the file only for updating or placing in the in-hospital box.

                        5)         Occasional auditing of the MPI is recommended to monitor filing accuracy.  This can be done by having the file clerk place a slightly higher card of a different colour behind each individual card at the time it is filed. A second person, known as the auditor or checker, removes the audit card after checking that each card has been correctly filed. It is useful to audit the filing done by new personnel to ensure that they are applying the rules correctly.

                        6)         A patient whose name has changed since a previous admission will need a new index card.  The new index card should be cross‑referenced to the original index card.  All information recorded on the original card should be entered on the new card.  The original card should be cross‑referenced to the new card.

            3.   Supplies and equipment for a manual Master Patient Index

Index cards, index guides and filing equipment are needed for maintaining a manual MPI.

                  a)  Index cards ‑ 3 x 5 inch cards (7.5 x 12.5 cms) are generally used, but the size may vary depending on the amount of information to be recorded.

                        Since the MPI is a permanent file, the card must be durable to withstand much handling.  Remember, however, that the heavier the card, the more space required in the file.

                  b)  Index guides ‑ Index guides for an alphabetical or phonetic MPI file facilitate the location of an individual patient’s card.  Being slightly larger than the patient’s card, the top of the guide with an initial letter of a common surname is extended above the other cards, thus serving as a guide.  Phonetic index guides will require, in addition to guides with initial letters or surnames, subguides indicating basic code numbers.  The size and activity of the index will determine the number of guides needed.  Sturdy construction of guides is also essential.

                  c)  Filing equipment ‑ Patients’ index cards may be filed in cabinets suitable to the card’s size.  If 3 x 5 inch (7.5 x 12.5 cms) cards are used, they are usually filed in vertical, eight‑drawer, triple compartment file cabinets. A power file is considered feasible when the MPI has more than 500,000 actively used cards.  At the touch of a button, a power file delivers the required section of the index to the front of the file for easy access.

            4.  Computerized Master Patient Index

As mentioned earlier, It is also possible to maintain the MPI in a computer.  At the time of admission to a facility, the registration staff searches the computer database for a particular patient.  If the patient has been in hospital or attended a clinic previously, the patient’s information is displayed on the computer screen.  The registrar then updates any demographic information that has changed since the previous admission or visit.  If the patient has not been to the hospital previously, the registrar collects the patient demographic information and the system automatically assigns a new registration, or medical record number, and stores this information in its memory. At the time of the patient’s discharge, the date of discharge is entered into the system, thereby completing the current MPI entry.  A computerized MPI is discussed in more detail in Unit 6.

SUMMARY

 

                        The master patient index (MPI) is a permanent listing of all patients who have ever been admitted to, or treated by, the clinic, doctor or hospital.  MPI cards should be prepared as soon as possible following the registration of a new patient and not later than 24 hours after the patient’s presentation to the clinic or admission office.  As the MPI is the key to finding a patient’s health record, in a manual system they must be filed promptly in alphabetical or phonetic order. 

The type of equipment required will depend upon the type and size of the cards used.

The size generally used is a 3 x 5 inch card (7.5 x 12.5 cms).  Regardless of the size of the card, however, only basic identification information needed to promptly locate a

medical record should be recorded.  MPI cards must be filed promptly and removed only for updating information.  To help find a card guides should be used at regular intervals. 

If computerization of hospital information is considered, the registration process and the MPI should be computerized first, if computer storage is available.  The patient

demographic and visit information contained on the cards can be stored in a computer

database, and at the time of a patient’s admission to, or outpatient encounter at a

hospital, the staff can check the name and file number via a computer terminal in the

office.

REVIEW QUESTIONS:

1.         What is the purpose of a Master Patient Index?

2.         What are the contents of a Master Patient Index?

3.         How is a master patient index card prepared?  How are data collected?

4.         What equipment would be needed for a Master Patient Index?

5.         How does the “Soundex” phonetic system work? 

            When would it be most useful?

6.         Why is the Master Patient Index important?

7.         How long should a Master Patient Index be kept?

REFERENCES:

1.         American Health Information Management Association.  Practice Brief, “Master Patient (Person) Index (MPI)—Recommended Core Data Elements, “ Journal of the American Health Information Management Association (July 1997).

2.         Davis, Nadinia, LaCour, Melissa.  Introduction to Health Information Technology.

            Philadelphia, PA:  W.B. Saunders, 2002.

3.         Huffman, Edna K. Health Information Management.  10th ed. Berwyn, IL:    Physicians Record Company, 1994.

4.         Johns, Merida, ed.  Health Information Management Technology: An Applied Approach.  Chicago: AHIMA, 2002.

5.         Skurka, Margaret.  Health Information Management:  Principles and Organization for Health Information Services.  San Francisco, CA:  Jossey- Bass, 2003

selesai@hak cipta dr Iwan Suwandy 2010

Modul Pelatihan praktisi Rekam Medis Unit I.”Health Record”

INTERNATIONAL FEDERATION OF

 Education Module for Health Record Practice

Based on IFHRO Modul.

UNIT 1 ‑ THE HEALTH RECORD

 

In this first Unit participants are introduced to the health record, the forms within the record; documentation and content of a good health record, as well as the uses of and responsibility for a patient’s health record.

Participants are reminded of the importance of health records in patient care and are encouraged to develop an acute awareness of all the essential requirements of an accurate, complete health record.

OBJECTIVES:

 

At the conclusion of this unit the participant should be able to:

             1.        define what is meant by a “health record”

                         2.        explain in detail the reasons for developing and keeping health records

             3.        state five general principles of good forms design

                         4.        list and describe the four component parts of a problem oriented health record

             5.        describe the benefits of a structured health record

                         6.        state the value and uses of the health record together with the requirements for a good health record

             7.        state the purposes of a health record

                         8.        describe the development of a health record from admission to the discharge of a patient in a hospital

9.        design health record forms for use in a hospital or primary health care center

                        10.       identify the purpose of health record forms and describe what information should be included on each form

11.       identify who is responsible for the health records in hospitals or health centers and explain this responsibility

12.       describe the activities of a Health Record Committee and state who should be included on such a committee

            13.       develop a policy for the release of information from a health record

                        14.       design a form to be used for recording information to be released from a health record

15.       analyse privacy and confidentiality issues relating to health care in a hospital or clinic.

A.        THE HEALTH RECORD

            A health record is a written collection of information about a patient.  It is derived from the patient’s first encounter or treatment at a hospital, clinic or other primary health care centre.  The health record is thus a record of all the procedures carried out on that patient, whilst he is in 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.  As a document it may appear in many shapes and sizes with varied information related to the care of the patient recorded by many persons 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 systems, the information may be recorded digitally in a computer; the sheets of paper scanned onto optical media or the actual sheets may be microfilmed.

