TRAINING ON CLINICAL DOCUMENTATION IMPROVEMENT FOR HOSPITALPPTnew

TRAINING ON CLINICAL
DOCUMENTATION IMPROVEMENT FOR

HOSPITAL HEALTH INFORMATION MANAGEMENT
PRACTITIONERS
2-Jul-19 1
• Develop awareness of different views and aspects of HIMD
• Create an environment of professional practice with the
compliance of Philippine Health Standards.
• Promote safety and best state of culture of knowledge about
ideal, desirable and according to standard services set by
regulating and statutory bodies.
• Efficient utilization of resources.
• Growth of the organization.
• Enhance employee growth, technical skill and productivity.
2-Jul-19 2
HEALTH INFORMATION MANAGEMENT
DEPARTMENT (HIMD)
The Health Information Management Department (HIMD)

- is responsible in enhancing patient care through the use of data contained in the
health record, either collectively or individually.
General functions:
• To provide an organized system of measuring quality patient care and to ensure the
sufficient data is written in sequence of events to justify the diagnosis, warrant the
treatment and end results.
• Tasked to process, analyze, maintain and safekeep all health records
created/maintained in the healthcare facility
2-Jul-19 3
What to expect
• HIMD • Clinical Documentation
• Main Functions • What is Clinical documentation
• Medical Records Committee Improvement
• Joint Commission International (JCI • Clinical Audit
Standards
Measurable elements
• Continuous Quality
Improvement for Health Care
• Philippine Health Standards
Policies
• Qualitative vs. Quantitative
Analysis
2-Jul-19 4
What to expect
• HIMD
• Main Functions
2-Jul-19 5
DEPARTMENT (HIMD)
• Formerly Hospital
Medical Records
Management
Reference:
• Hospital Health Information Management
Manual 3rd ed. Department of Health ,
2010
2-Jul-19 6
DEPARTMENT (HIMD)
Main Functions:
Maintain all health records in accordance with the principles
and practices of efficient and effective health record
management.
Maintain comprehensive indexes (MPI, Disease index, Registers, OPD, ER,
Admission, Discharge, Birth/Death Registers.
Review records for completeness and accuracy, coding of
diseases, accdg to approved nomenclature & classifications.
2-Jul-19 7
DEPARTMENT (HIMD)
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.
Maintain and safeguard confidentiality of the health record.
Provide health records upon request for pt’s visit to OPD and
ER and admission.
2-Jul-19 8
DEPARTMENT (HIMD)
• Ensure that all diagnostic reports/results are promptly and

accurately filed in the respective health record.
• Collate and compile data and generate statistical reports required by
DOH as the health regulatory board and PHIC as the health
accreditation agency.
• Prepare periodic statistical reports on morbidity , mortality, birth,
utilization of hospital services, OPD/ER services, surgery performed
ans cases receiving special form of therapy.
• Provide data/information for use in approved research and study
programs.
• Participate in studies and research activities
2-Jul-19 9
DEPARTMENT (HIMD)
• Is considered as a storage area of patient information
• the information center of the health care facility.
Standard Staffing
• The number of staff required is determined by the category of a
health care facility.
• volume of work to be done.
• 1:20 required HIM ratio for in -patient(ABC- Authorized Bed
Capacity)
• 1:50 visits per day–OPD
2-Jul-19 10
Level 1
• HIMD Head
• Statistician (Level 3-4)
• Clinical coder
• Health record analyst/Assembly Clerk(Analysis clerk/
Compliance officer
• Retrieval Clerk
2-Jul-19 11
Staff Development: • External
• Internal • Basic/Advanced Med Records
• Orientation of HIMD to policies Mgmt
and procedures • Basic computer
• Rotation of staff every 2yrs • Statistical reports
• Continuous in-service training
needs
• Feedback to HIMD staff involving
effective changes and
appreciation of work
• Values orientation
2-Jul-19 12
What to expect
Medical Records Committee
• HIMD • (mandated only in level 2,3,4,
• Main Functions hospitals).
• Medical Records Committee • Recommends standards, policies,
systems and procedures in health
record documentation.
• Review the quality of
documentation
• Chairman
• Members- representatives : Hosp
Adm;Nsg Serv; allied health
2-Jul-19 13
Organizational Structure
Office of the Medical Chief
Integrated Hospital Operations and Continuous Quality Improvement

Management Program Program(CQI) and Patient Safety
Legal Affairs Internal Audit
Professional Education and Training Research

