Third Regional Seminar on Vital and Health Statistics : Hospital Medical Records and Statistics, Manila, Philippines, 28 November - 5 December 1966 : final report

WPRO 131

THIRD BmIONAL SEMINAR ON VlTALAND BBAmH fJrATlfJrICS: HOSPITAL MEDICAL Rl!XnmS ADD erATI8.I!ICS

Sponsored bY' the ,

WRLD HEAmH OmANIZATION BmIORAL OFFICE FOR THE WESrEBN PACIFIC Manila, Philippines

f

28 November - 5 December 1966

FINAL REPORT

NOT FOR SALE

PRm:rED AND DIfJrRIBUrED by the

RIDIONAL OFFICE FOR THE WES.rERN PACIFIC

of the WOrld Health Organization Manila, Philippines

April 1961

~JPR/204/67

The views expressed in this report are those of the advisers and participants at the seminar and do not necessarilY reflect the official policy of the World Health Organization.

f

I

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This report has been prepared by the Western Pacific Regional Office of the World Health Organization for Governments of Member States in the Region and for those who participated in the Third Regional Seminar on Vital and Health Statistics: Hospital Medical Records and Statistics l Manila, 28 November - 5 December 1966.

COrrrENTS

~

1. 2.

,

3.

4. 5.

......... ...... .• .....• • ..• .• • .• . GENERAL RDfARKS . . . . . . . . . . . • . • • . · .. . • . . • . • • . . . . • • . · •• COtJImlY REPORTS . ORGANIZATION OF A K>DERN MEDICAL BECOBDS llEPARI.IJ.tmRr ·... mrBODUC'UON

. OBJEC'rIVES . .

1 1 1

2 2 2

5.1 Hospital Medieal Records... •• ". • • • • • • 5.2 Basic content of medieal records • • • • • • • • 5.3 Notes on mechanics of recording and recol"Ci1ng procedures • • • • • • • • • • • • • • • • • • •

4

5

6•. RESroNSIBILITIES, SCOPE AND AaI!IVITIESO!'fBi MEDICAL RECORDS DEPA~ • • • • • • • • • • • • • • • • • •• 6.1 Responsibilities and scope. • • • • • • • • • ••• 6.2 Record flow and control • • • • • • • • • • •• 6.3 Completeness of records • • • • • • • • • • • • •• 6.4 Numbering systems tor records • • • • • • • • • •• 6.5 Techniques of fUing • • • • • • • • • • • • • . . . 6.6 Conditions for the successful establishment of a ,medical records department • • • • • • • • • • • •• 6.7 Revision of records. • • • • • • • • • • • • • •• 6.8 Time limit for retention of records in file • • ••

7 7 8 8

7

7

9 9

8

7.

HOSP~L

BrATISTICS • • • • • . • • • • . . • . • • •••

9

7.1 Minimal data needed for effective hospital morbidity and mortality statistics. • • • • • •••

9 10 10

7.3 Statistics needed at the hosuital level • • • • •• 7.4 Statistics needed at the national level. • • • • • •

7.2

Dally census. • . . . . . . . . . . . ... . . . ..

n

8. OllGARIZATION AND DEVEWPMEl'lI! OF HOSPITAL STATISTICAL WORK • • • • • • • • • • • • • • • • • • • • • • • • ••

16 16 18 21

8.1 Organization and development of general hospital 8.2 Organization and development statistics within the individual hospital • • • • • of a national hospital statistics system • • • • • • • • • • • • • • • • •

9. THE MEDICAL RECORDS OFFICER • • • • • • • • • • • • • •• 10. TRAINING OF HOSPITAL STATISTICIANS AND MEDICAL RECORDS OWICBRS . . . . . . . . . . . . . . . . . . • •

.....

22 22 22 23 25

10.1 General considerations • • • • • ~ • • • • • • •• 10.2 Grades of medical records personnel. • • • • • •• 10.3 Desirable eligibllity requirements tor entering a training course for medical records workers... 10.4 Refresher courses • • • • • • • • • • • • • • • ••

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Al'ffiEXES

1 2

LIgr OF PARTICIPANTS I OBSERVERS I CONStmrAMS

AND

~T

. . • • . . . . . . . . . . ..

21 33

AGENDA ••

3 4

GUIDELINES

...

• • • • • • • • • • ••

-'9

I. REFERENCES CITED nr '!'BE TEXT • II. BIl3LIOORAPHY • • • • • • • • •

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1.

mRODUC'l'ION

1'be Third RegiolUll Seminar on Vital aDd Health Statistics: Hospital Medical Records and Statistics, was convened in Manila by the World Health Organization Regiorml Office for the Western Pacific fran 26 November through 5 December 1966. There were twenty-two participants fran fifteen countries and territories tnthe Region. (see Annex 1). Two observers fran the University of Medical Sciences of the Gove1'lllllent of 'l'bailand and two fran the Department of Health of the Republic of the Philippines alao attended. ~ Seminar was assisted by one consultant from the School of Medical Record Librarians, Toronto, Carmda, and by ttve members of the World Health Organization who composed the secretariat. The work was organized by means of panel discussions where main t"q>ics were presented, group dis~uss1ons for more detailed studies and plenary sessions for presentation and approval of conclusions. A field viSit was made to the Bizal Provincial Hospital, Pasig, Rizal, to observe the organization of the ~dica1 records depflrtment. 2. OBJE~IVES

The fuq.damental objectives of the Seminar were: (1) (2) To discuss desirable standardS for hospital medical recorda and other records, related to the me4ical care of the patient. To study the methods of collection and caapilation of hospital statistical data, to stimulate the use of hospital statistics and to improve the comparability of hospital statistics fran different areas. To review the organization, administration and functions of medical record departments. trainiag of mecl1cal records personnel.

(3)

(4) To consider desirable standards and curricula for the (5) To try alXlreach agreement on general standards, procedures, aDd POl1c;ies for, certain critical areas of hospital records, hospital statistics, aDd training curricula for medical records personnel in the interests ..of promoting internat1onal comparabil.lty of, clerived iDf01'llllltion and as an aid to the future development of international standards.

3. GENERAL REMARKB 3.1 The Seminar was formal~ opened by Dr. FranciscoJ. Dy, :Begf,~l Director, who, after welcanioe; the partiCipants (Atinex 1), emphasized the 1mportanc~ of the Seminar in provi<ling the opportunity for a :free interchange of views and discussion on the organization of medicsl records departments j the value' and development of hosp!tal statistics; and the opportunity to reach conclusions of overall value to the development"

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of medical records and hospital statistics in the various countries of the region.

3.2

Dr. W.P.D. Logan, Director, Health Statistics Division, WHO Headquarters, addressed the partiCipants conveying greetings from the DirectorGeneral.

3.3 Orientation on the conduct of the seminar was presented by the Operational Officer. 3.4 The Seminar elected Dr. Amelia San Juan as Chairman, Mr. Garland J. Moore as the English Rapporteur and Dr. Jean Bears as the French Rapporteur. 3.5 The Programme of the Seminar as outlined in the Agenda (Annex 2) was adopted. Working papers were prepared by the consultants for each one of the three major topics. The papers were not read because they were distributed well in advance. Instead, they were discussed at panel sessions that followed their introduction by the competent consultant. After general discussions, the Seminar broke up into three working groups and continued the discussion in more detail. Guidelines (Annex 3) suggesting items for discussion were furnished to all partiCipants. In the working groups, attempts were made to obtain general agreement on points considered important and to present these as a consensus. Summaries of the group discussions were prepared by the group rapporteurs and submitted at the plenary sessions for approval. The results of the discussions in both the plenary and groups sessions have been edited and consolidated and are presented as summary statements. 4. COUNrRY REPORl'S

...

