HOSPITAL HEALTH INFORMATION MANAGEMENT MANUAL

Copyright 2020 by the Department of Health. All rights reserved. Subject to the acknowledgement of the Health Facility Development Bureau (HFDB), Department of Health, the Manual may be freely abstracted, reproduced or translated in part or in whole for noncommercial purposes only. If the entire Manual or substantial portions will be translated or reproduced, permission should be requested from the HFDB. Printed in the Republic of the Philippines.

National Library Cataloging-in-Publication Data

ISBN

Published by

Department of Health

San Lazaro Compound Rizal Avenue, Sta. Cruz, Manila 1003 PHILIPPINES

PRODUCTION CREDITS

Project Leader: Madeliene M. Gabrielle Doromal, MSW, RSW

Terence John M. Antonio, MD, MBA

Copy Editor: Camille Ann C. Ople

Development of this Manual was initiated, completed and subsequently published through the HFDB. For inquiries, contact the Bureau:

Phone: +63 2 8651 7800 locals 1401, 1403, 1408

Email Address: hfdb@doh.gov.ph

AUTHORIZATION

In accordance with the authority vested on the Secretary of Health, it is hereby declared that the standards and policies in this manual shall govern the organization, management, operations and activities of the Health Information Management Department in the Department of Health (DOH) Hospitals. The Manual can be used as reference of local government and other hospitals.

This shall take effect upon signing until revised and updated by the DOH.

FRANCISCO TOUQUE III, MD, MSc

Secretary of Health

The Department of Health (DOH) steers the health sector towards developing a productive, resilient, equitable, and people-centered health sector to realize its vision of making Filipinos among Southeast Asia's healthiest people in 2022. This is outlined in the strategy map of the DOH's FOURmula One Plus for Health (F1 Plus).

The Universal Health Care (UHC) Act aims for better health outcomes, more responsive health systems, and more equitable health care financing. Hence, the DOH is working to ensure high-quality and affordable health services for every Filipino, including the effective and efficient information management of the health facilities. Thus, this manual endeavors to provide an organized system of documenting quality health services

provided and to ensure that sufficient patient care data has been collected, maintained, and secured to warrant continuous quality improvement across all levels of care. Through these upgraded standards, the DOH calls for everyone to cooperate towards an interdisciplinary and coordinated delivery of high-quality and standardized management of health information.

I commend the Health Facility Development Bureau (HFDB) for its initiative and commitment in harmonizing and streamlining the standards and processes in health facility operations through the updating of the Manual of Standards for Hospital Health Information Management. The Health Information Management Department (HIMD) is a fundamental facet of hospital operations, with its role in the processing, maintaining, and safekeeping of all health records created in the health facility in the course of care.

We are confident that this manual shall be instrumental in fulfilling the Department of Health's aspiration of genuine Universal Health Care that is focused on people's needs and well-being while recognizing Filipinos diverse cultures, beliefs, and values.

Mabuhay!

FRANCISCO T. DUQUE III, MD, MSc

Secretary of Health

MESSAGE

The Universal Health Care (UHC) Act, also known as Republic Act (RA) No. 11223, mandates that the country's entire health sector shall ensure that all Filipinos have better access to appropriate health care services without experiencing financial hardship. This aspiration shall be achieved through a more responsive health system that makes them feel respected, valued, and empowered. This entails improving the quality of health care services in health facilities, where patients experience them first hand. Health facilities must then be venues of clinical quality, operational efficiency and people-centeredness.

This fourth edition of the Manual of Standards for Hospital Health Information Management aims to ensure that the collection and management of health information provided by patients in our health facilities adheres to current ethical and professional practice. The manual defines the Philippine Health Record Standards by combining the updated regulatory/mandatory policies such as RA 10173, the Data Privacy Act of 2012; RA 11223, the UHC Act; and RA 9470, the National Archives Act of the Philippines Act. The set standards also abide to the International Organization for Standardization (ISO 9001:2015), the PhilHealth Benchbook, the Licensing Standards as defined in Administrative Order No. 2012-0012 and the International Health Record Standard, as defined by the Joint Commission International Accreditation Standards.

The Manual emphasizes the important role of the Health Information Management Department in providing quality health care to patients in facilities. The latest edition has eight chapters divided into 3 main parts: the first addresses the administration of the Health Information Management Department; the second details the Philippine Health Record standards, the specific policies as well as the health record systems and procedures; and the third discusses the continuous quality improvement program in strengthening the implementation of the existing Standard Operating Procedures (SOPs). These shall serve as reference of standards, policies and guidelines to achieve a uniform practice for efficient and effective health information management.

Also, the manual determines the responsibilities of the HIMD personnel and provides guidance in their performance of duties in support to each unit or service in the hospital. The manual shall serve as DOH hospitals' reference in the standard operating procedures of the HIMD, of which the DOH encourages other public and private health facilities to adopt in their practice. Thus, we enjoin our stakeholders in promoting continuous learning, peer support and mentorship alongside the implementation of this Manual of Standards so we could boost Universal Health Care for all.

LILIBETH C. DAVID, MD, MPH, MPM, CESO I

Undersecretary of Health Health Facilities and Infrastructure Development Team

FOREWORD

The Health Facility Development Bureau (HFDB) of the Department of Health (DOH) is at the forefront in leading the continuous development of quality health facilities that are efficient and responsive to the needs of Filipinos. Towards this end, the Bureau has been tasked to develop policies, programs and standards, as well as provide technical assistance and advisory in the development, planning, operations and maintenance of health facilities.

Following the recognition for a distinct Health Information Management Department (HIMD) in the hospital organization, the Manual of Standards for Hospital Health Information Management is the Bureau's response to standardize policies and procedures vital to the quality of health record management. The standards developed and prescribed in this manual shall serve as reference for HIMD Officers and staff to effectively and efficiently perform their respective duties and responsibilities; as well as consideration in meeting the rising expectations of their facility's clientele and the public. Finally, the manual dutifully integrates the DOH policy framework and objectives in the implementation of Republic Act No. 11223, the Universal Health Care Act.

The HFDB is extremely grateful for the generosity of the Technical Working Group members and experts, invited resource persons, and other stakeholders, who dedicated their time, expertise and effort. This latest edition of the manual shall address the hospitals' needs for continuous quality improvement, especially among the Hospital's HIM Officials and staff.

The health facility is the people's primary interface with the health system. It is where the actualization of the Universal Health Care becomes tangible for the Filipinos. The HFDB's initiatives coupled with stakeholders cooperation shall guarantee the achievement of the DOH's goals of financial risk protection, a more responsive health service delivery, and better health outcomes for all.

MA. THERESA G. VERA, MD, MSc, MHA, CESO III

Director IV

Health Facility Development Bureau

PREFACE

The 4th Edition of the Hospital Health Information Management Manual addresses the changes brought about by new mandates and issuances related to the practice of and updates on the Health Information Management in the Philippines. At the forefront of these policies are the licensing standards as defined in Administrative Order No. 2012-0012 or the Rules and Regulations Governing the New Classification of Hospitals and Other Health Facilities in the Philippines, the Republic Act (RA) 10173, also known as the Data Privacy Act of 2012 and its Implementing Rules and Regulation (IRR), and the International Organization for Standardization (ISO 9001:2015), and the RA 11223, also known as the Universal Health Care Act.

In line with the Department of Health's (DOH) goal on access to quality health care services, the HFDB has created a Technical Working Group (TWG) through Department Personnel Order No. 2019-5098. The said TWG is composed of the Supervising Administrative Officers and technical experts from mostly DOH, and select local government and private hospitals. The TWG reviewed existing mandates and issuances to align the standards and policies and come up with a uniform procedure for efficient and effective health information management. New standards and guidelines were developed relative to the current practice and statistical needs. In addition, coordination with stakeholders for their suggestions and inputs in the new edition of the manual was prompted.

Published in 2010, the nine (9) Chapters of the 3rd Edition of the Hospital Health Information Management Manual, has been streamlined into eight (8) Chapters in this latest edition. Several Chapters from the previous edition were merged as needed and a new Chapter was added which is the Introduction to Electronic Health Record. The new chapter introduces the electronic health record as an obligation of every health facility to address the rapid changes in the delivery of healthcare and the public demand for more extended and improved health services. Uniformity of terms related to issuances were also reflected in the manual, such as the Medical Records Committee now termed as Patient Health Records Committee following the established name of the Department. Furthermore, this edition included Medical Research Standards and Procedures to address the gaps and define the role of the Health Information Management Department in Medical Research.

The standards, policies and guidelines in this manual are envisioned to serve as reference for the effective implementation of HIMD services and reinforce patient safety in the government and private hospitals in the Philippines.

TERENCE JOHN M. ANTONIO, MD, MBA

OIC-Division Chief

Policy Planning and Program Development Division Health Facility Development Bureau

ACKNOWLEDGEMENT

The 4th Edition of the Hospital Health Information Management Manual was made possible by the exemplary commitment and dedication of the Technical Working Group and Technical Experts for their contribution and unselfish cooperation on the development of this revised manual:

THE TECHNICAL WORKING GROUP

TERENCE JOHN M. ANTONIO, MD, MBA

Project Leader

OIC-Division Chief, Policy Planning and Program Development Division Health Facility Development Bureau

MADELIENE GABRIELLE M. DOROMAL, MSW

Chairperson

Development Management Officer IV Policy Planning and Program Development Division Health Facility Development Bureau

MELINDA C. TAN, MPA

Vice-Chairperson

Supervising Administrative Officer Tondo Medical Center

Members

Ana Marie M. Acejas, MPA

Supervising Administrative Officer Zamboanga City Medical Center

Lina R. Patoc, MRM

Supervising Administrative Officer Bicol Medical Center

Lucila M. Villareal, MBA

Supervising Administrative Officer Dr. Jose Fabella Memorial Hospital

Michelle P. Ocampo

Supervising Administrative Officer Jose B. Lingad Memorial Regional Hospital

Rommel Paul G. Flores

Supervising Administrative Officer Baguio General Hospital and Medical Center

Haide M. Pleños, LPT, MPA

Supervising Administrative Officer Davao Regional Medical Center

Josephine N. Santiago

Supervising Administrative Officer Ilocos Training and Regional Medical Center

Josephine U. Hubilla, MHA

Chief Administrative Officer

National Kidney and Transplant Institute

Gensela L. Lacambacal, MM Records Officer V Myrna C. Beramo, MBA/PA Supervising Administrative Officer

Philippine General Hospital Research Institute for Tropical Medicine

Lani P. Paler, MPA, MBA-HA, FPCHA Isabel U. Asufra, MPA

Supervising Administrative Officer Southern Philippines Medical Center Supervising Administrative Officer Vicente Sotto Memorial Medical Center

Eileen B. Tabasin Nida V. Sonza, MMPM

Statistician II Supervising Administrative Officer

Western Visayas Medical Center West Visayas State University Medical Center

Our profound gratitude to the following Resource Persons/Consultants who have provided their expertise in writing, critiquing, and guiding in the development of this manual.

TECHNICAL EXPERTS

Roderick M. Napulan, CESE Division Chief

Research and Performance Management Division

Leriza L. Escarpe Records Officer III

Philippine General Hospital

Annabelle M. Cabral Medical Records-Supervisor

University of Santo Tomas Hospital

Sheila May A. Tronco Statistician II

West Visayas State University Medical Center

Ma. Leilani T. Tecson Head-Health Information Management

Department (HIMD)

Jose Abad Santos General Hospital

Frederick C. Dacanay Head-Health Information Management

Department (HIMD) Ospital ng Parañaque

PMAJ June Christy B. Manga, RN, MPA Chief, Health Information Management

Service (HIMS)

PNP General Hospital

Philip Aquino Administrative Officer V

Treatment and Rehabilitation Center-Bicutan

Xandro S. Mastura, RN Assistant Health Records Officer

Cotabato Sanitarium

Anthony General Administrative Officer III

Sulu Sanitarium

Dennis A. Adlawan, RN, MAN, MBA Administrative Officer V

Eversley Childs Sanitarium and General Hospital

Jennifer P. Buenaflor, RN Administrative Officer In-Charge-Health

Information Management Unit (HIMU) Mariveles Mental Wellness and General

Hospital

Emelita R. Maca Head, Health Information Management Unit

(HIMU)- Retired

Mariveles Mental Wellness and General

Hospital

Lourdes L. Palapal Supervising Administrative Officer- Retired

National Center for Mental Health

SECRETARIAT

Ms. Chrys Abigail M. Paita Development Management Officer III Ms. Myca E. Galat Development Management Officer III

Mr. Henry Ryan Dominic G. Cajandig Administrative Assistant III

We are grateful for the support and encouragement from Dr. Ma. Theresa G. Vera, Director IV of the Health Facility Development Bureau (HFDB), and Dr. Terence John Antonio, OIC-Division Chief of the Policy, Planning and Program Development Division of the HFDB in the completion of the manual.

We extend our sincere appreciation to the chiefs of the health care facilities for providing inputs during the consensus-building of the Manual, and who generously allowed their HIMD Officers, Statisticians, and Administrative Officers to join the Technical Working Group (TWG).

We are grateful for the assistance of the following Central Office Staff in providing their technical expertise, their guidance during the stakeholders' consultative write shops, workshops and in the series of virtual meetings, as well as administrative and clerical support, towards the completion of the Manual:

CENTRAL OFFICE

Ms. Josephine L. Guiao, RND, DCN, MSc Development Management Officer IV Ms. Faye Diana C. Chua, RPh Development Management Officer IV

Ms. Rhod-Ann A. Lebrino Administrative Assistant V

Ar. Jean Paolo L. Policarpio Development Management Officer III

Ms. Laika S. Guerrero Administrative Assistant VI

EDITORIAL SUPPORT

Mr. Glenn A. Cruz Development Management Officer III Ms. Camille Ann C. Ople Senior Administrative Assistant II

Definition of Terms

Autopsy Rate

This refers to a proportion of deaths that are followed by the performance of an autopsy.

Bed Occupancy Rate

This pertains to the ratio of actual Inpatient Service Days to the maximum inpatient days determined by bed capacity during any given period.

Bed Turnover Interval

This refers to the average period in days that an available bed remains empty between the discharge of an inpatient and the admission of the next.

Bed Turnover Rate

This refers to the number of times a bed, on average, changes occupants during a given period.

Caesarean Section Rate

This denotes the ratio of the number of Caesarian sections performed to the total number of deliveries including Caesarian sections for a certain period.

Census

This pertains to the number of patients present in the hospital at any given period with a standard cut-off time at midnight.

Clinical coding

This means the translation of diseases, health-related problems, and procedural concepts from the text to alphabetic/numeric codes for storage, retrieval, and analysis.

Complication

This refers to any disease or disorder that occurs during (or because of) another disease.

Confidentiality

This concerns a legal and ethical concept that establishes the healthcare provider's responsibility for protecting health records and other personal and private information from unauthorized use or disclosure.

This relates to the process by which patients are made to participate in the decisions involved in their health care. It includes a patient-doctor discussion on the nature of the decision for a procedure, reasonable alternatives to proposed intervention, the relevant risks, benefits, and uncertainties.

This refers to the copies of consents for admission, treatment, surgery, and release of information.

Consultation Rate

This pertains to the ratio of consultation following an attending physician's request to a consultant to examine a patient and give a second opinion.

Culling

This is the process of identification and removal of inactive records or files which have already reached the mandated and/or prescribed retention period from the filing/storage area for disposal.

Death Rate

This refers to the proportion of inpatient hospitalizations that ends in death; also serves as a basis in evaluating the quality of medical care.

Diagnosis

This is a term used by a physician to identify a disease from which an individual patient suffers or a condition for which the patient needs, seeks, or receives medical care assistance.

Diagnostic Procedure

This means any procedure employing analysis and examination to identify a disease or condition.

Discharge Summary

This pertains to a concise summary of a hospital stay: the reason for admission, significant findings from tests, procedures performed, therapies provided, response to treatment, condition at discharge, and instructions for medications, activity, diet, and follow-up care.

ED Death

This refers to deaths of patients occurring in the ER, including patients who were revived by initial resuscitative measures at the ER but eventually died, regardless of the time of stay in the ER.

Clinical Cover Sheet

This is also known as "Admission and Discharge Record" or "Face Sheet" which contains personal data like name, address, and other social data.

Fetal Death Rate

This refers to the ratio of intermediate and late fetal deaths to a total number of births including intermediate and late fetal deaths.

Health Facility

This refers to an institution that has health care as its core service, function, or business. Health care pertains to the maintenance or improvement of the health of individuals or populations through the prevention, diagnosis, treatment, rehabilitation, and chronic management of disease, illness, injury, and other physical and mental ailments or impairments of human beings.

Health Information Management (HIM)

This is the study of the principles and practices of acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care. HIM is the link to clinicians, technology designers, and information technology; and is the value-adding bridge between patients' health information and government and regulating agencies.

Health Record

This is formerly known as Medical Record: a chronological written account of a patient's examination and treatment that includes the patient's medical history and complaints, the physician's physical findings, the results of diagnostic tests and procedures, and medications, and therapeutic procedures.

Health Record Number

This is a permanent identification number assigned in straight numerical sequence by the admission staff and is recorded on all health record forms relating to a particular patient.

History and Physical Examination

This is a document that describes major illnesses, and surgeries, significant family history of the disease, health habits, and current medications of a patient.

Hospital

This refers to an institution, building or place, government or private, duly licensed by the Department of Health and accredited by PhilHealth, where installed beds, cribs, or bassinets for 24-hour use or longer by patients in the treatment of diseases, injuries, deformities, abnormal physical, and mental states, and/or maternity cases are available.

Imaging Reports

This describes the findings of x-rays, mammograms, ultrasounds, and scans. The actual films are maintained in the radiology or imaging departments or on a computer.

Immunization Record

This is a form documenting immunization given for diseases such as polio, measles, mumps, rubella, hepatitis, and flu. Parents should maintain a copy of their children's immunization records with other important papers.

Indicator

This is a measurable variable or characteristic that can be used to determine the degree of adherence to a standard or achievement of quality goals.

Infant Death Rate

This refers to the ratio of the total number of infant deaths including neonatal and postneonatal deaths rate of a live-born infant at any time from the moment of birth to the end of the first year of life (364 days, 23 hours, 59 minutes from the moment of birth).

Information

This refers to meaningful, interpreted, and processed data used to make a judgment on a hypothesis or answer a research question.

This is generally understood as the implied or explicit (read: written permission) given by the patient before initiation of care following the provision of sufficient information to make an informed judgment on medical treatment choices. It, however, refers more to the process by which patients are made to participate in the decisions involved in their health care. Informed consent is found on patients' legal and ethical right to direct what happens to their bodies and from the doctor's ethical duty to involve patients in the treatment process. It includes a patientdoctor discussion of the following issues: the nature of the decision or procedure; reasonable alternatives to the proposed intervention; the relevant risks, benefits, and uncertainties.

Inpatient

This refers to a patient admitted in the hospital receiving healthcare services and is provided with room, board, and continuous nursing services in a unit or area of the health facility.

Inpatient Service Days

This is a unit of measure denoting the services received by an inpatient in 24 hours or any fraction of the day thereof.

Laboratory Results

This describes the results of tests conducted on body fluids. Common examples include a throat culture, urinalysis, cholesterol level, and complete blood count (CBC). The health record does not usually include a blood type since blood typing is not part of routine lab work.

Legitimate Purposes

This refers to valid reasons for the request such as for Management Decision, Statistical Purposes and Reporting to DOH, Mortality/Morbidity Conferences of Clinical Departments, Submission to Regulatory bodies as per Republic Act, Administrative Orders, and Memorandum Circulars, for submission to Adjudicatory bodies (PNP, NBI, and other law enforcement agencies) with a written request from the Chief/Director of their respective agency.

Length of Stay

This refers to the number of days a patient remains in the hospital.

Loose Sheets

This contains vast quantities of unattached laboratory, ECG, and other tests results.

Maternal Death Rate

This refers to the ratio of deaths resulting from obstetric complications of the pregnancy state (pregnancy, labor, and puerperium) from interventions, omissions, incorrect treatment, or a chain of events resulting from any of the above.

Medication Record

This is a list of medicines prescribed or given to a patient.

Morbidity

This refers to the state of having a disease (including illness, injury, or deviations from normal health), the number of sick persons, or cases of disease concerning a specific population.

Mortality

This refers to the death rate concerning a specific population, or a fatal outcome: death. The word "mortality" is derived from the word "mortal": came from the Latin word "mors" meaning death.

Nurses' Notes

This contains observations of a patient, the treatment given, the response to treatment, and any unusual occurrences, medications, instructions, and the advice for follow-up consultations.

Operative Report

This is a document that describes surgery performed including the names of surgeons and assistants.

Outcome

This pertains to the effect of care on the health status of patients and populations seen in less impairment of functions, less pain, and suffering,

Out-patient

This refers to a patient who consults and receives health care services in the health facility without being admitted and does not occupy a bed for any length of time.

Pareto Chart

This is a data analysis tool that combines analysis of the frequency of a problem and analysis of its causes by identifying the most influential cause or causes, also called the "vital few," thereby separating them from the "trivial many."

Pathology Report

This describes tissue removed during an operation and the diagnosis based on examination.

Patient Rights

This is the moral and legal entitlement of a patient to care.

Perinatal Death

This refers to fetal deaths and lives births with only brief survival, usually days or weeks, or the death of an infant between birth and at the end of the neonatal period.

Physician's Orders

This refers to the physician's directions to other members of the healthcare team regarding medications, tests, diets, and treatments.

Plan-Do-Study-Act Cycle

This is a structured, cyclical process for developing and implementing change and improvement.

Power of Attorney

This is a legal document giving a person (called an "agent" or "attorney-in-fact") the power to act for another person (the principal).

When incapacity is anticipated, a person may grant power of attorney to another person. Power of attorney is the legally recognized authority to act and make decisions on behalf of another party. This authorizes the designee to act on behalf of the person who is now incapacitated. The person with power of attorney is often responsible for making decisions regarding the disclosure of health information to others.

Problem List

The is a list of illnesses, injuries, and other factors that affect the health of a patient, usually identifying the time of occurrence or identification and resolution.

Progress Notes

These are notes made by the doctors, nurses, therapists, and social workers caring for you which also contain a patient's response to treatment, observations, and plans for continued treatment.

Quality Improvement

This refers to upgrading from previously accepted minimal performance standards.

Quality Management

This is an act of organization-wide pursuit of quality.

Registers

This is an official list of all treated and/or admitted patients in a particular health facility.

Risk management

This pertains to an organized effort to identify, assess, and reduce, where appropriate, risks to patients, visitors, staff, and organizational assets.

SOAP

This is the sequence of evaluating the care needed for any particular patient.

Standards

These are statements of expectations for the inputs, processes, behaviors, and outcomes of health systems.

Stillbirth rate

You may see fetal death rate.

Tracers

This is also known as "outguides": used to ensure proper record control whenever the health record is removed from the file for any purpose.

Telemedicine

This refers to the practice of medicine using electronic and telecommunications technologies such as phone call, chat or short messaging service (SMS), audio- and video-conferencing, among others, to deliver healthcare at a distance between a patient at an originating site, and a physician at a distant site.

List of Figures

Figure

1	Organogram for HIMD	6
2	Organogram for Professional and Allied Health Services	7
3	Organogram for Government Hospital Level 3 with 200 to 1500 beds	7
4	Diagram Showing "Safety Pulpit Ladder" and Kick Stool	11
5	Standard Arrangement of Filing Cabinets	12
6	Working/Completion Area	13
7	Diagram Showing Proper Lighting	14
8	Process Flow of Health Record	38
9	Process Flow in Response to Subpoena duces tecum	93
10	The PDSA Cycle	104

List of Tables

Table

1	Example of Practical HIMD Planning	8
2	Advantages and Disadvantages of the Types of Health Record Assembly	43
3	Sample Table for Summary of 24-hr Floor Census Report per Ward	49
4	Sample Table for Summary of Daily Floor Census Report	50
5	Procedure on the Processing of 24-hr Floor Census	50
6	Procedure on the Preparation of Statistical Report	52
7	Advantages and Disadvantages of Filing Systems	60
8	Procedure in the Disposal of Health Records	67
9	Procedure in the Preparation of Birth Certificates	69
10	Procedure in the Preparation of Death Certificates/ Fetal Death	70
11	Comparison of Paper vs. Electronic	100
12	The PDSA Cycle- Step by step	104

List of Annexes

Annex

A	Overview of EMR	111
B	Patient's Health Record Audit	114
C	Outpatient Clinical Record	116
D	Emergency Treatment Record	117
E	Daily Floor Census	120
F	Clinical Cover Sheet	122
G	Doctor's Orders and Progress	123
H	Nurse's Progress Notes	124
I	Clinical Laboratory Result Form	125
J	Medical History and Physical Examination	126
K	Clinical Abstract	129
L	Discharge Summary/Clinical Abstract	130
M	Admission Slip	131
N	Patient Information Sheet	132
O	Request for Access to Health Records	133
P	Referral Form	134
Q	Inter-Departmental Referral Sheet	135
R	Certificate of Confinement	136
S	Medical Certificate	137

T	Medico-Legal Certificate	138
U	Proposed Qualification Requirements and Job Descriptions for the Different Categories of the HIMD Staff.	139
V	Proposed Standard Staffing Pattern for HIMD in Level 3 Government Hospital with 200 to 1500 Beds	149
W	Summary of Formulas for Hospital Statistics	149
X	Self-Assessment Tool	153

	Messages		iii
	Foreword		v
Preface			vi
	Acknowledgement		vii
	Definition of Terms		x
	List of Figures		xvi
	List of Tables		xvii
	List of Annexes		xviii
	Chapter 1	Health Information Management Department (HIMD) in Hospitals
1.1	Objectives		1
1.2	Functions		2
1.3		HIMD Linkages	3
	Chapter 2	Administration and Management of HIMD
2.1		Organizational Structure of HIMD	6
2.2		Management Process	7
2.3		Physical Facilities and Equipment	9
2.4		Standard Staffing Pattern 16
	Chapter 3	Health Record Standards and Policies
3.1		Overall Considerations in Defining the Philippine Health Record Standards	18
3.2		Philippine Health Record Standards and Policies	19
	3.2.1	Standard 1: Health Record Creation	19
	3.2.2	Standard 2: Health Record Documentation	23
	3.2.3	Standard 3: Health Record Storage and Safekeeping	26
	3.2.4	Standard 4: Health Record Accessibility	27
	3.2.5	Standard 5: Health Record Report Generation	32
	3.2.6	Standard 6: Continuous Quality Improvement	33
	3.2.7	Standard 7: Medical Research	34

Chapter 4	Health Record Systems and Procedures
4.1	Creation of Health Record	38
4.2	Assembly of Health Record	41
4.3	Analysis of Health Record	44
4.4	Clinical Coding	48
4.5	Collection of Statistical Data	48
4.6	Filing of Health Record	52
4.7	Retrieval of Health Records	62
4.8	Retention and Disposal of Health Records	66
4.9	Processing of Health Information/ Issuance of Certificates	68
4.10	Telemedicine	71
Chapter 5	Hospital Statistics
5.1	The Need for Hospital Statistics	73
5.2	Characteristic of Quality Hospital Statistics Data	74
5.3	Collection of Healthcare Statistics	74
5.4	Measures of Hospital Utilization	74
5.5	Measures of Health Facility Performance	79
Chapter 6	Health Records in Medico-Legal, Investigative and Court Procedures
6.1	Ownership of the Health Record	89
6.2	Accessibility	89
6.3	Confidentiality	89
6.4	Health Record with Investigative Concern	92
6.5	Records Subpoenaed by the Court	92
6.6	Informed Consent for Medical and Surgical Procedure	94
Chapter 7	Introduction to Electronic Health Record
7.1	Introduction	95
7.2	Electronic Health Record (EHR) Defined	96
7.3	Goals and Principles upheld by EHR Implementation	96
7.4	Guide for Health Facilities Towards Adopting EHR	97

7.5	Electronic Medical Records	100
	Chapter 8 Continuous Quality Improvement for HIMD
8.1	Composition of CQI Team in HIMD	102
8.2	Expected Outcomes of the Quality Improvement Activities	103
8.3	Essential Elements of Quality Improvement	103
8.4	Plan-Do-Study-Act (PDSA) Cycle	104
8.5	Risk Management	106
	References	108
Annexes		111

CHAPTER 1 Health Information Management Department in Hospitals

The Health Information Management Department (HIMD) is responsible for enhancing patient care through the use of data contained in the health record (digital or manual medical information), either individually or collectively. The general function of the HIMD is to provide an organized system of measuring quality patient care and ensure that sufficient data is written in a sequence of events to justify the diagnosis and warrant the treatment and results. The department is tasked to process, analyze, maintain, and keep safe all health records created/maintained in the health facility in the care. The department plays a vital role in generating health statistics for evidence-based medical care and management practices. Quality of records and documentation is also one of the emerging roles of the HIMD in hospitals. The revenues generated through reimbursements from third-party payers are dependent on the quality of records and documentation.

1.1 Objectives

The HIMD shall provide effective and efficient service to clients of the health facility and shall meet the following objectives and standards:

1. improve the accessibility of the health record;
1. ensure the creation and maintenance of quality and standardized health records for every patient treated;
1. ensure that data are electronically recorded using a health record system validated by the DOH in compliance with the EMR implementation;
1. ensure greater utilization of health facility statistical reports;
1. assist in strengthening quality programs: Patient Safety, Continuous Quality Improvement

Health Information Management Department in Hospitals

(CQI), Infection Prevention and Control, Risk Management, etc., in the health facility;

1. participate in research and studies which the facility, the members of the medical and allied staff, and other authorized researchers are engaged in; and
1. implement staff development.

1.2 Functions

1. Maintain all health records following the principles and practices of efficient and effective health record management.
1. Maintain comprehensive indexes (e.g., Master Patient Index, Disease Index) and registers (e.g., Admission, Discharge, Operation/Procedure, Delivery Room (DR), Out-Patient Department (OPD), Emergency Department (ED), Birth and Death Registers). These are official records for patient identification and essential retrieval tools for needed data and information when health records are already disposed of.
1. Review records for completeness and accuracy, coding of diseases, operations, and special therapies according to approved nomenclature and classification.
1. Maintain a comprehensive and up-to-date unit health record for each patient, ensuring that all relevant information is collected and written in the history and filed correctly.
1. Respond to all subpoena duces tecum addressed to the HIMD.
1. Maintain and safeguard the confidentiality of the health record.
1. Upon request, provide health records for patient's visit to the OPD and Emergency Department (ED) and admission to the inpatient's ward for benefit claims, insurances, and litigation/legal purpose/s.
1. Ensure that all diagnostic reports/results are promptly and accurately filed in their respective patient records.
1. Collate and compile data and generate statistical reports required by respective health facility management, the DOH, the health regulatory body, and Philippine Health Insurance Corporation (PHIC), as the country's health accreditation agency.
1. Prepare periodic statistical reports on morbidity and mortality, birth, utilization of hospital services, OPD/ED services, surgery performed, and cases receiving a particular form of therapy and other related data.
1. Participate in approved research activities and study programs conducted by doctors and authorized researchers by providing data/information from patient's health records.

1.2.1 Other Functions

Patient Health Records Committee (PHRC)

The Head of the HIMD in Level 1, Level 2, and Level 3 hospitals shall participate as a member of the Patient Health Records Committee (PHRC), formerly known as the Medical Records Committee. The PHRC may act as the Forms Committee and/or a liaison between the Chief of the Medical Service and other departments. The members

of PHRC shall consist of representatives from the various clinical services of the hospital. The committee shall provide efficient support to the Head of the HIMD in formulating effective institutional standards, policies, systems, and procedures, especially in the timely documentation and the completion of health records.

The membership of the PHRC includes, but is not limited to the:

Chairperson a representative from the medical service.
Member a representative from the hospital administration, nursing service, allied health services, and the Head of the HIMD.

