Hospital Health Information Management Manual

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PREFACE
This manual is the National Center for Health facility Development (NCHFD)
contribution to achieve the goals of the Department of Health's Fourmula One
(F1) for Health. The revision of the seven (7) hospital management manuals is one
of the NCHFD's strategies in response to the mandate of the Policy and
Standards Development Team for Service Delivery, where NCHFD is one of its
members, to ensure the development of policies, standards, and guidelines for
health programs.
In the Revised Organization and Staffing Standards for Government

Hospitals, the Medical Record Department has been renamed to Health
Information Management Department in response to the worldwide
changing role and scope of responsibilities of Medical Record Management.
The ever-increasing demand for safe, effective, efficient, equitable, responsive

and accessible healthcare delivery system requires a corresponding increase in
ensuring quality patient care thru quality documentation, maintenance, access,
appropriate storage and disposal of health records. The access and release of
health information must be governed by the confidential and private nature of
the information on the health records. These are the framework with which this
manual was founded.
This manual adheres to the international standards, DOH licensing standards,

Philhealth accreditation standards, and in consultation with the members of the
Technical Working Group, DOH Consultants, and other concerned staff in the
DOH hospitals. It is primarily designed to serve as reference in the
administration of the Health Information Management Department of
healthcare facilities.
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ACKNOWLEDGEMENT
The 3rd Revision of the Hospital Health Information Management Manual
(formerly Hospital Medical Record Management Manual) is made possible by
the exemplary commitment and dedication of Mr. Emmanuel M. Lagustan,
Medical Records Manager, Asian Hospital and Medical Center, and author of the
1st and 2nd revision, and to the following members of the team which crafted this
manual:
Rommel Paul G. Flores Baguio General Hospital and Medical Center

Rosario B. Aveña Baguio General Hospital and Medical Center
Lani P. Paler Davao Medical Center
Lucila M. Villareal Dr. Jose Fabella Memorial Hospital
Aniceto H. Baguio Gov. Celestino Gallares Memorial Hospital
Nora I. Bundalian Jose B. Lingad Memorial General Hospital
Las Piñas Gen. Hosp. and Satellite Trauma
Rizalina I. Waay Center
Alice S. Guballa National Kidney and Transplant Institute
Ramon R. Iscala San Lazaro Hospital
Elizabeth P. Lim Valenzuela Medical Center
We are grateful for the Chief of Hospital/Medical Center Chief and

Administrative Officers most specially the abovementioned hospitals and other
DOH hospitals, for generously allowing their officers and staff to participate in
the consultative meetings and writeshops.
We are forever indebted for the kind understanding our families extended to us
while conducting the consultative meetings/writeshop away from our homes.
We extend our sincere gratitude to the following officers/staff who grace our
invitation to participate in the consultative meetings and share their expertise:
Dr. Teresa Vera Bureau of Health Facilities and Services

Felicitas Mariano Bureau of Health Facilities and Services
Dr. Arturo Alcantara Phil. Health Insurance Corporation
Dr. Independencia R. Flores Phil. Health Insurance Corporation
Reggie R. Guillen Phil. Health Insurance Corporation
Rosanna L. Martinez Phil. Health Insurance Corporation
Dr. Adeline A. Mesina Phil. Health Insurance Corporation
Julita Presbitero Phil. Health Insurance Corporation
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Lourdes Palapal Phil. Medical Records Association

Emma Mogro Alabang Medical Clinic
We wish to thank our consultants: Dr. Robert S. Enriquez (+), Director of the
National Children’s Hospital and former Division Chief of the Management and
Operation Division of NCHFD; Dr. Peter P. Ng, Professor, University of Sto.
Tomas and Dr. Bu C. Castro, Legal Counsel, Private Hospital Association of the
Phil. for unselfishly offering their expert opinion in the medico-legal aspects of
health records. Special recognition to Dr. Bu C. Castro for allowing the use of his
crafted consent forms.
We deeply appreciate the artwork in the design and concept of the manual’s
cover as well as the formatting of the manuscript by Dante and Angelita
Contonjos.
We would also like to convey our deepest appreciation to Professor Nancy Felipe
of the Philippine Women’s University, who finalized the format and layout of
this manual.
Moreover, the contribution of the officers and staff of NCHFD in the

development of this manual is acknowledged, namely:
Madeliene Gabrielle M. Doromal Development Management Officer IV

Neriza N. Ellsworth Development Management Officer IV
Arvin Cesar M. Lagda Development Management Officer III
Imelda I. Lim Development Management Officer III
Ma. Teresa B. Mendoza Development Management Officer IV
Juris Triunfante Development Management Officer IV
Zenaida I. Villaluna Development Management Officer IV
Lastly, we acknowledge the wholehearted support and encouragement of Dr.

Melecio N. Dy, Technical Operation Division Chief and Dr. Criselda G.
Abesamis, Director of NCHFD.
FLORINDA G. TUVILLO
Development Management Officer IV
(Medical Records Adviser)
Manila, Philippines 2010

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LIST OF ABBREVIATIONS
ABC Authorized Bed Capacity

ACF International Classification of Functioning
AIDS Acquired Immune-Deficiency Syndrome
BOR Bed Occupancy Rate
COA Commission on Audit
COH Chief of Hospital
CQI Continuous Quality Improvement
CS Caesarian Section
Ctrl. No. Control Number
DAMA Discharge Against Medical Advice
DBM Department of Budget and Management
DOA Dead On Arrival
DOH Department of Health
DR Delivery Room
DSM Diagnostic and Statistical Manual of Mental Disorders
ED Emergency Department
ER Emergency Room
GSIS Government Service Insurance System
HIMD Health Information Management Department
HIV Human Immuno-deficiency Virus
HMO Health Maintenance Organization
HRN Health Record Number
HRS Human Resource Services
ICD International Classification of Diseases
ICD-DS International Classification of Diseases to Dentistry and Stomatology
ICD-O International Classification of Diseases for Oncology
ICD-R&O International Classification of Diseases to Rheumatology and
Orthopaedics
ICMD International Classification of Musculoskeletal Disorder
IHOMP Integrated Hospital Operations and Management Program
JCIA Joint Commission International for Accreditation
KAS Knowledge, Attitude, Skills
LCR Local Civil Registrar
LR Labor Room
MC Main Condition
MICU Medical Intensive Care Unit
MPI Master Patient Index
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NAP National Archives of the Philippines

NBI National Bureau Investigation
NCHFD National Center for Health Facility Development
NEC Not Elsewhere Classified
NICU Neonatal Intensive Care Unit
NOS Not Otherwise Specified
OC Other Condition
OPD Out-Patient Department
PCSO Philippine Charity Sweepstake Office
PDCA Plan-Do-Check-Act
PHIC Philippine Health Insurance Corporation
PICU Pediatric Intensive Care Unit
POMR Problem Oriented Medical Record
QA Quality Assurance
RMC Risk Management Committee
RMP Risk Management Program
RR Recovery Room
SICU Surgical Intensive Care Unit
SMS Short Message Service
SOP Standard Operating Procedures
SSS Social Security System
TQM Total Quality Management
TWG Technical Working Group
UCOD Underlying Cause of Death
WHO World Health Organization
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TABLE OF CONTENTS
Chapter Page
Messages iii
Foreword vii
Preface ix
Acknowledgements xi
List of Abbreviations xiii
List of Figures xix
List of Tables xx
List of Appendices xxi
1 HEALTH INFORMATION MANAGEMENT DEPARTMENT 1

Objectives 1
Functions 2
HIMD Linkages 4
Professional Education, Training and Research 8
2 ADMINISTRATION AND MANAGEMENT OF HIMD 9

Organizational Structure of the HIMD 9
Management Process 11
Physical Facilities and Equipment 14
Standard Staffing Pattern 22
Staff Development 29
3 HEALTH RECORD STANDARD AND POLICIES 31

Health Record Standards 31
International Health Record Standard (Joint Commission
Accreditation Standard) 31
Philippine Health Record Standards 32
Policies and Procedures 34
Health Record Completion 34
Release of Health Information 35
General Policies 35
Specific Policies 38
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Chapter Page
4 Systems and Procedures 43

Health Record Identification System 43
Alphabetic System 44
Numerical System 44
Assembly of Health Record 47
Source Oriented Health Record 47
Problem Oriented Medical Record 48
Integrated Health Record 51
Analysis of the Health Record 52
Documentation Standard 52
Quantitative Analysis of Health Record 56
Qualitative Analysis of Inpatient Health Record 57
Qualitative Analysis of Outpatient Health Record 57
Coding 58
Indexing 60
Filing of Health Record 61
Filing Systems 61
Types of Filing System 64
Other Considerations in Filing Systems 65
Retrieval of Health Records 69
Retrieval Tools 70
Essential Requisites for Easy Retrieval 76
Retrieval Procedure 77
Retention and Disposal of Health Record 77
Issuance of Certificates 84
Certificate of Live Birth 84
Certificate of Death 86
Certificate of Fetal Death 88
Certificate of Confinement 89
Medical Certificate 89
Medico-Legal Certificate 89
Other Certificates 89
Issuance of Photocopy of Health Records 90
5 CLINICAL CODING 91
History of the International Classification of Diseases 92
Overview of the ICD-10 Classification 94
Basic Coding Guidelines 104
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Chapter Page
Overview of Morbidity Coding 105

Rules for Reselection of Main Condition 107
Overview of Mortality Coding 111
Selecting the underlying cause of death 114
Rules for Modification 114
Assumption of Intervening Cause 116
6 HOSPITAL STATISTICS 119

Definition of Statistics 119
Characteristics of Quality Hospital Statistics Data 120
Inpatient 120
Measures of Healthcare Performance 124
Outpatient Statistical Data Collection and Calculation 135
Mortality 136
7 MEDICO-LEGAL ASPECTS OF HEALTH RECORDS 137

Ownership of the Health Record 137
Accessibility and Confidentiality 137
Records Subpoenaed by the Court 142
Consents and Certificates 143
Handling Telephone Inquiries 146
Dealing with HIMD Clients 147
8 CONTINUOUS QUALITY IMPROVEMENT FOR HEALTH RECORDS 149

Introduction 149
Continuous Quality Improvement (CQI) at the Health
Information Management Department (HIMD) 151
Documentation 154
The Plan–Do–Check–Act Cycle (PDCA) 155
Monitoring and Evaluation 168
9 RISK MANAGEMENT FOR THE HIMD 175

Risk Management Program 175
Program Description 178
Concurrent Analysis: A Risk Management Instrument 183
Authority and Responsibility 185
Duties and Responsibilities of the Risk Management Committee 187
Program Implementation 191
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Chapter Page
Education and Training 193

Performance Improvement Standards 195
Annual Effectiveness Evaluation 196
Bibliography 199
Glossary 203
Appendices 209
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LIST OF FIGURES
Figure Page
1 Proposed Organogram for Level 3 Non-Corporate Hospitals 10
2 Proposed Organogram for Level 4 Non-Corporate Hospitals 10
3 Departments Under the Medical Service 11
4 Diagram showing “Safety Pulpit Ladder” and “Kick Stool” 16
5 Standard Arrangement of Filing Cabinets 17
6 Working Completion Area 18
7 Diagram showing Proper Lighting 19
8 Health Record Management Procedure 81
9 Health Records Disposition 82
10 Procedure in the Preparation of Birth Certificates 85
11 Procedure in the Preparation of Death Certificate 87
11 Conceptual Framework of PDCA 143
12 Flowchart of Health Record Management 152
13 Conceptual Framework showing the Linkages of Risk 174

Management Program with other Health Facility Related
Committees/Programs
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LIST OF TABLES
Table Page
1 Example of Practical Hospital Planning 12
2 Department of Health Standard Staffing for HIMD by Category, 29

by Bed Capacity
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LIST OF APPENDICES
Appendix Page
A Release from Responsibility 211
B Informed Consent for Surgery, Anaesthesia or Other Procedures 212
C Voluntary Sterilization Consent Form 213
D Consent to Diagnosis/Treatment 214
E Consent for Procedure 215
F Consent for Admission/Confinement 216
G Certificate of Confinement 219
H Medical Certificate 220
I Medico-Legal Certificate 221
J Certificate of Dismembered Body Part 222
K Subpoena ad Testificandum 223
L Subpoena Duces Tecum 224
M Medical Record Forms 225
N Request for Radiologic Plates/Laboratory Slides 241
O Request for Copy of Medical Records 243
P DOH Circular No. 70s 1996 244
Q DOH Administrative Order No. 47s 2000 253
R DOH Administrative Order No. 2009-0020 256

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Health Information Management Department
1 HEALTH INFORMATION
MANAGEMENT
DEPARTMENT
____________________________________________________________
The Health Information Management Department (HIMD) is responsible in

enhancing patient care through the use of data contained in the health record,
either individually or collectively. The general function of the HIMD is to
provide an organized system of measuring quality patient care and to ensure
that sufficient data is written in sequence of events to justify the diagnosis,
warrant the treatment and end results. The department is tasked to process,
analyze, maintain, and safekeep all health records created/maintained in the
healthcare facility in the course of healthcare facility and its supervisor are
mandated to implement facility wide coordination and linkage. The department
plays a key role in the generation of healthcare statistics to evidence-based
medical care and management practices.
OBJECTIVES
The HIMD shall provide effective and efficient service to clients of the healthcare
facility and shall meet the following objectives and standards:
 Improve the accessibility of the health records.
 Ensure the creation and maintenance of quality health records.
 Encourage greater utilization of healthcare facility statistics.
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Hospital Health Information Management Manual
 Assist in strengthening quality programmes e.g., Patient Safety,

Continuous Quality Improvement (CQI), Infection Control, Risk
Management, etc., in the healthcare facility. Participate in research and
studies which the facility, the members of the medical and allied staff, and
other authorized researchers are engaged in.
 Implement staff development.
FUNCTIONS
Main Functions
 Maintain all health records in accordance with the principles and

practices of efficient and effective health record management.
 Maintain comprehensive indexes (e.g. Master Patient Index, Disease

Index) and registers (e.g. Admission, Discharge, Operation/Procedure,
Delivery Room (DR), Out-Patient Department (OPD), Emergency
Department (ED), Birth and Death Registers). These are official records
for patient identification and important retrieval tools for needed data and
information when health records are already disposed-of.
 Review records for completeness and accuracy, coding of diseases,

operations, and special therapies according to approved nomenclature
and classification.
 Maintain a comprehensive and up-to-date unit health record for each

patient, ensure that all relevant information is collected and written in the
record and filed correctly.
 Respond to all subpoena duces tecum addressed to the HIMD.
 Maintain and safeguard the confidentiality of the health record.
 Provide health records, upon request for patients’ visit to the OPD and
Emergency Department (ED), and admission to the inpatient’s ward.
2 Hospital Health Information Management Manual

 Ensure that all diagnostic reports/results are promptly and accurately

filed in their respective patient’s record.
 Collate and compile data and generate statistical reports required by

respective healthcare facility management, the DOH, as the health
regulatory body, and Philippine Health Insurance Corporation (PHIC), as
the country’s health accreditation agency.
 Prepare periodic statistical reports on morbidity and mortality, birth,

utilization of hospital services, OPD/ED services, as well as surgery
performed, and cases receiving special form of therapy and other related
data.
 Provide data/information from patient’s health record for use in

approved research and study programs.
 Participate in studies and research activities conducted by doctors and

authorized researchers by providing needed data/information.
Other Functions
The supervisor of the HIMD in Level 2, Level 3 and Level 4 hospitals only, shall
participate in the DOH licensing mandated/required committees, primarily the
Medical Records Committee (MRC). The MRC shall function as a separate
committee or it could also function as the Forms Committee. It may act as a
liaison between the Chief of the Medical Service and other departments.
Members should be representative of the various clinical services of the hospital.
The committee should support the supervisor of the HIMD in the formulation of
effective institutional standards, policies, systems and procedures most
especially in the timely documentation and the completion of health records.
The membership of the MRC includes, but not limited to the:
 Chairman – representative from the medical service.
 Members – representative from the hospital administration; nursing

service; allied health services and the supervisor of the HIMD.
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Medical Records Committee shall have the following functions:
 The Medical Records Committee should meet once every three months
and more frequently if required. The committee which is mandated only
in Levels 2, 3 and 4 hospitals meets every month during the formative
stage and less frequently when the committee is already in place and
functional. The members of the committee shall meet at least four times a
year. The chairman selects and represents to this committee all health
records not completed within the specified time.
 The committee shall recommend standards, policies, systems and

procedures in health record documentation for management’s approval.
 The committee members shall monitor the quality of documentation of the

health records.
 The committee shall review all health record forms to determine its
effectiveness in the collection of the needed data/information and revise if
there is a need for it.
HIMD LINKAGES
The HIMD must at all times maintain harmonious working relations with other
service components of the healthcare facility to efficiently and effectively
perform its functions particularly in the creation and maintenance of quality
health record for the benefit of the patient and facility in general.
Medical Service
 Clinical Group
- Provides needed data and records for patient care management
and research.

 Ancillary Group
o Pathology
- Coordinates in the creation of accurate and complete basic
patient’s demographic data.
- Provides needed data and statistical report.
o Rehabilitation
- Provides needed data and statistical report
o Dental
o Radiology
 Allied Health Group
o Pharmacy
o Medical Social Work

- Provides needed data and information for preparation of
case study for service patient and others seeking assistance
from concerned financial institutions.
- Provides clinical abstract/discharge summary service for
patient seeking financial assistance and insurance
reimbursement.
- Coordinates for abandoned clients and unclaimed
cadavers.
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o Nutrition and Dietetics

Nursing Service
 Provides standards in medical record documentation for the

creation of quality medical records.
 Provides data/information for case presentation, research and study.
 Coordinates with HIMD for request of release of patient’s

information.
 Provides technical assistance in the preparation of the floor census

and other reports and prompt distribution of the 24-hour census
report to serve as their management tool on a day to day basis except
when the healthcare facility is implementing a fully automated
information system.
 Provides prompt transcription of completely and accurately

accomplished pre-form/worksheet of Birth and Death Certificates.
Hospital Operations and Patient Support Services
 Human Resource Management Department

- Recommends appropriate qualification standards for the
various HIMD staff.
- Coordinates for the conduct of needed HIMD technical
trainings.
- Coordinates for technical assistance in recruitment, selection
and promotion of HIMD staff.
 Procurement, Property and Supply Management

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

Finance Service
 Billing and Claims

- Provides records and documents needed for insurance
purposes, e.g. insurance reimbursements for Philhealth and
other insurance companies.
 Budget
- Coordinates HIMD’s needed operational budget.
- Provides needed data and statistics.
 Accounting
- Coordinates for HIMD’s needed operational budget.
- Provides needed data and statistics.
 Cash Section
- Coordinates the cash advance/petty cash for emergency use of
HIMD.
- Coordinates for the order of payment for medical certificate and
reproduction of requested health records and other documents.
PROFESSIONAL EDUCATION, TRAINING AND RESEARCH
 Provides needed data/information and record/document for technical

trainings by the HIMD staff.
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Administration and Management of HIMD
2 ADMINISTRATION AND
MANAGEMENT
OF HIMD
____________________________________________________________
ORGANIZATIONAL STRUCTURE OF HIMD
Fundamental to effective management is the development of an organizational

chart which shows the line of authority and responsibility. The organizational
chart likewise indicates the channels of communication and protocol.
The institutional objectives, as well as the principles of effective organization are

considered foremost in the formulation of the organizational chart.
The Department of Health (DOH) published the “Revised Organization and

Staffing Standards for Government Hospitals” which is subject to review by the
Department of Budget and Management. It shows the following organizational
structure by hospital category.
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Figure 1. Proposed Organogram for Level 3 Non-Corporate Hospital
Proposed Organogram
Level 4 Non-Corporate Hospital
(Teaching & Training)
200-500 Bed
Office of the Medical Center

Chief
Integrated Hospital Operations Continuous Quality

& Management Program Improvement (CQI Program)
(IHOMP Unit) and Patient Safety
Legal Affairs Internal Audit
Professional Education and

Training Research
Non-
Medical Nursing
Medical
Hospital
Finance Operations and
Nursing Service Medical Service
Service Patient Support
Service
Figure 2. Proposed Organogram for Level 4 Non-Corporate Hospital

Office of the Medical Center

Chief
Medical Service
Clinical Ancillary Allied Health Team
Medicine Dept. of Laboratory Pharmacy
Surgery Medical Social Work

Blood Bank
OB-Gynecology Nutrition & Dietetics
Pediatrics Dept. of Radiology Health Information

Management
Anesthesia Dental
Out Patient Department
Public Health Unit

Operating Room
Delivery Room
Emergency Room
Specialized Care Areas:
Specialized Care Areas MICU, SICU, PICU, NICU, etc.
Special Services
Burn Unit, Rehab Med, Respiratory Med, Dialysis, Ortho, Urology, Neuro, etc
Special Services
Figure 3
Departments Under the Medical Service
MANAGEMENT PROCESS
Management is defined as the process of getting things done through and with
people. It is the effective utilization of resources towards the accomplishment of
the specified objectives. Four basic components emerge from any definition of
management: objectives, staffing, processes/procedure, and resources.
Five Functions of the Management Process
1. Planning involves the identification and implementation of activities and

programs to meet its objectives. Planning is the crucial step in the
management process, but is often the most neglected. It includes the review
and evaluation of the outcome in order to determine the planned objectives
where achieved. The planning process for health information management
involves:
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 Setting the objectives;

 Developing policies and procedures, rules and regulations;
 Setting standards and goals;
 Determining the projects and programs;
 Implementing and monitoring the plan;
 Evaluating the plan in relation to the effectiveness, efficiency and
impact on the goals/objectives of the HIMD;
Purposes of Planning
 Enables the HIMD to attain its goals and objectives;
 Facilitates the allocation of resources (e.g. time, people, supplies);
 Serves as a basis for measuring the performance and determining and
addressing deviations or variances (actual vs. planned); and
 Assist in the preparation of the budget.
Table 1 gives an example of practical hospital planning and the roles that
HIMD plays in the process.
Table 1. Example of Practical Hospital Planning
Basis Standards of Care

Examples
10 Leading Causes * Physical Facilities Refuse Admissions
of Admissions * Manpower No Vacancies
* Supplies & Materials Referrals Outside
10 Leading Causes * Equipment Transferred Out
of Outpatients * Laboratory & Other Lab Exams Done Outside
Consultation Ancillary Exams Prescriptions Unfilled
* Drugs & Medicines Overstaying Patients
10 Leading Causes * Administrative Delayed Operations
of ER Support
Consultation

2. Organizing - involves the identification, distribution, scheduling of

resources toward the accomplishment of the objectives. Organizing requires
an understanding of the principle of staffing and work distribution. It also
includes the allocation of materials, equipment and space. This is the
process by which employees in the HIMD must have coordination, either
within the department or with other departments.
Formalizing the organizational structure of the HIMD
 Organizational chart is a graphic representation of all positions in the

department.
 Organizational manual. The HIMD shall have set of written policies

and procedures which shall be properly disseminated.
 Organizational Development – this involves the following:

- continued in-service training and development for the staff
- regular meeting and communication between the staff and
officers
- dissemination of results of the medical Record Committee
meetings
- feedback mechanism on the performance of the staff.
3. Directing is the act of leading and motivating individuals to work

harmoniously, effectively and efficiently to attain the objective. It involves
leadership, supervision, delegation, communication, coordination,
motivation etc.
4. Controlling involves comparing against set standards, identifying unit of

work and index of performance.
5. Evaluating involves determining results against plans, using effectiveness

and objectives using effectiveness and efficiency of indicators.
13
PHYSICAL FACILITIES AND EQUIPMENT
The Health Information Management Department (HIMD) shall be big enough to

accommodate active, inactive and incoming medical records. Ideally, it shall
have a separate working area which shall be adequate for the HIMD staff and
other and sufficient filing/storage area for confidentiality, security and health
reasons. However, such requirement may vary depending on the category of the
healthcare facility.
HIMD shall be properly ventilated to protect the integrity and quality of written
and electronically produced documents.
Volatile and flammable liquids shall not be placed inside the records room, and
“NO SMOKING” and “AUTHORIZED PERSONNEL ONLY”, signages shall be
strategically posted inside the HIMD.
In the event the space allocated for the HIMD is not enough to accommodate all
records, a plan to transfer inactive records to an inactive records storage area
shall be considered. This shall decongest the filing area, give way to incoming
records, and shall facilitate prompt retrieval of needed medical records. A
medical record not activated within five (5) years or as maybe determined by the
healthcare facility’s management, after the last date of treatment and/or
admission of the patient shall be considered inactive.
Space Requirement
Space requirement for inpatient shall be calculated using the following formula:
(Annual Discharges including Newborn*)

+ (New Outpatient) x (Retention Period)
Storage Space Required = -----------------------------------------------------------------------
(Records per meter)
* Newborn = Non-pathologic

Example: Data Given
Annual Discharges = 23,000

New Admissions = 6,720
Re-admissions = 16,800
Annual New OPD Registration = 3,000
Newborn = 1,000
Retention period = 15 years
No. of records/meter = 200 records
(23,000 + 3,000 + 1,000) x 15

Storage Space Required = ------------------------------------------------
200
405,000
= ---------------
200
= 202.5 meters of shelving
Note: 10% of the computed required storage space should be added to the
computed value to account for the projected increase in number of
patient/year.
202.5 +20.25 = 222.75 meters of shelving
To calculate for the number of meters of shelving for each terminal the
formula is:
Meters of shelving required

No. of meters required for each section = -------------------------------------------
No. of sections in file
8,910
= ------------
100
= 2.22 meters/primary section
15
Filing Cabinets for Health Records
The open shelf type shall be used for the following reasons: space saving, ease of
filing, and easy retrieval although accumulation of dust and problem of security
are some of its disadvantages. However, the cited advantages outweigh its
disadvantages.
High stocking cabinets can be adapted to maximize the storage capacity of the
filing area. However, provision for “kick stools” or “safety pulpit ladders”
should be considered for the convenience and safety of the file and retrieval
clerks.
Figure 4. Diagram Showing “Safety Pulpit Ladder” and “Kick Stool”
Cabinets for Indexes
Cabinets for indexes come in standard sizes and these are oftentimes made of
steel.
For the master patient index, the cabinet must be able to accommodate 3” x 5”
index cards, whereas, for the disease, operation, and physician indexes, a cabinet
for 5” x 8” cards shall be used.

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

because this saves space and maximizes the storage capacity of the filing area.
Figure 5. Standard Arrangement of Filing Cabinets
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Working Tables
The physical arrangement of employees’ tables shall be in accordance with their

workflow. Efforts shall be made to lessen the travel time of paper within the
department, to improve output and increase efficiency, by optimizing the
workplace arrangement and the application of ergonomics.
Employees who are in constant contact with patients/clients shall be positioned

near the main entrance. Employees performing technical jobs like coding and
statisticians performing analytical work shall be positioned in an area free from
distraction and noise, as much as possible near the Health Information
Management Officer for better supervision and control.
Figure 6. Working/Completion Area

Transcriptionists/typists shall be positioned farther from other employees. Their

area shall be acoustically treated to lessen distraction.
The HIM supervisor’s room shall be positioned strategically so that he/she can
monitor his/her subordinates for more effective supervision and control.
Distances between tables of employees shall be maintained at 1-1.5 meters to

facilitate easy movement. A space of 5.57meters per employee shall be
maintained, if possible.
Proper Lighting
Research shows that proper lighting directly affects employee performance.
The level of lighting requirement (in foot candle) varies from activity to activity.
A 100 foot candle light is required for the following activities: regular office
work, reading or transcribing, handwriting, active filing, index referencing and
mail sorting. Age level has also direct influence on light requirement. Older
people tend to work efficiently and effectively in well lighted working areas.
Younger people, on the other hand, tend to prefer not too highly illuminated
working areas.
The light in the storage and filing area shall be situated in between cabinets and
should run parallel with the arrangement of the cabinets so that the illuminating
capacity of the light is maximize.
Figure 7. Diagram Showing Proper Lighting
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Proper Ventilation
Another important thing to consider in planning a good HIMD layout is good

ventilation. It is not only considered for health reasons but also for the protection
of the health records. Filing and storage areas with very humid conditions have
bad effects on the health records because papers absorb moisture to some extent
and this could affect the quality of the health record.
Proper Room Temperature
It is a fact that room temperature affects the performance of a person. The

temperature shall not be too warm nor too cold. Temperature which is just right
and conducive for working shall be provided.
Aesthetic Consideration
Research shows that the color of the working area has a positive effect on
employees’ performance. So the HIMD needs to consider light and color
combinations such as light yellow enhance performance and productivity.
The HIMD shall have a completion area, where doctors and researchers can do
their work. This area shall be provided with the following: long table, chairs,
pigeon hole for incomplete health records.
Equipment
The HIMD shall also be provided with sufficient good quality office supplies.
The basic equipment and supplies needed are the following:
 Mandatory
o Working tables and chairs
o Typewriters (electric or manual)
o Coding Tools (e.g., International Classification of Diseases -10, RVS
International Classification of Diseases-9-CM, bookstand,
bookmarker)
o Medical Dictionary

o Atlas Human Anatomy Book

o Dry Seal
o Sufficient filing cabinets for records, indexes and registers
o Safety Pulpit Ladder/Kick Stool
o Fire Extinguisher
o Emergency Light
o Pencil Sharpener
 Optional
o Telephone Service
o Numbering machine
o Heavy Duty Stapler/Stapler
o Heavy Duty Staple Wire Remover
o Heavy Duty Puncher/Puncher
o Heavy Duty Paper Cutter
o Paper Binder
o Index Card Sorter
o Photocopying machine
o Vacuum Cleaner
o Air-conditioning unit or electric fan
o Paper Shredders
o Calculators
If it is within financial possibility, the HIMD shall acquire modern equipment

because of the many benefits it offers. Some of these equipment include:
o Computers
o Computer Printer, preferably laser
o Scanner
o Dictating Equipment
o Transcribing machine
o Micrographics
o Electric Coding Tools
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STANDARD STAFFING PATTERN
The Health Information Management (HIMD) Department is considered as a

storage area of patient information or simply the information center of the
healthcare facility. For the department to be efficient and more responsive to the
needs and demands of its clientele, it shall have the required number of staff in
relation to its bed capacity and the volume of work to be done.
The number of staff required by the HIMD is determined by the category of the
healthcare facility. A research healthcare facility which needs a more
comprehensive and sophisticated records-keeping system shall naturally require
a greater number of staff compared to an institution which is not engaged in
research and teaching. Furthermore, the required HIM staff ratio shall be 1:20 of
the Authorized Bed Capacity (ABC) for In-Patient and for Outpatients, the ratio
shall be 1:50 visits per day.
The classification of personnel in the HIMD of a healthcare facility shall depend

on the following:
 The classification of the Director/Medical Center Chief
 Category and bed capacity of the healthcare facility
Listed below are the qualification requirements and job descriptions for the
different categories of the HIMD staff.
Position Title: Administrative Officer V
 Minimum Qualifications Standards

o Must have a masteral degree relevant to the position;
o Must have first grade civil service eligibility;
o Must have units thorough knowledge of Anatomy, Physiology
medical terminologies;
o Must have attended a Certificate Course in HIMD and training
course of at least 120 hours in HIM conducted by a Department of
Health recognized institution/organization or academe;
o Must have at least five (5) years of experience in the HIM
Department of a Level 2 or Level 3 hospital, one year of which must
have been in a supervisory capacity.

