Managing Medical
Records
            
Outcome-Based Learning Module for HIT level -IV
 
 
 
  
 
 
Managing Medical Records Learner Module

Acknowledgments

This learner module would not have been possible without the support of many
organizations and experts. The Ethiopian federal ministry of health and Tulane
international would like to express their gratitude to the regional Health Science Colleges
for their participation in the development of the draft materials for this learner module.
We also would like to gratefully acknowledge Harar health Science College for all kinds
of support provided during the initial draft development workshop held at the College.
Finally, an honorable mention goes to FMOH and Tulane International experts for their
invaluable contributions during the processes of the HIT occupational standard revision,
new curriculum development and lastly this learning material preparation.
Managing Medical Records Learner Module

Contents 
Introduction ................................................................................................................................... 7 

Topic 1:  Fundamentals of Medical Records ......................................................................... 13 

1.1  Introduction ................................................................................................................... 13 

1.2  Learning Objectives ....................................................................................................... 14 

1.3  Organizing  and Maintaining  Medical Record Unit ....................................................... 15 

1.4  Purposes of Medical Record .......................................................................................... 17 

1.5  Basic Requirements to Medical Record Unit ................................................................. 23 

1.6  Medical Record Forms and Design ................................................................................ 28 

1.7  Medical Record tools common in Medical Record unit(MRU) ...................................... 32 

1.8  Medical record documentation structure ..................................................................... 43 

1.9  Medical Record Data Type............................................................................................. 47 

1.10  Medical Record  Unit  working procedure..................................................................... 48 

1.11  Medical Record Data Quality ......................................................................................... 49 

Self ‐Check Assessment ................................................................................................................ 50 

Topic 2:  Patient/Client Reception and Registration ................................................................ 54 

2.1  Introduction ................................................................................................................... 54 

2.2  Learning Objectives ....................................................................................................... 54 

2.3  Patient/Client Reception and Identification .................................................................. 55 

2.4  Record Identification Systems ....................................................................................... 56 

2.5  Registering Patient ........................................................................................................ 57 

2.6  New Medical Records Preparation with Standardized Forms ....................................... 58 

Self‐Check Assessment ................................................................................................................. 59 

Topic 3:  Medical Record Indexing, Retrieval and Tracing Procedures .................................... 62 

3.1  Introduction ................................................................................................................... 62 

3.2  Learning Objectives ....................................................................................................... 62 

3.3  Indexing ......................................................................................................................... 63 
Managing Medical Records Learner Module

3.4  Retrieving Medical Records ........................................................................................... 68 

3.5  Tracing Medical Records ............................................................................................... 72 

Describe the purpose, mechanism and tools used for tracing medical records. .......................... 78 

Topic 4:  Collecting and Filing Medical Records ....................................................................... 79 

4.1  Introduction ................................................................................................................... 79 

4.2  Learning Objectives ....................................................................................................... 79 

4.3  Principles and procedure of returning medical records from service Units ................. 81 

4.4  Handling Collected Medical Records ............................................................................. 82 

4.5  Monitoring Medical Record Completeness ................................................................... 82 

4.6  Filing System .................................................................................................................. 84 

4.7  Types of Filing Systems .................................................................................................. 89 

4.8  Filing procedure ............................................................................................................. 91 

4.9  Monitor medical record filing procedures .................................................................... 92 

Self‐Check Assessment ................................................................................................................. 93 

Topic 5:  Privacy, Confidentiality of Patient Information and Medical Record Transferring ... 98 

5.1  Introduction ................................................................................................................... 98 

5.2  Learning Objectives ....................................................................................................... 98 

5.3  Responsibility of Data Clerks ......................................................................................... 99 

5.4  Transportation of health records .................................................................................. 99 

5.5  Privacy and Confidentiality to Patient /Client Medical Record ................................... 100 

5.6  Access to medical records ........................................................................................... 102 

5.7  Procedure for the Release of Medical Information in a Legal Case ............................ 103 

Self‐Check Assessment ............................................................................................................... 106 

Topic 6:  Monitoring Medical Record Keeping and Maintenance ......................................... 109 

6.1.  Introduction ................................................................................................................. 109 

6.2.  Learning Objectives ..................................................................................................... 109 

6.3.  Medical Record Maintenance ..................................................................................... 110 
Managing Medical Records Learner Module

6.4.  Medical Record Completion procedure ...................................................................... 111 

6.5.  Medical Record Control and Chart Tracking System ................................................... 112 

6.6.  Monitoring Medical Records ....................................................................................... 113 

6.7.  Accuracy, Timeliness and Completeness of Medical Records ..................................... 117 

6.8.  Archiving and Culling Procedures ................................................................................ 119 

Self‐ Check Assessment .............................................................................................................. 122 

Topic 7:  Software Applications Used in Medical Record Unit ............................................... 126 

7.1.  Introduction ................................................................................................................. 126 

7.2.  Learning Objectives ..................................................................................................... 126 

7.3.  Patient/client Registration   Using Software application/EMR ................................... 127 

7.4.  Updating/Editing Patient’s registration information .................................................. 130 

7.5.  Generating Report ....................................................................................................... 131 

7.6.  Data Quality Checks ..................................................................................................... 133 

Self – check Assessment ............................................................................................................. 135 

 
Managing Medical Records Learner Module

Introduction
This learner module is developed in line with the national competency standard in the
Health Information Technique (HIT) Training Package HLT HIT4 (Health sector,
Health information Technique level four) for the clustered units of competence of
Managing medical records (HLT HIT4 02 0112). The clustered units of competence
include:

• Organize and Maintain Medical Record Room(HLT HIT 4 01

0611)
• Medical Records Documentation, Arrangement, transportation and
tracing (HLT HIT 4 02 0611)
• Monitor health record documentation (HLT HIT 4 12 0611)
• Collect Daily Activities and Enter data into Formats (HLT HIT 4
03 0611)

This learner module contains information on managing medical records related to:
• Organizing and maintaining medical record unit including : Values of medical
record to different users, functions of Medical record unit, materials and other
requirements
• Medical recording tools used in medical record unit, contents of medical record
and the data types.
• Major working procedures of medical record unit, medical record data quality and
medical record audit
• Patient/client reception and registration procedure
• Indexing, retrieval and tracing procedures
• Data collection, medical record filling and transferring procedures
• Medical record archiving, maintenance and culling procedures
• Software application used to register patient or clients in medical record unit.

Completion of this module will help you better understand the requirements and
working procedures of medical record units, and manage this unit of a healthcare
Managing Medical Records Learner Module

facility. After you have completed this learner module, you are required to have the
following essential knowledge and skills.

Essential Knowledge:

• Values and purpose of medical record keeping

• Functions and main working procedures of medical record unit
• Basic material requirements of medical record unit
• Content of medical records in various health care settings
• Medical record data quality and audit
• Steps of patient or client registration
• Accessing medical record using Master Patient Index
• Steps of medical record filing, retrieving and tracing procedure
• Medical record archiving and culling procedures
• Data collection, coding cleaning and entry using registration applications
• Basic principles of privacy, confidentiality and security of health information
• Medical record maintenance procedure
• Monitoring medical records
• Medico Legal Issues
• How to deal with damaged or disordered medical records
• Concepts and evolution of electronic medical records.

Essential skill on:

• Specifying material requirements of medical record unit

• Applying patient reception and registration procedure
• Preparing master patient index card
• Perform filing and retrieval medical record according to the procedures
• Archive and maintain medical record
• Apply various security measures to keep privacy and confidentiality of patient
information
• Monitor medical records data quality
Managing Medical Records Learner Module

• Electronic clinical data entry and presentation

Learning Outcome Summary

Upon the completion of this learner module you should be able to:
• Prepare medical records to document patients’ care

• Apply proper medical record documentation system

• Apply medical records keeping procedures

• Assess the working procedures

• Maintain medical recording technique standards

• Apply proper client reception and registration procedures

• Apply basic principles of medical record transportation

• Confirm medical records are returned

• Implement retrieval and tracing methods for individual client medical records

• Apply proper data collection and handling techniques

• Monitor Patient record keeping and maintenance

• Apply basic skill of computer application to manage patient or client medical

records

Assessment criteria
The set of competency (skill, knowledge and attitudes) you have developed at the
completion of this module should allow you to demonstrate certain level of performance
in the work world. These may be assessed by the following assessment criteria.
1. Medical record documentation is maintained at all times
2. Methods used for daily data handling procedure are reviewed
Managing Medical Records Learner Module

3. Routine maintenance is ensured to be carried out in the record room as per the
standard operational plans (SOP’s) of the institution
4. Arrangement of documents in chronological order is ensured
5. Return of patient medical record on daily basis ensured
6. Completeness of daily registration formats is ensured
7. Systems used to collect and record health data are investigated
8. Health information needs gaps are assessed
9. The filing system for easy identification is ensured according to the national
standard Ensure daily records are filled appropriately
10. The quality of data handling procedure is ensured based on the organizational
standard
11. Medical record maintenance directives are applied
12. Application of standardized record filing procedures are ensured and verified.
13. Accuracy, timeliness and completeness of each medical record is maintained
according to the policies and procedures
14. Compliance to recording technique standards is monitored and supervised at all
levels
15. Patient needs are identified by interviewing patient or accompanying person
according to the set guidelines
16. Availability of previous medical record in the same facility is identified
17. Referred patients are checked to verify for possession of referral document.
18. Patients are registered according to the registration guidelines
19. New medical records are prepared with the standardized forms
20. Tracer card is issued
21. Master Patient Index (MPI) card is produced and catalogued during registration
22. Service identification card is issued to patients
23. Use of service identification card is explained to clients
24. Basic principles of medical record transportation to and from the medical record
room to the outpatient and inpatient departments are applied
25. Patient’s record confidentiality is ensured
26. Arrangements of medical records to be sent to the service units are ensured in
accordance with the applicable rules and regulations
27. Data Collection from the different units of the facility is ensured
Managing Medical Records Learner Module

28. Proper handling of the collected data is ensured

29. Data coded/entered to the prepared formats or computer soft ware is applied
30. Data as per the need is retrieved
31. Incomplete records are easily Identified

How to use the learner module

• This learner module is prepared for the clustered units of competence ‘Managing
medical records’ that contains knowledge, skills and attitudes required to organize
medical record unit and manage medical records in accordance with the work
procedures and standards for HIT level IV students. It contains training materials
and activities relevant to the aforementioned units of competence.
• You are required to go through a series of learning activities in order to complete
each of the topics of the module. In each topic and sub-topics, there are
Information and activities. Carry out those activities on your own at the end of
each learning activity. Each topic or sub-topic may have more than one learning
activity.
• This module will be the source of information that will enable you to acquire the
knowledge and the skills independently at your own pace or with minimum
supervision or help from your teacher.
Managing Medical Records Learner Module

Resource

Topics Resource/Learning materials

Fundamentals of Medical Medical Recording tools of HMIS ( Folder, MI card,
Records Service identification card, Appointment card,
Tracer card, Patient form & other clinical forms,
Shelves, MPI box etc.)
Patient/Client Reception Medical Recording tools of HMIS, HMIS
and Registration participant’s manual two

Medical Record Indexing, Medical Recording tools of HMIS, HMIS

Retrieval and Tracing participant’s manual two, Shelves MPI box

Procedures

Collecting and Filing Shelves, folders, fasteners

Medical Records

Monitoring Medical Medical records(folders), Deficiency notice form

Record Keeping and
Maintenance
Software Applications SmartCare, SQL 2008 management studio, Dot Net
Used in Medical Record framework

Unit
Managing Medical Records Learner Module

References

Topics Resource/Learning materials

Fundamentals of Medical IF HRO, International Federation of health records
Records organizations modules (1, 2, 3, 5 & 6), HMIS participants
manual II, WHO, Medical record manual.

Patient/Client Reception
Managing Hospital Records, International Records
and Registration
Management Trust, Michael Roper, Laura Millar,
HMIS participant’s manual II, WHO, Medical record
manual
Medical Record Indexing, Medical record manual, HMIS participant’s manual II,
Retrieval and Tracing Essential of health information management: principles and

Procedures practice Michelle A. Green, Mary Jo Bowie.

Collecting and Filing

Medical record manual, HMIS participant’s manual II,
Medical Records
Monitoring Medical
Medical record manual, HMIS participant’s manual II,
Record Keeping and
Medical record archives booklet, Improving data
Maintenance
quality WHO, Guide to Health informatics 2d edition,
Enrico Coiera.
Software Applications
EMR user’s manual Registration module, Improving
Used in Medical Record
data quality WHO.
Unit
Managing Medical Records Learner Module

Topic 1: Fundamentals of Medical Records

1.1 Introduction

Medical/Health Records form an essential part of a patient’s present and future health
care. As a written collection of information about a patient’s health and treatment, they
are used essentially for the present and continuing care of the patient. In addition, medical
records are used in the management and planning of health care facilities and services,
for medical research and the production of health care statistics.

Health care professionals write up medical/health records so that previous medical

information is available when the patient returns to the health care facility. The
medical/health record must therefore be available. If the medical/health record cannot be
available when it is needed for patient care, the medical record system is not working
properly and confidence in the overall work of the medical/health record service is
affected.

Under this topic, organizing and maintaining medical record units, medical recording
tools (specific to the Medical record unit), and medical record data types, contents of
medical record, medical record unit working procedures and data quality of medical
records are included. Each heading are discussed with appropriate details and contains
adequate illustrative pictures and relevant activities /self check exercises.

Before we proceed to specific areas of this topic mentioned above, we need to discuss the
medical record in terms of what it is, how it evolves and why it is so important.

A medical record is a compilation of facts about a patient’s life and health. It includes
documented data on past and present illnesses and treatment written by health care
professionals caring for the patient. A medical record also “must contain sufficient data to
identify the patient, support the diagnosis or reason for attendance at the health care
facility, justify the treatment and accurately document the results of that treatment”.
Managing Medical Records Learner Module

With many changes in health care delivery today, the medical record is often referred to
as the health record. This term generally refers to a broader view of health care in many
countries. A health record actually means a single record of all data on an individual's
health status from birth to death. That is, it would include birth records, immunization
records and records of all illnesses and treatments given in any health care facility.
Unfortunately, this type of record is not maintained in many health care facilities today.
The term medical record, therefore, should still be used to accurately describe the type of
record currently used in most hospitals and will be used in the following pages. The
health record, as described above, is becoming more popular and will be used more
extensively in the future. Therefore, the terms are interchangeably used throughout this
learner module.

1.2 Learning Objectives

Upon completion of this topic, you should be able to:

• Organize and maintain medical record unit

• Determine basic requirements of Medical record units
• Monitor medical record data quality
• Describe the purposes and values of health record
• Identify the major functions of a Medical Record Unit and perform basic
procedures understand the multiple uses of a medical/health record and the
confidential nature of medical/health record data
• Identify common medical record unit recording tools
• Implement and maintain a master patient index in Medical Record unit
• Assess the need for a new recording forms
• Identify health care data types and understand a disease and procedure index
Managing Medical Records Learner Module

1.3 Organizing and Maintaining Medical Record Unit

The medical record unit is a busy department of a healthcare facility and the work of
medical record clerks are highly demanding. Although staffs are not directly involved in
patient care, the information recorded in the patient’s medical record is an essential part
of that care. The medical record unit staffs are, therefore, required to perform an essential
service within the hospital. Sometimes, the nature of this work may not be understood by
the medical staff, hospital administrators, other hospital personnel, and even with some
medical record clerks, and often little emphasis is given.