There was no formal presentation of country reports, instead the salient facts about each country were brought out during the plenary and group discussions. Written presentations of country statements were prepared by Australia, Cbina{'l'aiwan), Malaysia, and Singapore, and these were reproduced and distributed to the Seminar participants. An analysis of some aspec,ts of hospital records and statistics in the various countries of the region was prepared by the Secretariat, based on returns of a questionnaire regarding the status of hospital records and statistics sent to the Member countries.

5. 5.1

ORGANIZATION OF A MODERN MEDICAL RECORDS DEPARTMENT

Hospital Medical Records

5.1.1 Basic records indispensable for medical care and fonow-up An up-tO-date hospital should have a basic set of record forms for use in recording findings on the patient, medical care g1ven, and

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~8e

for providing il3:f'ormat1.on, fQl:follow-up of thepatie!lt_~J:Lnece.8a17. records shoulct all be of standard slzeand desi8lled to mint., ze the labOur of recording information.

Specific prov1s1On should be made in the record forms tor re~:\'Dg the items given in the ta1>J.e 1>elow. When possl1>le, iDfo;rmation a1re8dT' recorded in any record form should not be repeated and when pertinent,a seperate in-patient record form should be provided for the major~ubjects listed. For out-patient~cords,· the amount of infOJ;'1llB1:10n reqUired is U!luall¥ smaller aDd the record form maY' be greatly reduced. . Type

ot Informat1on to· be Recorded in Hospital Medical Records Table 1 Required tor Out-patients Io-patients .. .

Type of Info;rmation

Biographical andsocio-econamic data Medical htstor,y including present complaint Results ot phyaj"cal examination including tentative.diag~is or 1mpress1on rature-Pulse-Respiration chart Doctor's orders Progress notes Results of laborato~. .

M M M

M

K M M M

M*

tests M* M* M*

M M*

Results of other special examinations SUrgical operation SUlllllla17 including anaesthesia notes Burse's notescleal1ng with cO,nd1tion of petient Discharge s'Ullllll8~ including final and accessor,y diagnoses -

M* M*

- -D

M

M

M .. minimal requirements, D .. desirable,. - ,.. not needed,

* • Wen appl1cable.

In addit1onto the ty,pes of records indicated as minimal in the above table, there are numero\Ul other types ot reoord forma that are useful in special ca.ses or to record specialized care such as tor obstetrical, paed1at:r1c,cancer and so on, but .these are not conslderedas essential to a. basic set of records.

_4-

..

5.1.2 Records used for retrieval of information or management of meci,ical records and patients In addition to the basic medical records there are other types of records oecessar,y or desirable for management, for location of a given chart or retrieval of specific items of information. Some of the common types are considered below: (l) Patient index. An index for locating records of any given patient from his name is a minimal requirement for a good records department. The index should be on cards filed alphabetically for languages using the Roman alphabet or in sane similar logical fashion for languages based on other alphabets, syllabaries or ideographs. (2) Diagnostic and other indexes. Indexes of diagnoses, surgical operations and physicians are of value in teaching and research hospitals but are not considered essential in hospitals where no teaching or research is done. Compilation and maintenance of such indexes when they are not specifically needed and used, may waste valuable time badly needed elsewhere.

(3) Record control systems. It is essential to have a record control system to ensure that records on the ward are returned to the record room. Several methods were discussed but no one was held preferable as the one employed would depend upon the needs of the particular hospital. It was pointed out that it is frequently possible to use some records already in existence (such as the patient alphabetic card) as a control device thus eliminating the need for a specific control record. (4) Other records. Numerous other types of records exist for records and patient management such as: admission orders, transfer orders, diet sheets, appOintment cards and so on. These were not considered in detail as the usage would var,y from hospital to hospital and no general conclusions could be drawn.

"

It was pointed out that there can be too many types of records and that the number of different kinds of record forma should be kept to a minimum. 5.2 Basic content of medical records

~urposes,

Information is entered into the medical record for a variety of such as: providing medical care, hospital administration (including evaluation and planning), statistics, epidemiological use, teaching and research, legal protection of patient, physician and hospital, and so on. There is considerable overlap among these purposes. The discussions centered mainly around the minimum amount that should be recorded in connection with various uses. The strictly clinical aspects of the information to be recorded were considered to be the responsibility of the hospital medical director or of the medical records committee and were discussed only in connection with the other needs. A synthesis of

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tllei'8sw.t8 cit these ·~i~cu,.810ns is shown in Table 2. 'rbe results are, ¢ necess1t¥, a oomprcmtJe--derived ~ the expressions of the experts in··the f'if!ld who verepre.ent !It· the Semiuar. , . Two .

camnents Oli specIfic items in the table are needed, to clarify' the Man1ng: of the t~. . Date of birth Should be recorded whenever ttia known .adage should be d,rived from the date of birth instead of from thepatllUlt.'s ~tatement •. This is necessary- to remove ambiguities resulting frean, different systems of counting ages.

9sentiaUy 'WOrthless ~nd that alive and dead were the only alte~tl,ves clrdlnarily ~ded. 'rbe question of patients discharged in a Inor1))UJld state for religious or famlly' reasons was discussed. These cases~ if, numerou,s, bias the true picture of he spital mortality and they should.be presented s~para~ly so that they can be considered in conjunction ~th the deaths occurring in the hospital. .

y recovered, improved' and not improved ve~ much too ambiguous

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.Conditions at dtschafge.

It was geQerally' felt that sucbte1'l!l8 and i

5.'

Note~

on mechantcs 01' rec9l'd1og and recording procedures

Medical record forms should be desiglaed to minimize the' Writing -work of -the pbysician and to allow the entry of different tnM!S of. data by other persons. For .ex8lQ.le, the admission clerks should ecimp1ete the biographical and socia-econanic parts of the form, accOllq)l1sh the index cards a~ simtlar dOCUlllents,1ICIIIe items of the history and scmemeaaure"; . ments such as temperature, pulse, etc., shoUld be recorded by the nurse, and similarl¥ with other sections. Recordi~ of data by the physlcian' sbould be limited to purely medicel matters where his a'lsistants could not p.rOper~. do it. Elllphaa1s should 'pe placed Upon the neceSsity of recording. information as ~oon.as it.,is obtained and not at a later date. Forms should be so desIgned that the information fis entered d1reetly and· not transfefted f'r9m one pie~e of paper. to anothel(. .

., .

. -.. -."

..-.

--,.._.

~

-.~-~.,----

_ ..

- 6Items included in In-Patient Record Form according to the purpose of the information Table 2 Information needed SQcioMedical Medical adminisn records purposes tive purposes or of mepurposes dical interest for! ~tatistical

..

Item of Information

& epidejn1ological purposes

Identification number of the hospital Patient's personal data: (a) Identification number (Record No.) ~b) Name c) Address ~d) Marital status e) Sex (f) Occupation (g) Date of birth (b) Age Name and address of person

E E E

E

F

C

E E E

F E D E

F E D E

.. ..