 Job Description
o Shall plan, organize and control all activities in the service;
o Shall attend court proceedings and represent the hospital in court
cases involving subpoena of medical/clinical records;
o Shall exercise direct administrative supervision and control over all
subordinates in the service;
o Shall establish policies and procedures in relation to the content,
control, storage and retrieval of records;
o Shall organize the workflow throughout the service;
o Shall represent the service to top management;
o Shall ensure the maintenance of the patient’s right to privacy and
confidentiality; in value health records / information.
o Shall serve on appropriate committees and attend meetings which
are of relevance to the HIM;
o Shall supervise the implementation and evaluation of quality control
measures of specified areas within the service;
o Shall meet and discuss with the administration of other departments
within the hospital, issues which are related to the HIM;
o Shall answer by correspondence or by telephone inquiries regarding
information recorded in the patients’ health records;
o Shall keep abreast of current medical record practices and
developments;
o Shall assist the medical staff in authorized research projects; and
o Shall perform other related functions as may be assigned by the
immediate supervisor.
Position Title: HIMD Head/Supervisor of Level 1 & Level 2 Hospitals
 Minimum Qualifications Standards

o Must have a college degree preferably with units in graduate studies;
o Must have first grade civil service eligibility;
o Must have units thorough knowledge of Anatomy, Physiology
medical terminologies;
o Must have attended a Certificate Course in HIMD and training in
International Classification of Disease-10 conducted by a Department
of Health recognized institution/organization or academe;
23
o Must have at least four (4) years of experience in the HIM

Department of level of a Level 2 hospital, one (1) year of which must;
have been in a supervisory capacity.
 Job Description
o Shall plan, organize and control all activities in the department;
o Shall attend court proceedings and represent the hospital in court
cases involving subpoena of medical/clinical records;
o Shall exercise direct administrative supervision and control over all
subordinates in the department;
o Shall establish policies and procedures in relation to the content,
control, storage and retrieval of health records;
o Shall organize the workflow throughout the department;
o Shall represent the service to top management;
o Shall ensure the maintenance of the patient’s right to privacy and
confidentiality of the health records or related documents;
o Shall serve on appropriate committees and attend meetings which
are of relevance to the HIM;
o Shall supervise the implementation and evaluation and quality
control measures of specified areas within the service;
o Shall meet and discuss with the administration of other departments
within the hospital, issues which are related to the HIM;
o Shall answer by correspondence or by telephone inquiries regarding
information recorded in the patients’ health records;
o Shall keep abreast of current health record practices and
developments;
o Shall assist the medical staff in authorized research projects; and
Position Title: Statistician of Level 3 and Level 4 Hospitals
 Minimum Qualification Standards

o Must have a college degree preferably with units in statistics and
graduate studies;
o Must have a first grade civil service eligibility;
o Must have knowledge in disease and operation coding;

o Must have attended Certificate Course in HIMD to include related

training course in International Classification of Diseases and
healthcare statistics conducted by a Department of Health recognized
institution/organization or academe;
o Must be computer literate and familiar with available statistical
packages;
o Must have at least three (3) years of experience in the HIM
Department of a Level 2 or Level 3 healthcare facility.
 Job Description
o Shall, as an assistant to the head of the HIMD in Levels 4 healthcare
facility, manage the department in the absence of the HIMD
head/supervisor;
o Shall consolidate the Daily Floor Census report into the 24-hour;
census report of the healthcare facility;
o Shall summarize and prepare monthly, quarterly and annual
statistical reports of healthcare facility activities;
o Shall recommend appropriate action to be taken based on the
analysis and interpretation of data gathered
o Shall, assist the resident physicians and other employees in the
conduct of their scientific research;
o Shall prepare a healthcare facility statistical reports in of budgeting
and planning processes; and
o Shall perform other related functions as may be required by the
Position Title: Clinical Coder

o Must have a college degree preferably with knowledge in Anatomy
Physiology, and medical terminologies;
o Must have a first grade civil service eligibility;
o Must have attended Certificate Course in HIM and basic course in
International Classification of Diseases conducted by a Department
of Health recognized institution/organization or academe;
o Must be computer literate;
25
o Must have at least one (1) year of experience as disease and

operations coder, and
o Must be well acquainted with the different coding tools.
 Job Description
o Shall work directly under the supervision of the chief of the HIMD;
o Shall analyze specific portions of the health record and assign code
numbers to disease and operations based on the mandated
classification system;
o Shall update and maintain the disease and operation index file;
o Shall file the disease and operation indexes numerically by disease
and operation codes; and
Position Title: Health Record Analysis/Assembly Clerk

o Must and have a college education;
o Must have a second grade civil service eligibility;
o Must have attended a training course in health record documentation
standards;
o Must have thorough knowledge of medical terminologies;
o Must have at least work in the HIMD or other related office; and
o Must be computer literate.
 Job Description
o Shall arrange and assemble the health record of discharged patients
based on the approved format;
o Shall analyze quantitatively and qualitatively health records to
ensure the creation of complete and accurate health records;
o Shall coordinate with concerned members of the medical and nursing
service in relation to incomplete health records;
o Shall maintain statistics of incomplete and complete health records
and prepare reports of delinquent doctors; and


Position Title: Medical Transcriptionist

o Must have a college education;
o Must have attended a medical record related training;
o Must have knowledge in Anatomy, Physiology and thorough
knowledge in medical terminology;
o Must have undergone training in medical transcription and/or is a
certified medical transcriptionist;
 Job Description
o Shall transcribe operating room reports and other dictated/recorded
information;
o Shall type/encode letters and reports, birth and death certificates;
and
o Shall transcribe operating room reports and other dictated/recorded
information;
o Shall transcribe all dictated medical reports;
o Shall transcribe birth, death, medical and medico-legal certificate
from the pre-form to the corresponding official forms;
o Shall coordinate with the concerned staff and/or patient in relation
to problems involving the accomplished birth, death, and other
certificate pre-form or worksheet;
o Shall transcribe official communications and reports; and
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Position Title: Filing/Retrieval Clerk

o Must have at least two (2) years of college education;
o Must have a background or experience in the process of filing and
retrieval; and
o Must have attended a training course in HIM.
 Job Description
o Shall file records and indexes according to the established and
approved system;
o Shall incorporate loose reports/sheets into the respective health
record;
o Shall maintain a follow-up system for borrowed/needed health
record;
o Shall maintain and update the patient master index;
o Shall retrieve requested health records for follow-up, research and
studies;
o Shall maintain the proper filing of the Health records and
periodically check files for misfiled health records; and
Table 2 presents the DOH standard HIMD staffing on the “Revised Organization
and Staffing for Government Hospitals”.

Table 2
Department of Health Standard Staffing for HIMD
by Category, by Bed Capacity
CATEGORY/BED CAPACITY
Level Level 2 Level 3 Level 4
POSITION SG 1
10 -15 25 50 75 100 150 200 200 300 400 500
Supervising Admin 22 1 1 1 1
Officer
Statistician III 18 1 1 1 1
Admin Officer V 18 1 1 1
Statistician II 15 1 1 1 1 1 1 1
Admin Officer IV 15 1 1 1 1 1 1
Admin Officer III 14 1 3 5 6
Admin Officer II 11 1 1 1 2 2
Statistician I 11 1 1 1 1 1
Admin Officer I 10 1 2 2 2 2 3 7 10
Admin Assistant II 7 1 1 1 2 2 3 3 4
Admin Aide VI 6 1 1 1 2 2 2 2 3 3 4
Admin Aide IV 6 2 2 2 3 3
T O TA L 1 2 3 5 6 10 13 13 18 25 32
Note: * AO - Administrative Officer
** AA - Administrative Assistant
Number of required manpower per bed capacity will follow depending upon the result of the
Rationalization Plan.
Staff Development
 Internal
o Orientation of HIMD staff in relation to the existing policies and
procedures;
o Rotation of staff within the HIMD every two (2) years;
o Identification of staff in-service training needs;
o Conduct of continued in-service education program for HIMD staff;
o Participation and involvement of staff in planned changes;
o Feedback to HIMD staff involving effective changes and appreciation
of work undertaken by staff; and
o Values Orientation Workshop
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 External
o Basic/Advanced Medical Records Management
o International Classification of Disease-10 Coding of Diseases
o Basic Computer Courses
o Integrated Hospital Operations & Management Program/Power
Builder
o Healthcare Facility Statistical Report Preparation

Health Record Standards and Policies
3 HEALTH RECORD
STANDARDS AND
POLICIES
____________________________________________________________
Standards and policies are important in HIMD to achieve a uniform practice for
effective and efficient Health Information Management.
Standards, policies and procedures are crucial, but their application may not fit
every possible situation encountered, most especially where there are insufficient
human and material resources. Modification should not deviate from the
standard to the extent of adversely affecting the level of departmental
performance and quality of patient care in general.
The patient’s health record shall contain a complete and accurate set of
information to facilitate effective and `efficient patient care management.
HEALTH RECORD STANDARDS
International Health Record Standard (Joint Commission International

Accreditation Standard)
 The healthcare facility maintains health records that are documented

accurately and in a timely manner are readily accessible, and permit
prompt retrieval of information including statistical data.
 The health record contains sufficient information to identify the patient,

support the diagnosis, justify the treatment and document the course and
results accurately.
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 Health records are confidential, authenticated, legible and complete.
 The Health Info Mgt Department is provided with adequate direction,

staffing and facilities to perform all required functions.
Philippine Health Record Standards
 The health record shall be sufficiently detailed to enable:

o a patient to receive continuing care;
o effective communication within the health team;
o the attending physician to have available information required for
the consultation;
o other medical practitioners and health personnel to assume the
patient care; and
o concurrent or retrospective evaluation of patient care.
 Entries in the health record shall be made only by duly authorized staff of
the facility including dates and signed with corresponding designation.
 All entries, including alterations, shall be legible.
 Only abbreviations and symbols accepted by World Health Organization

(WHO) or the Medical Record Committee (MRC) of the healthcare facility
shall be used.
 Original medical records prepared by the medical nursing and allied

health professionals shall be filed in the health record.
 Each health record shall contain the following demographic data of the
patient:
o Unique patient identifier
o Patient’s full name
o Address
o Date of birth
o Gender
o Civil Status
o Religion

o Person to notify in case of emergency An “ALERT” notation for

conditions such as allergic responses and Adverse Drug Reaction
shall be prominently displayed on the Admission and Discharge
Record.
 The health record shall contain a written admitting diagnosis by the

medical practitioner who admitted the patient.
 The health record shall contain patient’s history, pertinent to the condition
being treated, which are relevant details of:
o Present and past medical history

o Family history
 A sufficiently detailed report of a relevant Physical Examination (PE),

performed by a medical practitioner, shall be included for the purpose of
admission.
 Properly filled up and accomplished consent forms shall be attached to

the health record, in cases where medical/surgical operations and
procedures are done.
 Drug orders shall be written in the health record by the medical staff.
 Therapeutic and special diagnostic test orders shall be reflected in the

health record.
 There is evidence in the health record that patient care plans were made.
 Progress notes, observations, and consultation reports shall be written by

medical, nursing, and allied health staff to record all significant events
such as alterations in the patient’s condition and responses to treatment.
 The Admission and Discharge Record is completed at the time of

discharge or as soon as all relevant information is available. It shall
contain all diagnoses and procedures using terminology based on the
International Standard Nomenclature of Medicine.
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 A discharge summary for each patient shall be completed upon patient’s

discharge. The discharge summary shall include the following:
o Discharge diagnosis
o Procedures performed
o Follow-up arrangements
o Therapeutic orders (Home medications)
o Patient home instructions
 When a patient is discharged or transferred to another facility, a certified

copy of discharge summary shall be issued.
 When an autopsy is performed, a provisional diagnosis is noted in the

health record within 72 hours. A copy of the autopsy report shall be filed
in the health record.
POLICIES AND PROCEDURES
A policy is a general guide to decision-making. It is a framework consistent with

the organizational objective to help managers make decisions.
A procedure is a specific guide to decision-making. It is a tool for implementing

a policy and a series of inter-related sequential steps.
Health Record Completion
 The patient’s health record shall be forwarded to the HIMD within 24

hours after discharge.
 History and PE shall be completed within 24 hours upon admission.
 A health record with pending diagnostic results shall be completed in

the HIMD within 15 days after the patient’s discharge; otherwise, it
shall be considered a delinquent health record.

 The attending physician has the major and final responsibility for the
completeness and accuracy of the data entry in the health record. He is
also encouraged to raise the level of quality of the individual health record
and sustain a high level of recording.
 The accomplishment of History, Physical Examination, and Discharge

Summary may be delegated to the residents and interns. However, these
forms shall be reviewed, corrected and countersigned by the attending
physician.
 The HIMD staff shall assist the attending physician in reviewing records
for completeness by checking for omissions and discrepancies to ensure
that health records comply with set standards and policies.
Release of Health Information
The HIMD receives many and varied requests for information contained in the
health record. It is therefore emphasized that great caution shall be exercised in
releasing any information and this should be done in accordance with the
existing health record standards and policies.
The health record is a confidential document and the patient's right to privacy of
patients must be the primary concern in the release of health information. The
clinical information contained in the health record is a confidential communication
between the doctor or other health professional and the patient.
Release of health information is a very sensitive issue in several aspects. The

confidentiality of the health record shall always be the concern of people
involved in the release of health information.
General Policies
 The healthcare facility shall safeguard all information contained in

the health record against loss, destruction, or unauthorized use.
 All information in the health record shall be treated as confidential

and shall be disclosed only to authorize individuals.
35
 It shall be the policy of all healthcare facilities not to use the health record
in a way which will be jeopardized the interest of the patient. But the
healthcare may use the record to defend itself against any complaint or
legal controversy or case.
 The release of information is delegated to the supervisor of the Health

Information Management Service. But in cases where a problem arises
beyond his/her control, it shall be referred to the Chief Administrative
Officer/Chief of the Health Care Facility for appropriate action.
 Release of information with clinical value shall be done only with the
written consent/waiver from the patient.
 Where the patient is a minor, a parent consent or that of the legal guardian
shall be secured before any information of clinical significance is released.
 The health record is the physical property of the healthcare facility.

However, the patient has a right to the record since its content concerns
his/her own clinical information.
 In cases where litigation is likely to happen and is intended against the

health care facility or any of its staff, the Chief of the Health Care Facility
may refuse or deny access to the record even with the patient’s written
authorization, except on court order.
 Request for Medical Certificate or Clinical Information when the patient is

still confined shall be referred to Attending Physician.
o Certificate of Confinement, signed by the head of the HIMD, shall

be issued while the patient is still confined in the health care
facility.
o Medical Certificate shall be signed by the attending physician

when the patient is already discharged.
o Medico-legal Certificates shall be duly signed by the Attending

Physician and/or by the Chief of the healthcare facility and
released with dry seal.

o Certificate for Serious and Less Serious Injury (to be established as

additional certificate)
 Certified photocopies of a patients’ health record shall be released but

limited to the following:
o Discharge Summary/Clinical Abstract
o Laboratory and diagnostic results
o Report of Operation
 Information of no clinical value can be disclosed by the staff of the

healthcare facility when there is no hold order from the patient. However,
institutional policy shall be considered before the release of non-clinical
information. Such information includes the following:
o Name
o Address
o Attending Physician
o Name of relative staying with patient during admission
o Admission and discharge dates
 The health record shall not be taken out of the healthcare facility premises
except on court orders. Those authorized to do research and studies shall
use the records inside the HIMD.
 Incomplete health record shall be referred to the Attending Physician

before entertaining any request to access and review the health record.
 Verbal request for clinical information shall be discouraged in favor of

written requests.
 The staff of the Medical Social Service shall have access to the health
records for purposes of establishing patient classification and referrals.
 Information may be released to other health care facilities thru the

coordination of Health Information Service, upon written request that the
patient is now under their care.
37
 Health care facility management may permit the use of health records for
research and studies provided that no information which may directly
identify the patient shall be published.
Specific Policies
 Physicians
o Physicians and members of the allied health profession may review

records of patients presently under their care.
o Physicians who are members of the medical staff but not members of
the team assigned to the patient shall be armed with a written
authorization signed by the patient/parent/guardian and the
Attending Physician before they are given access to the record.
o The privilege against disclosure belongs to the patient and not the
treating physician, therefore, the patient has the right to claim it. It
is a good practice however to notify the Attending Physician prior to
the release of any information, as a sign of courtesy.
o The health care facility management may withhold access to the

health record until a subpoena is issued.
o Outside physicians intending to do research/studies in a particular

health care facility shall seek the written approval of the
management before they are given access to the health record.
o Insurance company physicians/verifiers shall present a notarized

authorization from the patient, or a duly accomplished original
insurance waiver, before given access to health record.
o Company physicians who are presently caring for a patient may be

given access to the patient’s health record only upon presentation of
patient’s written request.
o Consultants shall have access to records of patients referred to them.

o It shall be the responsibility of the attending physician to inform

his/her patient about his health condition.
o The Medical Staff may borrow/sign-out health records of re-

admitted patients for reference purposes.
 Nurses
o Student nurses shall have access to a patient’s record who is assigned

to them while the patient is still in the ward.
o Private Nurses shall only be allowed to review the health records of

those patients assigned to them.
o Ward nurses may review and complete all health records for purpose
of compliance before these are forwarded to the Health Information
Management Service.
o Ward nurses must always see to it that health records are in a secure
place away from the patients or the patients’ relatives.
o Ward nurses shall be liable to the loss of a patient’s health record

while the patient is still admitted and these records of discharged
patients which are not yet submitted to the HIMD.
 Other Concerns
o An insurance verifier shall be required an original copy of the

waiver duly notarized before being given access to the health
record/information about a patient. The copy of the waiver shall also
be countersigned and dated by the insurance verifier and shall be
filed with the record. Insurance verifiers representing Philippine
Health Insurance Corporation and other Health Maintenance
Organization shall be properly identified by the head of the HIMD
before given access to review health records for reimbursement
purposes.
39
o Researchers from other medical institutions could gain access to

health records only after complying with the requirements set by the
concerned institution.
o Patient’s relative making inquiries about the health status of their

patients shall be referred to the attending physician.
o Adjudicatory agencies from Philippine National Police, National

Bureau of Investigation and other law enforcement agencies shall
need a written request duly signed by the Chief/Director of their
respective agency before being given access to the record.
o A patient’s right to access to their record may not be allowed to

prevent misinterpretation of technical medical information which
may lead to complaint / litigation. However, the patient’s physical
and mental condition shall be explained only by the attending
physician.
o Health information may be release by the healthcare facility without

the written authorization of the patient in the following situations:
- Court Order. A hospital or other healthcare facilities shall

release health information in response to court orders.
- Administrative Agency Order. A healthcare provider shall

release health information when there is an adjudicative order
from an administrative agency authorized by law.
- Subpoena. In a court proceeding, a party or an administrative

agency may issue a subpoena, subpoena duces tecum, or notice
to appear covering health information held by a healthcare
provider. Where the subpoena is valid, the healthcare facility
shall disclose the health information.
- Subpoena duces tecum or notice directing the head of the

HIMD to appear in court on a specified date and time shall be
served within five (5) working days prior to scheduled court
hearing.

- Subpoena ad testificandum mandates physicians and other

allied health professionals to deliver oral testimony in court
and shall be served personally to the individual named
therein.
- Subpoena mandamus is a judicial order that mandates a

healthcare facility in relation to compulsory presentation of a
health record in court.
- Arbitration Order. An arbitration panel may issue an order

authorizing the discovery of health information in an
arbitration proceeding.
- Search Warrant. A government law enforcement agency

which has been issued a search warrant shall be entitled to
receive any health information covered by a warrant.
- Medical Research. Health information shall be disclosed to

public agencies, clinical investigators, health care
organizations or accredited education or health care
institutions for purposes of bonafide research duly approved
by the Research and Ethics Committee of the healthcare
facility. But before the medical information is released, the
health record staff shall take reasonable steps to ensure that
the research is legitimate, and proper safeguards in the release
of information are instituted.
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Systems and Procedures
4 SYSTEMS AND
PROCEDURES
____________________________________________________________
HEALTH RECORD IDENTIFICATION SYSTEM
An effective and efficient health record system depends on how well the HIMD
supervisor chooses the systems and procedures which shall facilitate handling of
health records.
In the effective management of health record specifically in identifying, the

medical record two things are highly considered. First, is the correct and
complete name of the patient and second, the assigned health record number
(HRN). These are considered the most important patient identifiers in the
The patient’s name is recorded in the following manner, last name, followed by
the first or given name, and lastly, the middle name. The HRN is assigned to a
patient upon admission or consultation. A unit number is recommended for
effective management of voluminous records.
The use of the patient’s name is a way of alphabetically identifying the health
record in a healthcare facility and the assigned HRN serves as the numerical
system of identifying the health record. The name and the assigned health record
number serve to uniquely identify a particular patient in a healthcare facility.
The use of a unit number to uniquely identify a patient has a direct influence on
the filing system for prompt and timely retrieval of health record. In order to
avoid duplication and discrepancy, a unique record identification is needed
whether in alphabetic or numeric.
43
Alphabetic System
Alphabetic System is the simplest form of record identification, using the

patient’s name to identify and file the patients’ health record.
Advantages:
 The easiest method of record retrieval is the master patient index as there
is no need to cross reference the patient name to the health record number.
It is necessary to train staff to verify patient’s names and spellings.
 An accurate and consistent health record filing.
 Most practical in small healthcare facilities without a computerized

system.
Disadvantage:
 In this type of record identification, patient’s confidentiality, is not

safeguarded.
Numerical System
The Numerical System employed has a direct influence on the filing system.
Upon admission, the patient’s unique Health Record Number shall be assigned.
The use of a Master Patient Index (MPI) to cross-reference the patient’s name
with his or her HRN is required.
Two main systems of numbering the patient health record:
 Serial Numbering
Under this method, the patient receives a new number on every inpatient
admission or out-patient visit to the healthcare facility. That is, the patient is
treated as a new patient each time with a new number, new index card and
new record, filed totally independent from the previous health records.

Serial numbering is only useful in a small healthcare facility with a low (rate
of re-admission.) daily census.
 Unit Numbering
The patient is assigned a unique identification number on his first contact

with the healthcare facility, whether it is for an admission, emergency room
attendance or outpatient clinic visit including healthcare facility newborn
babies shall be assigned an HRN. The use of unit-number leads to the
implementation of a unit record. Irrespective of the number of records a
patient has, his/her health records are filed in one folder only.
The same number is maintained and used on all subsequent visits, whether
as an inpatient, outpatient, or emergency patient. Having one number
assigned per patient and only one Master Patient Index card results in
easier access to the patient’s health record.
When using a unit record, it is important to note that it is essential for all
HIMD staff to check the MPI before issuing a new health record folder.
Advantages of Unit Numbering
o Provides an integrated overall picture of a patient’s medical history

because all records of admissions, visits and encounters are
maintained in one folder only, commonly known as a unit record .
o Eliminates the task of gathering separate parts of a patient’s health

record together, like in the serial system where a new number is given
to a particular patient after every admission or visit.
o Eliminates the task of transferring the previous health record to the

new location and assigning a new admission number.
The Unit Number. A patient who is admitted or attended as an outpatient,

or on an emergency basis including a newborn baby is issued a six-digit
identifying number. This is the patient’s unit number also called the Health
Record Number (HRN).
45
The HRN is grouped into three sets of two-digits. These are referred to as
the primary, secondary and tertiary numbers.
Example of a unit number:
16 55 82
Tertiary Secondary Primary
Assignment of the Unit Number. The collection of patient data and the
assignment of the HRN should be the first step in every admission or visit
to a healthcare facility and it is done at the Admitting Office/Outpatient
Department (OPD). This facilitates the retrieval of properly identified
documents.
Two ways by which numbers can be assigned are:
o Centralized Assignment of Numbers. The responsibility for number

allocation is retained at the Admitting Office in coordination with the
HIMD.
o Decentralized Assignment of Numbers. Pre-determined blocks of

numbers are issued to the Admitting Office/OPD. This is done by
the hundreds, depending on the projected number of patients for the
day. This process should be done with outmost care as chances of
duplication are greater compared to when only one area is in charge
of assigning patient numbers.
Six digit numbers are used ranging from 00-00-00 to 99-99-99. The
very first health record received by the HIMD shall be numbered 00-
00-00, the second health record, 00-00-01, and so on, until the first
hundredth record, which shall be numbered 00-00-99 is reached. The
record after this shall be numbered 00-01-00, the next, 00-01-01,
followed by 00-01-02, and so on until it reaches 00-01-99. Next shall
be 00-02-00 to 00-09-99 then from 00-10-00 to 00-99-99, next 01-00-00
until 99-99-99.
Numbering of the records shall be done serially and the necessary

digits are added to complete the required six digits. An HIMD
maintaining a centralized health records-keeping system must keep

numbering patients regardless of whether the health record is for in-

patient or for out-patient. The HIMD with a decentralized health
records-keeping system shall maintain a separate number for an in-
patient, out-patient record, and E.R. patient’s records.
From the time the HIMD starts implementing the unit numbering
system, the last health record that you receive in any given day plus
one (1) shall represent the total number of patients that the
healthcare facility has served. Hence, if the last number assigned is
00-20-99, the healthcare facility already has served a total of 2,100
patients.
Assembly of Health Record
After receiving the inpatient health records from the Nursing Service, the HIMD
performs essential procedures prior to filing and storage.
In assembling the health record, the forms are arranged in the order upon
admission of the patient, to give the Attending Physician and other health staff
who shall handle the health record a clear picture of the health condition of the
patient in its chronological order.
 Source Oriented Health Record
This is the conventional form of arranging the health record. The patient’s
health record is organized in sections according to the patient care
department which provides care and the corresponding diagnostic results
as the case maybe. The health record is arranged in reverse chronological
order for the convenience of the doctors in the ward and those forms
frequently used appear on top of the file of forms. Upon the patient’s
discharge, the HIMD re-arranges the health record based on the approved
sequence or arrangement.
Advantages
o It is easy to determine the assessment, treatment and observations

which a particular department has provided.
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o Most health professionals are familiar with this conventional or

traditional way of arranging the health record.
o This results in prompt and easy retrieval of needed data/information.
Disadvantages
o Prompt determination of all the patients’ problems is not facilitated

promptly.
o All treatments provided to the patient cannot be determined easily.
 Problem Oriented Medical Record
Problem oriented medical records or the “POMR” is another form of

structured health record. First developed by Dr. Lawrence Weed in the USA
in the late 1970s, and is structured as a total approach to patient care. It
prompts the staff to take a comprehensive and structured look at a patient’s
problem and treatment. It requires health professionals to approach all
problems of a patient, treat each problem individually in its proper context
within the total number of problems, and the inter-relationship of the
problems.
This is the most logical format of arranging the health record and it is
computer-based and research-based as well. The four basic components of
this format are as follows:
o Database - Collection of data
The database includes the following information:

- Chief complaints
- History of the Present Illness
- Patients profile
- Past history and review of the system
- Physical examination results
- Base-line laboratory plan

o Problem List - Formulation of problems
The problem list is a mere listing of all the problems which need
medical management. Problems are numbered and titled from the
most to the least severe complaint of the patient. The list may include
anything that requires management from past to social, economic, and
demographic problems. It may also contain a statement of a symptom,
an abnormal finding, a physiological finding, or a specific diagnosis.
Addition or changes are made in the list as new problems are
identified and active problems resolved.
o Initial Plan - Development of a care plan
The initial plan describes the steps to be taken in order to learn more
about the patient s condition, the treatment to be applied, and ways to
educate the patient about his physical condition.
Specific plans for each problem are delineated and fall under three
categories:
- Diagnostics – plans for collecting more information
- Therapeutic – plans for treatment
- Patient education – plans for informing the patient on what is to
be done
Problems are dated, numbered and titled with the problem status
clearly defined as active, inactive or resolved.
o Progress Notes - Numbered and titled progress notes
The progress notes are follow-ups for each problem. Each note is
preceded by the number and title of the appropriate problem and may
include all of the following elements:
- Subjective (symptomatic) – written in the patient’s own words.

- Objective (measurable, observable) – doctor’s observation and
test results.
- Assessment (interpretation or impression of the current
condition)
- Plan statements for contained treatment.
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The acronym for this process is SOAP, and the writing of progress
notes in the POMR format is often referred to as SOAPING.
The emphasis is on unresolved problems. A slightly different way to

describe the patient’s progress, other than the narrative method
mentioned, is through the use of flow sheets. Flow sheets are
recommended in situations where several factors are being monitored
or when the patient’s condition is changing rapidly.
The discharge summary and transfer note are also included in the
progress note category. These should address all the numbered
problems on the patient’s list. It may be necessary for the physician to
use an over-all summary and use flow sheets to clarify the patient’s
progress. It is recommended that certain forms (e.g. physician’s orders,
consultant’s reports, and nurse’s notes) be done in the problem–
oriented style with reference to titled and numbered problems. Other
data in the record may be in the conventional format, such as
laboratory and operative reports.
Advantages
o Physician is required to consider the patient’s problems in its total

context.
o The record clearly indicates the goals and methods of the

physician in treating the patient.
o Medical education is facilitated by the documentation of logical

and thorough processes done by the attending physician.
o Quality assurance process is easier because the data is logically

arranged.
Disadvantages
o The format usually requires additional training for the medical

and professional staff.

o To be effective in a facility, a significant number of physicians

must be convinced of the system’s worth or at least must be
willing to try it.
 Integrated Health Record
In the integrated format, the information is organized in strict reverse

chronological order, with the most current entries at the beginning of the
health record. The forms from various sources are intermingled, thus, history
and physical examination may be followed by a progress note, a nurse’s note,
an x-ray report, a consultation, and so on. The forms for each episode of care
are organized in separate sections of the record.
Advantages
o All information on a particular episode of care is in a single file, thus,

providing a clear picture of the patient’s illness and response to
treatment.
o A patients’ progress can be determined promptly because the current

notes of all disciplines are incorporated in one file.
o The number of specialized forms is reduced.
o The team concept of health care is encouraged.
Disadvantages
o It is difficult to compare similar information over a series of admissions

because the reports are not in the same section as that of the record.
o Only one person can document at a time.
o It may be difficult to identify the professions/positions of the

individuals making the entries unless notes are always followed by the
title of the record.
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Analysis of the Health Record
One of the most important functions of the HIMD is the health record analysis to
ensure maintenance of quality documentation.
The health record reflects the quality of care rendered to patients. As such, at
any point in time during admission and consultation, the record should
accurately and clearly document the care provided.
Since the major concern of most doctors and nurses is the care of the patient and
documentation and/or recording of data is just secondary to patient care most
health records forwarded to the HIMD are lacking in some important
requirements.
The HIMD is responsible in assisting the members of the medical and allied
medical staff in spotting deficiencies to correct errors and omissions. Analysis is
the process of evaluating and/or checking health records to ensure
completeness, accuracy and adequacy of documentation. Both quantitative and
qualitative analysis should be performed on the health record.
DOCUMENTATION STANDARD
The general documentation guidelines used to ensure quality documentation are

as follows:
 There must be a health record for each patient confined/treated in the

 Documentation in the health record must reflect the patients’ physical

condition, and the orders and care provided from admission to discharge.
 Documentation must reflect observation and must be objective and non-

judgmental.
 There must be a standard format for health record documentation which

must include demographic and assessment data.

 A unit record must be maintained for each patient. This shall include all
admissions and consultations to the healthcare facility, discharge
summaries and quality documentation by the physician and other inter–
disciplinary team members who participated in the care of the patient.
 All documentations must be legible and written in ink or typewritten.
 Any person making an entry on the health record must date and sign his
entry or properly authenticate the entry made.
 Documentation of the inpatient health record must be completed within

48 hours upon the patient’s discharge. History and Physical Examination
must be completed within 24 hours upon admission of the patient.
However, outpatient health records must be endorsed to the HIMD daily.
 Every healthcare facility must develop an ongoing review of health

records to assure quality documentation. This must be one of the major
functions of the Medical Records Committee.
 It must be the policy of every healthcare facility not to allow the use of
abbreviations in writing the diagnosis. But for symbols which might be
written by the authorized person, an explanatory legend shall first be
approved by the said healthcare facility.
 Short forms like laboratory and other results must be securely fastened to
the health record to prevent loss.
 The health record is a legal document, so no form maybe detached once it

is filed. Furthermore, there must be no erasures of any sort. In order to
correct an error, the following shall be done:
o Draw a single line through the information to be corrected or

changed.
o Affix the attending physician’s initial, date and time.
o Write the correct entry near the information to be corrected.
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 In cases where the patient wants some data corrected especially on the
demographic/sociological data, the correction should not be done on the
original entry, but shall appear as an amendment only.
 The health records must contain all original copies of examination

results, operations, and other required forms.
The inpatient health record must be completed and it must include the following
forms properly accomplished, signed, and dated:
 Patients’ data sheet which includes personal data like name, address and
other social data.
 Admitting and final diagnosis, as well as a description of any operation

and procedures performed.
 History sheet which contains the chief complaint, personal and family
history (past and present).
o Past history records the previous operations and illnesses of the

patient, particularly those that might be related to the present illness.
o Social history presents facts about the patient’s life and habits that
might affect his/her condition. If, for example, he/she has an allergic
condition, it may be important to know his/her diet, pets he/she
owns, the plants that grow around his/her house, and the materials
he/she comes in contact with at work and at home.
o Family history records the diseases which members of the patient's

immediate family have or had which might directly affect the patient
either through heredity or contact.
 Physical examination sheet contains all pertinent (positive and negative)

findings and impressions.
 Physician's order contains all of the doctor's orders.