PHRC shall have the following functions:

1. conduct regular meetings (once every three months or more frequently, if required) for performance evaluation of planned activities of the committee, including monitoring of all health records not completed within the specified time;
1. recommend standards, policies, systems, and procedures in health record documentation and implement Clinical Documentation Improvement (CDI) in the hospital;
1. monitor the quality of documentation of the health records;
1. review all health record forms to determine its effectiveness in the collection of the needed data/information and revise if there is a need for it;
1. validate health record analysis concerning hospital's performance; and
1. lead the implementation of accurate and complete Medical Certification of Cause of Death (MCCOD) for quality mortality data in the hospital.

1.3 HIMD Linkages

The HIMD must maintain harmonious working relations with other service components of the health facility to efficiently and effectively perform its functions, mainly in creating and maintaining quality health records for the benefit of the patient and facility. The Head of HIMD is mandated to implement facility-wide coordination and linkages to other departments.

A. Office of the Medical Center Chief of Hospital/Chief of Hospital

1. Professional Education, Training and Research Office/Unit (PETRO/PETRU)

Coordinates needed data/information on available technical Learning Development Intervention (LDI) and corresponding budget for the HIMD staff.
Provides lists of participants to undergo LDIs.

2. Integrated Hospital Operations and Management Service (IHOMS)

● Coordinates the maintenance of the hospital's Health Information System (HIS) and other systems used by the HIMD, including the provision, repair & maintenance of IT equipment.

Health Information Management Department in Hospitals

● Provides assistance in the enhancement of electronic health/medical records.

B. Medical Service

Coordinates in creating accurate and complete medical information/ diagnostic results for patient care management for proper and timely documentation.
Provides assistance in the completion of health records (digital/manual) and research studies.

C. Allied Health Professional Service

1. Pharmacy

● Provides data/information on the drugs, medicines, intravenous fluid (IVF), and other dispensed for the treatment and care of the clients during the period of confinement and pharmacy interventions provided to patients.

Provides data/information on the classification of a patient, social services extended, or assistance provided to the patient for his treatment and care.
Coordinates needed data/information to prepare a case study for service patients and others seeking assistance from concerned financial institutions.
Request for clinical abstract/discharge summary for absconded patients seeking financial assistance and insurance reimbursement with prior approval of the Medical Center Chief.
Assists in the identification of John Doe/Jane Doe, abandoned clients, and unclaimed cadavers.
Assists in the completion of birth certificates for abandoned newborn babies and death certificates for unclaimed cadavers.

3. Nutrition and Dietetics

Provides data/information on the nutrition-related services given to the client, such as diet during confinement and diet counseling.
Coordinates with the nutrition and dietetics service in the implementation of the Nutrition Care Process.
Provides technical assistance to the Registered Nutritionist Dietitian in preparing bi-annual hospital Nutrition Care Process reporting form.

D. Nursing Service

Submits 24-hour daily floor census together with the health records of discharged patients.
Coordinates prompt submission of completed and accurately accomplished pre-form/ worksheet of Birth and Death Certificates.
Provides standards in documentation for the creation of quality health records.

● Provides assistance in completing health records (digital/manual), case presentations, and research studies.

E. Hospital Operations and Patient Support Services (HOPSS)

1. Human Resource Management Office (HRMO)

Coordinates with PETRO for the conduct of needed HIMD technical LDI.
Coordinates for technical assistance in recruitment, selection, and promotion of HIMD staff.
Recommends adequate human resources and appropriate qualification standards for the various HIMD staff.
Submits regular reports on hospital human resources complement to HIMD.
Complies with the prescribed HRMO requirements relative to HIMD personnel.

2. Procurement Section and Materials Management

● Coordinates the selection and purchase of needed HIMD office supplies and equipment.

3. Engineering and Facilities Management

● Provides assistance and maintenance related to the infrastructure of the HIMD working area

F. Finance Service

1. Billing and Claims

Coordinates with HIMD for the health records and documents needed for insurance purposes, e.g., insurance reimbursements for PhilHealth, HMO, and other insurance companies.
Provides needed data for monthly mandatory hospital statistical reports.

2. Budget

Coordinates with the HIMD's needed operational budget.
Provides needed data and hospital statistics.

3. Accounting

Coordinates with HIMD in the release of operational budget based on approved work and financial plan and Project Procurement Management Plan (PPMP).
Provides needed data and hospital statistics.

4. Cash Section

● Provides order of payment for a medical certificate and other requested health record documents/issuances.

CHAPTER 2

Administration and Management of HIMD

2.1 Organizational Structure of HIMD

Fundamental to effective management is developing an organizational chart that shows the line of authority and responsibility. Likewise, it indicates the channels of communication and protocol. The institutional objectives and the principles of effective organization are considered foremost in formulating the organizational chart.

A new functional and organizational structure is proposed and is still subject to the approval of DBM as of this writing (See Figure 1) to cope with the current trends in the Hospital HIMD. There is an existing Organizational Structure, and Staffing Standards for Government Hospitals approved last 2013.

Figure 1. Organogram for HIMD.

Figure 2. Organogram for Professional and Allied Health Services.

Figure 3. Organogram for Government Hospital Level 3 with 200 to 1500 Beds.

2.2 Management Process

Management is defined as the process of getting things done through and with people. It is the effective utilization of resources towards the accomplishment of the specified objectives. Four basic components emerge from any definition of management: goals, staffing, processes/procedures, and resources.

Five Functions of the Management Process

Planning involves the identification and implementation of activities and programs to meet its objectives. Planning is the crucial step in the management process but is often the most neglected. It includes the review and evaluation of the outcome to determine if the planned objectives were achieved. The planning process for health information management involves:

Administration and Management of HIMD

setting the objectives;
developing policies and procedures, rules and regulations;
setting standards and goals; Determining the projects and programs;
implementing and monitoring the plan; and
evaluating the plan concerning the effectiveness, efficiency, and impact on the goals/objectives of the HIMD.

Purposes of Planning

It enables the HIMD to attain its goals and objectives.
It facilitates the allocation of resources (e.g., time, people, supplies).
It serves as a basis for measuring the performance and determining and addressing deviations or variances (actual vs. planned).
It serves as a useful reference in the preparation of the budget.

Table 1 below gives an example of practical HIMD planning that affects its performance.

Table 1. Example of Practical HIMD Planning

Issues	Impact	Action Plan	Timeline
1. Incomplete health record	Delay in the processing of health records, statistical reports, and issuances	Strengthen hospital policies and procedures.	End of the first quarter
2. Unauthorized access of health record	Noncompliance to Data Privacy Act of 2012	Review of existing policy. Reorientation of the HIMD personnel on Data Privacy Act.	Immediately
3. Inadequate storage	Occupational risk	Observe regular disposal of valueless records.	Annual
	Inaccessibility of health records	Request additional storage space/filing shelves.	Immediately

Organizing involves the identification, distribution, and scheduling of resources toward the accomplishment of the objectives. Organizing requires an understanding of the principle of staffing and work distribution. It also includes the allocation of materials, equipment, and space. This is how employees in the HIMD must have coordination, either within the department or with other departments.

Formalizing the organizational structure of the HIMD

a. An organizational chart is a graphic representation of all positions in the department.

b. Organizational manual. The HIMD shall have a set of written policies and procedures which shall be appropriately disseminated.
c. Organizational Development this involves the following:
- continued in-service training and development for the staff,
- regular meeting and communication between the staff and officers,
- dissemination of results of the Patient Health Records Committee meetings, and
- feedback mechanism on the performance of the staff.
3*. Directing* is the act of leading and motivating individuals to work harmoniously, effectively, and efficiently to attain the objective. It involves leadership, supervision, delegation, communication, coordination, motivation, etc.
4*. Controlling* involves comparing against set standards, identifying a unit of work and performance index.
5. Evaluating involves determining results against plans, using effectiveness and objectives, and using the efficacy and efficiency of indicators.

2.3 Physical Facilities and Equipment

The Health Information Management Department (HIMD) shall be big enough to accommodate active, inactive, and incoming health records. Ideally, it shall have a separate working area adequate for the HIMD staff and a sufficient filing/storage area for confidentiality, security, and health reasons. However, such requirements may vary depending on the category of the health facility.

HIMD shall be properly ventilated to protect the integrity and quality of written and electronically produced documents.

Volatile and flammable liquids shall not be placed inside the records room, and "NO SMOKING" and "AUTHORIZED PERSONNEL ONLY '' signages shall be strategically posted inside the HIMD.

It is crucial to consider the accessibility of the location, i.e., possibly near ER and OPD, the number of personnel, records generated, and its prescribed retention period. The designated area for the activities involves a complete area for doctors, health record imaging/scanning, and sorting of health records for filing and safekeeping. It is a must that the working area and storage area should be separated to ensure the confidentiality and security of health records.

If the space allocated for the HIMD is not enough to accommodate all records, a plan to transfer inactive records to the storage area shall be considered. This action shall decongest the filing area, give way to incoming documents, and facilitate prompt retrieval of needed health records. A health record not activated within five (5) years or as may be determined by the health facility's management after the last date of treatment and/or admission of the patient shall be considered inactive.

2.3.1 Space Requirement

Space requirement for inpatient records shall be calculated using the following formula:

(Annual Discharges including Newborn*) + (New Outpatient) x (Retention Period) Storage Space Required = ------------------------------------------------------------------------------------------- (Records per meter) * Newborn = Non-pathologic Example: Data Given Annual Discharges = 23,000 New Admissions = 6,720 Re-admissions = 16,800 Annual New OPD Registration = 3,000 Newborn = 1,000 Retention period = 15 years No. of records/meter = 200 records (23,000 + 3,000 + 1,000) x 15 Storage Space Required = --------------------------------------- 200 405,000 = ----------- 200

Note: 10% of the computed required storage space should be added to the calculated value to account for the projected increase in the number of patients/year.

= 202.5 meters of shelving

$$202.5 + 20.25 = 222.75$$ meters of shelving

To calculate the number of meters of shelving for each terminal, the formula is:

Meters of shelving required No. of meters required for each section = ------------------------------------------- No. of sections in the file 8,910 = ------------ 100 = 2.22 meters/primary section

2.3.2 Filing Cabinets for Paper-based Health Records

The open shelf type shall be used for the following reasons: space-saving, ease of filing, and easy retrieval. Although accumulation of dust and problems of security are some of its disadvantages, its advantages outweigh its disadvantages.

High stocking cabinets can be adapted to maximize the storage capacity of the filing area. However, provision for "kick stools" or "safety pulpit ladders" should be considered for the convenience and safety of the file and retrieval clerks.

Figure 4. Diagram Showing "Safety Pulpit Ladder" and "Kick Stool."

2.3.3 Cabinets for Indexes

Cabinets for indexes come in standard sizes, and these are often made of steel. For the master patient index, the cabinet must accommodate 3" x 5" index cards, whereas, for the disease, operation, and physician indexes, a cabinet for 5" x 8" cards shall be used.

2.3.4 Arrangement and Distance of Filing Cabinets

The physical arrangement of the cabinets has a direct effect on the efficiency of the filing and retrieval processes. The cabinets shall be arranged for minimum walking. It is also important to remember that the direction of the expansion of the files shall always be from left to right.

A back-to-back arrangement of filing cabinets shall also be highly considered because this saves space and maximizes the storage capacity of the filing area.

Figure 5. Standard Arrangement of Filing Cabinets.

2.3.5 Working Tables

The physical arrangement of employees' tables shall be per their workflow. Efforts shall be made to lessen the travel time of paper within the department, improve output and increase efficiency by optimizing the workplace arrangement and applying ergonomics.

Employees who are in constant contact with patients/clients shall be positioned near the main entrance. Employees performing technical jobs like coding and statisticians performing analytical work shall be placed in an area free from distraction and noise, as much as possible near the Health Information Management Officer for better supervision and control.

Figure 6. Working/Completion Area.

Transcriptionists/typists shall be positioned farther from other employees. Their area shall be acoustically treated to lessen distraction.

The HIMD Head's room shall be positioned strategically to monitor subordinates for more effective supervision and control.

Distances between tables of employees shall be maintained at 1-1.5 meters to facilitate easy movement. A space of 5.57meters per employee shall be maintained, if possible.

2.3.6 Proper Lighting

Research shows that proper lighting directly affects employee performance. The level of lighting requirement (in foot candles) varies from activity to activity. 100-foot candlelight is required for the following activities: regular office work, reading or transcribing, handwriting, active filing, index referencing, and mail sorting. Age level also has a direct influence on the light requirement. Older people tend to work efficiently and effectively in well-lighted working areas. Younger people, on the other hand, tend to prefer not too highly illuminated working areas.

The light in the storage and filing area shall be situated between cabinets. It should run parallel with the arrangement of the cabinets so that the illuminating capacity of the light is maximized.

Figure 7. Diagram Showing Proper Lighting.

2.3.7 Proper Ventilation

Planning a good HIMD layout also requires proper ventilation. It is not only considered for health reasons but also the protection of health records. Filing and storage areas with very humid conditions have harmful effects on the health records because papers absorb moisture to some extent, which could affect the quality of the health record.

2.3.8 Proper Room Temperature

It is a fact that room temperature affects the performance of a person. The temperature shall not be too warm nor too cold. The temperature which is just suitable and conducive for working shall be provided.

2.3.9 Aesthetic Consideration

Research shows that the color of the working area has a positive effect on employees' performance. So, the HIMD needs to consider light and color combinations, such as light yellow, to enhance performance and productivity.

The HIMD shall have a completion area where doctors and researchers can do their work. This area shall provide a long table, chairs, and pigeonhole for incomplete health records.

2.3.10 Equipment and materials

The HIMD shall also be provided with sufficient good-quality office supplies. The basic equipment and supplies needed are the following:

A. Mandatory

1. Working tables and chairs
1. Computers with printers and Uninterrupted Power Supply (UPS)
1. Typewriters (electric or manual)
1. Photocopying machine
1. Air-conditioning unit or electric fan
1. Exhaust fan
1. Sufficient filing cabinets for records, indexes, and registers
1. Safety Pulpit Ladder/Kick Stool
1. Coding Tools (e.g., International Classification of Diseases (ICD), RVS International Classification of Diseases-9-CM, medical terminology, bookstand, bookmarker, electronic coding tools, etc.)
1. Medical Dictionary
1. Atlas Human Anatomy Book
1. Stamper and stamp pad/ Self-inking stamp
1. Dry Seal
1. Telephone Service/Mobile phone service
1. Paper Shredders
1. Numbering machine
1. Calculator
1. Heavy-Duty Puncher/Puncher
1. Heavy-Duty Stapler/Stapler
1. Heavy-Duty Staple Wire Remover
1. Heavy-Duty Puncher/Puncher
1. Pencil Sharpener

Administration and Management of HIMD

1. Fire Extinguisher
1. Emergency Light
1. Mini hammer

B. Optional

1. Mobile-compactor
1. Paper Scanner (heavy duty)/Document Management Imaging System (DMIS)
1. Facsimile (Fax machine)
1. Air purifier
1. Automatic Punching Machine
1. Paper Binder
1. Barcode scanner
1. Vacuum Cleaner
1. Automatic Punching Machine
1. Heavy-Duty Paper Cutter
1. Index Card Sorter

2.4 Standard Staffing Pattern

For the HIMD to be efficient and more responsive to the needs and demands of its clientele, it shall have the required number of staff concerning its bed capacity and the volume of work to be done.

The category of the health facility determines the number of staff required by the HIMD. A research health facility that needs a more comprehensive and sophisticated records-keeping system shall naturally require more staff than an institution that is not engaged in research and teaching.

Furthermore, the required HIM staff ratio shall be 1:20 of the Authorized Bed Capacity (ABC) for In-Patient and Outpatients; the ratio shall be 1:35 visits per day.

The classification of personnel in the HIMD of a health facility shall depend on the following: (1) classification of the Director/Medical Center Chief, and (2) category and bed capacity of the health facility.

(See Annex U for the qualification requirements and job descriptions for the different categories of the HIMD staff.)

2.4.1 Staff Development

A. Internal

Orientation of HIMD staff about the existing policies and procedures

1. Rotation of staff within the HIMD every two (2) years, or upon recommendation by HIMD Head
1. Facilitation of in-service training and continued education of staff within HIMD
1. Participation and involvement of staff in planned changes
1. Evaluation of staff performance involving effective changes of work undertaken
1. Values Orientation Workshop

B. External

1. Basic/Advanced Health Information Management
1. Latest International Classification of Disease Coding of Diseases
1. Latest Advanced Mortality ICD Coding
1. Clinical Documentation Improvement
1. Problem-Oriented Health Records Training
1. Risk Management in HIMD
1. Data Privacy Act
1. Medico-Legal Aspects on HIM
1. Civil Registry Updates on Birth and Death
1. Records Administration and Disposition
1. Medical Certification on the Cause of Death
1. Health Facility Statistical Report Preparation

CHAPTER 3

Health Record Standards and Policies

Standards and policies are critical in the HIMD to achieve a uniform practice for efficient and effective health information management. Since patients' health records serve as a form of communication between health care professionals, the quality and form of these records must adhere to certain standards.

Standards are a set of desired and achievable levels of performance against which actual performance is measured. Standards enable health organizations to imbed practice and effective quality improvement into their daily operations.

On the other hand, policies serve as a framework or general guide consistent with organizational decision-making objectives.

This chapter shall define the standards and the corresponding policies needed to achieve uniform and consistent practices within and across health facilities. Observance and adherence to said standards and policies will help improve the quality of patient care management. In implementing these standards, it is likewise important for health facilities to assess and modify them according to their context. However, the modification should not deviate from the standard to adversely affect departmental performance and quality of patient care in general.

3.1 Overall Considerations in defining the Philippine Health Record Standards

The overall considerations in defining the Philippine Health Records Standards include:

1. licensing Standards as defined in Administrative Order No. 2012-0012,
1. other regulatory/ mandatory policies:
- a. RA 10173, also known as the Data Privacy Act of 2012 and its Implementing Rules and Regulation (IRR), an act protecting Individual Personal Information and Communications System in the Government and the Private Sector, creating for this purpose a National Data Protection Commission and other purposes,
- b. RA 11223, also known as the Universal Health Care Act, and its IRR
- c. AO 2013-0005, entitled National Policy on the Unified Disease Registry Systems of the Department of Health (Chronic Non-Communicable Diseases, Injury Related Cases, Persons with Disabilities and Violence Against Women and Children Registry System) its amendment, and
d. RA 9470, also known as the National Archives Act of the Philippines 2007, includes the DOH Circular No. 70, s. 1996, dated May 8, 1996, Revised Disposition of Medical Records Amending Ministry Circular 77, s. 1981, proposed by DOH and duly approved by the National Archives of the Philippines,
1. International Health Record Standard as defined by the Joint Commission International Accreditation Standards,
1. PhilHealth Benchbook, and
1. International Organization for Standardization (ISO 9001:2015).

3.2 Philippine Health Records Standards and Policies

3.2.1 Standard 1: Health Record Creation

3.2.1.1 Specific Standards

1. The health facility shall initiate and maintain a standardized health record for every patient assessed or treated and determine the record's content, format, and location of entries.
1. Health records of patients should meet the education, research, and statutory requirements as provided by law.
1. Each patient confined and consulted in a health facility has a sufficiently detailed health record that correctly identifies the patient, supports the diagnosis, justifies the treatment, and documents the course and results of treatment.
1. The collection of personal information is accompanied by a Data Privacy Consent form to be signed by the patients or their authorized representative.
1. Authorized personnel to make entries in the health record are clearly defined as per Hospital Policy.
1. The health facility uses standardized diagnosis and procedure codes and ensures the standardized use of approved symbols and abbreviations across the hospital.
1. The health records of patients receiving emergency care include the time of arrival and departure, the conclusions at the termination of treatment, the patient's condition at discharge, and follow-up care instructions.
1. Relevant, accurate, quantitative, and qualitative data are collected and used in a timely and efficient manner to deliver patient care and manage services.
1. Patient charts are coded and indexed to ensure timely production of quality patient care information and reports to PhilHealth.
1. The hospital has a process to address the proper use of the copy and paste function when electronic health records are used.
1. Standard Health Record Arrangement
- a. Clinical Cover Sheet

Health Record Standards and Policies

b. Admission slip
c. Triage slip
d. Data Privacy Consent Form
e. Informed Consent for Admission or Confinement
f. History and Physical Examination
g. Discharge Summary
h. Clinical Laboratory Test Result Forms
i. Doctor's Order and Progress Notes
j. Nurses Notes (FDAR)
k. Monitoring Sheet
l. Intravenous Fluid Sheet
m. Medication Sheet
n. Pharmacist's Notes/ Pharmacist's Intervention Form
o. Nutrition Care Plan
- TPR
- Pain Monitoring Sheet
- Input and output
- Vital Signs

3.2.1.2 Specific Policies

1. HIMD shall use standardized forms to ensure overall quality care, at the same time, serve as an effective cost control measure. WHO recommended in 1969 that ". . . consideration should be given to standardizing the medical record at the national level, to include the size of the folder, the size of the record form, and the content of the case summary. This should be within an individual hospital or with all hospitals of a system."
1. A Forms Committee should be established to help the Head of the Health Information Management Department determine the forms needed by the hospital and the proper design of the documents. The Patient Health Records Committee (formerly known as Medical Records Committee) could also function as the Forms Committee if the former is already in existence, subject to approval by the Hospital Management.
1. All forms in the health record must be reviewed and approved by the Patient Health Records Committee and registered with the Document Controller before officially being used.
1. Health record forms consist of standard/primary and supplemental/special forms. Standard or basic forms are those that are fundamental to or essential portions of all health records. Supplemental or special forms are forms added to certain patient health records as required by the case. These forms shall be added after the standard health record arrangement.
1. A consent form from the health facilities shall be incorporated in the admission/confinement form of hospitals. These treatment/ health facilities shall be accomplished before the patient's admission or management.
1. The health facility identifies staff members who are authorized to make entries in the patient health record. Thus, every patient health record entry identifies its author and shall indicate when the entry was made.
1. All health records shall contain all relevant and complete demographic data of the patient, at least but not limited to the following:

a. For OPD Records

Patient Hospital Number
Patient's full name
Address
Date of Birth
Place of Birth
Age
Gender
Civil Status
Religion
Nationality
Contact Number
E-mail Address
Name of Spouse
Father's name
Mother's name
Next of Kin to notify
- Address
- Relationship to patient
Contact Number

b. For Inpatient Records

In addition to the OPD patient's demographic data, the following shall be included:

File Number,
Room Number,
Admission date/time,
Discharge date/time,
Length of stay,
Social Service Classification,
Admitting Diagnosis, and
Alert notation for Allergies and Adverse Drug Reaction.
1. A health record with pending diagnostic results shall be completed in the HIMD within 15 days after the patient's discharge; otherwise, it shall be considered a delinquent health record.
1. The Attending Physician (AP)/nurse on duty and other authorized staff have the final responsibility for the completeness and accuracy of the data entered in the health record. The discharging nurse on duty shall be responsible for counterchecking the completeness of the health record as to documentation and quantity before endorsing the same to the HIMD.
1. The accomplishment of History, Physical Examination, and Discharge Summary may be delegated to the interns. However, these records shall be reviewed, corrected, and countersigned by the attending Physician.
1. The HIMD staff shall assist the attending Physician in reviewing records for completeness by checking for omissions and discrepancies to ensure that health records comply with set standards and policies.
1. The processing of health information for certificates adhere to the following policies:

a. Certificate of Live Birth

The accomplishment of the Certificate of Live Birth shall be under the Civil Registry Administrative Book No. 1, series of 1993 (Implementing Rules and Regulations of the Republic Act no. 3753 and other laws on Civil Registration).
Preparation of the Certificate of Live Birth of all babies born inside the health facilities shall be done by the person who has witnessed the baby's (babies') delivery.
Only the baby's parents shall be interviewed and shall sign the Certificate of Live Birth. If the mother dies or is mentally incapacitated, the husband or any nearest kin shall act as the informant and sign the Certificate of Live Birth.
For illegitimate births, the father may execute the Affidavit of Acknowledgment/Admission of Paternity as father and his surname reflected in the Certificate of Live Birth. Further, the mother must sign the Affidavit to Use the Surname of the Father (AUSF), duly notarized.

b. Certificate of Death

Preparation of the Death Certificate shall be done by the person who has witnessed the occurrence.
All the data given by the informant are presumed correct, and the health facility shall not be held liable for any erroneous data entered in the death certificate.
No correction of data shall be done unless supported by a duly notarized affidavit of correction and other supporting documents. However, a death certificate that bears the LCR registration number will no longer be corrected.

c. Certificate of Fetal Death

Registration shall be made in the office of the City Municipal Civil Registrar where the event occurred.
Registration should be made within the 30-day reglementary period.
The Certificate of Fetal Death is to be accomplished in 4 copies; with assigned registry number and entered in the Register's Book of death.
If the death occurred in a health facility, the hospital (care) administrator, the parents, relatives, or the attendant of the patient should register the Certificate of Fetal Death

3.2.2 Standard 2: Health Record Documentation

3.2.2.1 Specific Standards

a. The health record is a legal document. No form may be detached once it is filed at the HIMD.
b. The health record contains a complete and accurate set of information to facilitate effective and efficient patient care management.
c. All documentation must be legible and written in ink or typewritten.
d. Decision-makers and other staff members are educated and trained in the principles of information use and management.
e. Written documents, including policies, procedures, and programs, are managed consistently and uniformly.
f. On their first encounter, a health record number is assigned to the patients and will serve as their permanent unique identification number for future visits to the health facility.
g. Refer to Chapter 4 for Health Record Systems and Procedure.

3.2.2.2 Specific Policies

a. The health record shall contain all original copies of examination results, operations, and other required forms.
b. There shall be a standard format for health record documentation which must include demographic and assessment data.
c. Each form in the health record shall contain at least two (2) of the following unique identifiers: Health Record Number (HRN), Patients Name, Date of Birth, and Date of admission/consultation.
d. Collection of personal data shall include a Patient Information Sheet accompanied by a Data Privacy consent form to be signed by the patient/authorized representative, the latter to form part of the health record.
e. All required forms shall be appropriately filled out. If not applicable, NA or None shall be placed. For skipped and blank spaces, a single slanting line from bottom to top shall be drawn, and the persons responsible shall affix their signature over their printed name.
f. All consent forms shall be appropriately filled out and accomplished to be attached to the health record as needed.
g. All entries in the health record shall be made only by duly authorized staff of the health facility with the print name, signature, and designation of the author and date and time such entries were made.
h. The health record shall contain an Admitting Diagnosis by the medical practitioner who admitted the patient.
i. The health record shall contain the patient's history pertinent to the condition being treated and relevant details of family history, present, and past medical history, and physical examination accomplished by the AP within 24 hours from the date and time the patient was first seen.
j. The health record as a legal document must have no erasures of any sort. Entries made in error shall be immediately corrected legally. Refer to Chapter 4 under Analysis of the Health Record for the procedure in correcting an error.
k. Correction and additional entries in the health record shall be made while the patient is still admitted and while the health record has not been processed.
l. If the patient requests for the correction of personal data and demographic information, the patient shall accomplish an amendment form and attach a Valid Identification (ID) Card, birth certificate, marriage contract or any of the identity documents listed under PSA Memo Circular No. 2019-16 dated June 11, 2019.
m. If there is a need for additional entries and the space would not be enough, a separate blank sheet shall be properly labeled with the patient's name, hospital number, birth date, date of consultation/admission. It will be called an addendum to the chart.
n. No abbreviations shall be used in writing the patient's final diagnosis in the clinical cover sheet, discharge summary, clinical abstract, operative record, and medical certificates. Only abbreviations and symbols approved by the World Health Organization (WHO) and the medical center chief upon the recommendation of the Patient Health Records Committee (PHRC) are allowed.
o. Documentation using forms specific/ unique for clinical departments, nursing service, and other allied services shall follow the standards in completion as agreed upon by their specific departments/units/particular areas that utilize the forms. As such, HIMD staff shall evaluate the form as completeness and legibility and not content relevance.
p. Drug orders shall be clearly written in the health record by the attending physician.
q. Therapeutic and special diagnostic test orders shall be reflected in the health record.
r. Progress notes, observations, and consultation reports shall be written by the physician and the nursing and allied staff of the health facility.
s. A certified copy of the discharge summary and an accomplished original document of referral notes shall be issued when a patient is transferred to another facility.
t. A discharge summary for each patient shall be completed upon patient discharge and shall include but not be limited to discharge diagnosis, procedures performed, follow-up arrangements, therapeutic orders (home medications), and patient home instruction/s.
u. In processing the Certificate of Live Birth, the health facility shall be responsible for its transmission to the Local Civil Registrar within thirty (30) days.
v. When an autopsy is performed, a provisional diagnosis shall be made. The final diagnosis shall be noted in the health record within 48 hours after the occurrence of death. A copy of the autopsy report shall be filed in the health record.
w. The health facility shall develop an ongoing review of health records to assure quality documentation. This shall be one of the primary duties of the Patient Health Records Committee (formerly known as the Medical Records Committee.)

3.2.3 Standard 3: Health Record Storage and Safekeeping

3.2.3.1 Specific Standards

a. The health facility safeguards the health records against loss/destruction or unauthorized use.
b. Inactive records are transferred to inactive filing storage to give way to the incoming records, decongest the area, and facilitate retrieval.
c. The Integrated Hospital Operations Management Section (IHOMS) is responsible for storing health records on the server.
d. Inherent to health records is the ability to be retrieved for any authorized use. A good retrieval system reflects the efficiency of the HIMD.
e. A good filing area that ensures the speedy location and retrieval of health records must be maintained.
f. Refer to Chapter 2, Administration and Management of HIMD on the specifications on Physical Facilities and Equipment and Chapter 4, Health Records Systems and Procedures

3.2.3.2 Specific Policies

a. The health facility shall be responsible for providing the HIMD with appropriate office space and storage area considering the health and safety requirements of staff, and (specifically for storage area) with proper environmental controls and adequate protection against fire, flood, and theft.
b. Health records in whatever form or media shall be kept by the health facility for the duration of time required by the Department of Health's records retention regulation mandated by Republic Act No. 4226 or the Hospital Licensure Act.
c. Health records shall not be taken out of the hospital premises except on court orders.
d. The health facility IHOMS shall be responsible for ensuring an efficient and effective program for HIMD, with provisions for back-up and records recovery and security measures.
e. All health records not in the processing stage and not in use shall be placed in the file/storage area.
f. Health facilities shall adhere to the provision of Department Order No. 13-A, Art. III, Rule 2.2 states that "Agencies shall not dispose of their health records earlier than the period indicated for each record series. However, records may be retained for longer periods if there is a need to do so."
g. Disposal of health records shall be guided by the latest Records Disposition Schedule issued by the Philippines' National Archives.

3.2.4 Standard 4: Health Record Accessibility

3.2.4.1 Specific Standards

a. Health records are readily accessible to facilitate patient care, are kept confidential and safe, and compliant with all relevant statutory requirements and codes of practice.
b. Information privacy, confidentiality, and security, including data integrity, shall be strictly observed.
c. The health facility may release health information without the written authorization of the patient in the following situations:
- 1. Court order,
- 1. Administrative agency order,
- 1. Subpoena duces tecum,
- 1. Subpoena ad testificandum,
- 1. Subpoena mandamus,
- 1. Arbitration order, and
- 1. Search warrant.

3.2.4.2 Specific Policies

1. Access to Health Records

a. The health facility shall have a filing system maintained in a definite sequence at all times to facilitate accessibility and prompt retrieval of the health records.
b. A patient's request to access his record may not be allowed to prevent misinterpretation of technical and medical information, which may lead to complaint/litigation. However, the patient's physical and mental condition shall be explained to him by his attending physician.
c. Physicians access to health records:
- Physicians and members of the allied health profession may review records of patients presently under their care.
- Physicians who are medical staff members but are not members of the team assigned to the patient shall require a written authorization signed by the patient/parent/guardian and the Attending Physician before giving access to the record.
- The privilege against disclosure belongs to the patient and not to the Attending Physician (AP).
- The health facility management may withhold access to the health record

until a subpoena is issued.