C C

C F E D

-

E D E

-

-

c

E

to be notified in case of emergency Date of admission Date of discharge Length of stay in hospital Department or service Condition at discharge Type of discharge DoctQr in. charge (respons1ble physician) Final diagnosis of cause of admission C~licat10ns and other diagnoses Details of external cause of injury Underlying cause of death Other causes mentioned in death certificate Age at death Surgical operations Ethnic group Religion

E E E E E

E

D D D D

C C

•

E D

•

E

E

..

E E E

..

E

E

E E

.. ..

E

E E E E E E D D

.. .. .. ..

E E

E D

-

E

F E E E E D

E E E E D

.. D D

•

F F E= essential, D= Desirable, F... Frequently recorded but of doubtful use .. '" Not needed, C= Needed for checking, computational purposes or for deriving 1nformation but not ordinarily used directly.

..

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6.

RESPOBSIBILl'nES, SCOPE. AIm Aan:vrn:ES OF 'l'BB., • MEDICAL RECORDS - .. .. .. ....... ., 'i>.EP~

,"1. "

6.1

Be!!Pffi!~bt;1ties and sCQl!e

UDBnimous agreement was reached that the responsibilities and scope of activities of the records department should be ofa ~cl DBture and that the department should be responsible for' all facets Oi record maaagement aQd (lontrol ~eptWhen the records wre actual.J.;y being used on the ward or by a ph;ysic.1au or for other authorized purposes. ~re 'WIlS general ap'eeDIent that when no nstioDBlhOSPitalstat1lJtics ue' organized the records department should be responsible tor mos1; or I'll statistical reporting for the hospital and, 1il addition, tar such items as diagnostic, operations, physicians 'and patient indexes, s~Z8tlon and tabulation ,of bed counts (patient m.ovaent data).

, In such cases, it. was suggested that the department should be called the Department of Medical Records and· Statistics and should be headed (in the larger hospitals) by a medical records officer or a statis~lcian.as called. tor.by major type of work done by the department. On the other hand, when a national system is organized, each hospital should be responsible on~ for the proper mainteDBnce of the medical rec~8 department and for ,submission of bas1cdata that would be consol1dated,tabulated ,and ·ansl¥zed in a central office whichllOUld feed ~ckperiodical reports to all hospitals.

6.2

Record flow and control

When starting a new records department or when reorganizing an 010 department,' a number of cCXI\Plex problems of record flow and cOntrol muatbe .sol,ved •. The use of flow charts in solving such problems • • discussed together with the usefulness of techniqUes 'in designiDS a records system, preparation of instruction manuals and arrangement of offices. ' The necessity for the strict control of records to prevent loss .aoQ.:toprovtde.a firm beais for statistical reports was emphail12led. It was, noted that when a~ '.appreciable percentage of patient- records has not"been returned to the record department saiiepartieuJ.ar p~lc1an or department of the.hospital is' apt 'to be at fault aridtbat: e'are .of "indiVidual patients may be ll8JIr.pei'ed and, also, statist-icalSUllllllltries prepare4' without the missing records are apt to be biased.

~e function of the record department in checking charts for cCXIr.Pleteness of recording and for missing items such as laboratory reports liBS discussed and the importance of the function emphasized. The use of a check list for attachment to all records was recCXllllended to ensure cCXIr.Pleteness.

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6.4

Numbering systems for records

Several systems of numbering records were discussed and the Unit-Number System (one number issued for life) was considered preferable. out_patient and in-patient records should have the same number when filed separately to facilitate cross-reference.

6.5

Techniques of filing

For very small hospitals with a limited number of records, filing may be done alphabetically but for larger hospitals filing by the patient's number is more efficient. For a c~ratively small number of charts straight numerical filing is satisfactory. For a large number of records terminal-digit filing may have several advantages including more rapid retrieval of a given record and equal size of search units. Colour coding when used with terminal-digit filing is an aid in filing. Different colour folders are used for each terminal digit consistently. The disadvantage of running out of stock of some colours at a given moment was however mentioned with great e~hasls. Edge-filing of charts on shelves is recommended as being more econanical of space and less expenaive than filing cabinets. Numerical filing of records requires that an index be maintained for locating a giVen record when the patient's identification number (record number) is unknown. Such an index should be built up fran cards containing the name of the patient and arranged in alphabetical or equivalent order for Romanized languages or in sane equally logical fashion for other languages. The patient-index card should contain only the strictly necessary information for proper and safe identification, such as name, sex, date of birth and record tl\IIIber.

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6.6

Conditions for the successful establishment of a medical records department

Before a medical records department can be successfully established it is necessary to have clear-cut policy deciSions in the hospital a8 to the authority and responsibilities of the department. It was suggested that the following policies should be adopted by the hospital as a prerequisite for the establishment of record departments: (a) The medical records of patients are the property of the hospital, not of any individual physiCian, department, or service, and ~ be removed fran the hospital premises only with the consent of the hospital director or his deSignated representative.

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(b)

It is the policy of the hospital to improve the quality of medical records and to ensure that all recordings be c0mpleted within a reasonable length of time after the discharge of the patient. The medical records department is responsible for, and custodian of, all medical records, includiD6 out-patient records. When the records are being used in the cliniCS, the wards or by a staff physician for pUr,pose of study or research, control should. be maintained by the medi-cal department.:

(c)

It :was also felt that the medical records department sbcnWi be and directly responsible to the hospital director am!w1tb d1zect access to him. It this u· not feasible the depart_nt sbould have liaison with a tunctioniog medical records cc:mn1ttee to ad¥tse aDd support the medical recOl'ds officer whenapproprtate.· ind~ndent

6.7

Revision of records

Medical record forms becane out-dated or obsolete and·a"continuing review should be made of all record forms to seewbether they should be revised or· discontinued. It was considered that a controll1Dgccmmittee could review all forms at periodic intervals and also before printing. At these periodical reviSions, introduction C)f ~:v:.1'~ or deletion of other forms could also be" studied.

6 8 L

Time limit for retention of records in. file

This problem was discussed in considerable detail but it _s not found possible to reach any detinite conclusions or suggest a~tirm policy. There was general agreement that records should be kept tor 8S long as possible within the limits of storage space and that when this limit 'WIlS reached the older records sbol1ld be removed anddiapoaed of in terms of local conditions _nd legal requirements.

7. HOSPITAL S'.rATISTICS 7.1 Minimal daW needed. tor effective .hospital morbidity· and IIOrtality statistics

A summary ot: tbelllin1mal data needed for in-patient hospital morbidity and mortality statistics is given in table 2. In addition to the data listed in the table, the following items are f'requently needed for special tabulations: For obstetrical.C8/i1es: Parity and/or gravidity Mode of delivery Result of delivery: livebirth, stillbirth, number in b1,r!;h

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• For newborn infants delivered in the hospital: Clinical maturity Birth weight Abnormalities Sex 7.2 Daily census

On discussion it was found that practices on collecting and compiling the daily census varied widely fran country to country. In some areas the daily census is only a count of patients lodged in the wards which is sent to the kitchen as a guide in preparing meals. At the other extreme .. every patient present in the hospital is listed by name, ward, and tentative diagnosis with special lists for admission and discharges. It was felt that the daily census should consist of the actual count of patients occ~ing a bed, taken at midnight, or some other suitable time, plus a list of admissions and discharges. These censuses when consolidated over a period ot time supplies the basis for computing bed occupancy, total days of patient care, average length of stay and other indices. The list of discharges can be used by the medical records department to check that all charts have been returned and as an aid in compiling the daily and other reports. Statistics needed at the hospital level Discussion of the types of statistics needed at the hospital level led to the conclusion that the following are useful or potentially useful: Measures of hospital performance: maternal death rate, post-operative infection rate, prevalence of hospital acquired infections, average length of stay for selected diseases. Administrative statistics: percentage of bed occupancy by wards or departments, length ot stay, over-stay, and under-stay by departments, work load of staff, e.g. beds per doctor, beds per nurse, admissions by place of residence of patients, admissions and discharges by department, out-patient work load. Special statistics for teaching and research to be compiled on ad hoc baSiS, viz: percentage of laboratory confirmed diagnosis (for special diseases). Morbidity and mortality statistics: leading causes of hospital admission, general tables of morbidity and mortality. (These are discussed in the next section).