 Diagnostic and other report sheet contains the results of all laboratory,
radiologic and other procedures.
 Progress notes sheet includes the doctor's positive and negative

observations and comments. It gives a chronological picture of the clinical
condition of a patient.
 Discharge summary summarizes the significant findings and events

occurring during the patient's hospitalization, final diagnosis, operation (if
performed), complications (if any), condition on discharge,
recommendations and arrangements for future care (OPD, follow-up
treatment), and classification of injury (if it is a medico-legal case).
 Anesthesia record (if an operation was performed).
 Report of operation records which authenticate a pre-operative

diagnosis before surgery. The record shall then contain a report of all
findings, a description of the surgical technique used, a description of any
“tissue” removed, and a post-operative diagnosis.
 Nurses' notes (recorded in a brief narrative style) contain the notes of all
the nurses who care for the patient. These include their observations of the
patient the treatment given, the response to treatment, and any unusual
occurrences. The first page shall always contain a record of checking the
patient in the unit, recording his/her physical condition at the time, and
the listing of personal belongings he/she has brought with him/her. The
admission portion is completed when the patient is first admitted to a
particular nursing unit; while the discharge portion is completed when
the patient is discharged from the unit. The discharge notes shall include
basic information such as the time of discharge, the condition upon
discharge, and person with the patient. This also includes the medication/
instructions and the advice for follow-up consultations.
 Certificate of Livebirth, Fetal and Death Certificate, if either of these

events occurred.
 Other records contain medication and treatment, vital signs record, etc.
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Quantitative Analysis of Health Record
After recording and assembly, the health record undergoes the process of
analysis. The analysis clerk shall perform the following:
 Check basic forms required by the case.
 Check all the forms which are explicitly ordered.
o The analysis clerk shall read the doctor's order and countercheck it
with the nurses' notes to confirm whether or not the order was
carried out.
o When the nurses' notes state so, the analysis clerk shall see to it that
the result of such an order is attached.
o The analysis clerk shall check on the explicitly ordered forms. (Forms
included in a block)
 The analysis clerk shall check all the required information.
o Every page should contain the name and HRN of the patient.
o Every form shall be properly filled-up.
o Accounts of all tests, treatments, and observations shall be reflected

in the record.
 The analysis clerk shall check all necessary authentications.
o Check whether all reports of treatment, medication, examination or

evaluation of the patient were dated and signed by the person who
made the report.
o Check if all orders were dated and signed.
o Verbal, telephone and Short Message Service (SMS) orders of the

doctor received and written by a licensed nurse on the health record

were signed and dated by the nurse and countersigned by the doctor
as soon as possible.
 Analysis clerk shall check if all necessary authorizations are attached to

the health record.
o Check if the authorization was dated, signed by the patient, and

signed by a witness (these are needed in order for the authorization
to be considered valid).
o Check if special procedures performed had corresponding

authorization.
o If there was surgical intervention, check if there is surgical consent.
Qualitative Analysis of Inpatient Health Record
Analysis clerk shall check for errors or unexplained inconsistencies.
 Check spelling of names and correct Health Record Number.
 Check if there are inconsistencies between one part of the record and
another (e.g., if the pre-operative diagnosis differs from the post-operative
diagnosis), the discrepancy shall be noted and/or referred to the
attending physician.
 When the analysis clerk finds an incomplete health record, a “Deficiency

Slip” shall be attached and placed in a pigeon hole for completion.
Qualitative Analysis of Outpatient Health Record
After receiving the outpatient health record, the clerk shall perform the
following:
 Check all information required by the case.
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o Check if every page contains the name, age, sex and Health Record
Number of the patient.
o Check if accounts of all tests, treatment and observations are

reflected in the health record.
 Check necessary authentications.
o Ensure that all consultations are properly documented together with

the physician’s name and signature.
o Check if all orders are dated and signed.
 Checks for errors or unexplained inconsistencies such as spelling of

names, HRN and other information.
 Review health record and assign disease and operation code
CODING
It is a process of assigning numbers to represent diagnosis or problems and

surgical procedures. This is done to allow for a systematic sorting of medical
records by diagnosis and operations for easy retrieval. Coding is performed to
meet internal and external demands for information. Internally, coding, when
done correctly, helps achieve accurate, precise, and meaningful statistics which
may be used by the management to plan and evaluate program implementation.
Likewise, these act as an aid to assess the quality of care rendered and to make
decisions about staff, facility and resource allocation. Externally, other agencies
and third party payers use this information to forecast healthcare needs, evaluate
the utilization of healthcare facility and the appropriateness of health care cost,
and conduct epidemiologic studies.
All diagnoses shall be coded using the International Classification of Diseases

(ICD-10) or any available coding tools approved by the DOH. Every final
diagnosis and complication or operation performed is listed on the face sheet by
the relative value scale code mandated by the Philippine Health Insurance
Corporation (PhilHealth), the health accreditation agency. These codes should be
entered in the correct order in the marked area.

The coder is expected to determine if a diagnostic statement is complete or not

prior to actual coding basically because integral to coding is analysis of specific
parts of the medical record pertinent to coding which will ensure quality coded
data
When the code numbers have been entered on the face sheet they should also be
recorded on the cards making up the “Disease Index”. These cards should be of
good quality to withstand considerable handling. A 5”x 8” card printed on both
sides shall be used.
Since doctors often require medical records from a certain year when doing
research (studying) the treatment of a particular disease (diagnosis), the
recording of “other diseases” by their codes would enable doctors to clearly
define the particular records they wish to review base on the parameters of their
research (study).
Health records are coded to enable the retrieval of information in diseases and
injury. This information is used:
 at a national level for planning a healthcare facility

 determining the number of healthcare staff required
 educating the population and health risks within their country
 used at international level in comparing the health status of countries.
Diagnosis is a statement by the physician of the patient's health problem.
 Admitting diagnosis is the condition stated on entry (prior to entry) to the

health care facility as the reason for hospitalization.
 Working diagnosis is a diagnosis that describes a condition arising after

admission that modifies the course and treatments of the patient's illness
or the healthcare required.
 Final or discharge diagnosis is/are the condition/s stated at the time of

discharge.
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Steps in Coding
 Locate the main term in the alphabetical index.
 Refer to any notes under the main terms.
 Refer to any sub-terms indented under the main term.
 Follow cross-referencing instruction, if the needed code is not located.
 Verify the code number in the tabular list.
 Read and be guided by any instructional terms.
In cases of death, the discharge diagnosis will be the underlying cause of

death and all other diseases.
INDEXING
Disease index is a numerical listing of patient’s health records by code number

assigned to diseases and/or condition for which the patient is treated.
Steps in Indexing
Provide an index card for every coded disease.
 Record the ICD-10 code, disease and year for every Disease Index Card.
 List down the following based on the patient’s health record:

o Health Record Number
o Patient’s Name
o Age
o Sex
o Other Disease
o Result
o Operation (if any)

o Date of Admission
o Date of Discharge
o Disposition/Result
o Attending Physician
 When a particular card is filled-up, a new one should be added to be filed

in front of the old one.
 When the year ends while a card is still unfilled, a line should be drawn
under the last entry to show the cut-off date.
 Index cards should be kept in file drawers.
FILING OF HEALTH RECORD
Filing Systems
An effective and efficient filing system is a vital requirement in the HIMD. All
health records shall be filed in one established sequence. An adequate filing area
that will ensure the rapid location and retrieval of health records must be
maintained. The following are the systems of filing health records:
 Alphabetical filing system
When no health record number is assigned, and the patient’s name is the
only identifier, then the alphabetical filing is the only possible method to
use. All records of discharged patients are filed in strict alphabetical order
from A to Z. Filing is by patient surname first, then given name and last the
middle name.
This method of filing system is only useful for healthcare facilities with
limited patients and a small filing area.
 Numerical filing system
61
When a numerical record identification system is adopted, then a numerical

filing system is used. There are two systems of filing records numerically:
straight numeric and terminal digit.
Terminal Digit Filing System
For terminal digit, a six-digit number shall be used and divided into three
(3) parts.
o Part 1 – The PRIMARY digits which are the last two (2) digits on the
right hand side of the assigned number.
o Part 2 – The SECONDARY digits which are the two (2) middle
numbers.
o Part 3 – The TERTIARY digits which are the first two (2) digits on the
left of the assigned number.
For example, the unit number 19-30-90 is divided as follows:
19 30 90
Tertiary Secondary Primary
The inpatient’s health records of a healthcare facility shall be filed and

stored in terminal digit-filing system. This means that they shall be filed in
the order of primary digits (that is, last two digits of the HRN and then the
secondary digits and finally the tertiary digits).
When filing health records under the terminal digit system, the unit number
shall be first considered. This shall be divided into three parts- in pairs of
digits. Taking health record 509326, this divides as follows- 50-93-26 and the
process of filing commences by considering the part of the number on right
hand or “terminal” digit. The filing area shall have 100 terminals (primary
sections) starting from 00, 01, 02, 03, 04, 05, ... 99.
When filing, the clerk shall take the health record to the primary section
corresponding to the terminal pair of digits. Once in the right terminal, the
row of records shall be located by considering the secondary or the middle
number which, in the above example, “93”. Within each secondary section,
health records shall be filed in order of their tertiary (left hand) pair of

digits. Every 100 processed records shall be equally distributed throughout

the 100 terminals.
If someone is looking for a record, it shall be in the order shown below (or a
tracer shall be in its place).
An example of sequence is:
46-52-02 98-05-26 98-99-30

47-52-02 99-05-06 99-99-30
48-52-02 00-05-05 00-99-31
49-52-02 01-06-26 01-00-31
Note: A misfiled record may take hours to locate or could be lost forever.
File all records correctly.
06
05 51
04 51 10
03 51 10
02 51 10
01 51 10
00 51 10
51 10
10
Advantages of terminal digit filing
o Records are easily distributed throughout the 100 primary sections.
63
o Only every 100th new health record shall be filed in the same primary
section of the file.
o Elimination of personnel congestion in the filing area.
o Staff shall be assigned responsibility for certain sections of the filing

area.
o Work can be evenly distributed among the HIMD staff.
o Inactive health records may be pulled out from each terminal digit
section as new ones are added, thus eliminating the need to backshift
records.
o Misfiled records are reduced.
Disadvantage of terminal digit filing
It requires adequate storage area for the implementation of one hundred

(100) primary sections.
Types of Filing Systems
 Centralized Filing System
o The records of the patient shall be filed in one location, usually the
Health Information Service Department.
o The patient may have different health records (in-patient records,

emergency room record, outpatient record) but they shall be brought
together in one unit record, or at least filed under the same number in
the same place.
o The main objective of the Health Information Management

Department is to maintain a continuous health record of a patient,
which shall be available at all times.. The implementation of a unit
number and a centralized record filing system is the best way to
achieve this objective.

 Decentralized Filing System
o The health records of the patient shall be filed in multiple patient care
areas.
o This maybe under the same unit number if the HIMD is maintaining a
unit record or with totally unrelated numbers if serial numbering is
employed.
o Under strict supervision by the Health Information Management

Supervisor, the HIMD staff shall maintain centralized records keeping
because it is cost effective in terms of resource utilization and effective
supervision can be attained if only one system is employed
Other Considerations in Filing Systems
Management of Misfiled Health Records
 A system of ensuring that no file is missing or misfiled shall be in place.
 In locating misfiled records the following shall be applied:
o Check for the transposition of digits in a number. For example, 963615

may be filed as 963651 or 693615.
o Check for missing files under similar looking numbers such as “3”
under “5” or “8” or vice versa. Or “7” or “8” under “9”.
o Check for a certain number such as 714 under 713 or 715 or under a
similar combination.
o Check for the transposition of the first and last numbers.
o Check the medical record immediately before and after the particular
missing record.
65
o Check the shelf immediately above and below where the record should
be filed.
 The file room shall be checked once a month to ensure that:
o All records are standing straight on the shelves.
o There is no dust on the shelves (including the very top shelves).
o The floor should be clean.
Management of Loose Sheets
Vast quantities of unattached laboratory, ECG, and other tests results (loose
sheets) are produced daily and make their way to the Health Information
Department. These reports contain vital patient information and it is essential
that they are filed promptly and accurately to maintain complete, comprehensive
and effective health records.
 Sorting
Loose sheets are delivered to the HIMD from the different services or clinics
of the healthcare facility. The in-patient sheets should be separated from the
out-patient loose sheets in a decentralized health record keeping system.
Then they shall be pre-sorted terminally in preparation for the actual filing
process. The procedure shall be as follows:
o Separate loose sheets which have been stapled together
o Date stamp all loose sheets received
o Check names and numbers on the loose sheets
Note: For loose sheets forwarded to the HIMD without corresponding

numbers, the Master Patient Index shall be consulted.
 Locating the record

When using the manual system, an in-house box shall be maintained to

determine whether or not the patient has already been discharged.
For patients whose names are not in the in-house box, the MPI shall be
consulted for the HRN, then the health record shall be retrieved from the
permanent file area.
Health Records which are not in the permanent filing area shall be recalled
from the respective borrower in order to incorporate loose sheets.
Any loose sheets that were not filed the first time shall be retained for a
future attempt.
 Filing Loose Sheets
The patient’s HRN and date on the report shall be checked and re-checked
if they correspond to the number and date indicated on the health record.
o The loose sheets shall be refilled using the “Assembly of Health

Records” list as a guide to correct filing order.
o Reports from each department shall be filed chronologically within

each admission.
o Statistics on loose sheets received by the HIMD shall be maintained

for any administrative use.
Rules on Alphabetical Filing
 Place the surname first, then the given name, followed by the middle name
and file in strict alphabetical sequence.
 Arrange index cards in alphabetical order.
 When a patient requires more than one card to accommodate all of his
admissions, the cards shall be arranged in chronological order, with earliest
first, working from front to back in the drawer.
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 If there is more than one person with the same surname and given name,
the cards shall be arranged alphabetically by middle initial. If no middle
initial is given, the cards shall be arranged according to birth date, filing the
oldest card first.
 Names with prefixes of D, dela, De, Des, Di, Du La, Mc, Mac, Ma, Van, Von,
etc. shall be filled alphabetically as D-e-l-a-C-r-u-z; D-e-l-a-F-u-e-n-t-e.
 Names beginning with Sta. and St. shall be filed as S-a-n-t-a and S-a-I-n-t, as
in S-a-n-t-a-M-a-r-i-a and S-a-i-n-t.
 Compound or hyphenated names shall be filed as one word; thus,

Navarette-Clemente shall be filed under N-a-v-a-r-e-t-t-e- C-l-e-m-e-n-t-e.
 Names with religious title such as Reverend, Mother, Father, Brother, and
Sister shall be filed under the surname, the titles disregarded followed by
the given name. Father Jose Romero is filed as Romero, Jose or Romero, Jose
(Father).
 If an initial is given instead of a person’s first name or middle name, the

rule is “file nothing before something” Thus, J. Romero shall precede M.
Jose Romero and Miguel Jose Romero.
 It is customary for people of Spanish descent to combine the name of the

mother with the name of the father. For instance, with the name Soto
Ramirez, Soto is the surname of the father and Ramirez is the surname of
the mother. These are filed in alphabetical sequence, the father’s name first,
followed by the mother’s name. Thus, the name Maria Dolores Soto
Ramirez shall be filed in the section of the file in the following order; S-o-t-
o-R-a-m-i-r-e-z, Maria Dolores.
 If the patient’s name has changed since a previous admission, a cross-

reference shall be made to the former name. For instance: If Dayrit, Josefina
is admitted a cross-reference should be made to her previous admission as
Manalastas, Josefina.
 When looking for a given person’s name card, one must keep in mind that
there may be many spellings of the same name. A thorough search must be

made under every possible spelling of the name before stating that there is
no card for that name.
 The Master Patient Index shall contain sufficient alphabetical guides for
speedy reference. As a rule, no more than 20 cards shall be filed behind a
guide.
 To maintain uniformity in the patient index when a personnel change is

made, filing directions shall be explicit. Whenever possible, only one person
shall be responsible for filing the index cards.
 Card files should be audited regularly for misfiled records.
 Additional training of Master Patient Index clerks shall be provided as

necessary.
RETRIEVAL OF HEALTH RECORDS
All health records not in the processing stage and that not in use shall be placed
in the file/storage room. Inherent to documents and records is the ability to be
retrieved from the permanent file for further use.
A good retrieval system directly affects the total efficiency of the HIMD.
It is a good practice for small healthcare facility with a small filing/storage area
to transfer inactive records to the inactive file to give way to the incoming
records, in order to decongest the area, and to make retrieval easy.
It shall be the policy of the healthcare facility maintain a filing system that shall
facilitate accessibility and prompt retrieval of the health record and it shall be
maintained in a definite sequence at all times.
A retrieval process will not be efficient and effective if there is no provision for
adequate finding aids, captions, locator aids and retrieval tools.
Retrieval tools in the medical record are classified into three, namely: (1) indexes,
(2) registers, and (3) tracers.
69
Retrieval Tools
 Indexes
o Master Patient Index (MPI) is one of the most important tools in the
Health Information Department.
- It is the key in locating medical records maintained in the file.

- It serves to identify the patient and helps in the retrieval process
of health.
- The patient index is maintained as a permanent file.
- MPI is maintained manually in a 12cm x 7cm or 3”x5” card.
- It is filed in strict alphabetical order by the patient’s name.
The minimum data requirements for the patient index card are as
follows: the patient’s name, HRN, age, date of birth, sex, civil status,
date of admission and discharge and the name of the physician.
____________________________________
NAME OF HEALTH CARE FACILITY
MASTER PATIENT INDEX
_____________________________________________________ _____________________
NAME: FAMILY FIRST MIDDLE Health Record Number
________ _________________ ____________ ____________________

AGE DATE OF BIRTH SEX STATUS
ADDRESS: ____________________________________________________________________
ADMISSION DISCHARGE ATTENDING PHYSICIAN

o Disease Index is a listing on a card for specific disease based on

standard classification/nomenclature, arranged according to code
number.
___________________________________
CODE NO. DISEASE: YEAR
Health Age Date/ Date/

Patient Civil Other Operation/ Attending
Record Address Result Time Time
Name M F Status Diseases Procedure Physician
No. Adm. Disch.
o Operation Index is a listing on a card for a specific operation according

to standard classification/nomenclature, arranged according to code
numbers.
_______________________________________
OPERATION INDEX
CODE NO. OPERATION: YEAR
Health Age Other Date/ Date/

Patient Civil Attending
Record Address Operating Result Diagnosis Time Time
Name M F Status Physician
No. Procedures Adm. Disch.
71
o Physician’s Index is a record of the work done and the results of

treatment rendered by the physician practicing in the hospital or an
index containing a list of all the patients a doctor has. These cards are
filed alphabetically according to the doctor’s name.
_______________________________________
PHYSICIAN’S INDEX
CODE NO. PHYSICIAN’S NAME: YEAR
Health Age Date/

Patient Civil Type of
Date Record Address Time Days Cons. Result
Name M F Status Service
No. Disch.
 Registers
A register is an official list of all patients treated and/or admitted in a

particular healthcare facility. It is considered a permanent document to be
maintained by the healthcare facility as mandated by the health regulatory
body, Bureau of Health Facilities and Services, Department of Health. Also,
it is a source of data/information when the original copy of the health
records is already disposed of after the prescribed retention period.
o Admission Register. This is a list of all patients admitted in a particular

healthcare facility. This register shall be done daily as patients are
admitted. Each section of this register shall be maintained in
chronological order. This register is a permanent record, and as such, all
entries shall be made in ink. It shall be maintained manually or
computerized as mandated by the Philippine Health Insurance
Corporation effective January 2006. The minimum data requirement for
an admission register are as follows: Control number, date and time of

admission, health record number (HRN), name of patient, age, sex,

address, admitting diagnosis and admitting physician.
NAME OF HEALTHCARE FACILITY
(Address)
ADMISSION REGISTER
Ctrl. Admitting Admitting

Date & Time HRN Name of Patient Age Sex Address
No. Diagnosis Physician
o Discharge Register. This is a list of all patients discharged from a

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

(Address)
DISCHARGED REGISTER
Ctrl. Date Name of Discharge Operation/ Attending

HRN Age Sex Address
No. &Time Patient Diagnosis Procedure Physician Service Disposition Result
73
o Birth Register. This is a chronological listing of all the names of the

children delivered in a particular health care facility.

(Address)
BIRTH REGISTER
Ctrl. Date & Birth Attendant at

HRN Name Sex Name of Mother
No. Time Weight Birth
o Death Register. This is a record of all deaths occurring within the health
care facility. This is listing of all the names of the patients who died in a
particular health care facility and arranged according to the date of
death.

(Address)
DEATH REGISTER
Ctrl. Date Cause of Death

HRN Name of Patient Age Sex Address Physician
No. &Time (Underlying & other diseases)

o Out-Patient Register. Every out-patient who comes in for consultation

must be listed in the Out-Patient Register. If a logbook is utilized for this
purpose, at the end of the year, it should be forwarded to the Health
Information Service for safekeeping. This register is classified as a
permanent file/record.
If, however, this register is maintained on a loose sheet or loose leaf, at

the end of every month it must be forwarded to the Health Information
Management Department for the preparation of Notifiable or Reported
Diseases which is prepared monthly. This is also necessary for the
compilation and collation process.

(Address)
OPD REGISTER
Operation/
Ctrl. Date Name of Attending
HRN Age Sex Address Diagnosis Procedure
No. &Time Patient Physician
Done
o Other Registers. Other required registers that government healthcare

facilities need to maintain are as follows: Emergency Room Register,
Delivery Room Register, Operating Room Register, Laboratory Register,
Radiologic Register, Tumor Register and Injury Register.
75
 Tracers
A tracer is use to ensure proper record control, whenever the health record
is removed from file for any purpose. Tracers or “outguides” enable health
records to be traced when not on file.
Essential Requisites for Easy Retrieval
 Efficient and effective filing system. This is an important factor that makes
retrieval easy because it is adaptable to the type of records maintained.
Proven to be very effective in managing voluminous health records is the
full knowledge of the movement of the records such as the terminal digit
filing. However, to be truly effective, it needs to adopt the corresponding
unit numbering system.
 Time element is very crucial in health record management. Retrieval time of

health records shall be as short as possible because the information that may
be retrieved from the health record might be the deciding factor between
the patient's life or death.
 Monitoring of chart movement. Another important factor to consider in the

efficient and effective management of health records is the full knowledge
of the movement of the records. This is the reason why the Health
Information Management Department shall maintain an effective tracking
or follow-up system. The use of such a system coupled with the full
knowledge of the workflow shall help the health record staff control the
records more effectively.
 Good Physical Layout. In order to attain a good physical layout, the Health
Record Service shall consider flexibility and functionality. The arrangement
of the employees should (1) follow the work flow, (2) facilitate smooth flow
of paper work, and (3) improve coordination between / among employees.
The physical location of the Health Information Management Department

shall be near the Out-patient Department and Emergency Room as the
activity rate of medical records is considered high in these services.

Retrieval Procedure
 The authorized requesting party shall fill up borrower's slip form.
 The requesting party/authorized representative shall bring the request to

the HIMD and shall give it to the health record personnel.
 The health record personnel receives and verifies whether the borrower is
authorized to borrow. He/She also checks the HRN on the request form.
 Requests without the corresponding Health Record Numbers shall be

checked against the Master Patient Index. Records of requests with Health
Record Numbers /Patient Numbers shall be pulled out from the permanent
file.
 After retrieving the health record, the borrowed shall be charged out to the
authorized borrower.
o The borrowed health record shall be recorded in the tracking system.
o The tracer card shall be placed where the record was pulled out.
 The borrower/authorized representative shall acknowledge the receipt of

the record.
RETENTION AND DISPOSAL OF HEALTH RECORD
Retention period is the period of time established and approved by proper

authority after which records shall be deemed ready for disposal. It is
recommended however, that those institutions where active health records
cannot be maintained for five years in the active file may transfer their health
records to another designated storage area because of limited space.
Health records should be kept by the facility for the duration of time required by
the by the Department of Health’s record retention regulation. This is mandated
77
by the Hospital Licensure Act, otherwise known as Republic Act 4226 which
requires healthcare facility to maintain health records from 10 to 25 years.
Aside from this legislation, the Department of Health issued Ministry Circular
77, series of 1981 which further qualifies the 25 year retention period for all
hospitals under the Department of Health regardless of its
category/classification. The period of health records’ retention is amended by
Department Circular No. 70 s. 1996. OPD records of patients who are attended
only at the OPD must be disposed of after ten (10) years starting from the last
visit. However, admitted patients’ records, including their OPD records, must be
maintained at a minimum of fifteen (15) years. Healthcare institutions shall
formulate their respective health records retention schedule which shall conform
to the minimum number of years of retention. They are allowed to go beyond
the prescribed number of years depending on the needs of the healthcare
facilities on these records.
Transfer of Inactive Records
Health records shall be kept for as long as they are being used for patient care,
medico-legal, research and teaching purposes. If there is no available space, a
decision must be made to determine the length of time records shall be kept in an
“active file” after which shall be transferred to an “inactive” area while waiting
for the prescribed retention period.
Inactive records can be stored in an inactive file area in the HIMD office or,
somewhere else within the health care facility, or even maintained in commercial
records storage facilities.
Culling
Culling is the identification and removal of inactive records or those which have
already reached their mandated and/or prescribed retention period from the
filing/storage area for disposal. These are records which are not activated for a
period of fifteen (15) years from the last date of activation. The process shall
decongest the file area, provide more room for the filing of in-coming medical
records and facilitate prompt retrieval of needed medical records.

Disposal
Disposal of health records in government health care facilities/institutions is

governed by Department Circular No. 70 series of 1996: The Revised Disposition
Schedule of Medical Record amending Ministry Circular 77 series of 1981.
Department Order 13-A, Article III, Rule 2.2, specifically states that: “Agencies
shall not dispose of their health records earlier than the period indicated for each
record series. However, records may be retained for longer periods if there is a
need to do so.”
The disposal of health records must be done in close coordination with the
National Center for Health Facility & Development (NCHFD) and National
Archives of the Philippines (NAP), the government agency in charge of health
record disposal.
Procedure in the Disposal of Health Records
 Check the Record from the file which has reached the required retention
period based on (Department Circular No. 70 series of 1996).
 Pull out health records from file.
 Check the year when the record was last activated.
 Prepare a list of records for disposal.
 Communicate with the NAP regarding a request to dispose of health

records addressed to the Chief, Current Records Division, NAP, through the
Director, National Center for Health Facilities and Development
Department of Health, Manila. National Center for Health Development
Facilities will endorse the request to the said office.
 Upon receipt of the request, the NAP will assign a record management
analyst to appraise and examine the records for disposal. Finally, the record
79
analyst will also recommend the manner or method to be use in the disposal
of the record.
 The director of NAP will issue the authority to dispose the records and the
manner of disposal.
 Actual disposal shall be directed by the Director NAP or its authorized

representative.
 A certificate of disposal shall be prepared in five (5) copies by the agency,

witnessed by representatives of the Commission on Audit, NAP, and a
representative from the agency.
 The certificate shall include the following information:

o Nature of the record
o Manner of disposal
o Place of disposal
o Date of disposal
o Approximate volume in cubic meters
o Weight of the records

HEALTH INFORMATION MANAGEMENT WORKFLOW
Figure 8. Health Record Management Procedure

81

Figure 9. Health Records Disposition
83
ISSUANCE OF CERTIFICATES
Certificate of Live Birth
Live birth is the complete expulsion or extraction of a product of conception from

its mother, irrespective of the duration of pregnancy, which after such
separation, breathes or shows any other evidence of life, such as beating of the
heart, pulsation of the umbilical cord, or definite movement of voluntary
muscles, whether or not the umbilical cord has been cut off or the placenta is still
attached; each product of such birth is considered alive.
A fetus with intra-uterine life of seven (7) months or more and born alive at the
time it was completely delivered from the maternal womb but died later shall be
considered as live birth and shall be registered in the registry of births.
However, if the fetus had an intra-uterine life of less than seven (7) months, it is
not deemed born if it dies within 24 hours after its complete delivery from the
maternal womb (Article 41 R.A 386). For statistical purposes, a certificate of Live
Birth shall be prepared in duplicate copy, a copy which shall be forwarded to the
office of the Civil Registrar-General and the other copy for the Civil Registrar’s
file.
Policies
 Accomplishment of the Certificate of Live Birth shall be in accordance with

the instruction manual: Civil Registry Administrative Book No. 1, series of
1993 (Implementing Rules and Regulations of the Republic Act no. 3753 and
other laws on Civil Registration).
 Preparation of the Certificate of Live Birth of all babies born inside the
healthcare facilities shall be done by the person who has witnessed the
baby’s (babies’) delivery.
 Only the baby’s parents’ shall be interviewed and shall sign the Certificate
of Live Birth. If the mother died or is mentally incapacitated, the husband or
any of the nearest kin shall act as the informant and shall sign the Certificate
of Live Birth.

Figure 10. Procedure in the Preparation of Birth Certificate
 For illegitimate births, the father may execute the affidavit of

Acknowledgment / Admission of Paternity as father and his surname to be
reflected in the Certificate of Live Birth duly notarized.
 All the data given by the informant are presumed correct and the healthcare
facility shall not be held liable for any erroneous data entered in the
Certificate of Live Birth.
85
 It is the duty of the healthcare facility (hospital) staff to transmit the

Certificate of Live Birth to the Local Civil Registrar within 30 days.
 Only the Local Civil Registrar shall release the Certificate of Live Birth
containing the registration number.
Certificate of Death
Death is a permanent disappearance of all evidence of life at any time after live
birth has taken place (postnatal cessation of vital functions without capability of
resuscitation).
Kinds of Death
 Cardiopulmonary Death
o There is an absence of natural respiratory and cardiac functions and

attempts at resuscitation would not be successful in restoring those
functions.
o In this case, death shall be deemed to have occurred at the time these
functions ceased.
 Brain Death. There is an irreversible cessation of all brain functions; and

considering the absence of such functions, further attempts at resuscitation
or continued supportive maintenance would not be successful in restoring
such natural functions.
In this case, the death shall be deemed to have occurred at the time when these
conditions first appeared.
Policies
 Preparation of the Death Certificate shall be done by the person who has
witness the occurrence.

 All the data given by the informant are presumed correct and the healthcare
facility shall not be held liable for any erroneous data entered in the death
certificate.
Figure 11. Procedure in the Preparation of Death Certificate
87
 No correction of data shall be done unless supported by a duly notarized

affidavit of correction and other supporting documents. However, a death
certificate that bears the LCR registration number will no longer be
corrected.
 Death certificate shall be released only to the legal heirs or the nearest of kin
available.
 The person who claimed the death certificate shall be responsible for LCR
registration within 48 hours after death.
 In cases of lost unregistered death certificate, re-issuance can only be done

upon presentation of an affidavit of loss and other supporting document.
Certificate of Fetal Death
Fetal Death is the death prior to the complete expulsion of a product of

conception, irrespective of the period of pregnancy. The death is indicated by the
fact that after such separation, the fetus does not breathe nor show any other
evidence of life, such as the beating of the heart, pulsation of the umbilical cord
or definite movement of voluntary muscles.
Policies
 Registration shall be made in the office of the City Municipal Civil Registrar
where the event occurred.
 Registration should be made within the 30-day reglementary period.
 The Fetal Death Form is to be accomplished in 4 copies; assign a register

number and enter in the Registers Book of death.
 If death occurred in a health care facility, the hospital (care) administrator,

the parents, relatives or the attendant at death will register the Fetal Death.

