CHAPTER NINE

ACCIDENT AND EMERGECY RECORDS PROCEDURE

Learning Objectives

Students should be able to: -

Identify the types of records to be kept.

Describe how appointments are made in this department

Describe how patients are disposed of from this department

Describe the legal requirements to be observed in this department.

After a patient has been seen at the health centre he may be having some ailment which needs
immediate and urgent attention. Definitely the doctor will refer him to a hospital for immediate
attention. He will find himself in an accident and emergency department. Also patients with any type of
accident will be brought to this department directly.

1. Records to be kept

(a)Firstly a register must be maintained at the Accident and emergency department. The following
should be included in this register; name address, age doctor referring him, time of arrival, brief
description of injury, brief details of injury, brief description of injury, brief details of treatment, and the
mode of disposal. The particulars of the person who has brought this to the accident and emerge
departments must be taken also. If it is a police officer his number must be recorded in the register. The
register may be in loose leaf or in bound volumes. From the register statistics of attendance will be
compiled.

(b) Clinical record

(i) Single card measuring 8’ x5’ or 6’ x4’ on which the identification details are recorded. For an R. T. A
(Road traffic accident) patient, time and place of accident must be given and the space left for the
clinician to write on.

(ii) Two part card

A card with carbonized part made from N.C.R material. The card is made up in an envelope from so that
x-ray report and any other correspondence may be filled in it.
(iii)Thick paper envelope four and an eighth by five and three quarters inches(half the size of A4 paper).
The envelope will serve as a card and a pocket for reports.

2 . Appointments

Most patients attending this department rarely come back for return appointment. For those patients
that need return appointments this can be carried out in two ways:-

Appointment register may be retained by the receptionist and the appointment written on the patient’s
attendance card.

Pre-printed appointment cards for each day and time may be given to the patient. A different colour of
the card could be kept for each day of the week and when a patient arrives seeking an appointment a
card is simply pulled out and given to him.

Disposal of patients

Disposal of patients attending this department could be in one of these categories:-

Treatment to finality and discharge.

Treatment initially and referred back to the nearest health centre.

Referred to an out-patient consultation clinic.

Referred to a consultant clinic.

Admitted to the wards for further treatment. Here full documentation for admission will be carried out
before the patient goes to the ward.

Transferred to another hospital for further treatment.

In the case of patient who has been brought dead(B.I.D)the doctor just goes to certify the death and the
body is conveyed straight to the mortuary.

Legal requirement

It is important to note that the same legal requirements that are applicable to other health records as
far as retention is concerned still apply in accident and emergency records. They may be retained for a
minimum of six years after the last attendance. The records may be filed numerically or alphabetically
depending on the number of records created annually. At the beginning of the year, 1 st January, a new
file is started. The records should be kept o/in lock because most of these records are usually required in
court and as much details as possible should be recorded. Most patients who have 7been involved in
road traffic accidents need some claims in future. Therefore statistics for these patients may be sent to
finance department so as to issue the necessary claims.
 CHAPTER TEN
WAITING LIST FOR INPATIENT AND DAY CASE TREATMENT
Introduction
This chapter will discuss what a waiting list is, types of waiting list, advantages and
disadvantages of each and how to maintain a waiting list.

Learning objectives

Students should be able to: -

Define a waiting list

Describe the functions of a waiting list

Explain the types of waiting lists

Describe how to maintain a waiting list

Explain the methods of filing to be used

Describe the procedures used in admitting patients

Awaiting list is an index of all patients waiting admission to hospital or waiting treatment on a
day case bases.

1. Functions of a waiting list

The wai8ting list must be organized that enquiries can be answered from individual patients
waiting top know when they are supposed to be admitted in a health institution. Individual
consultants would like to know how many patients are on their waiting list should immediately
be furnished with such information. The main function of the waiting list is to be able to make
full use of the available beds in a health institution.

2. Types of waiting list

The waiting list may be maintained in various ways:-

(i) Centralized waiting list

This waiting list is held in one office and contains the names of all patients awaiting admission
under all the consultants in the hospital.
(ii)Decentralized waiting list

The decentralized waiting list will be maintained in several places possibly each consultant’s
secretary, or an individual wards or individual departments.

Advantages of centralized waiting list

Gives a fair representation of the demands being made on the in-patients facilities.

All enquiries are referred to one place.

Staffs dealing with the waiting list develop skills in dealing with enquiries, and in the
maintenance of the waiting list.

Updating procedures such as change of address, death are easily carried out.

Checking admissions and discharges from the daily returns is easier.

When one staff falls sick or goes on leave another staff can carry on with the work.

Disadvantages of centralized waiting list

Consultants need to walk to the central office to select their patients form the waiting list.

The list becomes so big so that some patients may be left out waiting list.