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•

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No specific conclusions as to which statistics should be used

were fOl'lllUlated, as it was felt that this was a ma,tter that was still. de_loping aad depended upon the needs and resources of the dUferent countries. ' 7.4 Statistics lleeded .at thenat.ionallftvd

7.4.1 General remarkB Hospital statistics needed at the national level 11181' be subdivided into three groups, namely: statistics about the patients especially morbidity and mortality; statistics about the work and performanceof a hospital; arid statistics about the hospital as a unit including data on facilities and resources.' Of these three, morbidity and mortality were discussed in most detail. 7.4.2 MOrbidity and mortality 7.4.2.1 Which of multiple diagnoses should be used for tabulation When multiple diagnoses are recorded for a patient the problem arises as to which diagnosis should be used for tabulation as it is seldom possible 1n ordinary circumstances to tabulate more than C)~ diagnosiS, there was much spirited discussion on this subject. Two bales for tabulation were considered. They were:

(l)

Disease, injUry or condition which (after investigation and evaluation) was found to have led to admission, final diagnosis of cause of admission. Underlying cause of disease, injury or condition for which the patient was treated.

(2)

Although the majority was in favour of the statement ufinal diagnoses of cause of admission", no conclllsion couldbe' ~d,e as,to which should always be preferred, but the prinCipal proponents finally agreed that both definltlonslead to the same diagnosis in the great majority of cases. The participants agreed that the problemwas'import.. ant and that there should be awareness of the necessity of making adecision for international use. It ws pointed out that medical care to deliveries and hospital newborns were exceptions and that when deliveries were complicated" .' the compUcation should always be tabulated. When more than one cem.. .. plication of delivery was recorded, the most severe complicationsbould be chosen for tabulation. Similarly for infants delivered in the hospital the most severe abnormality, condition or injury" shouldbecbol!ler1,. for tabulation. 7.4.2.2 ~~_~1 morbidity and mortality Factors to be used in tables of morbidity and mortality In preparing tables of morbidity and mortality fran hospitals or any other sources, there is a minimum set of factors that must be

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employed 11' the tabulated data are to be of use. Tables giving only the name of· the disease and the numbers of cases seen are of c~rat1vely little use. Sex-age distribution were reviewed, comments and conclusions resulting from the discussion on these factors are summari~d. Disease, injury, condition or other reason for hospital admission The number of possible specific diagnoses for diseases seen in a hospital and the descriptions of possible injuries or other ressons for hospital admission is far too large for any economically feasible tabulation aod a condensation of the various conditions into groups must be made. The International Classification of Diseases (ICD), (Ref. 4, Annex 4), provides a satisfactory classification for this purpose and is internationally employed to achieve comparability between countries for health statistics reporting. Sex -

•

There is a strong difference between sexes for some diseases and conditions aod it is highly desirable to specify sex when reporting.

Age is a very important factor in mortality and morbidity and information on the age distribution of a disease is a vital necessity in planning disease prevention, control or eradication campaigns. It is, of course, impracticable to report morbidity and mortality by the exact ege and, therefore, ages are usually classified into groups of convenient size. Recommended age groupings are given in Article 6, World Health Organization's Nomenclature Regulations, 1948, as amended by the Additional Regulations of 21 May 1956. (ICD Vol. 1, page 391, Ref. 4) • Other factors Tabulation by cause, sex and age is adequate for many purposes. Due consideration should be given to Regulations and Recommendations to be promulgated along with the introduction of the Eighth Revision of the International Classification of Diseases (ICD). If space, facilities and funds permit, other factors may be useful and throw further light upon the disease pattern. Tabulations by place of residence of patients are frequently very informative on the geographical distribution of diseases. Tabulation by ethnic groups may reveal unexpected disease patterns. ~s

•

of tables needed

The types of tables needed in reporting in-patient hospital morbidity and mortality depend upon the needs of the area and upon special interests of the people USing the tables. For in-patient statistics, four basic types of tables were mentioned:

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- -(1)

Hospital discharges class1f1ed by age, sex and by broad disease groups. This is a general SUlllJll8ry table and should cover all discharges except neWborns. Classiflcationof diseases is usually by one of the condensed reporting lists such as tm A-List (Ref. 4). Deliveries in the hospital by age at delivery, condition and mode of delivery. Live-births and foetal-deaths occurring in the hospital by sex, maturity and disease, injury or abnormality. Deaths occurring in hospital by age at death, sex and underlying cause of death.

(2)

(3)

(4)

Equivalent tables, when relevant, are used for data on outpatients. As a-basis for discussion of the various types of tables the participants were supp11ed with copies of the Statistical Report for 1964 of the Department of Medical Services (Hospitals), Ministry of Public Health, Government of Thailand as an example of hospital statistical reporting on a national level (Ref. 1). Also supplied were the Annual Statistical Reports for 1964 of the Wanen's and Children's Hospital (Ref. 2) and Sir~j Hospital (Ref. 3), both of Bangkok, Thailand. List D of 300 conditions for tabulation of hospitalmorbidity to be recommended together with the Eighth Revision of the ICD Should alao be considered. There was general agreement that the tables mentioned were desirable and that all countries Should make efforts to accOOIplish them. If, because of limited facilities, some of these tabulations would be beyond the present capability of some countries, at least the general table of morbidity and mortality should be made. It was pointed out that tables involving pregnancy and sequelae and those cover1ng newborn infants were potentially valuable in pinpointing maternal and child health problems; that the table of underlying causes of death was of special use in mortality statistics because of the higher accuracy of the diagnoses; and that the table on external causes of injury was useful in describing the non-medical causes of admission and in giving an indication of where accident prevention campaigns might be most useful. It was emphasized that detailed tabulations of morbidity and mortality should be accompanied by a commentary which should explain the general meaning of the statistics and single out special items for more detailed analysis, particularly where this can point the way to preventive action or improvement of treatment methods •

t

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- 14 -

Preparation of hospital morbidity and mortality. statistics at national level It was the consensus that i f a national hospital statistics scheme (or .ystem) is organized, nation-wide hospital statistics should be compiled at the national level directly from individual case summaries rather than from periodic canpilations made at the individual hospital and consolidated at the national level. Compilation at the national level provides greater consistency in coding, avoids the errors iDherent in successive consolidations and makes more efficient use of the available manpower and .equipnent. Morbidity statistics should be done first on in-patients as providing data of higher reliability. Out-patient morbidity should be considered only after the in-patient morbidity is on a firm basis and should probably be done by sampling because of the large llUIIlbers of patients involved. '!'he concept of an episode of illness can aerve as the basis of out-patient reporting.