In resource limited countries, there is inadequacy of funding medical record units that
may cause medical record units not to run effectively. Therefore, medical record staff
should be resourceful and dedicated to working in a busy and extremely important
section of the health facility.

Figure 1.1 Medical Record unit of Ayder referral hospital, Tigrai-Ethiopia

Hospitals and health centres in Ethiopia have a designated, medical record unit that is
commonly known as called Medical Record Unit or “Card Room”. Cards (medical
records) are kept for all patients and retrieved from the card room when it is needed.
Managing Medical Records Learner Module

In the previous time, some service units have kept medical records of patients within the
service unit with no integration. For example, paediatrics department may have their own
card room; a clinic that treats HIV/AIDS patients may have its own a card room.
However, following the implementation of reformed HMIS (health management
information system); all the medical records of a patient for various services are kept in
the medical record unit in integrated fashion contained in a folder.

Value of the Medical Record

An accurate and complete health record has value:

• To the patient
• To health facility
• To the doctor and other health professionals
• For research, statistics, disease & service reports and teaching
• For patient billing

Patient
As the health record contains a complete report of a patient's illness and results of
treatment, it is of great value to the patient for:
• Future care for the same or other illnesses
• Informing them (by giving access) of their care and treatment
• As a legal document to support claims for injury, or malpractice/quality of
health service provided

Hospital, Health Centre or other health facility

The health record may be used by the health facility to evaluate the standard of care
rendered by healthcare providers and the end results of treatment. If adequate records are
not kept, the facility cannot justify the results of treatment. The health record is also of
value to the facility for medico legal and disease and service reporting purposes as a
source of relevant information.
Managing Medical Records Learner Module

Doctor and other health professionals

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

For medical research, statistics and teaching

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

For patient billing

Without the information within a health record, payment for services could not be
justified. Often the health insurance agencies require supporting evidence for claims - this
evidence is found in the health record. Federal ministry of health is working on the area
of health insurance system to be implemented in the country in the near future. Therefore,
the importance or value of medical record for such purpose in Ethiopia is inevitable.

1.4 Purposes of Medical Record

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

Health records are kept for purpose of:

1. Communication
2. Continuity of patient care
3. Evaluation of patient care
4. Medico legal (as legal document)
5. Statistical
Managing Medical Records Learner Module

6. Research and education

7. Historical purposes

1. Communication

Health records are kept initially for communication between persons responsible for the
care of the patient for present and future needs. While under care, these care providers
keep records of care for a patient. Those who may be involved in looking after a patient
and who contribute to the health record include.

• All Physicians
• Health officers
• All Nurses, Midwives
• Pharmacy professionals
• Laboratory technicians
• Radiologist
• Dieticians/Nutritionists
• Medical & Health Sciences students

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

2. Continuity of patient care

The patient may be readmitted to the same or another hospital or visit a health centre
where all his past medical history should be available for assessment in the light of
current symptoms. Communications on the basis of the health record is essential between
hospitals, health centres and primary health workers (It could be health extension worker
in our situation) in contact with the patient.
Managing Medical Records Learner Module

The main function of the health record unit in a hospital or Health Centre, in this context,
is to ensure that medical records should be produced and kept for patient care at all times
and as quickly as possible. Also, discharge summaries and feedback letters must be
processed so that people outside the health facility may be informed of the patient's
progress and their continued management after discharge.

3. Evaluation of patient care

In any setting in which an individual puts the responsibility for their health and
well-being into the hands of others, there should be some mechanism that enables
evaluation of the standard of care being given. In some countries, the health record
services of a hospital must meet predetermined standards.

Other methods of evaluation of patient care in hospitals include:

1. Patient care committee - meets regularly and may review samples of

medical records and evaluate the standard of care recorded.
2. Peer review - Doctors of a service may evaluate the work of each other and
the unit through the medical records.
3. Hospital administrative committee - may evaluate the standard of care in a
particular ward or by a particular physician or surgeon using the medical
records.
4. Statistics - derived from records may also be used in assessment of
standards. This may be within the hospital, for example, evaluating the
infection rate in a particular ward or for a particular operation or between
clinics, hospitals, states or countries, in which case the statistics are used by
ministry of health, regional health bureau or the facilities themselves. In
most countries the department of public health (Public Health Emergency
Management) also requires notification of communicable diseases, such as
tuberculosis, cholera, meningitis, etc.
Managing Medical Records Learner Module

4. Medico legal

Here, the main use of the medical record is as evidence of unbiased opinion of a patient's
condition, history and prognosis, all assessed at a time when there was no thought of
court action, and therefore extremely valuable. It is used both in and outside the court for
settlement of such disputes as:
• Assessing extent of injury in accident cases
• Establishing negligence of the health professional or hospital in the treatment
of a patient.

5. Statistical purposes

Statistics are collected in hospitals and primary health care centres (Health Centres and
Health posts). They may be used to tabulate numbers of diseases, surgical procedures
and other curative or preventive services to assess areas that the hospital or primary
healthcare unit serves. The disease and service statistics are also used to report the
performance of the healthcare facility and for informed decision making and planning at
higher level in the healthcare delivery system.

6. Research and education

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

Analyses of the types of people, together with studies of the types of diagnosed illnesses
within the hospital, a particular ward or clinic, are essential for planning future services
and equipment. The turnover rate of patients is an indication of the numbers of staff
required in all departments. The workflow of the hospital or health centre can be
analysed once it is recorded in the medical record as it is used and developed by different
health professionals involved in the patient's care.
Managing Medical Records Learner Module

7. Historical purposes

The record acts as a sample of the type of patient care and method of treatment used at a
particular point in time.

Functions of Medical Record Unit

A medical records unit has a number of functions in a healthcare facility. Some of these
are:
• Patient Registration
• Medical record filing (includes record retention and tracing)
• Record assembly and analysis and processing
• Coding (Health Management Information System (HMIS) disease classification
and International Classifications of Disease)( this is usually performed by care
providers in the Ethiopian case)
• Record disclosures and release of medical records
• Completion of monthly and annual statistics related to the medical record unit
activities
• Medical record unit administration (management, retention, research, quality
audits and professional roles and responsibilities)
• Maintenance of medical records and medical record services
• Safeguard medical records from tampering, loss and unauthorized use
• Maintain patient’s right to privacy and the confidentiality of the information
stored within the medical record
• Developing and maintaining policies and procedures related to the medical record
services of health facility
• Admission procedure, including patient identification and the development and
maintenance of the master patient index (MPI)
• Retrieval of medical records for patient care and other authorized user
• Discharge procedure and completion of medical records after an inpatient has
been discharged or died
• Evaluation of the medical record service
Managing Medical Records Learner Module

• Medico-legal issues relating to the release of patient information and other legal
matters

It is generally accepted that the staff of a medical record department are responsible
for the initiation, completion and maintenance of a medical record for every person
attending the facility as an inpatient, outpatient or accident/emergency case.

The major responsibilities of a medical record unit staff are:

• The initiation of medical record documentation, and the design & control of all
medical record forms
• Initiation and maintenance of a unique patient identification system and master
patient index (MPI)
• Preparation of health record forms for a new patient
• Completion and control of incomplete records for discharged/deceased inpatients
• Classification of diseases and collection of morbidity/ mortality statistics for all
hospital discharges/deaths
• Collection of health facility statistics relating to discharges/deaths, length of stay,
occupancy rates for administrative and health department use
• Filing and retrieval of all inpatient and outpatient health records with an inbuilt
record control system
• Transcription services covering discharge summaries, operation reports,
outpatient letters and medico legal correspondence (using word processing
software)
• Services to medical and other health professionals for the retrieval of health
records for research and teaching purposes
• In some situations the functions of the health record services includes patient
reception and processing registration for outpatient or emergency services.
• Failure to undertake any of these procedures could result in a poor medical
record service.
Managing Medical Records Learner Module

1.5 Basic Requirements to Medical Record Unit

As part of HMIS reform, there are set of standards or requirements that medical record
units of health facilities in Ethiopia should fulfill. These are:

1. Human resources
• Health information technician (HIT)
o Hospitals require 2 HIT, and 1 HIT for a health center
• Card room clerks (card room workers)

2. MRU physical specifications

• Adequate room with height of 3 meters and minimum of 2windows(
including those for fast tracking) and one window for cashier
• A minimum of 60 square meter space in a hospital
• At least 24 square meter space in a health center

Medical record units not fulfilling these requirements should be expanded (extended) or
merged with adjacent rooms or shifted (rearranged) or renovated-if there is no other
option.

3. Shelves
• 4 columns, 8-10 rows
• 2.75m height by 2m length (see figure 1.2)
• Cell: height 25cm, width 35cm, length 50cm, based on size of new folder
and preferred size of a shelf
Managing Medical Records Learner Module

Figure 1.2 Specifications for medical records shelf

4. MPI boxes (see figure 1.3)

• 1.5m height by 2m length for a hospital
• 1.5m height by 1m length for a health centre
• Each with 26 alphabets (pockets) for each of the levels,
preferably 50 and more pockets for the hospitals (as there is
more repetition of some alphabets).
Managing Medical Records Learner Module

Figure 1.3 – Specifications for cells and MPI box and the card drawer

5. Partition for adult and pediatric age can be considered in health facilities with bigger
capacity. Therefore, a shelf with 2.75m height and 4 columns-with 50 cm length each,
and 8-10 rows with-25cm height each, is the preferred size for standard height rooms.

However, in some health facilities, there should be pre-measurement of roof height

before ordering for shelves so that it fits the existing physical structure of the medical
record unit. A 25cm gap between the roof and the top of a shelf should be kept. This
space may be used for interim storage of older and less active folders before they are
moved to temporary storage.

The shelf specifications in rooms with smaller height are similar. While the height of the
shelves may vary as mentioned earlier, there should always be 25cm space between the
top of the shelf and the ceiling.
Managing Medical Records Learner Module

Other Requirements

Medical record units of hospitals or health centres require adequate facilities and
equipment for the efficient day-to-day operation of the service. Some of these
requirements that a facility should consider for the medical record unit are:

• The medical record unit should be located in such a place as to facilitate the rapid
retrieval and distribution of health records.
• The unit and work space should be sufficient for medical record unit staffs to
perform their duties and for other authorized personnel to work with health
records, including electronic health records with computers.
• There should be sufficient storage space for health records to allow for future
storage needs. This includes:
o An active storage area with sufficient space to include all health records
currently in use by hospital staff, and
o Available space to provide for both active and inactive health records
being stored based on the legal guidelines
• Areas for active and inactive health record storage should be sufficiently secured
to protect records against loss, damage, or use by unauthorized persons.

When a responsible body plan to have a health record unit in a health facility, whether for
a new hospital or relocation within an existing hospital, it should consider the
involvement of three people. Theses are:

• Health information management/health record professional (HIT)

• The facility's plan and program head
• The an architect (engineer)

The health information management/health record professional contributes ideas

especially on the detailed functions of the proposed medical record unit. The facility's
plan and program head has an understanding of the total requirements within the facility
and co-ordinates all departmental planning. The architect (engineer) is responsible for
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defining, both verbally and graphically the building and related specifications that are
necessary for the well functioning of the medical record unit.

To design a medical record unit that will offer both efficient and effective services, the
planning team must clearly define the functions of the unit and the inter-relationships of
the proposed department with other departments/areas of the facility. For example, will
the health record unit be responsible for transporting health records, for ordering and
storing health record forms, or will these functions be the responsibility of another
department.

This involves looking at procedures to be performed, staff requirements for the

performance of these procedures, the flow of work planned for the unit and the hours of
services offered. This information should be stated in clear, logical writing, with
sufficient detail for an architect to understand what is required.

When preparing for planning to build a health record unit, there are five major points to
be considered. These are:

• Location of the unit with regard to services and inter-relationship of service

areas.
• Space requirements for records, personnel and equipment including computers.
• Functional design and logical placement of key work areas.
• System of communication within the health record unit and between the
departments and other areas of the facility.
• Systems to be used to transport health records within the unit and to other
service units including wards.

Location

When determining location consideration must be given to the need for the department to
be centrally located where it will provide:
• Prompt service for all patients : inpatients, outpatients and emergency
departments
• Accessibility for medical officers and other users
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• Easy availability for administrative use

1.6 Medical Record Forms and Design

What is a form?

A form could be defined, as a piece of paper or card on which there is a formal

arrangement of data entry fields, usually with spaces for the entry of additional data. Or,
it could be defined as a prescribed written means of shaping information for
communication.
Forms are used to collect, record, transmit, store and retrieve data. That is, they request
action, record the outcome of the action, instruct and assist with the evaluation of data.

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

Workers in the health information management/health record management field should

be aware of the variety of record forms, duplication, and lack of uniformity that may be
found in many hospitals and/or primary health units.
Whether one works at the administrative or technical level, one should be aware of the
essential and recurrent task of correct form design so that, as far as possible, they can
ensure that all forms are neat, simple in appearance, easy to understand, write up and
interpret.

When these forms are being designed, the needs of all health professionals involved with
patient care must be taken into consideration, as well as the needs of health officials
requiring information about the occurrence of disease, outcome of care, as well as
demographic and epidemiological data.
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Data entry in a form is the first step in data collection. The design of forms, their
physical layout, the determination of the data to be requested, and the way, in which it is
collected, has an impact on the quality and quantity of data collected and subsequent
information produced. We will see all the features of good form with the Standardized
Health Management Information System (HMIS) recording and reporting forms in
module 6.

Standards must be established when you design forms so that consistency can be
maintained. In addition, there should be fixed responsibility for form design, so that
individuals and departments cannot start their own forms in isolation.

The term ‘form’s physical layout’ refers to a number of issues and can be summarized as
follows:
• How the information is displayed on the form(see figure 1.4)
• How material is presented
• The order and the logical connections between data requested, the space between
entries, whether columns, boxes, or highlighting will be used, the size and type
of print, and the need to allow adequate space for entries

Questions to ask before designing a new form include:

• What is the general purpose of the form?

• Is the form really necessary?
• What benefits will be derived from the introduction of a new form?
• What information is to be provided and what is its general purpose and need?
• What are the operations, through which the form will pass, for example, entry
of data, sorting of data?
• How is it (the form) going to be filed? Where will it be attached - side or top?
• Who will the users be? When is the form to be used?
• Where will the form be used and what will the associated working conditions
be?
• Are there any other special features, which need to be considered?
• If a signature is required, is it also necessary to ask for the name to be printed?
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Figure1.4 ART (Antiretroviral treatment) clinic patient intake form physical layout

General principles to be considered when designing a form

• All health record forms used in the clinic or hospital should be of standard size.
They should also be readable, useful and allow for the standardisation of
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information. The kind and size of typeface, margins, ink, and paper colour and
weight, should be standard within a hospital, clinic or primary health centre.
• All forms should have a standard format at the top to include the name of the
patient, medical record number, and date. This information should appear in the
same place on all forms.
• The persons who will be required to use the form should understand the language
used on the form.
• Each form should have a descriptive title, e.g. Service Identification Card,
Laboratory Reports (see figure 1.4).
• All forms should have simply printed instructions for use to ensure uniformity in
the collection of information. If these instructions are detailed they could be
printed on the reverse side or in a separate instruction sheet.
• Captions should clearly indicate the data to be entered, for example, just name is
not sufficient, usually one wants "full name of patient". The use of boxes is also
very good and saves time, for example, male and female categories may be set up
in a boxed arrangement as follows:
Male … Female …
• If one piece of data depends on another, put the dependent data after the other in
the order to be filled in, for example, date of birth - age; previous admission date.
That is, group items into order of action and be logically consistent with related
forms so that data are easily used after entry on the form.