Advantages of decentralized waiting list

Consultants need not to go the central office to select their patients from the waiting list.

The secretaries get familiar with their patients and can call them by name.

Disadvantages of decentralized waiting list

Several staffs will be deployed in the maintenance of the waiting list in different areas.

It will be very expensive since each department will need to use its own equipment.

A clerk will have to walk to the central records to check for admissions and discharges from the
daily returns.
3. Creation of the waiting list records

Most of the waiting list records are initiated at the out-patients clinics. Some other patients
may come from another hospital and be put in the waiting list for another different hospital,
where there are more beds or facilities. There are four ways in which information can be
conveyed to the waiting list:-

(a)Card- The card is created for every patient who is to be put on the waiting list. This card will
be filed and form part of the waiting list.

(b)The nurse or doctor may send a list the patient to be included in the waiting to the records
department for action.

(c)Letter- Consultant in one hospital may wish to include his patients name in his waiting list, in
another hospital for his to be included in that waiting list. In this letter he will include diagnosis,
and priority for admission. A case folder will then be created for this patient. The information to
be included in this records are: the patient’s name, address, title, telephone number, holiday
date, diagnosis, operation to carried out , duration of stay in the hospital, name of the surgeon,
or consultant.

4. Method of filing

Awaiting list contains dozen names and needs two files:-

Alphabetical index of the names of all patients on the waiting list. These cards should be
removed until the patient is admitted.

Consultants list will make provision for date, time, and ward. These lists will have priorities
indicated – routine, soon, and urgent.

These two files should be able to answer an enquiry from a patient and consultant.

5. Filing equipments

The types of filing to be used will depend on the size of the list.

(a)Visible edge card filed in trays.

When this is used to maintain a waiting list may be in the form of manila flaps, with a rigid bar
at the top and a transparent plastic pocket about half an inch deep at the lower edge of flap. A
card is inserted into this pocket and the flap is held in a metal tray in such way that all the
information in the plastics is visible. Date is put on the list, diagnosis, operations and admission
priority is pit to allow the consultant to select his patients

(b) Strip index

A strip index is limited in space so that no space is left for change of address. It can only be used
if the list is not too long. It has being mentioned as one of the equipment used in the
maintenance of the patients master index card.

(c) Diaries

Each consultant could have a diary for his patients put on the waiting list according to dates. Its
danger is that a patient can easily be missed or overlooked on date which passed.

(d) Colour coding

Colour coding could be used to indicate soon, urgent and routine case.

6.Procedures for admitting patients from list

The patient is selected from the waiting list y the consultants.

The clerk writes to the patients or telephones him inviting the patients to the hospital

The records are got out the filing area and to the documentation office.

The waiting list card is sent to the admission office so that the patient is expected on the day he
comes in the admission office checks the record before the patients comes.

Patients is admitted and sent to the ward.

When the patient has been discharged his name is removed from the waiting list.

Certain checks are made on the waiting list to remove the names of the patients who have died
to remove their names form the waiting list.

7. Statistics

Regular returns are compiled form the waiting list for hospital activity analysis. The procedures
described above also apply to patients who come for day case treatment. Special letters are
sent to this patients because of the preparation needed if general anesthesia is to be given.

CHAPTER FIFTEEN
LEGAL ASPECT OF HEALTH RECORDS AND VARIOUS ACTS RELATED TO
THEM
Introduction
This chapter will describe how and interpret the legal requirements affecting health records and
the various acts related to them. It will concentrate on confidentiality, ownership, security and
disclosure of information.

Learning Objectives

The students should be able to:-

1. Analyze and interpret legal aspects concerning:-

-Confidentiality

-Disclosure

-Ownership

-Retention

-Security

-Consent of Operations

-Medical Records Ethics

Confidentiality

Information concerning a patient is confidential and should not be release to any unauthorized
persons. If a member of the hospital staff improperly discloses any information concerning a
patient whereby that patient suffers material loss, the patient can easily sue the hospital and
the officer who is in breach of his duty had made any improper disclosure. If a hospital
authority is to minimize its risk in the matter, it is suggested that it should have a rule for strict
secrecy about all information regarding patients, their disease, their affairs, and the affairs of
their families obtained by any officer in the course of his duties. Further it is recommended
that:-

No unauthorized information should be given concerning patient or former patients.

Apart from normal replies, and enquiries concerning the progress of a patient’s illness is to be
given except from instruction of the consultant.

Case notes are not produced to unauthorized members of staff.

There are five main categories under which contents of patients records can be disclosed;-

Consent by the patient which could be expressed or implied.

If there is a court order.

If the interest of the doctor or hospital cannot be otherwise safeguarded.

If transference between hospitals, clinics or doctors in the interest of the patient.

If there exists a higher duty than the private duty e.g. notification of infectious disease,
notification of births and deaths registration, and notification of poisons.