Consent from the patient and Attending Physician shall be required of company physicians presently caring for the patient before giving access to health records.
Visiting consultants shall have access to records of patients referred to them.
It shall be the attending physician's responsibility to inform the patient about the latter's health condition.
Members of the Medical Staff may review charts of readmitted patients for continuity of care with the verbal or written consent of the main Attending Physician from the prior admission/consultation.

d. Nurses access to health records:

Student nurses shall have access to patients' health records while the patient is still in the ward.
Private Nurses shall only be allowed to review the health records of those patients assigned to them.
Ward nurses may review and complete all health records before forwarding them to the Health Information Management Department.
Ward nurses must always see that health records are secure away from the patients or the patients' relatives.
Ward nurses shall be liable for the loss of a patient's health record while the patient is still admitted and for the health records of discharged patients which have not yet been forwarded and endorsed to HIMD.

e. Other Interested Parties

An authorized insurance verifier shall be required to submit an original copy of the patient waiver, duly notarized before accessing the health record/information about a patient. The waiver shall also be countersigned and dated by the insurance verifier and filed in the health facility. Insurance verifiers representing the Philippine Health Insurance Corporation and other Health Maintenance Organizations shall be properly identified by the Head of the HIMD before accessing and reviewing health records.
Authorized researchers from other medical institutions could gain access to health records only after complying with the requirements set by the concerned institution.
Patients' relatives making inquiries about the health status of their patients shall be referred to the attending physician.
Adjudicatory agencies, i.e., Philippine National Police, National Bureau of Investigation, and other law enforcement agencies, shall need a

written request duly signed by the Chief/Director of their respective agencies before being given access to the record.

2. Exceptions to the Policy on Access to Health Record

Instances where information contained in health records may be released without proper authorization from the patient shall be limited to the following cases:

a. Court Order. Hospitals and other health facilities shall release health information in response to court orders;
b. Administrative Agency Order. A health provider shall release health information when there is an adjudicative order from an administrative agency;
c. Subpoena Duces Tecum or Order. Subpoena Duces Tecum or order directs the head of the HIMD or an authorized representative to appear in court on a specified date and time to certify as to the authenticity of health records submitted as evidence;
d. Subpoena Ad Testificandum. Subpoena Ad Testificandum mandates physicians and other allied health professionals to deliver oral testimony in court. The document shall be served personally to the individual named therein, NOT to any member of the HIMD Staff;
e. Subpoena Mandamus. Subpoena Mandamus is a judicial order that mandates a health facility to present a health record in court;
f. Arbitration Order. An arbitration panel may issue an order authorizing a health facility to present specific portions of the health record before an arbitration proceeding;
g. Search Warrant. A government law enforcement agency that has issued a search warrant shall be entitled to receive any health information covered by the warrant;
h. Medical Research. Refer to standard 7 of this chapter; and

Refer to Chapter 6 for Health Records in Medico-legal, Investigative, and Court Procedures.

3. Review of Health Records

a. The reviewer shall accomplish a written letter of request or a data request form (Refer to Annex O, Form on Request for Access to Health Records) from the following before being given access to the health records:
- City Government,
- Regional Epidemiology and Surveillance Units (RESU),
- Provincial Government,
PHIC and DOH licensing inspection team,
Medical Audit Committee on Investigation, and
Complaints from clients.
b. Insurance verifiers shall be required to submit a notarized original copy of the waiver signed by the patient/or an authorized representative before being given access to the health record.
c. DOH RESU staff are allowed to review charts of cases reported to them as per RA 11332; a data request form shall be accomplished before they are given access.

4. Accession and Borrowing of Health Records

a. As a general rule, NO health records shall be brought out of HIMD except for legitimate purposes by legitimate requestors.
b. Legitimate requestors shall include the main Attending Physician, Chief Resident, Head Nurse as per old chart to the floor, Researcher and/or Principal Investigator, Chairman Medical Audit/ Quality Assurance Committee, PhilHealth Section of the health facility, Disease Surveillance Officers, Medical Center Chief, Assistant Hospital Director for Health operations and Chairmen of Investigation Committees.
c. HIMD personnel shall seek permission from the last main attending physician based on records if a new physician would want to be given access to the said record.
d. Physicians and allied health professionals may review records of patients presently under their care. If a patient is co-managed, the attending physician shall be notified by phone or in writing before permitting the borrower to access the health record.

5. Release of Health Information

a. All information in the health record shall be treated as confidential and safeguarded against loss, destruction, and unauthorized use.
b. Only authorized persons shall be given access to health records with personal and sensitive personal information.
c. Patients may not be allowed to access their health records to prevent misinterpretation of medical information, which may lead to complaint/ litigation.
d. Patients' relatives making inquiries about the patient's health status shall be referred to the attending physician.
e. Release of information with clinical value shall be done with the consent of the physician in charge to prevent misinterpretation.
f. Verbal requests for clinical information shall be discouraged in favor of a written appeal.
g. The health facility shall safeguard all information contained in the health record against loss, destruction, or unauthorized use.
h. It shall be the policy of all health facilities not to use the health record in any way that will jeopardize the patient's interest. Conversely, the health facility may use the record to defend itself against any complaint or legal controversy/case.
i. The authority to release information is delegated to the Head of the Health Information Management Department. If a problem arises beyond control, the matter shall be referred to the Chief of Medical Professional Staff/ Chief of the Health Facility for decision/appropriate action.
j. Parental consent or that of the legal guardian shall be secured before any information of clinical significance is released if the patient is a minor.
k. The health record is the physical property of the health facility. However, patients have the right to the record since its content concerns their clinical information. As such, the release of information with clinical value shall be done only upon explicit, written consent/waiver from the patient.
l. In cases where litigation is likely to happen and is intended against the health facility or any of its staff, the Chief of the Health Facility may refuse or deny access to the record even with the patient's written authorization, except on court orders.
m. The issuance of Certificate of Confinement signed by the HIMD head for patients still admitted and Medical Certificate to patients who are still confined with a working diagnosis approved and signed by the Attending Physician may be allowed for the legitimate purposes.
n. Certified photocopies of portions of the health record may be released upon patient's request but shall be limited to discharge summary, clinical abstract, laboratory and diagnostic results, and report of operation.
o. No portion of the health record shall be reproduced, printed, photographed, or photocopied, in any manner without the explicit, written consent by the patient or parent/s or guardian of the patient if the latter is a minor, and/or approval by the HIMD Head.
p. In the event that a patient is unable to sign the authorization because of physical or mental disability, the consent should be signed by the next of kin or the legally appointed guardian. If possible, verification of such disability should be obtained from a physician.
q. If the patient died, the consent must be signed by the identified next of kin or by the administrator or executor of the decedent's estate.
r. Institutional policy referenced in the provisions of the Data Privacy Act of 2012 shall be considered before the release of non-clinical information, i.e., name of patient, address, Attending Physician, name of relative staying with the patient during admission, admission, and discharge dates.
s. The health record shall not be taken out of the health facility premises except on court orders. Those authorized to do research and studies shall use the records inside the HIMD Office.
t. Incomplete health records shall be referred to the Attending Physician before entertaining any authorized request to access and review the health record.
u. The staff of the Medical Social Service shall have access to the health records to establish patient classification and referrals.
v. Death Certificates shall be released only to the nearest of kin. The person who claimed the death certificate should be responsible for the LCR registration within 48 hours after death.
w. Information may be released to other health facilities where the patient is now under their care upon the facility's written request.

6. Health Information and Aggregate Data Requests

a. The Data Privacy Officer shall verify the authenticity and purpose of the request for the health data and shall have the authority to approve and disapprove.
b. Legitimate requestors shall fill out the data request form (Refer to Annex O, Form on Request for Access to Health Records) stating the purpose and indicating the sole and exclusive use of the data.
c. Legitimate requestors shall not, in any case, reproduce, distribute and/or publish the data and shall securely and adequately dispose of the same after use.
d. Disclosure of Health Information to legal authorities or any government agency may only be allowed under a lawful order of a court or upon presentation of a written request duly approved by the Head of the health facility, or a duly authorized representative.

3.2.5 Standard 5: Health Record Report Generation

3.2.5.1 Specific Standards

Requisition of needed data and information to the hospital are met on a timely basis and in a format that meets user expectations with the desired frequency.

1. The organization provides resources for data generation, collection, and aggregation methods.
1. For health facilities using iHOMIS or other information systems, all data needed for statistical report preparation shall be electronically recorded and generated. Hence a manual collection of data shall be no longer necessary.

Refer to Chapter 5 on Hospital Statistics and Annex for the list of Standard formulas.

3.2.5.2 Specific Policies

1. All diagnoses and surgical/medical procedures in the health record shall follow the International Classification Standards for generating statistical reports using quality statistics data.
1. All hospitals shall adhere to RA 4226, otherwise known as the "Hospital Licensure Act," by ensuring that the Hospital Statistical report is prepared and submitted to regulatory agencies following the set standards.
1. Generating, preparing, and submitting hospital statistical reports shall emanate from units concerned where data are captured and encoded. All units shall submit all needed reports to HIMD without delay.
1. Each department/unit shall have an existing mechanism and work instructions in collecting data for every service encounter for required reports.
1. All hospitals shall abide by AO 2013-0005 or the National Policy on the Unified Disease Registry System of the DOH based on the final diagnosis for each health record received. HIMD is obliged to report all reportable cases for UDRS online and shall maintain a log of reported cases for legitimate purposes.
1. Generated statistical data collated by respective departments and units shall not be limited to required reports in the Annual Hospital Statistical Report required by the Department of Health.

3.2.6 Standard 6: Continuous Quality Improvement

3.2.6.1 Specific Standards

1. Data from the patient charts are routinely collected, aggregated, and reported for use in quality improvement activities and administrative purposes enhancement and mandatory reporting to the DOH and PhilHealth.
1. As part of its monitoring and performance improvement activities, the hospital regularly assesses patient health record content and completeness.

Refer to Chapter 8 on the Continuous Quality Improvement for HIMD.

3.2.6.2 Specific Policies

Quality improvement activities shall be evidence-based and shall utilize the riskbased approach.

2. HIMD shall pursue CQI to:

strengthen the implementation of the existing SOPs of HIMD;
provide quality health records for the continuity of care and research purposes; and
assess and determine the quality of service delivered and identify the areas that need improvement to attain excellent service.
1. The results of the implementation of QI activities and continuous monitoring using relevant indicators by HIMD shall be integrated with iHOMIS or their existing hospital information system and utilized in decision-making.
1. The health facility's Integrated Hospital Operations Management Program shall extend full assistance to HIMD to coordinate continuous improvement efforts.
1. HIMD shall undertake a continuous improvement of its processes to improve the quality of service to patients.

3.2.7 Standard 7: Medical Research

3.2.7.1 Specific Standards

1. There should be a unified and clear guideline in the data gathering procedure for approved research and clinical trials in the health facility.
1. Principal investigators for institutional researchers and outside physicians intending to do research may be given access to review patients' health records enrolled in their study provided the research has been approved by the health facility's Research Ethics Committee (REC).
1. The health facility shall safeguard all information contained in the health record against loss, destruction, or unauthorized use.
1. Hospital Management may, at its discretion, permit the use of health records for research, stressing that no information which will directly identify the patient shall be published.
1. The anonymity of respondents/participants is assumed to be an integral feature of Ethical Research.

3.2.7.2 Specific Policies

1. Health information shall be disclosed to public agencies, clinical investigators, Healthcare organizations, accredited education, or health institutions for bona fide research purposes.
- a. Regulatory body They can access health records of research-related information, sourced document data concerning their role as a regulatory body. Upon request of the auditor, IRB (Institutional Review Board)/REC, or regulatory authorities, the Investigator/Institution should make available for direct access to all requested trial-related records.
They shall advise the HIM Department on any incoming activities for the readiness of the health records to be accessed
b. Clinical Research Monitors/Associates may access personal health information, which is acceptable based on including one or more of the following controls. The Institutional Review Board (IRB) or Ethics Committee approves informed consent signed by the patient or his legal representative, including the authorization for access to Protected Health Information (PHI).

The Informed Consent Form should explicitly state the following:

what is the process of collection of confidentiality of information during the clinical trial;
how records that identify the subject will be kept; and
the possibility that the FDA or other authority may inspect the records.

The Informed consent form that is signed and dated by the subject is valid.

Authorization signed by the patient or his legal representative grants access to his PHI.
They are to ensure the security of patient information by signing the Non-Disclosure Agreement prior to its access.
c. Internal researchers shall seek the approval of the hospital management prior to access to health records and shall follow the HIMD protocol on access.
- A Non-Disclosure Agreement (NDA) shall be executed by the staff who have access to health information and/or are involved in processing personal data/health information.
d. External Researchers/Physicians from other medical institutions intending to do research/studies in a particular health facility shall seek the written approval of the management before they are given access to the health record.
- All information in the health record shall be treated as confidential and shall be disclosed only to authorized individuals.
1. Consent from the data subject shall be required prior to processing health information in all health facilities.
1. An approved informed consent document signed by the patient or a legal representative includes the authorization for access to Protected Health Information (PHI) and must contain the following:
- a. the name and signature of the patient authorizing the release of medical information,
b. the date of the written authorization,
c. the name of the individual or organization that is authorized to release the medical information,
d. the name of the designated representative (individual or organization) that is authorized to receive the released information, and
e. a general description of the medical information that is authorized to be released.
1. Confidentiality of patient's data shall be maintained at all times and shall be used only for the declared purpose stipulated in the patient authorization/consent.
1. Access to information with clinical value shall be done only with the written consent/waiver from the patient.
1. Where the patient is a minor, a parent's consent or that of a legal guardian shall be secured before any information of clinical significance is accessed.
1. Health care providers directly attending to the patients and authorized entities shall have access to the patient's health information provided that an accomplished consent form from the patient is present.
1. Consenting patients or clients shall have the right to access how their personal data/health information shall be used. The health facility shall ensure that disclosures and any subsequent changes are under the law and are properly documented.
- a. The health facility/HIMD shall ensure that the research is legitimate and safeguard all information contained in the health record against loss, destruction, or unauthorized use.
  - Hospital Management may, at its discretion, permit the use of health records for research, provided that no information which will directly identify the patient shall be published.
  - A copy of the approved protocol by the Institutional Review Board (IRB)/Research Ethics Committee that contains the patient authorization/consent shall be submitted to HIMD to ensure the legitimacy of access to patient information.
  - Health records shall not be taken out of the health facility except on court orders. Those authorized to do research and studies shall use the records inside the HIMD only.
  - No cameras in any form shall be authorized inside the HIM Department while doing research.
- b. It shall be the policy of all health facilities not to use the health record to jeopardize the patient's interest.
The rights of the data subject shall be respected and protected at all times in processing data.
For the processing of health information, the processor shall ensure the utmost protection of the right to privacy of an individual.
Processing of personal information shall be held under strict confidentiality and shall be used only for the declared purpose.
In processing health information for research, research institutions/individuals shall comply with the legal and ethical standards following the National Ethics Guidelines for health and health-related research and other pertinent rules and regulations.

CHAPTER 4

Health Record Systems and Procedures

An effective and efficient health record system depends on the procedures used for facilitating and handling health records. In managing patient's health records in hospitals, the following procedures are done in sequence: creation, assembly, analysis, coding and data collection for statistical data, and filing.

Figure 8. Process Flow of Health Record.

4.1 Creation of Health Record

Creating a health record through patient registration is the first step to establish patient identification for safe, accurate, effective, and efficient patient care. All personal information needed for patient care shall be obtained and reflected in the health record.

4.1.1 Health Record Identification System

Two things are highly considered in identifying health records. First is the correct and complete name of the patient, and second is the assigned health record number (HRN).

The patient's name is recorded in the following manner: the last name, first or given name (including extension names, e.g., Jr., III, etc.), and middle name as a way of alphabetically identifying a health record. The HRN is assigned to a patient upon admission or consultation, which serves as a unique numerical identifier for a particular patient to manage health records effectively.

Using a unit number to uniquely identify a patient directly influences the filing system for prompt and timely retrieval of health records. A unique record identification is needed, whether alphabetic or numeric system, to avoid duplication and discrepancy.

4.1.1.1 Alphabetic System

The Alphabetic System is the simplest form of record identification, using the patient's name to identify and file the patients' health record.

In filing health records using the alphabetic system, the arrangement is the last name, first or given name and middle name. In cases where the last names are the same, consider the first name, and if the last and given names are the same, the middle name is to be noted. If the aforementioned has already been applied, arrange the patients' records by birth date. (Refer to 4.6 Filing of Health Record for further discussion.)

4.1.1.2 Numerical System

The Numerical System has a direct influence on the filing system. Upon admission, the patient's unique Health Record Number shall be assigned. The use of a Master Patient Index (MPI) to cross-reference the patient's name with their HRN is required.

Two main systems of numbering the patient health record

1. Serial Numbering

Under this method, the patient receives a new number on every inpatient admission or outpatient visit to the health facility. The patient is treated as a new patient with a new number, index card, and record filed independently from previous health records.

Serial numbering is only useful in a small health facility with a low daily census (re-admission rate).

2. Unit Numbering

The patient shall be assigned a unique identification number or HRN on the first contact with the health facility, whether for an admission, emergency room attendance, or outpatient clinic visit, including the newborn babies delivered in the health facility. The use of unit-number leads to the implementation of a unit record. Irrespective of the number of records, patient's health records are filed in one folder only.

The same number is maintained and used on all subsequent inpatient, outpatient, or emergency visits. Having a number assigned per patient and only one Master Patient Index card results in easier access to the patient's health record.

When using a unit record, it is essential for all HIMD staff to check the MPI before issuing a new health record folder.

Advantages of Unit Numbering

● Provides an integrated overall picture of a patient's medical history because all records of admissions, visits, and encounters are maintained in one folder only, commonly known as a unit record.

Health Record Systems and Procedures

Eliminates the task of gathering separate parts of a patient's health record together, like in the serial system where a new number is given to a particular patient after every admission or visit.
Eliminates the task of transferring the previous health record to the new location and assigning a new admission number.

The Unit Number. A patient admitted or attended as an outpatient or an emergency, including a newborn baby, is issued a six-digit identifying number. This is the patient's unit number, also called the Health Record Number (HRN).

The HRN is grouped into three sets of two-digits. These are referred to as the primary, secondary, and tertiary numbers.

Example of a unit number:

16 55 82 Tertiary Secondary Primary

Assignment of the Unit Number. The collection of patient data and the assignment of the HRN should be the first step in every admission or visit to a health facility, and it is done either at the Admitting Office or Outpatient Department (OPD). This facilitates the retrieval of properly identified documents.

Two ways by which numbers can be assigned

a. Centralized Assignment of Numbers. The responsibility for number allocation is lodged under the Admitting Unit of HIMD.
b. Decentralized Assignment of Numbers. Predetermined blocks of numbers are issued to the Admitting Office/OPD. This is done by the hundreds, depending on the projected number of patients for the day. This process should be done with utmost care as the chances of duplication are more significant than when only one area is in charge of assigning patient numbers.

Six-digit numbers are used, ranging from 00-00-00 to 99-99-99. The first health record received by the HIMD shall be numbered 00-00-00, the second health record, 00-00-01, and so on, until the first hundredth record, which shall be numbered 00-00-99, is reached. The record after this shall be numbered 00- 01-00, the next, 00-01-01, followed by 00-01-02, and so on until it reaches 00- 01-99. Next shall be 00-02-00 to 00-09-99 then from 00-10-00 to 00-99-99, next 01-00-00 until 99-99-99. If the six-digit numbers are already used, the numbers will expand to 8 digits and so on (e.g., 01-00-00-00)

Numbering of the records shall be done serially, and the necessary digits are added to complete the required six digits. The HIMD must keep numbering patients regardless of whether the health record is for inpatient or outpatient to maintain a centralized health records-keeping system. The HIMD with a decentralized health records-keeping system shall maintain a separate number for inpatient, outpatient, and E.R. patient's records.

When the HIMD starts implementing the unit numbering system, the last health record that receives on any given day plus one (1) shall represent the total number of patients the health facility has served. Hence, if the last number assigned is 00-20-99, then the health facility has served a total of 2,100 patients.

4.2 Assembly of Health Record

4.2.1 Inpatient Health Record Assembly

The clinical departments may adapt arrangements based on their needs while the patient is still under care/management. But upon the patient's discharge, the nurse on duty should arrange the chart according to the standard arrangement before forwarding it to the HIMD. The received health records should be recorded and indexed (MPI) prior to assembly.

In assembling the health records, the forms are arranged in the order upon admission of the patient to give the Attending Physician and other healthcare staff who shall handle the health record a clear picture of the patient's condition in its chronological order.

A. Source Oriented Health Record

This record is the conventional form of arranging the health record. The patient's health record is organized in sections according to the patient care department, which provides care and the corresponding diagnostic results as the case may be. The health record is arranged in reverse chronological order for the convenience of the doctors in the ward, and those forms frequently used appear on top of the file of documents. Upon the patient's discharge, the HIMD re-arranges the health record based on the approved sequence or arrangement.

B. Problem-Oriented Health Record

Problem-oriented medical records (POMR, now called Problem-Oriented Health Record is another form of the structured health record. POMR was first developed by Dr. Lawrence Weed in the USA in the late 1970s and is structured as a total approach to patient care. It prompts the staff to take a comprehensive and structured look at a patient's problem and treatment. It requires health professionals to approach all problems of a patient. It treats each problem individually in its proper context within the total number of problems and the inter-relationship of the problems.

This record is the most logical format for arranging the health record, and it is computerbased and research-based as well.

The four basic components of this format

1. Database - Collection of data

The database includes the following information:

Chief complaints,
History of the Present Illness,

Health Record Systems and Procedures

Patient's profile,
History and review of systems,
Physical examination results, and
Base-line laboratory plan.

2. Problem List - Formulation of problems

A problem list is a mere listing of all the problems which need medical management. Problems are numbered and titled from the most to the least severe complaint of the patient. The list may include anything that requires management from the past to social, economic, and demographic problems. It may also contain a statement of a symptom, an abnormal finding, a physiological finding, or a specific diagnosis. Additions or changes are made to the list as new problems are identified, and active problems are resolved.

3. Initial Plan - Development of a care plan

The initial plan describes the steps to learn more about the patient's condition, the treatment to be applied, and ways to educate the patients about their physical condition.

Specific plans for each problem are delineated and fall under three categories:

Diagnostics plans for collecting more information,
Therapeutic plans for treatment, and
Patient education plans for informing the patient on what is to be done.

Problems are dated, numbered, and titled, with the problem status clearly defined as active, inactive, or resolved.

4. Progress Notes - Numbered and titled progress notes

The progress notes are follow-ups for each problem. Each note is preceded by the number and title of the appropriate problem and may include all of the following elements:

Subjective (symptomatic)– written in the patient's own words,
Objective (measurable, observable) doctor's observation and test results,
Assessment (interpretation or impression of the current condition), and
Plan statements for contained treatment.

The acronym for this process is SOAP, and the writing of progress notes in the POMR format is often referred to as SOAPING.

The emphasis is on unresolved problems. A slightly different way to describe the patient's progress, other than the narrative method mentioned, is through flowsheets. Flowsheets are recommended when several factors are being monitored or when the patient's condition is changing rapidly.

The discharge summary and transfer notes are also included in the progress note category. These should address all the numbered problems on the patient's list. It may be necessary for the physician to use an overall summary and use flow sheets to clarify the patient's progress. It is recommended that certain forms (e.g., physician's orders, consultant's reports, and nurse's notes) be done in the problemoriented style concerning titled and numbered problems. Other data in the record may be in the conventional format, such as laboratory and operative reports.

C. Integrated Health Record

The information is organized in strict reverse chronological order in the integrated format, with the most current entries at the beginning of the health record. The forms from various sources are intermingled. Thus, history and physical examination may be followed by a progress note, a nurse's note, an x-ray report, a consultation, and so on. The forms for each episode of care are organized in separate sections of the record.

Table 2. Advantages and disadvantages of the types of health record assembly

determined promptly because the

SOURCE ORIENTED ADVANTAGES: DISADVANTAGES: ● It is easy to determine the assessment, treatment, and observations that a particular department has provided. ● Most health professionals are familiar with this traditional way of arranging health records. ● This results in prompt and easy retrieval of needed data/information. ● Prompt determination of all the patients' problems is not facilitated promptly. ● All treatments provided to the patient cannot be determined easily. PROBLEM-ORIENTED MEDICAL RECORD ● Physicians are required to consider the patients' problems in their total context. ● The record indicates the goals and methods of the physician in treating the patient. ● Medical education is facilitated by the documentation of logical and thorough processes done by the attending physician. ● The quality assurance process is easier because the data is logically arranged. ● The format usually requires additional training for the medical and professional staff. ● A significant number of physicians must be convinced of the system's worth or must be willing to try it to be effective in a facility. INTEGRATED HEALTH RECORD ● All information on a particular episode of care is in a single file. Thus, a clear picture of the patient's illness and response to treatment can easily be provided. ● A patients' progress can be ● It is difficult to compare similar information over a series of admissions because the reports are not in the same section as the record.

current notes of all disciplines are incorporated in one file.
The number of specialized forms is reduced.
The team concept of health care is encouraged.
Only one person can document at a time.
It may be challenging to identify the professions/positions of the individuals making the entries unless the record's title follows notes.

Upon receiving the health records from the different clinical wards, the HIMD staff should check and assemble the patient health records according to the approved sequence of arrangement by the Patient Health Records Committee. Refer to Chapter 3 for the Standard health record arrangement.

4.2.2 Outpatient Health Record Assembly

Outpatient visits are documented in an outpatient record with a Health Record Number (HRN) assigned. They should be arranged chronologically in ascending order. If there are diagnostic results, other procedures performed, and records from previous confinement should be based on the standard sequence. All diagnostic results may not be attached to the outpatient record; instead, results should be recorded.

4.2.3 Emergency Health Record Assembly

Emergency patients are identified similarly as inpatients and outpatients using the same HRN sequence. If the patient is admitted, the record should be attached to the inpatient record. If not admitted, it should be forwarded to the HIMD Outpatient Unit for filing. Those ED health records of medico-legal cases should be filed in a secured filing area under lock and key.

4.3 Analysis of the Health Record

After recording and assembling, the health record undergoes the process of analysis. The health information analyst shall perform two kinds of analyses: quantitative and qualitative.

One of the most important functions of the HIMD is the health record analysis to ensure the maintenance of quality documentation.

The health record reflects the quality of care rendered to patients. At any point during admission and consultation, the record should accurately document the care provided.

The HIMD is responsible for assisting the medical and allied medical staff in identifying deficiencies to correct errors and omissions. The analysis is the process of evaluating and/or checking health records to ensure completeness, accuracy, and adequacy of documentation. Both quantitative and qualitative analysis should be performed on the health record.

In the analysis of health records, the general documentation guidelines used to ensure quality documentation are as follows:

1. there must be a health record for each patient confined/treated in the health facility;
1. documentation in the health record must reflect the patients' physical condition and the orders and care provided from admission to discharge;
1. documentation must reflect observation and must be objective and non-judgmental;
1. a unit record must be maintained for each patient. This shall include all admissions and consultations to the health facility, discharge summaries, and quality documentation by the physician and other interdisciplinary team members who participated in the care of the patient;
1. any person making an entry on the health record must affix signature and date to authenticate the entry made properly;
1. documentation of the inpatient health record must be completed within 48 hours upon the patient's discharge. History and Physical Examination must be completed within 24 hours upon admission of the patient. However, outpatient health records must be endorsed to the HIMD daily;
1. every health facility must develop an ongoing review of health records to assure quality documentation. This must be one of the primary functions of the Patient Health Records Committee.
1. It must be the policy of every health facility not to allow abbreviations in writing the diagnosis. But for symbols written by the authorized person, an explanatory legend shall first be approved by the said health facility.
1. Short forms like laboratory and other results must be securely attached to the health record to prevent the loss and/or pasted on an official form for proper filing. May consider pasting on an official form for appropriate filing.
1. The health record is a legal document. No form may be detached once it is filed. Furthermore, there must be no erasures of any sort. To correct an error or insert missing entry/ies, the following shall be done:
- a. draw a single line through the information to be corrected or changed;
- b. write the correct entry near the information to be corrected; and
- c. affix the attending physician's/nurse's initial, date, and time.
1. If the patient wants to correct some data, especially the demographic/ sociological data, the correction should not be done on the original entry but shall appear as an amendment using the official form. Corrections can only be done while the patient is still confined. It is important to require a Valid Identification (ID) Card, birth certificate, marriage contract or any of the identity documents listed under PSA Memo Circular No. 2019-16 dated June 11, 2019, as an attachment.
1. The health records must contain all original copies of examination results, operations, and other required forms.

The inpatient health record must be completed, and it must include the following parts properly accomplished, signed, and dated with the following:

1. Admission and Discharge Record/Clinical Cover Sheet/Face Sheet, which includes personal data like name, address, and other social data,
1. Admitting and final diagnosis, as well as a description of any operation and procedures performed and disposition and results upon discharge,
1. Medical /Clinical abstract which contains the chief complaint, brief clinical history, pertinent diagnostic examinations, and diagnosis,

Health Record Systems and Procedures

1. History sheet which contains the chief complaint, personal and family history (past and present), including obstetrics history for women,
1. Physical examination sheet which contains all pertinent (positive and negative) findings and impressions,
1. Physician's order which contains all of the doctor's orders; (Note: This form may also contain progress notes that may be referred to as Physician's order and Progress Notes),
1. Diagnostic and other report sheets which contain the results of all laboratory, radiologic and other procedures,
1. Progress notes sheet which includes the doctor's positive and negative observations and comments with chronological pictures of the clinical condition of a patient,
1. Discharge summary which summarizes the significant findings and events occurring during the patient's hospitalization, final diagnosis, operation (if performed), complications (if any), condition on discharge, recommendations and arrangements for future care (OPD, follow-up treatment), and classification of injury (if it is a medico-legal case),
1. Anesthesia record (if an operation was performed),
1. Report of operation records which authenticate a pre-operative diagnosis before surgery and which shall contain a report of all findings, a description of the surgical technique used, a description of any "tissue" removed, and a post-operative diagnosis,
1. Nurses' notes, which contains observations of the patient, the treatment given, the response to treatment, and any unusual occurrences, medication and/or instructions, and the advice for follow-up consultations,
1. Consent and waivers with signature over printed name/thumb mark of the person giving consent including the witness,
1. Certificate of Live Birth, Fetal and Death Certificate, if either of these events occurred, and
1. Other records that contain medication and treatment, monitoring sheets, e.g., vital signs record, etc.

4.3.1 Quantitative Analysis of Health Record

After recording and assembling, the health record, whether inpatient, outpatient, or ER patient, shall undergo the process of analysis.

The duties of health information analyst

1. Check basic forms required by the case.
1. Check all the forms which are explicitly ordered:
- the analysis clerk shall read the physician's order and counter-check it with the nurses' notes to confirm whether or not the order was carried out;
- when the nurses' notes state so, the health information analyst shall see to it that the result of the order is attached; and
the analysis clerk shall check on the explicitly ordered forms. (Forms included in a block).
1. The analysis clerk shall check all the required information:
- every page should contain the name, age, sex, room/ward number, and HRN of the patient;
- every form shall be properly filled out; and
- accounts of all tests, treatments, and observations shall be reflected in the record.
1. The analysis clerk shall check all necessary authentications:
- check whether all reports of treatment, medication, examination, or evaluation of the patient were dated and signed by the person who made the report;
- check if all orders were dated and signed; and
- verbal, telephone, and Short Message Service (SMS) orders of the doctor received and written by a licensed nurse on the health record shall be signed and dated by the nurse and countersigned by the doctor as soon as possible.
1. Analysis clerk shall check if all necessary consents/waivers are attached to the health record:
- check if the consent/waiver was dated, signed by the patient, and signed by a witness;
- check if special procedures performed had corresponding consent; and
- if there was surgical intervention, check for surgical consent and fill out corresponding OR Blocks.