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

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

• Those responsible for the form and its content

• Those who will be entering data on the form
• Those who do not enter data but who refer to it to gain information from
the data.
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Another important point to keep in mind is that successful implementation of a new or

revised form is just as important as the analysis and design of the form. Testing is an
important part of forms design. You may ask the question "How can forms be tested?"
To start with they should be tested in a realistic environment and secondly the end users
should test them by using them for some specific period of time.

Figure 1.5 a descriptive tile for woman’s Card

1.7 Medical Record tools common in Medical Record unit(MRU)

In medical record unit, the HMIS has introduced a number of recording tools that
facilitates the day to day operations of the unit and keep important personal demographic
and identification information of individual clients/patients. Under this topic, common
recording tools available in the MRU are discusses with great detail.

Medical record Folder (simply a folder)

All clinical or service records related to a patient/client should be kept together to

maintain integrity of patient information about his or her health. This to happen, the
reformed HMIS has introduced a tool called Folder.
This folder is a paper file folder with expandable spine and fastener on the left side.
Registration or identification information of a patient is contained on the front cover with
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the summary sheet on the inside of the front cover. The summary sheet is used to write
the summary of each service provided in the health facility.

The folder is kept in MRU and filed by individual’s MRN. When the patent receives care
in a facility, the folder containing the medical records is taken to the appropriate service
unit. A tracer card is used to track the folder’s location.

The purpose of a medical record folder is to integrate all medical and health service
records of an individual to be accessed when it is required. Specifically it contains:
• Individual’s medical records from all services (preventive, OPD, and IPD).
• Provides individual’s demographic information
• Contains summary sheet for all services provided in a facility

Maintaining a folder

A medical record unit staff:

• Issues the folder upon registration of a new individual patient
• Retrieves the folder from the filing shelves for a registered patient when she
or he returns for service
• Tracks its location until it is returned to the medical record unit
• Files it in its location

In health care institution where shelves/lockable storage rooms are used, medical records
should be filed on their supine position so that the medical record number is clearly
visible for filing and searching purpose. Care provider uses the recording tools already in
the folder or adds new forms while providing service. At the end of providing service,
the care provider write notes on the summary sheet regarding the care provided. And it
will be checked by the MRU clerk for its completeness.
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Contents

In addition to the registration and summary sheet information contained by the folder
itself, it may contain the following common recording tools needed and used by the care
providers and card room clerk:
• Tracer card
• Patient card
• Integrated Reproductive Health (RH) card
• Admission/discharge card
• Woman’s Card
• Other service & clinical forms such as lab result form and progress report
form
Materials

It is preferable to use a manila folder (see figure1.6) as it is durable and more protective.
If possible stronger cardboard folders should be used. However, since these materials
may be costly to afford, the issue of sustainability should be considered while choosing
material to make a folder. If possible, material should be those locally produced but
durable in order to guarantee continuous supply.

Figure 1.6 a Manila folder (left) and commonly used a paper folder (right)
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Master Patient Index Card

The master patient index (MPI) card is prepared by responsible medical record
department staff in the MRU and is the key to locate the medical record. In paper based
systems, it is a card index. It can also be computerized to facilitate and enable fast
searching. MPI cards are small sized, hard papers which contain information necessary to
identify a patient. MPI cards also contain the patient’s medical record number. More
detail description about the preparation and storage of MPI card will be available in the
next topic.

Service Identification, Appointment and Tracer Cards: these recording tools (cards)
are discussed in the next topic.

Patient form/Card
This form contains care provider’s clinical observations, notes, diagnosis, and HMIS
diagnosis for every outpatient encounter and admission (see figure 1.7). This recording
tool is inserted into and kept in the folder when a patient visits a facility for services.
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Figure1.7 HMIS Patient form

Integrated RH (reproductive health) card

This recording tool is A3 sheet which is folded to create a four-sided folder. It is used to
record antenatal, labor, delivery, newborn, and postnatal care services for a single
pregnancy. This card is kept in individual’s medical records folder (see figure1.6) and
inserted into the medical record folder when a pregnant women visit a facility for
antenatal care or delivery or postnatal care.
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Figure 1.6 the integrated reproductive health card (RH card)

Woman’s Card
This form is designed to record woman’s immunization history for Tetanus Toxoid
Vaccine (TT) family planning service and abortion care. This Woman’s card is issued
when a woman visit a health facility for either of the above services.
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Figure 1.7 HMIS woman’s Card

Admission/discharge card

It is used to records medical, demographic, contact, and administrative information on

admission and discharge. It is A4 size paper and kept in individual folder (see figure 1.8).
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This Card/form is issued to the patient when the care provider decides to admit the
patient and the card will be inserted into the medical record folder at the health facility’s
admission/discharge department.

Figure 1.8 Admission/discharge Card

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Other Medical Recording forms

As mentioned previously, a written health record should be maintained on every patient

attending a hospital or seen in a primary health care unit. The health record stores the
information created due to interaction between a patient and the care providing health
professionals associated with that Health facility. A health record should contain
sufficient information to:

• Identify the patient

• Support the diagnosis
• Justify the treatment, and
• Document the results facts accurately

For better patient care, only one health record should be kept for each patient. For the
reasons mentioned earlier while discussing the value of medical records, good medical
care generally means a good health record that developed and maintained on each patient.
An inadequate health record, that is, one that does not contain 'sufficient information to
identify the patient, support the diagnosis and justify the treatment given, may reflect a
poor standard of care given by the doctors, nurses or other health professionals within the
clinic or hospital.

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

Clinical Forms

Clinical forms for inpatients constitute the bulk of a patient's medical record, and include
the following:
• A form for medical/general history : This is usually divided into a number
of sections and includes space for data relating to:
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o Presenting signs and symptoms

o Previous illnesses and operations
o Family history
o Occupation and social data
o Current drug therapy and treatment

• A form for Physical examination: This is used for the collection of baseline
data about a patient presenting (clinical signs) for care or service. The content
of this form usually includes:
o General survey and state of health of patient
o System review - all systems checked
o Vital signs, such as pulse, respiration, blood pressure, temperature
& provisional diagnosis

• Doctors orders or plan for care: A form that is used by the doctor to record
his/her patient findings and writes a course of action outlining the planned
care and treatment for the patient. These orders should be dated and signed as
should all entries in a health record.

• Progress notes: These notes indicate the condition of the patient and his/her
response to treatment on a continuing basis throughout the admission.
Progress notes should be recorded at least once a day and more often in cases
of acutely ill and critically injured patients.

• Laboratory, Pathology, Radiology and other Special investigations:

Appropriate forms should be used to record investigations such as pathology,
laboratory, and radiography. These forms are filled by appropriate data (test
results) following the order of the physician to be investigated. Then, those
forms that contain the results are kept in the individual medical folder to make
them available when it is needed.

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

• Operative and anaesthetic and recovery forms: These forms are important
for surgical patients and should contain information on surgery,
pre-anaesthesia and post-anaesthesia, the operation procedure, and other
relevant data required.

Administrative Forms

Consent forms are extremely important and should be part of every health record. The
form usually carries a statement indicating that the patient agrees to basic treatment. In
hospital situation, special consent forms are required for any non-routine diagnostic or
therapeutic procedures performed on the patient. These forms provide written evidence
that the patient understands the nature of the procedure, including any risks involved and
likely outcomes, and consents to the specified procedure.

The patient is asked to sign consent form after having all details clearly explained to
him/her by the attending doctor. That is, the patient gives informed consent (Figure1.9).

Figure1.9 a Surgical procedure consent form

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Forms, such as referral form and medical certificate form with their respective contents
and purpose should be further explored by you during your practice in health facilities.

1.8 Medical record documentation structure

The documentation of care given to patients during their stay in the hospital is an
essential part of the provision of that care. The tool used for this documentation is the
patient's medical record.
.
The content of a medical record is developed as a result of the interaction of the members
of the health care providing team who use it as a communication tool. Inside the medical
record folder, the documentations can be organized in four common medical record
structures. Theses are:

a. Integrated medical record

b. Source Oriented Medical Record
c. Problem Oriented Medical Record (POMR)
d. Protocol oriented medical record

a. Integrated Medical record documentation

Data are presented in a strictly chronological (with time sequence of events) order,
identifying each episode of care by time and date. Data arriving from an investigation
such as radiology could then be followed by progress notes written by a clinician, a
change to medication orders or a laboratory test results.

The limitation of integrated record is that it provides little or no structure to the data
beyond a time-stamp, and consequently guidance is not offered on navigation through the
records. It also doesn’t indicate what elements may be more important than others for a
given task.
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b. Source Oriented Medical Record

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

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

c. Problem Oriented Medical Record (POMR)

The POMR organizes data according to the list of patient problems, which may be
anything from symptoms through to well-defined diagnoses.This method starts with a
database to collect information, followed by a problem list, which helps the doctor decide
what is wrong with the patient.

This information is placed at the front of the record so everyone caring for the patient is
aware of all problems. From the database and problem list, the initial plan for treatment
and diagnostic work-up is developed. That is, the doctor caring for the patient decides
what to do. The next step is to follow through recording problem oriented progress notes
using the Subjective compliant-Objective compliant –Assessment –Plan (SOAP) method
for each individual problem. The problem oriented medical record has four parts:

• Database -----------Collection of all data

• Problem List-------Formulation of problems
• Initial Plan ---------Development of a care plan
• Progress Notes-----Numbered and titled progress notes
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Database

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

Problem List

Once the database has been collected, an assessment of the information is made and a
problem list is developed. The problem list is kept in the front of the record. The most
conceptual difference between a source oriented and problem oriented health record is
this PROBLEM LIST.

Initial Plan

The development of the initial plan for the management of a patient's problems, as
defined in the problem list, is the third step in planning patient care using a problem
oriented health record. It has three parts: Diagnostic plan (to collect more information on
diagnosis), Therapeutic plan (which a plan for treatment) and the patient education plan
(plan to inform the patient as to what to be done).

Progress Notes

The fourth step in the formation of a POMR is the problem oriented progress notes.
These should indicate:
• What has happened to the patient
• What is planned for the patient
• How the patient is responding to therapy

Progress notes should contain four component parts:

• Subjective part - written in the patient's own words
• Objective part - the doctors observation and test results
• Assessment of progress
• Plan for continued treatment
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d. Protocol oriented medical record

When a patient is being given a standard treatment for a well-understood condition such
as tuberculosis or diabetes, pre-structured forms are used by the doctors/care providers.
These forms dictate what specific data are to be obtained and what the treatment plan
should be for the patient.

The protocol-oriented record is clearly a very prescriptive document format, but it is

useful in highly repetitive situations, such as ART clinics. It does not only guarantee
standardized patient records across different care providers, but also tends to be more
complete since the pre-defined structure acts as a prompt to remind clinicians to ask
specific questions or carry out specific investigations.

No matter whether a record is organized with any of the above approaches, the health
information technician should assist medical staff and other health professionals by
preparing well-structured forms to enhance data collection and easy access to information
relating to patient care at all levels.

A summary sheet contains information about the types of services given to the patient
during previous visits of a health facility and it needs to be placed where it is immediately
accessible and must not become ‘buried’ in the middle of the file. In the Ethiopian case,
the summary sheet of patient medical record is printed on the inner front cover of the
folder. This will automatically keep the summary details in a prominent position but does
not allow for continuation sheets to be used. The front side of a folder is not
recommended to be a summary sheet, as it would soon get damaged through repeated
handling.

Which internal organization of medical records approach is practiced in

Ethiopian health facilities?
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1.9 Medical Record Data Type

A medical record can contain different types of data. These are:

• Socio-Demographic Data: Statistical information about an individual in

relation to the population. This includes but not limited to age, place of
residence, gender, religion, ethnic group, marital and educational
status.
• Clinical Data: Most common type of health information – signs,
symptoms, diagnoses, treatments, and outcome of the care process.
• Financial Data: Data about payments and other money related aspects
of care and treatment.

As it is discussed earlier, each facility should establish a method of chart/form ordering to

be followed when arranging all the forms in the individual medical record folder. This
ensures that those who use the records are able to find information in the records easily as
each chart/form will then be in the same order.

The forms and charts within a patient medical folder should be attached using a fastener.
Staples should not be used as they tend to rust and additional forms are then difficult to
add. Fasteners are attached in the inside of the chart folder either along the crease in the
folder or at the top of the folder. Forms can be pre-punched for quick assembly into the
record. As forms are added to the record, they are then held in place by the fastener.
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Figure1.10 poorly organized medical charts/forms of a chronic patient

1.10 Medical Record Unit working procedure

There are a number of working procedures in medical record unit of a hospital/health

center. Some of the most important procedures are:

• Registration procedure: allow you to register new or repeat patient for

health services
• Filing procedure: helps you to file (arrange and locate) medical records
in such a way that retrieval or access to a medical record is simple.
• Retrieval procedure: a set steps and rules to retrieve a medical record
from the shelf
• Archiving procedure: allows you to store medical records which are
inactive during the archiving time.

Each procedure will be discussed in detail in the subsequent topics.

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1.11 Medical Record Data Quality

Health care data are maintained for the present and future care of the patient
regardless of the level at which the service is provided. The quality of that data is
crucial, not only for use in patient care, but also for monitoring performance of the
health service and employees. Data collected and presented must be accurate,
complete, reliable, legible and accessible to authorized users if they are to meet the
requirements of the patient, doctor and other health professionals, the health care
facility, legal authorities, regions and national government health authorities. The
characteristics and assessment tools for quality data are described under topic six of
this learner module.
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Self -Check Assessment

Activity: 1

Write a brief description of a nearby health facility organizational structure and indicate
how the medical record unit is structurally and functionally related to the rest parts of the
health facility.

Activity: 2

Which of the following is not considered as a Medical Record Unit work procedure?
a. Reception
b. Registration
c. Retrieval
d. Filling
e. All are work procedures of a MRU

Activity: 3
The type of data that include the name of the patient, sex, date of birth, educational level,
patient’s permanent address and a unique personal identifier is?

a. Socio-Demographic Data
b. Financial Data
c. legal data
d. Clinical data
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Activity: 4
All health record forms used in the clinic or hospital should be of standard size
a. True
b. False
Give reasons why for the choice you made

Activity: 5

With your own word describe the value of medical record to:

a. The patient

b. The healthcare provider

c. The facility and other health institutions

d. The health researcher and statistics

Activity: 6

Assume that you are working as HIT for a woreda health office. The woreda planned to
build a health center for the catchment population and you are asked to provide the
specifications or basic requirements that a medical record unit should fulfill in terms of
physical structure equipment and human resource. What would be your list of
specification? Please write it down with relevant explanations.
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Activity: 7

A medical record unit of a health facility is the most important department that provides
essential service to patients/ clients of a health facility. Identify and define the major
functions of a medical record unit.