            Huffman (1994) defines 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 standardised 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 sufficient forms to cover the needs of the ‘centre’, without unnecessary and useless forms, which add bulk. The forms should be of a standard size within each record system.

B.        PURPOSE OF THE HEALTH RECORD

            As indicated above a good complete health record should encompass all information about a patient’s health, ill health and treatment over a period of time and be readily accessible.

            Health records are kept for:

            1.     communication purposes

            2.     continuity of patient care

            3.     evaluation of patient care

            4.     medico‑legal purposes

            5.     statistical purposes

            6.     research and education.

            7.     historical purposes

            1.     Communication purposes

                    Health records are kept initially for communication between persons responsible for the care of the patient for present and future needs.  Many health professionals often see a patient.  In a hospital the registration staff collects identification information and finds out the patient’s financial status.  While under care, others who may be involved in looking after a patient and who contribute to the health record include:

  • all medical staff including consultants, physicians, surgeons, obstetricians, etc
  • nurses
  • physical therapists
  • occupational therapists
  • medical social workers
  • laboratory technicians
  • dieticians
  • medical students
  • radiologists, etc.

 

                    All the data collected about a patient must be recorded and coordinated. The findings of each professional must be available for others to perform their function intelligently, especially the doctor responsible for the patient who must make the final diagnosis and order treatment on the basis of all the documented findings.

                    This first use of the record is a personal one and is in the interest of the patient for both present and future care.

            2.     Continuity of patient care

                    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 current symptoms. Communications on the basis of the health record is essential between hospitals, clinics and primary health workers in contact with the patient. It is vital that the primary health worker, 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 hospital.

                    The 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.

            3.     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. Accreditation by this Board leads to increased status and is necessary for acceptance of post‑graduate trainees in many areas.

                    Other methods of evaluation of patient care in hospitals include:

                    a)      Patient care committee ‑ meets regularly and may review samples of records and evaluate the standard of care recorded.

                    b)            Peer review ‑ Doctors of a service may evaluate the work of each other and the unit through the records.

                    c)      Hospital administrative committee ‑ may evaluate the standard of care in a particular ward or by a particular physician or surgeon.

                    d)            Statistics ‑ derived from records may also be used in assessment of standards. This may be within the hospital, for example, evaluating the infection rate in a particular ward or for a particular operation or between clinics, hospitals, states or countries, in which case the statistics are used by Government Departments such as the Department of Public Health, Bureaus of Census and Statistics or non‑government organizations such as the World Health Organization. In most countries the Department of Public Health also requires notification of communicable diseases, such as tuberculosis, cholera, hepatitis, etc.

            4.     Medical‑legal

                    Here, the main use of the record is as evidence of unbiased opinion of a patient’s condition, history and prognosis, all assessed at a time when there was no thought of court action, and therefore extremely valuable.  It is used both in and outside the court for settlement of such disputes as:

  • assessing extent of injury in accident cases

 

  • establishing negligence or otherwise of the health professional or

         hospital in the treatment of a patient.

                    This assists in protecting the legal interests of the patient, hospital, and health professional. 

            5.     Statistical purposes

                    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.  They are also used in planning for future development.

            6.     Research and education

                    In the past, health records have been mainly used in medical research, but demographic and epidemiological information contained in the record is more often used today for administrative and other public health research.

                    Analyses of the types of people, together with studies of the types of diagnosed illnesses within the hospital, a particular ward or clinic, are essential for planning future services and equipment. The turnover rate of patients is an indication of the numbers of staff required in all departments.  The workflow of the hospital or clinic can be analysed once it is recorded in the medical record as it is added to by different health professionals involved in the patient’s care. All this information shows the efficiency or otherwise of health planning and communication systems.

            7.     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.

C.        USES OF THE HEALTH RECORD

            The uses of the health record can be divided into personal and impersonal use depending on whether the user of the record is viewing the patient as a ‘person’ or as a ‘case’. For example, the statistical, research and historical uses are usually impersonal, the name of the patient is not important.

            In other cases the use is patient‑oriented.  When a record is to be used in a “PERSONAL” way; AN AUTHORIZATION FOR RELEASE OF INFORMATION MUST BE OBTAINED FROM THE PATIENT, unless there is a legal obligation to provide information.  The information compiled in the record is private and privileged and given to the health professional in complete confidence. This trusting relationship between health professionals and the patient must not be broken by revealing the contents of the health record to unauthorized persons.

            In IMPERSONAL uses, however, WHERE THE NAME OF THE PATIENT IS NOT REVEALED, authorization is not usually necessary. It is usual to obtain the consent of the health professional in charge of the patient before allowing a record to be used for research.  But remember that consideration must always be given to the patient’s rights in any release of information.

 

D.        DEVELOPMENT OF THE HEALTH RECORD

            a)     The health record usually begins at the registration counter of the clinic or the admission office of the hospital, or the emergency room office the first time a patient presents or is brought in for care/treatment or is seen for the first time.

            b)     The collection of essential and accurate identification information is the first step in the development of the medical record and will be discussed in full in the next Unit. The essential identification data includes the patient’s:

  • full name (family name, given, and middle name or initial)
  • health record or hospital file number
  • date of birth
  • address
  • gender.

 

            c)     If the patient is being admitted to hospital, the provisional or admitting diagnosis must also be included at this time, that is, the reason the patient is being admitted for care/treatment should be recorded on the front sheet of the health record.  The patient is then sent, with the health record, to the clinic, emergency room or unit, whichever is applicable.

  • In the clinic ‑ the nurses and doctors record the information collected at this time onto the forms provided, remembering to write the name and hospital file number on the top of every new form used.  The person who provides the service should sign each entry.

 

  • In the emergency room ‑ the same procedure as for clinic.

 

  • In the unit ‑ the nurse adds data relating to nursing care plan and doctors record their notes on a patient’s:

 

  • past medical history
  • family medical history
  • history of present illness
  • physical examination
  • plan for treatment and
  • requests for laboratory/X‑ray tests.

 

                    The doctor continues to record, on a daily basis, writing notes on the patient’s progress, medical findings, treatment (including prescriptions for medication), test results, and the general condition of the patient.

                    Nurses record all observations, medications administered, treatment and other services rendered by them to the patient.

                    Other health professionals record their findings and treatment as required during the patient’s hospitalization.

  • At discharge ‑ when the patient is discharged, the doctor records, at the end of the progress notes, the condition of the patient at discharge, the prognosis, treatment and whether the patient has to return for follow up. In addition, the doctor should also write a discharge summary, and write, on the front sheet of the record, the principal diagnosis, other diagnoses and operative procedures performed, and sign the front sheet to indicate responsibility for the information recorded under his signature.