4.3.2 Qualitative Analysis of Health Record

The analysis clerk shall check for errors or unexplained inconsistencies in the health records of inpatient, outpatient, and ER patients.

The duties of clerk analyst

1. Check if every page contains the name, age, sex, and Health Record Number of the patient.
1. Check the spelling of names and correct Health Record Numbers.
1. Check if inconsistencies exist between one part of the record and another (e.g., if the preoperative diagnosis differs from the post-operative diagnosis). The discrepancy shall be noted and/or referred to the attending physician.
1. Check if accounts of all tests, treatments, and observations are reflected in the health record.
1. Check if all consultations are properly documented, signed, and dated.
1. Check if the final diagnosis coincides with the diagnostic results attached in the health record.

Health Record Systems and Procedures

When the analysis clerk finds an incomplete health record, a "Deficiency Slip" shall be attached and placed in a pigeonhole for completion.

4.4 Clinical Coding

Without complete and accurate documentation of health records, accurate coding cannot be achieved. Health implementers use precise and meaningful health statistics to plan and evaluate health programs. Likewise, these serve as an aid to assess the quality of care rendered and make decisions about staff, facility, and resource allocation.

Health records are coded to facilitate the retrieval of information concerning diseases and injuries. This information is used:

at a national level for planning a health facility,
in determining the number of healthcare staff required,
in educating the population and identifying the health risks within their country, and
at the international level in comparing the health status of countries.

4.4.1 Steps in Coding

1. Locate the main term in the alphabetical index.
1. Refer to any notes under the main terms.
1. Refer to any sub-terms indented under the main term.
1. Follow cross-referencing instructions if the needed code is not located.
1. Verify the code number in the tabular list.
1. Read and be guided by any instructional terms.

4.5 Collection of Statistical Data

4.5.1 From 24-hr Floor Census

Report of 24-hour Floor census is submitted to HIMD before 9:00 am by the nursing staff on duty and the health record of discharged patients. Upon receipt, the HIMD should check the completeness and accuracy of the report. The number of admissions should tally with the census report submitted by the Admitting Unit, and the number of discharges is the same as the number of health records attached to the report. See Annex E for the Daily Floor Census Report.

Collection of Statistical Data from 24-hr Floor Census Report

1. Check completeness of the 24-hr Floor Census Report.
1. Check the number of admissions from the report of the Admitting Section.
1. Check the number of discharges from the actual number of discharged patients, including deaths.
1. Check for a double recording of admissions, discharges, including transfer in and transfer out.
1. Count the number of patients admitted and discharged/ died on the same day.
1. Check and validate the computation on the summary of the census report.
1. Add the number of admitted and discharged patients on the same day to get the inpatient service day of care.
1. Consolidate the 24-hour floor census report in the Summary of 24- Hour Floor Census Report Per Ward (See Table 3 for the sample table).
1. All data generated from the Summary of 24- Hour Floor Census Report Per Ward should be indicated on the Summary of the Daily Floor Census Report for The Month**.** See Table 4 for the sample table.
1. Collect the needed data for the preparation of monthly/annual Statistical report, e.g., Total No. of Census, Total No. of Admissions, Total No. of Discharges, Total No. of Discharges Alive, Total No. of Deaths, No. of patients admitted and discharged on the same day, and Total No. of inpatient service days of care.
1. Compute the average daily census, bed occupancy rate, bed turnover interval, and bed turnover rate for the month/annual, refer to Chapter 5, Hospital Statistics, for the Formula.

Table 3 Sample

	SUMMARY OF 24- HOUR FLOOR CENSUS REPORT PER WARD DATE:
Line	PARTICULARS	Ward	Ward	Ward	Ward	Ward	TOTAL
no.		1	2	3	4	5
1	Remaining last report
2	Admitted
3	Transferred in from other Census Unit
4	Total of Lines 1, 2 and 3
5	Discharged
6	Transferred out to other Census Unit
7	Absconded
8	Expired
9	Total of Lines 5, 6, 7 and 8
10	Remaining at midnight (L4-L9)
11	Admitted and Discharged the same day
12	Actual Inpatient Service Days (L10+L11)

Table 4 Sample

SUMMARY OF DAILY FLOOR CENSUS REPORT FOR THE MONTH OF

Line no.	PARTICULARS	1	2	31	TOTAL	Cumulative
1	Remaining last report
2	Admitted
3	Total of Lines 1 and 2
4	Discharged
5	Died
6	Total of Lines 4, 5, and 6
7	Remaining at midnight (L3-L6)
8	Admitted and Discharged the same day
9	Actual Inpatient Service Days (L7+L8)

Table 5. Processing of 24-hour Floor Census

	Description	Person/Departme	Interface/Form/
		nt Responsible	Document
1.	Prepares and submit 24-hour Floor	Head Nurse	Daily Floor
	Census from each ward.		Census
2.	Acknowledges receipts of the duplicate	HIMD Staff	Daily Floor
	copy of the floor census.		Census
3.	Validates all floor census report into	HIMD Staff	Daily Hospital
	hospital daily census.		Census
4.	Consolidates, collects, and records data	Statistician	Daily Hospital
	from the daily hospital census for		Census
	statistical purposes.
5.	Furnishes copy to the COH/MCC,	HIMD Staff	Daily Hospital
	CMPS, and Chief Nurse.		Census
6.	Files one copy of the daily hospital	HIMD Staff	Daily Hospital
	census.		Census

4.5.2 From Patient Health Record

It is important that prior to collecting data, the health record should be processed completely and should have ICD10 code/s. To facilitate efficient and effective data collection, HIMD must have a sheet template or any similar form to use.

Steps in the Collection of Statistical Data from Patient Health Record:

1. Count the number of discharges per day, per service. Refer to the floor census report.
1. Compute for the length of stay, exclude the date of admission. For example, if the admission date is Jan 1 and the patient was discharged on Jan 10, the length of stay is nine (9) days.
1. Consolidate all lengths of stay of the discharged patients.
1. Count the total number of conditions on discharge, i.e., improved/ recovered, transferred, HAMA, absconded, unimproved or died, of all discharged patients. (May include census on No. of consultation, No. of patients who died ten (10) days postop, etc.)
1. Identify and count all deaths under and over 48 hours of all discharged patients.
1. All data collected daily should be summed up to come up with a monthly report.
1. All monthly reports should be summarized to get the annual report.

Note: The template below is just a sample format. This can be modified and improved depending on the need of the end-user/statistician.

SERVI
CE: MONTH:

DATE	No. of	Condition on Discharge
	Patients	R / I T H A U DIED
			<48	>48
			HRS	HRS
1
2
3
4
5
6


31
TOTAL

4.5.3 Reports from other Services

1. Receives monthly reports from dietary, pharmacy, laboratory, radiology, and other concerned offices.
1. Checks and validates the accuracy of the submitted report.
1. Consolidate data for the preparation of the annual report.

Table 6. Preparation of Statistical Report

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Collects and consolidates data from the different units/sections (pharmacy, laboratory, radiology, dietary, and other concerned offices) at the end of each month.	Statistician	Statistical report; reports of operating units
2.	Computes the required hospital indicators (e.g., bed occupancy rate, the average length of stay, etc.) based on the collected data from the 24-hour hospital census report and health records.	Statistician	Statistical report; Reports of operating units
3.	Determines the leading causes of morbidity and underlying causes of mortality.	Statistician	Statistical report
4.	Validates hospital statistical reports through coordination with the concerned units/departments and the Patient Health Records Committee.	Statistician/HIMD Head	Statistical report
5.	Reviews and affixes initials on the hospital statistical report.	HIMD Head	Statistical report
6.	Reviews and approves the statistical report and forwards the transmittal letter to the COH for review and signature.	Chief Medical Professional Staff/Head of the Allied Health Professional Service	Statistical report and transmittal letter
7.	Approves and signs statistical reports.	COH/Medical Center Chief	Statistical report and transmittal letter
8.	Submits statistical report to DOH and through the Online Hospital Statistical Reporting System (OHSRS)	Statistician	Statistical report and transmittal letter
9.	Retains a file copy of the report and transmittal letter.	Statistician/HIMD staff	Statistical report and transmittal letter

4.6 Filing of Health Record

4.6.1 Indexing

Indexing is essential for the protection of files and documents of a large size. Several indices are used, such as Master Patient Index (MPI), Disease Index, Operation Index, and Physicians Index. The use of cards is the standard method for indexing; 3''x 5'' size of index card is used for MPI while 5''x 8'' is for Disease and Operation Index.

Records indexing is generated and maintained manually in the HIMD, which may require additional costs for the health facility. Therefore, for those with existing IHOMIS or other health information systems, indices can be automatically generated, maintained, or dispensed to save space.

4.6.1.1 Steps in Indexing

1. Provide an index card for every coded disease.
1. Record the ICD-10 code, disease, and year for every Disease Index Card.
1. List down the following based on the patient's health record:
- a. Health Record Number,
- b. Patient's Name,
- c. Age,
- d. Sex,
- e. Other Disease,
- f. Result,
- g. Operation (if any),
- h. Date of Admission,
- i. Date of Discharge,
- j. Disposition/Result, and
- k. Attending Physician.
1. A new card should be added for filing before the old one when a particular card is filled up.
1. A line should be drawn under the last entry when the year ends while a card is still unfilled to show the cut-off date.
1. Index cards should be kept in file drawers.

4.6.1.2 Types of Indexes

1. Master Patient Index (MPI) is one of the most important tools in the Health Information Department.
- It is the key to locating health records maintained in the file.
- It serves to identify the patient and helps in the retrieval process of health.
- The patient index is maintained as a permanent file.
- MPI is maintained manually in a 12cm x 7cm or 3"x5" card.
- It is filed in strict alphabetical order by the patient's name.

The minimum data requirements for the patient index card are as follows: the patient's name, HRN, age, date of birth, sex, civil status, date of admission and discharge, and the name of the physician.

					NAME	E OF HEA	LTH FA	ACILITY
					MAS	STER PA	TIENT I	NDEX
NAM	ИЕ:	F	AM	ILY	F	FIRST	MI	DDLE	– – Hea	alth Rec	ord Number
	AGE			DATE	OF BIRTI	н -	S	SEX .		S	TATUS
ADDRE	SS:
	ADMISS	SION				DISCHARG	E		ATTE	NDING PH	YSICIAN




	2				on/nomeno		ranged	according			ed on a standa ber.
					T N/ (IV)	IL OF TILF	VEIIII /	OILITT
CODE NO	Э.			DIS	EASE:				YEAR
Health Record No.	Patient Name	M	ge F	Civil Status	Address	Other Diseases	Result	Operation/ Procedure		Date/ Time Disch.	Attending Physician

Operation Index is a listing on a card for a specific operation according to standard classification/nomenclature, arranged according to code numbers.
			_		NAME	E OF HEAL	TH FACI	LITY
					c	PERATION	N INDEX	,
CODE NO. OPERATION: YEAR
Health Record No.	I Patient I Age I Civil I				Result	Diagnos	Date/ sis Time Adm.	Date/ Time Disch.	Attending Physician




	4. Physician's Index is a record of the work done and the results of treatment rendered by the physician practicing in the hospital or an index containing a list of all the patients a doctor has. These cards are filed alphabetically according to the doctor's name.
						OF HEAL
CODE	NO.		PH	ΗYS	ICIAN'S	HYSICIAN'S NAME:	5 INDE	X	YEAR	l.
Date	Health Record No.	Name Name Status Address					Date/ Time Disch.	Day s	Type of Service	Cons.	Result

4.6.2 Filing Systems

An effective and efficient filing system is a vital requirement in the HIMD. All health records shall be filed in one established sequence. An adequate filing area that will ensure the rapid location and retrieval of health records must be maintained.

The systems of filing health records:

4.6.2.1 Alphabetical filing system

When no health record number is assigned, and the patient's name is the only identifier, the alphabetical filing is the only possible method. All records of discharged patients are filed in strict alphabetical order from A to Z. Filing is by patient surname first, then given name and the middle name.

This filing system method is only useful for health facilities with limited patients and a small filing area.

Rules on Alphabetical Filing

1. Place the surname first, then the given name, followed by the middle name, and file in strict alphabetical sequence.
1. Arrange index cards in alphabetical order.
1. When a patient requires more than one card to accommodate all admissions, the cards shall be arranged in chronological order, with the earliest first, working from front to back in the drawer.
1. If more than one person has the same surname and given name, the cards will be arranged alphabetically by middle initial. If no middle initial is given, the cards shall be arranged according to the birth date, filing the oldest card first.
1. Names with prefixes of D, dela, De, Des, Di, Du La, Mc, Mac, Ma, Van, Von, etc., shall be filled alphabetically as D-e-l-a-C-r-u-z; D-e-l-a-F-u-e-n-t-e.
1. Names beginning with Sta. and St. shall be filed as S-a-n-t-a and S-a-I-n-t, as in S-a-n-t-a-M-a-r-i-a and S-a-i-n-t.
1. Compound or hyphenated names shall be filed as one word; thus, Navarette-Clemente shall be filed under N-a-v-a-r-e-t-t-e- C-l-e-m-e-n-t-e.
1. Names with religious titles such as Reverend, Mother, Father, Brother, and Sister shall be filed under the surname, the titles disregarded followed by the given name. Father Jose Romero is filed as Romero, Jose or Romero, Jose (Father).
1. If an initial is given instead of a person's first or middle name, the rule is "file nothing before something." Thus, J. Romero shall precede M. Jose Romero and Miguel Jose Romero.
1. It is customary for people of Spanish descent to combine the mother's name with the father's name. For instance, with the name Soto Ramirez, Soto is the father's surname, and Ramirez is the mother's surname. These are filed in alphabetical sequence, the father's name first, followed by the mother's name. Thus, the name Maria Dolores Soto Ramirez shall be filed in the file section in the following order; S-o-t-o-R-a-m-i-r-e-z, Maria Dolores.
1. A cross-reference shall be made to the former name if the patient's name has changed since a previous admission. For instance: If Dayrit, Josefina, is admitted, a cross-reference should be made to her previous admission as Manalastas, Josefina.
1. When looking for a given person's name card, one must remember that there may be many spellings of the same name. A thorough search must be done under every possible spelling of the name before stating that there is no card for that name.
1. The Master Patient Index shall contain sufficient alphabetical guides for speedy reference. As a rule, no more than 20 cards shall be filed behind a guide.
1. Filing directions shall be explicit about maintaining uniformity in the patient index when a personnel change is made. Whenever possible, only one person shall be responsible for filing the index cards.
1. Card files should be audited regularly for misfiled records.
1. Additional training of Master Patient Index clerks shall be provided as necessary.

4.6.2.2 Numerical filing system

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

4.6.2.3 Terminal Digit Filing System

For terminal digit, a six-digit number shall be used and divided into three (3) parts.

Part 1 – The PRIMARY digits, which are the last two (2) digits on the right-hand side of the assigned number

Part 2 – The SECONDARY digits, which are the two (2) middle numbers

Part 3 – The TERTIARY digits, which are the first two (2) digits on the left of the assigned number

For example, the unit number 19-30-90 is divided as follows:

19 30 90 Tertiary Secondary Primary The inpatient health records of a health facility shall be filed and stored in a terminal digit-filing system. This means that they shall be filed in the order of primary digits (the last two digits of the HRN, then the secondary digits, and finally the tertiary digits).

When filing health records under the terminal digit system, the unit number shall be first considered. This shall be divided into three parts- in pairs of digits. Taking health record 509326 divides as follows- 50-93-26, and the filing process commences by considering the part of the number on the right hand or "terminal" digit. The filing area shall have 100 terminals (primary sections) starting from 00,01,02,03,04,05,..99.

The clerk shall take the health record to the primary section corresponding to the terminal pair of digits when filing. In the right terminal, the row of records shall be located by considering the secondary or the middle number, which, in the above example, is "93". Health records shall be filed in order of their tertiary (left hand) pair of digits within each secondary section. Every 100 processed records shall be equally distributed throughout the 100 terminals.

If someone is looking for a record, it shall be in the order shown below (or a tracer shall be in its place).

An example of sequence is:

46-52-02	98-05-26	98-99-30
47-52-02	99-05-26	99-99-30
48-52-02	00-05-26	00-99-31
49-52-02	01-06-26	01-00-31

Note: A misfiled record may take hours to locate or could be lost forever. File all records correctly.

In PH hospitals, the common practice adapted is a modified Terminal Digit Filing system wherein the First Two is the secondary, the Middle Two is the Tertiary, and the Last Two will still act as the terminal digit. It is a practical method that is easy for filing and retrieval since it enables quick inspection because numerals placed at both ends are more accessible to spot than those placed in the middle. For example, 50-97- 26, 26 is the terminal digit; 97 is the tertiary or the middle two-digit, and 50 is the secondary or the first two digits. The sequence considering 50-97-26 as the first health record in a series is shown below:

50-97-26
50-98-26
50-99-26
51-00-26
51-01-26

The advantage of a modified terminal digit filing system is eliminating the process of culling, which requires additional manpower.

4.6.2.4 Ways of Filing

1. Centralized Filing System

a. The patient's records shall be filed in one location, usually in the Health Information Management Department.
b. The patient may have different health records (inpatient records, emergency room records, outpatient records). Still, the documents shall be brought together in one-unit record or at least filed under the same number in the same place.
c. The main objective of the Health Information Management Department is to maintain a continuous health record of a patient, which shall be available at all times. Implementing a unit number and a centralized record-filing system is the best way to achieve this objective.

2. Decentralized Filing System

a. The health records of the patient shall be filed in multiple patient care areas.
b. This may be under the same unit number if the HIMD maintains a unit record or with totally unrelated numbers if the serial numbering is employed.
c. Under strict supervision by the Health Information Management Head, the HIMD staff shall maintain centralized records keeping because it is costeffective resource utilization. Effective supervision can be attained if only one system is employed.

Table 7. Advantages and disadvantages of filing systems

ALPHABETIC SYSTEM
	ADVANTAGES:	DISADVANTAGES:
1.	The easiest method of record retrieval is the master patient index, as there is no need to cross reference the patient name to the health record number. It is necessary to train staff to verify patient's names and spellings.	In this type of record identification, a ● patient's confidentiality is not safeguarded.
2.	An accurate and consistent health record filing
3.	Most practical in small health facilities without a computerized system
	NUMERICAL SYSTEM
1. 2. 3.	Confidentiality is ensured. The expansion of files is easy. Reveals certain information like total	Not applicable for small health facility ●
	number of patients and the like TERMINAL DIGIT SYSTEM

1.	Records are easily distributed	It requires an adequate storage area for ●
2.	throughout the 100 primary sections. Only every 100th new health record shall be filed in the same primary section of	the implementation of one hundred (100) primary sections.
3.	the file. Elimination of personnel congestion in the filing area
4.	Staff shall be assigned responsibility for
5.	certain sections of the filing area. Work can be evenly distributed among the HIMD staff.
6. 7.	Inactive health records may be pulled out from each terminal digit section as new ones are added, thus eliminating the need to backshift records. Misfiled records are reduced.

4.6.5 Other Considerations in Filing Systems

Management of Misfiled Health Records

1. A system of ensuring that no file is missing or misfiled shall be in place.
1. In locating misfiled records, the following shall be applied:
- a. check for the transposition of digits in a number. For example, 963615 may be filed as 963651 or 693615;
- b. check for missing files under similar-looking numbers such as "3" under "5" or "8" or vice versa. Or "7" or "8" under "9";
- c. check for a certain number such as 714 under 713 or 715 or a similar combination;
- d. check for the transposition of the first and last numbers;
e. check the health record immediately before and after the particular missing record; and
f. check the shelf immediately above and below where the record should be filed.
1. The file room shall be checked once a month to ensure that:
- a. all records are standing straight on the shelves;
- b. there is no dust on the shelves (including the very top shelves); and
- c. the floor should be clean.

Management of Loose Sheets

Vast quantities of unattached laboratory, ECG, and other test results (loose sheets) are produced daily and make their way to the Health Information Department. These reports contain vital patient information, and it is essential that they are filed promptly and accurately to maintain complete, comprehensive, and effective health records.

1. Sorting

Loose sheets are delivered to the HIMD from the different services or clinics of the health facility. The inpatient sheets should be separated from the outpatient loose sheets in a decentralized health record-keeping system. Then they shall be pre-sorted terminally in preparation for the actual filing process. The procedure shall be as follows:

a. separate loose sheets which have been stapled together;
b. date stamp all loose sheets received; and
c. check names and numbers on the loose sheets.

Note: For loose sheets forwarded to the HIMD without corresponding numbers, the Master Patient Index shall be consulted.

2. Locating the record

When using the manual system, an in-house box shall be maintained to determine whether or not the patient has already been discharged.

For patients whose names are not in the in-house box, the MPI shall be consulted for the HRN. Then the health record shall be retrieved from the permanent file area.

Health Records which are not in the permanent filing area shall be recalled from the respective borrower to incorporate loose sheets.

Any loose sheets that were not filed the first time shall be retained for a future attempt.

3. Filing Loose Sheets

The patient's HRN and date on the report shall be checked and re-checked if they correspond to the number and date indicated on the health record.

The loose sheets shall be refilled using the "Assembly of Health Records" list as a guide to correct filing orders.

Health Record Systems and Procedures

1. Reports from each department shall be filed chronologically within each admission.
1. Statistics on loose sheets received by the HIMD shall be maintained for any administrative use.

4.7 Retrieval of Health Records

All health records not in the processing stage and not in use shall be placed in the file/storage room. Inherent to documents and records is the ability to be retrieved from the permanent file for further use.

A good retrieval system directly affects the total efficiency of the HIMD.

It is a good practice for small health facilities with a small filing/storage area to transfer inactive records to the inactive file to give way to the incoming records to decongest the area and make retrieval easy.

A retrieval process will not be efficient and effective if there is no provision for adequate finding aids, captions, locator aids, and retrieval tools.

Retrieval tools in the health record are classified into three: (1) indexes, (2) registers, and (3) tracers.

4.7.1 Retrieval Tools

4.7.1.1 Indexes

An index serves to guide, point out, or facilitate reference to organize patients' health records through demographic data comprehensively, disease-related/treatment-related information, and clinical history.

The following are the types of indexes (refer to indexing part of this chapter for discussions):

a. Master Patient Index (MPI),
b. Disease Index,
c. Operation Index, and
d. Physician's Index.

4.7.1.2 Registers

A register is an official list of all patients treated and/or admitted to a particular health facility. It is considered a permanent document to be maintained by the health facility as mandated by the Health Facilities and Services Regulatory Bureau of the Department of Health. Also, it is a source of data/information when the original copy of the health records is already disposed of after the prescribed retention period.

a. Admission Register. This is a list of all patients admitted to a particular health facility. This register shall be monitored regularly as patients are admitted. Each section of this register shall be maintained in chronological order. This register is a permanent record, and as such, all entries shall be made in ink. It shall be maintained manually or computerized as mandated by the Philippine Health Insurance Corporation effective January 2006. The minimum data required for an admission register are as follows: Health record number (HRN), date and time of admission, name of the patient, date of birth, sex, address, membership, admitting diagnosis, and admitting physician.

NAME OF HEALTH FACILITY (Address)

ADMISSION REGISTER

HRN	Date/Time of Admission	Name of Patient	Age	Date of Birth	Sex	Address	Membership	Admitting Diagnosis	Admitting Physician

b. Discharge Register. This is a list of all patients discharged from a particular health facility. This register shall be done daily as patients are discharged. Each section of this register shall be maintained in chronological order. This register is a permanent record, and as such, all entries shall be made in ink. It could be maintained manually or computerized as mandated by the Philippine Health Insurance Corporation effective January 2006. The minimum data requirements for a Discharge Register are as follows: Date & Time of the Discharged, Health Record Number (HRN), Name of Patient, Age, Sex, Address, Membership, Discharge Diagnosis, Operation/Procedure, Attending Physician, Service, Disposition and Result.

NAME OF HEALTH FACILITY (Address)

DISCHARGE REGISTER

Date & Time	HRN	Name of Patient	Age	Sex	Address	Discharge Diagnosis	Operation/ Procedure	Attending Physician	Service	Disposition	Result

Note: In the absence of a computerized system, the Admission and Discharge Register can be combined in one Register Logbook provided that the Admitting Section is adjacent to HIMD.

c. Birth Register. This is a chronological listing of all the names of the children delivered in a particular health facility.

NAME OF HEALTH FACILITY (Address)

BIRTH REGISTER

Date & Time	HRN	Name	Sex	Birth Weight	Name of Mother	Attendant at Birth

d. Death Register. This is a record of all deaths occurring within the health facility. This is a listing of all the names of the patients who died in a particular health facility and arranged according to the date of death.

NAME OF HEALTH FACILITY (Address)

DEATH REGISTER

Date & Time	HRN	Name of Patient	Age	Sex	Address	Cause of Death (Underlying & other diseases)	Physician

e. Out-Patient Register. Every outpatient who comes in for consultation must be listed in the OutPatient Register. If a logbook is utilized for this purpose, it should

be forwarded to the Health Information Management Department for safekeeping at the end of the year. This register is classified as a permanent file/record.

If, however, this register is maintained on a loose-sheet or loose-leaf, at the end of every month, it must be forwarded to the Health Information Management Department to set Notifiable or Reported Diseases, which is prepared monthly. This is also necessary for compilation and collation processes.

_______________________________________ NAME OF HEALTH FACILITY (Address)

OPD REGISTER

HRN	Date &Time	Name of Patient	Age	Sex	Address	Diagnosis	Operation/ Procedure Done	Attending Physician

f. Other Registers. Other required registers that government health facilities need to maintain are as follows: Emergency Room Register, Delivery Room Register, Operating Room Register, Laboratory Register, Radiologic Register, Tumor Register, and Injury Register.

4.7.1.3 Tracers

A tracer is used to ensure proper record control whenever the health record is removed from the file for any purpose. Tracers or "outguides" enable health records to be traced when not on file.

4.7.2 Essential Requisites for Easy Retrieval

Efficient and effective filing system. This is an important factor that makes retrieval easy because it is adaptable to the type of records maintained. Proven to be very effective in managing voluminous health records is the full knowledge of the movement of the records, such as the terminal digit filing. However, to be truly effective, it needs to adapt the corresponding unit numbering system.

1. Time element is very crucial in health record management. Retrieval time of health records shall be as short as possible because the information retrieved from the health record might be the deciding factor between the patient's life or death.
1. Monitoring of chart movement. Another important factor to consider in the efficient and effective management of health records is the full knowledge of the movement of the

Health Record Systems and Procedures

records. This is the reason why the Health Information Management Department shall maintain an effective tracking or follow-up system. Using such a system coupled with the full workflow knowledge shall help the health record staff control the records more effectively.

Good Physical Layout. To attain a good physical layout, the Health Information Management Department shall consider flexibility and functionality. The arrangement of the employees should (1) follow the workflow, (2) facilitate the smooth flow of paperwork, and (3) improve coordination between/among employees.

The physical location of the Health Information Management Department shall be near the Outpatient Department and Emergency Room as the activity rate of health records is considered high in these services.

4.7.3 Retrieval Procedure

1. The authorized requesting party shall fill out the borrower's slip form and be duly signed by concerned signatories (Refer to Annex O, Form on Request for Access to Health Records).
1. The requesting party/authorized representative shall bring the request to the HIMD and give it to the HIMD Staff.
1. The HIMD Staff receives and verifies whether the borrower is authorized to borrow and checks the request's completeness.
1. The HIMD Staff assigned shall retrieve the requested health records.
1. After the retrieval, the HIMD Staff shall record the borrowed health record in the tracking system and place the tracer card where the record was retrieved.
1. The HIMD Staff assigned in the retrieval shall charge out the borrowed health record to the authorized borrower.
1. The borrower/authorized representative shall acknowledge the receipt of the record and shall review/access within HIMD.

4.8 Retention and Disposal of Health Records

Retention period is established and approved by proper authority, after which records shall be deemed ready for disposal. However, it is recommended that institutions where active health records cannot be maintained for five years in the active file, may transfer their health records to another designated storage area because of limited space.

Aside from this legislation, the Department of Health issued Ministry Circular 77, series of 1981, further qualifies the 25-year retention period for all hospitals under the Department of Health regardless of its category/classification. The period of health record retention is amended by Department Circular No. 70 s. 1996. The National Archives of the Philippines (NAP) also issued a general circular on guidelines on the establishment and use of general records disposition schedule (GRDS) that can be used as a guide in the disposal of other records maintained by the HIMD.

4.8.1 Transfer of Inactive Records

Transfer of inactive records shall follow the retention disposition schedule. All active records that reached the retention period shall be transferred to the inactive file area while waiting for the actual disposal. If there is no available space to accommodate active records, a decision must be made to determine the length of time and/or appropriate storage where inactive records shall be kept.

4.8.2 Culling

Culling is the identification and removal of inactive records or those which have already reached their mandated and/or prescribed retention period from the filing/storage area for disposal. The process shall decongest the file area, provide more room for filing incoming health records, and facilitate prompt retrieval of needed health records.

4.8.3 Disposal

Department Circular governs the disposal of health records in government health facilities/institutions No. 70 series of 1996: The Revised Disposition Schedule of Medical Record amending Ministry Circular 77 series of 1981, Department Circular 2021-0226, and NAP General Circular 3, GRDS.

Department Order 13-A, Article III, Rule 2.2, specifically states that: "Agencies shall not dispose of their health records earlier than the period indicated for each record series. However, records may be retained for longer periods if there is a need to do so."

The disposal of health records must be done in close coordination with the National Archives of the Philippines (NAP), the government agency in charge of health record disposal.

Table 8. Procedure in the Disposal of Health Records

Description	Person/ Department Responsible	Interface/Form/ Document
1. Initiates the disposal of valueless health	HIMD staff	Records Inventory
records based on the records		and Appraisal
disposition schedule.		(Form 1)
		Records Disposition
		Schedule
		(Form 2)
2. Culls out valueless records.	HIMD staff
3. Prepares requests to dispose of	HIMD staff	Request letter
records and forwards to the Chief of
Medical Professional Service (CMPS).
4. Endorses request to dispose of records	CMPS	Request letter
to RMIC.

5. Recommends request to dispose of	Records	Request for
records and submits to COH for	Management and	Authority to Dispose
approval.	Improvement	of Records (Form 3)
	Committee
	(RMIC)

6. Approves requests for authority to	COH
dispose.
7. Submits requests to NAP.	RMIC
8. Receives, evaluates, and assigns a	NAP
representative to evaluate & examine
records for disposal.
9. Approves the submitted request for	NAP Director	Authority to dispose
authority to dispose with analysis report
and recommended manner for
disposal.
10. Coordinates with concerned	RMIC/Administrat	Letter for availing
offices/agencies (concerned	ive Service	NAP official buyer
departments/unit, COA, NAP, official
buyer) for witnessing and disposal of
valueless health records.
11. Disposes of valueless health records	RMIC/
through a sale (public bidding or official	NAP/COA/
buyer of NAP as per recommendation	NAP Official
of NAP).	buyer
12. Issues OR to the official buyer.	Cashier
13. Signs Certificate of Disposal and	NAP, COA,	NAP Form No. 6
provides a copy to concerned offices.	RMIC, official	Certificate of
	buyer	Disposal of Records
14. Files copy of the Certificate of Disposal	RMIC	Certificate of
from NAP.		Disposal

4.9 Processing of Health Information/ Issuance of Certificates

4.9.1 Certificate of Live Birth

Live birth is the complete expulsion or extraction of a product of conception from its mother, irrespective of the duration of pregnancy. After such separation, any other evidence of life, such as the beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut off or the placenta is still attached, is considered alive.

A fetus with an intrauterine life of seven (7) months or more and born alive when completely delivered from the maternal womb but died later shall be considered live birth and registered in the registry of births.

However, if the fetus has an intrauterine life of less than seven (7) months, it is not deemed born if it dies within 24 hours after its complete delivery from the maternal womb (Article 41 R.A 386). For statistical purposes, a certificate of Live Birth shall be prepared in duplicate copy. This copy shall be forwarded to the office of the Civil Registrar-General and the other copy for the Civil Registrar's file.