Non-
Medical Nursing
Medical
Hospital Operations and

Medical Service Nursing Service
Support Services
2-Jul-19 14
Organizational Structure
OFFICE OF THE MEDICAL CHIEF
MEDICAL SERVICES
ALLIED HEALTH
CLINICAL ANCILLARY TEAM
Pathology Health Information

Out Patient Dep't
Management
Anatomic & Clinical
Emergency Medicine Laboratory Admitting/Information
Blood Bank
Clinical Depts Medical Social Work
Department of Radiology
Clinical Care Areas Nutrition & Dietetics
Dental
2-Jul-19 Pharmacy 15
OFFICE OF THE MEDICAL CHIEF
Nursing Service
Clinical Nursing Units Operating Room Delivery and Labor Room
Central Supply &

Special Care Areas
Sterilization
2-Jul-19 16
What to expect
• HIMD
• Main Functions
• Medical Records Committee
• Joint Commission International (JCI
2-Jul-19 17
International Health Record Standard
(JCI –Joint Commission International)
2-Jul-19 18
• Conducted by 16 countries, organizational leaders and health
experts around the world.
• 13-member international panel composed of experts and
experience in health care
2-Jul-19 19
• Standards- define the performance expectations, structures
(staffing,risk factors) or functions that must be in place for a
hospital to be accredited.
• Measurable elements –indicate what is reviewed and scored;

identify the requirements for full compliance with the standard
2-Jul-19 20
• Standard
The medical record contains adequate information to identify the
patient, to support the diagnosis, to justify the treatment and to
document the course and results of treatment .
• Measurable elements:
1. Patient medical records contain adequate information to identify
the patient.
2. Patient medical records contain adequate information to support
the diagnosis
3. Patient medical records contains adequate information to
document the course and results of treatment .
2-Jul-19 21
• Standard
Every patient medical record entry identifies its author and
when the entry was made in the medical records.
1. The author can be identified for each patient medical record
entry.
2. The date of each patient medical record entry can be
identified
3. The time of each patient medical entry can be identified.
2-Jul-19 22
• Standard
The Medical record contains sufficient information, to identify the patient, to
support the diagnosis, to justify the treatment, and to document the course
and the results of the treatment .
1. The medical records of all emergency patients include arrival and departure
times
2. The medical records of discharged emergency patients include conclusions
at the termination of treatment.
3. The medical records of discharged emergency patients include the patient’s
condition on discharge
4. the medical records of discharged emergency patients include any follow-up
care instructions.
2-Jul-19 23
• A medical record is initiated for every patient assessed or
treated.
• Patient medical records are maintained through the use of an
identifier unique to the patient
• The specific content, format and location of entries for patient
medical records is standardized and determined by the
hospital.
2-Jul-19 24
• Health records are confidential, authenticated , legible and
complete.
• The Health Information Management Department is provided

with adequate direction, staffing and facilities to perform all
required functions.
2-Jul-19 25
What to expect
• HIMD
• Main Functions
Standards
Measurable elements
Policies
2-Jul-19 26
Philippine Health Record Standards
Composed of nine chapters:
 Health Information Management Dept
 Administrative and Management of HMD
 Health Record Standards and Policies
 System and Procedures
 Clinical Coding
 Hospital statistics
 Medico-legal Aspects of Health Record
 Continuous Quality Improvement
 Risk Management for the HMD
2-Jul-19 27
Each health record shall contain the following demographic data of the
patient: (P)
• Unique patient identifier
• Patient’s full name
• Date of birth
• Gender
• Civil status
• Religion
• Person to notify in case of emergency an “ALERT” notations for
allergic responses and ADVERSE DRUG REACTION shall be
prominently displayed on the Admission and Discharge Record(P)
2-Jul-19 28
• Entries in the health record shall be made only by duly authorized
staff of the facility including dates and signed with corresponding
designation. (P)
• All entries including alterations, shall be legible (P)
• Only abbreviations and symbols accepted by WHO or MRC Medical