7.4.3

Hospital statistics relating to the hospital as a unit

'!'here was little general discussion on this subject but some cO!lllDents were made and some facts presented. In SlJIIIIII8ry: Hospital statistics relating to the hospital as a unit are usually collected and presented as an inventory of hospital resources. The information may be used to assess the adequacy of a hospital system, serve as a basis for extension of the system and also serve as a basis for allocation of patients and supplies in emergencies such as widespread epidemics or outbreak of war. The number of factors on Which information can or should be collected is large and varies from country to coUntry. A review of· the practices in different countries will be found in Reference 5. Some of the major headings under Which information is usually collected are: 1. 2. Category of hospital, location Hospital facilities and services Out-patient facilities and services Special diagnostic facilities Special therapeutic departments Personnel Expenditures utilities supplied to hospital Sanitary facilities In-patient load Out-patient load

•

•

3. 4.

5. 6. 7. 8. 9.

10. 11.

.

It was noted that this type of information is difficult to collect in a satisfactory manner by means of a questionnsire and that when possible direct observation would be the procedure of choice.

..

- 15 -

7.4.4

Uses and users of hospital stati8tics Results of the discussions can be summarized as follows: (1) Hospital administration, at the individual hospital, regional and national level. The main usage of hospital statistics in actual practice

is for a wide range of administrative ~ses rangiag from such matters as the ordering of consumable supplies to the .planning of new hospitals. The group noted that routine hospital statis-

tics.otten provide inadequate information for the most effective distribution of financial resources. (2) Patient management

A second and most ~rtant use ot hospital statistics, which is trequent4" not used to full advantage, is to monitor and improve the effectiveness of treatment. VariOUS examples were discussed, including the use of special indicators such as rates of post-operative and post-natal infections, length of bed stay, and even hospital mortality rates for specific types of illness. The group agreed that the proper use of hospital statistics with a good feedback to the clinicians could help them to improve their method8 of treatment. (3) Public health applications

Information derived from hospital statistics is useful to the public health author1ties. Exam;ples mentioned included the control of communicable diseases in which hospital statistics can act as a form of not1fication. (4) Research and education

The use of hospital statistics for epidemiological and special mortality studies was considered. The group felt that they could be ot value in des1gniog medical curricula and even adult health education progra!llllles.

(5)

Public relations

The group noted that hospital statistics may often be ot interest to the general public and can assist in programmes to cr·tain public support tor their hosp1tal services. This intormatic~ to the public in turn. can generate public demands which result in political action.

- 16 -

7.4.5 Place of hospital statistics in the national vital and health statistics system It was agreed by the participants that hospital statistics should be an important and routine part of the national system for vital and health statistics. It was noted that there is a growing appreCiation of the value of health statistics in the region and that hospital statistics are beginning to be included in the national reports on vital and health statistics subjects. However, it was felt that much progress remained to be achieved. It was noted that in this region, Japan has made important progress in deriving information on morbidity from a one-day hospital survey and from reports received in connection with health .insurance plans. Korea uses a one-day hospital in-patient enquiry to derive information on morbidity seen in the hospitals and publishes this along with other data on health. Australia is planning to derive hospital morbidity data from its national health insurance scheme. 8. ORGANIZATION AND DEVEIDPMENT OF HOSPITAL STATISTICAL WORK

It is assumed that a satisfactory records system was in operation before the statistical system was developed or that reorganization and improvement of the records system is proceeding. 8.1 Organization and development of general hospital statistics within the individual hospital It

8.1.1 Recording of data and control of records A prerequiSite to the organization and development of a statistical system within the hospital is that the basic records must be complete and that all of the records be available for summary and tabulation. This in turn requires that: (1) There must be a system to ensure that all in-patient records are returned to the record department upon discharge of the patient from the hospital. If some records are missing, even if rarely, it must be possible to determine the department and physician responsible so that the records could be localized and returned. The system must ensure that no records are lost. (2) The record department must have a system for checking returned charts to see that all essential data have been recorded and have authority to demand completion from the defaulter. 8.1.2 Definitions of terms to be used in general ho~ital

statistics

Before starting a system of hospital statistics it is highly desirable to define the basic terms used in the collection and presentation of general hospital statistics. There are no internationally accepted

.. 17definitions for most of the terms, and usage varies from country to country. (See Ref. 5). A number of definitions ofvarlous :Ltema were consldei-ed by the seminar but no attempt was mede to reach a COll8enaus. However, elements of definitions of essential terms considered are listed be1olr:fQl' Qonven1.ence. (See Ref. 5 in part). A bed meintaiaed in a hospita1 for continuous .available conin <the broad sense as the normal place for a hospital patient to 11e down on and includes baSSinets,..cribs, me~s,hslllll1OckB, or pallets on the floor whenever these are customary. ImPlicit in the definition is the requirement that the bed must be for occupation by an in-patient. "BedS" not intended for a continuous twenty-four-hour occ~ation such as labour-;oom beds and postoperative. recovery room beds are not considered as hospital. beds. twentY'-~our-hour use by patients and with nursing service tinuous~ on a twentY-four-hour basis. Bed is to be taken

H08J?italbed.

Bed ca®lement of a h08J?ital. The number of hospital beds norma~ and continuoUSlY available for regular use. Alao termed "installed" beds. The number is not changed by the erection of "temporary" beds or the shorttime withdrawal of beds for various reasons.

1

Admission - in-patient. An in-patient is considered to have been when he has been accepted for admiss.ion and has reeetved medical attention, even if other admission formalities had not been fULfilled before he leaves or dies. A patient 'Who did not receive medical attention and left or died is not considered an admission, even if other formalities bad been fulfilled. admitt~

!

Admission - out-patient. A person 'Who registered and received medical attention in the· OPD facilities is considered to have been admitted as an out-patient. A person 'Who registered in the OPD but left With.. out receiving medical attention is not to be considered as an out-patient admission. Discharge. This term includes all patients who cease from receiving medical care from the hospital 'Whether bY' death, egress, absconding or transfer aSin';patients, or treatment termination or death as outpatient. . Length of stf' This is most commonlJr ccmputed by counting the day of admission bU not the day of discharge. A person admitted and discharged the same day is considered as having stayed one day. 8.1.3 Collection ot data should start after the groundwork of records proced.UN8-bas been laia and· speeifieations and definitions of the data to be obtained have been made. Usually, it is best to start the p1"Oduction ot neW or revised statistics at the beginning of a Y'ear for annual statistics and at the beginning ot the appropriate period for other statistics. However, it 1s wise to start collecting .the data at an earlier period as a practice session to see. that all problems have been foreseen and "bugs"· eliminat.ed.

- 18 -

• 'i

Types of data to be collected for general hospital statistical reports are: (1) Mm1SSiOD and discharge. Relevant information is recorded in the individual admission and discharge record. Any type of classification of these data is feasible fram that form, when onlY classification by departments or services is important, a properlY done dailY censua could be an expeditious source. (2) ~ng!;h of stay. The best source is the individual admission and discharge record.

(3) Bed com:,plement is usuallY a fixed figure that is known by 'Wards and changes onlY 'With the addition of new facilities or when chronic overcrowding causes the permanent addition of new beds by one means or another. (4) Bed occpeancy is the proportion of patients enumerated in the dailY census to the bed complement. (5) other types of data. such as hospital acquired infections, normal tissues removed at operations, diagnoses and surgical operations for use in indexes are usuallY collected from the patient's medical record after discharge. 8.1.4 Types of statistical reports and COmpilations commonlY prepared

!

A large number of different types of general statistical ~orts and compilations can be prepared and a few of the more common ones are mentioned below: (1) (2) Reports of admissions, discharges and deaths by departments. UsuallY prepared dailY with monthlY and annual summaries. length of patient stay by departments (days of patient care given) • Percentage of bed occupancy by departments. Hospital death rates, normal tissue rates and similar figures.