Activity: 8

Assume that you are employed by a hospital to manage the work of its medical record
unit. What are those very important medical recording tools you need to have for the
MRU to function properly? Write the purpose and the contents of these recording tools.

Activity: 9

While you are working as a hospital’s HIT, the head of a diabetic clinic informed you
that he wants to see the effect of his treatment approaches on his patients and wants to
develop a follow up form for diabetic patient. What are the general rules you advice him
to follow?
_________________________________________________
___________________________________________________
_________________________________________________
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Activity: 10

What are the characteristics of quality health records? Who is responsible for maintaining
quality health record?

Activity: 11

Compare and list dawn the advantages and disadvantages of the four common types of
arranging medical records internal structure.
a. Problem oriented medical record
b. Integrated Medical record
c. Source oriented medical record
d. Protocol oriented medical record

Activity: 9

Most of the Ethiopian health facilities organize the internal structure of the medical
records in a similar way. Examine how a medical record is organized in the nearby
hospital and list down the associated problems in terms of access and easy of retrieval
particular piece of patient information from the medical record.

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
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Topic 2: Patient/Client Reception and Registration

2.1 Introduction

This topic guides registration procedure. Patient reception usually starts at triage room
so that a triage nurse should screen the patient and send to medical record unit for
registration. At Triage room, the triage nurse should follow certain procedure to screen
the patient. After the patient is screened, the registration procedure starts. This
registration process may vary depending on the type of visits i.e. new or repeat. The tools
and procedure for patient registration, searching for previous medical record and patient
reception are covered under this topic.

2.2 Learning Objectives

On completion of this topic, the learner should be able to:

• Perform patient reception
• Register patient/ client
• Identify previous medical record in a facility
• Prepare new medical record with standard formats
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2.3 Patient/Client Reception and Identification

Identification information is an important part of a patient's medical record and it should

include enough information to uniquely identify an individual patient. Some health
facilities will ask to view and/or copy the patient’s identification card in order to verify
this data. The patient identification data that is collected during the patient registration
process is used to populate the Master Patient Index (MPI), which will be discussed later
in this topic. The patient identification data may be entered into a computerized database,
or manually typed onto the outer front page of the medical record folder.

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

• The full legal name of the patient, including the first name, middle name and
grandfather name and prefixes (e.g., Doctor) if any. It is also important to
collect the patient’s alias, previous name, or middle name, as the patient may
have been seen at the facility under another name.
• Internal identification number or hospital registration number. This is the
number used to identify and file a health record, also called the patient’s
medical record number. (This number may be assigned at the patient’s first
encounter at a health facility)
• Date of birth (DD/MM/YYYY), gender, marital status, address and phone
numbers.
• Name, address and telephone number of nearest relative (next of kin) or friend.
• Date of registration (DD/MM/YYYY)

The above information should be obtained from the patient, if possible, or otherwise from
the person accompanying the patient to the hospital or primary health care unit. Care
must be taken to ensure the correct spelling, complete and accurate recording of the
identification information.
Patients should be asked how they spell their names (first name, middle and last names)
as names that sound alike may be spelled quite differently. Names should be recorded in
the manner used for all official documents of the regional state or country.
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2.4 Record Identification Systems

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

a. Alphabetic Identification

The simplest form of record identification is alphabetic, using the patient’s name to
identify and file the patient’s medical record. And because only the patient’s name is
used to identify the record, it is also the easiest method of record retrieval, as the master
patient index (MPI) is not needed to cross-reference the patient’s name to the medical
record number.

This type of record identification system is most practical in smaller health care facilities
with stable patient populations. Larger patient populations would result in multiple
patients with the same name, leading to possible mix-ups of patient files. The other
concern with this type of record identification method is confidentiality of patient
information as patient’s identity (name) is not protected. This method is used to identify
MPI cards for cross reference in health facilities MRUs of Ethiopia. However, this type
of medical record identification system is not practiced in Ethiopia to identify medical
records (folders).

b. Numerical Identification

A numerical record identification system requires that a unique health record number be
assigned. It requires the use of MPI to cross-reference the patient’s name with his or her
health record number. The country’s medical record identification system uses such
numerical system for medical record identification.
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Previous/old Medical Record Identification in Health Facility

There are some typical conditions that need different approaches to identify the patient
medical records. Let see some of the scenarios.

• Patient with medical records in a heath facility with previous visit and has the slip
card: In a well-coordinated MRU, locating records of visiting patients may not
take longer time. The responsible clerk should collect the slip card of the patient
and locate the records using the medical record number.

• Patient with medical record in a heath facility with previous visit but lost the
slip/service identification card: the clerk should try to get as much identification
information as possible from the patient and locate the medical record using the
master patient index.

• Patient with duplicate medical record number or records: If a patient is found to

have more than one medical record numbers and subsequently two medical
records, the duplicated number should be canceled and the medical records should
be combined under the first number. A cross reference must be made linking the
duplicated numbers on the master patient index cards and neither of the numbers
is canceled.

2.5 Registering Patient

The complete and accurate collection of patient identification information is an important

part of the patient registration process. For statistical purposes such as the hospital’s or
health centres daily patient flow, a method for counting all outpatient encounters and
hospital admissions each day is essential.
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Patient registration procedure:

• When a patient presents at a hospital or Health centre for the first time, they
should be registered as a new patient. However, to make sure that the patient is,
in fact, a new patient they should be asked if they have been to the hospital or the
health centre previously. Even if they say no, you should still check it in the
facility’s computerized patient database or the manual master patient index card
in the MPI box depending upon the level of computerization at the facility. This
step is necessary to ensure that duplicate medical records are not created.

• If the patient does not have an entry in the MPI or a medical record number, the
identifying information is collected and a new MPI card will be issued.

• If the patient has an existing file with the MPI card, the current registration
information (personal identifying information) should be checked with previous
data and changes will be noted or updated.

2.6 New Medical Records Preparation with Standardized Forms

If the patient has no health record in a healthcare institution previously, the next number
in the number register should be allocated. Once a patient has been identified and the
next unused number (MRN) in the number register has been given to that patient, this
number is how the patient and his/her medical record will be identified for all visits and
services. This number should belong to the patient for the rest of his/her life, and should
not be given to another patient.

According to the patient’s or client’s types of service need, additional individual medical
forms ( mentioned earlier in the first topic) will be prepared and put inside the folder and
a runner will take the medical record folder and the forms to the respective service unit.
 Managing Medical Records Learner Module

Self-Check Assessment

Activity: 1

         What are the different methods of record identification systems are used in health
record practice?

_______________________________________________________

_______________________________________________________

Activity: 2

How do you manage a Patient with two or more medical record numbers or records?

Activity: 3

Which of the following systems is the simplest way of record identification?

a. Alphabetic Identification

b. Numerical Identification

Activity: 4
Registration process may vary depending on the type of visits
a. True

b. False
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Activity: 5
Mr. Mekonnen Belay is a 34 yrs patient from Harrari region who came to Addis Ababa to
be seen at Black lion hospital as a case of Liver Cancer. He was seen initially at Hiwot
Fana hospital in Harrar and his medical records were documented and kept in the MRU
of the hospital before he was referred to Addis. Answer the following questions based on
this case scenario.

a. Who should receive this patient first in Black line hospital?

____________________________________________________
b. With what document the patient has to come to get service at the referral
hospital?
___________________________________________________
c. How you register the patient in Black lion hospital? New or repeat?
___________________________________________________

d. Do you issue a new Medical record number at Black lion Hospital? If yes
why? 
___________________________________________________________
_______________________________________________________
___________________________________________________________

Activity: 6

Wr/o Aster Belda, resident of Jimma city, is a seven month pregnant lady. However, she
has never visited Jimma referral hospital for any service before. Today, she decided to
visit the hospital for her health problems developed recently. Assume that you are the one
who is in charge of registering this patient at the Medical record unit of the hospital.

a. List down the steps that you should follow to register this patient

b. What sort of recording tools you are going to use to complete registering this
client?

_______________________________________________________
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c. During the registration process, you found out that she is also interested to have
her First antenatal care visit in the hospital. List down the medical recording tools
you will consider when you prepare new medical record for her.
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Topic 3: Medical Record Indexing, Retrieval and Tracing

Procedures

3.1 Introduction

This topic will introduce the concepts, procedures and tools for indexing, retrieving
and tracing medical records. The purpose, the procedures and the tools of each work
procedure are included in this topic with enough detail. Activities relevant to each
procedure are also part of this topic.

3.2 Learning Objectives

Upon completion of this topic you should be able to:

• Identify indexing and MPI filling tools

• Apply Indexing procedure
• Understand how and why records are retrieved
• Retrieve medical record
• Understand the purpose of tracer cards and record requests
• Perform tracing medical records
• Describe the various appointment systems: computerized and manual
• Understand and use a chart tracking system
• Perform a chart audit to identify any misfiled records
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3.3 Indexing

The Master Patient Index (MPI) is a permanent listing containing the names of all
patients who have ever visited a hospital or Health Centre (also called Patients' Index or
Master File).

In health care, a master patient index is maintained to link patient demographic

information and the medical record number to the medical records of the patient
(commonly known as medical record folder), and hence allow fast and easy retrieval of
patient’s medical record when Service Identification (SID) card is lost or when the record
is needed for some other purposes. Thus, the retrieved medical records can be used for
data collection, patient care management, quality of patient care, and the study of
diseases and their outcomes.

Because the Master Patient Index is the key to locating a patient's health record, it is
considered to be one of the most important tools maintained in the medical record units
of health facilities. Since health records are filed numerically in most healthcare facilities,
the MPI is used to identify a patient’s health record number and locate the corresponding
medical record easily when needed.

Typically, a manual MPI is maintained using individual index cards for each patient that
are filed alphabetically. In a manual MPI, each patient who is registered in the facility
has an index card that is maintained in the health record unit. However, an increasing
number of health facilities are maintaining computerized Master Patient Indexes and this
is described in detail under topic seven of this learner’s module.

A computerized MPI is maintained using specialized database software. Reference to the

computerized MPI will be made in this topic, when applicable. The basic principles are
the same, whether the data collection is done manually or by computer
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Indexing Mechanisms

All new patients should have MPI cards filled with their identifying information and a
medical record number on arrival to the MRU. Some of the identifying information from
the MPI card may also be written on the medical record folder as described earlier.

In order to minimize errors, the MPI should be completed by the same person who
recorded the information on the folder. MPI cards should be filed in a card drawer of MPI
box in strict alphabetical order.

Each drawer should contain guides, which are empty cards with a tab protruding above
the other MPI cards. The guides are used to show subsections of alphabets with a drawer
that contains the MPI cards. There are situations where the patient might come sometime
with changed identification, for instance the name/fathers name is changed. In such cases,
the medical record unit should apply cross-referencing the new MPI Card with the
previous one.

Cross-Referencing

Cross-Referencing is the method of linking one MPI card with another. This is usually
done in cases in which the patient has changed their name, or when there are two medical
record numbers (and two medical record folders) for one patient. In cases of name
change, the new MPI card should possess the same information as the previous card
except that the name is changed. One has to make sure that the medical record number
remains the same.

In cases of duplicate medical record numbers, one number should be chosen and a note
made on the other MPI card referring searchers to the chosen number. The medical
records contained in the folders should be combined. In both cases, the MPI cards (either
with an old name or an old medical record number) should not be discarded.
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Indexing Tools

MPI Card and MPI box are most important indexing tools in the medical record units.
Index guide can also be used to chunk the index cards in a cabinet for quick retrieval.
These days some of the health facilities are using computerized master patient indexing
tool.

MPI Card

The information on the MPI card should at least include (see figure 3.1):
1. Facility identifier
2. Medical record number
3. Registration date
4. The client’s full name
5. Date of birth (age is not recorded on the card because it changes)
6. Gender
7. The patient’s full address

Figure 3.1 Master patient index card

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Medical Record Number

Each patient or client who is offered health care service at any health facility in Ethiopia
should have a unique identification number called the medical record number (MRN).
This number is then used in all visits to identify that patient and his/her medical record.
MRN links the patient with their integrated medical record, and all the components of the
medical record with one another. The MRN is unique for each patient in order that
patients are not to mistaken for one another.

Using a MRN also enables you to:

• Find a patient’s medical record whenever he/she come to the health care
facility easily
• Link patient’s previous admission or outpatient attendance to the current visit
using his or her medical record number
• Find the correct medical record of a patient when there is more than one
patient with the same name

Assigning MRN

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

MPI box: Patients' index cards may be filed in cabinets suitable to the card's size. MPI
box is used to file MPI cards in Ethiopia. The box and cabinet/card drawer’s size
specifications are mentioned in the previous topic.
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Organization of the MPI

The most popular and efficient method of maintaining the MPI is on index cards arranged
alphabetically in a vertical file with a separate card for each patient.

Using this method a single index card can be located readily in one search. If using a
book, it is divided into alphabetical sections. It is not recommended to maintain the
master patient index by year of encounter as patients often forget the date of their last
visit if they were ever registered to a particular hospital at all.

Method used for filing MPI card

Alphabetical: The MPI cards are arranged in the file like the words in a dictionary,
following letter by letter of the first name. If there are two or more patients with the same
first name, index cards should be filed alphabetically by the letter order of the father’s
name.

General filing rules for a Master Patient Index

• Filing MPI cards should be based on rules. It is not easy to locate medical records
if you cannot locate the correct MPI card. Filing rules should be posted near the
patients' master index box for easy reference.
• Filing and use of the MPI cards should be by authorized personnel only. Careful
orientation of new employees to the proper MPI filing procedure is necessary.
• The MPI should be a continuous file in terms of time that is to say it is not divided
into years.
• A patient whose name has changed since a previous registration will need a new
index card. The new index card should be cross-referenced to the original index
card. All information recorded on the original card should be entered on the new
card.

Whether the MPI is computerized or manual will determine the amount of data that will
be maintained as space is a limitation for the manual. In a manual system, only
information of an identifying nature necessary for prompt location of a particular medical
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record should be recorded on the patient’s MPI card. A computerized MPI will allow the
facility to maintain additional information such as patient’s visit type and contact
information.

3.4 Retrieving Medical Records

Medical records are primarily stored in the medical record unit on the shelves using
appropriate filing system. A medical record can be retrieved or temporarily removed
from its location for various purposes such sending medical records to service units for
care, research or medical audit.

Medical Record Retrieval Procedure

It is very important that standard procedures are followed while searching for and
retrieving medical records. Procedures help to facilitate the prompt, uniform, and
efficient retrieval of health records. It also ensures that patient’s information
confidentiality is maintained and retrieval is performed only by authorized persons.

Assuming patients come with their slip card, the medical record unit worker should
follow the following steps to retrieve the medical record.