Disclosure with patient’s consent

A patient can give his consent for disclosure either expressly or implicitly. Implies consent arises
only in certain limited circumstances as, for instant, when records are disclosed to another
medical agency for purpose of continued treatment. Express consent obtained when the
patient signs a document authorizing the hospital to disclose his medical history for some
specific purpose.

In general the consent form should always indicate the reasons for that disclosure, and no
disclosure should be made expect for that reason. If the reason and change, specific consent
should again be obtain. Where a consent form reaches the hospital, the hospital is at liberty to
disclosure and the patient would have no ground for complaint if the disclosure was wider than
the intended.

In cases where requests for clinical information are received from solicitors claiming to be
acting on behalf of the patient care should be taken to make sure that the solicitors really are
acting on behalf of the patient, and not, in fact him.

Request from insurance companies and similar bodies should only be acceded to with the
patient’s written consent but should be referred to the hospital authorities.

(b)Disclosure by an order of court

A court in the pursuit of justice may make an “Order for Discovery” or a Subpoena to produce
case records. There is no question but that such an order must be obeyed. Generally the
appropriate person to attend court and produce the appropriate record would be the Records
officer. It is the original document that should be produced in court but if the original document
cannot be traced then the court may accept the photocopies must be certified to be the true
copy of the original document.
(c)Disclosure to safeguard the interest of a doctor or hospital

If an action is brought against a hospital or doctor, then the disclosure of a patient’s record
may be done. Of equal important is the fact that disclosure is permissible if the hospital is to
work effectively. Disclosure of the contents of contents of a medical record is necessary
between departments or between members of medical staff in staff in the hospital and this is
justifiable of course, as being in the patient’s interests. Such disclosure if made publicly by any
member of the hospital staff, resulting in the patient’s interest affected could adversely
affected could result in action for damages.

(d)Disclosure in transfer of information between authorized medical agencies

A doctor dealing with a patient has full rights of access to any clinical data at the time (expect of
course, where patient has been referred for treatment who is acting for a third party). When a
patient is seen subsequently by another, strictly speaking that doctor has doctor no legal right
of access to the notes made by the previous doctor.

(e)Disclosure as a ‘higher’ duty

The existence of the higher duty may be said to apply when the interest of needs of the public
are better served if there is some relaxation of the private duty and in some cases there is a
clear legal duty to give information which supersedes the doctrine of confidentiality. More
common instances are in the following circumstances:-

Notification of infectious disease by medical doctors to local medical officers of health under
the Public Health Act (1936).

Notification of the cause of death under the Births and Deaths registration Acts 1836-1962.

Notification of the industrial poisonings under the Factory and Workshop Act 1901. (i) to (ii)
above represent statutory obligations, whereas (iv)below are good causes. A statutory
obligation must be complied with, whereas although a good cause should be there, there is no
breach of law if it is not.

Claims for sickness benefits under the National Insurance Acts.

Exchange of records between doctors for research purposes.

Discloses to a central body for collective statistics purposes e.g. hospital activity analysis.

In the foregoing instances, it is plain that disclosure is in the public’s interest.

Ownership

There records do not belong to the patient even if fees have been paid. The records belong to
the various health institutions which created them. In the case of government institutions they
belong to the government. Case records of private belong to the institutions because they have
contributed to the creation of the records.
Retention

The Public Records Act stipulates that authorities responsible for public records have a duty to
make proper arrangements for selecting those records which should be permanently be
preserved and for disposal of the rest. There are some records that spelled out by that Act and
they should not be destroyed.

(a)Post Mortem books

(b)Summary of clinical notes

(c)Discharge registers containing diagnosis

The rest of health records in the folder may be destroyed. This should be done six years after
the patient’s last attendance. Each hospital should be able to decide on which records to be
destroyed depending on the institution’s demands.

Security

It is the responsibility of each and every health institution to ensure that there is security in
storage and handling of health records. This security could be maintained by:-

Provide adequate security in the departmental procedures and use of equipment.

Instructing lay staff on the confidentiality of health records.

Require all lay staff to sign a declaration of secrecy.

Health records staff accepting responsibility for disclosure of contents of health records in the
possession.

Consent for operations

It is legal requirement that a health institution should obtain consent from patient/ client
before an operation or anaesthesia is administered to him in order to safeguard it. This only
becomes difficult in the case of children and unconscious patients. In the case of unconscious
patient, the surgeon should carry on with the necessary procedures. In case somebody under
16 years it is necessary for parent or guardian to give consent. In case of emergency, consent
should not delay the procedure because this could increase the risk. In case the operation is to
be done on the child the father is the right person to give the consent but if the father is not
accessible, the mother’s consent would be acceptable. Failing that of the father, mother and
then a legal guardian would be obtained.