Table 9. Procedure in the Preparation of Birth Certificate

Person Responsible	Action
Informant (Parent)	Fills up the Birth Certificate (BC) preform/worksheet 1.
	given by the nurse.
	Submits accomplished BC form to the nurse. 2.
Nurse/Midwife	Receives accomplished BC preform/worksheet from 1.
	the parent/informant.
	Checks completeness and accuracy by interviewing 2. the patient.
	Forwards the accomplished form worksheet with four 3. (4) copies of the COLB to the HIMD.
Medical Transcriptionist of	Acknowledges receipt of accomplished COLB with 1.
HIMD	preform from Nursing Staff.
	Rechecks the preform for accuracy and completeness 2.
	of data entry.
	Counter checks all COLB from the census/delivery 3.
	registry for validation.
	Transcribes data from BC preform to the COLB. 4.
	Checks COLB for completeness, correct spelling of 5.
	names, dates, and other details.
	Forwards the COLB to the nurse/midwife. 6.
Nurse/Midwife	Acknowledges receipt of accomplished COLB. 1.
	Secures the signature of the informant. 2.
	Seeks signature of the attending physician on the 3. COLB.
Attending Physician	Checks and affixes signature on appropriate space(s) 1.
	on the COLB
Nurse/Midwife	1. Forwards signed COLB to the HIMD
	Prepares transmittal letter to the Local Civil Registrar's 1.
Medical Transcriptionist of	Office (LCRO)
HIMD	Forwards transmittal letter with the attached COLB to 2.
	HIMD Head/Officer-in-Charge for signature
	Checks all the attached COLB against the list of names 1.
HIMD Head/Officer-In	on the transmittal letter
Charge	Affixes signature on the transmittal letter 2.
	Sends back the transmittal letter with all the attached 3.
	COLB to the HIMD staff.
	Transmits the prepared COLB to LCRO. 1.
HIMD staff	Monitors and safe keeps a duplicate copy of the 2.
	transmittal letter and hospital copy of COLB for future
	reference.

4.9.2 Certificate of Death

Certificate of Death provides information on the deceased's cause of death determined by the last attending physician. It also informs the deceased's family on conditions, diseases, and circumstances that might occur or could be prevented. Also, it is used to process funeral arrangements and other legal purposes, including wills and testaments.

Table 10. Procedure in the Preparation of Death Certificate / Fetal Death

Person Responsible	Action
Nurse-on-Duty	1. Facilitates preparation of the draft copy of the COD.
	2. Forwards the prepared draft COD to the attending
	physician.
Attending physician	1. Accomplishes the medical certificate portion of COD and
	other required details.
	2. Affixes signature on the draft COD.
	3. Return the accomplished draft COD to the nurse on duty.
Nurse-on-Duty	1. Receives the accomplished draft COD from the attending physician.
	2. Checks draft COD for completeness of data entry.
	3. Secures signature of the informant.
	1. Confirms the accuracy and completeness of the
Informant/ Relative	information.
	2. Signs draft copy of COD.
	1. Forwards the draft COD to the medical transcriptionist of
Nurse-on-Duty	the HIMD.
Medical Transcriptionist of	1. Acknowledges receipt of the draft COD.
HIMD	2. Rechecks accuracy and completeness of the COD.
	3. Transcribes the data from the draft COD into four copies of the official COD.
	4. Returns the transcribed copies of the official COD to the
	nurse on duty.
	1. Acknowledges receipt of the official COD.
	2. Signs and secures the signature of the informant and
	attending physician.
Nurse-on-Duty	3. Incorporate one (1) copy of the COD into the patient's
	health record.
	4. Issues three copies of official COD to the nearest kin and
	gives the advice to register it within 48 hours upon receipt
	to the Local Health Office (LHO)
	1. Acknowledges receipt of the three (3) copies of COD in
Next-of-Kin	the Logbook for registration to the Local Civil Registrar
	Office (LCRO).

Note: The Certificate of Death must be registered to the Local Civil Registrar within 48 hours from the date/time of occurrence.

4.9.3 Certificate of Fetal Death

Fetal Death is the death prior to the complete expulsion of a product of conception, irrespective of the period of pregnancy. Death is indicated that after such separation, the fetus does not breathe nor show any other evidence of life: the beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, as defined in the 2nd Edition Medical Certification of Death Handbook for Filipino Physicians, Guidelines and Procedures.

Procedure

The preparation of the Certificate of Fetal Death shall follow the procedure in preparing the Certificate of Death.

4.9.4 Certificate of Confinement

Certificate of Confinement, signed by the head of the Health Information Management Department, shall be issued while the patient is still confined in the health facility. This certificate should be a controlled document. The health facility should pre- number them, and the HIMD should record their issuance. This should be released with a dry seal.

4.9.5 Medical Certificate

Medical Certificate shall be issued when the patient is already discharged. This document should be a controlled file. The HIMD should pre-number and record the issuance. It is the attending physician who shall certify the medical certificate. This should be released with a dry seal.

4.9.6 Medico-Legal Certificate

Medico-legal Certificates shall be certified by the Attending Physician/Chief of the Health Facility/Medico-legal Officer and released with a dry seal.

4.9.7 Certifying of Health Records

Certified copies of the following health records may be requested:

1. Discharge Summary/Clinical Abstract,
1. Laboratory and diagnostic results, and
1. Report of Operation.

4.10 Telemedicine

As defined in the Joint Memorandum Circular No. 2020-0001 issued by DOH and the National Privacy Commission dated March 28, 2020, telemedicine refers to the practice of medicine using electronic and telecommunications technologies. Such technologies are phone calls, chat, or short messaging services (SMS), audio and video conferencing, to deliver healthcare at a distance between a patient at an originating site and a physician at a distant location.

Through the National Telehealth Center, DOH, and the University of the Philippines, Manila issued the Joint Memorandum Circular (JMC) No. 2020-0001 entitled "Telemedicine Practice Guidelines," which reiterates the implementation of telemedicine practice among health care providers. All telemedicine consultations should have proper documentation, which includes but is not limited to the following:

a. Patient name and location,
b. Family members or other companions present during the telemedicine consultation,

Health Record Systems and Procedures

c. Patient consent,
d. Referring physician, if applicable,
e. Telemedicine platform or videoconference or communication software used, and
f. Patient's feedback about the telemedicine consultation.

All health care providers whose services are sought through telemedicine shall keep records of all electronic clinical abstracts/consultation summaries, prescriptions, and/or referral forms issued.

CHAPTER 5

Hospital Statistics

Statistics is the collection, analysis, interpretation, and presentation of facts as numbers or numerical facts, which break down data into a concise, useful form.

Accurate and comprehensive data collection is vital in statistical preparation and the effectiveness of statistical reports depending upon the terminology used. There must be a mutual/ common understanding of its meaning between the person who prepares the statistical report and its users. It would also be essential to know what and how data will be collected.

Hospital Statistics serves as a tool in planning, monitoring, and evaluating hospital operations and management effectiveness. Effective and efficient health indicators are considered an integral part of managers' decision support system in any major decision-making.

5.1 The Need for Hospital Statistics

1. Provide data for management activities.
- a. Administrative Level
  - Budgeting and resource allocation
  - Capacity Utilization
  - Cost Accounting
  - Disbursement of funds
  - Planning, Decision-making and evaluation
  - Organizing staffing levels
  - Data for accreditation purposes
  - Licensing and Accreditation of Hospitals and their services
- b. Clinical Level
  - Assessment of the quality of care
  - Appraisal of medical, nursing, and allied health professionals' performance
  - Training and Research purposes
1. Present a comparison of the past and present performance of health facilities.
1. Provide information for both internal and external agencies.
1. Meet legal requirements.
1. Serve as a reference for education, research, and service development.

5.2 Characteristics of Quality Hospital Statistics Data

1. Accuracy and validity of the original source data are present.
1. Data is reliable, consistent, and the information generated is understandable.
1. All required data are present and complete.
1. Data are readable and legible.
1. Data are recorded, current, and timely at the point of care.
1. Data is available to authorized persons when and where needed.

5.3 Collection of Healthcare Statistics

Healthcare statistics are collected and generated from multiple sources using different data collection methods. Data collection is done daily using a 24-hour floor census, patient health records, and routine reporting of various concerned sections. The Health Information Management Department (HIMD) coordinates with different departments/units/sections to improve the quality of health information. The accuracy of data collection relies heavily on gathering by the concerned unit and a clear understanding of the significance of reports needed.

The following services are some of the data sources for statistical reports:

Medical Service,
Allied Health Professional Service,
Nursing Service,
Hospital Operations and Patient Support Services,
Finance Service, and
Professional Education, Training and Research Office.

5.4 Measures of Hospital Utilization

5.4.1 Inpatient

Inpatient is a patient admitted to the hospital receiving health care services and is provided with room, board, and continuous nursing services in a unit or area of the health facility.

Census indicates the number of patients present in the hospital at any given period with a standard cut-off time at midnight, e.g., the Daily Floor Census Report for May 3 will include admitted, discharged, death, transfer-in, and transfer-out of patients from 12:01 to 12:00.

Census = Inpatients remaining at midnight + Admissions - Discharges & Deaths

● Average Daily Census is the average number of inpatients per day. The factors that influence this indicator are the inpatient service days and the number of days in the same period.

Total Inpatient Service Days for a period Average Daily Census = ------------------------------------------------------- Total days in the same period

Newborn census records must be reported separately. Average Daily Census can also be computed by the wards or specialty departments, using the same formula.

Sample Computation:

To compute the average daily census of a 100 authorized bed capacity health facility with an accumulated 2,750 inpatient service days for the month of January, divide 2,750 (total inpatient service days) by 31 (number of days in the month).

Average Daily Census = $$\frac{2750}{31}$$

The average daily census for the month is 89.

Inpatient Service Days is a unit of measure denoting the services received by an inpatient in 24 hours or any fraction of the day thereof.

Inpatients Admitted & Inpatient Service Days = (remaining + Admissions) – Discharges & Deaths + discharged on at midnight the same day

Sample Computation:

To compute for the inpatient service days of a 500 bed capacity with 597 remaining inpatients at midnight, admission of 116, discharges of 112 and admitted and discharged the same day of 22.

Inpatient Service Days = $$597 + (116 - 112) + 22 = 623$$

Total Inpatient Service Days of care is compiled on the 24-Hour Daily Census Report, and the grand total for the month is listed on the last day of the month.

1. Bed Occupancy Rate (BOR) is the ratio of actual Inpatient Service Days to the maximum inpatient days determined by bed capacity during any given time. Health experts suggest that the bed occupancy rate should not exceed 85% not to compromise the quality of care of the health facility (Bontile, 2013).
- Bed Day The World Health Organization defines Bed Day as 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.
- Bed Count – This is the number of beds, whether occupied or unoccupied, that have been set up and staffed for use in a designated inpatient area of a hospital or institution. Beds from special areas are not to be counted, such as Operating Room (OR), Labor Room (LR), Recovery Room (RR) or temporary set-ups for temporary overflow beds in the hall, etc., beds in the ward setup but with no staff or patients using them (vacant or closed off area or wards, stored beds). The patients in special areas only occupy them for a short period and are assigned to another bed in the hospital. Bassinets used by newborns are to be counted and reported separately.
- Authorized Bed Approved number of beds issued by the Health Facilities and

Services Regulatory Bureau, the licensing office of DOH

Implementing Bed Actual beds used based on hospital management decision (This is not the basis for computing Bed Occupancy Rate)
Actual Bed Actual number of beds utilized by the patients within the period

Additional Bed Used – Actual number of beds minus the number of implementing beds for the period

Total Inpatient Service Days for a period Bed Occupancy Rate = --------------------------------------------------------------------- x 100 Total no. of authorized beds x Total days in the same period

Sample Computation:

An example of bed occupancy rate for the month of June: 1,380 inpatient service days were provided at a health facility that has an authorized bed capacity of 50.

Bed Occupancy = $$\frac{1380}{50 \times 30}$$ x $100 = \underline{92}$

Taking into account that June has 30 days, the bed occupancy for that period is 92.00%.

Bed Turnover Interval (BTI) is the average period in days that an available bed remains empty between the discharge of one inpatient and the admission of the next.

(Implementing beds x days in the period) – Inpatient Service Days for a period Bed Turnover Interval = ----------------------------------------------------------------------------- Total discharges & deaths in the same period

Sample Computation:

An example of bed turnover interval for the month of October 2008: a total of 12,420 inpatient service days were provided at a tertiary health facility with implementing beds of 462.

Bed Turnover Interval = $$\frac{(462 \times 31) - 12, 420}{1,400} = \frac{\textbf{1.36} \sim \textbf{1}}{1,400}$$

During the period, a total of 1,400 patients were discharged and died. The bed turnover interval is one (1) day.

At a given BOR, the BTI indicates how efficient a hospital's system is in readying the bed for the next patient. A short BTI indicates better efficiency. However, very short BTI should be looked at cautiously. Studies have shown that a short BTI is linked to increased hospital-acquired infections such as MRSA (Methicillin-resistant Staphylococcus aureus).

Bed Turnover Rate (BTR) is the number of times a bed, on average, changes occupants during a given period.

No. of discharges (including deaths) for a period Bed Turnover Rate = ------------------------------------------------------------- Average bed count during the period

Sample Computation:

A good example of a bed turnover rate is a 200-bed health facility that supplied the following information for 2008: patients discharged, including deaths, are 6,500.

6500 Bed Turnover Rate = ----------------- = 32.5 200

This example shows that the health facility's 200 beds have changed occupants about 32 times during the year. This helps measure the health facility's level of efficiency and productivity in terms of vacant bed availability.

High BTR generally indicates better utilization. It means patient turnover is high, and the hospital treats more patients in a given time. BTR and BOR provide an excellent understanding of how well the hospital's beds are being utilized.

Length of Stay is the number of days of care rendered to an inpatient from admission to discharge. The duration of an inpatient's hospitalization is considered one (1) day if he has been admitted and discharged on the same day and if he has been admitted on one day and discharged the next day.

It is used in utilization management that evaluates the hospital's efficiency in providing necessary services in the most cost-effective manner while also evaluating the level of care rendered.

Average Length of Stay (ALOS) is the average number of days each inpatient stays in the hospital for each episode of care. It is calculated by dividing the total number of occupied bed days by the number of separations in the same period and expressing the result as an average for all inpatient discharges or the average number of days of service rendered to each inpatient discharged during a given period.

Total Length of Stay of discharged patients for a period Average Length of Stay = ---------------------------------------------------------------------- Total discharges and deaths in the same period

Sample Computation:

In June 2010, a health facility discharged a total of 2,086 patients (including deaths). Their combined length of stay was 13,654 days. Using the above formula, the average length of stay of discharged patients is 7.

13, 654 Average Length of Stay = -------------- = 6.54 ~ 7 days 2, 086

It should be noted that the total length of stay of patients discharged during the month (regardless of the date of admission) is taken from the actual days of confinement from each patient chart for the period. The figure derived at is used as the numerator in computing for the ALOS. A patient admitted and discharged on the same day is considered as having stayed one day.

Note:

In computing for the length of stay, the admission date is counted but not the day of discharge.
Newborn (born alive and well) must not be included in computing for this indicator.

5.4.2 Outpatient

Outpatient is a patient who receives health care services without being admitted for inpatient medical care or health care services. An outpatient does not occupy a bed for any time, or a patient who consults and receives health care services in the health facility without being admitted.

1. Total Number of Outpatient Visits refers to the total number of outpatients attended and who received healthcare services in the health facility for a given period.
- New visits refer to the total number of outpatient first visits and group by age and sex.
- Revisits or Follow-up visits refer to the total number of outpatient second and subsequent visits grouped by age and sex.
1. Total Number of Encounters refers to the number of health care services given to outpatients during the visit.
1. Average Number of Outpatient Visits per OPD day refers to the average number of outpatients attended for a given period.

Total no. of Outpatient visits/attended (both new and revisits) during a period Average no. of Outpatient = --------------------------------------------------------------------- visits per OPD Day Total no. of days for the same period

* where total no. of days refers to OPD days.

Sample Computation:

A health facility with an outpatient service operating six (6) days per week has a total number of new outpatient visits of 38,949 and a total number of revisits of 254,911.

38,949 + 254,911 Average no. of Outpatient = --------------------------- = 1020 visits per OPD day 288

5.4.3 Emergency Department

Emergency Department is a health facility or primary care department that provides initial treatment to patients with a broad spectrum of illnesses and injuries. Some may be lifethreatening and require immediate action, or a health facility or primary care department that provides initial treatment to patients in response to an increased need for rapid assessment and management of critical illnesses.

1. Total Number of ED Consults refers to the total number of emergency patients attended and who received health care services in the health facility for a given period.
- Emergency patients refer to a patient with a condition or state wherein immediate danger and delay in initial support and treatment may cause loss of life or cause permanent disability to the patient, or in the case of a pregnant woman, permanent injury or loss of her unborn child, or would result in a noninstitutional delivery, as based on the objective findings of a prudent medical officer on duty for the day.
- Non-Emergency patients refer to patients afflicted with minor injuries or illnesses who arrive late at night or when the regular clinics of the health facility are closed.
- 1. Average Number of ED Patients per day refers to the average number of ED consult and non-emergency patients attended to in the Emergency Room for a given period.

Total no. of ED Consults Average number of = ------------------------------------------------------------------- ED patients per day Total no. of days for the same period

Sample Computation:

A health facility has a total number of 55,010 emergency patients attended in the ER.

Average number of ED patients per day = $$\frac{55,010}{365}$$

5.5 Measures of Health Facility Performance

5.5.1 Morbidity

Morbidity refers to the state of having a disease (including illness, injury, or deviations from normal health) or the number of sick persons or cases of a condition in relation to a specific population.

Morbidity usually relates to a single episode of health care. An episode of health care may be defined as:

a period of inpatient care, or
a contact (or series of contacts in a specific period) with a health care practitioner in relation to the same condition or its immediate consequences.

Source of Morbidity Data

Sources of data for morbidity coding include:

1. Hospital records,
1. School health records,
1. Death certificates,
1. Armed services records,
1. Occupational health records,
1. Health surveys,
1. Outpatient records (ambulatory care),
1. Maternal and child health records,
1. Recording of occurrence of 'sentinel' conditions or conditions such as congenital anomalies, communicable diseases, etc.,
1. Cancer and chronic disease registry records,
1. Follow-up of people born at a specific time, those who have suffered from a specific 'index' disease or injury, and
1. Others.

Uses of Morbidity Data

Morbidity data may be used, among other things, to provide clues to the causes of disease. It may form the basis on which decisions are made about previous measures or the allocation of resources or priorities for disease prevention programs.

Coding and selection rules for morbidity

The clinician should record all conditions that affected the patient at the end of a period of care. The latest revision of the ICD guides morbidity coding for the selection and coding of the "main condition" to be considered for morbidity tabulation.

The country adapts multiple coding policies, wherein all conditions are coded, but only the main condition is tabulated for statistical purposes. Applicable morbidity coding rules shall be used to select the correct main condition for morbidity tabulation.

A. Infection Rate

This may be calculated separately for a specific infection, such as surgical wound, puerperal and respiratory, urinary tract, and blood infections, and so on.

Gross Infection Rate is the rate of those infections that have occurred following clean wound operations or births or have developed into medical cases after admission in the health facility.

Total no. of infections in the health facility (or ward) for a period Gross Infection = --------------------------------------------------------------------------- x 100 Rate Total discharges and deaths on the health facility (or ward) for the same period

Sample Computation:

The Infection Control Committee of a health facility reported a total of 45 infections for the year 2010. Total discharges, including deaths for the same period, were 2,000. The gross infection rate is calculated as follows:

45 (Total No. of infections)

Gross Infection Rate = $$\frac{45 \times 100}{2,000}$$ (Total discharges including deaths).

Note:

The infection to be included shall be a health facility acquired and determined by a committee (i.e., Infection Control Committee) or a physician.
Up to two percent (2%) is considered normal by Western standards.
1. Net Infection Rate is the rate of Health-Associated Infections (HAI) that can be spread in many ways. Some transmission can occur through touch and some through the air (via sneezing or coughing). The most prevalent infections acquired during health facility stays are pneumonia and bloodstream, surgical sites, and urinary tract infections.

Total no. of infections debited against health facility (or ward) for a period Net Infection = -------------------------------------------------------------------------- x 100 Rate Total discharges and deaths from the health facility (or ward) for a period

Sample Computation:

For the month of August 2020, the Infection Control Committee reported a total of 9 infections in the hospital ward. The total discharges and deaths in that period were 555 and 91, respectively.

9 Net Infection Rate = ------------------- x 100 = 1.39% 555 + 91

Postoperative Infection Rate is when infections occur after a clean surgical operation (OP) or procedure.

Total no. of infections occurring after a clean surgical operation Postoperative Infection Rate = ------------------------------------------------------------- x 100 Total number of clean surgical operations/ procedures for the same period

Sample Computation:

In the month of December 2009, a health facility performed and reported 658 cases of surgical operations. The ICC reported 2 cases of post-operative infections in a clean surgical case. Based on the formula, the Post OP infection rate for the month is computed as follows:

Postoperative Infection Rate = $$---- \times 100 = 0.30%$$ .

Consultation Rate is the consultation ratio following an attending physician's request to a consultant to examine a patient and give a second opinion.

Total consultations (all departments) for a period Consultation Rate = --------------------------------------------------------------- x 100 Total discharges and deaths

Sample Computation:

A health facility reported a total of 9,528 consultations for the year 2010. Total discharges and deaths for the same period were 8,098.

9,528 x 100 Consultation Rate = ------------------- = 1.18% 8,098

Note:

Newborns are included in computing for this indicator.
Twenty percent (20%) is considered normal for teaching hospitals and is acceptable by Western standards.
A ten to fifteen (10-15%) is acceptable by Western standards.
1. Caesarean Section Rate is the ratio of the number of Caesarean sections performed to the total number of deliveries, including Caesarean sections for a certain period.

Total no. of Caesarean sections in a region in a given period Caesarean Section Rate = --------------------------------------------------------------- x 100 Total no. of deliveries for the same period

Sample Computation:

Four (4) caesareans were performed for the month of August 2011, during which there were 350 deliveries. Following the formula, the caesarean section rate is 1.14%.

Caesarean Section Rate = $$\frac{4}{350}$$ = $\frac{1.14%}{350}$

Note:

A three to four percent (3-4%) rate or lower is acceptable by Western standards.
Regardless of the delivery outcome, i.e., one child, twins, etc., and whether a dead or live newborn is delivered, the mother is considered to have delivered only once.

5.5.2 Mortality

Death certificates are the main source of mortality statistics. The information recorded in death certificates helps decision-makers determine health priorities for preventing deaths due to similar causes in the future. Health decision-makers and planners all around the world make extensive use of mortality statistics.

Source: University of Melbourne. (2016). Handbook for doctors on the cause of death certification. CRVS technical guides. (2nd Edition). University of Melbourne, Civil Registration and Vital Statistics Improvement, Bloomberg Philanthropies Data for Health Initiative. https://crvsgateway.info/file/9582/57

The person certifying the cause of death should enter the sequence of events leading to the death (morbid conditions that led directly to death and any antecedent conditions giving rise to this cause) on the death certificate, which conforms to the international format.

From the standpoint of prevention of death, it is necessary to break the chain of events or effect a cure. The most effective public health objective is to prevent the precipitating cause from operating.

The underlying cause of death is used for mortality statistics tabulation and reporting purposes.

The underlying cause of death is defined as:

the disease/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.

The ICD-10 or the latest revision of the ICD guides mortality coding for selecting and coding the "underlying cause of deaths" to be considered for Mortality tabulation.

Applicable Mortality coding rules shall be used to select the correct underlying cause of death for Mortality tabulation.

● Dead on Arrival (DOA) refers to patients brought to a health facility without cardiopulmonary and brain functions. This includes patients who did not respond to initial resuscitation and patients with Rigor Mortis, Livor Mortis, and Algor Mortis signs. This excludes cases of decapitation not susceptible for resuscitation and patients brought in an advanced state of decomposition (as per Administrative Order No. 2020-0008).
**● ED Death/**ER Death refers to deaths of patients occurring in the ER, including patients who were revived by initial resuscitative measures at the ER but eventually died there, regardless of the duration of time (as per Administrative Order No. 2020-0008).

Death Rate is the proportion of inpatient hospitalizations that ends in death. It has always been important information for health facilities in evaluating the quality of medical care.

Gross Death Rate is the ratio of all inpatient deaths, including newborns, to the total number of discharges, including deaths, for a given period. This is also known as the Mortality Rate.

Total deaths including newborns for a given period Gross death rate = ---------------------------------------------------------------- x 100 Total discharge and deaths for the same period

Sample Computation:

If the health facility had four (4) deaths and 385 discharges for the month, the gross death rate is:

Gross death rate = $$\frac{4}{385}$$ x $100 = 1.04%$ .

Note:

Do not include Dead on Arrival (DOA), stillbirth, and ED deaths.
Include newborn deaths in computing for this indicator. Below three percent (3%) is acceptable by Western standards.
1. Net Death Rate is the ratio of deaths excluding those under 48 hours of admission. It produces a lower figure than the gross death rate. This is also known as Institutional Death Rate.

(Deaths, including newborns) – (Deaths under 48 hours for the period) Net death rate = ----------------------------------------------------------------------------------- x 100 (Institutional (Total no. of discharges, including deaths and newborns) – (deaths under 48 hours for the same period) death rate)

Sample Computation:

A health facility had 424 deaths for the year 2008, 183 of which died less than 48 hours after confinement. The total number of discharges for the same period is 16,500. The net death rate is 1.47%.

Net death rate = $$\frac{(424) - (183)}{(16,500) - (183)}$$ $\times 100 = 1.47%$

Note:

Death occurring at the ER is not counted if the patient is not yet considered admitted. The 0.5-2.5% rate is acceptable by Western standards.

Maternal Death Rate is the ratio of deaths resulting from obstetric complications of the pregnancy state (pregnancy, labor, and puerperium) from interventions, omissions, incorrect treatment, or a chain of events resulting from any of the abovementioned events.

Types of Maternal Deaths

a. Direct Cause is a death resulting from obstetric complications of the pregnancy state (pregnancy, labor, and puerperium) from interventions, omissions, incorrect treatment, or a chain of events resulting from any of the above.
b. Indirect Cause is a woman's death resulting from a previously existing disease or a disease that developed during pregnancy, labor, or the puerperium that was not due to obstetric causes. Although, the physiologic effects of pregnancy were partially responsible for the death, also known as Indirect Obstetric Death.

Total no. of direct maternal deaths in a given period Maternal death = ---------------------------------------------------------------------------- x 100 rate Total no. of maternal (obstetrical) discharges including deaths for the same period

Sample Computation:

For example, two (2) mothers died after delivery at a health facility having annual OB discharges of 7,000. The maternal death rate derived from the formula is 1.14%.

Maternal death rate = $$\frac{2}{7,000}$$ x $100 = 0.31%$

Note:

To be counted, death must occur between conception and puerperium.
Up to two and a half percent (2.5%) is considered normal by Western standards.
Count only those patients whose death directly resulted from an obstetric complication of pregnancy, labor, or puerperium from interventions, omissions of treatment, or chain of events resulting from any of these.
A woman who dies following an abortion is maternal death; it is a situation where an obstetrical patient dies before the delivery of a cause due to pregnancy.
1. Postoperative Death Rate is the ratio of the total number of post-operative deaths (deaths within ten (10) days after surgery) to the total number of patients operated on during that period.

Total postoperative deaths for the period Postoperative death rate = ------------------------------------------------------- x 100 Total patients operated for the same period

Sample Computation:

For example, a health facility had a total of 72 surgical operations performed for the month of February, one (1) of which died due to coronary artery bypass after ten (10) days of surgical operation. The computation is as follows:

Post-operative death rate = $$\frac{1}{72}$$ x $100 = 1.39%$ .

Perinatal Death refers to the number of stillbirths and deaths in the first week of life (early neonatal mortality). (WHO definition)

(Early neonatal deaths + stillbirths) Perinatal mortality rate = ----------------------------------------------- x 100 Total births

where total births = live births + stillbirths

Perinatal mortality rate = $$\frac{48 + 12}{5877}$$

1. Fetal Death Rate (Stillbirth Rate) is the ratio of intermediate and late fetal deaths to the total number of births, including intermediate and late fetal deaths. Fetal deaths are classified as:
- a. Early Fetal Death less than 20 weeks of gestation (500 grams or less),
- b. Intermediate Fetal Death 20 weeks of gestation but less than 28 weeks (501 to 1000 grams), and
- c. Late Fetal Death 20 or more weeks of gestation (1001 grams stillbirth).

Total no. of intermediate and late fetal deaths for the period Fetal death rate = ------------------------------------------------------------------------------- x 100 Total no. of birth (including intermediate and late fetal deaths) for the same period

Sample Computation:

For example, in January, a health facility had a total of 98 live births, one (1) intermediate, and four (4) late fetal deaths. The total number of intermediate (1) and late fetal deaths (5) is divided by the total number of live births and the intermediate and late fetal deaths (98+5) to determine the fetal death rate. The computation is as follows:

Fetal death rate = $$\begin{array}{c} 1+4 & 5 \ ----- & x \ 100 = ---- & x \ 100 = 4.85 \ 98 & 5 & 103 \end{array}$$

Note:

Below two percent (2%) is considered normal by Western standards.

Neonatal Death Rate (infant Newborn Mortality Rate) is the ratio of newborn deaths to the total number of newborn discharges, including deaths.

Total no. of newborn deaths for the period Neonatal death rate = ------------------------------------------------------------------------ x 100 (Infant newborn Total no. of newborn infant discharges (including deaths) for the same period mortality rate)

Sample Computation:

For example, a health facility reported the following statistics for 2010: newborn deaths 3, newborn discharges 3,850. Infant newborn mortality rate is 0.08%.

Neonatal death rate = $$\frac{3}{3,850}$$ x $100 = 0.08%$

Note:

Final deaths of less than 20 weeks shall not be included, and those admitted after their deliveries/births outside the health facilities.
For infant death rate, below 2% is acceptable by Western standards.

Neonatal Death could be divided into:

1. Neonatal Period I from the hour of birth through 23 hours and 59 minutes
1. Neonatal Period II from the beginning of the 24th hour of life through 6 days, 23 hours, and 59 minutes
1. Neonatal Period III from the beginning of the 7th day of life through 27 days, 23 hours, and 59 minutes
1. Infant Death Rate is the ratio of the total number of infant deaths, including neonatal and post neonatal deaths rate of a live-born infant at any time from the moment of birth to the end of the first year of life (364 days, 23 hours, 59 minutes from the moment of birth).

Total no. of Infant deaths (neonatal and post neonatal during a period Infant Death Rate = ---------------------------------------------------------------------- x 100 Number of live births during the period

Sample Computation:

Using the same data on the above example on the computation of Infant Newborn Mortality rate with total live births of 3,856, the infant death rate is calculated as follows:

Infant death rate = $$\frac{3}{100}$$ x 100 = 0.08%.

1. Autopsy Rate is the proportion of deaths that are followed by the performance of an autopsy.
- a. Gross Autopsy Rate is the ratio of all autopsies performed in the health facility to all in-patient deaths in the health facility.

Total no. of autopsies performed for a period Gross autopsy rate = -------------------------------------------------------------- x 100 Total no. of inpatient deaths for the same period

Sample Computation:

For example, in September 2010, a health facility discharged 942 patients with 36 deaths (including newborns) and performed 11 autopsies. Using the formula given above, the gross autopsy rate is:

Gross autopsy rate = $$\frac{11}{36}$$ x $100 = 30.56%$ .

b. Net Autopsy Rate is the ratio of all autopsies to all inpatient deaths minus the unautopsied cases during the period.