• Ask the patient for slip card or his / her full name if the slip card is lost
• Access the patient’s identification information from the MPI and identify the
medical record number or use the SID to identify the MRN for those who are with
their slip card
• Locate the medical record using the Medical record number
• Remove the medical record from the shelf
• Replace the medical record with a tracer card and make ready the medical record
for the purpose it is retrieved

Every facility should have a process in place for after-hours retrieval of records in case of
an emergency. Since evening and night shift staff may not be available in some health
facilities, alternate arrangements may be required for duty staff to be able to access
Managing Medical Records Learner Module

medical records. These staff should also be trained in retrieval, the sign-out process, and
other relevant procedures.

One way of managing patient flow in a health center or hospital, is to maintain an

appointment list of patients who are returning for visits on certain days. Each area that
sees patients should record on an appointment list or in the patient record when the
patient is scheduled to return to the clinic for treatment. The medical record clerks can
then retrieve the records in advance of the patient appointment and route the records to
the correct area for the patient’s visit.

Recording tools used for Medical record retrieval

Under topic one of this learner’s module we have seen those common medical recording
tools used in the medical record unit of a health facility. Among these, the tools that we
discussed further here are important for retrieval of medical records.

a. Service Identification Card

This tool is used to identify an individual patient registered at health facility. A service
identification (SID) card should be issued to each new patient registered for outpatient or
inpatient services. Most importantly, it links the patient to their medical record number.

Content

A service ID card is a small pocket-sized (1/8 A4 size) card used as an identification card
for individual patient. The contents of the patient service card are:

1. Name of the facility

2. Date of registration
3. Medical record number
4. Name of client, age, sex
5. Client address
Managing Medical Records Learner Module

Figure3.2 Service identification card

b. Appointment Card

The appointment card is used to remind patients of their next appointment at the health
facility. It is similar in size to the service ID card. The front side contains identifying
information, and the reverse includes space for 9 appointments. Service providers should
complete the date and service for future appointments as needed.

                         

Figure 3.3 Appointment Card

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c. MPI for Medical Record Retrieval

The master patient index (MPI) is prepared by responsible medical record unit staff in
the MRU and is the key to locating the medical record. In paper based systems, it is a
card index. It can also be computerized to facilitate and enable fast searching. When
the retrieval of a medical record is for providing health service purpose, the data clerk
should ask the patient/client about her/his identification information as much as
possible ; using the MPI identify, the clerk can identify the medical record number
and retrieve the medical record folder. The detail on the contents and the rules for
using MPI card are elaborated in the previous sub topic.

Figure3.4. A clerk while retrieving medical records

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3.5 Tracing Medical Records

A tracer card (or out- guides) replaces a medical record that is removed from the shelf
for any purpose. They should be made of strong material; preferably different colour
from medical record folder and it can be as simple as a blank piece of A4 card where the
information is recorded. There are various types of tracers available. However, all do
the same job. They indicate where the record is when not on shelf.

When the medical record is returned to the MRU, the tracer card is then placed inside
the medical record folder. Using the tracer makes it easier to find a medical record
when it is not on file. Regardless of what size the card is, the destination of the
medical record should always be written on the tracer card and crossed out when the
medical record returns.

If the patient has more than one appointment, this should be noted on the Tracer Card
and the treatment areas should be sure to forward the medical record to other areas for
the doctors or nurses to use it while seeing the patient.

Tracing Tool

Commonly utilized tracing tool in health facilities is Tracer Card. This card is A4 paper
and kept in the medical record folder when the medical record folder is filed in the
medical record unit. It then will replace the folder when the folder is removed for
different purposes. The tracer card should contain the following information:
• Patient name
• Patient medical record number
• Location where the integrated medical record folder was sent
• Date the record was sent/removed from the file
• Receivers signature
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Figure 3.5 HMIS tracer card

Tracing Mechanism

In healthcare facilities, Different tracing mechanisms are applied to locate where the
medical record is after it is removed from the shelf. The following steps explain the
procedure by which tracing of medical records is performed in the medical record unit of
a health facility.
• Tracer card is prepared and assigned with a medical record folder during
first visit/ registration of a patient or client in a health facility
• When a folder is to be sent for service, the tracer card will be filled with
the following information:
Managing Medical Records Learner Module

o The patient name, MRN, where the medical record is sent

(department and responsible healthcare provider) and the date that
the medical record is removed from the file
• The tracer card will be placed on the shelf by replacing the medical record
folder when it is distributed out of shelf for the service.
• The tracer card should be signed by the receiving unit.
• When the folder returns to the MRU, the tracer card should be placed
inside the folder and be re-shelved along with the folder (see figure 3.6)

Figure 3.6 tracer cards replacing medical record folders on shelf.

Automated tracking systems

The requesting and tracking of records with the aid of a computer helps to reduce or
eliminate some very routine jobs. An automated chart tracking system is a computerized
database containing all of the information needed to process chart requests.
Managing Medical Records Learner Module

The computer can print requisition slips, sort them, store and provide information on the
record location and keep waiting lists of different requests. For example, if a medical
record of is taken to Dr. Jemal‘s office where he is working (OPD case team1) for the
purpose of providing service for the patient and yet not returned to medical record unit,
the following summary report that contains information on the status of the medical
record (file), location, the one in charge of the medical record and the purpose of the
medical record retrieval) will be generated from the computer system i.e. Incomplete
file, Case Team 1, Dr. Jemal, for Service Whenever the location of the medical record
changes, such as a transfer of the patient from medical ward to surgical ward, the
information must be updated on the computer.

When requests are processed through a computerized medical record tracking system, the
computer can produce a list of all medical records that are not yet returned to the medical
record unit.

The main purpose of this kind of automation is to reduce the delivery time from request
entry to record receipt, and to speed up the sign in and sign out process. A number of
record tracking systems utilize bar codes on the folders and bar code scanners to even
more fully automate this process.
Managing Medical Records Learner Module

Self-Check Assessment

Activity: 1

Write down the main purpose of having a Master Patient Index card to the medical
record unit? And what are its contents?

Activity: 2

Which of the following recording tools is used for indexing?

a. Patient form
b. Service identification card
c. Master patient index card
d. Appointment card

Activity: 3

A 10 years old patient called Mustafa Mohamed came to your hospital with his father for
outpatient service for the first time. He is living in a town where the hospital is located.
The MRU clerk asked you to complete registering Mustafa as he has something to do
urgently.

a. How do you prepare a master patient index card for Mustafa? Describe each
step.

b. File Mustafa’s MPI in the MPI box. Describe the steps

_________________________________________________
Managing Medical Records Learner Module

Activity: 4

Write the possible reasons for retrieval of medical records of a patient form the medical
record unit.

__________________________________________________________________

Activity: 5

List down the steps and the recording tools used to retrieve patient’s medical record from
the shelf

________________________________________________________________________
________________________________________________________________________

Activity: 6

Kebede is a chronic case of bronchial asthma who frequently visits your hospital where
you are working for. Since he started to have new symptoms, he came to the hospital to
be seen at outpatient department. However, he didn’t bring the service identification card
with him.
Write the steps you need to perform in order to retrieve Mr Kebede’s previous medical
record.

___________________________________________________________________
Managing Medical Records Learner Module

Activity: 7

Describe the purpose, mechanism and tools used for tracing medical records.

________________________________________________________________________
Managing Medical Records Learner Module

Topic 4: Collecting and Filing Medical Records

4.1 Introduction

This topic contains information on how patient’s medical record is collected from
different service units of a health facility to medical record unit and filing systems that
applied to store medical records in MRU in a way that locating and retrieving are easy
and systematic.

This topic also provide you information on the advantages and disadvantages of various
types of filing systems, with the various methods to identify and file paper-based medical
records, and comparison of manual versus computerized systems for numbering.

The record identification and filing systems form the first step in a series of procedures in
the management of medical record keeping services. A medical record has no value if it
cannot be found once it is stored somewhere in the file area. Careful planning of the
record identification and filing systems to be used is of great importance. The choice of
the system, however, also depends on the specific type and circumstances of the health
care facility for which it is selected. Planning of filing activities should also include a
policy on record retention. Storage space is generally a scarce resource that needs to be
used efficiently in the healthcare facilities.

4.2 Learning Objectives

Upon the completion of this topic, you should be able to:

• Identify and apply principles of collecting medical records

• Monitoring medical record completeness
• Identify different ways of filling medical/health records
• File patient records in a numeric system on shelves
Managing Medical Records Learner Module

• Identify the best option for filing records in a facility

• Locate and/or prevent records from being misfiled
• Explain the advantages and disadvantages of terminal digit filing
• Monitoring medical record filing procedures
• Explain the storage options for health records with advantages and
disadvantages.
Managing Medical Records Learner Module

4.3 Principles and procedure of returning medical records from service

Units

All medical records should be sent to the medical record unit by the clinic/ ward staff at
the end of the day through the runners. In some cases, a staff member from the medical
record unit collects the medical records from the outpatient department and wards at a
specific time every day. You should note that medical records collected from the wards
are upon the discharge of patients. It is a recommended practice to list and send the
summary of discharge and dead patients to the medical record unit on daily return of the
medical records.

A clerk in the medical record unit checks each medical record to ensure that all the forms
are in the medical record folder. For example, if the patient has had an operation report
should be in the record. In addition all progress notes, pathology and x-ray forms, nursing
notes etc. should be included. There should also be a final discharge note made by the
attending doctor including to where the patient has been discharged and arrangements for
follow-up for patients who need subsequent visits to the hospital/health center.

The clerk then sorts the forms in to the correct order (if they are not already correctly
sorted and it actually depends on the health facility’s way of practice in organizing
medical records: see the discussion made in topic 1). In case of a new patient, the forms
are attached into medical record folder with a clip or fastener. If the patient has been in
the healthcare facility before, then any old records are retrieved and the latest forms are
added by placing them behind the appropriate divider or in chronological order in case of
integrated medical record organizing method.

The clerk also needs to check if the doctor or healthcare provider has completed the
lower part of the front sheet of admission/discharge form. This should include the HMIS
diagnosis along with any other condition or treatment while in the facility. The signature
of the healthcare provider is important as it shows that the doctor/care provider has
completed the medical record and takes responsibility for the content.
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For records that may be used again, damaged file covers (folder) should be replaced
before filing. If the damaged folder has been used to record unique information it must be
copied or placed inside the new folder. No medical record should be replaced unless the
correct tracer card is in its position on the shelf to avoid possible misfiling.

4.4 Handling Collected Medical Records

Even in a hospital where there is better medical record handling and security system in
place, medical records can be lost, destroyed, or stolen for various reasons. To minimize
such harm, a system should be in place and enforced. One of the most physical security
measures that must be in place is a record sign-out and sign –in system for all types of
medical records. This process should identify when a record has been removed, who took
the record, and where it is located. Clerks should monitor the sign- out process and assure
that records are returned promptly.

Once in a month the medical record room should be checked for:

a. All records are standing straight on the shelves
b. There is no dust on the shelves
c. The floor is clean

4.5 Monitoring Medical Record Completeness

The medical personnel in the facility rely on the medical records personnel (Health
information technicians) to analyse medical documentation and notify them of omissions,
inconsistencies or missing information that is reflected on the patient record. In addition,
it is the permanent and legal document of the information that identifies the patient and
their medical history. Therefore, it is important to make sure that all of the documentation
in the record is complete and accurate. Each time a patient visits a facility, the
documentation from that visit should be reviewed for completeness and accuracy before
returning the record to its place on the shelf.
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The supervisor/head of the medical record unit and a representative from the medical
staff of each service unit of a health facility should determine the procedure to be
followed to notify doctors and nurses that they must complete a patient medical record.

Most often, the recommended process is that the medical record unit personnel identify a
specific area of the file room where medical records are filed in numerical order that are
marked as “Incomplete Records” or “To Be Completed.” The medical records should be
kept in this area and monitored regularly until the doctor or health officer or other
relevant personnel visit the unit and correct the deficiencies. Then the record can be
returned to the file.

In order for the doctor or nurse to understand what is missing or incomplete, a form can
be devised and attached to the front of the folder that identifies the responsible party and
the deficiency observed. For example:

Responsible Item for Date Assigned/Completed

Person Completion

Sr. Almaz Discharge 12/20/00

summary

The name and MRN of the patient does not need to be on this form since this form would
be attached to the patient’s medical record. Despite its considerable benefits and easy
applicability, such practice is not seen the medical record units of most of the health
facilities in Ethiopia.
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4.6 Filing System

So far under this topic we have seen the how to collect medical records from service units
and the monitoring of records for completeness. Now, let us see the filing systems and
procedures used to store medical record for easy and quick retrieval.

In many developing countries, where medical records tend to be a health record from
birth to death, a lot of space will be required to store medical records. There are some key
points you need to remember when you work to have efficient filing system in your
health facility.

Filing Shelves

The basic requirements of medical record unit are discussed in the first topic. Here, some
of very important points that should be considered during shelving of your medical
record unit to facilitate filing procedure are listed.

• Filing shelves should be used, NOT filing cabinets

• Wood filing shelves are preferable and can be built by the local carpenter based
on the standards (specifications)
• Metal filing shelves are also very good, except in damp areas because of rust
problems
• If possible, compact filing shelves should NOT be used to file active medical
records, but can be used in the secondary (inactive) file room. An active medical
record is one that is still being actively used for patient care. An inactive medical
record is the one that belongs to a patient that has not attended the hospital for a
specific number of years (5-7 years in the Ethiopian case).
• Enough space should be left between the filing shelves to allow space for a person
to walk between the shelves to file and retrieve records. The general standard is
90cm.
• Filing shelves should be no higher than the average person can reach (HMIS
standard is 2.75 meter for shelf height) and steps should be made available for
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access to the top shelf. Filing medical records at the bottom of a shelf is not
recommended. The bottom of a shelf tends to attract more dust. Also, some
people find it hard to file and retrieve records accurately from the bottom of a
shelf.
• Medical record folders and the filing shelves should be designed to enable the
records to be filed lying on their spines so that the MRN is clearly visible for ease
of retrieval and filing.
• Each filing shelf should be labeled with the range of numbers of medical records
filed on that particular shelf. Number guides should be placed at regular intervals.

Lighting

Before setting up the filing shelves, check the position of the lights. It is best to use long
fluorescent lights which run in between filing shelves giving light into each section.

Security

There should be procedures to protect medical records from fire, water damage, rodent
damage, and unauthorized access. In addition, the following preventive security measures
should be in place.

a. The file room should have a lock on all doors.

b. Access should be restricted to the medical record unit staffs and to clinical
staff out of hours (during the duty hours).
c. There should be one open entrance to the medical record file room and a fire
exit.
d. There should be a strict no smoking policy in the file room.
e. There should be regular pest/rodent control in the file room.

Location of file

File location in a health facility can be centralized (this is supported by one of the
principle of HMIS i.e. principles of integration)) or decentralized.
Managing Medical Records Learner Module

a. Centralized: The medical records of the patients are filed in one location, which is
the health record unit. The patient may have visited different service units (inpatient
, emergency , outpatient etc…), but all the information from each service unit
brought together in one medical record folder and filed under the same and medical
record number in the same place.

In a centralized unit record system, centralization refers to filing a patient's: inpatient,

outpatient and emergency records in one location. For good control of medical
records, all medical information about a patient should be stored in one folder and
location or file. This makes access of health information of a patient quick and easy
because it is filed in one place using single number that is unique in the health
facility.