 

E.        VALUE OF THE HEALTH RECORD

            An accurate and complete health record is of value:

            1.     to the patient

            2.     to the hospital, clinic, or other health facility

  1. to the doctor and other health professionals
  2. for research, statistics and teaching

            5.     for patient billing.

            1.     The patient

            As the health record contains a complete report of a patient’s illness and results of treatment, it is of great value to the patient for ‑

                    a)            future care for the same or other illnesses

                    b)            informing them (by giving access) of their care and treatment, and

                    c)      as a legal document to support claims for injury, or malpractice.

            2.     The hospital, clinic or other health facility

            The health record may be used by the health facility to evaluate the standard of care rendered by staff and the end results of treatment. If adequate records are not kept, the facility cannot justify the results of treatment. The health record is also of value to the facility for medico‑legal purposes.

            3.     The doctor and other health professionals

            The health record is of value to all health professionals caring for a patient. The patient may have been treated by them previously or by other health professionals.  The health record enables pertinent clinical, social or other relevant information to be readily available for continuing patient care.  In addition the health record is of value for review of certain diseases, treatment and response to treatment.

            4.     For medical research, statistics and teaching

            In scientific research the health record is a major tool.  The information within a health record supplies a practical and reliable source of material for the advancement of medical science.  This information is also valuable in the collection of statistics on health care and the incidence of diseases, and for teaching future health professionals.

            5.     For patient billing

            Without the information within a health record, payment for services could not be justified. Often the health insurance agencies require supporting evidence for claims ‑ this evidence is found in the health record.

F.         CONTENT OF THE HEALTH RECORD

As mentioned previously, a written health record should be maintained on every patient attending a hospital or clinic, or seen in a primary health care setting.  The patient may be an inpatient, an outpatient, an emergency patient, or domiciliary patient.

            The health record stores the information concerning a patient and the care given by health professionals associated with the hospital or clinic.  To be complete and of use for future patient care, medico‑legal purposes, research and teaching, the health record must contain sufficient information to:

            IDENTIFY the patient,

                    SUPPORT the diagnosis,

                         JUSTIFY the treatment, and

                               DOCUMENT the results facts accurately.   (Huffman 1994)

            For better patient care, only one health record should be kept for each  

           patient.

                    Good medical care generally means a good health record is developed and maintained on each patient.  An inadequate health record, that is, one that does not contain ‘sufficient information to identify the patient, support the diagnosis and justify the treatment given (Huffman, 1994), may reflect a poor standard of care given by the doctors, nurses or other health professionals within the clinic or hospital.

The actual forms and their content make up a health record. The organization of data on each form, however, is determined by the needs of each individual health facility.  Listed below are forms that are found in a health record.

            1.     Administrative Forms

                    a.      The admission or identification form, which should always be kept at the front of each admission or at the beginning of the outpatient or primary care record.  This form contains space for identification and sociological data to positively identify a patient.  The type of data recorded here is discussed in Unit 2.

                    b.      Consent forms are extremely important and should be part of every health record. The back of the admission form is generally used for consent and authorisation for treatment data. The form usually carries a statement indicating that the patient agrees to basic treatment.

                    Separate sections of the forms relate to the consent for release of information.  When signed by the patient the health facility can release information from the medical record to health insurance, workers, compensation agencies and private insurers.

                    The patient in the admission or reception office of the facility signs both these authorizations. The purpose of the forms, however, should be clearly explained to the patient by the staff collecting the identification and sociological data.

                     In the hospital situation, special consent forms are required for any non‑routine diagnostic or therapeutic procedures performed on the patient.  These forms provide written evidence that the patient understands the nature of the procedure, including any risks involved and likely outcomes, and consents to the specified procedure.  The patient is asked to sign the form after having all details clearly explained to him/her by the attending doctor.  That is, the patient gives informed consent.

2.  Clinical Forms        

                    Clinical forms for inpatients constitute the bulk of a patient’s health record, and include the following:

                    a.      Medical/general history or data base ‑ This is usually divided into a number of sections and includes space for data relating to:‑

  • presenting signs and symptoms
  • previous illnesses and operations
  • family history
  • occupation and social data
  • current drug therapy and treatment.

 

                    b.      Physical examination, which is used for the collection of baseline data about a patient presenting for care.  The content of this form usually includes:

  • general survey and state of health of patient
  • system review ‑ all systems checked
  • vital signs, such as pulse, respiration, blood pressure, temperature
  • provisional diagnosis.

 

                    c.      Doctors orders or plan for care ‑ Once the data base has been established the doctor records his/her findings and writes a course of action outlining the planned care and treatment for the patient.  These orders should be dated and signed as should all entries in a health record.

                    d.      Progress notes ‑ These notes indicate the condition of the patient and his/her response to treatment on a continuing basis throughout the admission.  All health professionals should document the care they provide and the patient’s response to treatment. Some hospitals use special forms for each specialty, which is not really necessary; as an integrated progress note is more effective.

                        Progress notes should be recorded at least once a day and more often in cases of acutely ill and critically injured patients.

                    e.      Pathology, radiology and other special investigations ‑ Appropriate forms should be used to record special investigation such as pathology, chemistry, radiography. These forms are often mounted on a backing sheet or in hospitals with a computerized system cumulative reports are generated on a daily basis.  Whatever the method it is important to make sure important findings are readily available in the record.

                    f.       Nurses notes and graphic charts ‑ Appropriate forms should be used for all nursing care including bedside notes, temperature, pulse and respiration charts, blood pressure charts, medication and treatment charts.  Most of these forms are designed in flow chart sequence.

                    g.      Operative and anesthetic and recovery forms ‑ These forms are important for surgical patients and should contain consent for surgery, pre‑anesthesia and post-anesthesia reports, the operation report, and other relevant data required.

                    h.            Discharge summary ‑ All health records should have a final summary of the patient’s hospitalization, which is usually referred to as the discharge summary.  It should contain a concise summary of the patient’s course of treatment and significant findings with treatment on discharge and follow‑up arrangements.

                    i.       Other forms for special services such as obstetrics, newborn and paediatrics, neurological, physiotherapy, occupational therapy, speech therapy, dental therapy, and short stay admissions, should be available if required.  However, the use of the form must be determined before introducing it to an already bulky record.

            3.     Outpatient and ambulatory care forms:

                    a.      Patient history and general findings similar to the inpatient form usually completed at first attendance.

                    b.      Clinical observations and progress notes.

                    c.      Pathology, radiology and other test reports as for inpatients.

                    d.      Special forms for individual specialties caring for ambulatory patients.  These would include special diabetic forms, growth charts, home care plan for treatment, etc.

            These are only a few of the forms used in health care facilities.  Their production should be based on their need and the needs of the health professional caring for the patients.  This need will vary from large metropolitan hospitals to isolated primary health care units.  Both are important and simple forms should be available for use to meet the needs of the situation.