Procedure
 The registration of fetal death shall follow the procedure in the

registration of death.
Certificate of Confinement
Certificate of Confinement, signed by the head of the Health Information

Management Department, shall be issued while the patient is still confined in the
health care facility. This certificate should be controlled document. The health
care facility should pre- number them and their issuance should be recorded by
the HIMD.
Medical Certificate
Medical Certificate shall be issued when the patient is already discharged. This
certificate should be controlled document. The HIMD should pre-numbered
them and their issuance should be recorded by the HIMD.
Medico Legal Certificate
Medico-legal Certificates shall be duly signed by the Attending Physician/Chief

of the Health Care Facility/Medico-legal Officer and released with dry seal.
Other Certificates
Other certificates requested by patient/relative are allowed except for doctor’s

order and nurses notes, and to be signed by the Health Information Management
Officer with dry seal.
89
Issuance of Photocopy of Health Records
Certified photocopies of patients’ health record may be released but (not) limited
to the following:
 Discharge Summary/Clinical Abstract

 Laboratory and diagnostic results
 Report of Operation

Clinical Coding
5 CLINICAL CODING
____________________________________________________________
Clinical Coding is the translation of diseases, health related problems and

procedural concepts from text to alphabetic/numeric codes for storage, retrieval
and analysis.
CLASSIFICATION VS. NOMENCLATURE
A classification is a system of categories or groupings to which diseases, injuries,

conditions and procedures are assigned according to established criteria. It is the
element of grouping similar terms which distinguishes a statistical classification
from a nomenclature. A nomenclature requires a separate name or title for each
disease or procedure concept.
Statistical Classification
ICD-10 is a statistical classification, which means that it contains a limited

number of mutually exclusive code categories, which describe all disease
concepts. The classification is hierarchical in structure with subdivisions to
identify broad groups and specific entities. The classification includes specific
rules to guide its use.
Importance of Using Classification
 To allow easy storage, retrieval and analysis of data.
 To allow comparisons of data between hospitals, provinces or countries.
 To allow comparisons in the same location across different time periods.
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Clinical Coding
HISTORY OF THE INTERNATIONAL CLASSIFICATION OF DISEASES
The theory of disease classification began in the 17th Century when John Graunt
recognized the need to organize mortality data into some logical form and
therefore developed the first statistical study of disease, called the London Bills of
Mortality. In this work, Graunt classified the deaths of all children who were born
alive but who died before they reached the age of six. Death were classified as due
to thrush, convulsions, rickets, teeth and worms, chrysomes, livergrown, smallpox,
swine pox, measles and worms without convulsions. It was hoped that clues
regarding the nature and aetiology of these diseases would be brought to light and
that this understanding would ultimately lead to better treatments.
During the 18th Century, Sauvages first attempted to systematically classify all
diseases in a work called "Nosologia Methodica".
William Farr, the first medical statistician, who worked in the newly formed
General Register Office of England and Wales in the mid-1800s, further developed
the work of both of these men. Farr's work formed the basis of a recommendation
to create the International List of Causes of Death, which was presented to the first
International Statistical Congress, held in Brussels in 1853. Although modified in
1874, 1880 and 1886 to suit the needs of the time, Farr's classification did not receive
universal acceptance, despite his best efforts to promote it. The general
arrangement of the classification - which included the principle of classifying
diseases according to body site - became the basis for work carried out by Dr
Jacques Bertillon from Paris. Bertillon developed a classification that distinguished
between diseases that affected the body as a whole (systemic diseases) and those
that were localized to a particular body site. The Bertillon Classification of Causes
of Death received general approval and was adopted for use by several countries.
When the American Public Health Association recommended its use for Canada,
Mexico and the USA, it also developed plans for the updating of the classification
every ten years. At this time, in the very early 1900s, there were only 179 groups of
causes of death!
In 1920, the Health Organization of the League of Nations, which had taken an
active role in the collection and classification of death statistics, determined that it
would take over the management of the Causes of Death classification. When
revising the classification for the fourth and fifth times, in 1929 and 1938, this
organization included classifications for non-fatal conditions for the first time.

Clinical Coding
In 1946, the Interim Commission of the World Health Organization was charged
with the responsibility for the continued revision of the classification. The sixth
revision conference marked a milestone in the collection of health and vital
statistics. A new publication entitled "International Classification of Diseases,
Injuries and Causes of Death" was issued in 1948, based on the previous work but
including recommendations for the collection of morbidity data, as well as
mortality statistics. This classification underwent minor amendment in 1955 and
1965 but mainly to correct errors of fact and inconsistencies. The 1965 revision
included, for the first time, two volumes - a tabular list and an alphabetical index.
In 1975, the 46 member states of the WHO convened in Geneva to begin

development of the ninth revision of the ICD, as it came to be known. In addition to
the member states, a number of medical specialty groups sent representatives, due
to the now almost universal interest in using the classification for medical record
coding and indexing, monitoring and evaluation of health services and
epidemiological research. The next year, the World Health Assembly agreed to the
revision of the classification and to the development, on a trial basis, of a procedure
classification as an accompaniment to the disease classification. Thus the ICD-9 and
ICPM (International Classification of Procedures in Medicine) were introduced.
Work on the tenth revision of the International Classification of Diseases began in

September 1983 when a preparatory meeting on ICD-10 was convened by the
World Health Organization in Geneva. This was followed by several meetings of
an expert committee in 1984 and 1987 to make decisions on the direction the work
should take and the form of the final proposal. In addition to the technical
contribution provided by the expert committees, a large number of comments and
suggestions were received from WHO member states and regional offices as a
result of the worldwide circulation of the draft proposals for revision and review.
It became clear that many users wished the ICD to encompass types of data other
than simply diagnostic information. Even if it was restructured, the ICD could not
cope with the extremes of the requirements. The concept was therefore developed
of a "family" of classifications, with the main ICD as the core, covering the
traditional mortality and morbidity statistics, while the needs for more detailed or
different classifications would be dealt with by other members of the family such as
the International Classification of Functioning (ICF) and the Diagnostic and
Statistical Manual of Mental Disorders (DSM).
93
Clinical Coding
Several alternative models for the restructure of the main ICD were investigated,
and the final decision was to use an alphanumeric system, which would give a
better balance to the chapters and allow sufficient space for future additions and
changes without disrupting the codes.
The alphanumeric coding scheme uses one letter followed by three numbers, at the
fourth character level. This has more than doubled the size of the coding frame in
comparison with the ninth revision and has enabled the vast majority of chapters to
be assigned a unique letter or group of letters, each capable of providing 100 three
character categories. Of the 26 available letters, 25 have been used - the letter U
having been left vacant for future additions and changes and for possible interim
classifications to solve difficulties arising between revisions.
ICD-10 is part of the ICD family of classification systems, which also includes:
 International Classification of Functioning, Disability and Health (ICF)
 International Classification of Diseases for Oncology (ICD-O)
 Application of the International Classification of Diseases to Dentistry and

Stomatology (ICD-DA)
 Application of the International Classification of Diseases to

Rheumatology and Orthopaedics (ICD-R&O), including the International
Classification of Musculoskeletal Disorders (ICMSD).
OVERVIEW OF THE ICD-10 CLASSIFICATION
ICD-10 is a variable-axis classification - meaning the epidemiological data and

statistical data coded to it may be grouped as follows:
 epidemic diseases
 constitutional or general diseases
 local diseases arranged by site
 developmental diseases
 injuries

Clinical Coding
There are three (3) main elements to the structure of the ICD-10. They are:
 3 volumes
 22 chapters
 the structure of the code is alphanumeric.
Volumes of the ICD-10
 Volume 1 is the Tabular list, which is an alphanumeric listing of diseases

and disease groups, along with inclusion and exclusion notes and some
coding rules.
 Volume 2 provides:
o an introduction to, and instructions on how to use volumes 1 and 3

o guidelines for certification and rules for mortality coding
o guidelines for recording and coding for morbidity coding
 Volume 3 is the comprehensive Alphabetical index of the diseases and

conditions found in the Tabular list.
Chapters of the ICD-10
The ICD-10 contains 22 chapters, each of which is identified by a Roman

Numerals i.e. I, II, III, IV, V etc. When referring to a chapter, call it by its chapter
number and not by the letters of the codes associated with it. For instance, refer
to Diseases of the Digestive System as Chapter XI and not as the K chapter. This
is because some chapters contain more than one letter and some letters are used
in more than one chapter.
Structure of the ICD-10 Code
The first character of the code is an alpha character, followed by two, three or
four numeric characters.
95
Clinical Coding
The structure of the three-character category is:
A37
first character followed by
A to Z 2 digits
Most three-character categories are further subdivided into sub-categories to

enable coding of a disease or condition more specifically.
A37.1
first character followed by a lastly
A-Z 2 digits point another
digit
Volume 1 – Tabular List
Chapters using more than one letter
Chapter I Certain infectious and parasitic diseases A, B

Chapter II Neoplasms C, D
Chapter XIX Injury, poisoning and certain other
consequences of external causes S, T
Chapter XX External causes of morbidity and mortality V, W, X, Y
The titles of the chapters of the ICD-10 indicate that the conditions included are
wide ranging, therefore a large number of codes are required to cover all the
conditions. Using an alpha character at the beginning of the code has allowed for
2,600 available 3-character codes. This in turn allows for a large number of 4
character subcategories. Each 3-character code can have up to 10 subcategories.

Clinical Coding
Blocks
Each chapter has been divided into blocks of related conditions. The blocks are
then divided into three, four and five digit categories.
Three character categories or rubrics
Some blocks have three character categories for single conditions. Other blocks
contain groups of diseases.
Four character categories or rubrics
These are not mandatory for reporting at international level but the use of fourth
characters adds detail and specificity to the coded data. The use of fourth
characters allows up to ten subcategories.
Conventions
The ICD-10 Tabular List (Volume I) makes use of certain abbreviations,

punctuations, symbols and instructional terms which must be clearly
understood. These are referred to as the coding conventions.
 Inclusion Terms
Within the three and four character rubrics there are usually listed a
number of other diagnostic terms in addition to the code title. These are
known as "inclusion terms" and are given as examples of diagnostic
statements to be classified to that rubric. They may refer to different
conditions or be synonyms. They are not a sub-classification of the rubric.
They are to be used as a guide to the content of the rubric, keeping in mind
that the list is not exhaustive.
○ Most chapters are associated with particular body systems, special

diseases or external factors. There is, however, one exception which is
Chapter XVIII “Symptoms, signs and abnormal clinical and laboratory
findings, not elsewhere classified.”
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Clinical Coding
○ The number of categories assigned to a chapter is influenced by the

number of diseases and conditions that fall within the scope of the
chapter.
○ Fourteen of the chapters have a single letter assigned to them and use
most of the 100 categories available. For example, Chapter XI contains
codes ranging from K00 to K93. The codes K94 to K99 have not been
used at this stage and have been left vacant for future additions to the
classification.
○ Three chapters have a smaller range of categories assigned to them and

share letters.
○ Four chapters use more than one letter in defining categories. e.g.
Chapter II contains codes beginning with C and D.
 Exclusion Terms
Certain rubrics contain lists of conditions preceded by the word "Excludes".

These terms are to be coded elsewhere, not within this category as the code
may suggest. The correct code that should be assigned is in parentheses
following the term.
 Glossary Descriptions
Chapter V Mental and Behavioural Disorders uses glossary descriptions to

indicate the content of rubrics. This device is used because the terminology
of mental disorders varies greatly, particularly between different countries
and the same name may be used to describe quite different conditions. The
glossary is not intended for use by coding staff to make a diagnosis but is
intended as a guide for clinicians to indicate the content of the rubric.
 Dagger and Asterisk Convention
The dual coding system of creating combinations of codes through

attachment of daggers (†) and asterisks (*) has been used in ICD-10, thus
allowing the description of a condition in terms of its underlying cause or
aetiology (†) and current manifestation (*). This enables a better description

Clinical Coding
of the medical care provided and resources used in its treatment to be

given.
Using this convention, two codes are assigned for diagnostic statements that
contain information about both an underlying generalized disease and a
manifestation in a particular organ or site which is a clinical problem in its
own right.
The primary code is for the underlying disease and is marked with a dagger
(†). An optional code for the manifestation is marked with an asterisk (*).
It is a basic principle of the ICD that the dagger code is the primary code
and must always be used for single condition coding. An asterisk code
should never be used alone. When coding underlying cause of death for
mortality purposes, the dagger code should be used, never an asterisk code.
There are 83 asterisk categories in ICD-10 (listed at the start of relevant

chapters) which may be used in conjunction with a dagger code, but must
not be used alone. Asterisk categories are listed at the beginning of each
chapter, block and rubric where appropriate.
 Parentheses ( )
Parentheses are used in four ways in Volume 1:
○ To enclose supplementary words, which may follow a diagnostic term

without affecting the code number, to which the words outside the
parentheses, would be assigned.
○ To enclose the code to which an exclusion term refers.
○ To enclose the three-character codes of categories in a particular block.
○ To enclose the dagger code in an asterisk category or the asterisk code

in a dagger term.
99
Clinical Coding
 Square brackets [ ]
Square brackets are used:
○ For enclosing synonyms, alternative words or explanatory phrases.
○ For referring to notes.
○ For referring to a previously stated set of fourth character subdivisions

common to a number of categories.
 Colon :
The colon [:] is used in listings of inclusion and exclusion terms when the
words that precede it are not complete terms for assignment of the
diagnosis to that rubric.
In other words, the words require one or more of the modifying or

qualifying words indented under the lead term before the diagnosis can be
assigned to the rubric.
 Brace }
A brace is used in listings of inclusion and exclusion terms to indicate that

neither the words that precede it nor the words after it are complete terms.
In other words, one or more of the terms that follow the brace should be
part of the diagnosis, to qualify any of the terms before the brace.
 Not Otherwise Specified (NOS)
NOS is an abbreviation for 'not otherwise specified', implying 'unspecified'

or 'unqualified'. Coders should be careful not to code a term as unqualified
unless it is quite clear that no other information is available that would
permit a more specific code assignment from elsewhere in the classification.

Clinical Coding
 Not elsewhere classified (NEC)
NEC stands for not elsewhere classified. When used in a three-character

category title, NEC serves as a warning that certain specified types of the
listed conditions may appear in other parts of the classification.
 "And" in code titles
In Volume 1 of ICD-10, "and" stands for "and/or".
 Point dash .-
When used as a replacement for the fourth character of a subcategory, a

point dash [.-] indicates to the coder that a fourth character exists and
should be sought in the appropriate category in the Tabular list.
 Corrections and addenda
There have been some corrections to the Tabular list which have been
included in a corrigendum at the back of volume 3. ICD-10 books
published AFTER 1997 corrections may have already been made.
Coders should ensure that the changes outlined in the corrigenda and the
addenda are made before commencing coding. This will assist in
maintaining comparability with statistical reporting in other countries, and
will ensure that the classification reflects current clinical practice.
Volume 3 – Alphabetic Index
Volume 3 is an alphabetic index to the Tabular Listing of Volume 1. As such, it

contains far more diagnostic terms than the tabular list, reflecting the many and
varied ways that doctors and other clinical staff describe diseases.
Volume 3 consists of:
 an Introduction, explaining the purpose of the index, its general

arrangement and conventions used in the index
101
Clinical Coding
 Section I which is an alphabetic listing of terms relating to diseases, nature

of injury, reasons for contact with health services and factors influencing a
person’s health
 Section II which is an alphabetic listing of external causes of injury,

morbidity and mortality
 Section III, which is an alphabetically arranged table of drugs and

chemicals.
Structure of Index entries
Index entries contain:
 Lead terms (usually nouns) to the far left of each column, in bold. They refer
mainly to the names of diseases or conditions.
 Modifiers at different levels of indentation to the right. They usually refer to

varieties of sites or circumstances that affect coding. Modifiers which do not
affect code assignment appear in parentheses ( ) after the condition. All
modifiers appear in alphabetical order except “with” which always appears
first.
 Code numbers follow the terms in the index and may appear as a 3-
character category or be subdivided with either the appropriate 4th digit or
a dash (.-). Where the dual system of coding († and *) applies, both codes
are given in the index. The dagger is always mentioned first, followed by
the asterisk code.
 If the lead term cannot be identified in the Index, there are a number of
standard ways that codes can be found. Try using one of the following
‘generic’ lead terms:

Clinical Coding
- disease - assault
- complication - legal intervention
- syndrome - war operations
- pregnancy - counselling
- labour - observation
- delivery - examination
- puerperal - history
- maternal condition affecting - problem
fetus or newborn - screening
- injury - status
- sequelae - vaccination
- suicide
Note : American spelling is used throughout Volume 3, with cross-references

wherever diphthongs appear at the beginning of a term. However, in
Volume 1 so-called English spelling is used.
Conventions
 Parentheses ( )
Parentheses are used in the same way as in Volume 1, to enclose non-

essential modifiers which do not affect code assignment.
 Not Elsewhere Classified (NEC)
"Not elsewhere classified" indicates that specified variants or types of the

disease are classified elsewhere, and that where appropriate, a more precise
term should be looked for in the Index. If the specific diagnostic term
cannot be found in the Index, then the NEC code can be used indicating that
the condition does not have a unique code elsewhere in the classification.
 Cross-references
Cross references are used to avoid unnecessary duplication of terms in the

Index.
103
Clinical Coding
○ "See" requires the coder to refer to the other term. This is a mandatory
instruction.
○ "See also" directs the coder to refer elsewhere in the Index if the
statement being coded contains other information that is not found
indented under the term to which "see also" is attached. This helps the
coders to find the most specific code possible for the diagnosis being
coded.
It is imperative that Volumes 1 and 3 be used together in locating codes to

accurately describe each clinical case - coders should not fall into the trap of
coding straight from the Alphabetical Index or browsing around the Tabular List
looking for a code that seems to fit the case being coded.
BASIC CODING GUIDELINES
 Identify the type of statement to be coded and refer to the appropriate

section of the Alphabetical Index. (If the Statement is a disease or injury or
other condition classifiable to Chapters I-XIX or XXI, consult Section I of the
Index. If the statement is the external cause of an injury or other event
classifiable to Chapter XX, consult Section II.
 Locate the lead term. For diseases and injuries this is usually a noun for the
pathological condition. However, some conditions expressed as adjectives
or eponyms are included in the Index as lead terms.
 Read and be guided by any note that appears under the lead term.
 Read any terms enclosed in parentheses after the lead term, as well as any
terms indented under the lead term, until all the words in the diagnostic
term have been accounted for.
 Follow carefully any cross-references ("see" and "see also") found in the
Index.
 Refer to the Tabular List to verify the suitability of the code number
selected.

Clinical Coding
 Be guided by any inclusion or exclusion terms under the selected code or

under the chapter, block or category heading.
 Assign the code.
OVERVIEW OF MORBIDITY CODING
Morbidity covers illness, injuries and reasons for contact with health services
including screening and preventive care. Coding usually relates to an episode of
health care in a health institution but may also apply to surveys or other
diagnostic data.
Morbidity usually relates to a single episode of health care. An episode of health

care may be defined as:
 A period of inpatient care; or
 a contact (or series of contacts in a specific time period) with a health care
practitioner in relation to the same condition or its immediate consequences.
Sources of Morbidity Data
Sources of data for morbidity coding include:
 Hospital records
 School medical records
 Death certificates
 Armed services records
 Occupational medical records
 Health surveys
 Outpatient records (ambulatory care)
 Maternal and child health services records
 Recording of occurrence of ‘sentinel’ conditions or conditions such as
congenital anomalies, communicable diseases etc.
105
Clinical Coding
 Cancer and chronic disease registry records

 Follow-up of people born at a specific time, those who have suffered from a
specific ‘index’ disease or injury
 Other
Uses of morbidity data
Morbidity data may be used, among other things, to provide clues to causes of
disease, and it may form the basis on which decisions are made about previous
measures or the allocation of resources or priorities for disease prevention
programs.
Central concepts for morbidity coding
 At the end of an episode of care, the clinician should record all conditions
which affected the patient in that period.
 Practice may vary from establishment to establishment or health authority

to health authority - in some places, one diagnosis will be singled out for
coding (single-condition coding) while in other places, all diagnoses will be
coded for each episode of care (multi-condition coding). Coders need to be
aware of the policy of their establishments in this regard.
Why single-condition coding?
Some establishments may implement this policy because of lack of resources (e.g.
coding, administrative) or because the resultant simpler data may be more
appropriate for its needs.
With single-condition coding, there is the need to choose the main condition
from the set of diagnoses so that it can then be coded.

Clinical Coding
What distinguishes the main condition (MC) from the rest of the recorded
conditions?
The main condition is the diagnosis established at the end of the episode of
health care to be the condition primarily responsible for the patient receiving
treatment or being investigated i.e. that condition which is determined as being
mainly responsible for the episode of health care.
What then are other conditions (OC) which might be coded?
Other conditions are defined as those that coexist or develop during the episode
of health care and affect the management of the patient.
For coding purposes, other conditions (also known as additional diagnoses)

should be interpreted as conditions that affect patient management in terms of
requiring any of the following:
• therapeutic treatment
• diagnostic procedures
• increased nursing care and/or monitoring
One or more of the above factors will generally result in an extended length of
hospital stay. 1
RULES FOR RESELECTION OF MAIN CONDITION
In some instances, the Main Condition recorded by the clinician may not be
consistent with the WHO definition. Alternatively, no Main Condition may have
been specified. WHO has developed a set of rules that can be used to ensure that
the Main Condition selected and coded reflects the condition mainly responsible
for the episode of care.
1 Extracted from NCCH ICD-10-AM, July 2002, General Standards for Diseases.
107
Clinical Coding
MB1. Minor condition recorded as main condition, more significant condition

recorded as other condition.
Where a minor or longstanding condition, or an incidental problem, is

recorded as the main condition, and a more significant condition, relevant to
the treatment given and/or the specialty that cares for the patient, is recorded
as an other condition, reselect the latter as the main condition.
MB2. Several conditions recorded as main condition.
If several conditions that cannot be coded together are recorded as the main
condition, and other details on the record point to one of them as the main
condition for which the patient received care, select that condition.
Otherwise select the condition first mentioned.
MB3. Condition recorded as main condition is presenting symptom of

diagnosed, treated condition.
If a symptom or sign (usually classifiable to Chapter XVIII), or a problem

classifiable to Chapter XXI, is recorded as the main condition and this is
obviously the presenting sign, symptom or problem of a diagnosed condition
recorded elsewhere and care was given for the latter, reselect the diagnosed
condition as the main condition.
MB4. Specificity
Where the diagnosis recorded as the main condition describes a condition in

general terms, and a term that provides more precise information about the
site or nature of the condition is recorded elsewhere, reselect the latter as the
main condition.
MB5. Alternative main diagnoses
Where a symptom or sign is recorded as the main condition with an

indication that it may be due to either one condition or another, select the
symptom as the main condition. Where two or more conditions are recorded
as diagnostic options for the main condition, select the first condition
recorded.

Clinical Coding
Coding of conditions to which the dagger and asterisk system applies (dual
system)
The dagger and asterisk codes should be used together, wherever possible,
because they describe different aspects of the condition. The dagger code is the
preferred main condition.
External causes of morbidity and injuries
Injuries may be classified by their nature (Chapter XIX) and by the external cause
that led to the injury (Chapter XX). Both codes should be used but the nature of
the injury code is the preferred main condition for morbidity coding.
Sequelae (late effects) of certain conditions
A number of categories are available which enable the coding of a past condition
which is itself no longer present, but which is the cause of a present problem. In
such a case, the current condition is the preferred main condition.
However, where a past condition is responsible for the presence of multiple

current conditions and not one of the current conditions can be identified as
predominant, then the sequela code (for past condition) may be used as the
preferred main condition and followed by codes for each of the current
conditions.
Coding of suspected conditions, unexplained symptoms and abnormal

findings and non-illness situations
Codes from Chapters XVIII and XXI should only be used if the clinician is unable
to describe the case more specifically. If the final diagnosis is “suspected” or
“questionable” or if it is documented with a question mark (?), it should be
coded as if it is a certain diagnosis.
109
Clinical Coding
Multiple conditions
Categories exist which allow indication of multiple conditions within one code
(this mainly applies mainly to conditions associated with HIV). Where
appropriate, a multiple code can be used as main condition, and additional codes
may appear to describe each of the conditions specifically. This is only an issue if
no one single condition is indicated by the clinician as the MC or if none can be
stated as the predominant focus of treatment.
Combination categories
This is where the presence of two or more conditions (or a condition plus
associated conditions) can be represented by one code.
Acute (or sub-acute) on chronic conditions
Where the patient is suffering an acute exacerbation of a chronic illness and there
is no combination category available, the acute aspect of the condition should be
assigned as the preferred main condition, with the chronic aspect as an optional
additional code.
Post-procedural conditions and complications
The code range T80-T88 (Chapter XIX) is available to classify certain

complications relating to surgical and other procedures. Complications coded
here generally affect the whole body. Other categories are also provided near the
end of most body system chapters for conditions which occur either as a
consequence of specific procedures and techniques or as a result of the absence of
an organ or post-procedural conditions which affect a specific body system.
Post-procedural conditions or complications are defined as:
 conditions caused by acquired absence of an organ;

 any conditions resulting from surgical procedures;
 the after-effect of radiotherapy or similar treatment.

Clinical Coding
Some conditions are common post procedurally. They are coded in the normal
way but an additional code may be used to identify the relationship of the
condition to a previous procedure. The additional code would be assigned from
Chapter XX, External causes of morbidity and mortality (Y83 and Y84).
When a post-procedural condition or complication is recorded as the main

condition, it is essential that the coder refers to modifiers in the Index to ensure
arrival at the correct code.
Specific Notes
The general guidelines and rules as discussed previously apply to all chapters
unless a specific chapter note states otherwise.
OVERVIEW OF MORTALITY CODING
The International Classification of Diseases has its origins in the preparation of

mortality statistics.
Death certificates are the main source of mortality data. Information on death
certificates may be provided by either a health practitioner or in the case of
accidents or violent deaths, a coroner. In some jurisdictions, another official (who
may not be medically trained) is responsible for the completion of the medical
certificate of cause of death.
The person certifying the cause of death will enter the sequence of events leading
to the death on the death certificate in the international format specified by
WHO.
WHO recommends that, where practicable, a separate certificate should be used

to record perinatal death. An international format is also recommended for this
certificate.
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Clinical Coding
Concept of underlying cause of death
WHO has defined the underlying cause of death as:
 the disease or injury which initiated the train of morbid events leading
directly to death; or
 the circumstances of the accident or violence which produced the fatal

injury.
Therefore, the underlying cause of death is the condition, event or circumstances

without which the patient would not have died.
International Form of Medical Certificate of Cause of Death
Approximate interval between

Cause of Death
onset and death
I
Disease or condition (a) …………………………….. …………………………………….

directly leading to death* due to or as a consequence of
Antecedent causes
(b) …………………………… …………………………………….
Morbid conditions due to or as a consequence of
giving rise to the above
cause, stating the underlying
condition last
(c) …………………………… …………………………………….

due to or as a consequence of
II
Other significant conditions contributing to the death,
but not related to the disease or condition causing it
………………………………………………
……………………………………………………………………………
………………………………………………
……………………………………………………………………………
……………….………………………………
……………………..........................……………………………………
*This does not mean the mode of dying e.g. heart failure, respiratory failure.
It means the disease, injury or complication that caused death.

Clinical Coding
The death certificate has 2 parts.
 Part I is used for diseases related to the sequence of events leading directly
to the death.
 Part II is used for unrelated conditions which have no direct connection

with the events leading to death but which, by their nature, contributed to
death.
Where two or more conditions must be recorded, the certifying practitioner

should record the sequence of events leading to death. Each event in the
sequence should be recorded on a separate line, in reverse order.
 The direct cause of death is entered on the first line

 The underlying cause of death is entered on the lowest used line
 Any intervening causes are entered on the lines between the first line and
the lowest used line.
The completed certificate therefore contains the following information:
 Direct cause
 Intervening Cause of (a)
 Intervening cause of (b)
 Originating cause of (c)
There are two ways of classifying injuries:
 By their nature (chapter XIX)

 By the external cause resulting in the injury (chapter XX)
For mortality purposes it is the external cause that should be used for single
cause coding and tabulating underlying cause.
113
Clinical Coding
SELECTING THE UNDERLYING CAUSE OF DEATH
The World Health Organization has defined a set of procedures or coding rules
to be followed for coding the underlying cause of death. This series of steps will
be outlined in the following pages. When coding, for each case the rules should
be applied in a logical sequence beginning with the General Principle.
General Principle
When more than one condition is entered on the certificate, the condition
entered alone on the lowest used line of part I should be selected only if it
could have given rise to all the conditions entered above it.
In about 25% of cases the General Principle cannot be applied for some reason.
Rules 1, 2 and 3 then need to be applied.
Rule 1. If the General Principle does not apply and there is a reported
sequence terminating in the condition first entered on the certificate,
select the originating cause of this sequence. If there is more than
one sequence terminating in the condition mentioned first, select the
originating cause of the first-mentioned sequence.
Rule 2. If there is no reported sequence terminating in the condition first

entered on the certificate, select this first-mentioned condition.
Rule 3. If the condition selected by the General Principle or by Rule 1 or Rule

2 is obviously a direct consequence of another reported condition,
whether in Part I or Part II, select this primary condition.
RULES FOR MODIFICATION
In some cases the underlying cause that has been selected using the above rules
is not the most useful or informative for public health or prevention purposes,
e.g. senility or a general disease process such as atherosclerosis. In such cases
modification rules may need to be applied after the General Principle, Rule 1,
Rule 2 and Rule 3 have been applied.

Clinical Coding
There are 6 modification rules (A-F).
 Rule A. Senility and other ill-defined conditions
Where the selected cause is ill-defined and a condition classified elsewhere

is reported on the certificate, reselect the cause of death as if the ill-defined
condition had not been reported, except to take account of that condition if
it modifies the coding. The following conditions are considered ill-defined:
I46.9 (Cardiac arrest, unspecified), I95.9 (Hypotension unspecified), I99
(Other and unspecified disorders of circulatory system), J96.0 (Acute
respiratory failure), J96.9 (Respiratory failure unspecified), P28.5
(Respiratory failure of newborn), R00-R94 or R96-R99 (Symptoms, sings and
laboratory findings, not elsewhere classified). Note that R95 (Sudden Infant
Death Syndrome) is not regarded as ill-defined.
 Rule B. Trivial conditions
Where the selected cause is a trivial condition unlikely to cause death, and a
more serious condition (any condition except an ill-defined or another
trivial condition) is reported, reselect the underlying cause as if the trivial
condition had not been reported. If the death was the result of an adverse
reaction to treatment of the trivial condition, select the adverse reaction.
When a trivial condition is reported as causing any other condition, the

trivial condition is not discarded, i.e. Rule B is not applicable.
 Rule C. Linkage
Where the selected cause is linked by a provision in the classification or in

the notes for use in underlying cause mortality coding with one or more of
the other conditions on the certificate, code the combination.
Where the linkage provision is only for the combination of one condition
specified as due to another, code the combination only when the correct
causal relationship is stated or can be inferred from application of the
selection rules.
115
Clinical Coding
Where a conflict in linkage occurs, link with the condition that would have
been selected if the cause initially selected had not been reported. Make any
further linkage that is applicable.
 Rule D. Specificity
Where the selected cause describes a condition in general terms and a term
that provides more precise information about the site or nature of this
condition is reported on the certificate, prefer the more informative term.
This rule will often apply when the general term becomes an adjective
qualifying the more precise term.
 Rule E. Early and late stages of disease
Where the selected cause is an early stage of a disease and a more advanced
stage of the same disease is reported on the certificate, code to the more
advanced stage. This rule does not apply to a "chronic" form reported as
due to an "acute" form unless the classification gives special instructions to
that effect.
 Rule F. Sequelae
Where the selected cause is an early form of a condition for which the
classification provides a separate "Sequelae of …" category, and there is
evidence that death occurred from residual effects of this condition rather
than from those of its active phase, code to the appropriate "Sequelae of …"
category.
ASSUMPTION OF INTERVENING CAUSE
On some medical certificates, one condition may be indicated as due to another,

but the first one is not a direct sequel of the other. In such cases it may be
possible to assume that there are intervening causes that have not been reported
but which, if understood by the coder, will enable the 'construction' of a correct
sequence of events.

Clinical Coding
When making an assumption about intervening causes, you should only assume
an intervening cause for the purpose of interpreting the sequence not for
modifying the coding of the death.
Highly improbable
Sometimes the recorded sequence is highly improbable. The words ‘highly

improbable’ are used to describe a non-acceptable sequence.
NOTE : acute or terminal circulatory disease which are reported as being

due to malignant neoplasm, asthma or diabetes are acceptable as
possible sequences when they occur in PART I of the certificate.
Duration
The stated time factor (or duration) in a sequence should be considered. This is
important when you are considering whether one condition was caused by
another. However, this is often a poorly completed item on a death certificate
and this should be taken into account when interpreting entries.
Sequelae
The terms sequelae or late effects are used to describe a certain group of
conditions where a considerable amount of time might elapse between cause and
effect. The aetiology or originating condition is often no longer present when the
late effect occurs. Certain categories in ICD-10 have been designated for use in
coding sequelae as the underlying cause of death. They are:
B90-B94; E64.-; E68; G09; I69.-; O97; Y85-89
Rheumatic Fever with Heart Involvement
If there is no statement that the rheumatic process was active at the time of death,
assume activity if the heart condition (other than terminal conditions and
bacterial endocarditis) that is specified as rheumatic, or stated to be due to
rheumatic fever, is described as acute or subacute. In the absence of such
description, the terms carditis, endocarditis, heart disease, myocarditis and
pancarditis can be regarded as acute if either the interval between onset and
117
Clinical Coding
death is less than one year or, if no interval is stated, the age at death is under 15
years. Pericarditis can be regarded as acute at any age.
Nature of Injury
Although the external cause of an injury or injuries should be coded as the

underlying cause of death, WHO also recommends that the nature of injury is
also classified. When more than one kind of injury to a single body region is
recorded, and there is no clear indication as to which caused death, you must
apply the General Principle and selection rules in the usual way. This relates to
categories: S00-S99, T08-T35, T66-T79.
Malignancy
When malignancy is given as the underlying cause of death three factors must be
taken into consideration when assigning a code. These are the: Site,
Morphology, Behaviour of the neoplasm. If there are 3 factors associated with
recording malignant neoplasms as a cause of death then it is not surprising that
problems can arise with the way the certificate has been completed.

