Conclusiones del capítulo

 The lawyer representing a patient shall only be given access after presenting a written authorization duly signed by the patient.

 An insurance verifier shall be required a waiver before being given access to the record/information about a patient. The original copy of the waiver shall also be filed with the record.

 Researchers from other medical institution could again access to medical records only after complying with requirements set by the institution concerned.

 Patient’s relative making inquiries about their patient shall be referred to the attending physician.

 Law enforcement agents shall need a written request duly signed by the Chief/Director of their respective agency before being given access to the record. Should it be possible however, to get the written consent of the patient and attending physicians.

 Patients also have a right to their record. But to prevent misinterpretation of medical information which may lead to litigation, patient may not be allowed access to his own record. However, his physical and mental condition shall be explained only by the attending physician.

 The health care facility may, in some situation, release health information even without the written authorization. Such situations are as follows:

 Court Order

A hospital or other health care facility must release health information in response to court orders.

 Administrative Agency Order

A provider must 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 health provider. Where the subpoena is valid, the hospital must disclose the health information.

 Arbitration Order

Either an arbitrator or 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 is entitled to receive any health information covered by the warrant.

 Medical Research

Health information may be disclosed to public agencies, clinical investigators, health care research organizations or accredited education or health care institutions for purposes of bonafide research. But before the medical information is released, the medical record staff should take reasonable steps to ensure that the research is legitimate, and proper safeguards in the release of information are instituted.

Preparation of Hospital Census

PROCEDURES PERSON/S RESPONSIBLE

a) Collates 24-hour census forwarded by the Nursing Service;

b) Prepares census report (4 copies); Administrative Aide III c) Reviews and signs census report;

d) Enters report in the worksheet for the monthly report; and

Medical Records Officer

e) Files hospital census report. Administrative Aide III

Issuance of Medical and Medico-Legal Certification

PROCEDURES PERSON RESPONSIBLE

a) Receives formal request for medico-legal certification from authorized party or law enforcement agents;

b) Retrieves medical records from file;

c) Seeks clearance from the attending physicians;

d) Instructs requesting party to pay fee to the Cashier;

e)Types certification on the Medical Certification Form in triplicate;

f) Forwards it to the attending physician and other physicians concerned for review and signature;

Administrative Aide III

Administrative Aide III

g) Signs certification and returns to the Medical Records Section;

Attending Physicians &Other Physicians Concerned h) Affixes seal of the hospital on the certification

and forwards it to the COH (only for Medico-legal certification)

Administrative Aide III i) Attest and signs certificate and returns it to the

Medical Records Section:

Chief of Hospital j) Presents official receipts to the Medical Records

Section Clerk; Requesting/ Authorized Party

k) Indicate the official receipt number and releases the certificate to the Authorized Party; and

l) Files copy on the patient’s chart.

Administrative Aide III

Preparation of Birth Certificate a) Fills up draft form;

b) Interviews parents and verifies data;

c) Signs blank official birth certificate form;

d) Types data into the official form and forwards to the Ward Nurse;

Administrative Aide III

e) Checks the official birth certificate form and

forwards to the attending physician; Ward Nurse

f) Signs birth certificate and return to Ward Nurse who in turn gives the BC back to the Medical

Records Section; Attending Physician

g) Prepares list of BC and transmittal letter to the Local Civil Registrar duly signed by the Medical Records Officer.

Administrative Aide III h) Forwards BC and transmittal to the Local Civil

Registrar; and

i) Upon receipt of the registered BC files the copy in the patient’s medical record.

Administrative Aide III

Issuance of the Death Certificate

PROCEDURES PERSON RESPONSIBLE

a) Prepares Death Certificate and forwards it to the attending physician;

Nurse on Duty b) Completes and signs death certificate and

returns It to the nurse;

Attending Physician c) Checks accuracy and completeness of the data

and forwards it to the Releasing Medical Records Clerk;

Administrative Aide III

d) Records and released to the official logbook e) Acknowledges acceptance of the Death Certificate and signs in the logbook;

Patient’s Relative f) Advises patient’s relative to register the Death

Certificate to the Local Civil Registrar;

g) Files Death Certificate accordingly.

Administrative Aide III

Release of Information to Insurance Verifier

PROCEDURES PERSON RESPONSIBLE

a) Receives written request (waiver) from the authorized insurance verifier.

b) Retrieves patient’s chart from the permanent files;

c) Authentic signature of the patient on the waiver d) Informs the attending physician of the request;

e) Determines whether or not the information may be released;

f) Authenticates photocopy, affixes hospital’s seal;

g) Records and release photocopied information to the insurance verifier in the official logbook;

h) Files waiver/request in the patient’s permanent file after insurance verification acknowledges the receipt of the information.

Administrative Aide III

Retrieval of Patient’s Chart for Requesting Party/Authorized Borrower

PROCEDURES PERSON RESPONSIBLE

a) Submits duly accomplished request to the

Medical Records Clerk; Requesting Party/Borrower

b) Verifies patient’s number from their master’s index for patients;

c) Retrieves chart from files;

d) Records in the book/logbook, indicating the name of the patient, the requesting

party/authorized borrower, the date when borrowed, and the name of recipient of the patient’s chart.

Administrative Aide III

e) Signs logbook. Authorized borrower

7. Processing of Medical Records Received for File

PROCEDURES PERSON RESPONSIBLE

a) Checks all charts received against the list of discharges reflected in the Daily Census Report;

b) Records all charts received;

c) Prepares the master patient index based on the list of admission

d) Rearranges the record according to the standard format

e) Analyses data on patient’s chart;

f) If data are incomplete, fills in the deficiency

Administrative Aide III

slips, attaches it to the chart and returns it to the Ward clinical concerned.

f.1 Upon receipt of incomplete chart and

deficiency slip (Medical) Ward Nurse fills in the data required and returns to the Medical Records Clerk,however, most of the time the Medical Records Clerk does the procedure herself;

g) Completes the data and forwards completed chart to the Coding and Indexing Clerk;

Administrative Aide III

h)Codes and indexes diseases and operations as per prescribed code tools;

i) Forwards coded chart to the Filing Clerk;

Administrative Aide III

j) Sorts out coded chart according to the terminal digit filing system and prepares folders; and

k) Files chart Administrative Aide III

NUTRITION AND DIETETICS SERVICE