(3)

(4) 8.2

Organization and develgpment of a national hospital statistics system

In discussing the organization of a national hospital statistics system it was assumed that the primary effort should be towards the collection of information and preparation of reports on the morbidity and mortality seen in the hospitals. Several prerequisites to the establishment of such a system were discussed. A summary of these discussions and the sequence of steps to follow are:

..

... 19 -

6.2.1 Stand!!dmedical record fQ.l'llls It is highly desirable for comparability of resultA between hospitals that all of the hospitals in the hospItal atatiat1ca ftporting systems should use standard medical record forms for recording the iDfarmetionon the patient. .

6.2.2 Unit of reporting Por bospitals with a relatively sbort length of patient stat in the hospitals- (short-stay hospitals) the unit of'reporting should' be ~the discharge. For long-stay hospitals where the patient may have the.elUDe diagnosis for several months or years and may be in and' oUt of the hOSPital several times the unit of reporting should be the patient himself with an indication of the number of re-admissions.

6.2., Discharge summary A discharge sUDllll8ry should be prepared for all patients as they leave the hospital.. It Is essential that cross-checks should beset up to ensure that this is done and that all sUlDlllaries are s~nt to the central office. Because of Widely d1ffel"ent problems, special discharge' ~17 fol"lll8 may be neCe8Sa17 for general. patients, obstetr1csl.cases, newborn infants delivered in the hospitals, psychiatric and others. 1

8.2.4 Step I in setting-up a national. hospitalstatisticB system !be first step in setting-up a national hospItal statistics system is to select orie, or preferably several small ho~itals of d1fterent type where the system can be developed, tested out and contil'1tl8llY rev:l.sed until a satisfactory working system is obtained. These hospitals can then be 'qsed as "centres of excellence" for illustratIng and demonstrating the system and for training staff.

Once the hospitals are selected, a central office location must be established and staff hired and trained. Three categories of staff are required ata miniDlum, namely., clerical workers, coders and data processors.' The last two require special mention. Coders are required to convert the raw data on the SUIIIIIBry fol"lll8 intO Il\IIIerical data that can be more readily processed. The job requiring the most training is that of coding the diagnoses according to the ICD.4 Nurses make the best coders and require relatively l1ttle training. If nurses are not available, people with training in biology are preferred. A min1lllUlli of twelve years of schooling is required snd IIIOl'e is preferable. Persons with minimum schooling and little background in biology requ4'e a long period of training both formal and 01'1the-job ~o becane even average coders. Data processors. Mechanical or electronic data processing is essential for a national hospital statistics system ss 1t iSPQt· feasible to hand-tabulate 1nformation on hundreds of thousands ot patients. Machine eperators must be trained andprocessillg and tabulating procedures worked out.

t

- 20 -

• Along with the training of the staff, procedures for controlling, handling, and checking the incoming discharge summaries can be developed and trial runs made of the coding and tabulating. Tabulation programme Of primary importance in the development of the hospital statistics system is the determination of what types of tables and information are to be prepared from the material received from the hospitals. A discussion of tbe various types of morbidity and mortality tables is given in Section 7.4.2. References 2 and 3 are examples of statistical reports for single hospitals and Reference 1 is an example of a country-wide hospital statistical report. The discussion in Section 7.4.2 and an examination of the references may help in deciding what tables are to be prepared for tbe report and what format should be used. 'i

The tabulating programme should be designed with care and with due attention to the necessity for checks and cross-checks at each step to ensure that no cards are lost and that no extraneous cards are added. (In the discussion that follows it is assumed that the discharge summaries have been coded, punched into cards and the punching verified and that there is either an adequate set of mechano-electrical data processing machines or a computer available for the processing). The tabulation programme should include as a minimum the following features: (1) Consistency checking or editing. Cards should be cheCked to see that they do not contain inconsistencies ariSing from recording, punching or coding errors. This is possible to some extent only. For example, diagnoses peculiar to women should be checked to see that they are in fact punched with the code for females. Some of the obvious cbecks which should be made are: Sex versus diagnosis for diagnoses peculiar to a given sex. Age versus diagnosis for diseases of the neWborn and for other diseases which are strongly correlated with age. That if the patient is recorded as dead then there must be a diagnosis of the underlying cause of death. That the ICD Code Numbers whicb have been punched are not empty numbers with no entry in the ICD. Certain columns should be chosen whose contents are known, e.g. sex or year of admission and checked to see that there bas not been a "column slip". The list of possible checks is large and will depend upon the exact material punched into the card but as many checks should be made as time allows. I

•

•

• 21··

(2)

Preparation of summaries. SUIIIII8ries should be prepar.edfor each line of the planned table and when possible should be punched into summary cards for ease in printing the final table. Format of table. Control panels should be prepared or computers pl"Q8%'8llll1ed to give the format of the table. Preliminary drafts of the. final tables should be made and ch~cked closely for errors.

(4)

Preparation of final table. It is usus~ possiblew1th a tab1iia ting machine or a computer to prepare the final table on the machine oompletely except for ruling of the lines ore the typing in of a word or two. If tables are prepared on good quality paper they can usus~ be photographed directly and printed by photo-offset at a great saving in cost and added reliability.

Preparation of reports As a final step in the development of a demonstration centre an annual statistical report of hospital morbidity and mortalltyshould be prepared and .printed as an example of what can be accomplished.

•

8.2.5

Step 2 in setting-up a national hOspital statistics syste~

Once the details and procedures have been worked out, tested in a few hospitals and proved to be satisfactory, the programme can then be extended to other hospitals. This is best done a few at a time 80 as not to overload the central statistics unit which must be gradua~ enlarged as the number of hosp1tals in the system is increased. f~an

The technique of installing the system .in new hospitals will VBrY'. one country to another but in general should be done by holding a short training course for the persons 1nvol~d.

9. THE MEDICAL RECORDS OFFICER The medical records officer (MHO) is very important in the field of medical records and hospital statistics both 1n the development and improvement of existing facilities and in the maintenance of these facilities that have reached a satisfactory state. UnfortunateJ.y, :there are very few properly trained and qualified medical records officers in the . countries of the Western Pacific Region and, at present, little incentive for people to enter this field. Taking note of tle fact that the status of the medical records officer is often not clear, the Seminar considered the sl,lbject and came to the following conclusions: el} The properly qualifIed medical records officer has gone throush a long period of training over a wide range of subjects and he should be considered to belong in a professional paramedical category.

- 22(2) In view of the long training and his numerous skills thEI medical records officer should be p&1d • salary COIIiIIeftsurate with his professional paramedical status. . (}) Medical records and hospital statistics shoUld be considered as a career service and medical records officers should receive career

•

appointments •.

(4) Medical records specialist of a rank lower than medical records officers, Le. medical records technicians and medical records clerks should be placed in the same general category as the MRO but should have a' rank and salary proportionate to their skills. They should also have career appointments and be encouraged to take mare training and advance to higher levels. 10. TRAINIlI} OF HOSPITAL 8rATI8l'ICIANS AND

MEDICAL RECORDS OFFICERS

10.1

General considerations

:J:n most of the discussions on this subject, the training of hospital statisticians ws not considered as a separate subject as it ws felt tha t in most cases the medical records officer would be responsible fQ1' .000000~Del~ hospital statistics without advice from a statistician and that only in exceptional circumstances would there be both a statistician and a medical records officer in the same hospital. It _s also felt tbatthe fully qualified medical recQrds officer should have considerable training in statistics as part of.his normal background. The discussions centred largely about the ideal situation with the unspoken assumption that there were training courses in existence for the training of various grades of medical records personnel. The discus8ionS were wide ranging and not all groups covered the same points or reached the same conclusions.