Total no. of autopsies performed for a period Net autopsy rate = -------------------------------------------------------------------- x 100 Total deaths – un-autopsied cases for the same period

Sample Computation:

In July 2011, a health facility had a total of 32 deaths and performed 12 autopsies. Three (3) bodies were released to the forensic examiner for an autopsy. Therefore, 3 cases are subtracted from the denominator because the health facility did not autopsy them. Dividing the number of inpatient autopsies performed (12) by autopsy rate of 41.38%

Net autopsy rate = $$\begin{array}{c} 12 \ ----- \ (32-3) \end{array}$$ x 100 = $\begin{array}{c} 12 \ ---- \ x 100 = 41.38% \end{array}$

Note: Exclusions:

Stillbirth, dead on arrival (DOA)
Death in the Emergency Department when a patient is not admitted (ED Death)
Medico-Legal cases are referred to the proper authority.

CHAPTER 6 Health Records in Medico-legal, Investigative, and Court Procedures

6.1 Ownership of the Health Record

Health facilities own the physical aspect of the health record, but legally, the privilege against disclosure belongs to the patient and the attending physician. In a health facility setting, proper notification of the Attending Physician prior to the release of clinical information is ideal for protecting the legal interest of the doctor and other healthcare providers and the health facility. Hence, verbal requests for clinical information shall be discouraged in favor of written requests.

6.2 Accessibility

As a general rule, all health professionals directly involved in treating a patient shall have access to the patients' health record. In cases where the patient is discharged and the health records are turned over to the HIMD, all access requests must be put in writing, requiring the approval of the HIM Head or the Chief of Hospital/Medical Center Chief or a duly authorized representative.

The health record is a legal document. As such, all records shall be stored in areas where only authorized staff are allowed to access, and appropriate security measures are instituted. No clinical information concerning a patient or client shall be released to another person without the patient's consent or authorized representative.

6.3 Confidentiality

A health record is confidential, and the patients' right to privacy must be the primary concern in releasing information. It serves as privileged communication between the physician or other health professionals and the patient. The following are rules on the confidentiality of specific health records according to law:

6.3.1 Records of Drug Dependents

6.3.1.1 Records under the Voluntary Submission Program

In accordance with Section 60 of Republic Act 9165, "Judicial and medical records of drug dependents under the voluntary submission program shall be confidential and shall not be used against him for any purpose, except to determine how many times, by himself/herself or through his/her parent, spouse, guardian or relative within the fourth degree of consanguinity or affinity, he/she voluntarily submitted himself/herself for confinement, treatment, and rehabilitation or has been committed to a Center under this program."

6.3.1.2 Records under the Compulsory Submission Program

In accordance with Section 64 of Republic Act 9165, "The records of a drug dependent who was rehabilitated and discharged from the Centre under the compulsory submission program, or who was charged for violation of Section 15 of the Comprehensive Dangerous Drug Act of 2002, shall be covered by Section 60 of this act. However, the record of a drug dependent who was not rehabilitated, or who escaped but did not surrender himself/herself within the prescribed period shall be forwarded to the court, and their use shall be determined by the court, taking into consideration public interest and the welfare of the drug dependent."

6.3.2 Health Information on Violence against Women and their Children

In accordance with Section 44 of Republic Act 9262, "All records pertaining to cases of violence against women and their children including those in the barangay shall be confidential, and all public officers and employees and public or private clinics to hospitals shall respect the right to privacy of the victim. Whoever publishes or causes to be published, in any format, the name, address, telephone number, school, business address, employer, or other identifying information of a victim or an immediate family member, without the latter's consent, shall be liable to the contempt power of the court."

6.3.3 Health Information of Human Immunodeficiency Virus (HIV) Patient

Medical confidentiality shall protect and uphold the right to privacy of an individual who undergoes HIV testing or is diagnosed with HIV. It includes safeguarding all health records obtained by health professionals, health instructors, co-workers, employers, recruitment agencies, insurance companies, data encoders, and other custodians of said records, files, or data.

Confidentiality shall encompass all forms of communication that directly or indirectly lead to disclosing information on the identity or health status of any person who undergoes HIV testing or is diagnosed to have HIV.

This information may include but is not limited to the name, address, picture, physical description, or any other characteristics of a person, which may lead to identification.

Concerned officials, agencies, and institutions shall adopt protocols and policies to safeguard the confidentiality of a person's HIV/AIDS record.

6.3.3.1 Exceptions to the mandate of confidentiality

The requirement for medical confidentiality shall be waived in the following instances, as stated in Sec. 45 of Article VI Confidentiality of the Philippine HIV and AIDS Policy Act (RA 11166):

When complying with reportorial requirements of the national active-passive surveillance system of the DOH: Provided that the information related to a person's identity shall remain confidential;
When informing other health workers directly involved in the treatment or care of a PLHIV: Provided that such worker shall be required to perform the duty of shared medical confidentiality; and
When responding to a subpoena duces tecum and subpoena ad testificandum issued by a court with jurisdiction over a legal proceeding where the main issue is the HIV status of an individual: Provided that the confidential medical record shall remain anonymous and unlinked and shall be properly sealed by its lawful custodian, hand-delivered to the court, and personally opened by the judge after having been verified for accuracy by the head of the office or department: Provided further, that the judicial proceedings be held in executive session.

6.3.3.2 Release of HIV/AIDS Test Results

Likewise, the IRR of RA 11166 states that the result of HIV/AIDS testing shall be confidential and shall be released on to the following:

The person who was tested,
Parent of a minor who was tested,
Legal Guardian or a duly assigned licensed social worker or health worker, whichever is applicable, for a minor, a mentally incapacitated person, or an orphan who was tested,
The person authorized to receive such results in conjunction with the DOH Monitoring Body, and
A judge of the Lower Court, Justice of the Court of Appeals, or Supreme Court Justice who has jurisdiction over the case.

6.3.4 Health Information of Psychiatric Patient

Health information of psychiatric patients shall be released only upon presentation of written authorization from the patient's nearest kin or by a person appointed by the court as the legal guardian. If the request is from a psychiatric facility where the patient is presently confined, the information shall be released as soon as approval from the Head of Health facility is obtained.

The Mental Health Act or Republic Act 11036 states that "Confidentiality of all information, communications, and records, in whatever form or medium stored regarding the service user, any aspect of the service user's mental health, or any treatment or care received by the service user, which information, communications, and records shall not be disclosed to third parties without any written consent of the service user concerned or the service user's legal representative except in the following circumstances:

Disclosure is required by law or pursuant to an order issued by a court of competent jurisdiction;
The service user has expressed consent to the disclosure;
A life-threatening emergency exists, and such disclosure is necessary to prevent harm or injury to the service user or other persons;

Health Records in Medico-legal, Investigative, and Court Procedures

The service user is a minor, and the attending mental health professional reasonably believes that the service user is a victim of child abuse; or
Disclosure is required in connection with an administrative, civil, or criminal case against a mental health professional or worker for negligence or a breach of professional ethics, to the extent necessary to completely adjudicate, settle, or resolve any issue or controversy involved therein."

6.4 Health Record with Investigative Concerns

Prior to the release of health records for any investigative concerns, it shall undergo a thorough quantitative and qualitative analysis to ensure the accuracy and completeness of all information that the case requires.

During and after the investigation, the Head of HIMD or an authorized representative shall ensure that there are no alterations of the information and no pages detached or missing.

6.4.1 Insurance (PHIC, SSS, GSIS, Private Insurance Companies)

An insurance verifier shall be required an original copy of the waiver from the patient or patient's next of kin in case of death or physical/mental disability, duly notarized before being given access to the health record/information about the patient. The waiver copy shall also be countersigned and dated by the insurance verifier and filed with the record. The head of the HIMD shall properly identify insurance verifiers representing PHIC and other Health Maintenance Organization before being given access to review health records for reimbursement purposes.

6.4.2 Adjudicatory Agencies (PNP, NBI, CIDG, BJMP, PDEA, and other Law Enforcement Agencies)

If there is a need for a review of the health record concerning the investigation of a certain case, a representative shall be allowed to have access provided that a written request duly signed by the Chief /Director of their respective agency is approved by the Head of the health facility.

6.4.3 Clinical Research/Studies

Researchers may be given access to health records only after complying with the requirements set by the Research Ethics Committee or the Standing Policy of the Health facility.

6.4.4 Patients Complaints (CHR, PRC, CSC, Presidential Hotline)

Any complaint of a patient has to be validated. It is the Head of HIMD to review the health record following standards on the release of clinical information.

6.5 Records Subpoenaed by the Court

Subpoena testificandum is directed to a person to attend and testify in any investigation conducted under Philippine law. A person may also be required to bring books, documents, or other materials that may be required by the Court, in which case, it is called a subpoena duces tecum.

Subpoena duces tecum ad testificandum is issued when a person is mandated to testify and bring the documents to the court.

Often, the HIMD receives a subpoena duces tecum, which only requires the HIMD head to bring a particular record(s) to court.

A legally served subpoena is binding on the person to whom it is addressed. The HIMD staff should not accept any subpoena not directly addressed to HIMD. If a subpoena is addressed to a particular doctor, it must be served to the doctor or a representative.

If a subpoena is served to a doctor who is no longer connected with the institution, a letter of notification signed by the MCC addressed to the presiding Judge shall be accomplished and submitted to the court.

Upon receipt of the subpoena, the recipient must always indicate the time and date of receipt.

Exceptions – The provisions of Sections 8 (Compelling Attendance) and 9 (Contempt) of rule 21 of the 1997 Rules of Civil Procedure shall not apply to a witness who resides more than 100 kilometers from its residence to the place where to testify by the ordinary course of travel, or to a detention prisoner if no permission of the court.

Figure 9. Process Flow in Response to Subpoena duces tecum

Health Records in Medico-legal, Investigative, and Court Procedures

If the health record can no longer be provided in court, the following shall apply:

REASON	ACTION
1. Misfiled/ Lost Health Record	Bring In-patient / Operating Room / Delivery Room / Birth
	and Death Registry to court
2. Disposed of under the Law on	Certificate of Disposal from National Archives of the
Records Disposition	Philippines (NAP)
3. Destroyed by Calamities	In-Patient Registry, if available or Certification from
	concerned agencies of the damaged records due to
	calamities.

As a general rule, no treatment or procedure may be performed without the patient's/relative's consent. There are instances where consent could not be obtained from an incapacitated person (for example, when a patient is comatose or a minor). Therefore, surrogate consent must be obtained from the parent, nearest-of- kin, or legal guardian.

Valid consent must be signed by the patient/relative together with a witness and must also be dated and timed. Aside from these requirements, the person giving the consent should be legally and mentally competent. The consent must be freely/voluntarily given and clearly understood by the authorized person.

CHAPTER 7 Introduction to Electronic Health Record

7.1 Introduction

The rapid changes in healthcare delivery and public demand for more extended and improved health services have made electronic health records an obligation of every health facility. The Republic Act No. 11223 or the Universal Health Care (UHC) Act, signed on February 20, 2019, mandates that all Filipino citizens be automatically enrolled in the National Health Insurance Program and prescribes complementary reforms in the health system. This gives citizens access to the full continuum of health services they need while ensuring financial risk protection. To illustrate, below is an excerpt of Section 36, Health Information System, of the UHC Act:

"All health service providers and insurers are required to maintain a health information system on enterprise resource planning, human resource information system, electronic health records, and electronic prescription log, including electronic health commodities logistics management information, which shall be electronically uploaded on a regular basis through interoperable systems consistent with the standards set by the DOH and PhilHealth and in consultation with the DICT and NPC; Provided, That the applicable standards shall set depending on variables such as type and level of healthcare providers."

Further, the Health Information System practitioners play important roles in applying eHealth in the Philippine standards: optimizing processes and registration, improving data collection to processing and analysis of health data, aligning with the Data Privacy Act of 2012 or RA No. 10173.

Thus, DOH has continuously addressed the challenges and demands to improve healthcare service deliveries and outcomes through government hospitals' DOH Integrated Hospital Operations Management Information System (iHOMIS). The iHOMIS is a computer-based information system developed by the DOH to support hospital management for effective and quality health care providing timely, relevant, and reliable information. It uses data from other systems (e.g., DOH Licensing, NHFR (National Health Facility Registry) Systems, PSA data, and others). It also assists planning, decision-making, and linkages with the different hospital service components and other health facilities.

7.2 Electronic Health Record (EHR) defined

The Electronic Health Record:

contains all personal health information belonging to an individual;
is entered and accessed electronically by healthcare providers over the person's lifetime; and
extends beyond acute inpatient situations, including all ambulatory care settings at which the patient receives care.

The World Health Organization's declaration of Health for All by the Year 2000 highlighted the need for better health care services at the hospital (secondary) level and primary healthcare and community health services. This has required a change of focus in healthcare in many areas to ensure, if possible, that the implementation of an electronic health record covers healthcare delivery services across a broad spectrum of healthcare.

Ideally, it should reflect the entire health history of an individual across a lifetime, including data from multiple providers from a variety of healthcare settings.

However, such an extensive system has not been introduced by many institutions/countries to date, although many are planned, but may still not be possible in some developing countries or, even in some developed countries.

Whatever the type of electronic health record decided upon, the health information must be organized primarily to support continuing, efficient, and quality healthcare. It must also continue to meet the patient's legal, confidential, and retention requirements, the attending health professional, and the healthcare institution/country.

For this manual, the title electronic health record (EHR), as defined above, will be used as the preferred definition.

7.3 Goals and Principles upheld by EHR Implementation

With the many advances in information technology over the past years, particularly in healthcare, a number of different forms of electronic health records (EHR) have been discussed, developed, and implemented. Some institutions/countries are currently planning to introduce a national electronic health record, while others have implemented EHR. However, the type and extent of electronic health records vary, and what a country calls an EHR may not be the same as that developed in another country.

In addition, some medical practitioners and health professionals' resistance to a change from manual to electronic documentation may be a problem in both developed and developing countries. Most health administrators and information managers know that changing or modifying health practitioner behavior and attitudes may take time.

It is recognized as well that more than simply adopting a paperless system, the focus on encouraging departments and healthcare practitioners to move to an electronic system should stem from the following goals:

a. improvement in the accuracy and quality of data recorded in the health record,
b. enhancement in the healthcare providers' access to patient's health care information enabling it to be shared by all for the present and continuing care of the patient,
c. improvement in the quality of care as a result of having health information immediately available at all times for patient care,
d. improvement in the efficiency of the health record service, and
e. reduction of health costs brought about by inefficient systems.

With these, the following principles shall be considered in adopting EHR:

1. Patient-centered design

a. The use of an EHR should add value to health care delivery.
b. The primary purpose of an EHR is clinical care.

2. Health care professionals

a. The use of an EHR should improve, or at a minimum not reduce, the well-being of health care workers.
b. The use of an EHR should align the work with the training of the worker.
c. The EHR is a shared information platform for individual and population health.

3. Efficiency

a. The use of an EHR should minimize waste.
b. Electronic workflows should align with clinical work.
c. Various methods of communication, including non-electronic forms, will be necessary for optimal patient care.

4. Regulation and payment

a. Sufficient resources should be available for the new work associated with the advanced use of an EHR.
b. Policies around EHR use should reflect the strength of evidence-based support.
c. A regulatory balance between competing values (i.e., clinical quality vs. security or efficiency vs. performance measurement) should be sought.

5. Privacy, Confidentiality, and Security

The EHR shall uphold the principles of privacy, confidentiality, and security.

a. Privacy This pertains to a legal concept referring to the protection accorded to an individual to control both access to and use of personal information. Privacy protection varies from one jurisdiction to another and is defined by laws and regulations. Privacy protections provide the overall framework within which both confidentiality and security are implemented.
b. Confidentiality This concerns individuals' right to protect their data during storage, transfer, and use to prevent unauthorized disclosure of that information to third parties.
c. Security This refers to the collective body of physical, electronic, and procedural processes designed to prevent breaches in information confidentiality. Security also concerns system availability, including identifying and managing predictable risks to data systems, such as power outages, staff shortages, natural disasters, and user error.

7.4 Guide for Health Facilities towards adopting EHR

The following steps/procedures should be conducted to guide health facilities to transition into EHR and ensure that all issues and concerns related to its implementation can be addressed.

7.4.1 Needs Assessment and Review of Current System

1. All health facilities shall ensure that hospitals adhere to standards set for keeping health records as these EHRs follow the same principles.
1. Emphasis is given to the following:
- A numbering system dedicating a unique number system for each patient (numbers are not repeated); and
- Ensuring that all health records associated with the patient are kept.
1. Assessment usually shows the things that the health facility needs to address prior to implementation of the EHR to ensure the smooth transition.

7.4.2 Planning considerations in the transition to EHR

1. Once issues and challenges are identified, health facilities are to do the following:
- a. Establishment of a Steering Committee,
- b. Preparation of a clearly defined statement of the type of EHR to be implemented,
- c. Identification of perceived benefits to the institution with the introduction of an EHR system,
- d. Preparation of a list of clearly stated goals and strategies for implementation,
- e. Review of current health record policies and procedures and develop them to cover proposed changes, and
- f. Identification of record structure and content:
  - Ensure a patient identification system is in place; and
  - Determine an effective means of obtaining the patient's informed consent.

2. Other possible issues may include:

a. Clinical data entry issues and lack of standard terminology,
b. Resistance to computer technology and lack of computer literacy,
c. Strong resistance to change by many healthcare providers,
d. High cost of computers and computer systems and funding limitations,
e. Concern by providers as to whether the information will be available on request,
f. Concerns raised by healthcare professionals, patients, and the general community about privacy, confidentiality, and the quality and accuracy of electronically generated information,
g. Quality of electronic healthcare information and accuracy of data entries,
h. Lack of staff with adequate knowledge on disease classification systems,
i. Human resources issues lack of staff with adequate skills,
j. Environmental issues electrical wiring and supply of electricity, amount and quality of space needed for computers, etc., and

k. Involvement of clinicians and hospital administrators.

7.4.3 Identifying the EHR Design and Technical Specification

1. The EHR design review should also be conducted to ensure that the following concerns or issues are avoided in the selected EHR:
- a. Variable levels of functionality and data security,
- b. Unpredictable vendor/technical support,
- c. Issues with long-term sustainability,
- d. Variable reporting functionality, and
- e. Limited feedback of data in EHR systems for patient care.
1. EHR should be able to do the following:
- a. Collect and display essential demographic patient information such as name, birth date, gender, rank, etc.;
- b. Manage patient's problem/diagnosis list: coded diagnosis, onset date, history, chronicity, date resolved;
- c. Collect and show patient medications;
- d. Collect and show patient allergies;
- e. Collect and show test results;
- f. Accept encounter clinical data: vital signs, weight, height, calculate BMI, frequency of rehabilitation; and
- g. Accept clinical notes in a structured format and in free text format, which include the Armed Forces of the Philippines (AFP), Philippine National Police (PNP), Bureau of Jail Management and Penology, Bureau of Fire Protection (BFP), and Treatment and Rehabilitation Centers (TRCs).
1. In addition, ensure that DOH accredits the EHR through Licensing/ Accreditation Implementation of the National eHealth Electronic Health Record System Validation (NEHEHRSV) based on existing guidelines.
1. Implementation
- a. Full implementation requires the following:
  - detailed preparation with all technical requirements in place,
  - fully operational and working telecommunication infrastructure,
  - thoroughly tested system, and
  - ready and fully trained staff.
- b. Data for all active patients must be uploaded immediately before the identified cutoff schedule for full migration (e.g., identification and demographic details uploaded in the new system)

c. The capacity of the electronic system to back up files safely is a critical factor in determining the full transition from a manual system to an electronic system.

7.5 Electronic Medical Records

Electronic Medical Records (EMRs) are a digital version of the paper charts in the clinician's office. An EMR contains the medical and treatment history of the patients in one practice. EMRs have advantages over paper records.

Electronic Medical Record or EMR, as with Automated Health Records, has been used to describe automated systems based on document imaging or systems developed within a medical practice or community health center. These have been used extensively by general practitioners in many developed countries and include patient identification details, medications, prescription generation, laboratory results, and all healthcare information recorded by the doctor during each visit by the patient. In Korea, EMR is used to define an electronic record system within a hospital, which, as well as the above, includes clinical information entered by the healthcare professional at the point of care.

Advantages of Electronic Medical Records

Providing accurate, up-to-date, and complete information about patients at the point of care
Enabling quick access to patient records for more coordinated, efficient care
Securely sharing electronic information with patients and other clinicians

Table 11. Comparison of Paper vs. Electronic Systems

FACTOR	PAPER	ELECTRONIC
Storage/Space Requirement	Filing cabinets	Computers, servers, switches,
	Records Room	etc.
		Data Center
Manpower	Less efficient work	More efficient work processes
	processes	Computer proficiency required
	Need not be computer
	experts
Supplies	Paper, ink, folders, pens,	Data servers, computers, etc.
	etc.	Electricity/back-up generator
	Environmental cost
	May or may not need
	electricity
Management/Sharing	Reproduce copy	Download file
	File/Re-file	Easy back-up
	Slow mobility	Fast transmission
	Difficult to collaborate	Easy collaboration
	Maintain original copies
Access	Manual retrieval	System search and retrieval
Security/Protection	Location – strategic	Location – strategic
	Records room –	Data Center – authorized staff
	authorized staff	Install CCTV / Air-conditioning
		System Log-in

Introduction to Electronic Health Record

	Install CCTV / Air conditioning	Firewall Maintenance – Annual
Retention/Disposal	Follow NAP guidelines Permanent records – perpetual Temporary records – disposal	Follow NAP guidelines Retention period same as paper records

(See Annex A for the Overview of Electronic Medical Records and its Operations by World Health Organization, 2006)

CHAPTER 8 Continuous Quality Improvement for HIMD

The DOH Administrative Order No. 2020-0034, "Revised Guidelines on the Implementation of Continuous Quality Improvement (CQI) Program in Health Facilities in Support of Quality Access for Universal Health Care," mandates establishing the CQI program in health facilities. Each department of the health facility is encouraged to implement CQI for the overall quality improvement.

Continuous Quality Improvement (CQI) for HIMD strengthens the implementation of the existing Standard Operating Procedures (SOPs). It provides quality health records for continuity of care to patients and quality data for the health facility planning and decision making to attain cost-effective health record management. It evaluates the quality of service delivered and facilitates necessary corrective actions to provide feedback. This identifies staff in-service training needs and provides an objective basis for disciplinary actions. It also encourages employees to achieve an optimum level and recognizes excellence in employee performance to institute staff development.

CQI evolved from Quality Assurance (QA) Program, which its main framework provided guidelines for health facilities to plan and systematize procedures in delivering quality service. When CQI is adopted by the health facility management as one of each ideal, as part of the health management system, the result is Total Quality Management (TQM). CQI is founded on a total quality management philosophy, established in a quality management system compliant with ISO 9001:2015 standards, and strategically managed on platforms such as the Performance Governance System and the Strategic Performance Management System.

8.1 Composition of CQI Team in HIMD

At the level of HIMD, a quality improvement team can be organized with the following members:

One who is involved and who knows the process,
One who is affected by the problem,
One who has the technical expertise,
One who decides the process, and
Other members who can contribute to the formulation and implementation of solutions.

The composition of the team may be multidisciplinary or cross-functional. An employee of the health facility with the expertise or one who is affected by the problem can be a member of a QI team regardless of the department the person belongs to.

The team is mandated to meet regularly to identify problems, understand and analyze the causes, and formulate the best solutions for implementation. Evaluation and monitoring must be carried out to institute corrective actions making CQI a continuing cycle.

8.2 Expected Outcomes of the Quality Improvement Activities

Continuous improvement project of clinical and non-clinical care and service
Identification of barriers in the achievement of higher quality patient care
Motivation for the staff to be more aware of and interested in standards of patient care and service
Delivery of safe and efficient care and service
Efficient and effective allocation and use of resources
Ensuring that the program is ongoing, upgraded, improved standards are long-lasting and conform to the standard required by law and/or regulatory bodies through the commitment from staff/management
Constructive input, from all staff levels, into the continuing education program of the complex
Communication at all levels about problems related to standards of quality care and service
Cooperative problem-solving, where a service involves more than one area in the complex

8.3 Essential Elements of Quality Improvement

1. Planned and Systematic Approach. A quality assurance plan should exist and address the following:
- a. Scope of the program,
- b. Objective,
- c. Methods to be used, and
- d. The individuals to be involved in the program.
1. Monitoring. There should be a systematic, ongoing process of collecting information on clinical and non-clinical performance.
1. Assessment. The periodic analysis and interpretation of the information collected to identify problems in patient care.
1. Action. At this stage, important problems in patient care or opportunities to improve care are identified, action/studies are undertaken.
1. Evaluation. The effectiveness of actions taken is evaluated to ensure long-term improvement.

Feedback. Results of the activities should be regularly relayed to the staff or people involved in the program to be effective.

8.4 Plan-Do-Study-Act (PDSA) Cycle

One of the frameworks established to facilitate quality improvement is the PDSA Cycle. It is a four-stage problem-solving model used to improve processes and provide a system of organization in its dynamic environment over time. The cycle is shorthand for testing change by systematically identifying the problem and its root cause (Plan), carrying out the test (Do), understanding and learning from the results (Study), and determining the needed modifications to be made (Act). Below is a model of the cycle showing the processes involved.

Figure 10. The PDSA Cycle

Table 12. The PDSA Cycle - Step by step (DOH Administrative Order No. 2020-0034)

Steps	Guidelines	Tools and Techniques	Expected Output
PLAN: Define the problem and identify the root cause
Step 1: Identify areas for improvement	1. Identify the area, problem, or opportunity for improvement. 3. Estimate and commit the needed resources.	- Brainstorming -Prioritization Matrix Criteria - Check sheet (for data collection)	- List of problems identified
Step 2: Assemble a team.	1. Identify and assemble team members. 2. Specify team member roles and responsibilities. 3. Specify meeting frequency and structure. 4. Develop a SMART aim.		- Developed SMART aim statement - Complete Team with well-defined roles and responsibilities

Step 3: Identify the current process.	1. Examine the current approach or process flow.	- Brainstorming - Flowchart	- Constructed flowchart
	2. Obtain existing baseline data or create a plan to obtain	- Cause and	- Data requirements
	needed baseline data.	Effect/ Fishbone Diagram/ Ishikawa	- List of real causes of the problem
	3. Obtain input from stakeholders.	Diagram - Control Charts	- Final Problem statement
	4. Determine the causes of the problem.
Step 4: Identify potential change strategies.	1. Identify all potential change strategies based on root causes.		- Alternative solutions or strategies
	2. Select change strategy (or strategies) most likely to achieve the SMART aim.
Step 5: Identify improvement	1. Develop a theory of change for the change strategy.	- Documentations / reports i.e.	- Evidence-based Strategies
theory.	2. Develop a strategy to test the theory on a small scale (small number of participants.)	journal articles	- Evaluation Plan
	3. Determine how the strategy will be measured.
	DO: Customer Protection and Countermeasure
Step 6: Test the theory.	1. Carry out the test on a small scale.	- Check sheet - Flowchart	- Data on the effectiveness of the strategy
	2. Collect, chart, and display data to determine the effectiveness of the change strategy.		- Documented problems, unexpected effects,
	3. Monitor fidelity of implementation of the change strategy. Document problems, unexpected observations, and unintended side effects.		and general observations
STUDY: Confirm the effectiveness
Step 7: Study the results.	1. Determine whether the improvement was successful on a small scale.	- Pareto Diagram or Charts - Control Charts	- Trends - Conclusion and recommendations
	2. Determine if the results matched the theory/ prediction.		based on the result

Continuous Quality Improvement for HIMD

	3.Determine unintended consequences, if any.
	4. Describe and report what was learned.
ACT: Feedback/ Feedforward
Step 8: Scale up implementation.	1. Scale up successful change strategies and continue testing until improvement is achieved. 2. Develop and test new theories for unsuccessful changes. 3.Standardize successful improvements.	- 5 Ws and 1H (What, When, Where, Who, Why, and How)	- New test theories
Step 9: Establish plans.	1. Repeat the PDSA cycle when needed. 2. Take steps to preserve gains and sustain successes. 3. Make a long-term plan for additional improvements. 4. Celebrate your successes.		- Team development plan - Radar Chart

8.5 Risk Management

Risk management is an organized effort to identify, assess, and reduce the appropriate risk to patients, visitors, staff, and organizational assets. It helps minimize risks and extra costs that may be incurred by any threat to the operations of the HIMD. One important strategy is the identification of serious clinical documentation errors/problems. Clinical Documentation as the foundation of the health record should be accurate, timely, and reflect the scope of services provided.

The HIMD has full knowledge of the different documentation and /or recording standards used to guide health records' quantitative and qualitative analyses. An inherent function of the HIMD is to assist the members of the medical, nursing, and other professionals to come up with quality documentation.

Below introduces the CDI and its direct impact on patient care.

A. Clinical Documentation Improvement (CDI)

To facilitate quality, clinical documentation improvement (CDI) is a team approach to improving concurrent (while the patient is receiving care) documentation practices through ongoing education and clarification of clinical documentation that cannot be matched with the latest ICD code.

The goals of CDI are to facilitate clear, concise, clinically accurate information in the health record through the identification of incomplete, vague, and/or missing diagnoses to ensure that all applicable diagnoses are captured and coded to reflect:

Accurate reimbursement,
Quality of care/services provided,
Severity of illness/risk of mortality, and
Updated hospital and physician profiles.

The Role of CDI

General mission:

Facilitate creating a health record that accurately represents the acuity of the patient's illness and the hospital resources used to treat the patient by ensuring provider documentation can be "matched" with the ICD code.
Work collaboratively with the medical staff and coding department to translate provider documentation into diagnostic terms captured by ICD codes while the patient is receiving inpatient hospital treatment (concurrent review).

What is the importance of CDI?

The convergence of clinical, documentation, and coding processes is vital to a healthy revenue cycle, and more importantly, to a healthy patient.
To that end, CDI directly impacts patient care by providing information to all members of the care team and those downstream who may be treating the patient at a later date.

Characteristics of High-Quality Documentation

1. Legible clear enough to be read and easily deciphered
1. Reliable trustworthy, safe, yielding the same result when repeated
1. Precise accurate, exact, strictly defined
1. Complete has the maximum content, thorough
1. Consistent not contradictory
1. Clear unambiguous, intelligible, not vague
1. Timely performed at the time of service

B. Self-Assessment Tool of HIMD

The self-assessment tool of the HIMD can be used to evaluate and monitor compliance to the prescribed standards. Refer to Annex X.