This type of practice can be facilitated by the use of electronic health records in order
to share patient information. Health facilities and higher health institutions,
concerned with an expanding volume of medical information, are developing
systems, designed to link all health records belonging to one patient that are
physically located in different buildings or hospitals, within a city, state or province
or across a country.

Figure 4.1 a data clerk filing medical record folders on the shelf at St. Lalibela Health centre
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b. Decentralized

The records of the patient are filed in multiple patient care areas. This may be under the
same unit number (linkage) or with totally unrelated numbers (no linkage). Such way of
locating patients medical records in a health facility, doesn’t bring the patient’s all health
information in a single medical record folder and hence it is difficult for the health care
provider to get complete past medical information of the patient that may help him or her
to approach the current health problems. In principle as well as in practice HMIS doesn’t
support the decentralized way of locating medical records at various service units. This is
because in decentralized record keeping, in addition to what has been mentioned earlier,
the quality control for medical record is more difficult; record keeping demands more
time and cost; and there would be duplication of efforts.

Advantages of centralized record keeping

Centralization has some significant advantages over decentralization. Some of these are:
• All information concerning a patient's care is stored in one place and open to all
medical care providers.
• There is less duplication of information.
• Costs for creation and storage of records (space, equipment) are lower.
• Record control is easier.
• Implementation of overall administrative record procedures is possible.
• Standardized job descriptions and supervision of specifically trained personnel
result in greater efficiency.

When the hospital is a large complex of different buildings or health service units, some
degree of decentralization might be necessary for reason of medical record availability
and accessibility. In a large hospital there may be multiple and simultaneous requests for
the same record. In those limited circumstances, centralization and unit records can
cause problems of access. When hospitals implement electronic health records, the issues
surrounding paper-based records, such as filing and availability (simultaneous and
multiple access to the same record), are no longer of concern.
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Medical Record identification Methods

It is important that each record has a unique identifier, either alphabetic or numeric. The
alphabetic record identification method has been discussed in the previous topic. Here,
we will see the numeric system of medical record identification with some detail.

Numerical Identification

A numerical record identification system requires a unique medical record number to be

assigned. It also requires the use of MPI to cross-reference the patient’s name with his or
her medical record number (MRN).

There are two main systems of numbering patient records:

• Serial numbering
• Unit numbering

a. Serial numbering

With serial numbering method, the patient receives a new medical record number on
every visit to the hospital or primary healthcare unit. This implies that a patient is treated
as a new patient each time with a new number, new index card and new record, filed
totally independently from previous medical records.

Serial numbering is not used extensively today and is only useful in small hospitals with
a low rate of patient flow. This method is not applicable in the Ethiopian healthcare
facilities.

b. Unit numbering

In this case, the patient is assigned a unique identification number on his first contact
with a health facility, whether it is for an emergency services or outpatient clinic visit.
The same medical record number is kept and used on all subsequent visits. A unit
Managing Medical Records Learner Module

medical record number results in the creation of one, central or integrated medical record
for the patient. In our case, this unit numbering system assigns five or six digit number to
a patient as MRN (medical record number) in health centres and hospitals respectively.

Advantages of using a unit number (MRN) are:

• The number is unique to the individual patient and therefore distinguishes him/her
from any other patient in the hospital or Health Centre
• The number does not change regardless of how often a person visits hospital or
health centre
• Patients' health records are centralized in a single folder
• Health records are filed in one place

Disadvantages of using a unit number are:

• Health records may become quite thick and additional folders may be required
• More Space may need to be allocated to allow for the expansion as more new
visits added to the shelves.

N.B It is the unit numbering methods that is used widely to file medical records in the
Ethiopian setup (health facilities).

4.7 Types of Filing Systems

There are three basic types of filing systems which are frequently used in the medical
record unit. These are sequential, alphanumeric and Terminal Digit filing systems.

a. Sequential (straight numerical) filing

Medical records are assigned a sequential number in chronological sequence. If the last
number to be assigned was 000500, the number issued to the next patient would be
000501. This method is simple, easy to assign, and easy to control. As it is described
Managing Medical Records Learner Module

previously the MRN issued in health facilities are either six or five digit sequential
numbers depending on the type of health facility.

b. Alphanumeric numbering/filing system

This type of numbering is a combination of letters and figures. See the example given
below.

E.g. AA6699 instead of 666699

This method has the advantage of a greater capacity with the same number of characters,
for example, letters: A-Z (26); figures: 0 to 9 (10). However, this method is not
extensively used.

c. Terminal digit filing system

In this method, numbers are allocated in the same way as for straight numeric filing. The
difference is how they are filed. A six-digit number is generally used and divided into
three parts e.g., the number 102030 is divided as 10-20-30 with each part containing two
numbers. The last two numbers on the right-hand side (30) are called the primary digits
(that is, the first two digits considered when filing). The middle two digits (20) are called
the secondary digits (the second set of digits to be considered when filing). The two digits
on the left-hand (10) are the tertiary digits (the third and last set of digits to be considered
when filing).

10: Tertiary
20: Secondary
30: Primary

• With this method, the filing area can be divided into 100 sections for the primary
digits 00 - 99. This then allows the filing to be distributed among a number of
medical record unit staff.
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• Within each primary section, medical records are grouped by the secondary digits
and, again, this ranges from 00 - 99.
• Within each secondary section, medical records are grouped by the tertiary digits
and, again, this ranges from 00 - 99.

To file a medical record, after locating the primary and then the secondary section, the
MRU staff files the medical record by its tertiary digits. For example, to file the number
10-20-30, the “30” primary section needs to be located followed by the “20” secondary
section. The record 10-20-30 is then filed before 11-20-30 and after 09-20-30.

Some hospitals also use a color code on the folder to assist with identifying the medical
record quickly and to improve the efficiency of the filing clerks. The Terminal digit filing
is not recommended in Health facilities where the number of medical records is small and
data clerks are not trained in its implementation and use.

4.8 Filing procedure

The data clerk in the medical record unit should follow the following steps to file those
medical records returned to the medical record unit.

• A medical record unit should have a set of shelves for medical records waiting to
be filed.
• Medical records that are returned to the MRU should be “sorted” in a manner
which will enable them to be found, if required, while waiting to be filed.
• The Shelves should be numbered in sections of 200s-300s and the records
placed on the correct numbered shelf. This makes easier both filing and
retrieval.
• At the end of every day, there should be no medical record waiting for filing i.e.
all the medical records should be completed, returned and filed.
• When filing medical records, torn or damaged folders should be replaced and
any loose forms should be secured.
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Other filing rules

• Only medical record unit personnel should be authorised to file and retrieve health
records.
• Records with torn covers or loose pages should be repaired before filing.
• A Staff assigned for medical record filing should be responsible for keeping the
shelves neat and orderly.
• Staff should be trained to maintain control over the files and see that medical
records are filed properly.

4.9 Monitor medical record filing procedures

As it is discussed earlier, filing is a method of storing medical records in a systematic

manner. The type of system selected is based on facility specific factors such as:
• Volume of filing, admissions, discharges, requests for records
• Filing space
• Storage type (open shelf filing vs. filing cabinets)
• Security concerns
• Predicted number of patients that could come to get service in the healthcare
institution

Medical records which are too big to file should be separated into two or more Volumes
and clearly marked as VOL. 1, VOL 2, etc. and filed together in the correct place.
Regular checks should be in place to check the file for missing medical records or
medical records filed in the wrong place.

To check for a misplaced file the MRU staff should:

• Check the medical record just before and just after the one needed
• Check the shelf immediately above/below where the record should be filed.
• Check the shelf immediately above/below where the record should be filed.
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Self-Check Assessment

Activity: 1
Describe how medical records are collected back to the medical record unit for filing?

Activity: 2

Which of the following is not an activity that a clerk has to check for once in a month?

a. All records are standing straight on the shelves

b. There is no dust on the shelves
c. The floor is clean
d. All the above activities have to be checked for on monthly bases.

Activity: 3

Each time a patient visits a facility, the documentation from that visit should be reviewed
for completeness and accuracy before returning the record to its place on the shelf.

a. True
b. False

Activity: 4

What is Medical Record filing? Describe the procedure and rules for medical record
filing.
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Activity: 5

Read the following case and try to identify the wrong considerations while shelving a
medical record unit and suggest the correct requirements.

Mr. Mesiker is HIT of Awash National hospital in Afar region. The hospital built new
medical record unit per the HMIS standard and the responsibility of furnishing the MRU
was given to Mr. Mesiker. Mr. Mesiker bought six metallic filing shelves even though
there are two carpenters who can provide him with wood shelves with cheaper cost. The
heights of the shelves were 2.85 meters which are above the average height of a person
can reach. When he arranges the shelves, the space left between each of them was 30cm.
He filed the medical records without labeling them because he thought that labeling may
make the shelves less attractive.

Activity: 6
To protect medical records from fire, water damage, rodent damage, and unauthorized
access, which of the following should be done?

a. Access should be restricted to the medical record clerks/officers and to clinical staff
out of hours.
b. There should be a strict no smoking policy in the file room.
c. There should be fire equipment and written procedures on what to do in case of fire
in the file room.
d. There should be regular pest/rodent control in the file room.
e. All are the correct measures.
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Activity: 7

Write the difference between Centralized (integrated) and decentralized file or medical
record location. List down the advantages of integrated medical record (centralized
location).

_________________________________________________________

Activity: 8
Write the two most common way of medical record identification.

___________________________________________________________

Activity: 9

Write the advantages and disadvantages of unit numbering (assigning unique identifier
like MRN)

Activity: 10

Among the three filing system, sequential or straight numbering filing system is the one
implemented in the health facilities of the country (a file system that uses the medical
record number to file medical records). Compare this filing system with the terminal digit
filing i.e. write advantages and disadvantages for each.

__________________________________________________________________
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Activity: 11

The medical record number assigned to a patient at heath center is six digits i.e.
XXXXXX.

a. True
b. False

Explain your answer

________________________________________________________________
________________________________________________________________________

Activity: 12

Write the characteristics of good unique identifiers (MRN)

Activity: 13

Write the steps to check for misfiled medical record

Activity: 14

Wr/o Mulu is chronic diabetic patient who visits your hospital frequently. Her medical
record (file) becomes too big to file in one folder. What are the steps you should follow to
manage her medical record?
Managing Medical Records Learner Module

Activity: 15

Assume you are working at Menilik II hospital and assigned in the medical record unit to
file the medical records. Write the steps you should follow to file those medical records
returned to the medical record unit at the end of each working day.
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Topic 5: Privacy, Confidentiality of Patient Information and Medical

Record Transferring

5.1 Introduction

Medical records contain valuable patient information generated during interaction

between patient and health care providers in a health facility. Such information to be
captured and recorded on the integrated medical record, the medical record should be
transported or transferred to and from service units of the health facility including the
medical record unit where it is permanently located. During such transportation, filing
and retrieval of the medical records, the privacy and confidentiality of patient or client
information has to be maintained, and such responsibilities are heavily depend on the
medical record unit workers. Therefore, this topic will discuss the principles of medical
record transportation and issues related to privacy and confidentiality to patient /client
medical records

5.2 Learning Objectives

Upon the completion of this topic you should able to:

• List basic responsibilities of data clerk working in the medical record unit
• Apply basic principles of medical record transportation
• understand confidentiality and privacy of patient/client health information
• Apply principles of privacy and confidentiality of patient health information
Managing Medical Records Learner Module

5.3 Responsibility of Data Clerks

The MRU is often the first point of contact with patients, and is busiest unit almost in
every health care facility. Patient registration and medical record keeping are essential to
the functioning of any health facilities. A well trained, highly motivated MRU staff is
required to maintain an efficient and effective MRU services.

Basic tasks for MRU staff:

• Patients Registration Issuing and maintenance of the master patient index

• Retrieval of medical records for patient care and other authorized use
• Verifying free and credit health care services
• Distributing and delivering medical records to individual service units
• Collecting medical records from individual service units
• Filing medical records
• Seeing that all forms related to the care of a particular patient are in that patient’s
medical record folder
• Ensuring completion of medical records and making them readily available when
required
• Dealing with Medico-legal issues with regard to the release of patient
information

5.4 Transportation of health records

Transportation of records is a very important part of record handling. This can be done
manually or automatically. Messengers (runners) can be employed to carry records to
and from the health record unit (service units), or records can be automatically
transported electronically in a healthcare facility where electronic health recording
system (EHR) is implemented.
Managing Medical Records Learner Module

The messengers may be staff of the health record unit (preferably) or part of a total
hospital messenger service. Frequency of transporting the medical records is dependent
upon the amount of request for medical records of routine and non routine activities.

5.5 Privacy and Confidentiality to Patient /Client Medical Record

Recorded information in a medical record is a privileged communication. A privileged

communication is one that contains certain confidential information given by a patient to
his or her care provider. Unless the patient has given written consent to release
information from his or her medical record, the information contained in it can only be
released to by a court order. Next to this, we will try to define some of terminologies that
might convey new concepts to you.

Confidentiality: This term refers to the restriction of access to personal information to

authorized persons, entities and processes at authorized times and in an authorized
manner. When we say that Patients have the right to confidentiality, it refers to the
process of keeping privileged communication secret and cannot be disclosed without the
patient’s authorization (with exception of information released to court order (will be
discussed in the next topic).

A breach (failure to keep) of confidentiality occurs when patient information is disclosed

(or released) to other(s) who do not have a right to access the information. Patient health
care information is considered confidential and should be released only in accordance
with a health care information disclosure policy developed by federal ministry of health
or regional health bureau. A person, who receives health records from a provider, may
not release a patient’s health records to any person without a signed and dated consent
from the patient or the patient’s legally authorize agent.

Information Privacy: It refers to the right of an individual to exercise appropriate

control over the extent to which personal information about him / her is available to
others.
Managing Medical Records Learner Module

The principles of information privacy:

• The right information

• To the right people
• For the right reason
• In the right way
• At the right time

The information contained in the medical record including the registration information that
the clerks gather from the patient must be confidential, therefore, the clerk should try to
obtain the information in a way that respects the person’s privacy. Patients or clients may
not want others to know where they live, where they are being seen or give out telephone
numbers, etc.

Clerks might also have to interview a family member if the patients themselves are too sick
or unable to provide the necessary information. In that case, you must be very careful to get
all of the information correct as they may not know all of the facts about the patient either.

Figure5.1 Confidentiality and medical records

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5.6 Access to medical records

Health records are the property of the health facility where they were created, and
therefore in public health facility they ultimately form part of the records of the national
health data. However, the information in a patient’s medical record is the intellectual
property of the patient and the health professionals treating him or her.

Therefore, this information without the patient’s consent should not be made available to
anyone except those involved in the care of the patient and in case of court order. The
confidentially of patient records has obvious implications for the security and
accessibility of medical record-keeping system in health facility.

Patients have a right to expect that the information they provide to health professionals is
always treated confidentially. Confidential records must be protected against loss,
damage, unauthorized access, modification or disclosure, and all staff should be required
to sign a written undertaking to observe strict confidentiality.

Clear guidelines should be in place as to which members of health facility staff are
entitled to have access to patient’s potentially sensitive records. In addition, senior staff
should be identified who have the power to authorize the release of clinical information
to persons outside the hospital. Such information should always be conveyed in writing.
The supply of information from medical records to patients themselves, or to their
relatives, may be regulated by law or by federal government directives.