 

G.        DOCUMENTATION AND RECORD STRUCTURE

            1.     The documentation of care given to patients during their stay in the hospital is an essential part of the provision of that care.  The tool used for this documentation is the patient’s medical record. As previously mentioned, it is the WHO, WHAT, WHY, WHERE and HOW of patient care, and to be complete, the medical record must contain:

                    a.      sufficient information to clearly identify an individual patient

                    b.      a comprehensive medical history, including:

  • chief complaint
  • history of present illness
  • family medical history
  • physical examination

 

                    c.      detailed progress notes showing the course of the patient’s illness, treatment and end results of that treatment

                    d.      a discharge summary displaying comprehensive data to justify the treatment, support the diagnosis and record the end results (Huffman, 1994).

            2.     The content of a health record is developed as a result of the interaction of the members of the health care team who use it as a communication tool.  Documentation may be organized according to the source of the data or by patient problems. 

            3.     There are two basic formats that a paper-based health record may take:

                    a.      Source Oriented Medical Record

                    In a source oriented medical record, the information about a patient’s care and illness(es) is organized according to the “source” of the information within the record, that is, if it is recorded by the physician, the nurse, or data collected from an x‑ray or laboratory test, usually in chronological order.

                    How effective is an average health record as a communication tool?  Information goes in, but is it easily and readily retrievable? In many cases it is not, because the documentation is often unstructured and scattered in admission notes, medical histories, progress notes, nurses’ notes, or in X‑ray and laboratory reports, often without reference to the condition or problem to which it refers.  The health record often becomes bulky and disorganized, making the retrieval of vital information both difficult and frustrating, and communication within the health care team is hampered.

                    Many experts consider that the answer to this problem is to develop a health record that is STRUCTURED, and facilitates easy access to information relating to care given to a patient during hospitalization.

                    Structure refers to a form, which has been planned so that the language and layout are uniform.  That is, all persons using the form follow the same format and yet the structure of the record is adaptable to all situations.  An example of a structured form appears in Appendix 2.

                    Structured records are more easily automated and with the present increase in the use of computers in health care, a change from a manual to an automated record system would be easier if a structured record format was already in use.

                    A disadvantage of a fully structured health record, however, is that there is less room for individual description and health workers find it too restricting.

                    b.      Problem Oriented Medical Record (POMR)

                    One form of structured health record developed to meet these criteria is the problem oriented medical record or the “POMR.”

                    First designed by Dr. Lawrence Weed in the late 1950s, this concept requires the doctor to approach all the problems of a patient, treating each problem individually, in its proper context within the total number of problems and the inter‑relationship of the problems (Weed, 1969).

                    The decision pathway used by the doctor in defining and handling each problem is clear and can be evaluated on the bases of all the facts available.

                              The problem oriented medical record has four parts:

ü  DATABASE                    Collection of data       

ü  PROBLEM LIST                         Formulation of problems               

ü  INITIAL PLAN                 Development of a care plan          

ü  PROGRESS NOTES    Numbered and titled progress notes

                              1)   Data Base

                    The first step in the establishment of a problem oriented health record is a comprehensive database.  As with the traditional source oriented health record, the data base should include the chief complaint as expressed by the patient; a patient profile including history of the present illness, past medical history, family medical history, a systems review and results of a physical examination.

                              2)   Problem List

                    Once the database has been collected, an assessment of the information is made and a problem list is developed.  The PROBLEM LIST is kept in the front of the record and can be likened to a table of contents in a book.  That is, the problem number and name are equivalent to the chapter number and title.  The most conceptual difference between a source oriented and problem oriented health record is this PROBLEM LIST. Another conceptual characteristic of the POMR is problems are expressed at the level of the writer’s understanding and do not include diagnostic impressions which are considered as part of the treatment plan.

                    Before progressing further we should clarify the term “Problem.” A problem is anything requiring management or diagnostic workup, that is, a problem is anything that interferes with the health, well being and quality of life of an individual, and may be medical, surgical, obstetric, social or psychiatric.

                    When constructing a problem list, each problem should be dated, numbered and titled with problem status clearly defined as active, inactive or resolved.  The function of a problem list is to:

  • register all problems
  • maintain efficiency, thoroughness, and reliability in treating the ‘whole’ patient
  • communicate with peers, patients, other health professionals and with oneself
  • indicate the status of problems, whether active, inactive or resolved
  • serve as a guide for patient care.

 

                        3)  Initial Plan

                    The development of the initial plan for the management of a patient’s problems, as defined in the problem list, is the third step in planning patient care using a problem oriented health record.

                              The initial plan should be considered in 3 parts:

  • Diagnostic (Dx) ‑ that is plans for collecting more information
  • Therapeutic (Rx) ‑ plans for treatment and,
  • Patient Education ‑ plans for informing the patient as to what is to be done.

 

                        4)  Progress Notes

                    The fourth step in the formation of a POMR is the problem oriented PROGRESS NOTES.

                              These should indicate:

  • what has happened to the patient
  • what is planned for the patient, and
  • how the patient is responding to therapy.

 

                              Progress notes should contain four component parts:

ü  Subjective part ‑ written in the patient’s own words

ü  Objective part ‑ the doctors observation and test results

ü  Assessment of progress and

ü  Plan for continued treatment.

                    The progress note must be problem oriented.  That is, since each problem must be dealt with individually, each must clearly denote the problem by number and name and be divided into the four components or SOAP parts.

                    This structured type of progress note increases the doctor’s ability to deal with each problem clearly and to show the logic of his thought process and decision pathways. If correctly written, both the current level of understanding of each problem and the management of each problem will be clear to everyone involved with the care of the patient, and in evaluating the quality of that care.

                              Some additional items may supplement the progress notes:

                                   

                              a)         Flow Sheet

                    When dealing with multiple, fast‑moving problems, the doctor may want to supplement the progress notes with the use of a flow sheet.  Flow sheets provide the most appropriate method of monitoring a patient’s progress, and are also used with source oriented health records.

                                          Steps to be taken when designing a flow sheet include:

ü  define the clinical setting within which the flow sheet will be used

ü  define the clinical status of the patient to be monitored          

ü  define the monitoring frequency of data collection required to give maximum care.

                                    This is usually specified across the top of the page.  The clinical situation in which the flow sheet will be used will usually dictate the monitoring frequency.

Flow sheets are a special form of progress note and may be added to the record if warranted, but do not necessarily need to be put into every problem oriented or source oriented medical record.

                        b)         Discharge Summary

                    The final step in completing any medical record is the preparation of a discharge summary.  In the problem oriented medical record this task is made a lot easier.

                    When dictating a problem oriented discharge summary, the doctor can briefly summarise the therapeutic outcomes, which resulted in the resolution of a patient’s specific problems. They can emphasise the problems NOT resolved at discharge and outline a diagnostic, therapeutic and educational plan for future care.