Hospital Statistics
6 HOSPITAL STATISTICS
____________________________________________________________
DEFINITION OF STATISTICS
Statistics is the process of collection, analysis, interpretation and presentation of

facts as numbers or numerical facts, which break down data into concise, useful
form.
The accuracy and comprehensive data collection are vital in statistical

preparation and the effectiveness of statistical reports depending upon the
terminology used. There must be a mutual/common understanding of its
meaning between the person who prepares the statistical report and its users. It
would also be essential to know what data to collect and how to collect them.
Hospital Statistics serves as a tool in planning, monitoring and evaluation of the

effectiveness of hospital operations and management. Effective and efficient
health indicators are considered integral part of the decision support system
which managers use in any major decision-making.
The Need for Hospital Statistics
 To provide data for management activities:
o Administrative Level
- Budgeting and resource allocation
- Cost Accounting
- Disbursement of funds
- Decision-making and evaluation
- Organizing staffing levels
- Data for accreditation purposes
- Licensure approved hospital and their services
119
Hospital Statistics
o Clinical Level
- Assessment of the quality of care
- Appraisal of medical, nursing and allied health professionals’
performance
- Teaching purposes
 Presents a comparison of the past and present performance of healthcare

facility
 Provides information for both internal and external agencies
 Meets legal requirements
 Serves as reference for research and education
CHARACTERISTICS OF QUALITY HOSPITAL STATISTICS DATA
 accuracy and validity of the original source data;
 reliability – data are consistent and information generated are

understandable;
 completeness – all required data are present;
 legibility – data are readable;
 current and timely – data are recorded at the point of care; and
 accessibility – data are available to authorized persons when and where

needed.
INPATIENT
Inpatient is a patient admitted in the hospital receiving healthcare services and

who is provided room, board and continuous nursing services in a unit or area of
the healthcare facility.

Hospital Statistics
 Inpatient Service Days is a unit of measure denoting the services received

by an inpatient in a 24-hour period or any fraction of the day thereof.
○ Census indicates the number of patients present in the hospital at any

given period with a standard cut-off time at 12:00 midnight e.g. the
Daily Floor Census Report for May 3 will include patients’ admitted,
discharged, death, transfer-in and transfer-out from 12:01 to 12:00
midnight.
Inpatients
CENSUS = remaining + Admissions – Discharges & Deaths
at midnight
Inpatients Admitted &

INPATIENT = remaining + Admissions – Discharges + discharged
SERVICE DAYS at midnight & Deaths same day
 Average Daily Census is the average number of inpatients per day. The
factors that influence this indicator are the inpatient service days and the
number of days in the same period.
○ Calculation of Average Daily Census
Total Inpatient Service Days for a period

AVERAGE DAILY CENSUS = -----------------------------------------------------------------
Total days in the same period
Total Inpatient Service Days of care is compiled on the 24-Hour Daily

Census Report and the grand total for the month is listed on the last
day of that month.
Newborn census must be reported separately. Average Daily Census

can also be computed by the wards or specialty departments, using the
same formula.
121
Hospital Statistics
To compute for the average daily census of a 100 authorized bed

capacity healthcare facility with an accumulated 2,750 inpatient service
days for the month of January is to divide 2,750 (total inpatient service
days) by 31 (number of days in the month). The average daily census
for the month is 88.
 Bed Occupancy Rate (BOR) is the ratio of actual Inpatient Service Days to
the maximum inpatient days determined by bed capacity during any given
period of time.
Total Inpatient Service Days for a period x 100

BED OCCUPANCY RATE = ----------------------------------------------------------------------------------
Total no. of authorized beds x Total days in the same period
Newborns must not be included in the computation. It is reported

separately. Beds in the Labor Room (LR), Emergency Department (ED),
Clinics, Examination Room, Recovery Room (RR) or temporary set-ups for
temporary overflow beds in hall, etc. or beds in the ward setup but with no
staff or patients using them (vacant or closed off area or wards, stored beds)
are not to be counted. To be counted, a bed must be permanently in use and
capable of being staffed just as any other bed (85% is the minimum required
to stay “even” or support the hospital’s existence at no profit whatsoever).
An example of bed occupancy rate for the month of June, 1,380 inpatient
service days were provided at a healthcare facility that has an authorized
bed capacity of 50. Taking into account that June has 30 days, the bed
occupancy for that period is 92.00%.
 Bed Turnover Interval is the average period in days that an available bed
remains empty between the discharge of one inpatient and the admission
of the next.
(Implementing beds x days in the period) – Inpatient Service Days for a period
BED TURNOVER = -----------------------------------------------------------------------------------------------------------------
INTERVAL Total discharges & deaths in the same period

Hospital Statistics
An example of bed turnover interval for the month of October 2008, a total
of 12,420 inpatient service days were provided at a Tertiary (Level 4)
healthcare facility with implementing beds of 462. During the period a total
of 1,400 patients discharged and died. The bed turnover interval is 1 day.
 Bed Turnover Rate is the number of times a bed, on average, changes

occupants during a given period of time.
No. of discharges (including deaths) for a period

BED TURNOVER RATE = ---------------------------------------------------------------------------
Average bed count during the period
A good example of bed turnover rate is a 200-beds healthcare facility

supplied the following information for the year 2008: patients discharged
including deaths are 6,500. This example shows that during the year, each of
the healthcare facility 200-beds changed occupants about 32 times.
 Length of Stay is the number of days a patient stays in the hospital, from
the date of admission to date of discharge. It is use in utilization
management which evaluates the hospital’s efficiency in providing
necessary services in the most cost-effective manner, while also evaluating
the level of care required.
 Average Length of Stay is the average number of days each inpatient stay in
the hospital for each episode of care. It is calculated by dividing the total
number of occupied bed days for a period by the number of separation in
same period and expressing the result as an average for all inpatient
discharges, or the average number of days of service rendered to each
inpatient discharged during a given period.
Total Length of Stay of discharged patients for a period x 100

AVERAGE LENGTH = -------------------------------------------------------------------------------------------
OF STAY Total discharges and deaths in the same period
Example: In June 2010, a healthcare facility discharged a total of 2,086

patients (including deaths). Their combined length of stay was 13,654 days.
Using the above formula the average length of stay of discharged patients is
6 days.
123
Hospital Statistics
It should be noted that the total length of patients discharged during the
month (regardless of the date of admission) is taken from the Daily Analysis
of Discharges compiled in the AMRS (please see Appendix). Actual days of
confinement is taken from each patient’s chart and totaled for the month.
The figure derived at is used as the enumerator in computing for the
Average Length of Stay.
A patient admitted and discharged that same day is considered as having

stayed one day.
Note:
o In computing for the length of stay, the date of admission is counted
but not the day of discharge.
o Newborns must not be included in computing for this indicator.
MEASURES OF HEALTHCARE PERFORMANCE
Morbidity refers to the state of having a disease (including illness, injury or

deviations from normal health), the number of sick persons or cases of disease in
relation to a specific population.
 Infection Rate may be calculated separately for a specific infection such as

surgical wound, puerperal and respiratory, urinary tract, blood infections
and so on.
 Gross Infection Rate is the rate of those infections which have occurred
following clean wound operations or births, or have developed into medical
cases after admission in the healthcare facility.
Note:
- The infection to be included shall be healthcare facility acquired and
shall be so determined by a committee or a physician.
- Up to two percent (2%) is considered normal by Western standards.

Hospital Statistics
Total no. of infections in the healthcare facility (or ward) for a period X 100
GROSS INFECTION = --------------------------------------------------------------------------------------------------------------
RATE Total discharges and deaths in the healthcare facility (or ward) for same period
The Infection Control Committee of a healthcare facility reported a total of 45

infections for the year 2010. Total discharges including deaths for the same
period were 2,000. Using the above formula, the gross infection rate is
calculated as follows:
45 (Total no. of infections) x 100

GROSS INFECTION RATE = -------------------------------------------------
2,000 (Total discharges including deaths)
GROSS INFECTION RATE = 2.25%
 Net Infection Rate is the rate of Healthcare Associated Infections (HAI) that
can be spread in many ways. Some transmission can occur through touch
and some through the air (via sneezing or coughing). The most prevalent
infections acquired during healthcare facility stays are pneumonia and
bloodstream, surgical site and urinary tract infections.
NET Total no. of infections debited against the health care facility (or ward) for a period X 100
INFECTION = -------------------------------------------------------------------------------------------------------------------------
RATE Total discharges and deaths from health care facility (or ward) for same period
For example, if an obstetrical patient develops a urinary tract infection, a

physician must determine whether it was healthcare facility acquired (those
acquired during hospitalization) or due to a recurrence of previous UTI. In
addition, determines whether acquired infections are attributable to specific
patient care wards/departments operations, patients with specified diseases
or individual physicians.
 Post-Operative Infection Rate is the rate these infections are occurring after
a clean surgical operation (OP) or procedure.
Total no. of infections occurring after a clean surgical operation X 100

POST O.P. = ---------------------------------------------------------------------------------------------
INFECTION RATE Total number of clean surgical operations /procedure for the same period
125
Hospital Statistics
For example, for the month of December 2009, a healthcare facility

performed and reported 658 cases of surgical operations. The ICC
reported 2 cases of Post OP infections in a clean surgical case. Based on the
formula, the Post OP infection rate for the month is computed as follows:
2 x 100
POST O.P . INFECTION RATE = ----------------
658
POST O.P. INFECTION RATE = 0.30 %
 Medical
Consultation Rate is the ratio of consultation following an attending

physician’s request to a consultant to examine a patient and give a second
opinion.
Total consultations (all departments) for a period X 100

CONSULTATION RATE = -----------------------------------------------------------------------------
Total discharges and deaths
Example: A healthcare facility reported a total of 9,528 consultations for the

year 2010. Total discharges and deaths for the same period 8,098.
Based on the formula, consultation rate is 1.18%.
CONSULTATION RATE = 9,528 x 100

8,098
CONSULTATION RATE = 1.18 %
Note:
- Include newborns in computing for this indicator.
- Twenty percent (20%) is considered normal for teaching hospitals and

which is acceptable by Western standards.
- A ten to fifteen percent (10 – 15%) is acceptable by Western standards.

Hospital Statistics
 Obstetrics
o Caesarean Section Rate is ratio of the number of Caesarian sections

performed to the total number of deliveries including Caesarian
sections for a certain period.
Total no. of Caesarian sections in a given period X 100

CAESARIAN SECTION RATE = -------------------------------------------------------------------------------
Total no. of deliveries for the same period
For example, four (4) caesarean sections were performed for the month
of August 2011, during which there were 350 deliveries. Following the
formula, the caesarean section rate is 1.14 %.
CAESARIAN SECTION RATE = 4 x 100

350
CAESARIAN SECTION RATE = 1.14 %
Note:
- A three to four percent (3 – 4%) rate or lower is acceptable by
Western standards.
- Regardless of whatever the outcome of delivery i.e. one child,

twins, etc. and whether a dead or live newborn is delivered, the
mother is considered to have delivered only once.
o Maternal Death Rate is the ratio of deaths resulting from obstetric

complications of the pregnancy state (pregnancy, labor, and
puerperium) from interventions, omissions, incorrect treatment, or
from a chain of events resulting from any of the above.
Types of Maternal Deaths
- Direct Cause are deaths resulting from obstetric complications of

the pregnancy state (pregnancy, labor, and puerperium) from
interventions, omissions, incorrect treatment, or from a chain of
events resulting from any of the above.
127
Hospital Statistics
- Indirect Cause is the death of a woman resulting from a (Indirect

Obstetric Death) previously existing disease (or a disease that
developed during pregnancy, labor, or the puerperium) that was
not due to obstetric causes, although the physiologic effects of
pregnancy were partially responsible for the death.
Total no. of direct maternal death in a given period X 100

MATERNAL DEATH RATE = ------------------------------------------------------------------------------
Total no. of maternal (obstetrical) discharges
including deaths for the same period
For example, two (2) mothers died after delivery at a healthcare facility
having annual OB discharges of 7,000. Maternal death rate derived from
the formula is 1.14%.
MATERNAL DEATH RATE = 2 x 100 = 1.14%

7,000
MATERNAL DEATH RATE = 1.14%
Note:
- To be counted, death must occur between conception and puerperium.
- Up to two and a half percent (2.5%) is considered normal by Western

standards.
- Count only those patients whose death was a direct result of an

obstetric complication of pregnancy, labor or puerperium from
interventions, omissions of treatment or chain of events resulting
from any of these.
- A woman who dies following an abortion is a maternal death, as in

an obstetrical patient who dies before the delivery of a cause due to
pregnancy.
- Non-maternal death rate is an obstetric death resulting from

accidental or incidental cause and not related to pregnancy or its
management.

Hospital Statistics
 Death Rate is the proportion of inpatient hospitalizations which ends in

death. It has always been an important information for healthcare facilities
in evaluating the quality of medical care.
o Gross Death Rate is the ratio of all inpatient deaths including

newborns for a given period to the total number of discharges
including deaths for a given period. This is also known as Mortality
Rate.
Total deaths including newborn for a given period X 100

GROSS DEATH RATE = --------------------------------------------------------------------------------
Total discharges and deaths for the same period
For example, if the healthcare facility had 4 deaths and 385 discharges
for the month, the gross death rate is:
GROSS DEATH RATE = 4 x 100

385
GROSS DEATH RATE = 1.04 %
Note:
- Do not include Dead on Arrival (DOA), stillbirth, and ER deaths.
- Include newborn death in computing for this indicator. Below three

percent (3%) is acceptable by Western standards.
o Net Death Rate is the ratio of deaths excluding deaths under 48 hours
of admission. It produces a lower figure than the gross death rate. This
is also known as Institutional Death Rate.
Deaths (including newborn) – those deaths under 48 hours for the period) X 100
NET DEATH RATE = --------------------------------------------------------------------------------------------------------------
(INSTITUTIONAL Total no. of discharges (including deaths and newborn) – deaths under
DEATH RATE) 48 hours for the same period)
129
Hospital Statistics
For example, a healthcare facility had a total of 424 deaths for the year
2008, 183 of which died less than 48 hours after confinement. The total
number of discharges for the same period is 16,500. Net death rate is
1.47 %.
NET DEATH RATE = (424 – 183) x 100 = 24,100

(16,500-183) 16,317
NET DEATH RATE = 1.47%
Note: Death occurring at the ER is not counted if the patient is not

yet considered admitted. 0.5 – 2.5% rate is acceptable by
Western standards.
o Post-Operative Death Rate is the ratio of deaths within 10 days after

surgery to the total number of patients operated on during that period.
Total post-operative deaths for the period X 100

POST OPERATIVE DEATH RATE = -----------------------------------------------------------------
Total patients operated for the same period
For example a healthcare facility had a total of 72 surgical operations

performed for the month of February, one (1) of which died due to
coronary artery bypass after ten (10) days of surgical operation,
computation is as follows:
POST OPERATIVE DEATH RATE = 1 x 100

72
POST OPERATIVE DEATH RATE = 1.39 %
o Anesthesia Death Rate is the ratio of deaths caused by anesthetic

agents during a specify period of time to the number of anesthetics
administered. This includes those deaths that occurred within ten (10)
days of surgery.

Hospital Statistics
Total no. of deaths caused by anesthetic agent for a period X 100

ANESTHESIA DEATH RATE = --------------------------------------------------------------------------------------
Total no. of anesthetics administered for the same period
o Maternal Death Rate is also included as an indicator in the

computation of mortality rate. (Please refer to p. 110 for the formula)
o Perinatal Death refers to fetal deaths and live births with only brief
survival usually days or weeks, or the death of an infant between birth
and at the end of the neonatal period.
○ Fetal Death Rate (Stillbirth Rate) is the ratio of intermediate and late
fetal deaths to total number of births including intermediate and late
fetal deaths.
Total no. of intermediate and late fetal deaths for the period X 100
FETAL DEATH RATE = ---------------------------------------------------------------------------------------------
(STILLBIRTH RATE) Total no. of birth (including intermediate and late fetal deaths)
for the same period
For example, in January, a healthcare facility had a total of 98 live

births, one (1) intermediate fetal death, and 4 late fetal deaths. To
determine the fetal death rate, the total number of intermediate (1) and
late fetal deaths (5) is divided by the total number of live births and the
intermediate and late fetal deaths (98 + 5). The computation is as
follows:
FETAL DEATH RATE = 5 x 100 = 5 x 100

98+5 103
FETAL DEATH RATE = 4.85%
Note:
- Below two percent (2%) is considered normal by Western
standards.
131
Hospital Statistics
- Fetal deaths are classified as:
▪ Early Fetal Death – less than 20 weeks of gestation (500

grams or less)
▪ Intermediate Fetal Death – 20 weeks of gestation but less

than 28 (501 to 1000 grams)
▪ Late Fetal Death – 20 or more weeks of gestation (1001

grams – stillbirth)
○ Neonatal Death Rate (Infant Newborn Mortality Rate) is the ratio of

newborn deaths to the total number of newborn discharges including
deaths.
Total no. of newborn deaths for the period X 100

NEONATAL DEATH RATE = -------------------------------------------------------------------------------------
(INFANT NEWBORN Total no. of newborn infant discharges (including deaths)
MORTALITY RATE) for the same period
For example, a healthcare facility reported the following statistics for

the year 2010: newborn deaths 3, newborn discharges 3,850. Infant
newborn mortality rate is 0.08%.
NEONATAL DEATH RATE = 3 x 100

3,850
NEONATAL DEATH RATE = 0.08%
Note:
- Fetal deaths of less than 20 weeks shall not be included as well as
those who were admitted after their deliveries/births outside the
healthcare facilities.
- For infant death rate, below 2% is acceptable by Western

standards.

Hospital Statistics
Neonatal Death could be divided into:
- Neonatal Period I – from the hour of birth through 23 hours and 59

minutes.
- Neonatal Period II – from the beginning of the 24th hour of life

through 6 days, 23 hours, and 59 minutes.
- Neonatal Period III – from the beginning of the 7th day of life
through 27 days, 23 hours, and 59 minutes.
○ Infant Death Rate is the ratio of the total number of infant deaths
including neonatal and post neonatal deaths rate of a liveborn infant at
any time from the moment of birth to the end of the first year of life
(364 days, 23 hours, 59 minutes from the moment of birth)
Total no. of Infant deaths (neonatal and post neonatal during a period X 100
INFANT DEATH RATE = ----------------------------------------------------------------------------------------------------------
Number of livebirths during the period
Using the same data on the above example on the computation of

Infant Newborn Mortality Rate with total livebirths of 3,856, the infant
death rate is calculated as follows:
INFANT DEATH RATE = 3 x 100

3,856
INFANT DEATH RATE = 0.08%
 Autopsy Rate is the proportion of deaths that are followed by the

performance of an autopsy.
o Gross Autopsy Rate is the ratio of all autopsies performed in the

healthcare facility to all in-patient deaths in the healthcare facility.
Total no. of autopsies performed for a period X 100

GROSS AUTOPSY RATE = -------------------------------------------------------------------------
Total no. of inpatient deaths for the same period
133
Hospital Statistics
For example, in September 2010, a healthcare facility discharged 942

patients with 36 deaths (including newborn) and performed 11
autopsies. Using the formula given above, the gross autopsy rate is:
GROSS AUTOPSY RATE = 11 x 100

36
GROSS AUTOPSY RATE = 30.56 %
o Net Autopsy Rate is the ratio of all autopsies to all inpatient deaths
less the unautopsied cases during the period.
Total no. of autopsies performed for a period X 100

NET AUTOPSY RATE = ------------------------------------------------------------------------------
Total deaths – unautopsied cases for the same period
For example, in July 2011, a healthcare facility had a total of 32 deaths

and performed 12 autopsies. Three (3) bodies were released to the
forensic examiner for autopsy. Therefore, 3 cases are subtracted from
the denominator because they were not autopsied by the healthcare
facility. Dividing the number of inpatient autopsies performed (12) by
the total number of bodies available for autopsy (32-3=29) yields a net
autopsy rate of 41.38%.
NET AUTOPSY RATE = 12 x 100 = 1,200 = 41.38%

(32-3) 29
NET AUTOPSY RATE = 41.38%
Note:
Exclusions:
- Stillbirth
- Dead on Arrival (DOA)
- Death in the Emergency Room when patient is not admitted.
(ER Death)
- Medico-legal cases referred to the proper authority.

Hospital Statistics
OUTPATIENT STATISTICAL DATA COLLECTION AND CALCULATION
Out-Patient
Out-patient is a patient who receives health care services without being

admitted for inpatient medical care or healthcare services and does not occupy a
bed for any length of time; or a patient who consults and receives health care
services in the healthcare facility without being admitted.
 Total Number of Outpatient Visits refers to the total number of outpatients

attended and who received health care services in the healthcare facility for
a given period of time.
o New visits refer to the total number of outpatient first visits, and
grouped by age and sex.
o Revisits or Follow-up visits refer to the total number of outpatient

second and subsequent visits, and grouped by age and sex.
 Total Number of Encounters refers to the number of health care services

given to outpatients during the visit.
 Average Number of Outpatient Visits per OPD day refers to the average
number of out-patients who were attended for a given period.
Total no. of Outpatient visits/attended (both new and revisits)

during a period
AVERAGE NO. OF OUTPATIENT = --------------------------------------------------------------------------------------
VISITS PER OPD DAY Total no. of days for the same period
Emergency Room
Emergency Room is a healthcare facility or primary care department which

provides initial treatment to patients with a broad spectrum of illnesses and
injuries, some of which may be life-threatening and requiring immediate action;
or a healthcare facility or primary care department which provides initial
treatment to patients in response to an increased need for rapid assessment and
management of critical illnesses.
135
Hospital Statistics
 Total Number of Patients refers to the total number of emergency patients

attended and who received health care services in the healthcare facility for
a given period.
o Emergency patients refer to patients who frequently arrive with

unstable conditions and hence must be treated quickly.
o Non-Emergency patients refer to patients afflicted with minor injuries

or illnesses who arrive late at night or at times when the regular clinics
of the healthcare facility are closed.
 Average Number of ER Patients per day refers to the average number of

both emergency and non-emergency patients who were attended in the
Emergency Room for a given period.
Total no. of Emergency and Non-Emergency Patients

attended in the ER for a given period
AVERAGE NUMBER OF = --------------------------------------------------------------------------------
ER PATIENTS PER DAY Total no. of days for the same period
Mortality
Mortality refers to death rate in relation to a specific population; or a fatal

outcome or in one word, death. The word “mortality” is derived from the word
“mortal” which came from the Latin “mors” meaning death.
 Dead on Arrival (DOA) refers to the condition in which a patient arrived in

a healthcare facility with no life processes and is pronounced dead by a
physician.
 ER Death refers to the condition in which a patient who arrived in the

healthcare facility breathing and showed evidence of life but died after a
short period of time.

Medico-Legal Aspects of Health Records
7 MEDICO-LEGAL ASPECTS
OF HEALTH RECORDS
____________________________________________________________
OWNERSHIP OF THE HEALTH RECORD
The health record is the physical property of the healthcare facility and is
maintained for the benefit of the patient, the physician, the healthcare facility and
the community. As a general rule, ownership carries with it the right and power
to control the utilization of the said property. If the healthcare facility maintains
the record then that facility owns the physical aspect of the health record. If the
physician maintains the record then the physician owns the physical aspect of
the health record. However, ownership is not absolute because the patient also
has a right to the information written on the record, that being his/her health
history, therefore, the patient owns the content of the health record.
Accessibility and Confidentiality
As a general rule, all the people who are directly involved in the treatment of a
patient shall have access to the record.
The health record is a legal document, as such, all records shall be stored in areas
where only authorized staff is allowed access and appropriate security measures
are instituted. No clinical information concerning a patient or client shall be
released to another person without the consent of the patient.
 If the patient is a minor, a person below 18 years of age, authorization of the

parent or legal guardian should be obtained.
 In the event the patient is unable to sign the authorization by reason of

physical or mental disability, the authorization should be signed by the next
137
of kin or the legally appointed guardian. If possible, verification of such

disability should be obtained from a physician.
 If the patient has died, the consent must be signed by the identified next of
kin, or by the administrator or executor of the decedent’s estate.
 The original health record is the physical property of the healthcare facility
and it should not be taken out of the hospital except on court order.
Request for Information from Doctors or Health Institution Required

for Continuing Patient Care
Advances in healthcare delivery gave rise to what is known as the “team care
approach”. This requires a wider range of health professionals who shall have a
legitimate need for access to information from the health record. In this sense,
institution should formulate guidelines to restrict access to records to those who
are only actually involved in the care of a particular patient.
Request for Information from the Health Record for Research and Studies
Healthcare facility owns the physical aspect of the health record, but legally, the
“privilege against disclosure belongs to the patient and the physician and
nobody else”. In a healthcare facility setting, proper notification of the attending
physician prior to the release of information is ideal, in order to protect the legal
interest of the doctor and the healthcare facility as well.
In cases of research and studies, the management and/or Research/Ethics

Review Committee shall decide on who can and who shall not be given access to
the health record. While the healthcare facility may give access to a patient’s
health record for research study and publication, the law emphasizes the need to
protect the identity and the name of the patient should not be mentioned in the
published reports.
A research proposal to be presented for approval should be accompanied by a

comprehensive protocol detailing the objectives methods and reasons for the
study. Records for research purposes should not be removed from the health
facility.

Health Information of Psychiatric Patient
Health information of psychiatric patient shall be released only upon

presentation of a written authorization from the patient’s nearest kin or by a
person appointed by the court as the legal guardian. If the request is from a
psychiatric facility where the patient is presently confined, the information shall
be released as soon as possible for the patient’s benefit.
Health Information of Human Immuno-deficiency Virus (HIV) Patient
Medical confidentiality shall protect and uphold the right to privacy of an

individual who undergoes HIV testing or is diagnosed to have HIV. It includes
the safe guarding all medical records obtained by health professionals, health
instructors, co-workers, employers, recruitment agency, insurance companies,
data encoders, and other custodians of said records, file or data.
Confidentiality shall encompass all forms of communication that directly or

indirectly lead to the disclosure of information on the identity or health status of
any person who undergoes HIV testing or is diagnosed to have HIV. This
information may include but is not limited to the name, address, picture,
physical description or any other characteristics of a person, which may lead to
his/her identification.
To safeguard the confidentiality of a person's HIV/AIDS record, protocols and

policies shall be adopted by concerned officials, agencies and institutions.
Exceptions to the Mandate of Confidentiality
The requirement for medical confidentiality shall be waived in the following

instances:
 When responding to a subpoena duces tecum and subpoena ad testificandum

issued by a court with jurisdiction over legal proceedings where the main
issue is the HIV status of an individual;
 When complying with the reporting requirements for AIDSWATCH (Sec.

39 of IRR on RA 8043); and
139
 When informing other health workers directly involved or about to be

involved in the treatment or care of a person with HIV/AIDS and such
treatment or care carry the risk of HIV transmission.
Health workers who are exposed to invasive procedures and may potentially be
in contact with blood and bodily fluids likely to transmit HIV shall be informed
of the HIV status of a person, even without his/her consent. This information is
vital to their protection against acquiring and transmitting the HIV infection
through safe practices and procedures.
Release of HIV/AIDS Test Results
The Result of HIV/AIDS testing shall be confidential and shall be released on to

the following:
• Person who was tested;
• Parent of a minor who was tested;
• Legal guardian of an insane person or orphan who was tested;
• Person authorized to receive said result for AIDSWATCH; and
• A judge of the Lower Court, Justice of the Court of Appeals or Supreme

Court Justice who has jurisdiction over the case
Health Information on Violence Against Women and Children
Records of the cases shall be treated with utmost confidentiality. Whoever

publishes or causes to be published, in any format, the name, address, telephone
number, school, business address, employer or other identifying information of
the parties or an immediate family or household member, without their consent
or without authority of the court..

Confidentiality of Records Under the Voluntary Submission Program
Medical records of drug dependents under the voluntary submission program

shall be confidential and shall not be used against him for any purpose, except to
determine how many times, by himself/herself or through his/her parent,
spouse, guardian or relative within the fourth degree of consanguinity or
affinity, he/she voluntarily submitted himself/herself for confinement,
treatment and rehabilitation or has been committed to a Center under this
program.
Confidentiality of Records Under the Compulsory Submission Program.
The records of a drug dependent who was rehabilitated and discharged from the
Center under the compulsory submission program, or who was charged for
violation. However, the records of a drug dependent who was not rehabilitated,
or who escaped but did not surrender himself/herself within the prescribed
period, shall be forwarded to the court..
Request for Information from the Media
The DOH recommends that all of the following procedures be observed in giving
information to the press:
• Request should be addressed to the COH for approval.
• No information identifying the patient shall be released without proper

consent.
• Consent should be secured if the patient is legally capacitated. If the patient

is legally incapacitated, the consent of the parent, next of kin or legal
guardian should be secured before release of information.
• Consent of the attending physician should be secured.
141
Records Subpoenaed by the Court
Subpoena testificandum is a process directed to a person requiring him to attend

and to testify in any investigation being conducted under Philippine law. He
may also be required to bring with him books, documents, or other materials
under his control, in which case, it is called a subpoena duces tecum. Subpoena
duces tecum ad testificandum is issued when a person is mandated to testify and
to bring the documents to court.
Oftentimes, the HIM receives a subpoena duces tecum, which only requires the
HIM supervisor to bring a particular record(s) to court.
A legally served subpoena is binding on the person to whom it is addressed. The

HIM staff should not accept any subpoena not directly addressed to HIM. If a
subpoena is addressed to a particular doctor, it must be served to the doctor or
his representative.
In situations where a subpoena is served to a doctor who is no longer connected

with the institution, a letter of notification signed by the COH, addressed to the
presiding Judge shall be accomplished and submitted to the court.
Upon receipt of the subpoena, the recipient must always indicate the time and
date of receipt.
Procedure in Response to Subpoena Duces Tecum:
 Check the Master Patient Index (MPI) if the patient mentioned in the
subpoena was admitted/treated in the healthcare facility.
 Check the file and retrieve the record.
 Re-analyze the health record for completeness/consistencies of entries.
 Notify management and the attending physician about the subpoena.
 Number all the pages consecutively in a discrete manner.

 Transfer the record in a secure place preferably under lock and key.
 Photocopy the original record before going to court.
 Never leave the original copy in court when it is not requested by the court.
Informed Consent for Medical and Surgical Procedure
As a general rule, no treatment or procedure with risk involved may be

performed without the patient’s/relative’s consent. But there are instances where
consent could not be obtained from a legally incapacitated person (for example
when a patient is comatose or a minor) then surrogate consent must be obtained
from the parent, nearest-of- kin or legal guardian.
To be considered valid, consent must be signed by the patient/relative and a

witness and must also be dated and timed. Aside from these requirements, the
person giving the consent should be legally and mentally competent. The
consent must be freely given to the authorized person and the patient must be
well-informed for him/her to reach a reasonable voluntary decision.
CONSENTS AND CERTIFICATES
The following documents require specific signatures and must have their legal
requirements completed before they can be included in the record:
 Consent to Involvement in Clinical Trials (Therapeutic)
 Consent of Recipient to Operation, Transplantation or Grafting of Tissue
 Informed Consent of Surgery, Anesthesia of Other Procedures

This consent must be signed and witnessed after a doctor has explained to
the patient the nature of the operation or the procedure to be informed. This
consent must be completed before the patient is given pre-operative
medication.
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 Discharge Against Medical Advice (DAMA)

This consent has two parts. The first section, whenever possible, should be
completed before the patient leaves the ward (in some cases, this
requirement may cause him to change his mind). If the patient leaves
without signing, the second part of this form should be completed, signed
by a nurse and witnessed by someone who is not a member of the hospital
staff.
 Consent to Release of Patient Medical Information

This consent should be secured and notarized before any confidential
information is released. Should law enforcement agent request confidential
information, he must present an authorization signed by his Head of Office.
This authority should always be confirmed by calling the said office before
releasing the information.
 Consent to Remove Organ for Transplant (Living Donor)

This consent has two parts. The first part is signed by the patient (donor),
and the second part is the confirmation, which is to be accomplished by the
doctor.
 Voluntary Sterilization Consent Form

This consent requires that parties, husband and wife, sign the consent for it
to be considered valid.
 Therapeutic Abortion Form

This form is to be accomplished by both the husband and the wife before
the procedure is performed by the physician. This also requires the
signatures of at least two witnesses.
 Refusal to Permit Blood Transfusion

The patient has the right to refuse medication or treatment (e.g., blood
transfusion), which might be against his/her religious belief. In which case,
this consent form should be properly accomplished.
 Consent to the Administration of Electro-Convulsive Therapy

This form must be accomplished in mental hospitals before the
administration of electroconvulsive therapy.