Patient confidentiality should be respected and maintained when medical records are
transferred from the medical record unit to an archive repository. In some countries there
are legislative provisions for the number of years which must pass before patient medical
records can be made accessible to the public.

Only to those involved in care of a patient or in case of court order

that medical records may be released without the patient’s consent. 
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5.7 Procedure for the Release of Medical Information in a Legal Case

The healthcare facility may permit a patient’s lawyer to view the medical records in the
presence of a doctor, upon the written authorization of the patient. In most cases, the
lawyer will send a letter to the health facility requesting specific information from a
patient’s medical record. Lawyers must present this written permission before the health
care facility can release information. The health care facility is not legally bound to
release any information if it affects the healthcare facility or the attending doctor or other
staffs.

The procedure to be followed when handling this request from the lawyer/court:

• Request from lawyer will be registered and date of receipt of request recorded by
the healthcare facility administration and forwarded to a medical records unit
administrator for processing.
• The medical record is located and the patient’s signature checked against the
signature on the consent form in the medical record (if collected earlier).
• In some countries a charge/fee is made for the reproduction of medico-legal
(involving both medicine and law) reports. The amount charged varies from
healthcare facility to healthcare facility and the clerk must be familiar with the
charge in his or her healthcare facility. The information requested is identified and
the attending doctor asked to write a report. In many health care facilities a pre-
designed form may be used. The clerk should notify the healthcare facility
administration that the report has been sent. In most cases the report is all that is
required. If the actual medical record is needed the lawyer must produce a court
order or subpoena to allow the release of the medical record.

Preparing a medical record for court

A subpoena is the term used in most English speaking countries for a legal order to
produce records to a court. It is usually addressed to “the custodian of medical records,”
Managing Medical Records Learner Module

directing that person to appear in court on a specified date and time along with the
medical records of the patient named in the subpoena.

On receipt of a subpoena the clerk should record the date and time the subpoena was
received and records in a diary the date and time the medical record is due in court. The
clerk should then notify the attending doctor and healthcare facility administration that a
subpoena has been received for the release of the medical record to court. In many
countries if the patient is not involved in the court case he or she is also notified by the
health care facility that the subpoena has been received. The patient is also told the place,
date, and time of the court hearing, to allow the patient to arrange to attend the court he or
she so wishes.

The Clerk should locate the medical record. If the medical record is on shelf, the Clerk
should find it and keep it in a safe place awaiting preparation for court. A tracer is made
showing that the medical record is with the clerk for medico- legal purposes. The clerk
should check that all necessary information, as specified in the subpoena, is in the
medical record folder and that it is complete.

In some countries the original medical record is not sent to a court. If a photocopy is
permissible as evidence in court, all forms in the integrated medical record folder should
be photocopied and numbered indicating that a copy exists. On return from court, the
photocopied medical record will need to be destroyed in order to protect the privacy of
the patient.

Sending and Receiving Medical Records

The medical record should be placed in a large envelope addressed to the clerk of the
court (or specified person in the subpoena) with the receipt attached to the front. The
tracer on the shelf is changed or updated to indicate that the medical record was sent to
the court and the date it was sent. The medical record should be forwarded under
adequate security to the clerk of the court named in the subpoena.
Managing Medical Records Learner Module

If the medical record has not been returned to the health facility by the specified date, the
clerk must check to find out if the case is over. If it is, the clerk should request the prompt
return of the medical record. On return from court, the medical record should be checked
to ensure that all pages (forms) are present. As mentioned previously, if a photocopy has
been made it must be checked and then destroyed.
Managing Medical Records Learner Module

Self-Check Assessment

Activity: 1
Assume you are the head of a medical record unit of a new hospital and the government
has employed six staffs. What responsibilities you will assign to these staffs as clerk?
List down and describe each of them.

Activity: 2
Describe the role of runners in transporting medical records to and from service u nits
units of a health facility.

Activity: 3
Provide precise definitions for the following terms:
a. Confidentiality
b. Privacy
c. Access to information

__________________________________________________________
__________________________________________________________
__________________________________________________________
Managing Medical Records Learner Module

Activity: 4

Write the facility activities along which the confidentiality of patient information should
be maintained.

Activity: 5

Patient’s medical record /information can be released to close relatives even if the
relative is not an authorized person.
a. True
b. False

Activity: 6

It is not necessary to maintain patient confidentiality when medical records are

transferred from the medical record unit to an archive repository (to store when it is
inactive).

a. False
b. True

Activity: 7

Medical record information shouldn’t be released for any one without the consent of the
patient and there is no exception for this confidentiality issue.

a. True
b. False
Managing Medical Records Learner Module

Activity: 8

Mr. Ketema sustained car accident and developed fracture of his leg 2 months ago. He
was admitted to your hospital and treated for the injury he sustained during the car
accident. The car driver who made the accident has disappeared since then and Mr.
Ketema’s lawyer wants to take this to the nearby court and requested your hospital for
medical record of Mr. Ketema’s as legal document by writing a letter.

a. Can the hospital provide the information to the lawyer without the knowledge of Mr.
Ketema? __________________________________________

b. Write down the steps one should follow when this procedure is carried out.

Activity: 9

List down those important point you should consider when you prepare a medical record
for court order.
____________________________________________________________
____________________________________________________________
____________________________________________________________

Activity: 10
Provide precise answer for the following questions

A. ________________ refers to the restriction of access to personal information to

authorized persons, entities and processes at authorized times and in an authorized
manner.

B. Write the five principles of information privacy.

A.______________
B.______________
C.______________
D._____________
E._____________
Managing Medical Records Learner Module

Topic 6: Monitoring Medical Record Keeping and Maintenance

6.1. Introduction

This topic briefly discusses about maintenance of the medical record, medical record
completion procedure, arrangement of medical records, medical record control and chart
tracking system, medical record archiving and culling procedure.
.

6.2. Learning Objectives

Up on the completion of this topic, you should be able to:

• Maintain medical records

• Complete medical record registration
• Arrange medical records
• Monitor& evaluate medical record
• Assist medical record audit
• Implement medical record Archiving procedure
• Cull inactive medical records
• Identify incomplete documentation on a form
• Understand responsibilities of medical personnel for record completion
• Apply Procedure for the Release of Medical Information in a Legal Case
• Verify accuracy and timeliness of data
• Check medical records for its completeness according to the standard
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6.3. Medical Record Maintenance

Maintenance of medical record is a daily care of medical records while they are on
shelves, move from or return to shelves. This ensures the general protection of medical
records against environmental hazards or other physical dangers. There are four basic
rules which must be followed to ensure physical facilities are adequate to maintain
medical records in good conditions. These are:

• The medical record unit must be secured. The MRU must be kept locked at all
times so that users and other unauthorised people cannot gain access to the filing
room. Entry must be by key or pass, and the issue of keys or passes must be
strictly controlled, for authorised members of staff only.
• Once medical records have been placed on shelf, they must be removed only if
approved procedures (for retrieval) are followed.
• There must be no smoking, eating or drinking in any area where records are
stored or used. Smoking is a fire hazard, while food and drink can damage
records and other materials both directly and indirectly through the
encouragement of rats and other predators.
• All staff must follow prescribed procedures at all times with no exceptions.
Procedures must be respected and followed or else they may soon become
neglected and the medical records will again be at risk.

In addition to replacing the damaged medical records by the new one after the
information is copied, the MRU should keep the following maintenance requirements to
protect medical records and other materials from damage.

• Ensure air circulates well in the medical record unit building, particularly in
storage areas, so that heat and humidity have less chance of causing damage to
materials.

• Do not open or close windows or doors unnecessarily, unless they can be used to
control temperature and humidity.

• If windows or doors are kept open, cover them with screens to keep insects and
rodents out.
Managing Medical Records Learner Module

• Check the roof , pipes and drainages regularly and repair leaks or cracks to avoid
water damage.

• Ensure the MRU is well cleaned regularly, with floors swept , shelves and work
surfaces dusted thoroughly, as well as cases and cabinets, and any other areas
where dust might gather. Cleaning staff should not use damaging materials such
as bleach or detergent cleaners in areas where records might be placed, as the
residual chemicals can damage materials and leave pollutants in the environment.

• Proper equipment, such as tables, trolleys and ladders, should be used for all filing
tasks, in order to protect staff and ensure materials are appropriately managed.

• Medical records should be reorganised on shelves periodically to allow sufficient

storage space and to ensure nothing has been damaged over time.

6.4. Medical Record Completion procedure

The data clerk in the MRU needs to check to ensure that all the forms are in the medical
record. This procedure is often called the discharge analysis. For example, a medical
record is checked to ensure that if the patient has had an operation, an Operation Report
is in the integrated medical record folder. However, this procedure can also be applied for
checking completion of medical records from outpatient service units. In addition, the
clerk needs to check that all progress notes, laboratory results and x-ray forms, nursing
notes, discharge summary etc. are included for inpatient services.

In the case of a new patient, the forms are attached to a medical record folder with a clip
or fastener and the patient's name and MRN are clearly written in the correct place on the
folder. The data clerk also need to check if the main condition has been recorded along
with any other condition treated while in hospital. The MAIN CONDITION is the disease
condition that made the patient to get admitted. The detail descriptions of such medical
completion procedure are discussed in the subsequent topics.
Managing Medical Records Learner Module

6.5. Medical Record Control and Chart Tracking System

In the existence of paper-based records, the health record department must maintain
control over all filing procedures and medical record usage. All medical records being
removed from file, for any reason, should be signed out and tracked as to its location.

It is important that some mechanism be in place to sign medical records out of the
medical record unit in order to maintain record control. Personnel within the hospital or
health centre receiving a health record should assume responsibility for returning it in
good condition and not sending it anywhere else without first contacting the MRU to
have the location changed. If this step is not taken, they are still responsible for the
record, and if it is missing they will be the person responsible for relocating it.

Health record request policies

a. Records should not be removed from the health record department except for
patient care.
b. All records being sent to clinics or service units must be signed out showing the
patient's name, record number, date and the name of the health facility, doctor or
unit whichever is appropriate.
c. A timeframe must be set in which all records must be returned by the requesting
individual, preferably by the end of the day. Records of discharged patients
should be sent to the MRU by the day the patient is discharged. The MRU staff
should follow-up on any records not returned within the required timeframe.
d. Records for research should be reviewed in the MRU, if possible. If space is not
available, they must be signed out and be readily available if the patient presents
for treatment.
e. Where possible, patient services that are made on an appointment basis, such as
for ART clinic visits or other outpatient services, should be known in the MRU
within a specified period of time, a 24 hour period being a good minimum. This
allows the MRU staff to have ample time to retrieve old records for reference
during the new encounter.
f. Record requests for research purposes should be considered as routine requests.
Managing Medical Records Learner Module

g. The health information technicians should develop procedures in order to

maintain complete control over incoming and outgoing medical records.

6.6. Monitoring Medical Records

In many countries, the health system is facing the following data quality related
problems.

• Poor medical record documentation

• Large backlogs(an accumulation over time of work waiting to be done) of medical
records waiting to be coded
• Poor coding quality
• Poor access to and utilization of morbidity data

To address these problems and improve the quality of data collected, and the
information generated from this data, quality control measures need to be implemented.

MRU is often the first department in a hospital or primary healthcare unit to introduce
quality assurance. As the MRU has connections with most other departments within the
health facility, it is the best place to check the medical care and treatment given to
patients.

It should be noted that quality checking of the medical record often results in action
being required by staff outside the MRU. One approach to quality checking is to ask
staff from other departments to check the services of the MRU using a check-list. The
results of these Quality checks (or audits) are kept on a chart (or graph) in the MRU.

This process is often the beginning of a quality-checking program with other

departments, which could result in an improvement in the quality of procedures
throughout the health care facility.

Areas medical record unit should monitor and evaluate are:

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• Are medical records filed promptly?

• Is the file room clean and tidy?
• Are Master Patient Index cards filed promptly?
• Are all discharges returned to the MRU the day after discharge?
• Are medical record forms filed in the correct order?
• Are all medical records completed within a specified time after discharge?
• Are the monthly and yearly statistics collected within a specified time in
relation to the medical record unit activities?

The content of a medical record can be evaluated by reviewing to see if the following has
been done:

For Outpatient visits

a. The name of the patient and MRN

b. Clinical notes on the date of the visit
c. Signature on the notes
d. If lab tests or radiology tests were ordered, there is documentation
included or results noted
e. HMIS diagnosis

For Inpatient visits

There is more analysis required for inpatient visits than for out patient department (OPD)
visits mostly because there are more forms to complete by medical personnel for the
patient stay and some patients may stay for several days thereby generating many more
forms.

• Patient name and MRN All forms belong to the same patient (remove any
that are mistakenly mixed in with this record)
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• All forms have staff signatures and dates

• The Physical Examination Form is completed accurately and signed
• The Nursing Assessment is complete and signed and dated by the nurse
• The Discharge Summary is completed and signed by the care provider and
dated
• Ancillary(supporting the diagnosis) reports are present and complete (lab
and radiology reports)
• If a delivery occurs, the Delivery/postnatal form (part of the integrated RH
card) is completed with all information checked or filled and signed by
appropriate personnel
• If surgery was performed, there should be a record of the operation,
anaesthesia and a recovery record, all of which must be dated and signed
by the treating care providers
• Consents for treatment and surgery should be dated and signed by the
patient and the treating care provider

If all of these are present, the medical record may be filed back into the file area. If there
is missing information, a Deficiency Notices (this form can be devised in any healthcare
facility and used to communicate the incomplete information about a patient care with the
care provider for completion of the medical record as noted by the clerk) is completed,
attached to the front of the medical record and the folder is placed in the “Incomplete
Record/Chart Area” of the filing shelves in numeric order.

The responsible party for completion is then notified that he or she has a record to
complete in the medical record unit.

A sample of a Deficiency Notice Form used to notify doctors or Health officers or other
medical personnel of incomplete or deficient items on a patient medical record is
depicted below (see figure6.1).
Managing Medical Records Learner Module

Ras Desta Damtew Memorial Hospital

Medical Record Deficiency Notice

Patient Name: ________________________MRN:_____________________________

Dr/Health officer/Other: ___________________________ Complete by(MRU staff):

__________________

Date of Service/Treatment/Discharge: ________________________________________

Please complete the following on this patient:

_______The Physical Examination Form is incomplete

_______The Physical Examination Form is not signed

_______The Nursing Assessment is not complete

_______The Nursing Assessment is not signed and dated by the nurse

_______The Discharge Summary is not filled out completely

_______ The Discharge Summary is not signed by the doctor and/or nurse and dated
.
_______Ancillary reports are not present but ordered (copies are not in record or results
F
are not present) the doctor may follow up or note why results are not available.
F
_______The
i integrated RH form is not completed with all boxes and information checked
or filled out.
g
u The integrated RH form is not signed by appropriate personnel
_______
r
_______There is a no record of the operation, anaesthesia and a recovery record, or it is
e
incomplete.

_______ Operation notes, anaesthesia and recover record not dated and signed by the
6
doctors and nurses
.
_______
1 Consents for treatment and surgery missing, or not signed, and dated properly.