REFERENCES

1. Bontile, H. L. R. (2013). Performance of DOH-Retained Hospitals in the Philippines. Discussion Papers DP 2013-36, Philippine Institute for Development Studies. https://doi.org/10.13140/RG.2.1.1847.4409
1. Department of Health (DOH), Department of Science and Technology (DOST), and Philippine Health Insurance Corporation (PHIC) Joint Administrative Order 2016-0001 & 2016-0002 (2016).
1. DOH Administrative Order No. 2013-0005 (2013).
1. DOH Administrative Order No. 2020-0008 (2020).
1. DOH Administrative Order No. 2019-0060 (2019).
1. DOH Department Circular No. 2021 0226 (2021).
1. DOH Department Circular No. 70 Series of 1996 (1996).
1. DOH. (2016). Medical Certification of Death Handbook for Filipino Physicians, Guidelines and Procedures (2nd ed.). Knowledge Management and Information Technology Service. Retrieved from the Department of Health: https://doh.gov.ph/sites/default/files/publications/Medical%20Certification%20of%20Death _Handbook%20for%20Filipino%20Physicians_2nd%20ed.pdf
1. DOH-DBM Joint Circular No. 1. Series 2013 (2013).
1. DOH-NPC Joint Memorandum Circular No. 2020-0001 (2020).
1. DOH-UP Manila Joint Memorandum Circular No. 2020-0001 (2020).
1. European Medicines Agency. (2016). Guideline for good clinical practice E6(R2). Retrieved from European Medicines Agency Science Medicine Health Portal: https://www.ema.europa.eu/en/documents/scientific-guideline/ich-e-6-r2-guideline-good clinical-practice-step-5\_en.pdf
1. FDA Circular No. 2020-0030 (2020).
1. IFHIMA. (2018). Education Modules for Basic Health Records Practice. Learning Center IFHIMA. Retrieved from: https://ifhima.org/learning-center/
1. Joint Commission International. (2013). JCI Accreditation Standards for Hospitals (5th ed.). Joint Commission Resources. https://www.jcrinc.com/-/media/deprecatedunorganized/imported-assets/jcr/defaultfolders/items/jcih14\_sample\_pagespdf.pdf?db=web&hash=5BCFA0824C1F1A90B6CF616 75140714E
1. Minnesota Department of Health. (n.d.). PDSA: Plan-Do-Study-Act (Rapid Cycle Improvement). Retrieved from https://www.health.state.mn.us/communities/practice/resources/phqitoolbox/pdsa.html
1. National Archives of the Philippines General Circular No. 1 & 2 (2009).
1. National Archives and Records Administration (NARA). (2001, June). Records Management Self Evaluation Guide (EPA 220-B-97-002). National Service Center for Environmental Publications(NSCEP). https://nepis.epa.gov/Exe/ZyPDF.cgi/P100MPER.PDF?Dockey=P100MPER.PDF
1. NSW Government. (2020, August 6). Records Management Assessment Tool. NSW State Archives. https://www.records.nsw.gov.au/recordkeeping/advice/monitoring/records management-assessment-tool
1. Philhealth Circular No. 25, s-2005 (2005).
1. PSA Memorandum Circular No. 2019-16 (2019).
1. Republic Act No. 10173 Data Privacy Act (2012).
1. Republic Act No. 11036 (2018)
1. Republic Act No. 11132 (2019).
1. Republic Act No. 11166 (2018).
1. Republic Act No. 386 (1949).
1. Republic Act No. 4226 (1965).
1. Republic Act No. 9165 (2002).
1. Republic Act No. 9262 (2004).
1. Republic Act No. 9470 (2007).
1. University of Melbourne. (2016). Handbook for doctors on cause of death certification. CRVS technical guides. (2nd Edition). University of Melbourne, Civil Registration and Vital Statistics Improvement, Bloomberg Philanthropies Data for Health Initiative. https://crvsgateway.info/file/9582/57
1. World Health Organization. (2007, September). Guidelines for Medical Record and Clinical Documentation: WHO-SEARO coding workshop. Wordpress. https://occupationaltherapy2012.files.wordpress.com/2012/03/2007\_guidelines\_for\_clinical \_doc.pdf
1. World Health Organization. (2008, June). HEALTH INFORMATION SYSTEMS: Toolkit on monitoring health systems strengthening. World Health Organization. https://www.who.int/healthinfo/statistics/toolkit\_hss/EN\_PDF\_Toolkit\_HSS\_InformationS ystems.pdf

References

1. World Health Organization. (2016). International statistical classification of diseases and related health problems, 10th revision, vol. 2, 10th edn, World Health Organization, Geneva.
1. World Health Organization. (2006). Medical records manual: a guide for developing countries. Manila: WHO Regional Office for the Western Pacific. https://apps.who.int/iris/handle/10665/208125
1. World Health Organization. (2006). Electronic health records: manual for developing countries. Manila: WHO Regional Office for the Western Pacific. https://apps.who.int/iris/handle/10665/207504

ANNEXES

ANNEX A: Overview of EMR

Implementation of a computerized MPI

Computerization of the MPI would be spread over a period of time through:

entry of information already held on index cards from the manual MPI card system, including all patients in hospital at the time of implementation,
inpatient registration, and
outpatient registration.

The data entry on new patients should be when they are admitted as inpatients or registered as outpatients, that is, in the Admission office for inpatients and the outpatient department registration desk for outpatients.

Search Program

As for the manual system, in a computerized MPI, the search program should enable the operator to locate a particular patient to determine if that patient has been in hospital previously and has a health record number.

Limited information on a number of patients (one patient per line) may be displayed on a screen for review or further action. These can be displayed by:

patient name-giving hospital number, and
hospital number giving the patient's name.

When the particular person is identified, that selected patient's full index file information may be displayed on the screen. If there are changes to the patient's identification details, they should be made at the time of admission.

When retrieving information, strict security codes should be used to prevent unauthorized access and alterations. Patients should have their user name and a password assigned by the computer manager and changed periodically.
Only an authorized user should access information relating to a patient and change, add to or delete records on the master file.

The MPI should force a name search before a name can be entered unless the name is being entered with a pre-existing medical record number.

Operation of a Computerized MPI

All name searches should use the name and at least one unique patient characteristic (see PATIENT IDENTIFICATION).
As in a manual system, the correct spelling of names is vital to minimize duplicate registration of a patient.
Entry of at least one unique patient characteristic is compulsory when adding a patient to the MPI.
Entry of the medical record number is compulsory when adding a patient to the MPI.
The computer automatically issues medical record numbers in strict numerical order.
The MPI should enable the manual entry of pre-existing medical record numbers.
Reports generated from the MPI should include:
- 1. a daily printout of numbers issued, in number order, creating the NUMBER REGISTER, and
- 1. regular printouts in alphabetical order of all names by family name or by the first name, depending on the naming conventions of the country.

A. Computerized Admission, Transfer, and Discharge (ATD) System

Like the MPI, the ATD system is one of the most computerized systems involving medical records. Introducing this system enables staff to maintain a file on all patients currently in hospital, awaiting admission, and recently discharged. It also enables authorized users around the hospital to have direct access (via a computer terminal) to the file and automatically generate bed census and other daily statistics required by the hospital administration.

The objectives of such a system are to:

provide an inpatient booking service for patients awaiting admission;
keep records of the bed state and bed allocation;
trace patients for inquiries;
provide daily patient census reports and related statistics;
provide information for the MPI (directly linked to the MPI system); and
provide a complete database for all authorized users of patient identification and location information.

Within such a system, a data file is maintained on all patients:

currently in hospital,
awaiting admission, and
recently discharged. In a computerized admission (transfer and discharge system), all admissions are entered at the time of admission, and the discharge details are entered for all discharged /dead patients at the time of discharge or death.

Important Points of a Computerized ATD System

All admissions must have an entry in the MPI.
There must be a linkage between the MPI and the ATD System to enable a name added to the MPI as part of the admission procedure.
Daily reports are generated, including:
- a. an admission list,
- b. a discharge list,
- c. a list of all inpatients at a given time, and
- d. a list of inpatients for longer than 90 days.

B. Computerization of the Disease and Procedure Index

A computerized disease and procedure index has been developed in many hospitals to enhance medical information retrieval for research. A manual system would contain diagnoses and procedures in coded form to retrieve individual cases for medical research. It could use the ATD system as the base records to which disease and procedure codes are added following the completion of the medical record at discharge or death of a patient.

Such a system could also accommodate information relating to tests performed during hospitalization for later review of the utilization of hospital services.
The program would process the "discharge" area of the ATD master file. In such a system, relevant records in the discharge area are accessed. However, a specific time limit should be determined regarding the transfer from the discharge area to the disease/procedure index. Seven days is the suggested minimum transfer time.

1. Coding

The MRO or the person given this responsibility coded the main condition/principal diagnosis and procedure. The diagnosis/procedure and code numbers are entered into each patient's admission record via a computer terminal.

2. Retrieval

The system would enable information retrieval and report generation on the types of diseases/ procedures treated within the hospital. It should enable retrieval by disease/procedure and sex/age/doctor/associated diseases and hospital number.

Reports from a computerized Disease/Procedure Index could include:

a list of all discharges not coded,
a list of all patients with a particular code or range of codes,
a list of last month's discharges by ICD code, and
a list of discharges by notifiable disease code.

The ATD system writes into the MPI and disease and procedure systems. It is a temporary database of patients and kept for about two to five years. It is then archived. The MPI is permanent.

C. Computerized Record Location/Tracking System

Many types of computerized file location/tracking systems are available. With such a system, the location of a medical record can be readily found. In addition, a list of previous places where the medical record was sent can be printed, e.g., clinics, including the date when the record was sent to that location. Some hospitals use a barcode system, as seen in department stores and supermarkets, while others enter details via a computer terminal in the Medical Record Department.

Source: World Health Organization. Regional Office for the Western Pacific. (2006). Medical Records Manual: A Guide For Developing Countries. Manila: WHO Regional Office for the Western Pacific.

View full document through this URL:https://apps.who.int/iris/handle/10665/208125

ANNEX B: Patient's Health Record Audit

PATIENT NAME HEALTH RECORD NUMBER (HRN):
	Last Name Name	First Name	Middle		DISCHARGE DATE:
	NOTE: Please check 🗹	corresponding boxes for the completeness of the patient's health
		record. This form shall be accomplished upon discharge.
		BASIC HEALTH RECORD FORMS
		For Nurse		For HIMD use only
		Station
No	Health Record Form	(Nurse		Checke
			Supervisor/		d and	Remarks
			Head		verified
		Nurse)
1.	Clinical Cover Sheet
2.	Admission Slip
3.		Informed Consent for Admission/Confinement
		(for outpatient and ER, informed consent for
	treatment)
4.	Amendment Form (if any)
5.		Emergency Room/Emergency Department
		Record or Elective Admission Form for OPD
	patient
6.		History and Physical Examination
7.		Clinical/Diagnostic Laboratory Result Forms
8.		Doctor's Order and Progress Notes
9.	Nurse's Notes (FDAR)
10.	Monitoring Sheet
	TPR -
	-	Pain Monitoring Sheet
	-	Input and Output
	Vital Signs -
11.	Intravenous Fluid Sheet
12.	Medication Sheet
13.		Discharge Summary/ Tagubilin

SUPPLEMENTAL HEALTH RECORD FORMS
	A. Operation Block
1.		Informed Consent for Surgery
2.		Informed Consent for Anaesthesia
3.	Anaesthesia Record
4.	PACU Monitoring Sheet
5.		WHO Surgical Safety Checklist
6.	Pre-operative Checklist
7.	Operative Record

	B. Delivery Block

1. 2.	Labor Room Record (Partograph) Operative Technique

3.	Newborn Record
4.	Essential Intrapartum Newborn Care (EINC)
5.	Delivery Slip



	PATIENT NAME		HEALTH RECORD NUMBER (HRN):
	Last Name First Name Name	Middle	DISCHARGE DATE:
	NOTE: Please check 🗹 corresponding boxes for the completeness of the patient's health record.
	OTHER HEALTH RECORD FORMS
		For
No	Health Record Form	Nurse	For	Remarks
		Station	HIMD
1.	Inter-departmental Referral Sheet
2.	Blood Request Form
3.	Clinical Abstract
4.	Nutrition Care Plan
5.	Medical Social Worker's Notes
6.	Physical Therapy Notes
7.	Respiratory Therapy Notes
8.	Interventional Radiology Notes
9.	Clinical Pharmacist's Notes
10.	AMS Forms (Antimicrobial)
11.	Fall
12.	Consultation Sheet
	Non-Disclosure Agreement for Access of
13.	Health Records
14.	Patient Referral Form

Checked by: __________________________ Received by:__________________________

ANNEX C: Outpatient Clinical Record

PATIENT NAME						HEALTH RECORD NUMBER (HRN):
Last Name		First Name	Middle Name
ADDRESS					SEX: [ ] Male [ ] Female	STATUS: [ ] Single [ ] Married
No. DATE OF BIRTH (mm/dd/yyyy)	Street AGE	BIRTHPLACE	City/Municipality/Province CONTACT NUMBER	NATIONALITY	[ ] RELIGION

NAME OF SPOUSE			NEXT OF KIN TO NOTIFY
FATHER'S NAME			ADDRESS
MOTHER'S NAME (MAIDEN)			RELATIONSHIP
ALERT NOTATION:
		Allergy to: (specify)		Others:
			CONSENT TO CARE
to my attorney.		I hereby authorize Dr and the staff of your Hospital to perform the treatment and procedures deemed necessary for my care. I also give authorization for the hospital to supply information from my health records to my insurance carrier and/or
Signature Over Printed Name of Patient			Signature of Next of Kin (for minor and/or mentally incompetent patients)			Triage Nurse/Witness

DATE			DOCTOR'S NOTES (S O A P)

ANNEX D: Emergency Treatment Record

I. TRIAGE RECORD

			PATIENT INFORMATION
Name (Last, Given, Middle)
Age	Sex	Male		Female			Date of Birth
Address
Referred by:	Mode of Arrival		Historian					Private MD
Self •	•	Ambulance		•	Patient			Guardian
OPD •	Walk-in • •		Parent
Priv MD •	•	Private vehicle		•	Family			MS
Hospital •	•	Police escort		•	Friend
VITAL SIGNS:	HR/RR		BP		T			oncerned children Weight
CHIEF COMPLAINT								thers
HISTORY OF PRESENT ILLNESS
			REVIEW OF SYSTEMS
GENERAL	EYE		ENT			CV		RESP
Fever	Redness		Congestion			Chest pain		DOB
Chills	Itching		Epistaxis				Palpitations	Cough
Weakness	Blurred vision		Sore throat		Orthopnea			Sputum
Nausea	Loss of vision		Hoarseness				Pedal edema	Hemoptysis
	Diplopia		Ear ache Ear discharge			PND		Wheezing
GI	GU		NEURO			MS		SKIN
Abdominal Pain Dysuria		Headache			Neck pain		Rash
Vomiting	Frequency		Blackout			Back pain		Swelling
Constipation	Nocturia		Numbness			Hip pain		Breast discharge
Melena	Vaginal discharge		Unsteady gait				Shoulder pain	Breast masses
Hematochezia	Vaginal bleeding		Seizure				Joint pain
Hematemesis
PSYCH OTHERS						ALL SYSTEMS REVIEWED
							Negative
Anxious							All other systems negative
Depression			Incomplete due to:
Hallucination					Loss of Consciousness/Intubated/Exposure to Toxic Chemicals
Stress
Not sleeping
			MEDICAL HISTORY
PAST MEDICAL/SURGICAL			MEDICATIONS		FAMILY			SOCIAL

None				None PTB Diabetes Hypertension			Smoker ppd X yrs
PTB							Alcoholic bev drinker
Diabetes							Illicit drug use
Hypertension
Asthma Cardiac					Asthma			ALLERGIES
ICU Admission					Cardiac Cancer
OR
Triage Officer								Time
					Date

II. EMERGENCY ASSESSMENT AND DISPOSITION

				PHYSICAL EXAMINATION

Initial Assessment
						DIAGNOSTICS
CBG • CBC • RBS BUN Crea Na K Cl Ca Mg P •				Blood CS • Urinalysis • Pregnancy Test • Urine GS/CS • Fecalysis • Stool GS/CS •				12-L ECG • XRAY chest abdomen
Uric Acid LDH Chol TG LDL HDL • ALT AST alk phos • Protime/PTT •							CT SCAN:		UTZ:
CPK MB CPK MM CPK Total • Trop I T •							Plain Contrast Cranial Cervical Abdomen		2D Echo HBT Pelvic Whole abdomen Transvaginal
						THERAPEUTICS
Oxygen: NPO IVF	Diet	LPM via
Medications:				Dosage				Time given Signature



Monitor
	CHEMISTRY		RESULTS
CBC		EKG					RADIOGRAPHS
					REFERRALS
Referred by		Time	Service			Reason for Referral		Time		Received by


					NURSES NOTES
DATE TIME
BP
HR
RR
TIME
WT
CBG Signature

			DISPOSITION
Date Time	Treated and Home Against Medical • • discharged Advice Absconded ED Death • • Admit Dead on Arrival (DOA) • •		Transfer of Hospital Self-conduction Ambulance Private
Discharge Diagnosis			Discharge Plans
Medications			Special Instructions

	FOLLOW-UP			ATTENDING PHYSICIAN
	Date	Time
			Date	Time

ANNEX E: Daily Floor Census

Unit/Ward:
------------	--

ADMITTED (Record total at line no. 2 of
summary)
No	TIME	HR	PATIENT	ROOM
		N	NAME
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
	TRANSFERRED IN (Record total at line no. 3 of
summary)
No	TIME	FR	PATIENT	TO
		OM	NAME
1
2
3
4
5
6
7
8
9

EXPIRED (Record total at line no. 8 of summary)
1
2
3
4

PREPARED BY:	CHECKED BY:

ABSCONDED (Record total at line no. 7 of summary)
No	TIME	FRO	PATIENT	TO
		M	NAME
1
2
3

		Date: DISCHARGED (Record total at line no. 5 of summary)
No.	TIME	HRN	PATIENT NAME	ROOM
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

		TRANSFERRED OUT (Record total at line no. 6 of summary)
No.	TIME	FROM	PATIENT NAME	TO
1
2
3
4
5
6
7
8
9

CENSUS SUMMARY FOR THE DAY
Line	PARTIC	No. of Patients
no.	ULARS
	Remaini
1	ng the
	last
	report
2	Admitte
	d
	Transfer
	red-in
3	from
	other
	Census
	Unit
	Total of
4	Lines 1,
	2 and 3
	Dischar
5	ged
	Transfer
	red out
6	to other
	Census
	Unit
	Abscond
7	ed
8	Expired
	Total of
9	Lines 5,
	6, 7 and
	8
	Remaini
	ng at
10	midnight
	(L4-L9)
	Admitte
	d and
	Dischar
11	ged the
	same
	day
	Actual
12	Inpatient
	Service
	Days
	(L10+L1
	1)

ANNEX F: Clinical Cover Sheet

PATIENT NAME			WARD/RM/BED/SERVICE:		HEALTH RECORD NUMBER (HRN):

Last Name	First Name	Middle Name
PERMANENT ADDRESS			TEL NO.:	SEX:	CIVIL STATUS:
				[ ] Male	[ ] S [ ] D [ ]SEP
				[ ] Female	[ ] W [ ] M [ ] N
No. Street		City/Municipality/Province			[ ] C
BIRTHDATE	AGE BIRTHPLACE	NATIONALITY	RELIGION	OCCUPATION
(mm/dd/yyyy)

EMPLOYER (TYPE OF BUSINESS)		ADDRESS			TELEPHONE NO./ CP NO.
FATHER'S NAME		ADDRESS	TELEPHONE NO./ CP NO.

MOTHER'S (Maiden) NAME		ADDRESS			TELEPHONE NO./ CP NO.
SPOUSE NAME		ADDRESS			TELEPHONE NO./ CP NO.

ADMISSION	DISCHARGE	TOTAL NO. OF	ADMITTING PHYSICIAN
		DAYS
DATE: TIME:	DATE: TIME:
ADMITTING CLERK			ATTENDING PHYSICIAN


TYPE OF ADMISSION			REFFERRED BY (Physician/Health Facility)
[ ] NEW [ ] OLD	[ ] FORMER OPD
SOCIAL SERVICE CLASSIFICATION	[ ] A	[ ] B [ ] C1 [ ] C2
[ ] C3 [ ] D
ALERT: ALLERGIC TO	HOSPITALIZATION PLAN		HEALTH INSURANCE NAME		PHIC
	(Company/Industrial Name)				[ ] SSS [ ] SSS Dependent
					[ ] GSIS [ ] GSIS
					Dependent
DATA FURNISHED BY:		ADDRESS OF INFORMANT		RELATION TO PATIENT

ADMISSION DIAGNOSIS:

DISCHARGE DIAGNOSIS				ICD/ RUV CODE:

PRINCIPAL DIAGNOSIS: OTHER DIAGNOSIS:
PRINCIPAL OPERATION/PROCEDURE


OTHER OPERATION (S) /PROCEDURE (S)
ACCIDENT/ INJURIES/ POISONING

DISPOSITION		RESULTS

[ ] Discharge	[ ] HAMA	[ ] Recovered	[ ] Died
[ ] Transferred	[ ] Absconded	[ ] Improved	[ ] -48 hours	[ ] Autopsy

		[ ] Unimproved	[ ] +48 hours	[ ] No

ANNEX G: Doctor's Orders and Progress Notes

DATE/	PHYSICIAN'S PROGRESS NOTES	PHYSICIAN'S ORDERS
TIME	(Affix printed name and signature.)	(Affix printed name and signature.)
	S – O – A – P

ANNEX H: Nurse's Progress Notes

DATE/ TIME/SHIFT	F=FOCUS	D=DATA	A=ACTION	R=RESPONSE

^*ALL ENTRIES SHOULD BE SIGNED AND DATED BY THE NURSES

NAME:		HRN:
(PLEASE PASTE THE RESULTS		CONSECUTIVELY STARTING FROM THE BOTTOM.)

ANNEX J: Medical History and Physical Examination

			2. Accreditation Number
3. Address of HCI Bldg. No. and Name/ Lot/ Block	Street/Subdivision/Village	Barangay/City/Municipality	Province	Zip Code
		PATIENT'S DATA II.
1. Name of Patient				2. PIN
Last Name	First Name	Middle Name		3. Age
5. Chief Complaint
				4. Sex [ ] Male [ ] Female
6. Admitting Diagnosis		7. Discharge Diagnosis		8. a. 1st Case Rate Code
				8. b. 2nd Case Rate Code
9. a. Date Admitted (mm/dd/yyyy)			9. b. Time Admitted:

			: hour	[ ] AM [ ] PM min
10. a. Date Discharged (mm/dd/yyyy)			9. b. Time Admitted:
			:	[ ] AM [ ] PM
			hour	min
	III.	REASON FOR ADMISSION

1. History of Present Illness: 2. a. Pertinent Past Medical History
b. OB/GYN History		G P ( ) LMP: [ ] NA
3.	Pertinent Signs and Symptoms on Admission (tick applicable box/es):
	[ ] Diarrhea	[ ] Hematemesis	[ ] Palpitations
[ ] Altered mental sensorium
[ ] Abdominal cramp/pain	[ ] Dizziness	[ ] Hematuria	[ ] Seizures

[ ] Anorexia	[ ] Dysphagia	[ ] Hemoptysis	[ ] Skin rashes
[ ] Bleeding gums	[ ] Dyspnea	[ ] Irritability		[ ] Stool, bloody/ black tarry/ mucoid
[ ] Body weakness	[ ] Dysuria	[ ] Jaundice	[ ] Sweating
[ ] Blurring of vision	[ ] Epistaxis	[ ] Lower extremity edema	[ ] Urgency
4.	Referred from another health care institution (HCI):

[ ] No [ ] Yes, specify reason

5.		Physical Examination on Admission (Pertinent Findings per System)
General Survey [ ] Awake and alert			[ ] Altered sensorium
Vital Signs:	BP:	HR:	RR: Temp:
HEENT:	[ ] Essentially normal [ ] Icteric sclerae	[ ] Abnormal pupillary reaction [ ] Pale conjunctivae	[ ] Cervical lymphadenopathy [ ] Sunken eyeballs	[ ] Dry mucous membrane [ ] Sunken fontanelle
		Others:
CHEST/LUNGS:	[ ] Essentially normal [ ] Lump/s over breast (s)	[ ] Asymmetrical chest expansion [ ] Rales/crackles/rhonchi	[ ] Decreased breath sounds [ ] Intercostal rib/ clavicular retraction	[ ] Wheezes
		Others:
	[ ] Essentially normal [ ] Irregular rhythm	[ ] Displaced apex beat [ ] Muffled heart sounds	[ ] Heaves and/or thrills [ ] Murmur	[ ] Pericardial bulge
CVS:		Others:

	[ ] Essentially normal [ ] Palpable mass (es)	[ ] Abdominal rigidity [ ] Tympanitic/ dull abdomen	[ ] Abdomen tenderness [ ] Uterine contraction	[ ] Hyperactive bowel sounds
ABDOMEN:		Others:

	[ ] Essentially normal	[ ] Blood stained in exam finger	[ ] Cervical dilatation	[ ] Presence of abnormal discharge
GU (IE):		Others:
	[ ] Essentially normal [ ] Edema/swelling	[ ] Clubbing [ ] Decreased mobility [ ] Weak pulses	[ ] Cold clammy skin [ ] Pale nailbeds	[ ] Cyanosis/mottled skin [ ] Poor skin turgor
SKIN/	[ ] Rashes/petechiae
EXTREMITIES:		Others:
	[ ] Essentially normal [ ] Abnormal reflex (es)	[ ] Abdominal gait [ ] Poor/ altered memory	[ ] Abnormal position sense [ ] Poor muscle tone/strength	[ ] Abnormal/decreased sensation [ ] Poor coordination
NEURO-EXAM:		Others:

COURSE IN THE WARD (Attach a photocopy of laboratory/imaging results) [ ] Check box if there is/are additional sheet (s). IV.
DATE	DOCTOR'S ORDER/ACTION






	SURGICAL PROCEDURE/RVS CODE (Attach a photocopy of OR technique):

	V.		DRUGS/MEDICINES [ ] Check box if there is/are additional sheet (s).
Generic Name	Quantity/Dosage/Route	Total Cost	Generic Name (cont)	Quantity/Dosage/Route (cont)	Total Cost (cont)










	VI.		OUTCOME OF TREATMENT
[ ] IMPROVED [ ] HAMA [ ] EXPIRED [ ] ABSCONDED [ ] TRANSFERRED Specify reason:

CERTIFICATION OF HEALTH CARE PROFESSIONAL VII. Certification of Attending Health Care Professional:

I certify that the above information given in this form, including all attachments, are true and correct.

	Signature over Printed Name of Attending Health Care Professional			Date Signed (mm/dd/yyyy)

ANNEX K: Clinical Abstract

PATIENT NAME		SEX (M/F)

Last Name First Name	Middle Name
SERVICE/WARD		[ ] ADMISSION DATE:

		[ ] CONSULTATION DATE:


Brief Clinical History:










Treatment/Operation/Procedure:









Pertinent Laboratory Examinations and Findings:














Interim Diagnosis/Impression:

(Signature Over Printed Name)

Date:

ANNEX L: Discharge Summary/ Clinical Abstract

PATIENT NAME


AGE	Last Name SEX (M/F)	WARD/SERVICE	First Name HRN:	Middle Name ADMISSION DATE:


				DISCHARGE DATE:

ATTENDING PHYSICIAN

ADMITTING DIAGNOSIS


FINAL DIAGNOSIS



CHIEF COMPLAINT/S


		BRIEF CLINICAL HISTORY & PERTINENT PHYSICAL EXAMINATION



		LABORATORY FINDINGS: (Incl. ECG, X-Ray & other diagnostic procedures)




	COURSE IN THE WARD: (Including Medications)








		DISPOSITION: (Indicate home medications, special instructions & follow-up)










				, MD
	DATE ACCOMPLISHED			RESIDENT IN-CHARGE

Date:	Time: [ ] AM [ ] PM
(mm/dd/yyyy)	(hh:mm)
PATIENT NAME		AGE	SEX (M/F)

Last Name Middle Name	First Name
COMPLETE ADDRESS		CIVIL STATUS


ADMITTING DIAGNOSIS




		, MD
		Admitting Physician

ANNEX N: Patient Information Sheet

PATIENT NAME				WARD/RM/BED/SERVICE:	HEALTH RECORD NUMBER (HRN):
Last Name		First Name	Middle
Name
PERMANENT ADDRESS				TEL NO.:	SEX: [ ] Male [ ] Female	CIVIL STATUS: [ ] S [ ] D [ ]SEP [ ] W [ ] M [ ] N [ ] C
No.	Street
City/Municipality/Province
BIRTHDATE (mm/dd/yyyy)	AGE	BIRTHPLACE	NATIONALITY	RELIGION	OCCUPATION
EMPLOYER (TYPE OF BUSINESS)			ADDRESS		TELEPHONE NO./ CP NO.
FATHER'S NAME			ADDRESS		TELEPHONE NO./ CP NO.
MOTHER'S (Maiden) NAME			ADDRESS		TELEPHONE NO./ CP NO.
SPOUSE NAME		ADDRESS		TELEPHONE NO./ CP NO.

ANNEX O: Request for Access to Health Records
	Date:
To the Head, Health Information Management Department (HIMD):

May we request from your good office to lend us the following charts of the patients for

__________________________________________________________________________.

(Purpose/Reason)

NO	HEALTH RECORD NO.	NAME OF PATIENT	DATE OF ADMISSION	DATE OF DISCHARGE	RECEIVED BY	RETURNED TO
1.
2.
3.
4.
5.

It is understood that I am responsible for the health mentioned above records, and I will return the said health records in the same order and condition as they were received.

	Very truly yours,
	Signature over Printed Name

Noted by:

Chairman of the Department
Or Duly Authorized Representative
Approved by:

Medical Center Chief II
Or Duly Authorized Representative

ANNEX P: Referral Form

Name of initiating facility		Contact Number:
		Address
Date of Referral		Time called*
	Name of Receiving facility Receiving personnel
Address	Response
Referral Category		Emergency Outpatient
Working Impression
Reason for Referral		Consultation
		Diagnostics
		Treatment/ Procedure
		Others
Name of Patient		Identity Number
Age		Sex Male Female
Address
Chief Complaint
Clinical History

Vital Signs: BP Weight	HR	RR	O2 sats Temp
(attach laboratory results)
Treatment Given
(attach treatment cards)

	Print Name & Signature of Health Professional		Date and Time
*for emergency cases
	ANNEX Q: Inter-Departmental Referral Sheet


		[ ] EMERGENCY [ ] URGENCY	[ ] ROUTINE
			HRN:

Last Name	First Name SEX (M/F)	Middle Name SERVICE/WARD	BED



[ ] OPINION [ ] CLEARANCE	[ ] CO- MANAGE [ ] TRANSFER SERVICE		[ ] OTHERS (Please specify)

		CLINICAL FINDINGS (Brief history, PE, patient laboratory) / State assessment and/or intervention done


Date: Time: PATIENT NAME AGE DIAGNOSIS REFERRAL TO: REASON(S) FOR REFERRAL			REFERRED BY:
			Printed Name & Signature

Annexes
Referral Received by: Date & Time:
	(TO BE FILLED BY RECEIVING DEPARTMENT/ SERVICE)
FINDINGS:

RECOMMENDATION:




Physician's Printed Name & Signature	Date (mm/dd/yyyy)	: [ ] AM [ ] PM Time


ANNEX R: Certificate of Confinement

			Certificate No HRN:
		Date:


This is to certify that has been confined in this hospital from	,		years old of
to the present.

This certification is being issued at the request of for

(Name of Person Requesting)		(Purpose)


		HIMD Head/Supervisor
(NOT VALID WITHOUT SEAL)

ANNEX S: Medical Certificate

	Certificate No HRN:
	Date:
	MEDICAL CERTIFICATE
This is to certify that	, years old of was examined and treated/confined in
this hospital from to with the following findings diagnosis:	and/or
	This certification is being issued at the request of for
(Name of Person Requesting)	(Purpose)
	Attending Physician
	License No

(NOT VALID WITHOUT SEAL)

ANNEX T: Medico-Legal Certificate

					Certificate No HRN:
					Date:
	MEDICO-LEGAL CERTIFICATE
To Whom It May Concern:
This is to certify that, years old male/female,
single/married/widow, Filipino, and a resident of at
about	AM/PM	for	the	following	lesion/injury


sustained by
In my opinion, the injury/injuries sustained by the patient will incapacitate or require medical attention for days barring complication. Otherwise, the period of healing will vary accordingly.

				Attending Physician
				License No
NOT VALID WITHOUT SEAL)

ANNEX U: Proposed Qualification Requirements and Job descriptions for the Different HIMD staff.