 Consent to Autopsy
The consent to autopsy must be properly signed, by whoever is the next of
kin of executor of the deceased, before doing the procedure.
 Refusal to Consent to Autopsy

This form should be accomplished in cases where it is applicable, by the
next of kin of the deceased.
 Request for Access to Medical Records

This form must be accomplished by the patient and other authorized parties
before any information, of clinical nature, can be released by the hospital or
health facility.
 Notification to Physician Request to Access

For the information of the attending physician, a notification form must be
accomplished, every time a request for medical information is received by
the Medical Records Service.
 Certificate of Confinement
This certificate should be accomplished and signed by the medical record
supervisor and should bear the hospital seal. It should also have a control
number for authentication purposes.
 Medical Certificate
This certificate should have a control number. It must be signed bye the
attending physician and must bear the hospital seal.
 Disposition of Cadaver
This form shows all the steps to be taken following the death of a patient. If
each item is accomplished correctly, then the hospital and its staff will be
free from any legal liability.
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HANDLING TELEPHONE INQUIRIES
The HIMD receives numerous telephone calls, which may involve requests for
information. Prudence must be observed before giving out any form of
information. These inquiries may come from the following:
• A doctor asking information about a patient
• A patient presently confined at the hospital
• A former patient of the hospital who wants information about

himself/herself
• A friend or relative of a patient
• A police officer
• A government agency (e.g., GSIS, SSS, PHIC, HMO, NBI, PCSO, etc.)
The following are the procedures for handling such inquiries.
 From A Doctor
o Ensure that the doctor identifies himself clearly.
o Find out the name of the patient; date of birth, if possible, or other
identifying information; and the approximate date of admission.
o Locate the Health Record number from the MPI in order to find the
record from the file.
o The record shall be forwarded to the supervisor of the HIM for him to
answer the inquiry.
o The supervisor shall take the name and address of the doctor for
reference purposes.

 From a Patient
o Ask the patient for identifying information and find out what he
wishes to know.
o Only the following data can be given directly to the patient without the
approval of the attending physician: admission and discharge dates,
name of the attending physician, and other demographic data except
any clinical information.
o If an approval has been obtained from the attending physician, the

patient may have the right to access all the clinical information needed.
 From Friends and Relatives

Any information about a patient shall not be given to his relative or friend
without his written consent.
 From the Police and Other Law Enforcement Agencies

Any information regarding a patient is not to be released to the police and
other law enforcement agencies except when there is a written request
signed by the head of the agency. The police should be reminded that the
said information could only be used for legal purposes.
 From Government Agencies

The only information that may be released to government agencies over the
telephone are the admission and discharge dates and the name of the
attending physician. The patient’s written consent shall be required should
any additional information be needed.
DEALING WITH HIMD CLIENTS
Different people approach the HIMD to make inquiries or request for in

formation. The procedures for handling such inquiries are as follows:
• Establish the identity of the requesting party through exhaustive interview.
147
• If the person wants to borrow any record, refer to “Handling Request for
Records”
• If the person is requesting information by phone, follow guidelines in

“Handling Telephone Inquiries.” Otherwise follow “Release of Information
Policy.”

Continuous Quality Improvement for Health Records
8 CONTINUOUS QUALITY
IMPROVEMENT FOR
HEALTH RECORDS
____________________________________________________________
INTRODUCTION
Health Service delivery has been changing over the past years. The evolving
science of medicine manifested in the discoveries of new diagnostic and
treatment modalities and changes in patient expectation in the face of limited
resources has placed a strain on the capability of healthcare providers to provide
the best care possible. This often results to failure in delivery of effective health
services resulting to increase litigation in healthcare and poor health outcomes.
Because of this the health sector has adopted the quality improvement
experience of the manufacturing industry in providing quality services.
Quality Assurance is a systematic approach in monitoring and assessing the

patient care provided or the service being delivered. Quality Assurance identifies
opportunities for improvement and provides a mechanism through which action
is taken to make and maintain these improvements.
Quality assurance should encompass the evaluation of structure, process, and

outcome. Structure factors include components such as staffing, funding, and
risk factors. Process, on the other hand, includes the care process and its
components like diagnostic, therapeutic, and after effects of care. Outcome
factors involve health status components such as physical functioning, patient or
physician satisfaction and wellness level.
149
Since its inception, Quality Assurance (QA) mechanisms have changed, with the
prescriptive mechanism evolving into more facility oriented systems. At present,
Continuous Quality Improvement (CQI) has become more accepted and can be
described as a process through which the level of quality is defined, pursued,
achieved and continuously improved through the establishment of formal
mechanism systems and structure within the organization. CQI describes the
overall effort of the hospital organization to achieve the most effective care with
the available resources and without comprising quality.
CQI is a strategic approach to providing the best healthcare possible. It is a

preventive strategic approach to providing the best healthcare possible. It is a
preventive strategy that was constant innovation to improve work processes and
systems by reducing time-consuming, low-value activities. Time that was once
spent on network and crisis management is now spent on planning, coordination
and control.
These include different perspective of quality:
 Clinical quality (providers) - refers to the degree to which health services for
individuals and populations increase the likelihood of desired health
outcomes and are consistent with current professional knowledge.
 Service quality (customers) - the emphasis on service quality has been

apparent since the growth of manage care.
 Cultural quality (administration) – refers to the recent movement in

healthcare called Total Quality Management (TQM) or CQI.
This is the effort to improve the level of performance across an entire

organization to achieve higher levels of customer satisfaction (Reference: DOH AO
# 2006-0002).

CONTINUOUS QUALITY IMPROVEMENT (CQI)

AT THE HEALTH INFORMATION MANAGEMENT DEPARTMENT (HIMD)
Standard
Continuous Quality Improvement is the structured organizational process for

involving personnel in planning and executing a continuous flow of
improvements to provide quality healthcare that meets or exceeds expectations.
Dr. W. Edwards Deming taught that by adopting appropriate principles of

management, organizations can increase quality and simultaneously reduce costs
(by reducing waste, rework, staff attrition and litigation while increasing
customer loyalty). The key is to practice continual improvement.
General Objective
To improve quality service to patients through the continuous improvement and

maintenance of various activities of the Health Record Department/Section.
Specific Objectives
 To strengthen the implementation of the existing SOPs of the HIM.
 To provide quality health record for continuity of care to patient and for
research purposes.
 To assess and determine the quality of service delivered and to identify the
areas which need improvement to attain the excellent service delivery.
 To provide feedback to facilitate necessary corrective actions, identify staff

in-service training needs, provide an objective basis for disciplinary actions,
encouraged each employee to achieve the optimum level, and recognize
excellence in employee performance in order to institute staff development.
151
 To provide quality statistical report for management planning and decision

making.
 To attain cost-effective health record management
Continuing Quality Improvement program evolved from Quality Assurance

(QA) Program. QA is its main framework that provided guidelines for health
care facilities to plan and systematize procedures in providing quality service.
CQI then is a process wherein the degree of quality desired is clearly defined,
followed, attained, evaluated, and continuously improved by establishing formal
mechanisms/systems and structure. When CQI is adopted by the healthcare
facility management as one of each ideals, imbibed by the system, the result is
Total Quality Management (TQM).
The benefits gained in pursuing Continuing Quality Improvement Program are:
 Higher employee morale

 Higher productivity
 Less firefighting resulting in more time for innovation and creativity
 Improved quality of services
 Increased market share
 Lower costs
 Increased customer satisfaction
 Higher profits
Composition of CQI Team
The PHIC Benchbook states that “Quality Improvement may be operationalized

through small scale quality projects in particular work areas through quality
circles.” Therefore, the HIMD will organize a quality circle with the following
members:
 One who is involved and who knows the process

 One who is affected by the problem
 One who has technical expertise

 One who makes decision about the process

 Other members who can contribute to the formulation and implementation
of solutions
An employee who has the expertise or one who is affected by the problem can be
a member of a QI team regardless of the department he belongs. The team then
may become multidisciplinary or cross functional.
The team is mandated to meet regularly to identify problems, understand and

analyze the causes, formulate best solution for implementation. Evaluation and
monitoring must be carried out in order to to institute corrective actions making
CQI a continuing cycle.
Expected Outcomes of the Quality Improvement Activities
 Continuous improvement project of clinical and non-clinical care and

service.
 Identification of barriers in the achievement of higher quality patient care.
 Motivation for the staff to be more aware of and interested to standards of

patient care and service.
 Delivery of safe and efficient care and service.
 Efficient and effective allocation and use of resources.
 Commitment from staff/management which will ensure that the program is

ongoing, upgraded, improved standards are long lasting and conformed to
the standard required by other agencies.
 Construction input, from all staff levels, into the continuing education
program of the complex.
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 Communication at all levels about problems related to standards of quality

care and service.
 Cooperative problem-solving, where a service involves more than one area

in the complex.
DOCUMENTATION
The results of the QI studies, the implementation of QI activities, and continuous

monitoring using relevant indicators should be documented and integrated into
the management information system and utilized in decision-making. The
elements of documentation include patient care or service issues discussed at
meetings, actions taken, persons responsible for the actions, and notes of
completed actions.
Essential Elements of Quality Improvement
 Planned and Systematic Approach. Quality assurance plan should exist and
address the following:
o Scope of the program

o Objective
o Methods to be used
o The individuals to be involved in the program
 Monitoring. There should be a systematic ongoing process of collecting

information on clinical and non-clinical performance.
 Assessment. The periodic analysis and interpretation of the information

collected in order to identify problems in patient care.
 Action. At this stage important problems in patient care or opportunities to

improve care are identified, action/studies are undertaken.

 Evaluation. The effectiveness of actions taken is evaluated to ensure long-

term improvement.
 Feedback. To be effective, results of the activities should be regularly

relayed to the staff of people involved in the program.
The Plan–Do–Check–Act Cycle (PDCA)
The PDCA Cycle is a checklist of the four stages which you must go through to
get from `problem-faced' to `problem solved'. The four stages are Plan-Do-
Check-Act, and they are carried out in the cycle illustrated below:
Figure 11. Conceptual Framework of PDCA
The concept of the PDCA Cycle was originally developed by Walter Shewhart,
the pioneering statistician who developed statistical process control in the Bell
Laboratories in the US during the 1930's. It is often referred to as `the Shewhart
Cycle'. It was taken up and promoted very effectively from the 1950s on by the
famous Quality Management authority, W. Edwards Deming, and is
consequently known by many as `the Deming Wheel'.
Use the PDCA Cycle to coordinate your continuous improvement efforts. It both
emphasizes and demonstrates that improvement programs must start with
careful planning, must result in effective action, and must move on again to
careful planning in a continuous cycle.
155
How to Use Each Stage of the Cycle
 Plan to improve your operations first by finding out what things are going
wrong (that is identify the problems faced), and come up with ideas for
solving these problems.
 Do changes designed to solve the problems on a small or experimental scale

first. This minimizes disruption to routine activity while testing whether the
changes will work or not.
 Check whether the small scale or experimental changes are achieving the
desired result or not. Also, continuously Check nominated key activities
(regardless of any experimentation going on) to ensure that you know what
the quality of the output is at all times to identify any new problems when
they crop up.
 Act to implement changes on a larger scale if the experiment is successful.

This means making the changes a routine part of your activity. Also Act to
involve other persons (other departments, suppliers, or customers) affected
by the changes and whose cooperation you need to implement them on a
larger scale, or those who may simply benefit from what you have learned
(you may, of course, already have involved these people in the Do or trial
stage).
The cycle is now completed to arrive at `problem solved'. Go back to the Plan
stage to identify the next `problem faced'.
If the experiment was not successful, skip the Act stage and go back to the Plan
stage to come up with some new ideas for solving the problem and go through
the cycle again. Plan-Do-Check-Act describes the overall stages of improvement
activity, but how is each stage carried out? This is where other specific quality
management, or continuous improvement, tools and techniques come into play.
The diagram below lists the tools and techniques which can be used to complete
each stage of the PDCA Cycle.
This classification of tools into sections of the PDCA Cycle is not meant to be
strictly applied, but it is a useful prompt to help you choose what to do at each
critical stage of your improvement efforts.

Quality Improvement Problem Solving Methodology (PDCA)
STEPS GUIDELINES TOOLS and EXPECTED

TECHNIQUES OUTPUT
1. Problem 1. What problems in > Brainstorming > List of

Identification your hospital need to problems
and be addressed in order > Prioritization identified
Prioritization to meet/enhance Matrix Criteria
customer satisfaction? > Priority
> Checksheet problem to
2. What is the priority (for data be addressed
problem the team will collection) by the team
address? How did you
decide on it? > Tentative
problem
statement
2. Understanding 1. Construct a flowchart > Flowchart > Flowchart

the Present to describe the process Constructed
System in which the problem
occurs; indicate the > Data/Data
beginning and end of requirements
the process.
> Final
2. What data will you Problem
collect to prove the Statement
existence of the
problem? Supply the > Tentative
data, based on your Objective
experiences, to prove Statement
that there’s a problem.
3. Formulate the (a) final

problem statement,
and the (b) tentative
objective statement.
157

TECHNIQUES OUTPUT
3. Analysis of the 1. Identify the root > Brainstorming > List of real
Root Causes causes of the problem causes of the
> Cause and problem
2. Plan data collection – Effect/
data you will collect, Ishikawa/ > Constructed
methods and tools Fishbone Diagram
Diagram
3. Use appropriate tools > Chart/
to present data Graphs
4. Formulate the final > Final

objective statement Objective
Statement
4. Formulation of 1. From among alter- > List of

Alternative native solutions, solutions to
Solutions identify the best and be
support your answer. implemented
2. Prepare an action > Gantt Chart

plan.
> Potential
3. Do a potential Problem
problem analysis. Analysis
Table
5. Solution 1. Prepare plan for > Monitoring

Implementation monitoring to include Plan
data to be collected,
methods for collection,
tools for presentation
of data
6. Evaluation of 1. Make an evaluation > Evaluation

Results plan to include data to Plan
be collected, methods
for collection, tools for
presentation of data


TECHNIQUES OUTPUT
7. Standardization/ 1. Standardize the > Use 5W’s

Institutionali- successfully (What,
zation implemented solution. When,
Where,
2. Integrate the new Who, and
policies and Why) and 1H
procedures in the (How much)
organization’s
manual/SOP.
8. Self-Evaluation 1. Evaluate your team’s > Radar Chart

and Future Plans performance in QI
activities, using your > Team
experience as a development
group/team. plan
2. Prepare a team
development plan
What is a Problem?
 Negative state of things

 Gap between what is desired and what is the current state
 Deviation from a standard or desired level of performance
 Threat – a situation/condition that might cause trouble
Brainstorming is a way for a group to generate as many ideas as possible in a

very short time by tapping into group knowledge and individual creativity.
Flowchart is a graphic representation of how a process works, showing, at a

minimum, the sequence of Steps.
159
Structure – Process - Outcome
 Structure – resources to provide adequate healthcare
 Process – the extent to which professionals perform according to accepted

standards
 Outcomes - changes in the patient’s condition following treatment
Nine Dimensions of Quality

(Source: QA Monogram URC Maryland, USA, 2002)
 Technical Performance
 Effectiveness of Care
 Efficiency of service Delivery
 Safety
 Access to Services
 Interpersonal Relationship
 Continuity of Services
 Physical Infrastructure and Comfort
 Choice
Continuous Improvement is carried out through a number of Basic Quality

Tools:
 Check Sheet. It is a data collection form. It allows the team to systematically

record and compile data from historical sources, or observations as they
happen, so that patterns and trends can be clearly detected and shown.
 Histogram. It is a bar graph representing the frequency of individual

occurrences or classes of data.
 Pareto Diagram. It is essentially a special form of vertical bar chart that

puts items in order (from the highest to the lowest) relative to some
measurable effect of interest: frequency, cost, time.

 Graph uses pictures to compare the sizes, amounts, quantities or

proportions of various items or groupings of items.
 Control Chart is a graph that provides a pictorial presentation of whatever

it is you are measuring over a period of time.
 Cause and Effect also called Ishikawa or Fishbone Diagrams, most widely
used tool of CQI. It allows team to identify, explore and graphically display,
in increasing detail, all of the possible causes related to a problem or
condition to discover its root cause (s).
 Scatter Diagram is a tool that represents the relationship between two

variables. It shows what happens to one characteristic as the other changes.
Example of Quality Improvement Study Template
TITLE OF QIP STUDY: Increasing Number of Incomplete Health Record
NAME OF CIRCLE TEAM:
ASSISTANT LEADER:
TEAM LEADER:
MEMBERS:
ADVISER:
COMPANY PROFILE:
CIRCLE HISTORY:
ABSTRACT OF THE PROJECT:
161
ACTIVITY PLAN:
ACTIVITY PLAN
Activities Year 2008 March April May June July August
1. Circle Formation
2. Problem Identification &
Prioritization
3. Understanding the present
system
4. Problem Statement
5. Objective Statement
6. Root Cause Analysis
7. Validation of Root Causes
8. Formulation of Best Solution
9. Solution Implementation
10. Evaluation of Results
11. Standardization
12. Future Plans/ Self-
Evaluation
Legend: Target
Actual

Step 1. Problem Identification and Prioritization
Problems Controllability Problem Existence Significance Remarks

Identified
1. Increasing From March 17-21,
number of 2008 there were
incomplete Controllable 40% occurrences of Significant GO
health record incomplete health
records
2. Long Waiting
Time in health
record retrieval
3. Misfiled health
record
Validation of Problems identified
 Problem #1. Increasing number of incomplete health record
Total Number Number of

Period of Health Occurrences % of Percentage
Record Incomplete
March 17-21, 2008 500 200 40%
 Problem #2. Long Waiting Time in health record retrieval
Total Number Health Record Percentage

Period of physician’s Given >3 minutes
request
March 17-21, 2008 100 10 10%
 Problem #3. Misfiled health record
Period Total Number Total Number Of Percentage

of Health Misfiled Health
Record Record
March 17-21, 2008 500 5 1%
163
Problem Statement
Based on the data gathered in March 17-21, 2008 at ABC Hospital Medical
Records Department, there was a total of 40% occurrences of incomplete health
record.
Objective Statement
Reduce the percentage of occurrences of incomplete health record from 40% to

15% by the end of June 2008.
Step 2. Understanding the Present System
Figure 12. Flowchart of Health Record Management

Step 3. Analysis of the Root Causes
Cause and Effect Diagram (Fishbone Diagram)
MAN METHOD
Increasing
number of
incomplete
health
records
MATERIALS ENVIRONMENT
Validation of Probable Cause
Probable Cause Validation Method Findings Decision
1. Non-compliance to Actual Observation Out of 300 doctors, 50 TRUE CAUSE

SOP on health of them were not -
record completion complying to SOP
2.
3.
165
Step 4. Formulation of Solution
A. Selection of Best Alternative Solution
Probable Cause Alternative Advantages Disadvantages Decision

Solution
1. Non- Strict Prompt Resistance to True

compliance on implementation delivery of changes Cause
SOP on health of the SOP. service.
record completion.
2.
3.
B. Potential Problem Analysis During Implementation
Solution Potential Most Likely Contingent Responsible Target

Problem Cause Action Person Date
1. Strict Working Least Reiteration Head, HIMD May 2008

implement- relationshi priority of SOP
ation of the p affected implement-
SOP. ation.
2.
3.

Step 5. Solution Implementation
Strict implementation of SOP on health record completion
Activity In- May June July Aug

charge
1. Re-orientation All
members
2. Implementation All
members
3. Evaluation of All
Implementation members
Legend: Target –
Actual -
Step 6. Evaluation of the Result
COMPARATIVE RESULT OF CQI STUDY ON HEALTH RECORD COMPLETION

March 17, 2008 - August 21, 2008
200 (40%)
200
180
160
140
Frequency
120
100
50 (10%)
80
60
40
20
0
BEFORE AFTER
Results
167
Tangible Benefits. Peso savings
Intangible Benefits. Teamwork, value of cooperation
Step 7. Standardization
Based on the result of the study, strict implementation of SOP on health

record completion was standardized effective August, 2008.
Step 8. Future Plans
To work on the next identified problem.
MONITORING AND EVALUATION
This section focuses on the monitoring and evaluation facilities and activities of
the HIMD to assess whether the set standards are being followed or whether
services and practices are delivered in accordance with institutional Standard
Operating Procedures (SOPs) and other state laws, rules and regulations.
Standard
The HIMD shall adopt a system of monitoring and evaluating the effectiveness
and efficiency of its services and measuring client satisfaction of said services. It
must be noted that the HIMD shall not only center its attention on its internal
problems but also on its relationship with other external stakeholders.
Analyzing the results of this measuring tool will show significant results and
must correspondingly be reported to decision makers of the health care facility
for appropriate actions. The results would either be the basis for drafting new
policies for implementation or would repeat a cycle of CQI.
Presented herein is an example of the evaluation tool. Users are not limited to
the Standards indicated and can establish their own parameters that is applicable
to their set up.

Example of Health Record Evaluation Checklist
Standard YES NO NA Remarks/Objective

Evidence
1. Physical Facilities
1.1 Is the space sufficient to maintain health
record for 15 years based on prospected
number of patients?
1.2 Is there a filing area for active and inactive

incoming health records?
> active file – 5 years
> inactive file – 10 years
1.3 Is the filing/storage area secured to ensure
the confidentiality of the health record & to
prevent unauthorized entry?
1.4 Is there a sufficient area where the staff could
work and the doctor could complete health
record?
1.5 Are there enough filing cabinets to
accommodate incoming, active and
inactive records?
2. Administrative Function
2.1 Is there a manual of procedure prepared by
the HIM Supervisor?
2.2 Is there an adequate staff in the HIMS? (20:1)
2.3 Is there a policy on release of clinical
information?
2.4 Is there a Record disposition schedule
approved by management and the
government agency concerned?
2.5 Is there a program of continuing education/
orientation conducted by the HIM
Department?
3. Policies
3.1 Is there a policy formulated for the release of
clinical information?
3.2 Is the policy for the release of information
enforced?
169

Evidence
3.3 Are policies written for the information of all
concerned?
3.4 Is the objective of the HIM clearly stated in
the policy?
3.5 Is the policy formulated by the HIM
Department consistent with the hospital-wide
policies?
3.6 Are policies circulated for the information
and guidance of all concerned?
3.7 Does the policy state the person authorized to
enforce it?
3.8 Was the policy formulated in consultation
with all concerned staff?
3.9 Is the policy updated to reflect the latest
trends in HIM?
3.10 Is there a written policy on borrowing
patient’s health record?
3.11 Is there a written policy for addressing Every proposed use or
information security, including data integrity transfer of person-
that is based on or consistent with law or identifiable information
regulation? within or from an
> the person who has access to organization should be
information clearly defined and
> the information to which an
individual has access
> the user’s obligations to keep
information confidential
> the process that followed when
confidentiality and security are
violated
3.12 Is the policy implemented?
3.13 Is the compliance with the policy
monitored?
4. Health Record Management
4.1 Do all the pages of the record bear the:
> Patient's name
> Health Record No.


Evidence
4.2 Do all forms have space for:
> Patient’s Name
> Health Record No.
4.3 Do all forms that required physician’s
signature have sufficient space?
4.4 Do all forms that required writing the date by
the doctor have sufficient space?
4.5 Do all forms have the name of the hospital?
4.6 Do all forms have a control number?
5. Process
5.1 Is the demographical data of the patient
complete?
5.2 Does the history of the patient contain the
following:
a. Present/past history
b. Family history
c. Social history
5.3 Does the Discharge Summary of the patient
contain the following?
a. Reason for admission
b. Significant physical and other findings
c. Discharge diagnoses: principal and co-
morbidities
d. Diagnostic and therapeutic procedures
performed
e. Medications and other treatments
f. Patient’s condition upon discharge
g. Discharge medications
h. Follow-up instructions
5.4 Are the entries signed and dated by the staff
concerned?
5.5 Does the consent form bear the signature of
the patient / nearest kin?
5.6 Is the consent form dated and signed by a
witness?
5.7 Are all pages of the health record correctly
identified?
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Evidence
5.8 Are all results of the requested examinations
properly attached to the health record?
5.9 Does the discharge note of the nurse
state the following:
a. The condition of the patient
b. The mode of discharge
c. The person who was with the patient.
5.10 Is the handwriting legible?
5.11 Are the abbreviations used standard?
5.12 Do all charts of well baby attached to the
mother’s health record?
5.13 Are all loose sheets forwarded to the HIM
stamp dated?
5.14 Are all loose sheets filed as soon as they
reach the HIM?
5.15 Are all loose sheets sorted and filed in their
correct health records upon receipt?
5.16 Do all loose sheets bear the patient’s name
and health record number?
5.17 Are all discharge diagnoses assigned ICD-10
codes?
5.18 Does the disease index contain all
diagnoses?
5.19 Are the disease indexes arranged according
to disease codes?
5.20 Is the morphology code (M code) used in
coding neoplasm?
5.21 Are the disease indexes updated daily?
5.22 Are all discharge diagnoses can be located
on the ICD-10 books?
5.23 Is the terminal digit filing system adopted?
5.24 Are health records sorted prior to filing?
5.25 Is the Unit Numbering System adopted?
5.26 Does the HIM maintain an active and
inactive records separately?


Evidence
5.27 Does the HIM maintain a centralized filing
system?
5.28 Are there captions to guide the filing and
retrieval process?
5.29 Are the filing shelves arranged for a
minimum of body movement?
5.30 Does the HIM maintain the following
indexes?
a. MPI
b. Disease Index
5.31 Are the following registers maintained/
stored for safekeeping?
a. Admission Register
b. Birth Register
c. Death Register
d. Delivery Room Register
e. Discharge Register
f. Emergency Room Register
g. Operating Room Register
h. Outpatient Department Register
5.32 Are all requested records located?
5.33 Are all requested records entered in the
tracking system?
5.34 Is the in-house box updated daily?
5.35 Are all the records in their designated filing
area?
5.36 Are incomplete records filed in their
respective pigeon holes?
5.37 Are all the records lent out properly
acknowledged by the authorized borrower?
5.38 Does the SOP clearly state the allowed
duration to borrow the health record?
6. Quality Improvement
6.1 Are records completed within 48 hours after
patient's discharge?
6.2 Are history and P.E. completed within 24
hours after admission?
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Evidence
6.3 Is incomplete health record completed within
15 days after patient’s discharge?
6.2 Can a research list furnished by researchers
promptly be obtained from the disease index?
6.4 Are all requested records made available to
borrowers? (100% except for charts not yet
forwarded to the HIM)
6.4 Has communication improved between

departments concerned as a result of CQI?
6.5 Is the 75-80% of implementation of
recommendations and suggestions made?
6.6 As a result of CQI Program, is there a need to
revise or change some systems and
procedures?
6.7 Is there a need to re-train the HIM staff?
6.9 Is there a feedback system from internal and
external stakeholders?
6.10 Are laws and other government rules and
regulations relative to delivery of services
adopted?

Risk Management for the HIMD
9 RISK MANAGEMENT
FOR THE HIMD
____________________________________________________________
Risk Management Program (RMP) is a functional planning approach to

identify, assess, and reduce or control risks that pose safety threats to patients
their relatives, visitors, and staff of the health care facility. The conceptual
framework of the program is to prevent the expenditure of funds for health on
litigation, to enable them to be used instead for the improvement of patient care.
Medical audit and quality assurance programs are intended primarily to
improve patient care, but it is only in combination with risks management that
the risk of litigation will be diminished.
The physicians’ liability and accountability for patient injury became an integral
part of each society’s medical practices. This expanded to non-physicians and
subsequently to the health care facility as civilization and the practice of
medicine evolved and became highly specialized and complex due to the
developments brought about by extensive medical researches and advances in
technology.
Today, health care facilities are corporately liable for:
 Exercising reasonable care in providing proper medical equipment,

supplies, medication, and food for their patients;
 Exercising reasonable care in providing safe physical premises for their

patients.
 Adopting internal policies and procedures reasonably estimated to protect

the safety and interest of their patients;
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 Exercising reasonable care in the selection and retention of hospital

employees and in granting of medical staff privileges.
 Exercising reasonable care to guarantee that adequate patient care is being

administered.
Safety and risk management, primarily concerned with the protection of human
and other resources from accidental losses and damages, should be an integral
function in any organization because it is impossible to have everything perfect
because human being who are the prime movers of a health care facility are not
perfect. It shall be the policy of concerned health facilities to conceptualize and
implement a hospital wide Risk Management Program (RMP), the activity of
which shall be done in close coordination with the hospital Quality Assurance
Program (QAP), for the benefit of its patients, visitors, stakeholders, and the
hospital staff as well.
On a day to day operation, the Health Information Management Department

(HIMD) is routinely exposed to risk management issues which probably are not
address for lack of technical and/or theoretical background of the H IMD staff in
this area. It is however, a different scenario for a technically trained supervisor
because he/she can easily identify which issues and problems can be categorized
under risk management category and subject to risk management protocols on a
time efficient and cost effective manner. The primary reason for which can be
attributed to the absence of a formal curriculum in the country to technically
train our HIMD practitioners to prepared them to technically handle their
important role as a member of the healthcare team in the health industry.
It is a known fact that one of the biggest problems beset by a HIMD practitioner
is incomplete documentation basically because documentation and/or recording
is a multi-disciplinary task. That is despite existing documentation guidelines
and standards, both local and international for concerned medical, nursing, and
other allied health professionals on the creation of quality documented health
record.
Daily, many issues and concerns bother the HIMD staff and supervisor which
need to be studied, addressed and acted upon so as to prevent further negative
effects on the service which may lead not only to departmental issue but
institutional concern when not solved. And when that is already the case, may
entail more time and resources to address.

Some of the most common issues and problems encountered by the HIMD are as
follows:
Documentation Issues and Problems
 The clinical coder can not code the diagnosis on the face sheet of the
medical record because there is inconsistency between the diagnostic
statement written by the attending physician on the face sheet and the
biopsy report (histopathology/biopsy report).
 That the analysis clerk noticed that there is inconsistency in documentation

on the “laterality on the operative report” with the other parts of the
medical records.
 That similarly in one record being analyze by the analysis clerk, she noticed
that the date and time of operation was not accomplished/filled up by the
concerned surgeon.
 That a clinical abstract attached to an international insurance claim was sent

back due to question on completeness and comprehensive of
documentation particularly medication prescribed and given to the patient
and course in the ward.
 That a medical record urgently requested by the patient is in the incomplete

file of the attending physician and the concerned physician is out of town
attending a conference or meeting.
 That a patient/relative approached the office with a question why he/she

was charged twice for x-ray procedure yet the patient remembered he/she
was x-rayed just once.
 The finance staff doing abstract on hospitalization cost can not verify from
the medical record whether or not CBC procedure was done three times
because the medical record documentation was not complete despite the
presence of three charged slips for the said procedure/examination.
 Nobody from the HIMD can analyze a certain medical record because the
handwriting of the physician cannot be read.
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Issues and Problems on Systems and Procedure
 Upon receipt of subpoena duces tecum from a court the subject medical record
is no where to be found despite efforts to retrieve it from the file.
 The subpoenaed medical record was incomplete and the supposed

attending physician is out of the country beyond the specified date the
record is supposed to be brought to the court.
 The records ordered by the court through subpoena were incomplete and
the attending physician has already resigned from the facility.
 That a medical record remains incomplete because the main attending

physician of that case can not be identified and the series of doctors who
attended to that particular patient do not want to complete the medical
record.
 The number of incomplete records by the busiest physician of the institution

approaches 100, and his incomplete file includes records that have no
operative or consultation notes for patients who were treated over six
months ago.
Program Description
General Functions of Risk Management Program in Health Facilities
The HIMD Risk Management Program has the following functions:
 Protect financial assets of the hospital.
 Protect human and intangible resources
 Prevent injury to patients, visitors, employees, and property.
 Cost reduction focusing on individual loss or on single incidents.