•

The syntheSiS given in the following sections tries to pull the various discussions and conclusions together without altering the differing points of view. 10.2 Grades"of' medical records personnel

It should be clearly recognized that the term nmedical records officer" is .f:requently used. in two different senses and that the distinctioD should be kept in mind. In the primary sense of the wrd as used in this Seminar a "medical records officern is a person who has had training in the fields appropriate to the subject (see 10.}.4) and is fully qualified to handle a large medical recOrds department in a teaching hospital. In the secondary meaning the "medical records officer" is the person in charge of the medical records department of a hospital whether.he is in fact :f'ully qualified for tlie post or not. The situation is analogous to the captain of a ship who is the person in charge of the ship whether he bolds the rank of captain or not. .

•

- 23 -

There are three baSic grades of medical records personnel which are commonly distinguished, they are: (1)

Medical records officer. A person :ruJ.J.y trained in 'the field of hospital records management and general hospital statistics and fU1J.y qualified to handle the records and statistics department of a large teaching hospital. Medical records technician or assistant medical records officer. A person trained in the handling and management of records but at a lower, level of traiD1ng and experience than the medical records officer. He shoul.d be able to handle the records department in a non-teaching, moderatesized hospital. Medical records clerk or medical records assistant. A person with little or no formal training in medical records work who handles the routine teChnical and clerical work of a records department, usualJ.y after on-the-job training. He should be capable of handling the records department of a small hospital.

10.3 t

Desirable eligibility requirements for entering a training course for medical records workers

10.3.1 Eligibility To be eligible for admission in formal courses for medical records the candidates should have at least twelve years of education with credits in science and mathematiCS, and knowledge of the language in which the course is taught. 10.3.2 Medical Records Clerk Course A brief course of about two montha t duration, followed by onthe-job training. The course should consider the fundamentals of: (1) (2) (3) (4)

purpose and uses of medical records. Definition of terms like hospital patient, hospital bed, etc.; the medical record; terminology; record-keeping; out-patient reception, appointment and follow-up; admission and discharge procedures; checking of c~leteness

(5) (6) (7)

of records, daiJ.y census routines;

-24 (8) Knowledge of the participation and responsibility of the doctor, nurses, etc., in medical recording; (9)Cod~ng of non-medical data, sorting and consolidation of data; .

•

(10) . Flling systems ,numberi ng systems, control systems;

(ll) Micro-filming and storage .of records.

10.,.' Medical Records Technician Course Basically, the same curricula as for Medical Records Clerks, but with a year's duration, so that all subjects could be taught in greater detail and depth, followed also by on-the-job training.

10.,.4 Mad.ical Records Officer Course Intended to form officers tully qualified for any type of medical records work in any type of hospital, is considered to be of two years' duration followed by in-service training. No attempts were made to establish a detailed curricula for this course, as it wes thought that there is notenougb ~rience for that purpose. Instead, the broad fields of knowledge that should· be considered 1Iere discussed and agreed as follows:

(1)

Medical sciences Anatany ) Physiology ) - essential Medical terminology) Pathology ) Parasitology ) Nosology ) Other medical sciences)

• •

- desirable

(2)

Medical record sciences Organization of medical records services Case histor,r routine - assembling, checking, binding, indexing Filing systems Indexes - patient's, diagnostiC, surgical operatiOns, physician's Analysis of clinical records The medical audit Record control systems Medical and paramedical recording Legal and ethical responsibilities of the medical records officer with respect to the use of the medical record.

•

- 25/26 ..

.. General hospital statistics Class1ticatlon of diseases accordlng to the lCD .. medlcal coding Classification of operations Statistics routinelY used in a hospital - rates, ratios, average length of stay, bed occupancy, dailY census, etc. E1ementary methods of obtaining and processing statlstical data .. work sheets, hand-tabulation, use of desk calculators

(4)

Biostatistics Statistical Methods Morbidity-Mortality Measurements of seasonal variation of disease Applied sampling techniques Use and misuse of hospital statistics - general and in clinical research studies Elementary prinCiples of Operations Research .. the integrated approach, fl.ow charts, flow of patlents, models, theory of hospitals

(5)

Machine tabulation Advanced methods of obtaining and processing of statistical data Punch cards techniques - design of cards, design of codes, design of tabulations; Machine operation f.or coding, punching, sorting, counting; Unit record machines .. reproducers, tabulators, editing machines, principles of control panel wiring. Elementary principles of computer usage - princlples of prograaming

•

(6) Other and general Organization and administration of health services Organization and admlnistratlon of hospitals DeSign of hospltal record and statistics systems Design of foxma Report writing (essential) 10.4 Refresher courses

Refresher courses every two years or so were suggested to keep the medlcal records officer and the assistant medical records officer up-to-date on neYadvances and techniques in the field. It lISS also considered that university graduates Yith major in biology could become qualified Medical Records Officers Yith ad hoc short specialized courses.

.

- 21 ;. AlmElC 1 LIST OF PAR'l'ICIPAlf.I!SI O~, CONSUIfrAlf.rS AIm SECRPa'ARIAT .:! .

1. Australia

P~ICIPANTS

Dr. Ronald H.C. Wells

(i) Secretary, National Health and Medical Research Council of' Australia (ii) First Assistant DirectorGeneral CCXIIIIOIlWalth Departmeat of' Health P.O. Box 9' Canberra, A.C.T. Australia China Mr. !ai Ling-Chung Chief', Department of Medical Record National Taiwan UniverSity Hospital No.1, Cbang-te Street Taipei, Taiwan Republic of' China

• Cook Islands

Dr. Pupuke Robati Assistant Medical Of'ticer of Health Goverllllent of' t]le Cook Islands c/o carrington Hall Dunedin New Zealand Mr'. Naibuka Navunisaravi Executive Officer Statistics Office c/o Medical DepartmentSuva ..

Fiji

Fi1f Japan Dr. Toshiro Matsuura Assistant Chief', National Sanatorium Sect., concurrentl¥, Hospital Guidance Medical Affairs Bureau c/o Chief' Liaison Off'icer International AUain Ministry of Health and Weltare Kasumlgaseki, Chiyoda-ku Tok;yo Japan

.

- 28 l

Malaysia

Mr. Edmund J. Martinez

Senior Medical Records Officer Ministry of Health Young Road Kua la Lumpur West Malaysia Mr. Khoo Heng Chuan Medical Records Officer Pensng General Hospital Georgetown, Pensng West Malaysia Mr. Ban Tsan Chuan

•

II

Chief Health Superintendent c/o Director of Medical Services Jesselton, Sebah East MalaySia Mr. Ong Soon Seng

Senior Hospital ASSistant c/o Matron, General Hospital KUching, Sarawa k East Malaysia New Caledonia Dr. Jean Bears

Capitaine d'administration Service de Sante Noumea Nouvelle-Caledonie New Hebrides Dr. Doche de la Quintaine *

•

c/o Monsieur le Chef du Service de sante du Condominium Port-Vila Nouvelles-Hebrides Papua & The Trust Territory of New Guinea Dr. John Wolstenholme

District Medical Officer Public Health Department Mewi, S.H. D. Konedobu Papua & The Trust Territory of New Guinea Philippines Dr. Teodolinda C. Vergara Medical Records Library Adviser Bureau of Medical Services Department of Health Manila Philippines • ~

*unable to attend.