Records Committee (P)
• Original medical records prepared by the medical, nursing and other
allied health professionals shall be filed in the health record.
2-Jul-19 29
• The health record shall be sufficiently detailed to enable:
– A patient to receive continuing care
– Effective communication within the health team.
– The AP to have available information required for the consultation
– Other medical practitioner to assume the patient care (Interdisciplinary
Form) to add:
– Concurrent or retrospective evaluation of patient care
2-Jul-19 30
• 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
– Present and past history
– Family history
• A sufficiently detailed report of a relevant Physical examination(PE)
performed by a medical practitioner
2-Jul-19 31
Philippine
PhilippineHealth
HealthRecord
RecordStandards
Standards
• Properly filled up and accomplished consent forms shall be attached
to the health record.
• Drug orders shall be written
• Therapeutic and special diagnostic test orders shall be reflected
• Evidence of patient care plans (CPG’s)
• Progress notes, observations, and consultation reports shall be
written (medical, nursing allied health staff (alterations to pts
conditions)it shall contain all diagnoses and procedure using terminology
based on the International Standard Nomenclature of Medicine
2-Jul-19 32
Philippine
PhilippineHealth
HealthRecord
RecordStandards
Standards
• The Admission and Discharge Record is completed at the time of
discharge or as soon as all relevant information is available, use
terminology based on International Standard Nomenclature of Medicine.
(P)
• A discharge summary for each pt shall be completed upon patient’s

discharge : (P)
– Discharge Dx
– Procedures performed
– Follow up arrangements
– Therapeutic orders
– Home instructions
2-Jul-19 33
• 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 24 hours.
2-Jul-19 34
POLICY AND PROCEDURE
• The pts health record shall be forwarded to the HIMD within
24 hours after discharge. (P)
• History and PE shall be completed within 24 hours after
admission (P)
• A health record with pending diagnostic results shall be
completed within 15 days after the patient’s discharge.
(P)Otherwise it shall be considered a delinquent health record.
2-Jul-19 35
POLICY
POLICYAND
ANDPROCEDURE
PROCEDURE
• The AP has the major and final responsibility for the
completeness and accuracy of the data entry in the health
record. (P)
• The accomplishment of History, PE and Discharge summary
may be delegated to the residents. (P)
• The HIMD shall assist the AP in reviewing records for
completeness by checking omissions and discrepancies.
2-Jul-19 36
General Policies
• The release of information is delegated to the HIMD Head.
But in cases where a problem arise beyond her control, it shall
be referred to the Chief Admin Offcr.
• Release of information with clinical value shall be done only

with the written consent/waiver from the patient.
2-Jul-19 37
General Policies
• Request for Medical Certificate or Clinical Information when the
patient is still confined shall be referred to the AP
• Certificate of Confinement – signed by the head of the HIMD , shall
be issued while the patient is still confined in the health care
facility. This document should be a controlled document , should be
pre-numbered and record its issuance.
• Medical Certificate- shall be signed by the AP when the patient is

already discharged and release with dry seal, with control number
for authentication purposes.
2-Jul-19 38
• Medico-legal certificate- shall be duly signed by the AP or
Chief of the Health care facilty.
• Certified photocopies of pts health record shall be released
but limited to the ff:
– Discharge Summary/Clinical Abstract
– Laboratory and diagnostic results
– Report of IOperation
2-Jul-19 39
What to expect
• HIMD
• Main Functions
Standards
Measurable elements
Policies
• Clinical Documentation
2-Jul-19 40
2-Jul-19 41
DOCUMENTATION
IMPORTANCE OF HEALTH RECORD DOCUMENTATION
Permanent part of the patient’s medical record
Patient safety
Written proof that you did something
 Written testimony
Quality assurance
 Operations
 Research
2-Jul-19 42
DOCUMENTATION
• Errors and Falsifications
admit when you made a mistake
• Revise if necessary
note date and time of revision
keep original document
include purpose of the revision
only the original author can make the correction
2-Jul-19 43
DOCUMENTATION
• Always be honest and true in your documentation
• Correction :
 Add a supplementary
 one line across the error initial the mistake and
make the corrections on written reports
• Complete reports as soon as possible
lost reports have HUGE legal implications
don’t keep copies of your reports
2-Jul-19 44
DOCUMENTATION
In summary:
Be professional • Collaborative
Accurate • Legible, correct spelling
Consistent • Tell the truth
• Follow protocols
Through
• Plain language
Clear
• Relevant information
Brief
• “The Jury”
Paint the picture • Have your partner review
2-Jul-19 45
PURPOSE OF PATIENT’S RECORDS
• Communication
• Quality-of-care recording
• Research
• Education
• Legal Documentation
2-Jul-19 46
LEGAL GUIDELINES FOR RECORDING
• DO NOT ERASE, apply correction
fluid, or scratch out errors made
while recording
• DO NOT WRITE retaliatory or
critical comments about a client
or care by other health care
professionals.
• RECORD all facts
• DO NOT LEAVE blanks.
2-Jul-19 47
• Record all entries legibly and in
ink.
• Chart only to yourself.
• Begin each entry with time, and
end with your signature and title.
• For computer documentation,
keep password to yourself.
2-Jul-19 48
DATA TO BE RECORDED IN THE
PATIENT’S CHART
(DOH HOSPITAL NURSING SERVICE
ADMINISTRATION MANUAL )
2-Jul-19 49
ADMITTING AREA –ER/OPD
• The observed disposition of valuables
• Admissions date, time, and endorsed for safekeeping
room/bed number • The admitting physicians
• Mode of admission • Written (orders) prescriptions of
• Vitasl signs physicians.
• Admission nots, with the latest • Medication given, date, time, dosage,
version charting - FDAR route
2-Jul-19 50
ADMITTING AREA –ER/OPD
• Specimen’s obtained
• Type of specimen
• Time it wasobtained
• Time it was submitted to the
laboratory with signature who
submitted and received the
specimen
• Status of patient during transferr