Position Title	Records Officer IV/ Supervising Records Management Analyst/ Supervising Administrative Officer (SG-22)
Minimum Qualification Standard	1. Qualification Standard based on CSC minimum requirement
Additional Requirements	1. Must be a graduate of master's degree. 2. Must have knowledge of Human Anatomy & Physiology and medical terminologies. 3. Must have attended a Certificate Course in HIMD and training course of at least 120 hours in HIM conducted by a Department of Health recognized institution/organization or academe. 4. Must have in-depth knowledge of the Data Privacy Act. 5. Must have at least five (5) years of experience in the HIM Department of a Level 2 or Level 3 hospital, one year of which must have been in a supervisory capacity.
Job Description	1. Shall plan, organize, and control all activities in the service. 2. Shall attend court proceedings and represent the hospital in court cases involving subpoena of medical/clinical records. 3. Shall exercise direct administrative supervision and control over all subordinates in the service. 4. Shall establish policies and procedures concerning the content, control, storage, and retrieval of records. 5. Shall organize the workflow throughout the service. 6. Shall represent the service to top management. 7. Shall ensure the maintenance of the patient's right to privacy and confidentiality: in value health records/information. 8. Shall serve on appropriate committees and attend meetings that are of relevance to the HIM. 9. Shall supervise the implementation and evaluation of quality control measures of specified areas within the service. 10. Shall meet and discuss with the administration of other departments within the hospital issues which are related to the HIM. 11. Shall answer by correspondence or by telephone inquiries regarding information recorded in the patients' health records. 12. Shall keep abreast of current medical record practices and developments. 13. Shall assist the medical staff in authorized research projects. 14. Shall perform other related functions as may be assigned by the immediate supervisor.
Competency	Core Competencies
	• Exemplifying Integrity
	• Professionalism

	• Service Excellence
	Organizational Competencies
	• Effective Communication Skills
	• Effective Interpersonal Relations
	• Organizational Awareness and Commitment
	Technical Competencies
	• Achieving High Standards
	• Government and Departmental Policies and Procedures
	• Management Acumen
	• Planning, Organizing and Delivering
	• Records Management
	• Respecting and Caring for Patients
	• Medico-legal aspects of health records
	• Coaching and Monitoring
Proficiency	Advanced

Position Title	Records Officer III/ Senior Records Management Analyst/ Administrative Officer V (SG-18)
Minimum Qualification Standard	1. Qualification Standard based on CSC minimum requirement
	1. Must have knowledge of Human Anatomy & Physiology and medical terminologies. 2. Must have attended a Certificate Course in HIMD and training in the latest International Classification of Disease (ICD) conducted by a Department of Health, recognized institution/organization, or academe. Must have in-depth knowledge of the Data Privacy Act. 3. 4. Must have at least four (4) years of experience in the HIM Department of a Level 2 hospital, one (1) year of which must have been in a supervisory capacity.
Job Description	1. Shall plan, organize, and control all activities in the department. 2. Shall attend court proceedings and represent the hospital in court cases involving subpoena of medical/clinical records. 3. Shall exercise direct administrative supervision and control over all subordinates in the department.

1. Shall establish policies and procedures concerning the content, control, storage, and retrieval of health records.
1. Shall organize the workflow throughout the department.
1. Shall represent the service to top management.
1. Shall ensure the maintenance of the patient's right to privacy and confidentiality of the health records or related documents.
1. Shall serve on appropriate committees and attend meetings that are of relevance to the HIM.
1. Shall supervise the implementation and evaluation and quality control measures of specified areas within the service.
1. Shall meet and discuss with the administration of other departments within the hospital issues which are related to the HIM.
1. Shall answer by correspondence or by telephone inquiries regarding information recorded in the patients' health records.
1. Shall keep abreast of current health record practices and developments.
1. Shall assist the medical staff in authorized research projects.
1. Shall perform other related functions as may be assigned by the immediate supervisor.

Competency Core Competencies

Exemplifying Integrity
Professionalism
Service Excellence

Organizational Competencies

Effective Communication Skills
Effective Interpersonal Relations
Organizational Awareness and Commitment

Technical Competencies

Achieving High Standards
Government and Departmental Policies and Procedures
People Management
Planning, Organizing and Delivering
Records Management
Respecting and Caring for Patients

Proficiency	Advanced
Position Title	Statistician III of Level 3 Hospitals (SG-18) (Advanced Statistics, Planning and Management, Clinical Documentation Improvement, Health Records Analysis, Filing and Archiving of Health Records, Encoding, and Clinical Coding)
Minimum Qualification Standard	1. Qualification Standard based on CSC minimum requirement
Additional Requirements	1. Must have a college degree, preferably a graduate of BS Statistics/BS Math. 2. Must have units in graduate studies. 3. Must have first-grade civil service eligibility. 4. Must have attended Certificate Course in HIMD to include related training course in the latest International Classification of Diseases (ICD) and healthcare statistics conducted by a Department of Health, recognized institution/organization, or academe. 5. Must have in-depth knowledge of the Data Privacy Act. 6. Must be computer literate and familiar with available statistical packages. 7. Must have at least three (3) years of experience in the HIM Department of a Level 2 or Level 3 health facility.
Job Description	1. Shall assist the head of the HIMD in the health facility and manage the department in the absence of the HIMD head/supervisor. 2. Shall consolidate the Daily Floor Census report into the 24- hour census report of the health facility. 3. Shall summarize and prepare monthly, quarterly, and annual statistical reports of health facility activities. 4. Shall recommend appropriate action to be taken based on the analysis and interpretation of data gathered. 5. Shall assist the resident physicians and other employees in the conduct of their scientific research. 6. Shall prepare a health facility statistical reports in budgeting and planning processes. 7. Shall perform other related functions as may be required by the immediate supervisor.
Competency	Core Competencies
	• Exemplifying Integrity
	• Professionalism
	• Service Excellence
	Organizational Competencies
	• Effective Communication Skills

	• Effective Interpersonal Relations
	• Organizational Awareness and Commitment
	Technical Competencies
	• Data Management
	• Data Recording and Reporting
	• Research and Analysis
	• Statistical Research for Health
	• Technical Consulting
Proficiency	Advanced

Position Title	Statistician II of Level 3 Hospitals (SG-15) (Health Records Analysis, Basic Statistics (interpretation and reporting), Clinical Coding, Filing and Archiving of Health Records)
Minimum Qualification Standard	1. Qualification Standard based on CSC minimum requirement
Additional Requirements	1. Must have a college degree/graduate studies preferably with units in statistics and a graduate of BS Statistics/BS Math. 2. Must have attended Certificate Course in HIMD to include related training course in the latest International Classification of Diseases (ICD) and healthcare statistics conducted by a Department of Health, recognized institution/organization, or academe. 3. Must have in-depth knowledge of the Data Privacy Act. 4. Must be computer literate and familiar with available statistical packages. 5. Must have at least two (2) years of experience in the HIM Department of a Level 2 or Level 3 health facility.
Job Description	1. Shall assist the head of the HIMD in the health facility and manage the department in the absence of the HIMD head/supervisor. 2. Shall consolidate the Daily Floor Census report into the 24-hour census report of the health facility. 3. Shall summarize and prepare monthly, quarterly, and annual statistical reports of health facility activities. 4. Shall recommend appropriate action to be taken based on the analysis and interpretation of data gathered. 5. Shall assist the resident physicians and other employees in the conduct of their scientific research. 6. Shall prepare a health facility statistical reports in budgeting and planning processes.

	7. Shall perform other related functions as may be required by the immediate supervisor.
Competency	Core Competencies
	• Exemplifying Integrity
	• Professionalism
	• Service Excellence
	Organizational Competencies
	• Effective Communication Skills
	• Effective Interpersonal Relations
	• Organizational Awareness and Commitment
	Technical Competencies
	• Data Management
	• Data Recording and Reporting
	• Planning, Organizing and Delivering
	• Research and Analysis
	• Statistical Research for Health
Proficiency	Intermediate

Position Title

Records Officer II (SG-14)
(Health Records Analysis, Basic Statistics, Clinical Coding,
Filing and Archiving of Health Records)

Minimum Qualification
Standard

1. Qualification Standard based on CSC minimum requirement

1.
Must have a college degree preferably with knowledge in
Human Anatomy & Physiology and medical terminologies.
2.
Must have first-grade civil service eligibility.
3.
Must have attended Certificate Course in HIM and a basic
course in
the latest
International Classification of Diseases
conducted
by
a
Department
of
Health,
recognized
institution/organization,
or academe.
4.
Must have in-depth knowledge of the Data Privacy Act.
5.
Must be computer literate.
6.
Must have at least one (1) year of experience as disease
and operations coder.
7.
Must be well acquainted with the different coding tools.

Job Description	Shall work directly under the supervision of the chief of the 1. HIMD.
	Shall analyze specific portions of the health record and 2. assign code numbers to disease and operations based on
	the mandated classification system. Shall update and maintain the disease and operation index 3.
	file. Shall file the disease and operation indexes numerically by 4.
	disease and operation codes. Shall perform other related functions as may be assigned 5. by the immediate supervisor.
Competency	Core Competencies
	• Exemplifying Integrity
	• Professionalism
	• Service Excellence
	Organizational Competencies
	• Effective Communication Skills
	• Effective Interpersonal Relations
	• Organizational Awareness and Commitment
	Technical Competencies
	• Computer Skills
	• Diversity Management
	• Managing Work
	• Providing Support and Services
	• Records Management
	• Respecting and Caring for Patients
Proficiency	Intermediate

Position Title	Records Officer I (SG-10) (Basic Statistics, Clinical Coding, Filing and Archiving of Health Records)
Minimum Qualification Standard	1. Qualification Standard based on CSC minimum requirement
	1. Must have Learning and Development Intervention in health record documentation standards.

Job Description	2. Must have thorough knowledge in Human Anatomy & Physiology and medical terminologies. Must have at least work in the HIMD or other related office. 3. 4. Must have in-depth knowledge of the Data Privacy Act. Must be computer literate. 5. 1. Shall arrange and assemble the health record of discharged patients based on the approved format. 2. Shall analyze quantitatively and qualitatively health records to ensure the creation of complete and accurate health records. 3. Shall coordinate with concerned members of the medical and nursing service concerning incomplete health records. 4. Shall maintain statistics of incomplete and complete health records and prepare reports of delinquent doctors. 5. Shall perform other related functions as may be assigned by the immediate supervisor.
Competency	Core Competencies
	• Exemplifying Integrity
	• Professionalism
	• Service Excellence
	Organizational Competencies • Effective Communication Skills

	• Effective Interpersonal Relations
	• Organizational Awareness and Commitment
	Technical Competencies
	• Computer Skills
	• Diversity Management
	• Energy to Work
	• Government and Departmental Policies and Procedures
	• Occupational Safety and Health Knowledge
	• Resilience
	• Respecting and Caring for Patients
Proficiency	Intermediate

Position Title	Administrative Assistant II (SG-8) (Encoding, Filing and Archiving of Health Records)
Minimum Qualification Standard	1. Qualification Standard based on CSC minimum requirement
Minimum Qualification Standard	Must have attended a medical record related training. 1. 2. Must have knowledge in Human Anatomy & Physiology and medical terminologies. 3. Must have undergone training in medical transcription and/or is a certified medical transcriptionist. Must have in-depth knowledge of the Data Privacy Act. 4.
Job Description	1. Shall transcribe operating room reports and other dictated/recorded information. 2. Shall type/encode letters and reports, birth and death certificates. 3. Shall perform other related functions as may be assigned by the immediate supervisor. 4. Shall transcribe operating room reports and other dictated/recorded information. 5. Shall transcribe all dictated medical reports. 6. Shall transcribe a birth, death, medical and medico-legal certificate from the pre-form to the corresponding official forms. 7. Shall coordinate with the concerned staff and/or patient concerning problems involving the accomplished birth, death, and other certificate pre-form or worksheet. 8. Shall transcribe official communications and reports. 9. Shall perform other related functions as may be assigned by the immediate supervisor.
Competency	Core Competencies
	• Exemplifying Integrity
	• Professionalism
	• Service Excellence
	Organizational Competencies
	• Effective Communication Skills
	• Effective Interpersonal Relations
	• Organizational Awareness and Commitment
	Technical Competencies
	• Computer Skills
	• Diversity Management
	• Managing to Work

	• Providing Support and Services
	• Records Management
	• Respecting and Caring for Patients
Proficiency	Basic

Position Title	Administrative Assistant I (SG-7) (Filing and Archiving of Health Records)
Minimum Qualification Standard	1. Qualification Standard based on CSC minimum requirement
Minimum Qualification Standard	1. Must have attended a training course in health record documentation standards. 2. Must have thorough knowledge in Human Anatomy & Physiology and medical terminologies. 3. Must have at least work in the HIMD or other related office. 4. Must have in-depth knowledge of the Data Privacy Act. 5. Must be computer literate.
Job Description	1. Shall arrange and assemble the health record of discharged patients based on the approved format. 2. Shall analyze quantitatively and qualitatively health records to ensure the creation of complete and accurate health records. 3. Shall coordinate with concerned members of the medical and nursing service concerning incomplete health records. 4. Shall maintain statistics of incomplete and complete health records and prepare reports of delinquent doctors. 5. Shall perform other related functions as may be assigned by the immediate supervisor.
Competency	Core Competencies
	• Exemplifying Integrity
	• Professionalism
	• Service Excellence
	Organizational Competencies
	• Effective Communication Skills
• Effective Interpersonal Relations
	• Organizational Awareness and Commitment
	Technical Competencies
	• Computer Skills

	• Diversity Management
	• Managing to Work
	• Providing Support and Services
	• Records Management
	• Respecting and Caring for Patients
Proficiency	Basic

ANNEX V: Proposed Standard Staffing Pattern for HIMD in Level 3 Government Hospital with 200 to 1500 Beds*

		Bed Capacity
Health Information Management Department	SG
		200	300	400	500	600	700	800	900	1000	1100	1200	1300	1400	1500
Records Officer IV	22	1	1	1	1	1	1	1	1	1	1	1	1	1	1
Records Officer III	18	3	3	3	3	3	3	3	3	3	3	3	3	3	3
Statistician III	18	1	1	1	1	1	1	1	1	1	1	1	1	1	1
Statistician II	15	1	1	2	2	4	4	4	4	5	5	5	5	5	5
Records Officer II	14	4	5	6	8	9	10	11	12	13	14	15	16	17	18
Records Officer I	10	16	20	24	28	32	36	40	44	48	52	56	60	64	68
Administrative Assistant II	8	3	4	4	4	5	5	5	5	6	6	6	6	6	6
Administrative Assistant I	7	4	4	5	5	6	6	6	6	7	7	7	7	7	7
Sub-total		33	39	46	52	61	66	71	76	84	89	94	99	104	109

^*Proposed as of June 2021. Subject to updates based on the Department of Budget and Management's latest Issuances

ANNEX W: Summary of Formulas for Hospital Statistics

Indicators/Rates	Formula	Reference/ Source
Inpatient service days/Inpatient bed days	Total inpatient service days/inpatient bed days= [(Inpatients remaining at midnight + total admissions) - Total discharges/deaths + (number of admissions and discharges on the same day)]	HHIM Manual 2010
Average Daily Census	Total Inpatient Service days for a period Total days in the same period	HHIM Manual 2010

Bed Occupancy Rate (BOR)	Total inpatient service days for a period x 100 Total number of authorized beds x total days in the same period	HHIM Manual 2010
Bed Turnover Interval	(Implementing beds x days in the period) - Inpatients Service days for a period Total discharges and deaths in the same period	HHIM Manual 2010
Bed Turnover Rate	No. of discharges (including deaths) for a period Average bed count during the period	HHIM Manual 2010
Average Length of Stay (ALOS)	Total length of stay of discharged patients (including Deaths) in the period Total discharges and deaths in the period	Annual Hospital Statistical Report
Average Number of Outpatient visits per OPD day	Total no. of Outpatient visits/attended (both new and revisits) during a period Total no. of days for the same period	HHIM Manual 2010
Average number of ER patients per day	Total no. of Emergency and Non-Emergency Patients attended in the ER for a given period Total no. of days for the same period	HHIM Manual 2010
Gross Infection Rate	Total no. of infection in the health facility (or ward) for a period x 100 Total discharges and deaths in the health facility (or ward) for the same period	HHIM Manual 2010
Net Infection Rate	Total no. of infections debited against the health facility (or ward) for a period x 100 Total discharges and deaths from a health facility (or ward) for the same period	HHIM Manual 2010
A. Device Related Infections
Ventilator Acquired Pneumonia (VAP)	Number of patients with VAP x 1000 Total Number of Ventilator Days	Annual Hospital Statistical Report
Blood Stream Infection (BSI)	Number of Patients with BSI x 1000 Total patient days	Annual Hospital Statistical Report

Central Line Associated Bloodstream Infections (CLABSI)	Number of patients with CLABSI x 1000 divided by Central line days	Based on WHO/ CDC formula
Catheter Acquired Urinary Tract Infection (CAUTI)	Number of Patients (with a catheter with UTI x 1000) Total Number of Catheter Day	Annual Hospital Statistical Report
B. Non-Device Related Infection
Surgical Site Infections (SSI)	Number of Surgical Site Infections x 100 Total number of Procedures	Annual Hospital Statistical Report
Post-operative infection rate	Total no. of infections occurring after a clean surgical operation x 100 Total number of clean surgical operations/procedures for the same period	HHIM Manual 2010
Consultation Rate	Total consultations (all departments) for a period x 100 Total discharges and deaths	HHIM Manual 2010
Caesarean Section Rate	Total no. of cesarean sections in a given period x 100 Total no. of deliveries for the same period	HHIM Manual 2010
Maternal Death Rate	Total no. of direct maternal death in a given period x 100 Total no. of maternal (obstetrical) discharges including deaths for the same period	HHIM Manual 2010
Gross Death Rate/Mortality Rate	Total deaths (including newborn for a given period) x 100 Total discharges and deaths for the same period	Annual Hospital Statistical Report
Net Death Rate	Total deaths (including newborn for a given period) - death <48 hours for the period x 100 Total Discharges (including deaths and newborn) - death <48 hours for the same period	Annual Hospital Statistical Report
Post-Operative Death Rate	Total postoperative deaths for the period x 100 Total patients operated for the same period	HHIM Manual 2010

Anesthesia Death Rate	Total no. of deaths caused by an anesthetic agent for a period x 100 Total no. of anesthetics administered for the same period	HHIM Manual 2010
Fetal Death Rate/ Stillbirth Rate	Total no. of intermediate and late fetal deaths for the period x 100 Total no. of birth (including intermediate and late fetal deaths) for the same period	HHIM Manual 2010
Neonatal Death Rate/ Infant Newborn Mortality Rate	Total no. of newborn deaths for the period x 100 Total no. of newborn infant discharges (including deaths) for the same period	HHIM Manual 2010
Infant Death Rate	Total no. of infant deaths (neonatal and postneonatal during a period) x 100 Number of live births during the period	HHIM Manual 2010
Gross Autopsy Rate	Total no. of autopsies performed for a period x 100 Total no. of inpatient deaths for the same period	HHIM Manual 2010
Net Autopsy Rate	Total no. of autopsies performed for a period x 100 Total deaths – not autopsied cases for the same period	HHIM Manual 2010

ANNEX X: Self-Assessment Tool

Address:
It is the duty of the Health Information Management Department (HIMD) to effectively and efficiently manage its records. The purpose the self-assessment tool is to evaluate and monitor the compliance of the HIMD staff to the policies and set standards.	to effectively and efficien IIMD staff to the policies a	tly manage its records. The purpoind set standards.	soc
This self-evaluation guide is intended for the use of HIMD Officials and staff to be able to:	aff to be able to:
a. Make a preliminary assessment on the status of their records management practices; b. Identify major problems to be included in the risk management scheme; c. Recognize priorities for the HIM Department on areas to improve; and d. Assist in the development of the health facility's own comprehensive health records management procedures and programs.	gement practices; eme; and ve health records managem	ent procedures and programs.
Instructions:
1. Complete all questions. Answers must accurately reflect the current environment. This will help you identify what is being done well your area and those that need improvement.	vironment. This will help y	ou identify what is being done we	we
2. After completing all questions, total your points and get the equivalent percentage. 3. Note other findings seen, if any. Write the Name and Designation of the assessor on the corresponding area on the tool.	ercentage. assessor on the correspond	ling area on the tool.
4. Refer to the interpretation of your scores given at the end of the tool to determine your next steps, if needed	letermine your next steps, i	f needed.
	Validation	Evidence Data SC Collected	SC
INPUT
Planning, Execution and Monitoring System
1. Has an existing Manual of Procedures or Operations Manual Do	Document Review	Presence (1 pt) Yes No

2. Has an approved Work and Financial Plan	Document Review	Presence (1 pt)	Yes	No No
3. Has an approved Division Performance Commitment and Review (DPCR)	Document Review	Presence (1 pt)	Yes	No.
4. Has an approved Project Procurement Management Plan (PPMP)	Document Review	Presence (1 pt)	Yes	No	l.
5. Compliant with the latest Standard Staffing Pattern	ffing	Compliant (1 pt) Yes	Yes	oN N
6. Approved Training Needs Assessment (TNA)	Document Review	Presence (1 pt)	Yes	No	5)
7. Approved Individual Development Plan (if necessary)	Document Review	Presence (1 pt)	Yes	No.
8. Training Report, if required; Re-entry Plan implementation	Document Review	Presence (1 pt)	Yes	No
9. All staff received Learning Development Intervention	Document Review	100% (1 pt) Less than 100% (0)	Yes	No
10. Provided with office and storage space compliant with DOH standards space requirement		100% compliant (1 pt) Less than 100% (0)	Yes	No
11. Provided with designated space for completion of health record	Ocular Visit	Presence (1 pt)	Yes	No.
12. Proper lighting, ventilation, and temperature of storage area	Ocular Visit	Presence (1 pt)	Yes	No
13. Provided with office equipment: adequate and appropriate working tables, filing cabinets, and mandatory office equipment and materials	Ocular Visit	100% compliant (1 pt) Less than 100% (0)	Yes	No
Administration and Supervision
1. Attendance at MANCOM Meetings	Document Review, NOM, Attendance Sheet	Presence (1 pt)	Yes	No
2. Regular Conduct of HIMD Meetings	Document Review, Minutes of Meetings	Presence (1 pt)	Yes	No
3. Functional Patient Health Records Committee (PHRC)	Document Review, Minutes of Meetings	Presence (1 pt)	Yes	No
PROCESS
Health Record Creation
1. With established Health Record Identification System.	Document Review, Interview	Presence (1 pt)	Yes	oN No

2. Maintain/Update a Standardized Health Record for every patient	Document Review		Yes	No
assessed or treated.		records are updated (1 pt)
3. Duly accomplished consent form should accompany each patient's health record.	Document Review (Sampling)	Presence (1 pt)	Yes	No
Authorized personnel to make entries in the health record are clearly defined as per Hospital Policy.	Document Review, Presence of Approved Policy and Procedures Manual	Presence (1 pt)	Yes	%
5. Abbreviations and symbols used in health records are following WHO or approved by the health facility upon recommendation by the PHRC.	Check documented process Compliant (1 pt) with policy		Yes	No.
6. Data of Patients receiving emergency care includes: - time of arrival and departure, - conclusion at the termination of treatment, - patient's condition at discharge, and - follow-up care instructions.	Document Review (Sampling)	Presence (1 pt)	Yes	No
7. Assign codes to Diagnoses.	Check documented process with policy and procedure	Compliant (1 pt)	Yes	No No
8. Observe proper use of copy and paste function when electronic health records are used.	Check documented process with policy and procedure	Compliant (1 pt)	Yes	No No
9. Check OPD and In-patient Records include all the necessary information based on the Standard.	Document Review (Sampling)	Presence (1 pt)	Yes	No
10. Health record follows Standard Health record arrangement.	Document Review (Sampling)	Follows proper arrangement (1 pt)	Yes	No
11. Observe "ALERT" notation for conditions (i.e., allergic responses and Document Review adverse drug reactions) prominently displayed on the Clinical Cover Sheet (Sampling)	Document Review (Sampling)	Presence (1 pt)	Yes	No
12. Include the patient's past medical history and a sufficiently detailed Document Review report of a relevant Physical Examination (PE) completed within 24 hours (Sampling) upon admission.	Document Review (Sampling)	Presence (1 pt)	Yes	No
13. Reflect Therapeutic and Special diagnostic test orders.	Document Review (Sampling)	Presence (1 pt)	Yes	No
14. Record Progress Notes, observations, and consultation reports.	Document Review (Sampling)	Presence (1 pt)	Yes	No

15. Complete admission and discharge record with all the diagnoses and Document Review procedures at the time of discharge or as soon as all relevant information is (Sampling) available.	ocument Review ampling)	Timely (1 pt)	Yes	No
16. Check admission and discharge records use terminology based on the with International Standard Nomenclature of Medicine. Doo	Check documented process with policy and procedure, Document Review	Compliant (1 pt) Yes	100	No
a. Discharge summary contains the following: a. Discharge diagnosis, b. Procedures performed, c. Follow-up arrangements, d. Therapeutic orders (home medications), and\ne. Patient home instructions.	Document Review (Sampling)	Presence (1 pt)	Yes	No
18. Certified true copy of the discharge summary is present when a patient Document Review is discharged or transferred to another facility.	Document Review (Sampling)	Presence (1 pt)	Yes	No
19. Autopsy report is filed when applicable, with provisional diagnosis Doc noted within 72 hours.	Document Review (Sampling)	Presence (1 pt)	Yes	No
20. Incomplete health records must be completed; diagnostic results must be submitted and attached to health records.	Document Review (Sampling)	Compliant (1 pt)	Yes	No
Health Record Documentation
1. Completeness of health records with no missing or detached form is Doc nresent	Documentation review, Onantitative/ Onalitative	Complete (1 pt)	Yes	No
	analysis checklist
2. Documents are legible and written in ink or typewritten. Documents are legible and written in ink or typewritten. (Sar	Document Review (Sampling)	Compliant (1 pt)	Yes	No
3. Written documents, including policies, procedures, and programs, are updated as necessary.	Presence of Approved and updated Policy and Procedures Manual	Presence (1 pt)	Yes	No
4. HIMD staff assists the attending physician in reviewing records for prescompleteness.	Presence of Approved and updated Policy and Procedures Manual	Presence (1 pt)	Yes	No
Health Record Storage and Safekeeping
1. Inactive records are transferred to inactive filing storage to give way to Doc the incoming records, decongest the area, and facilitate retrieval.	Document Review (Sampling)	Presence (1 pt)	Yes	No
icies and	Document Review (Sampling)	Presence (1 pt)	Yes	No

3. The hospital HIMD safeguards all information contained in the health record against loss, destruction, or unauthorized use.	Document Review (Sampling)	Presence (1 pt)	Yes	No.
Health Record Accessibility
1. All information in the health record is treated as confidential and Document Review disclosed only to authorized individuals.	Document Review (Sampling)	Presence (1 pt)	Yes	No
linical value is done only with	Document Review (Sampling)	Presence (1 pt)	Yes	No No
l information (name, address, attient during admission,	Presence of Approved and updated Policy and	Compliant (1 pt) Yes	Yes	%
admission, and discharge dates) is present.	Procedures Manual	$\neg$
4. Updated policy on releasing health records outside healthcare facilities and use for research and insurance providers is present.	Presence of Approved and updated Policy and Procedures Manual	Presence (1 pt)	Yes	%
	Presence of Approved and	Presence (1 pt)	Yes	No
	updated Policy and Procedures Manual:
for patient classification and referral:	Document Review (Check
	IIIIKages)
Health Kecords Systems and Procedures				1
	Presence of Approved and	Presence (1 pt)	Yes	No
1. Policy on health record identification system in place and implemented	updated Policy and Procedures Manual
	Presence of Approved and	Presence (1 pt)	Yes	No
	Updated Procedures
2. Established proper assembly of hearth records	Manual			1
3. Policy on the arrangement/structure/format of the content of health	Presence of Approved and updated Policy and	Presence (1 pt)	X es	0 N
	Procedures Manual
	Presence of Approved and	Presence (1 pt)	Yes	No No
	Updated Procedures
4. Documentation guidelines implemented	Manual
	Presence of Approved and	Presence (1 pt)	Xes	No
accordance to policies and procedures	upuateu roncy anu Procedures Manual
6. Disease indexing correctly carried out	Document Review	Presence (1 pt)	Yes	No

7. Policy/ procedure on the filing of health records in place and implemented	Presence of Approved and updated Policy and Procedures Manual	Presence (1 pt) Yes	No
B. Established proper filing and storage of health records	Presence of Approved and updated Policy and Procedures Manual	Presence (1 pt) Yes	No
John Maintaining and updating Procedure on Retrieval of health records	Presence of Approved and updated Policy and Procedures Manual	Presence (1 pt) Yes	No
10. Policy and Procedure on Retention and Disposal of Health Records adhere to NAP Guidelines	Presence of Approved and updated Policy and Procedures Manual	Presence (1 pt) Yes	No
ICD Coding
1. Staff trained on the latest ICD and clinical coding	Document Review	All staff is Yes trained. (1 pt)	No
2. Health records conform with the latest ICD and clinical coding	Document Review; Random Sampling	Compliant (1 pt) Yes	No
		-	_
1. Consents and certificates properly filled out with complete and accurate Updated Procedures clinical data before its intended use	Presence of Approved and Updated Procedures Manual	Presence (1 pt) Yes	No
2. Policy and procedure on handling telephone inquiries on demo data and clinical information	Presence of Approved and updated Policy and Procedures Manual	Presence (1 pt) Yes	No
3. Policy and procedure on dealing with HIMD clients requesting for patient's clinical information	Presence of Approved and updated Policy and Procedures Manual	Presence (1 pt) Yes	No
Continuous Quality Improvement (CQI)		41- 34
1. Trained staff on the development and implementation of CQI	Document review (Annual report)	Presence (1 pt) Yes	No
	Document review	Presence (2 pts) Yes	No
Risk Management			N S
Trained staff on the development and implementation of Risk Management	Document review (Annual report)	Presence (1 pt) Yes	No

2. Implements risk assessment and management for HIMD	Document review, Risk Management Plan	Presence (2 pts) Yes	Yes	No
OUTPUT					57
1. Analysis of Statistical Report, file copy duly received at the Office of Agency/Health Facility Head	Document review	Presence (1 pt)	Yes	No
2. The statistical reports are translated by Statisticians into relevant and meaningful information for use in the management process	Document review	Presence (1 pt)	Yes	No
3. Submission of timely and accurate statistical report required by the DOH, PhilHealth, and other agencies	Document review	Timely (2 pts)	Yes	No
4. Customer Satisfaction Rating meets/ exceeds set indicators	Document review	Presence (1 pt)	Yes	No
5. HIMD provides assistance to authorized researchers in compliance with Presence of Approved and updated Standards and Policies procedures Manual	Presence of Approved and updated Policy and Procedures Manual		Yes	No
Total Score:			5	100
Other findings:
Name and Position of Assessor:				1 [

Hospital Health Information Management Manual, 4th Edition

Document Info

HOSPITAL HEALTH INFORMATION MANAGEMENT MANUAL

ISBN

Department of Health

PRODUCTION CREDITS

AUTHORIZATION

MESSAGE

FOREWORD

PREFACE

ACKNOWLEDGEMENT

THE TECHNICAL WORKING GROUP

TERENCE JOHN M. ANTONIO, MD, MBA

MADELIENE GABRIELLE M. DOROMAL, MSW

MELINDA C. TAN, MPA

Members

Ana Marie M. Acejas, MPA

Lina R. Patoc, MRM

Lucila M. Villareal, MBA

Michelle P. Ocampo

Rommel Paul G. Flores

Haide M. Pleños, LPT, MPA

Josephine N. Santiago

Josephine U. Hubilla, MHA

CENTRAL OFFICE

Definition of Terms

Autopsy Rate

Bed Occupancy Rate

Bed Turnover Interval

Bed Turnover Rate

Caesarean Section Rate

Census

Clinical coding

Complication

Confidentiality

Consent

Consent Forms

Consultation Rate

Culling

Death Rate

Diagnosis

Diagnostic Procedure

Discharge Summary

ED Death

Clinical Cover Sheet

Fetal Death Rate

Health Facility

Health Information Management (HIM)

Health Record

Health Record Number

History and Physical Examination

Hospital

Imaging Reports

Immunization Record

Indicator

Infant Death Rate

Information

Informed Consent

Inpatient

Inpatient Service Days

Laboratory Results

Legitimate Purposes

Length of Stay

Loose Sheets

Maternal Death Rate

Medication Record

Morbidity

Mortality

Nurses' Notes

Operative Report

Outcome

Out-patient

Pareto Chart

Pathology Report

Patient Rights

Perinatal Death

Physician's Orders

Plan-Do-Study-Act Cycle

Power of Attorney

Problem List