Married women would give consent on their own right just as single women. It is wise to obtain
the husband’s consent particularly where sterility may follow an operation. For mentally
disordered patient the consent of the nearest relative should be obtained.
Medical records ethics

In Greece, Hippocrates, known as the “father of medicine” was born about 460BC. He was the
first to cast out superstition and to practice medicine on scientific principles. He was the author
of the Hippocratic Oath, which is pledge by physicians and other health workers including
health records personnel. It states in part: “whatsoever in my practice or not in my practice I
shall or hear amid the lives of lives which ought not to be noised abroad- as to this I will keep
silence, holding such things unfitting to be spoken”. That is how confidentiality of health
records originated and should be maintained until today.

CHAPTER SIXTEEN
MANAGEMENT OF SPECIAL HEALTH RECORDS
Introduction
This chapter discusses the special health records in that the way they are created and the
information contained in them and the way they are stored is different from that of general
records.

Learning objectives

The students should be able to:-

Define special health records.

Describe types of special records.

Describe the security and control of special health records.

Psychiatric records (infectious disease).

Tuberculosis records

Radiotherapy records.

HIV/AIDS records

Maternity records.

Psychiatric records

The way psychiatric records are maintained is different from the way general records are
maintained. This is prescribed in the Mental Health Act. The admission of psychiatric patients
may be “informal or formal”. Informal means a patient is admitted without legal or other
formalities and the hospital has no right to detain him in the hospital against his will.

Admissions are carried out in reference to the Mental Health Act. Discharge procedures are also
carried out in the same act.

The records office must ensure that the information inside the record is accurate. The same
responsibility being carried out by the health records officer in a general hospital are the same
ones carried out in a psychiatric hospital except for addition to the special statutory work
arising from the operation of the mental health act.

Tuberculosis records

Tuberculosis is one disease (cancer is the other) for which an attempt is made to complete
registration to identify that population. Since it is an infectious disease notification must be
made to the “Medical Officer of Health. A unit register is maintained for this notification. Copies
of the notification of new cases are sent to the chest clinic. A unit record is opened for this
patient and the information contained in it should be very comprehensive.

The records belonging to these patients are supposed to be kept for long periods and therefore
the case folder must be made for sturdy material to resist wear and tear. The notes should be
written in foolscaps instead of a4 size papers.

Radiotherapy records
Radiotherapy department present a special records problem. All radiotherapy cases are
supposed to be registered nationally for perpetual follow-up. These records could be filed in a
separate area but given the unit number, and copies of notes for the same patient form other
units in the hospital incorporated in the same unit file. This should be a radiotherapy number
given to each patient to be used for National Cancer Registration. This number is prefixed by
the year of first registration and is used in all follow-up correspondences, until the patient dies.
The prefix to the year of registration number is a precaution against confusion with unit
number which will be used for treatment and all other occasions in the hospital.

Security and control of special health records

The special health records should be if possible locked In cabinets and keys by the health
records/ information officer.

CHAPTER SEVENTEEN
PRIMARY HEALTH CARE RECORDS
Introduction
This chapter will describe the type of records that are created at the health centres and in the
and in the community Based Health Care Services.

Learning objectives

Students should be able to:-

Define Primary health care

Identify the type of services that are rendered at the community.

Describe the records created at this level.

Primary health care is a basic essential health service to the individual, family and the
community which is accessible, acceptable and affordable by the community and the country
with their full participation.
Community health services

These are services rendered to the families and community from birth until death. Health
records are to be kept for each individual patient. The role of the community health personnel
resolves around this service. The personnel involving in this service are expected to work as a
team. The team comprises of doctors in the health centres; health records technicians,
physiotherapists, dieticians, dieticians, counselors, and dentists.

Community records

Birth registration

Notification of births by the hospital still requires the parent to register the birth of the infant
within six months. A birth certificate is made out and given to the parent.

Ante-natal and post-natal cards

Expectant mother who attend the ante-natal clinic are given ante-natal or post-natal cards and
they are supposed to bring it to the clinic for every attendance.

Health visit records

From the birth of the infant health visitors start visiting the infant and they maintain some
records. These records will be used later as pre-school health records.

School health records

These records are kept in the school or in a local clinic or health centre. The information
collected is very comprehensive including hearing, vision, teeth, special tests, type of illness,
prophylaxis given, family history and home conditions, parent’s occupation, and educational
attainments.

Treatment cards

A general card for adults is created when he attends a health centre. This card is filed at the
health centre.

Charts

Growth to health charts are created at the child health clinics. In these charts immunization
cards are also created. Tally sheets to record the type of conditions treated are recorded in
these clinics.

Family planning
Family planning records are created and maintained at the Family at the Family Planning clinics.
Parents are also educated on how to plan families when they attend these clinics.