Health Records

Departmental Functions: - Professional registration and documentation of patients’ health records - Health Records Library Management - Hospital activities analysis - Clinical coding of diagnosis and procedures according to WHO’s standard - Systematic and accurate filing of patients’ health records - Effective patients’ scheduling - Professional management of medical correspondence - Forms management for continuous patients’ services - Systematic training of professional students SIWES and in-house workshop seminar for core staff.
Out-Patient Units Patient that has paid and obtained receipt will be registered, all his identification data will be recorded and the patient will be registered in unit numbering system, hand card and other necessary cards will be open for consultation then patient move to triage for normal vital signs, and be taken to see the doctor.

In-Patient All patients’ files are promptly collected from admission and discharged procedures afterward coding and indexing is done, then the file is taken to statistics unit for Hospital statistical analysis and reporting then for final filing in the library.

Clinics - Prompt retrieval of patient file from different units at least 24 hours before the clinic day. - Patient has to be booked and given future dates before the clinic day. - Record staff must present the number of patient to be seen per clinic as agreed by the team. - Filing of all the patients’ files after the clinic - Collection, analysis and reporting of relevant statistical data after each clinic.

Coding and Indexing After each day discharges, records staff collect all discharged files for coding and indexing according world health organization procedure using international classification of diseases 10 volumes I, II and III. - Then the coded files will be indexed in diagnosis and operation index card for research purposes - Proper arrangement of the content of case file is done by data (chronologically) - Complete tagging of patient records within the files
Medical correspondence and central records library - When the patient has paid and obtained receipt, the medical report will be typed and sent for proofreading, and then the final typing is done, the patients signed and collect it after a thorough cross checking and registration at CMAC office. - The death certificate is written and issued out from the same office and the next-of-kin would pay and collect on behalf of the family. - Discharged file are filed after all procedures from admission and discharged office - Entering the inactive files into the computer for further use such as research and legal purposes.

Statistics Unit Collection of statistics from relevant places for analysis and report on daily, weekly, monthly, quarterly, or on yearly basis. - Compiling special and usual investigation reports - All needed Hospital analysis for decision making will be presented to appropriate authority.
Head of DepartmentMRS