NEW BULAN ST.

JUDE MEDICAL CLINIC

PRIMARY GENERAL HOSPITAL
PHILHEALTH ACCREDITED
L. GRAFILO ST. ZONE 7 BULAN, SORSOGON

Policies and Procedures on Systematic Filling, Retrieval, Management

of Medical Records, Retention and Disposal of Medical Records
INTRODUCTION
The Medical Records shall maintain records for patient identification and also considered as indispensable
tools. By systematic filling or records it can help to improve the quality patient care. And to achieved a more
uniform practice for effective Management of Medical Records.
PURPOSE:
Medical Records are important clinically for the immediate diagnosis, treatment and welfare of the patient.
Likewise, these are vital to the hospital for the evaluation of its services and in the improvement of its
effectiveness through mortality, morbidity and better patient care.
DESCRIPTION:
Objectives
1. To improve the accessibility of medical records;
2. To create quality medical records;
3. To encourage greater utilization of hospital statistics generated in the Medical Records Section;
4. To implement staff development;
5. To increase quality assurance programs not only in the Medical Records Section but in the hospital
where relevant;
6. To participate in research and studies wherever it is necessary

POLICY

Retrieval Procedures
1. Authorized reporting party fills up borrowers slip form.
2. Requesting party/authorized representative brings the request to the Medical Records Section and it to
the Medical records custodian.
3. Medical Record Custodian receives and verifies whether the borrower is authorized to borrow.
4. After retrieving the record, change-out borrowed charts to the authorized borrowers
a. Records the charts in the borrowers logbook
b. Insert the borrowers slip in the place where the record was pulled out.
5. The borrowers/authorized representative acknowledge receipt of the records.

RETENTION AND DISPOSAL OF MEDICAL RECORDS

1. Medical Records shall be kept in the records room up to 20 years, to ensure that records are still intact
in case that there are medico-legal problems that may arise. Then the Medical Records are summarized
and the summary will be sent to the National Archives of the Philippines. The original can now be
disposed, taking care that the patient’s confidentiality are observed.
DUTIES AND RESPONSIBILITIES

Medical Records are responsible to give quality patient care and effective Medical Management. The
Medical Records Section are responsible to provide records of patient data for use in approved research
programs, respond to all subpoenas and medico-legal cases directed to the Hospital, provide records
upon request or the patients attendance to the wards.

Approved by:

MARIA ELSA REBUSTILLO-TAN, DMD

Administrative Officers
 NEW BULAN ST. JUDE MEDICAL CLINIC
PRIMARY GENERAL HOSPITAL
PHILHEALTH ACCREDITED
L. GRAFILO ST. ZONE 7 BULAN, SORSOGON

POLICY ON ACCURACY AND PREVENTION OF LOSS AND

DESTRUCTION, TAMPERINGS AND UNAUTHORIZED ACCESS
TO RECORDS

OBJECTIVE:
1. To maintain accurate and appropriate medical records.
2. To prevent loss and destruction, tampering and unauthorized access to records by making preventive
measures.

POLICY
1. Medical records shall contain sufficient and accurate information that identify the patient, such as the
name, age, sex, civil status, B.P., Wt., complete address, course with in the hospital admitting and final
diagnosis and attending physician, etc.
2. In connection with these, all charts and medical records must be kept in safe and dry place with proper
numbering and labelling of name and dates from prior to latest/present for every retrieval of records.
3. A borrower’s card and a logbook for recording medical records borrowed by the authorized persons shall
be maintained.
Borrowing Procedure:
a. Authorizes person fills up the borrowers slip and brings to the records custodian.
b. Medical records custodian receives the borrower’s slip and verifies if borrower is authorized to
borrow.
c. After retrieving, records the charts in the borrower’s logbook, endorse the record properly to the
borrower, note down the date/time and name of the borrower and make him/her sign.
d. Insert the borrower’s slip in the place where record was pulled out.
e. The borrower/authorized representative acknowledge receipts of the records.
4. All medical records shall be kept in a cabinet which is elevated. The room is properly locked to prevent
access to authorized person and destruction from flood, cockroaches and other vermin.
5. Strict confidentiality of patient’s record shall be observed.

DUTIES AND RESPONSIBILITIES:

The Medical records officer should assure the completeness of the data before filing. He is responsible for
proper filing and keeping of all hospital records of every patient. Such records can be provided to authorize
individuals or institution for use such as in research papers, legal case, gathering data and other purposes for the
patient’s welfare.

Approved by:
MARIA ELSA REBUSTILLO-TAN, DMD
Administrative Officer