                    The logical display system used in the structured problem oriented health record starts with the database to collect information, followed by a problem list, which helps the doctor decide what is wrong with the patient.  This information is placed at the front of the record so everyone caring for the patient is aware of all problems. From the database and problem list, the initial plan for treatment and diagnostic work-up is developed.  That is, the doctor caring for the patient decides what to do. The next step is to follow through on the decision by recording problem oriented progress notes using the SOAP method for each individual problem.  Progress notes may be narrative or in the form of a flow sheet.

                    The problem oriented health record is a useful communication tool because it encourages a clear display of medical data and communication between doctors and other health professionals. Appendix 3 illustrates samples of a POMR.

                    As mentioned previously, a structured health record enhances the application of computers in health record systems, clinical research and teaching.  It also improves information retrieval for patient care evaluation and helps elevate the quality of patient care by treating the ‘WHOLE’ patient and not just isolated incidents or episodes.

                    The use of a structured POMR, however, is not widespread, particularly in large busy hospitals. It is more widely used in small hospitals, clinics and primary health care centres.

                    No matter whether a record is source oriented or problem oriented the health information manager should assist medical staff and other health professionals by preparing well‑structured forms to enhance data collection and easy access to information relating to patient care at all levels.

H.        RESPONSIBILITY FOR HEALTH RECORDS

 

            1.     Medical and other health professional staff

            The primary function of a hospital, clinic, or other health care facility is to provide high quality patient care to all patients, whether inpatients, emergencies or outpatients.  The governing body of the facility, through the administrator, is legally and morally responsible for the quality of care rendered to patients.  This responsibility is in turn delegated to medical, nursing and other health professional staff.  As the information within a health record reflects the care given to patients, it is important that the health information management/health record professional understands the responsibilities within the clinic or hospital in order to assist the doctor and other professionals to maintain a complete, accurate and available health record.

            Poorly documented clinical information is of little use to a patient during his treatment, for his future care or for evaluation of the care rendered by doctors, nurses and other health professionals.  Alternatively, a complete well-written health record provides a clear picture of the patient’s illness and course of treatment.

            All health professionals, including doctors and nurses, can exercise their responsibility to ensure good quality health records through the Health Record Committee.

            2.     Medical Record Committee

            Doctors, nurses and other health professionals are responsible for the documentation of medical/health information that meets the required standards for accuracy, completeness and clinical pertinence.  The Health Record Committee is responsible for the following:

  •   Review of health records for timely completion, clinical pertinence, accuracy and adequacy of patient care, teaching, evaluation, research, and medico‑legal issues.

 

  •   Determination of the format of the complete health record, the forms used and any problems relating to storage and retrieval.

 

                    a.      Membership of the committee should include:

  • the hospital administrator
  • representatives from medical and surgical service
  • a representative from the nursing service
  • representatives from X‑ray, Pathology, and
  • the health information management/health record professional.

 

                    b.      Activities of the committee may include the following:

  • The committee should meet at least once every three months and more frequently if required.

 

  • The committee should establish/recommend policies regarding health record documentation.

 

  • Members should study random samples of health records to monitor the quality of recording.

 

  • Members are able to study the trend of clinical work in the hospital using statistics compiled by staff of the health record department.

 

  • Members of the health record committee may wish to conduct retrospective studies or set up some prospective research.

 

  • The health record committee should review all medical record forms, thus eliminating unnecessary duplication of information and attain uniformity of content, appearance, and size.

 

            3.     Health Information Management/Health Record Professional

            The health record is the property of the hospital or clinic and serves as a medico‑legal document for the benefit of the patient, the doctor, and the hospital or clinic.  The health record should contain sufficient information to enable another doctor to take over the care of the patient if required, and for a consultant to give a satisfactory opinion when requested. The responsibility for the accuracy and completeness of a health record rests with the attending doctor. The health information management/health record professional is responsible to the hospital administrator for providing the necessary services to the medical staff to assist with the development and maintenance of a complete and accurate health record.

I.          HEALTH RECORD FORMS

            Let us now look at the design of the forms contained in the record.

            Good forms design is essential in any office to assist in the efficient gathering of data and dissemination of information. Not only can it reduce the cost and time taken in processing forms, but it can also lessen the possibility of error or misunderstanding by staff or the public.

            Workers in the health information management/health record field should be aware of the variety of record forms, duplication, and lack of uniformity to be found in many hospitals, clinics and primary health service settings. It stands out quite markedly that there is a strong need for forms control, which, quite clearly, is a very large task.

            Whether one works at the administrative or technical level, one should be aware of the essential and recurrent task of correct forms design so that, as far as possible, they can ensure that all forms are neat, simple in appearance, easy to understand, write up and interpret.

           

            1.     Definition of a form

                    A form could be defined, as a piece of paper or card on which there is a formal arrangement of date, usually with spaces for the entry of additional data. Or, it could be defined as a prescribed written means of shaping information for communication.

                    Forms are used to collect, record, transmit, store and retrieve data.  That is, they request action, record the outcome of the action, instruct and assist with the evaluation of data.  When being designed, the needs of all health professionals involved with patient care must be taken into consideration, as well as the needs of health authorities requiring information about the incidence of disease, outcome of care, as well as demographic and epidemiological data.  Forms may also be designed to accompany legislation.

                    Filling in a form is invariably the first step in data collection.  The design of forms, their physical layout, the determination of the data to be requested, and the way, in which it is collected, has an impact the quality and quantity of data collected and subsequent information produced.

            2.     Forms design

                    a.      When preparing to design a form one must consider the:

ü  need for the form,

ü  purpose of the form, and then

                              design the form within the constraints that apply, such as  the budget, type of paper available, abilities of the printer, and the abilities of the users.

                              Standards must be established so that consistency is maintained.  There should be fixed responsibility for forms design, so that individuals and departments cannot start their own forms in isolation.  There must be positive control, especially from the point of view of cost.

                    b.      The term forms layout refers to a number of issues and can be summarized as follows:

  • how the information is displayed on the form
  • how material is presented, provided it is consistent with efficiency and economy, attractive presentation is an important secondary purpose
  • the order in which data will be requested, must also be considered along with the logical connections between data requested, the space between entries, whether columns, boxes, or highlighting will be used, the size and type of print, and the need to allow adequate space for entries.

                             

                        A well-designed form is appropriate to the work in which it is used, permits ease of entry, conveys information or instructions clearly, and is efficient to use.  A form should be set out in an orderly way of thinking, for example, bracket all the information of the same sort in one area as a well‑structured form points your thoughts in the direction of the information required.

                        Some forms summarize particular events or record data compiled from other forms, for example, a summary fluid balance form.

                    c.      Questions to ask before designing a new form include:

ü  What is the general purpose of the form?