to other patient areas
2-Jul-19 51
IN PATIENT AREAS
• Time of doctor’s visit and all • Reaction, attitudes, mood and
subsequent visits of the physician status of the patient
• Written orders of all physicians • Pertinent subjective observation
• Specimen (s) obtained: • Complaints of pain
• Type of specimen • Discomfort
• time it was obtained • State of depression
• time it was sent to the
Laboratory
2-Jul-19 52
IN PATIENT AREAS
• Reaction, attitudes, mood and • Medications
status of the patient • Prescribed diet and appetite of
• Pertinent objective observation the patient
• General appearance • Transfer as to date, time and
mode to and from any
• Attitudes/Observation unit/department
• Activity/Type of Activity • Nursing care rendered
• Vital signs • Nursing procedures
• Comfort measures
• Health teachings
• Evaluation of care
2-Jul-19 53
IN PATIENT AREAS
• Completion of the day’s charting as to time, date and
calendar date
• Use of black/blue ink for AM/PM shifts, red for night
shift
• Incident shall be reported to the immediate
supervisor and record indicating the time and
condition of the patient.
2-Jul-19 54
DOCUMENTATION
2-Jul-19 55
2-Jul-19 56
2-Jul-19 57
2-Jul-19 58
2-Jul-19 59
What to expect
• HIMD • Qualitative vs. Quantitative
• Main Functions
Analysis
• Joint Commission International (JCI • What is Clinical documentation
Standards Improvement
Measurable elements
• Clinical Audit
Policies
• Clinical Documentation
2-Jul-19 60
Clinical Documentation Improvement
What is CDI
 Clinical documentation is at the core of every patient encounter
 In order to be meaningful it must be accurate, timely, and reflect the
scope of services provided.
 Successful documentation improvement programs facilitate the
accurate representation of a patient’s clinical status that translates
into coded data.
 Coded data is then translated into quality reporting, physician report
cards, reimbursements, public health data, and disease tracking and
trending.
2-Jul-19 61
• CDI is the bridge between the clinical language and coding
• Concurrent review of health records for conflicting, incomplete
or nonspecific documentation.
• CDI should be viewed as a tool and not as a hindrance to being
able to perform patient care.
• CDI provide information about specificity in documentation
that supports consistency in care and supporting severity of
illness and length of stay.
2-Jul-19 62
Clinical Documentation
Improvement
Guidelines for Medical Record

and Clinical Documentation
• Ref: Guidelines for Medical Record and Clinical Documentation WHO-SEARO coding workshop September 2007
2-Jul-19 63
Clear
Confidenti
al Concise
Patient
Complete
centered
Medical
Records and
Clinical
Collaborat Documentation Contemp
ive orary
Compreh Consecuti
ensive ve
Correct
2-Jul-19 64
High Quality Documentation
COMPLETE ACCURACY COLLABORATIVE
•Are all data sets and data The degree to which the data to work with another person or
items recorded? mirrors the characteristics of the group in order to achieve or do
real world or objects it represents. something
UNIQUENESS CONTEMPORARY CONFIDENTIAL

No thing will be recorded Existing, happening or occurring entrusted with private or restricted
more than once based upon now information
how that thing is identified.
CONSISTENCY CONSECUTIVE CLEAR

Can we match the data set Things that happen one after the Easy to understand, perceive,
across the stores other simple
VALIDITY COMPREHENSIVE CONCISE