Figure 6.1 A Sample Deficiency form used to complete medical records

Managing Medical Records Learner Module

What is medical record auditing?

It is similar to a medical record review. Medical record audit, which is also a

retrospective review of selected medical records or data documents to evaluate the quality
of care or services provided compared with predetermined standards.

6.7. Accuracy, Timeliness and Completeness of Medical Records

The data quality problems and the definition of quality data has been discussed in the first
topic of this learner module.

Common attributes of quality data

• Accuracy: The data are representative of the intent and definition, and are
correct and valid.
• Accessibility: The data are easily obtainable for authorized users.
• Comprehensiveness - The data cover the complete scope and limitations are
identified.
• Consistency: The data are reliable and have the same meaning across
applications.
• Timeliness: The Extent to which data is sufficiently up-to-date for the work at
hand.
• Relevancy: The extent up to which data is applicable and helpful for the task
at hand.

Here we will see some of the above characteristics of quality data such as completeness,
accuracy and timeliness with adequate examples.

a. Timeliness: Information, especially clinical information, should be documented as

an event occurs, treatment is performed or results noted. Delaying documentation
could cause information to be omitted and errors recorded.
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Example
• A patient’s identifying information is recorded at the time of first
attendance and is readily available to identify the patient at any given
time.
• The patient’s past medical history, a history of the present illness/problem
as detailed by the patient, and results of physical examination, is recorded
at the time of attendance at a health facility.
• On discharge or death of a patient in a hospital, the patient’s medical
records are processed and completed within a specified time frame.

b. Completeness: All required data should be present and the medical/health record
should contain all pertinent documents with complete and appropriate
documentation.
Examples
• For inpatients, the medical record contains an accurately recorded main
condition and other relevant procedures done and the attending doctor’s
signature.
• Nursing notes, including nursing plan, progress notes, blood pressure,
temperature and other charts are complete with signatures and date of
entry.
• For all medical/health records, relevant forms are complete, with
signatures and date of attendance.

c. Accuracy: The original data must be accurate in order to be useful. If data are not
accurate, then wrong impressions and information are being conveyed to the user.
The Medical record documentation should reflect the event as it actually
happened. Recording data is subject to human error and steps must be taken to
ensure that errors do not occur or, if they do occur, are picked up immediately and
correction measure should be taken.

Examples
• The patient’s identification details are correct and uniquely identify the
patient.
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• All pages in the health record are for the same patient.
• The patient’s address on the record is what the patient says it is.
• A medical record with data entered ‘100’years for the age of a pregnant
women.

6.8. Archiving and Culling Procedures

There is no a set of rules formulated in Ethiopia when and how to eliminate (cull out)
inactive (old) medical records, registers, tallies and report forms. The reformed HMIS
proposes that records be kept in active storage for 5 years after the last entry, and at least
7 more years in inactive storage and then after to be removed. However, the time for
elimination or removal of inactive medical records depend mainly on the particular health
facility’s capacity (especially space) to manage the inactive medical records. Thus, time
period for the inactive medical record to be eliminated can be shorter than 5 years or
longer that the upper limit proposed by the HMIS (i.e. 7 years).

Why should a health organization have archives medical records?

Although a large percentage of medical records are of short-term value, the remainder
can be very important. Many of these records can also be used as the basis for a history of
a hospital’s origins, life, and culture, and can greatly contribute to the study of the history
of medicine.

Who uses these archives?

Archived medical records are important to the health facilities which initially created and
used them. They will be used by those in the legal, personnel and public relations
departments and the medical staff. The policies, facts and figures the medical records
contain can be quickly retrieved, and the reasons for decisions can be easily reviewed.
Your archives may also be used by individuals outside the organization. Additionally,
medical researchers, practitioners from other institutions, auditors, public health planners
Managing Medical Records Learner Module

and others will find this information useful. Bearing in mind that medical records
received or created by a publicly funded health care facility, the archived medical records
may be subject to Access to information legislation. Therefore, users can be anyone with
a legitimate need to use the medical records.

Culling procedure

Culling is the removal of medical records which have not been used for a pre-specified
number of years from the active filing room of the medical record unit. It is done so that
inactive medical records may be removed from the shelf to make more filing space
available.

Health facilities should define a specific retention policy for medical records they
maintained based on national law and professional practice standards. The year last
attended the health facility can be searched from the medical records folder’s summary
sheet. This can be used to indicate whether the medical record is active or inactive.
Inactivity can be also determined by subtracting the last visit date from the current date.
The culled medical records can then be stored in secondary storage or destroyed. Culling
should be done every year. Once authorization is obtained to destroy medical records,
acceptable methods of destruction should be used and records must be destroyed in a
manner that makes it impossible to reconstruct and read the information. Records must
not be sold or disposed of in the garbage containers without some type of shredding or
obliteration. Acceptable methods used today include shredding or incineration. It is
recommended that a facility maintain documentation of the records/ documents that are
destroyed and the date information destroyed. The master patient index cards and
destruction logs contain basic demographic information should be retained on permanent
basis.

When you are considering a retention policy for the health facility, the points listed below
should be considered.
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• The Average frequency of patient’s health facility visit per specified time period(
per year, per 3 or 5 years) The volume of medical research under taken by
healthcare facility staff
• Cost involved in finding inactive filing space Cost of destruction of medical
records
• The statute of limitation i.e. the national government law that restricts the time
within which legal proceedings may be brought (legal requirement)
Managing Medical Records Learner Module

Self- Check Assessment

Activity: 1

Write down the four basic rules which must be followed to ensure physical facilities are
adequate to maintain medical records in good conditions.

a. __________________________________________________
b. __________________________________________________
c. __________________________________________________
d. __________________________________________________

Activity: 2

Assume you are responsible for medical record maintenance in a hospital. In Addition to
replacing the damaged medical records, what requirements you will try to meet in order
to protect medical records and other materials from damage?

Activity: 3

Describe what a summary sheet is and its content

_______________________________________________________
Managing Medical Records Learner Module

Activity: 4

Dr. Fanta is conducting a research on the progress of the diabetic patients with h  should
keep the following maintenance requirements to protect medical records and other
materials from damage is new treatment approach. He also decided to work on secondary
data from 30 medical records of diabetic patients attending the diabetic clinic of your
hospital. The MRU has one special room assigned for researchers to deal with medical
records they need for their research. The HIT, who entertained Dr. Fanta, didn’t ask for
authentication letter and let him take the record to his office which is 2km away from the
hospital to collect the data he needs.

What are the mistakes committed by the HIT?

________________________________________________________

How do you entertain Dr. Fanta If you were the one responsible in this case?

Activity: 5

Which of the following is not a consideration that should be made by a clerk when
medical record is requested for routine and non-routine purposes?

a. A requisition slip containing information on the patient's name ,MRN, the

destination, the date and other information is necessary
b. A medical record can be removed from the shelf without being replaced by a
tracer.
c. If a computerized chart tracking system is used, tracers are not necessary.
d. The MRU should be informed when a record is moved from one area to another.
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Activity: 6

List down areas where medical record unit should monitor and evaluate.

_______________________________________________________

Activity: 7

What are the most important characteristics of quality data (medical records)?
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________

Activity: 8

Mr. Kemekem is a chronic care clinic attending patient in your hospital who has been
admitted and discharged in the hospital recently. When his medical records content is
checked the following findings are identified.

Vital signs: temperature 45C°, Pulse rate 78 Respiratory rate 18 and Blood pressure
110/80 mm mercury.
Body weight: 50 Kg, taken 1998 E.C
In addition, the discharge summary note is not available in the folder.

What are the evidences to conclude that Mr. Kemekem’s medical record is:

a. Incomplete
b. Inaccurate
c. Not current(timely)
Managing Medical Records Learner Module

Activity: 9

Describe what medical record auditing mean.

Activity: 10

What are the actual differences between archiving and culling medical records?

_______________________________________________________________________
Managing Medical Records Learner Module

Topic 7: Software Applications Used in Medical Record Unit

7.1. Introduction

This topic discusses about registration of patients, how to retrieve and view individual
patient registration information, how to generate report on patient registration
activities of the hospital with software application running in the medical record unit,
and data quality checking methods. Here we will see registration module of smartcare
software application (E MR) with its major functions. Most of tasks of exploring the
software will be part of your computer lab sessions.

7.2. Learning Objectives

Upon the completion of this topic, you should be able to:

• Register patient using software application (SmartCare).

• Retrieve patient registration information from database.
• Update registration information of patient with repeat visit.
• Generate predefined registration related reports.
• Apply methods of data quality check
Managing Medical Records Learner Module

7.3. Patient/client Registration Using Software application/EMR

The country has adopted an electronic health record system known to be SmartCare
software application. It is an electronic health record software application. The software
is built or developed in modularized way (complex system divided into manageable
smaller sizes and work in integrated manner to build the bigger software program).
Registration module is one of the several modules that constitute SmartCare application
software. It captures identification and personal information of patients. It also enables
users to produce individual level or summary report on the activities of medical record
service unit of a health facility.

To start using registration module, you have to activate the SmartCare application and
Logon to the system using your given Login name (user name) and Password by the
system administrator.

Getting started SmartCare

There are many ways to start with SmartCare software after it is properly installed and
configured. However we will start with the most convenient one.

Click on start Æ all programs Æ SmartCareÆclick on SmartCare. This step starts the
SmartCare application and it takes a while to initialize the database.

The welcome screen of SmartCare is displayed as shown below. This screen indicates
that the application starts and requires your Login ID and password (see figure 7.1). After
you click on the box of Login ID, you are expected to write/insert valid Login ID and
password Æclick on Login tab. If you didn’t insert either valid login ID or valid
password, you can’t login to the system and it requires re‐entry of the correct one. The
close button allows you to exit the application.
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Figure7.1 SmartCare Login windows

When you click on the ‘continue’ button, the home page of smartcare will be displayed.It
contains a number of interfaces that allow you to view Clinic appointments, send or
receive messages to and from the care providers, read patient information from
smartcard, and on screen key board with built in name dictionary and data entry fields for
searching existing patient or clients.

Here, our focus is to learn how to search patient registration information to know whether
he/she has been in the database or not (see figure7.2).

Figure7.2 existing patient search page

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To find registration information of a patient, you can use one or more values of the data
entry fields as search key/s (see figure 7.2). The more the number of search keys you use,
the more the search result will be filtered. Please exercise this in your computer lab for
better understanding.

Based on the search result you can recognize whether the individual is new or existing
patient. For existing patient (patient who visited the health facility and his/her registration
information is electronically captured using this system) what you have to do is update or
edit the registration information if necessary. For the new one, go to the registration page
and enter all relevant information pertaining to registration. Required fields are fields that
should not be left null (with no value) and are marked with read asterisk.

Basically the registration page has three tabs named patient, address and Note/Remark.
Each contains data entry fields as seen figure7.3 below.

Figure7.3 SmartCare’s patient registration data entry form/page

Patient Tab: This tab is mainly designed to capture patients’ personal information
• First Name, Father’s Name and Grand father’s name
• MRN: the Patient Medical Record Number. This can be assigned to each
patient either automatically or manually.
• Date of birth, place of birth, multiple births and religion
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• Appointment: The clerk in the MRU is expected to complete this field. You
can assign a patient to a particular clinic or service unit at a particular date. To
do this you need to enter the appointment information when the patient
registers (see figure 7.4).

Address Tab

Patient's address is one of the important information needed in healthcare service

delivery. The data collected could later be used to analyze disease distribution, service
utilization and resource allocation.

Patient’s current address: contains the patient’s current region, woreda/sub‐city/zone,

kebele, house number/peasant association, address details (like p.o.box, street number,
e‐mail, etc), home/office phone and mobile phone.

Next of kin/emergency (Address of contact person): The current address of the relative of
the patient or contact person. Commonly, this data is helpful in emergency conditions
like car accident cases and when the patient is unavailable for contact.

Note/ Remark Tab

If additional data entry is required in certain cases, a text data can be entered in to this
field. Detailed description could be typed in to this field about the patient's resident
address and phone numbers or others.

7.4. Updating/Editing Patient’s registration information

To edit the existing patient registration information, first search the patient using
appropriate search key (Preferably, using the MRN). Then take a look on the search result
display for the values of other attribute to be sure that the record you are going to edit is
the right one. Double click on the search result record (see figure 7.4) to go to the
registration page for editing.
Managing Medical Records Learner Module

Figure7.4 a page for displaying patient search results

7.5. Generating Report

Smartcare application has functionalities that enable the data clerk to generate report on
the registration service of the health facility. To produce such reports, follow the
following steps.
 
Steps

1. Log on to the system with user name and password that has a privilege to generate
report
2. Click on ‘Menu’ at the left upper most corner and then on the ‘modules’ and
continue navigating till you get “Facility Reports”
3. Click on ‘Facility Reports’ to display a page that contains facility report menu
4. Click on ‘Patient registration & Data monitoring’ and select ‘Patient
Registration’
5. Click on the ‘load Report’ button then a page allow you to set your report
specifications will e displayed.
6. Select the report specification s from the list to specify the periodicity, order, age
range or gender type (See figure7.6).
7. Click on ‘show report button to generate the report you want to have.
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8. A report that contains summary information (based on your criteria) with report
headings will be displayed (see figure7.7).

Figure 7.6 a page one specify the criteria to generate customized and periodic reports

Please try to register new patients with all registration information, edit patient
registration information, change the appointment and generate customized reports in
your computer lab. Use the smart care help menu for the steps when you perform these
things.
Managing Medical Records Learner Module

Figure 7.7 a sample Report generated using the SmartCare software for a medical record unit
of a health facility.

7.6. Data Quality Checks

Software applications commonly used in the medical record units to record patient socio
demographic information are locally developed. Of this, we have seen the Registration
module of smartcare (an EMR system which is currently considered as the standard
application software for health facilities in the country to record patient information).

As we have seen in the previous topic quality data has to be accurate, complete, timely
and integrated. Data is said to have integrity when the software is protected from
intentional manipulation (change) for different purpose (political or personal reason).

Most of the time, source of poor data quality is data entry. This application software has
some methods of data quality checks.
Managing Medical Records Learner Module

Required fields: some of the data entry fields are ‘required ‘fields marked by red asterisk
i. e. one has to give value for such fields in order to save the all registration information
of a patient. This helps data entry to be somehow complete and timely.

Role based security: The user and password is associated with certain privileges to
manipulate data based on your role in the health facility. Therefore, one cannot modify
patient information simply without having the right password and username. This helps
to keep data integrity and consistent data can be available all the time.
Managing Medical Records Learner Module

Self – check Assessment

All these activities (except the last one) should be practiced in your computer lab and
show the steps you followed and the results to your instructor.

Activity: 1

Register twenty new patients with different attributes (Age, Sex, Address, religion etc.)
and enter data for all valid data entry fields to all the patients.

Activity: 2

Search for all the female patients you registered in activity 1 one by one using their MRN
or name and change their appointment clinics.

Activity: 3
Modify or update the address information of all the male patents you registered in
activity 1.

Activity: 4
Generate report on patients registered in this week with age range of 15 and 60years

Activity: 5

What are the data quality checks (methods) SmartCare has? Describe each with your own
words.