ü  Is the form really necessary?

ü  What benefits will be derived from the introduction of a new form?

ü  What information is to be provided and what is its general purpose and need?

ü  What are the operations, through which the form will pass, for example, entry of data, sorting of data?

ü  How is it (the form) going to be filed?  Where will it be attached ‑ side or top?

ü  Who will the users be?  When is the form to be used?

ü  Where will the form be used and what will the associated working conditions be?

ü  Are there any other special features, which need to be considered?

ü  If a signature is required, is it also necessary to ask for the name to be printed?

ü  Does the form state what to do with it when it has been filled in?

                    d.      To summarize, the general principles to be considered when designing a form include:

1)    All health record forms used in the clinic or hospital should be of STANDARD SIZE. They should also be readable, useful and allow for the standardisation of information. The kind and size of typeface, margins, ink, and paper colour and weight, should be standard within a hospital, clinic or primary health centre.

2)    All forms should have a STANDARD FORMAT at the top to include the name of the patient, hospital number, ward, and name of attending doctor. This information should appear in the same place on ALL forms.

3)    The correct paper for the task of each form should be chosen with the aim for paper and printing economy.

4)    The persons who will be required to use the form should understand the language used on the form.

5)    Each form should have a descriptive TITLE, e.g. nurse’s bedside notes, laboratory reports.

6)    All forms should have simply printed INSTRUCTIONS for use to ensure uniformity in the collection of information. If these instructions are detailed they could be printed on the reverse side or in a separate instruction sheet.

7)    Captions should clearly indicate the data to be entered, for example, just name is not sufficient, usually one wants “full name of patient, family name last“. The use of boxes is also very good and saves time, for example, male and female categories may be set up in a boxed arrangement as follows:

                                    M  ¨   F ¨

                                    and the clerk then just has to add an “X” or a  check  mark.

8)    Forms should be FUNCTIONAL and spacing should allow sufficient room to record the data being requested.  If data are to be filled in with the use of a typewriter, this should be taken into consideration when planning the form.

9)    If one piece of data depends on another, put the dependent data after the other in the order to be filled in, for example, date of birth ‑ age; previous admission date. That is, group items into order of action and be logically consistent with related forms so that data are easily used after entry on the form.

10) If an automated or other type of embossed imprinting plate addressograph system is to be used, spacing on the form should be provided for the imprinting of patient identification.

11) The use of color is effective, but remember that different colored paper and ink will affect photocopying, microfilming and scanning in different ways.  Color strips along the outside edge are most effective and help with identification of the form, but may be expensive.

12) For forms management, each form should have a reference or form number for identification and ordering purposes, and carry a notation as to date designed or date printed and name of printer.

13) For filing requirements clinical forms should be pre‑punched for inclusion in the health record, and adequate space (margin) should be planned to allow for binding at top or side.

14)  Instructions in conjunction with explicit headings must be carefully   prepared so that the person filling in the form knows in advance what is required.  General instructions may be required for the completion of certain forms, for example, patient identification forms.

15)  If the form is to be put in an envelope, make sure it is the right size or that it will fit when folded.  Suggest arrows on the form as to where to fold.

16)  If photocopying, the quality of the copy will decrease each time it is copied. Best to keep the original and copy that each time.

17) A ‘Forms Committee’ should be set up (a subcommittee of the health record committee) to assume responsibility for forms design and production.  The health information management/health record professional should be a member of the Forms Committee and strict control maintained over the production of health record forms.  Criteria should be established to analyse the need, purpose, use and arrangement of each form.

                    e.      Specific technicalities

                              1)   Spacing

  • Printers allow 1/4″ (5 mm) before they start printing, so leave 1/4″ (5 mm) for the printer and design the form within that limit.

 

  • Allow a 7/8″ (20 mm) margin if holes are to be punched or the form is to be bound. Recommended margins:
    • At top 3/8″ or 8 mm
    • Other sides 1/4″ or 5 mm
    • Except filing margin 7/8″ or 20mm

 

  • Spacing for handwriting ‑ in general, 8 handwritten characters to the 1″ or 2.5 cms. However, it is important to remember that too much space seems to encourage bad handwriting.

 

                              2)   Line spacing

                                    Relate the form to the characteristics of any machine used to fill in the form so that the design is suitable to handwriting and machine entries, especially if it will be typewritten:

  • for handwriting use 6 mm or 7 mm line spacing
  • for typewriting it will depend on the size of typeface and line spacing should conform to the THROW of the typewriter (i.e. the distance covered by a turn of the roller).  The form should also be designed to allow for the use of typewriter TABS.

 

                                    Also, determine the PITCH or FONT SIZE (or width of each character) of the typewriter or golf balls used, usually 10 or 12 pitch preferred.

                                    Allow 1 space on each side of a vertical line, i.e. leave 1 space between entries and the vertical line.

                                    Extra space may be required to allow for typing near the very top or bottom, for example, a disease index card with tear off strip.

                              3)   Ballot box style ‑ for use with computerized data entry.  Be consistent with either left or right boxes on the form.  Provide clear instructions if it should be checked off or crossed off.  The format should make it very clear which box belongs to which question.

                              4)   Identification

                                    Remember, all forms should carry:

  • an identifying title
  • an identifying number of the form
  • the name of institution
  • the date of the last design review, particularly for forms used in data collections, which may change some data items each year.
  • may include the date of last print run, to facilitate storage and assist with ordering and identification.

 

                                    Identifying type should be punchy, explicit, tactful, boldly printed, with identifying numbers placed in a relatively inconspicuous part of the form.

                              5)   Ink

                                    Traditionally, almost all forms are printed in black, however, use of some coloured inks help to distinguish forms but often photocopy poorly. A strong colour contrast stands out. Consider the cost, but colour can be used effectively to group similar forms – for example anaesthetic, operation and consent forms with the same colour but different patterned borders.

                              6)   Ruling

                                    Thin lines are best used for column or caption break-ups and very thin lines for writing guides.

                    When designing new forms or reviewing existing forms remember to consult:

  • those responsible for the form and its content
  • those who will be entering data on the form
  • those who do not enter data but who refer to it to gain information from the data.

 

                    Another important point to keep in mind is that successful implementation of a new or revised form is just as important as the analysis and design of the form.  Often a form, which is badly implemented and introduced to the users, is worse than keeping an old form.  Therefore, evaluation and testing is an important part of forms design.  You may ask the question “How can forms be tested?”  To start with they should be tested in a realistic environment and secondly the end users should test them.