Quality of being correct or short and clear, expressing what
true. Encompassing all or everything needs to be said without
unnecessary words:
2-Jul-19 65
Professional documentation includes:
• Any and all forms of documentation by
a clinician recorded in a professional
capacity in relation to the provision of
patient care.
This documentation may include:
• written and electronic health records
• audio and video tapes, emails,
facsimiles, images (photographs and
diagrams)
• observation charts, check lists,
communication books
shift/management reports, incident
reports
• clinical anecdotal notes or personal
reflections (held by the clinicians
personally or any other type or form of
documentation pertaining to the care
provided.
2-Jul-19 66
• Other documentation not directly related to the patient
• Other documentation may be relevant to evidence of clinical practice and of

interest to the employer, a regulatory authority, the Department of Health,
courts, a funding body or the general public.
2-Jul-19 67
policies, procedures and protocols
critical incident / occupational health
and safety reports
staffing rosters personnel files
statistical and research data
reports related to service and funding
agreements
2-Jul-19 68
• Documentation Policy :Medical Record Officer should ensure they have documented policy,
procedure and quality assurance mechanisms in place which clarify: (P)
• the legislative requirements for documentation

• the minimum requirements for documentation
• format and type of documentation (including acceptable documentation tools
and forms)
• the roles and responsibilities of the clinical staff in relation to documentation
• accepted abbreviations in the organisation (including their agreed meaning)
• any requirements for witnessing or counter signing documentation (and the
meaning and responsibility assigned to these practices)
• requirements for access, storing, archiving and retaining documentation
• requirements for documentation of verbal orders and provision of telephone
advice/information
• requirements for confidentiality and privacy.
2-Jul-19 69
Documentation should be a record of first hand (direct) knowledge,
WHO? observation, actions, decisions and outcomes. Therefore it should be
recorded by:
Doctors Nurses Midwives Patients Other health Other care

Professionals providers
Clinical Documentation should reflect:

 Use of consistent data collection form
 Clarification of documentation requirements by HIM
 Identification of roles & responsibilities of each health care
provider
 Clear process for review, storage and archiving
 Clarification of access and communication process
2-Jul-19 70
All aspects of patient care
WHAT?
Collaboration and shared responsibilities between all relevant
health professionals/care providers
Complete information
Subjective and objective information
Observation, Assessment, actions , outcomes
Variances from expected outcomes or established protocol
Rationale for decisions and actions
Critical incidents involving the patient
2-Jul-19 71
 As a chronological records of actions and events
WHEN?
 At the time of or as soon as practicable after
 the action or event
 Collaborations
 Variances to expected outcomes
 Critical incidents
 An identified late entry
 Basis of communication between health professionals

WHY?  Informs and is a record of care provided
 Used to evaluate professional practice as part of quality
improvement
 Demonstrates accountability
 Used to abstract details for coding purposes
 Valuable source of data for research and tool for identifying
2-Jul-19
funding and resource allocation 72
HOW?  Concise, accurate and true record
 Clear, legible, permanent and identifiable
 chronological, current and confidential
 Based on observations, evidence, assessment
 Consistent with guidelines, organizational policy,
legislation
 Avoids abbreviations,. White space, ambiguity
2-Jul-19 73
CDI IMPLEMENTATION : STEPS
• STEP 1:
• Determine key stakeholders
– HIM coding department
– Medical staff executive leadership
– Patient financial services or billing
– Quality assurance
– Nursing
– compliance
2-Jul-19 74
• Step 2:
• Provide targeted EDUCATION
– Provide basic training based on needs
– Build collaboration between HIM, coding , physicians
– Ongoing education
– Open communication
2-Jul-19 75
• Step 3:
• Ongoing maintenance and updates
– Software updates
– Quarterly/annual coding
– Continual gap analysis
– CMI trending
– Addition of new services
– Expansion to new setting
– New staff training
– quality initiatives
2-Jul-19 76
What to expect
Standards
Measurable elements
Policies
Analysis
2-Jul-19 77
CLINICAL AUDIT
• WHAT IS AN AUDIT?
• “you cannot do an audit without audit tools.
2-Jul-19 78
Who should be involved in CLINICAL AUDIT
• is a quality improvement process that
seeks to improve patient care and
outcomes ….aspects of the structure,
processes, and outcomes of care are
selected and systematically evaluated
against agreed and proven standards
of clinical practice.
• Taking actions to bring practice inline