 Loss prevention to prevent incidents by improving the quality of care

through continuing and on going monitoring.
 Review of each incident and the pattern of incidents through the

application of the steps in the risk management process which are as
follows:
○ Recognition of the safety problem, analysis of hazards and probable

consequences (risk identification).
○ Recognition of the safety problem, analysis of hazards and probable

consequences. (risk identification)
○ Assessment of risk (risk analysis)
○ Decision on what to do with the risk (options: tolerate, treat terminate,

transfer) (risk monitoring and evaluation)
○ Decision on what to do with the risk (options: tolerate, treat terminate,

transfer) (risk monitoring and evaluation)
○ Review of risk management performance and results, upgrading of the

system (risk treatment)
Key Characteristics of the Program
 Activity Based Information which is:

○ linked to incident/accident reports
○ linked to quality protocols
○ linked to safety protocols
○ linked to effective systems and procedures
○ linked to other quality program output of the hospital
 Need to provide a context in which to analyze and investigate

incident/accident reports and produce statistics on risk management
activities
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○ data collection
- centralized recording/documenting of incidents/accidents
- every incident/accident documented and reported
○ data analysis and interpretation

- every incident/accident report reviewed and investigated by
concerned committee
○ quality control
- policies, systems and procedures, and professional ethical
standards reviewed, revised and updated as the need arises
General Principles
 Preventive and anticipatory program/activity
o No duplication of activities with other existing quality Committees
o Mandatory departmental participation
o Reduction of claim adjustments or settlements
o Link and overlaps with safety and quality program activities
o Hospital wide program
Why HIMD is Vital in Risk Management Program
Philippine Medical Malpractice Act brought in many changes in the medical

profession. And the medical record being the instrument created in the delivery
of health services was directly affected. One of the resultant effects of the law
was the effort to deliver quality service to patients in order to prevent being sued
for malpractice. Statistics on medical malpractice will really rise similar to other
countries. The implementation of risk management program in the industry in
general will help the healthcare facility to technically prepare for the PhilHealth
accreditation The same malpractice law created awareness to healthcare facility
administrators to expect delivery of quality patient care to protect financial
resource of the facility. As authorities theorized, “An effective Risk Management

Program detects actual and potential problems in patient care before they
precipitate legal action.”
The HIMD is one area of the facility where improvement is now being done
mainly brought about by Philheath accreditation requirements. The said
accreditation requirement not only created impact on the quality of service to
patients but also to the HIMD, because of medical record documentation.
Incidentally, this may partly address one of the very concerns of the HIMD, that
is incomplete or poorly documented medical records.
It is in documentation and/or recording where the HIMD can be of valued to the

Risk Management Program of the institution mainly because the HIMD has
knowledge of the common medical documentation errors giving it the credit of
being vital to the program.
The HIMD is important to the program because of the following:
 The HIMD has knowledge of the serious clinical mishaps and

documentation problems that make defending malpractice claims or suit
difficult if not impossible.
 The HIMD has full knowledge of the different documentation and /or
recording standards which is used as a guide in the quantitative and
qualitative analysis of medical records. An inherent function of the HIMD
to assist the members of the medical, nursing and other professional came
up with quality documentation.
 The HIMD have experience in quality assurance activities. HIMD in higher

category/level healthcare facilities, most especially with research
components has institutionalized quality assurance programs to safeguard
the quality of medical service rendered to their patients. Part of the strategic
management effort they put in place to improve marketability and cutting
edge to their competitors in the health industry.
 The HIMD staff particularly the trained statistician have data management
skills. That aside from having background in statistics he/she is trained in
health statistics, a very specialized technical training open with research
component. Such staff are experts in the collection, storage, retrieval and
analysis of risk management data. Modern days statistician are statistically
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trained in the use of the different statistical packages available in the market
to come up with a computerized quality/risk management data base for the
healthcare facility to the advantage of the quality and risk management
program implementation.
 The HIMD has inherent function to analyze the completeness of

documentation of the medical record giving HIMD staff giving him/her an
idea of the documentation problems, and because of quality assurance
program being implemented he/she always strive to constantly strive to
improve to attain excellence as influenced by the basic principles of quality
assurance program as its precursor.
How to Identify Documentation Problems which may pose risk
Problem in documentation can be identified through in-depth record screening

by the medical record and/or risk management committee members. Such
review should consider the legal integrity of the record like the record must
contain the proper signatures, dates and times, and the content is complete,
accurate and consistent.
To be reliable and objective, the review should be criteria-based.
 The criteria for medical record review must come from the following areas:
○ Medical staff rules and regulations
○ Hospital policies and procedures
○ Philippines Medical Record Standard
○ JCIA Standards (International Standard)
○ Department of Health Standards, Policies and Procedures
○ Legal aspects review criteria
 For risk management purposes, the review should concentrate on known

high-malpractice risk areas such as:
○ Emergency room records
○ Consent forms and procedures
○ Reports of and responses to negative findings
○ Patient education
○ “Do not resuscitate” orders

○ Reports of medication variances and other unusual incidents

○ Records from special units.
Safety and risk management, primarily concerned with the protection of human
and other resources from accidental losses and damages, should be an integral
function in any organization because it is impossible to have everything perfect
because human being who are the prime movers of a health care facility are not
perfect. The healthcare facility, in its effort to protect its valuable financial
resources shall, as a policy, conceptualize and implement a hospital wide Risk
Management Program (RMP), the activity of which shall be done in close
coordination with the hospital Quality Assurance Program (QAP), for the benefit
of its patients, visitors, stakeholders, and the healthcares facility staff as well.
Concurrent Analysis: A Risk Management Instrument
Traditionally, review of medical records to determine completeness and

compliance to standards was done retrospectively. That is after discharged of the
patient and the medical record are forwarded to the HIMD, analysis both
quantitatively and qualitatively is done by the HIMD staff. It was however
observed to have several negative effects on completeness of documentation as
some important details not documented remains incomplete after the discharge
of the patient. This very reason has lead to the conceptualization and
implementation of concurrent analysis. In the process the HIMD staff goes to the
different units of the facility particularly when there is already order to discharge
to review and analyze the health record for inconsistencies and incompleteness
based on standards.
Such practice of concurrent analysis ensures the timeliness of entries and

completion of the medical record even before records are forwarded to the
HIMD. It likewise improve interface between the members of the nursing,
medical and HIMD staff. Other benefits of concurrent analysis are; it saves
physicians time. When physicians are reminded to complete the record in the
nursing units, chances are they spend less time or even no time to visit the HIMD
since they do not have records of the discharged patients to be completed.
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When concurrent analysis is implemented in a healthcare facility,
 the role of the HIMD is made more visible;
 establishes direct communication between and among members of the

nursing and medical staff, and
 gives HIMD staff an opportunity of disseminating current documentation

guidelines to keep records current.
Concurrent review/analysis is essential in risk management.. If the analysis

procedure includes generic screening criteria, potentially compensable events
(PCE’s) can be detected before patients leaves the healthcare facility and steps
can be taken to avoid a potential lawsuit while patient is still hospitalized.
In the local setting the traditional review/analysis of record must be expanded to

look for incomplete or inconsistent documentation by nurses, therapist and other
members of the allied health professionals. The analysis should cover the
contents of the record, completeness of history and physical examination,
patients’ assessments, plans or recommendations, therapy goals, processes and
discharge notes, patient instructions and other comments. It should also include
a review of the legal problems; e.g. extraneous or inappropriate remarks or
illegal entries.
Incomplete and inadequate medical record has been a source of frustration for
physicians, health facility administrators, lawyers, professional societies,
regulatory bodies and re-imbursement agencies.
Incompletely documented medical record may have the possible effects:
 affect the implementation of quality assurance and risk management efforts;
 affect health facility re-imbursement when services rendered to patients are

not documented;
 may force health facility and physician to settle suit out of court or to lose
because attorneys can not prepare a solid defense.

As Arthur F. Southwick explains, “One of the best possible defense in

malpractice litigation is to present in evidence a medical record that is obviously
a complete and accurate record of the continuous care and treatment rendered to
the patient. Such a record is frequently convincing under all the facts and
circumstances.”
The result of analysis should be consolidated into a bi-monthly of monthly report

to be submitted to the Quality Officer and to management of the institution for
appropriate action.
Authority and Responsibility
 Authority
The R. M. P in coordination with the other health facility committees,

formulate relevant and sensible risk management policy/guidelines and
recommends measures to management to reduce if not totally eliminate
possible risk involving client-partners, doctor-partners, employee-partners
and most of all our shareholders in terms of financial threats to the hospital.
 Organizational Structure
○ The program shall be headed by a person appointed by the

management who at the same time is also the Quality Assurance
Officer of the Institution.
○ The appointed Committee head shall then, plan for the organization of
a group to form the “Risk Management Committee (RMC) of the
hospital.
○ From the RMC Members the TWG shall be identified.
○ The Risk Management Committee shall establish coordinating function

with the Chairman of the Infection Control Committee, the Safety
Committee, Hazardous Waste Management Committee and Disaster
Control Committee.
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○ The head of the Risk Management Committee shall report directly to

the Chairman of the Quality Assurance Committee.
The diagram below shows the line of authority and responsibility of key
personnel of the institution and the risk management coordinator.
Following is an illustration showing the linkages of Risk Management

Program with the other hospital committees relevant to its effective and
efficient implementation.
Risk Safety
Committee
Management
Committee
Quality
Assurance
Committee
Disaster Control
 Committee
Infection Control
Committee
Hazardous Waste
Management
Committee
Figure 13. Conceptual Framework showing the Linkages of Risk Management

Program with other Health Facility Related Committees/Programs

 Duties and Responsibilities of the Risk Management Committee
The Risk Management Committee (RMC), is task in establishing,

supporting and maintaining the Risk Management Program. This
committee shall monitor and evaluate potential organizational risk,
professional practice standards, applicable laws and regulations and come
up with effective policies and guidelines for implementation.
The following are the duties and responsibilities of the

Risk Management Committee:
o Evaluates all the interaction of all risk components and assess the risk
of the Healthcare Facility particularly in the known high
malpractice risk areas e.g. emergency room record, consent forms
and procedures, reports of and responses to negative findings,
patient education, reports of medication variances, records from
special care units, etc.
o Coordinates with the members of the Technical Working

Group and the different department heads for the
development/establishment of the departmental safety
guidelines, policies and procedures on risk management in
conformity with professional practice standards, regulatory
and accreditation agency requirements.
o Coordination with the members of the Technical Working

Group in the formulation of administrative policies, systems
and procedures to guide, assess, and measure the
implementation of the program.
o Initiates the creation and/or establishment of the Technical

Working Group whose members shall come from all of the
service components of the healthcare facility. Members of the
committee shall be identified from the following areas:
- Medical Services
- Nursing Services
- Ancillary Services
- Plant Operation Services
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- Support Services
- Security Services
○ Establishes close coordinating function and linkage with the existing

healthcare facility committees e.g. Safety, Infection control,
Hazardous Waste Management, for the dissemination of risk
management information for the information and guidance of the
concerned staff.
○ Exercises the leadership necessary to ensure the consistent

implementation of the program to meet set goals and objectives.
○ Continuously monitors the program implementation with the

assistance from the Technical Working Group.
○ Determines the training needs of the staff on risk and safety

management and conceptualize training programs to address their
needs.
○ Acts as secretariat to the Risk Management Program by performing

the following tasks:
- Receives, logs, and maintains incident/accident reports and

support information;
- Maintains appropriate statistical analyses and review from

gathered information;
- Maintains pertinent records and minutes of related committee

activities;
- Initiates immediate follow-up to risk problems situations;
- Coordinates and supplements risk prevention and corrective

activities throughout the organization; and
- Performs other related activities as the need arises.

 Specific Functions of the Risk Management Coordinator
o Directs the program implementation per instruction from the Quality

Assurance Officer.
o Assists in quality assurance activities throughout the hospital as they

relate to Risk management functions.
o Coordinates with the Quality Assurance Officer and the Chairman of

other relevant committees in the conduct of investigation of incident
and/or accidents.
o Directly reports to the Quality Program Officer relevant program

activities and /or accomplishments of the committee and receives
directional instructions for the effective and efficient implementation o
the program.
o Implements the maintenance of an efficient record system for

documentation purposes.
o Liaisons with the other concerned safety committees for

synchronization of planned activities for cost containment purposes.
o Determines training needs of the committee members and coordinate

with capable training agency for the conduct of appropriate training
program to address the needs of the members with the assistance of
Human Resource Services.
o Coordinates with the Human Resource Services and the Safety

Committee for the conduct of in-house training on safety and risk
management for the information and guidance of the concerned staff.
o Conceptualizes the different risk management activities to be able to

meet the institutional goal to effectively implement the program.
o Provides regular updates regarding the program to concerned staff.
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o Coordinates with the Security Officer regarding security and

protection measures being implemented for the benefit of patients,
visitors and staff of the health care facility.
 Role of the Medical Staff in Risk Management Program
o Develops written departmental safety guidelines and share it with the

RMC.
o Consistently enforces professional, ethical, and safety standards on the

medical profession.
o Be constantly alert for unsafe practices and unsafe conditions and be

prepared to take appropriate action to correct any irregularities.
 Role of the Medico-Legal Officer
o First and foremost, is to represent the healthcare facility in litigation

proceedings.
o Advises the health facility board regarding the legal implications of

bylaws, rules, regulations, policy establishment, and ultimate decisions
made by the board.
o Advises the medical staff relative to establishment and enforcement of

bylaws, rules and regulations.
o Assist medical staff committees dealing with medical evaluation and

other related activities with legal implication.
o Assist the health facility administrator in operational activities having

legal implications.
o Advises designated members of the health facility team in operational

matters having legal implications. These include the following;
administrator, medical record manager, the nursing director and the
risk management coordinator.

 Specific Role of the Patient Care Group (Nursing) in RMP
o Lead service component of the Health facility in the implementation of

Risk Management Program.
o Assist the Risk Management Committee through the different Patient

Care Managers monitor the implementation of the program.
o Provide technical support to the program implementation.
o Provide the necessary budgetary requirements were applicable to the

program implementation.
Program Implementation
The objective of the program is to institutionalize Risk Management Program

through close coordination and linkage with the other health facility quality and
safety committees to prevent unwise utilization of valuable resources associated
with the risk of medical malpractice or professional liability.
To institutionalize the program, the health facility shall implement the following
strategies.
 Preparation of an “Office Order/Center Order, which would spell out the

organization of the Risk Management committee;
 Organization of the “Technical Working Group (TWG), who shall be

chosen from the Risk Management Committee;
 Formulation/development of policies/guidelines, systems and operational

procedure;
 Formulation of risk management protocols by health facility service

components; and
 Identification of risk management activities by hospital service component

to met the overall goals and objective of the program.
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 Capability building/Human Resource Development
○ Conduct of consultative meetings with the other quality committees

and/or services for brainstorming on goals, objectives, and activities;
○ Training needs assessment;
- Conceptualization of appropriate training interventions base on

needs assessment; and
- Implementation/conduct of trainings
 Social mobilization
○ Orientation program about Risk Management Program;
○ Establishment of linkage with the other quality committees; e.g.

Infection, Waste Management, Safety, Disaster Management, etc.
○ Strengthening communication network between and among

committee members.
 Program assessment and monitoring:
o Assessment of the policies and procedures for compliance to risk

management requirements;
o Monitoring the implementation of risk management activities; e.g.

quality documentation, correct medication, etc.
Education and Training

Risk management activities in the clinical aspect of hospital operation and
management is quite new in the country hence statistics on agencies engage in
the conduct of risk management training is very rare except in the Western
countries where it is already institutionalized in the health industry because it is
a basics accreditation requirement.

To ensure the effective and efficient implementation of a functional Risk

Management Program, the staff involved must have thorough knowledge about
the program they will implement for them to appreciate and know how they can
be of importance to the program and further for their information and guidance.
To attain this objective, “Capability Building/Human Resource Development”
shall be implemented. Training is one of the interventions which shall be
initiated once the program is approved for implementation to upgrade the
knowledge, attitude and skills of the members of the committee regarding the
program.
Integral to the conceptualization of an effective training program is, training

needs assessment as initial step in the development of a training module. It shall
be done in close coordination with the Human Resource Services (HRS),
primarily on the technical aspect of the assessment process. Training shall be
conducted in-house or sourced -out to an appropriate training agency if the
H.R.S. has no capability in this technical area of risk management.
Risk management activities in the clinical aspect of hospital operation and

management is quite new in the country hence statistics on agencies engage in
the conduct of risk management training is very rare except for the local branch
of the World Safety Organization.
Appropriate topics for inclusion into the training module shall be identified by
the Risk Management Committee members in consultation with the Quality
Officer. The product of deliberation on the topic shall be recommended to the
awarded training agency should there be one. Following are some relevant topics
which could be considered for inclusion into the risk management training
module:
 Theoretical and conceptual framework of the program
 The program objective(s)
 Functions of the program
 Scope of the program
 The role and function of the different committees involved in the program
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 The role and function of the Risk Management Committee
 The specific role and function of the Technical Working Group (TWG)
 The steps in the preparation of departmental risk management protocol
 The content and format of the incident/accident report
 The procedure in the conduct of investigation after an incident/accident

report
 The incident/accident reporting procedure
 How to identify risk management problem(s)
 Documentation requirements and legal practices in:

○ completing consent forms
○ maintaining the legal integrity of the records
○ filling out special forms unique to the institution
 The confidentiality of medical record information
 Medical record completion policies
 Safety procedures:
○ Chemical and occupational hazards
○ Plant operation and maintenance
○ Housekeeping
 Reasons why people commit human errors
 Treatment and medication errors
 Accreditation and regulatory requirements in health industry (local and

international)
 Others

Other avenues to upgrade knowledge, attitudes, and skills of the members of the
RMCshall also be implemented with the assistance from the H.R.S.
Performance Improvement Standards
Inherent in the implementation of this program/project is the development of

performance standards to more or less ensure the effective implementation of the
Risk Management Program. The established performance standards shall also
serve as benchmark against accomplishment/output. That is to determine
whether or not the set goals and objectives are met, the activities are
accomplished, and the program plan carried out. Monitoring tool shall be
formulated based on selected performance indicators to facilitate logical and
realistic assessment and evaluation. Future program planning for performance
improvement shall be based on the result of the assessment and evaluation.
The following are the planned performance improvement standards for the Risk
Management Program.
 Development of more effective risk management protocols by health facility

service components.
 Identification of more potential risk and safety management indicators
 Review and revise Standard Policies and Procedures to ensure compliance

to risk management protocols, and regulatory requirements specifically on
the following which are highly potential risk areas:
○ patient admissions and identification
○ incident/accident reporting
○ infection surveillance
○ lost and found
○ drug and therapeutic management
○ noise control
○ patient valuables
○ safety
○ security
○ smoking
○ traffic control
○ patient transfer and transportation
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○ visiting policy
○ electrical safety
○ environmental control
○ safety responsibilities of employee
○ employee grievance/dissatisfaction
○ safety responsibilities of employee
○ occupational injury and illness
○ Others
 Strict implementation of Patient and Visitors education
 Development/revision of monitoring and assessment tool in risk

management
 Closer coordination and linkage between and among the various

committees involved in quality and safety activities.
Annual Effectiveness Evaluation
To ensure effective and efficient implementation of a viable and sustainable Risk

Management Program, strict monitoring and evaluation using established
criteria shall be done by the members of the Risk Management Committee using
the monitoring tool conceptualized by the committee members. Statistical report
generated shall be analyzed and interpreted to determine the progress and
performance of the program. The result shall be used as management tool to
strategically plan for the succeeding year of operation to address whatever
variance beset by the program which is associated with risk management.
 Few medication errors, transfusion errors, treatment/procedures errors,

admitted patient without informed consent, complaints about present/past
treatments.
 Total number of potentially compensable events is less than 4.6 percent base
on total annual admissions.
 Reduced number of patient complaints

 Less letters-demand from attorneys about injuries or other cases of patient

dissatisfaction
 Few negative findings of medical audit or other quality assurance

committee
 Ratio of investigated incident/accident reports over reported documented

incident/accident reports.
 Less litigation/court cases
 Functional Risk Management Committee
 Capability of Committee Members (KAS) upgraded through trainings/

orientations
 Effectiveness of training intervention employed
 Complaints amicably settled before reaching the court
 Few summons in court
197

199
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203
GLOSSARY
Authorization for the Release of Information

Authorization to obtain copies of information on your health care including, but
not limited to, treatment records such as progress notes, laboratory results,
history and physical reports, operative reports, and discharge summary reports.
Case mix
The type and number of patient groups an organization serves.
Clinical practice guidelines

Systematically developed statements, built on synthesis of evidence, which
provide formal recommendations about appropriate and necessary care,
intended to assist practitioner and patient to make decisions about appropriate
health care for specific clinical circumstances.
Co-morbidity
The presence of two or more illnesses in the same person at the same time.
Usually, these conditions are independent of one another, but have a significant
impact on the patient’s length of stay at a facility.
Complication
Any disease or disorder that occurs during the course of (or because of) another
disease.
Confidentiality
A legal and ethical concept that establishes the healthcare provider’s
responsibility for protecting health records and other personal and private
information from unauthorized use or disclosure.
Consent Forms
Copies of consents for admission, treatment, surgery, and release of information.
Diagnosis
A word or phrase used by a physician to identify a disease from which an
individual patient suffers or a condition for which the patient needs, seeks, or
receives medical care.
Diagnostic procedure
Any procedure employing analysis and examination to identify a disease or
condition.
204
Discharge Summary
A concise summary of a hospital stay, including the reason for admission,
significant findings from tests, procedures performed, therapies provided,
response to treatment, condition at discharge, and instructions for medications,
activity, diet, and follow-up care.
Emergency
Unforeseen combination of circumstances which calls for immediate life-
preserving or quality-of-life preserving actions (to preserve sight in one or both
eyes, hearing in one or both ears, extremities at or above the ankle or wrist).
Evidence-based medicine
Evidence-based medicine the use of current best evidence in making medical
decisions.
Flowchart diagram
Diagram used to show the actual flow or sequence of events in a process.
Health Information Management (HIM)

The study of the principles and practices of acquiring, analyzing, and protecting
digital and traditional medical information vital to providing quality patient
care. HIM is the link to clinicians, technology designers, and information
technology; and is the value-adding bridge between patients’ health information
and , government, and regulating agencies.
Health Information Management (HIM) Practitioners

Health facility staff who are the caretakers and guardians of patient health
information. They represent the patient’s interests in matters of privacy and
security, information release, issues and guidelines regarding record access, and
general consumer education about personal health records.
Health/Medical Record
A chronological written account of a patient’s examination and treatment that
includes the patient’s medical history and complaints, the physician’s physical
findings, the results of diagnostic tests and procedures, and medications and
therapeutic procedures.
History and Physical

A document that describes any major illnesses and surgeries you have had, any
significant family history of disease, your health habits, and current medications.
205
Hospital
An institution, building or place, government or private, duly licensed by the
Department of Health and accredited by PhilHealth, where there are installed
beds, cribs or bassinets for 24-hour use or longer by patients in the treatment of
diseases, injuries, deformities, abnormal physical and mental states, and/or
maternity cases.
Imaging Reports
Describe the findings of x-rays, mammograms, ultrasounds, and scans. The
actual films are maintained in the radiology or imaging departments or on a
computer.
Immunization Record
A form documenting immunizations given for disease such as polio, measles,
mumps, rubella, hepatitis, and the flu. Parents should maintain a copy of their
children’s immunization records with other important papers.
Indicator
A measurable variable or characteristic that can be used to determine the degree
of adherence to a standard or achievement of quality goals.
Information
Meaningful, interpreted and processed data used to make judgment on a
hypothesis or answer a research question.
Informed consent
Generally understood as the implied or explicit (read: written permission) given
by the patient prior to initiation of care following provision of sufficient
information to make an informed judgment on medical treatment choices. It,
however, refers more to the process by which patients are made to participate in
the decisions involved in their health care. Informed consent is founded on
patients’ legal and ethical right to direct what happens to their bodies and from
the doctor’s ethical duty to involve patients in the treatment process. It includes a
patient-doctor discussion of the following issues: the nature of the decision or
procedure; reasonable alternatives to the proposed intervention; the relevant
risks, benefits, and uncertainties
Lab Reports
Describe the results of tests conducted on body fluids. Common examples
include a throat culture, urinalysis, cholesterol level, and complete blood count
(CBC). Surprisingly, your health record does not usually contain your blood
type. Blood typing is not part of routine lab work.
206
Length of stay
The number of days a patient remains in the hospital.
Medication Record
A list of medicines prescribed or given to a patient.
Microfilm
A film bearing a miniature photographic copy of printed or other graphic matter,
usually of a document, newspaper or book pages, etc., made for a library,
archive, or the like. Microfilm allows for very compact storage of books and
documents.
Nosocomial infection
Infection acquired from the hospital
Operative Report
A document that describes surgery performed and gives the names of surgeons
and assistants.
Outcome
The effect of care on the health status of patients and populations seen in less
impairment of functions, less pain and suffering,
Pareto chart
Data analysis tool which combines analysis of the frequency of a problem and
analysis of its causes by identifying the most influential cause or causes, also
called the “vital few,” thereby separating them from the “trivial many.”
Pathology Report
Describes tissue removed during an operation and the diagnosis based on
examination of that tissue.
Patient Rights
The moral and legal entitlement of a patient to care.
Personal Health Record (PHR)

A personal health record (PHR) is a collection of important information that you
maintain about your health or the health of someone you’re caring for, such as a
parent or a child, which you actively maintain and update. Important
information PHR should include:
 Personal identification, including name and birth date

 People to contact in case of emergency
207
 Names, addresses, and phone numbers of your physician, dentist, and

specialists
 Health insurance information
 Living wills, advance directives, or medical power of attorney
 Organ donor authorization
 A list and dates of significant illnesses and surgical procedures
 Current medications and dosages
 Immunizations and their dates
 Allergies or sensitivities to drugs or materials, such as latex
 Important events, dates, and hereditary conditions in your family history
 Results from a recent physical examination
 Opinions of specialists
 Important tests results; eye and dental records
 Correspondence between you and your provider(s)
 Current educational materials (or appropriate web links) relating to your
health
 Any information you want to include about your health – such as your
exercise regimen, any herbal medications you take and any counseling
you may receive
Physician's Orders
Physician’s directions to other members of the healthcare team regarding
medications, tests, diets, and treatments.
Plan-Do-Check-Act cycle A systematic method for identifying areas for

improvement, pilot testing solutions, evaluating results, and institutionalizing
long-term solutions
Power of Attorney
A legal document giving a person (called an “agent” or “attorney-in-fact”) the
power to act for another person (the principal).
When incapacity is anticipated, a person may grant power of attorney to another

person. Power of attorney is the legally recognized authority to act and make
decisions on behalf of another party. This authorizes the designee to act on behalf
of the person who is now incapacitated. The person with power of attorney is
often responsible for making decisions regarding the disclosure of health
information to others.
Problem List
A list of significant illnesses and operations a person have had.
208
Progress Notes
Notes made by the doctors, nurses, therapists, and social workers caring for you
that reflect a patient’s response to treatment, their observations and plans for
continued treatment.
Quality Circle
A group of 5 to 10 workers from one work area of an organization who meet
regularly to identify and solve problems in their work area using their own
resources.
Quality Improvement
Upgrading from previously accepted minimal performance standards.
Quality management
The organization-wide pursuit of quality.
Risk management
An organized effort to identify, assess, and reduce, where appropriate, risks to
patients, visitors, staff and organizational assets.
SOAP
Sequence of evaluating the care needed for any particular patient.
Standards
Statements of expectations for the inputs, processes, behaviors and outcomes of
health systems.
Vaccine
A substance made from weakened or killed disease-causing microorganisms.
Vaccines are given to stimulate the body’s production of antibodies, which fight
infection and help improve resistance to a disease.
X-ray Reports
Describe the findings of x-rays, mammograms, ultrasounds, and scans. The
actual films are maintained in the radiology or imaging departments or on a
computer.
209
______________________
APPENDICES
______________________
210
211
Appendix A
RELEASE FROM RESPONSIBILITY

________________________________________________________________________
Republic of the Philippines

Department of Health
_________________________________________________________________
RELEASE FROM RESPONSIBILITY
SURNAME: ________________________________ AGE: ______ HRN: _____

GIVEN NAME: _____________________________ SEX: ______ Ward: _____
ATTENDING PHYSICIAN: ______________________________________________
This is to certify that I, the undersigned, release the

__________________________ and/or the Attending Physician from the
responsibility for any consequences, directly or indirectly due to (check one of
the following) :
[ ] Leave or absences from the hospital (OUT on PASS)

[ ] Discharged against advise of the attending physician
[ ] Refusal of medication, treatment, or diagnostic procedure
[ ] Refusal or admission in the hospital
[ ] Taking photograph for publication
[ ] Research studies perform with consent
[ ] _____________________________________________________
(write the reason if or when not mention above)
________________________________ ___________________________________
Witness Witness
________________________________ ___________________________________
Witness Witness
STATE THE CIRCUMSTANCES BRIEFLY:

212
Appendix B
INFORMED CONSENT FOR SURGERY, ANESTHESIA

OR OTHER PROCEDURES
________________________________________________________________________
_________________________________________________________________
INFORMED CONSENT FOR SURGERY, ANESTHESIA

OR OTHER PROCEDURES
To Whom It May Concern:
I, ___________________________________, _____ years old, married/single/widowed, of

(Given Name, Surname)
__________________________________________ hereby consent to the performance upon
(Address)
__________________________________________ who is my _________________________ ,
(Name of Patient) (Relationship)
the _____________________________________________ stated after these have been fully
(Procedure/Operation/Anesthesia)
explained to me by the doctors concerned including to me by the doctors concerned

including the risk and unforeseen complications that may occur in the performance of
the procedure.
I also consent to taking of photographs in the course of this treatment or operation for
the purpose of advancing medical knowledge.
IN WITNESS WHEREOF, I hereunto set my hand this _____ day of _________, 20____ at
____________________________.
___________________________________
Patient’s signature or “thumb mark”
or person giving free consent
IN PRESENCE OF
_________________________________ ________________________________
Witness Address
_________________________________ ________________________________
Interpreter Address
213
Appendix C
VOLUNTARY STERILIZATION CONSENT FORM

________________________________________________________________________
_________________________________________________________________
VOLUNTARY STERILIZATION CONSENT FORM
I, __________________________________________________, of legal age and sound mind

(Name of Patient)
residing at __________________________________________________________voluntarily
(Address)
present myself for Bilateral Tubal Ligation.
I understand that:
1. There are temporary methods of preventing pregnancy I can use instead of

sterilization for planning my family;
2. That the sterilization is a surgical procedure, that details of which my physician

has explained to me;
3. That the procedure involves risks;
4. That although the operation is know to be effective and irreversible, there are
instances of failure.
Understanding all these, if the surgical procedure will necessitate other added surgical
or medical measures or procedures, I hereby grant permission to carry out these
additional measures or procedure,
______________________________ ______________________________
Signature of Consenting Spouse Signature of Patient/Client
______________________________ ______________________________
Date Date
I HEREBY CERTIFY that I have fully explained the above information to the client and
spouse and that they consented to the performance of the operation.
_____________________________ _____________________________
Family Planning Personnel Date
214
Appendix D
CONSENT TO DIAGNOSIS/TREATMENT
________________________________________________________________________
__________________________________________
Name of Hospital
Address
CONSENT TO DIAGNOSIS/TREATMENT
I, ______________________________________________________, of legal age and sound mind, and

(Name of Patient)
residing at ______________________________________________ voluntarily present myself to be
(Address)
diagnosed and be given the best possible treatment procedure available.
That I have been duly informed by my physician of the nature and procedure, the risks involved,
the prospects of success, the potential danger if the procedure is not applied, and the alternative
treatments if any.
That I fully understand the possible consequences and complications of the application, and I
have been given NO guarantee or assurance as to the results that may be obtained.
In accordance to the above statements I am authorizing my physician to administer the

procedure as may be considered necessary or advisable according to the diagnosis.
___________________________________ ___________________________________
Witness Patient/Signature
___________________________________ ___________________________________
Date Date
NOTE: If the patient is a child or is unable to sign, please fill up the following:
Patient is a minor, he/she is ______________ year old and is unable to sign because
__________________________________________________________________________________
__________________________________________________________________________________
CONFIRMATION
I, _____________________________________, have clearly explained to the patient/person

legally responsible for the patient the nature and effect of the above procedure/s. It is to my
knowledge that he/she fully comprehends all the information given to him/her.
______________________________________
Name Signature of Physician
______________________________________
Date
215
Appendix E
CONSENT FOR PROCEDURE