J.         MEDICO‑LEGAL ASPECTS

            Health records should be kept for the benefit of the patient, the doctor, and other health professionals, the hospital or clinic for patient care, medical-legal purposes, research, statistics, and teaching. As a legal document, the record should have sufficient information to:

  • identify the patient,
  • support the diagnosis,
  • justify the treatment, and
  • accurately document the results

 

            As discussed previously, the health record is the property of the hospital or clinic as the information it contains is an integral part of a person’s life and may not be used without the patient’s written consent.  Patient consent is not always necessary, however, when the record is being used for statistics, research, or teaching, when the patient’s identity is not known or sought.

            Remember, the health record is a confidential document and the patient’s right to privacy must be considered at all times.  The information contained within the health record is a confidential communication between the doctor or other health professional and the patient. The patient should have access to the information which should be explained to him, if necessary, by the doctor or health professional responsible for his/her care.

            If a request is made for the release of information, the authorization should contain the following:

  1.   full name of patient, address and date of birth
  2.   name of person/persons or institution to receive information
  3.   purpose or need for information
  4.   extent or nature of information to be released, including treatment dates
  5.   signature of patient or authorised representative
  6.   date of patient’s or authorised representative’s signature.

 

            A letter from the patient which can be verified, directing the hospital to release certain information to a specified person or institution (eg. health insurance) is often accepted as proper authorisation as long as it is, or can be, verified.

                    In general, it is best to have written policies relating to the release of information and ensure that all staff are familiar with these policies.

SUMMARY

In this unit we have looked at the medical record, the forms within the record, content of the forms, uses and value of the medical record, medico‑legal requirements, and responsibilities, and the need to have a well‑structured, orderly, available medical record, regardless of whether in a hospital, clinic, community health centre, or other primary health care situation.

REVIEW QUESTIONS

1.  In your own words, explain the uses, purposes and value of a health record.

2.  List and describe the four component parts of a problem oriented health record.

3.  What is meant by a “structured” health record?

4.  Describe the development of an inpatient’s health record from admission to discharge.

5.  Who is responsible for the documentation, completeness and accuracy of a health record?

6.  Who should be on a Health Record Committee?  What activities would a Health Record Committee undertake?

7.  Outline five general principles of good forms design.

8.  Why is confidentiality and privacy an important issue in health record administration?

REFERENCES:

1.         Davis, Nadinia, and LaCour, Melissa.  Introduction to Health Information Technology.  Philadelphia, PA:  W.B. Saunders, 2002.

2.         Huffman, Edna K. Health Information Management.  10th ed. Berwyn, IL:    Physicians Record Company, 1994.

3.         Johns, Merida, ed.  Health Information Management Technology: An Applied Approach.  Chicago: AHIMA, 2002.

4.        LaTour, Kathleen M., and Eichenwald, Shirley.  Health Information Management:  Concepts, Principles and Practice.  Chicago:  AHIMA, 2002.

SELESAI @HAKCIPTA Dr Iwan Suwandy,MHA

5.         Skurka, Margaret.  Health Information Management:  Principles and Organization for Health Information Services.  San Francisco, CA:  Jossey- Bass, 2003.

THE MILAN COLLECTIONS EXHIBITION SPECIAL FOR MILAN IHFRO CONGRESS PARTICIPANT

SHOWCASE :

“The Milan Collections Exhibitions”

THE EXHIBITION DEDICATED THE ALL IFHRO CONGRESS MILAN 2010 PARTICIPANT

FRAME ONE : INTRODUCTION.

The Indonesian ‘s  IFHRO  South East asia President and Team will join the Milan IFHRO Congress 2010 in November 2010(one of the member of that team is Mrs Lily W ,SKM,MM is the wife of Dr Iwan s ) .this is the new info of the congress.

1. Location of congress is moved 

New Venue: the Congress has been moved to Milan downtown MIC Milano Convention Centre, the most important congress centre in the north of Italy!
BETTER INFORMATION FOR BETTER HEALTH
IFHRO

The International Federation of Health Records Organizations is affiliated with the World Health Organization (WHO) and it supports national associations to implement and improve health records and the systems which support them.

.
AIDOS

The Associazione Italiana Documentazione Sanitaria is the Italian representative of IFHRO.

The ultimate news about:
  • Health Information Management and Patient Safety
  • Electronic Health Records, Electronic Medical Records, Patient Health Records
  • Privacy and Security
  • Health Information Management and Scientific Research
  • Management and Integration of Care
  • Monitoring and Evaluation of Health
  • Classification systems, Clinical Coding and Data Quality
  • Management and Quality of Medical Records

2. IHFRO Education day schedule

IFHRO Education Day

 

November 15, 2010

 

  

Milan, Italy

0900 am Welcome – Leonardo la Pietra, President AIDOS, Italy

Introductions and Overview – Claire Dixon

 

Lee, USA and Kelly Abrams, Canada0920 am Panel Presentation –

 

Exploration of Global Health Information Professional Education

 

 

  

Yoo

 

kyung Boo, President, KMRA; Associate Professor, Eulji University, KoreaVicki Bennett, President, HIMAA, School of Population Health, University of

 

Queensland, Australia

Kelly Abrams, LOHIM Project, Canada

Claire Dixon

 

Lee, Executive Director, CAHIIM, Global Model Curriculum1045 am Break

 

1100 am Mervat Abdelhak , University of Pittsburgh, USA–

 

Computational Thinking andGenomics – Emerging Topics in Health Information Education

 

 

 

  

 

1130 am Leslie Gordon, Sitka, Alaska and Lynette Williamson, Oley, Pennsylvania, USA

 

Buildand Enhance an Online Course

 

 

 

  

 

1200 pm Lunch on your own

 

1315 pm Jennifer Nicol, School of Public Health, Queensland University of Technology, Australia

 

Education and Training Framework for HIS

 

 

  

1415 pm Break

 

1430 pm Discussion on

 

Global Health Information Education and Workforce Needs

Participantsbreak into small groups with Education Day faculty to respond to key questions,

 

identify issues and suggest action steps:

 

  

a) Global issues in education and workforce

b) Recommendations for IFHRO and member nations

1515 pm Groups report back and compile results

1600 pm Adjourn

3. Milan flea Market Info (happy shooping)

Milan Markets / Mercato (Milan, Italy)

 

  

// //

Milan MarketsFull of character and real life, the busy markets in Milan, Italy are an integral part of Milanese local life. They provide a great place to find bargains in Milan or just browse around the wide variety of stalls and enjoy the exciting atmosphere and local market banter. Milan’s bustling markets range from the very large to the small, discreet collection of stalls, situated in small squares in Milan. They are held in many districts of Milan and provide a fun way to shop, for both experienced and novice bargain hunters alike. Here are some of the main markets in Milan that are worth a visit.

Fiera di Senigallia – Via Calatafimi, Milan, Italy
Every Saturday along the small lake of Darsena is the long established Fiera di Senigallia flea market. Here you will find many bargains, including clothes, military items, jewellery and much more besides

 

DrIwan cybermuseum will add the historic collections of  Milan which found before and after the meetings for all the Health Information’s Experxt and Practitioner which join the IHFRO congress Milan 201o.