with standards so as to improve the
quality of care and health outcomes.
2-Jul-19 79
Who should be involved in CLINICAL AUDIT
2-Jul-19 80
Audit cycle
Clinical audit includes:
• Relevant documentation policy and
procedures
• Professional/regulatory/statutory
standards
• Consistency of understanding
documentation process across
organization
• Identified gaps of
inconsistencies/discrepancies in
documentation
• Content /context of documentation
2-Jul-19 81
CLINICAL AUDIT
A review of evidentiary compliance of the documentation
includes:
• That the document is contemporary
• That the documentation is based on evidence and observation
• The timeliness of entries
• Inclusive of planned care
• That the document is a complete record
2-Jul-19 82
CLINICAL AUDIT
Why is Clinical Audit important:
• Provides the framework to improve the quality of patient care
in a collaborative and systematic way.
Benefits:
• Promotes and enables expected practice
• Provides opportunities for educating and training
• Builds relationship between clinicians, mangers and patients
• Leads to improvement in service delivery and patient
outcomes
2-Jul-19 83
What to expect
Standards
Measurable elements
Policies
Analysis
2-Jul-19 84
CONTINUOUS QUALITY IMPROVEMENT FOR HEALTH
FACILITIES
• Quality Assurance – is a systematic approach in monitoring
and assessing patient care provided or the service being
delivered.
• CQI- Coninuous Quality Improvement – is the structured
organizational process of involving personnel in planning and
executing a continuous flow of improvements to provide
quality healthcare that meets or exceeds expectations.
2-Jul-19 85
Better patient
Better professional
outcomes development
Everyone
Improved quality of Communication Higher employee
service Cooperation morale
Documentation
Increased customer
Better opportunities
satisfaction
Effective allocation Education , awareness

and use of Better system and training
resources
performance
Higher productivity Lower costs Higher profits

2-Jul-19 86
CQI
Covers different perspective:
• Clinical Quality (providers) – refers to the degree to which health
services for individuals and populations increased 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 managed care.
• Cultural Quality- (administration) – refers to the recent movement in
healthcare.
2-Jul-19 87
2-Jul-19 88
Safety
Continuity
Timeliness
of Care
Quality
Dimensions
Patient
Centered Effectiven
& Equity ess
Efficiency
2-Jul-19 89
Safety
•Delivering health care which minimizes risk and harm, patient and staff
do not suffer undue harm
Timelines
Patient obtain health care that are timely and financially reasonable, socio
culturally sensitive, resources are appropriate
Effectiveness
Delivering health care that improve health outcomes based on evidence-
based knowledge.
Efficiency
Delivering health care which maximizes resources
Patient Centered and Equity

Deals fairly with the distribution of health care, regardless of religion, rece,
gender, political inclination, ethnicity
Continuity of Care
Establishes partnership among practitioners and families
2-Jul-19 90
• What one thing
will you apply
from this
lecture/re-echo
seminar?
2-Jul-19 91
2-Jul-19 92
Making a CQI Project
2-Jul-19 93
2-Jul-19 94

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TRAINING ON CLINICAL

DOCUMENTATION IMPROVEMENT FOR

The Health Information Management Department (HIMD)

Maintain a comprehensive and up-to-date unit health record

• Ensure that all diagnostic reports/results are promptly and

Integrated Hospital Operations and Continuous Quality Improvement

Professional Education and Training Research

Hospital Operations and

Pathology Health Information

Clinical Nursing Units Operating Room Delivery and Labor Room

Central Supply &

• Measurable elements –indicate what is reviewed and scored;

• The Health Information Management Department is provided

• All entries including alterations, shall be legible (P)

• Only abbreviations and symbols accepted by WHO or MRC Medical

• A discharge summary for each pt shall be completed upon patient’s

• When an autopsy is performed, a provisional diagnosis is noted

• Release of information with clinical value shall be done only

• Medical Certificate- shall be signed by the AP when the patient is

• Status of patient during transferr

Guidelines for Medical Record

UNIQUENESS CONTEMPORARY CONFIDENTIAL

CONSISTENCY CONSECUTIVE CLEAR

VALIDITY COMPREHENSIVE CONCISE

• Other documentation may be relevant to evidence of clinical practice and of

• the legislative requirements for documentation

Doctors Nurses Midwives Patients Other health Other care

Clinical Documentation should reflect:

Rationale for decisions and actions

Critical incidents involving the patient

 Basis of communication between health professionals

• “you cannot do an audit without audit tools.

• Taking actions to bring practice inline

Effective allocation Education , awareness

Higher productivity Lower costs Higher profits

Patient Centered and Equity

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