________________________________________________________________________
____________________________________
Name of Hospital
Address
CONSENT FOR PROCEDURE
I, (Name of Patient) _____________________________________________, of legal age and

sound mind, and residing at ____________________________________________,
voluntarily subject myself to the procedure called __________________________, and
that I am authorizing my physician (Name of Physician)______________________________
who is a specialist in __________________ to administer the procedure on me;
I understand that the said procedure is necessary and warranted by my medical

condition as essential to my well-being and immediate recovery;
That I have been duly informed by my physician of the nature and procedure, the risks
involved, the prospects of success, the potential danger if the procedure is not applied
and the alternative treatments possible, if there be any;
That I fully understand the possible consequences and complications of the procedure,
and I have been given NO guarantee or assurance as to the results that may be obtained;
That I was given the opportunity to consult with my family and relatives, to gain further
understanding and inform them of the procedure that will be performed including its
risks and benefits;
That this form, its content and significance, has been fully explained in a language and
dialect spoken and understood by me, and that I affixed my signature to this document
freely and voluntarily.
I understand that this document shall bind my heirs, assigns and successors and shall
prevail over any other existing or future document(s) that may appear contrary to its
contents.
___________________________________ ___________________________________
Witness Patient’s Name & Signature
___________________________________ ___________________________________
Date Date
216
Appendix F
CONSENT FOR ADMISSION/CONFINEMENT

________________________________________________________________________
____________________________________
Name of Hospital
Address
CONSENT FOR ADMISSION/CONFINEMENT
I. APPLICATION FOR ADMISSION AND CONSENT FOR TREATMENT:
I, _________________________________ (Name of Patient), hereby make

application for admission to ____________________________ (Name of Hospital),
as a voluntary patient.
I hereby consent to the rendering of medical care which may include

observation, evaluation, care and treatment including laboratory and diagnostic
tests and examinations and/or surgical procedures and medical treatment as
may be deemed appropriate and necessary for my health condition by my
attending physician, or by other members of the Hospital’s medical staff.
This may include the taking of blood, urine, tissue, fluids and other bodily
samples, blood transfusions, x-rays and radiographic or diagnostic procedures.
Hospital staff and nurses who are authorized to carry out the instructions of my
physician(s) with respect to examinations, diagnostic procedures and treatment
as will be necessary for my treatment and recovery.
I hereby disclaim any express or implied warranties provided by the medical

supplies, medical devices or other goods sold or given to me by my physician(s).
That I fully understand and hereby consent that all medicines and supplies
prescribed by my attending physician(s), if available, shall come from the
hospital pharmacy; and that the hospital shall have the right to refuse to
administer any medicine or medical supply not purchased from the hospital
pharmacy; in the event that said medicines and supplies were purchased outside
the hospital, I shall take full responsibility for the consequences thereof and that
the hospital and its staff are not liable from any legal responsibility resulting
there from.
217
II. AGREEMENT AND UNDERSTANDING:
a. I have the right to consent or refuse consent, to any proposed procedures or

therapeutic treatment and that I will be informed of the benefits, risks and
alternative treatment possible for me;
b. I understand that any surgery or treatment has inherent risks and I

acknowledge that no guarantee or cure has been made to me by my
physician as to the result of any treatment or examinations provided by the
hospital.
c. I will not be involved in any research or experimental procedure without my

full knowledge and consent.
III. DISCLOSURE OF INFORMATION:
I agree that the Hospital may disclose such treatment information pertaining to
my hospitalization to any corporation, organization, or agent thereof, which is, or
may be liable under contract to the Hospital or to me, or to any of my family
members or other person, for I understand that the purpose of any release of
information is to facilitate reimbursement for services rendered. In admission, I
authorize the Hospital to release information as is necessary to permit the
review. This authorization will expire once the reimbursement for services
rendered is complete.
The undersigned agrees that all records concerning this patient’s hospitalization
shall remain the property of the health facility. The undersigned understands
that medical records and billing information generated or maintained by the
facility are accessible to facility personnel and medical staff. Facility personnel
and medical staff may use and disclose medical information for treatment,
payment and health care operations and to other physician, healthcare personnel
or provider that is or may be involve in the continuum of care for this admission.
I understand that the hospital is authorized to disclose all or part of my medical
record to any insurance company, third party payor, workers compensation
carrier, self-insured employer group or other entity (or their authorized
representatives) which are necessary for the payment of my account. If the releases
may indicate the presence of a communicable disease or venereal disease which
may include, but not limited to diseases such as hepatitis, syphilis, gonorrhea
and the Human Immunodeficiency virus, also known as the Acquired Immune
Deficiency Syndrome (AIDS)], such information cannot be released without my
specific approval.
218
IV. TEACHING INSTITUTION: (*for Teaching and Training Hospitals)
I also acknowledge that the Hospital also functions as a teaching institution and
that I may be observed, examined and rendered care to by supervised
participants who are students of medical professions, as part of the hospital’s
educational program. I agree to participate, but reserved the right to limit my
involvement at any time.
V. PERSONAL ASSETS/VALUABLES:
I understand that I am responsible for personal property retained by me during

my hospitalization and that the hospital does not assume any responsibility for
safekeeping of any cash or personal valuables inside the room where I am
confined and that the hospital and its staff are not responsible or liable for the
loss or damage thereof.
Should I wish the Hospital to act as custodian for such property, it is my
responsibility to request that it be kept secure in a vault. I agree to sign a separate
personal valuables form and adhere to its terms should I choose to use this
service.
This form has been fully explained to me in a language and dialect spoken and
understood by me, and I have had the opportunity to ask questions and I am
satisfied that I understand its content and significance; that I affixed my
signature to this document freely and voluntarily, and that this document shall
bind my heirs, assigns and successors and this document shall prevail over any
other existing or future document(s) that may appear contrary to its contents.
_______________ ___________________________________
Date Patient’s Name & Signature
_______________ _____________________ ______________________________

Date Relationship to Patient Printed Name of Parent/
Guardian/Legal Representative
_______________ ________________________________________
Date Witness(es) Name & Signature
Patient Unable To Sign Due To: _____ Emergency _____ Refusal

OTHER (Reason(s)): ______________________________________________
______________________________________________
_____________________________________ ___________________
Signature over Printed Name Date
219
Appendix G
CERTIFICATE OF CONFINEMENT
________________________________________________________________________
_______________________________________
Name of Hospital
Address
Certificate No. __________

Health Record No. __________
Date ________________________
CERTIFICATE OF CONFINEMENT
This is certify that ________________________________________, ____ years old

of _____________________________________________ has been confined in this
hospital from _________________________ to the present.
This certification is being issued at the request of ____________________________

(Name of Person Requesting)
for ____________________________________ .
(Purpose)
____________________________
HIMD Head/Supervisor
(NOT VALID WITHOUT SEAL)

220
Appendix H
MEDICAL CERTIFICATE
________________________________________________________________________
_______________________________________
Name of Healthcare Facility
Address

Date ________________________
MEDICAL CERTIFICATE

of _____________________________________________ was examined and
treated/confined in this hospital from ________________ to ________________
with the following findings and/or diagnosis:
This certification is being issued at the request of ____________________________

(Name of Person Requesting)
for ____________________________________ .
(Purpose)
____________________________
Attending Physician
License No. _________________

221
Appendix I
MEDICO-LEGAL CERTIFICATE
________________________________________________________________________
_______________________________________
Address

Date ________________________
MEDICO-LEGAL CERTIFICATE
To Whom It May Concern:

male/female, single/married/widow, Filipino, and a resident of
______________________________________ at about _____ AM/PM for the
following lesion/injury __________________________________________________
________________________________________________________________________
sustained by ___________________________________________________________.
In my opinion, the injury/injuries sustained by the patient will incapacitate or

require medical attention for a period of _____ days barring complications,
otherwise the period of healing will vary accordingly.
____________________________
Attending Physician
License No. _________________

222
Appendix J
CERTIFICATE OF DISMEMBERED BODY PART

________________________________________________________________________
________________________________________
Address
Certificate No. ______________
CERTIFICATE OF DISMEMBERED BODY PART/S FOR DISPOSAL

1. PART/S OF THE BODY 2. LATERALITY 3. MANNER/CAUSE OF AMPUTATION
a. _________________ a. [ ] Left [ ] Right [ ] Accident, specify (Date/Time)________
b. _________________ b. [ ] Left [ ] Right Type: ____________________________
c. _________________ c. [ ] Left [ ] Right [ ] Operation (Date/Time) ____________
Indication:
_________________________________
[ ] Others, specify ____________________
4. PLACE OF AMPUTATION (Name of Hospital/Clinic/Institution/Address in case of accident)
5. AMPUTEE (First Middle Last) 6. SEX 7. AGE 8. CITIZENSHIP

[ ] Male
[ ] Female
[ ] Unknown
9. RESIDENCE House No., Street, Barangay, City/Municipality 10. OCCUPATION
11. CERTIFICATION
I hereby certify that the foregoing particulars are correct as near as same can be ascertained.
Signature _________________________________________
Name in Print _____________________________________
Title or Position ____________________________________
Address __________________________________________
Date _____________________________________________
12. INFORMANT 13. PREPARED BY:
Signature Signature _________________________________
__________________________________ Name in Print _____________________________
Name in Print Title or Position ____________________________
_______________________________ Address __________________________________
Relationship to Amputee Date _____________________________________
______________________
Address
____________________________________
14. MANNER OF DISPOSAL 15. BURIAL/CREMATION PERMIT
[ ] Burial
[ ] Cremation Number _______________________________
[ ] Others (Specify) Date Issued _______________________________
_________________________________ Issued by: _________________________________
16. NAME AND ADDRESS OF CEMETERY OR CREMATOR
223
Appendix K
SUBPOENA AD TESTIFICANDUM
________________________________________________________________________
________________________________________
Address
Date ______________________
HON.______________________
Presiding Judge
Regional Trial Court, Branch _________
National Capital Judicial Region, Manila
Dear _______________,
May we write in connection with the Honorable Court’s Subpoena ad

testification addressed to the undersigned and dated
___________________________, and directing me to appear and testify in the case
people vs. ______________________, Crim. Case No. _______ which is scheduled
for hearing on ________________, 20____. May I apologized in advance for the
reason that Dr. ___________________, the actual attending physician of patient
___________________ is no longer connected with our hospital / institution since
20______ and we have no knowledge of where he is currently residing or
practicing her profession. May I explain that I have no personal knowledge in
the manner of treatment of her patient and it is only the patient’s attending
physician who can intelligently explain the entries in the medical record which is
the subject of the Honorable Court’s Subpoena. My statements before the court
would only be bordering on speculations or hearsays.
Again our apologies for the situation and we express our willingness to help in
some other ways that we can in connection the case.
_______________________________
Chief of Hospital
224
Appendix L
SUBPOENA DUCES TECUM

________________________________________________________________________
_____________________________________
Name of Hospital
Address
Date ______________________
HON.______________________
Presiding Judge
Regional Trial Court, Branch _________
National Capital Judicial Region, Manila
Dear _______________,
This has reference with the Honorable Court’s Subpoena Duces Tecum dated
_________________, in the case of People vs. _______________________________,
_____________________, 20______.
We deeply regret that due to reasons beyond our control, we will not be to present the
subpoenaed document on the said date. May we request the honorable court to reset or
re-schedule the date for us to have ample time to locate the needed medical record.
Praying that this explanation merit your very kind consideration and understanding.
Thank you.
Respectfully yours,
_____________________________
HIMD Supervisor
Noted by:
______________________________
COH
225
Appendix M
MEDICAL RECORD FORMS

________________________________________________________________________
(Level 1 & 2)
_______________________________
Name of Hospital
Address
NAME : (Last, Given, Middle) AGE: SEX: HRN:
OCCUPATION: CIVIL STATUS: CITIZENSHIP: RELIGION:

ADDRESS:
EMERGENCY ROOM RECORD
DATE : ___________________
ARRIVAL: REFERRED BY: SOCIAL WORKER [ ] Emergency Case
AM PM [ ] SELF [ ] PRIVATE MD [ ] A [ ] B [ ] C [ ] D [ ] Non ER Case
[ ] OPD [ ] OTHERS [ ] Senior Citizen [ ] E M S
BRIEF HISTORY: (if accident, state where, when and how, injured. If illness describe, note case prior to admission)
NOI:
TOI:
DOI:
POI:
ALLERGIES LAST CURRENT Rx
TETANUS
CONDITION ON ARRIVAL TIME TEMP. CARDIAC BP RESP RATE
[ ] GOOD [ ] FAIR [ ] RATE
COMA AM PM
[ ] HEMORRHAGE [ ] POOR [ ]
DOA
[ ] CRITICAL [ ] SHOCK
PHYSICAL FINDINGS
DIAGNOSIS
TREATMENT
DISPOSITION
[ ] TREATED & DISCHARGED [ ] ADMITTED [ ] TRANSFERRED TO:
TIME :
CONDITION UPON DISCHARGED [ ] GOOD [ ] SATISFACTORY [ ] SERIOUS [ ] CRITICAL [ ] EXPIRED
SIGNATURE OF NURSE ON DUTY NAME / SIGNATURE OF ATTENDING

PHYSICIAN
226
_____________________________________
Name of Hospital
Address
NAME _______________________________________________________ HRN _________

Last First Middle
AGE _____ SEX _____ CIVIL STATUS _____ RELIGION _____ OCCUPATION ______
ADDRESS: ____________________________________________________________________
OUT PATIENT RECORD

227
_____________________________________
Name of Hospital
Address
ADMISSION AND DISCHARGE RECORD

HRN:
PATIENT’S NAME : (Last) (Given) (Middle) WARD/RM/BED/SERVICE:
PERMANENT ADDRESS: TEL NO. SEX CIVIL STATUS

[ ]M [ ]F [ ] S [ ] D [ ] SEP
[ ] W [ ] M [ ] N [ ] C
BIRTHDATE AGE BIRTH PLACE NATIONALITY RELIGION OCCUPATION
EMPLOYER (Type of Business) ADDRESS TELEPHONE NO/CP NO.
FATHER’S NAME ADDRESS TELEPHONE NO. /CP NO.
MOTHER’S (Maiden) NAME ADDRESS TELEPHONE NO. /CP NO.
SPOUSE NAME ADDRESS TELEPHONE NO. /CP NO.
ADMISSION DISCHARGE TOTAL NO. ADMITTING PHYSICIAN

DATE: DATE: OF DAYS
TIME: TIME:
ADMITTING CLERK ATTENDING PHYSICIAN
TYPE OF ADMISSION REFERRED BY (Physician/Health Facility)

[ ] NEW [ ] OLD [ ] FORMER OPD
SOCIAL SERVICE CLASSIFICATION [ ] A [ ] B [ ] C1 [ ] C2 [ ]C3 [ ] D

ALERT: ALLERGIC TO HOSPITALIZATION PLAN HEALTH INSURANCE PHIC
(Company/Industrial Name) NAME [ ] SSS [ ] SSS Dependent
[ ] GSIS [ ] GSIS Dependent
DATA FURNISHED BY: ADDRESS OF INFORMANT RELATION TO PATIENT
ADMISSION DIAGNOSIS :
DISCHARGE DIAGNOSIS ICD/RUV CODE:

PRINCIPAL DIAGNOSIS:
OTHER DIAGNOSIS:
PRINCIPAL OPERATION/PROCEDURE
OTHER OPERATION (S) PROCEDURE (S)
ACCIDENT/INJURIES/POISONING
DISPOSITION RESULTS
[ ] Discharged [ ] HAMA [ ] Recovered [ ] DIED
[ ] Transferred [ ] Absconded [ ] Improved [ ] -48 hours [ ] Autopsy
[ ] Unimproved [ ] +48 hours [ ] No
228
_____________________________________
Name of Hospital
Address
NAME: ____________________________________________________ HRN: _________

Last First Middle
AGE ________ GENDER ________ WARD/ROOM/BED _______________________
DISCHARGE SUMMARY
Date Admitted: _____________________ Date Discharged: ___________________
ADMITTING DIAGNOSIS: ____________________________________________________________

____________________________________________________________
____________________________________________________________
DISCHARGE DIAGNOSIS: ____________________________________________________________

____________________________________________________________
____________________________________________________________
OPERATION PERFORMED: ____________________________________________________________

____________________________________________________________
____________________________________________________________
BRIEF CLINICAL HISTORY: LMP: ___________

____________________________________________________ EDC: ___________
____________________________________________________ AOG:___________
____________________________________________________ G: ________ P: _________
ABORT: _______________
PERTINENT PE B.P. __________ C.R. __________ Temperature ______________
GENERAL SURVEY HEENT: __________________________________________________
Chest/Lungs: __________________________________________________
Heart : __________________________________________________
Abdomen: __________________________________________________
FH __________________ FHT ____________________
Extremities: __________________________________________________
Neurological Examination: _______________________________________

229
Course in the Ward: (include medications)
Laboratory Findings: (including EKG, X-ray and other diagnostic procedures
Medication:
Disposition: (indicate home medication, special instruction and follow-up)
ATTENDING PHYSICIAN _______________________________ _____________________

Signature over Printed Name Date Accomplished
230
_____________________________________
Name of Hospital
Address
NAME: ____________________________________________________ HRN: _________

Last First Middle
HISTORY AND PHYSICAL EXAMINATION
CHIEF COMPLAINT
PRESENT ILLNESS
HISTORY
ADMITTING IMPRESSION
Admitting Physician
_____________________________
Signature over Printed Name
231
_____________________________________
Name of Hospital
Address
NAME: ____________________________________________________ HRN: _________

Last First Middle
CLINICAL LABORATORY REPORT
10
09
08
07
06
05
04
03
02
(ATTACHED FIRST LABORATORY RESULT ON THIS LINE)

232
_____________________________________
Name of Hospital
Address
NAME: ____________________________________________________ HRN: _________

Last First Middle
DOCTOR’S ORDER
DATE/TIME DOCTOR’S ORDER

233
_____________________________________
Name of Hospital
Address
NAME: ____________________________________________________ HRN: _________

Last First Middle
NURSES PROGRESS NOTES
DATE/TIME FOCUS DATA, ACTION RESPONSE (DAR)

234
_____________________________________
Name of Hospital
Address
NAME: ____________________________________________________ HRN: _________

Last First Middle
INTRAVENOUS FLUID SHEET
DATE SHIFT BOT. KIND OF VOL. GTTS. TIME REMARK NURSE

No. SOLUTION STD
235
_____________________________________
Name of Hospital
Address
NAME: ____________________________________________________ HRN: _________

Last First Middle
MEDICATION SHEET
MEDICATION 6-2 2-10 10-6 6-2 2-10 10-6 6-2 2-10 10-6
236

_________________________________________________________________
PRE-OPERATIVE CHECKLIST
HRN: _____________________
Ward/Room: ______________
NAME: ______________________________________________________________________
Diagnosis: ____________________________ Contemplated: _________________________
Surgeon: ______________________________ Anesthesiologist: _______________________
YES NO
[ ] [ ] 1. Surgical consent signed
[ ] [ ] 2. Blood for OR use
Type: ___ Vol: ____ Exp. Date/Time: ______ Donor: ______
[ ] [ ] 3. Physical examination and history completed
[ ] [ ] 4. Clearance given by Dr _________________________________
cardio _____ pulmo _____ nephro _____ Others __________
[ ] [ ] 5. X-ray films [ ] CUTZ [ ] CT Scan [ ] Others ______
[ ] [ ] 6. Hospital gown on
[ ] [ ] 7. NPO since ____________________________________________
[ ] [ ] 8. Weight: _____ Temp.: _____ RR _____ CR _____ BP _____
[ ] [ ] 9. Pre-op antibiotic given: ________________________________
_____________________________________________________
[ ] [ ] 10. With contraption(s) ___________________________________
_____________________________________________________
[ ] [ ] 11. Materials available: Anesthesia: _____________________
Sutures: _____________________
Shunt: _____________________
Others: _____________________
[ ] [ ] 12. With financial assistance: Amount: ____________________
Preparation completed and checked by:
____________________________________
Signature of Ward Nurse
237

_________________________________________________________________
NOTIFICATION SLIP FOR OPERATION

(OUT PATIENT DEPARTMENT)
Date __________________ HRN ________________________

Ward/Room _________________
Patient’s Name _____________________________________ Age _____ Sex _____
Indication for Operation __________________________________________________
Surgeon ____________________________ Asst. Surgeon _____________________
Anesthesiologist _____________________ Anesthesia ________________________
Requested Operation ____________________________________________________
Requested Date/Time of Operation ________________________________________
Requested by:
____________________________
Attending Physician
238

_________________________________________________________________
INTER-AGENCY REFERRAL SLIP
Date: ___________________
HRN: ___________________
TO: ____________________________________ Address: ___________________________________
Name of Patient __________________________________________ Age _____ Sex _____ CS _____
Address _____________________________________________________________________________
Working Diagnosis ____________________________________________________________________
Management _________________________________________________________________________
_____________________________________________________________________________________
Reason for referral _____________________________________________________________________
Requesting Physician ___________________________________________________________________
Approved by:
_________________________________
Consultant/ Sr. House Officer
Patient Classification ___________________________ Justification __________________________
Note: Please accomplish in triplicate form

1. Medical Records file
2. Agency referral to
3. Patient
--------------------------------------------------------------------------
HRN: _________________
OPD: _________________
1st ENDORSEMENT
Respectfully returning to the Chief, of ____________________________________________

with the information RE: Patient _________________________________________________
age ____ sex ____ of __________________________________________________________
ACTION TAKEN: _____________________________________________________________
______________________________________________________________________________
COMMENTS AND RECOMMENDATION: _______________________________________
______________________________________________________________________________
_______________________________
Attending Physician & Designation
_______________________________
Address
239

_________________________________________________________________
PHILIPPINE VOLUNTARY BLOOD SERVICES PROGRAM
BLOOD REQUEST FORM

(FOR PEDIATRICS)
DATE _________________________ HOSPITAL _______________________
PATIENT’S NAME _____________________________________________ AGE _____ SEX _____

SURNAME FIRST NAME MIDDLE NAME
PHYSICIAN _______________________________ WARD _______ RM # _______ HRN _______
CLINICAL DIAGNOSIS ________________________________________________________________
PATIENT’S BLOOD TYPE _____________________________ RH TYPE _______________________
HISTORY OF BLOOD TRANSFUSION: WHEN __________ WHERE _______________________
TYPE OF REQUEST: [ ] ROUTINE [ ] STAT
CHECK COMPONENT NEEDED AND INDICATION FOR TRANSFUSION
[ ] WHOLE BLOOD
FOR EXCHANGE TRANSFUSION
[ ] HYPERBILURUBENEMIA IN INFANT WITH DIRECT BOLIRUBIN OF 20 mg/dl IN
FIRST WEEK OF LIFE
[ ] HYPERBILURUBENEMIA WITH PREMATURITY AND/OR OTHER
CONCOMITANT ILLNESS INCLUDING ONE OR MORE OF THE FOLLOWING:
A. PRENATAL ASPHYXIA
B. ACICOSIS
C. PROLONGED HYPOXEMIA
D. SEPSIS AND HEMOLYSIS
[ ] OTHERS (SPECIFY) _______________________________________________________
[ ] PACKED RBC [ ] WASHED RED CELLS

[ ] SIGNS AND SYMPTOMS OF ANEMIA (E.G. PALLOR, ETC.)
HPOVOLEMIA FROM ACUTE BLOOD LOSS WITH SIGNS OF SHOCK OR
ANTICIPATED BLOOD LOSS OF > 10%
[ ] CANDIDATES FOR MAJOR SURGERY AND HEMATOCRIT < 30% (NOCTURNAL
< 35%)
[ ] HYPERTRASFUSION FROM CHRONIC HEMOLYTIC ANEMIA: (THALASSEMIA)
[ ] ANEMIA WITH HGB < 8 gm/dl OR HCT < 25%
BLOOD VOLUME REDUCTION OF 10 ml/kg AND HCT < 45% IN NEWBORN
LESS THAN 4 MONTHS OF AGE
[ ] PULMONARY DISEASE OR CONGENITAL HEART DISEASE WITH HCT < 40-45%
[ ] OTHERS (SPECIFY) _________________________________________________________
240
[ ] PLATELET CONCENTRATE
[ ] ACTIVE BLEEDING AND THROMBOCYTOPENIA <50,0000/L, AT RISK FOR
INTRACRANIAL HEMORRAGE
[ ] ACTIVE AND QUALITATIVE DEFECT
[ ] SCHEDULED INVASIVE PROCEDURE AND THROMBOCYTOPENIA <70,0000/L
OR ASSOCIATED QUALITATIVE DEFECT
[ ] OTHERS (SPECIFY) _________________________________________________________
[ ] FRESH FROZEN PLASMA

SIGNIFICANT MULTIPLE COAGULANT FACTOR DEFICIENCY AND OR
ACCUARED FACTOR DEFICIENCY (E.G. DENGUE SHOCK SYNDROME)
SIGNIFICANT COGENITAL FACTOR DEFICIENCY
ANTI-THROMBIN DEFICIENCY
BLEEDING IN EXCHANGE TRNASFUSION OF MASSIVE TRANSFUSION (> 1%
BLOOD VOLUME)
OTHERS (SPECIFY) ________________________________________________________
[ ] CRYOPRECIPITATE
FACTOR VIII DEFICIENCY (HEMOPHILA A)
VON WILLEBRANDS DISEASE
DISSEMENATED INTRA VASCULAR COAGUATION
UREMIA WITH ACTIVE BLEEDING OR SCHEDULED INVASIVE PROCEDURE
OTHERS (SPECIFY) ________________________________________________________
NO. OF UNITS NEEDED _____________ NO. OF DONORS PROVIDED ______________

SCREENED ______________
UNSCREENED ______________
TYPE OF CROSSMATCHING
______ SALINE PHASE ONLY
______ SALINE AND ALBUMIN PHASE ONLY
______ SALINE, ALBINUMIN AND GLOBULIN PHASE
(PLEASE CHECK ACCEPTANCE OF RESPONSIBILITY FORM IF NECESSARY)
OTHERS
REMARKS
___________________________________
REQUESTING PHYSICIAN
(SIGNATURE OVER PRINTED NAME)
RECEIVED BY _____________________________ _____ DATE AND TIME _________________
EXTRACTED BY _________________________________ DATE AND TIME _________________

241
Appendix N
REQUEST FOR RADIOLOGIC PLATES/LABORATORY SLIDES

________________________________________________________________________
_________________________________
Name of Hospital
Address
REQUEST FOR RADIOLOGIC PLATES /LABORATORY SLIDES
I, _________________________________, of legal age, single/married, residing at

______________________________________, for my behalf or in behalf of my
child/ward __________________________, still confined, or previously confined,
in this hospital from ___________ to __________, respectfully request for the
following:
[ ] X-Ray plates dated ____________________

[ ] CT Scan Plates dated ____________________
[ ] MRI Plates dated ____________________
[ ] Histopath Slide dated ____________________
[ ] Blood Smear Slide dated ____________________
[ ] Ultrasound plates dated ____________________
[ ] Others _____________________________________
I am requesting the same for the purpose of ____________________; and it is my

full understanding that these plates/slides which I have requested and received
from the hospital are the only copies and henceforth, it is my responsibility that
nothing is left whatsoever with the hospital; it is also my full understanding that
due to passage of time there could already be deterioration in the condition of
the plate/slide which could lead to different interpretation/s and for which I
shall not fault the hospital or any of its staff;
242
It is also my undertaking that I shall not use the same for any legal action or for
any purpose against the hospital or against anyone of its staff. It is my further
undertaking that I shall consult my attending physician/s or nurses, or the
pathologist or radiologist or ultrasonologist, or anyone who have participated in
the interpretation of the same, on any query about the plate/slide that I obtained
and whom I shall ask for a written note signifying that I have consulted them on
the conditions, the reading or the interpretations thereof.
That the contents of this request have been fully explained to me in clear and
certain terms, by way of language and dialect spoken and understood by me,
and with the use of simple words readily understood by me, and that further, I
was given that chance to consult my family and my relatives, and to ask as many
questions as necessary to gain full understanding of this request;
I express further that my undertakings set forth in this document shall bind my
heirs, assigns and successors, or my representative/s; and that this document
shall prevail over any other existing or future document/s that may appear the
contents of which are contrary hereto.
__________________________________ ________________________________
Witness Signature of Parent/Relative
__________________________________ ________________________________
Date Date
243
Appendix O
REQUEST FOR COPY OF MEDICAL RECORDS

________________________________________________________________________
_________________________________
Name of Hospital
Address
REQUEST FOR COPY OF MEDICAL RECORDS
I, (Name of Patient) _______________________________________ of legal age and

with sound mind, and residing at _________________________________,
respectfully request for a copy of the following record(s) for the purpose of
______________________________.
[ ] General Data [ ] Laboratory Results [ ] Autopsy Results
[ ] History and P.E. [ ] Ancillary Results [ ] Medication Sheet
[ ] Doctor’s Order [ ] O.R. Record [ ] Monitoring Sheet
[ ] Nurses’ Notes [ ] Anesthesia Record [ ] Medical Abstract
[ ] Intake and output [ ] Histopath Result [ ] Others __________
That I shall be responsible for the expenses of reproduction of the medical record
or any part thereof that I will acquire from the hospital;
That I shall not use the same to submit for any legal action against or for the
purpose of jeopardizing the hospital or any of its members or staff.
____________________________ _______________________________
Date Patient’s Name & Signature
____________________________ ___________________________________
Date Printed Name of Parent/Guardian
244
Appendix P
DOH CIRCULAR NO. 70s 1996

________________________________________________________________________
245
246
247
248
249
250
251
252
253
Appendix Q
DOH ADMINISTRATIVE ORDER NO. 47s 2000

________________________________________________________________________
254
255
256
Appendix R
DOH ADMINISTRATIVE ORDER NO. 2009-0020

________________________________________________________________________
257
258
259
260
261

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In the Revised Organization and Staffing Standards for Government

The ever-increasing demand for safe, effective, efficient, equitable, responsive

This manual adheres to the international standards, DOH licensing standards,

Rommel Paul G. Flores Baguio General Hospital and Medical Center

We are grateful for the Chief of Hospital/Medical Center Chief and

Dr. Teresa Vera Bureau of Health Facilities and Services

Lourdes Palapal Phil. Medical Records Association

Moreover, the contribution of the officers and staff of NCHFD in the

Madeliene Gabrielle M. Doromal Development Management Officer IV

Lastly, we acknowledge the wholehearted support and encouragement of Dr.

Manila, Philippines 2010

ABC Authorized Bed Capacity

NAP National Archives of the Philippines

1 HEALTH INFORMATION MANAGEMENT DEPARTMENT 1

2 ADMINISTRATION AND MANAGEMENT OF HIMD 9

3 HEALTH RECORD STANDARD AND POLICIES 31

4 Systems and Procedures 43

Overview of Morbidity Coding 105

6 HOSPITAL STATISTICS 119

7 MEDICO-LEGAL ASPECTS OF HEALTH RECORDS 137

8 CONTINUOUS QUALITY IMPROVEMENT FOR HEALTH RECORDS 149

9 RISK MANAGEMENT FOR THE HIMD 175

Education and Training 193

1 Proposed Organogram for Level 3 Non-Corporate Hospitals 10

2 Proposed Organogram for Level 4 Non-Corporate Hospitals 10

3 Departments Under the Medical Service 11

4 Diagram showing “Safety Pulpit Ladder” and “Kick Stool” 16

5 Standard Arrangement of Filing Cabinets 17

6 Working Completion Area 18

7 Diagram showing Proper Lighting 19

8 Health Record Management Procedure 81

9 Health Records Disposition 82

10 Procedure in the Preparation of Birth Certificates 85

11 Procedure in the Preparation of Death Certificate 87

11 Conceptual Framework of PDCA 143

12 Flowchart of Health Record Management 152

13 Conceptual Framework showing the Linkages of Risk 174

1 Example of Practical Hospital Planning 12

2 Department of Health Standard Staffing for HIMD by Category, 29

A Release from Responsibility 211

B Informed Consent for Surgery, Anaesthesia or Other Procedures 212

C Voluntary Sterilization Consent Form 213

D Consent to Diagnosis/Treatment 214

E Consent for Procedure 215

F Consent for Admission/Confinement 216

G Certificate of Confinement 219

H Medical Certificate 220

I Medico-Legal Certificate 221

J Certificate of Dismembered Body Part 222

K Subpoena ad Testificandum 223

L Subpoena Duces Tecum 224

M Medical Record Forms 225

N Request for Radiologic Plates/Laboratory Slides 241

O Request for Copy of Medical Records 243

P DOH Circular No. 70s 1996 244

Q DOH Administrative Order No. 47s 2000 253

R DOH Administrative Order No. 2009-0020 256

(This page is intentionally left blank.)

The Health Information Management Department (HIMD) is responsible in

 Improve the accessibility of the health records.

 Ensure the creation and maintenance of quality health records.

 Encourage greater utilization of healthcare facility statistics.

 Assist in strengthening quality programmes e.g., Patient Safety,