Dr Iwan s hope this info of the Milan collections exhibitions will help all the IHFRO MIlan congress participant to know more info about MIlan City and  they will seen that famous and legend city with city tour.

Greeting dan happry congress from the founder of cybermuseum

Dr Iwan Suwandy,MHA

FRAME  : THE MILAN HISTORIC COLLECTIONS EXHIBITION

Milan
Milano

 

 

 

 

 

 

—  Comune  —
Comune di Milano

A collage of Milan: A characteristic tramway to the top left, followed by a panorama of the city seen from the top of the Duomo, the FieraMilano complex, the Palazzo Lombardia, the exterior of the Duomo, the Naviglio Grande neighborhood, the Teatro alla Scala and the triumphal arch of the Galleria Vittorio Emanuele II.


Flag

Coat of arms
Milan is located in Italy
Milan

Location of Milan in Italy

Coordinates: 45°27′51″N 09°11′25″E / 45.46417°N 9.19028°E / 45.46417; 9.19028Coordinates: 45°27′51″N 09°11′25″E / 45.46417°N 9.19028°E / 45.46417; 9.19028
Country Italy
Region Lombardy
Province Milan (MI)
Government
 – Mayor Letizia Moratti (PdL)
Area
 – Total 183.77 km2 (71 sq mi)
Elevation 120 m (394 ft)
Population (31 March 2010)[1]
 – Total 1,310,320
 – Density 7,130.2/km2 (18,467.2/sq mi)
Demonym Milanès/Milanese
Time zone CET (UTC+1)
 – Summer (DST) CEST (UTC+2)
Postal code 20100, 20121-20162
Dialing code 02
Patron saint Ambrose
Saint day December 7
Website Official website

Milan (Italian: Milano, About this sound listen (help·info) Italian pronunciation: [miˈla(ː)no]; Western Lombard: Milan, About this sound listen (help·info)) is a city in Italy and the capital of the region of Lombardy and of the province of Milan. The city proper has a population of about 1,310,000, while the urban area is the largest in Italy and the fifth largest in the European Union with a population of 4,345,000 over an area of 2,370 km2 (915 sq mi).[2] The Milan metropolitan area, by far the largest in Italy, is estimated by the OECD to have a population of 7,400,000.[3]

The city was founded under the name of Medhlan,[4] by the Insubres, Celtic people. It was later captured by the Romans in 222 BC, and the city became very successful under the Roman Empire. Later Milan was ruled by the Visconti, the Sforza, the Spanish in the 16th century and the Austrians in the 18th century. In 1796, Milan was conquered by Napoleon I and he made it the capital of his Kingdom of Italy in 1805.[5][6] During the Romantic period, Milan was a major cultural centre in Europe, attracting several artists, composers and important literary figures. Later, during World War II, the city was badly affected by Allied bombings, and after German occupation in 1943, Milan became the main hub of the Italian resistance.[5] Despite this, Milan saw a post-war economic growth, attracting thousands of immigrants from Southern Italy and abroad.[5]

An international and cosmopolitan city, 13.9% of Milan’s population is foreign born.[7] The city remains one of Europe’s main transportation[8] and industrial hubs, and Milan is the EU‘s 10th most important centre for business and finance (2009)[9] with its economy (see economy of Milan) being the world’s 26th richest by purchasing power,.[10] The Milan metropolitan area has Europe’s 7th GDP in 2008.[11] The province of Milan (which increasingly is becoming a single administrative urban unit to supersede the limited commune) had a GDP pp per capita of around €40,000 in 2007 (161% of the EU 27 average) which was the highest of any Italian province [12] (Il Sole 24 Ore Quality of life survey 2008) and the city’s workers have the highest average income rates in Italy,[12] and 26th in the world.[13] In addition, Milan is the world’s 11th most expensive city for expatriate employees,[14] and according to a 2010 study by the Economist Intelligence Unit, the city is the world’s 12th most expensive to live in.[15] Its economic environment has made it, according to several studies, the world’s 20th and Europe’s 10th top business and financial centre,[16][17] having been highly successful in terms of city branding.[18]

Milan is recognised as a world fashion and design capital, with a major global influence in commerce, industry, music, sport, literature, art and media, making it one of GaWC‘s major Alpha world cities.[19] The Lombard metropolis is especially famous for its fashion houses and shops (such as along Via Monte Napoleone) and the Galleria Vittorio Emanuele in the Piazza Duomo (reputed to be the world’s oldest shopping mall). The city has a rich cultural heritage and legacy, a vibrant nightlife,[20][21] and has a unique cuisine; it is home to numerous famous dishes, such as the Panettone Christmas cake and the risotto alla Milanese. The city has a particularly famous musical, particularly operatic, tradition, being the home of several important composers (such as Giuseppe Verdi) and theatres (such as the Teatro alla Scala). Milan is also well-known for containing several important museums, universities, academies, palaces, churches and libraries (such as the Academy of Brera and the Castello Sforzesco) and two renowned football teams: A.C. Milan and F.C. Internazionale Milano. This makes Milan the 52th Europe’s tourist destination, with over 1.914 million foreign arrivals to the city in 2008.[22] The city hosted the 1906 World Exposition and will host the 2015 Universal Exposition.[23]

Inhabitants of Milan are referred to as “Milanese” (Italian: Milanesi or informally Meneghini or Ambrosiani). The city is nicknamed by Milan’s inhabitants the “moral capital of Italy”.[5]

[edit] History

See also: List of rulers of Milan and Governors of the Duchy of Milan

[edit] Etymology

The word Milan derives from the ancient Celtic name of the city, Medhlan. This name is borne by a number of Gallo-Roman sites in France, such as Mediolanum Santonum (Saintes) and Mediolanum Aulercorum (Évreux) and appears to contain the Celtic element -lan, signifying an enclosure or demarcated territory (source of the Welsh word ‘llan’, meaning a sanctuary or church). Hence, Mediolanum could signify the central town or sanctuary of a particular Celtic tribe.[4][6]

The origin of the name and of a boar as a symbol of the city are fancifully accounted for in Andrea Alciato‘s Emblemata (1584), beneath a woodcut of the first raising of the city walls, where a boar is seen lifted from the excavation, and the etymology of Mediolanum given as “half-wool”,[24] explained in Latin and in French. The foundation of Milan is credited to two Celtic peoples, the Bituriges and the Aedui, having as their emblems a ram and a boar;[25] therefore “The city’s symbol is a wool-bearing boar, an animal of double form, here with sharp bristles, there with sleek wool.”[26] Alciato credits Ambrose for his account.[27]

The German name for the city is Mailand, while in the local Western Lombard dialect, the city’s name is Milán.

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