- 29 • Ph1lippiDeS (cont 'd. ) ~

.

-

Dr. Celina 'r. Michelena SUpervising Statistician Disease Intelligence Center Sen Ie zaro Compound Manila Ph1lippines Dr. Amelia San Juan Medical specialist 3 Bureau of Medical Services Department ot: Health San !azaro CaDpOund Manila Ph1lippines

~

Islands

Dr. Gerland J. Moore Hospital Administration specialist U.S. Civil Administration of the ~ Islands APO San Francisco, 96248 California United states of America Dr. Kenjun Nakayama Chief of the Medical Affairs Division Go-rernment of the ~ Islands Nabs Okinawa

• t

SIDppol'e 'rODp

Mr. Iyadural Nadarajah Medical Records Officer c/o General Hospital Re~of Singapore

Si~3

Dr. Vlliami 'ru:f'ui Medical Officer c/o Vaiola Hospital Nuku'alofa 'ronge Miss Virginia M. Breaks Chief, Division 01' Vital aDd Health Statistics c/o Trust 'rerritory Headquarters Saipan Mariana Islands 96950 M. Dinh-Van-Thai Chef du Bureau de StatlsttqUe 386/57 B Truong-minh-Glan

Trliat 'rerritory of the Pacific Is1aOO8

• Viet-Bam ~

~n R lique du Viet-Nam

- 30 -

V1et-Ham (cont'd.)

Dr. Phan D1nh Tuan

!

D1recteur de l'HOpital pour Ent'ants R Western Samoa s~on

i

b11que du Viet-NBm

Dr. Anesi T.Malaefou Acting Medical Superintendent Apia General Hospital Apia Western Samoa

2.

OBSERVERS Mrs. ~ia M. Castillo Records Officer Rizal Provincial Hospital Pasig, Rizal Mrs. Araceli Reodica Medical Record Librarian Laguna Provincial Hospital Ste. Cruz. Laguna

Philippines

Thailand

Dr. Vinitha Viseskul Chief Medical Records & Statistics Unit, Siriraj Hospital Bangkok Thailand

•

Miss Yupha Chuennaikij Statistician Chulalongkorn Hospital Bangkok Thailand

3. Miss D.T. McPherson

CONSUIJrANr

Medical Records Officer School for Medical Record Librarians st. Michael's Hospital Toronto Canada

4. SECRm'ARIAT Dr. W.P.D. Logan

Director, Health Statistics Division D1recteur, Division des Statistiques sanitaires Siege de l'OMB Geneve Suisse

- 3l/?/2 -

Dr. B. Skrinjar

Medical Officer Develappement des Services de Statistique sanitaires Division des Statistiques san1ta1res, Siege de 1 '<1m Geneve Suisse Statistician SEABO Hospital Statistics Project (SEARO-12) c/o WHO Regional Office for Soutb East Asia World Health House Indraprastha Estate Ring Road New Delhi India

Dr. L.A. Woodbury

Dr. M. Ishida

WHO Statistician Basic Public Healtb and Medical Care Services P.O. Box 288 I)nnll!8m

• Mr. A. Aldama Operational Officer CODSeiller regional Responsable -

Saudi Arabia

Regional Statistician & Prograaae EY'aluator Statisticien regional et Evaluateur des Programmes WHO Regional Office for the Western PacifiC United Nations Awnue Manila Philippines

..

II

- 33 • t

ANNEX 2 AGENDA

Monday, 28 NOV'ember 0900-1000 1000-1030 1. 2. Registration Introduction of Dr. Francisco J. 'Iq, Regional Director, WBD/WPRO Mr. A. Al.dama 2.1 Opening address 2.2 Address (Greetings from D1rector-Oenera1) 1030-1045 1045-1200 3. Coffee break Introduction of participants Mr. A. Al.dalll8

Dr. Francisco J. 'Iq Dr. W.P.D. IDgan

,., 1200-1230 4.

3.1 Seminar staff 3.2 Country participants Observers 3.4 Group distribution Dr. L.A. Woodbury

Greetinss to partiCipants Lunch break

• !

1230-1400 1400-1415

5.

Orien~tion

on the conduct of Mr. A. Al.dama

the Seminar

1515-1530 1530-1600 1600-1645 1645-1700

Coffee break

6. Election of Seminar Chairman and Rapporteurs

7. Adoption

of the agenda

8. Election of group moderators and rapporteurs

Tuesgay,

29 .Bovember 9. Introduction to topic 1 "Organization of a modern medical records department" DOcument WPR/ f1I!AT/16.

0)00-1000

Miss D.T. McPherson

1000-1030 1030-1045

10. Panel discussion Coffee break

- 34 1045-1230 11. Group discussions* 11.1 The hospital medical record 11.1.1 basic records 11.1.2 basic content of records 11.1.3 recording procedures 1230-1400 1400-1515 Lunch break 12. Group discussions* 12.1 Responsibilities and scope of activities of the medical records department 12.2 Record flow and control 12.3 Filing system of records Coffee break 13. Group discussions* 13.1 Conditions for the successful establishment of a medical records department 13.2 Location of the medical records office in the hospital 13.3 Minimal personnel, equipment and space in the medical records office 13.4 Time limit for the keeping of records on file

•

1515-1530 1530-1700

•

Wednesday, 30 November 0900-1030 14. 14.1 14.2 14.3 Plenary session, Topic 1 Discussion on group reports Approval of group reports Summary report Coffee break 15. Introduction to Topic 2 nMedical Records and Hospital statistics" Document WPR/f11!AT/17 Dr. L.A. Woodbury Panel discussion Lunch break

1030-1045 1045-1145

1145-1230 1230-1400

16.

&

*Guide1ines (Annex 3)

.- 35 •

1400-1515

17. Group discussions * 17.1 Sources of hospital statistics 17.2 Personnel's participation and responsibilities 17.3 Minimal data that must be recorded for effective records and statistics 17.4 Need of minimizing repetition on data recording Coffee break 18. Group discussions* 18.1 statistics needed at hospital level 18.2 Hospital statistics needed at national level

1515-1530 1530-1700

Thursday, 1 December 19. Gro1.q> discussions* 19.1 Uses and users of hospital statistics 19.2 Link of hospital statistics to national vital and health statistics 1030-1045 Coffee break 20. Group discussions* 20.1 Due recognition of the validity of the medical records officer 20.2 Salary scale commensurate with knowledge and responsibilities 20.3 Medical Records. A career'l Lunch break 21. Group discussions* 21.1 Organization and development of statistical work in a hospital Coffee break 22. Group discussions* 22.1 Organization and development of a national ~stem of hospital statistics

•

1045-1230

1230-1400 1400-1515

1515-1530 1530-1700

*Guideltnes (Annex 3)

- 36 Friday, 2 December 0900-1030 23. 23.1 23.2 23.3 Plenary session. Topic 2 Discussion on group reports Approval of group reports Summary rep<>rt Coffee break 24. Introduction to topic 3 "Training of Hospital Statisticians and Medical Records Officers" Document WPR/m!AT/18 Dr. B. Skrinjar Panel discussion Lunch break 26. Group discussions* 26.1 Qualifications of the medical records officer . Coffee break 21. Group discussions* 21.1 Training curriculum for medical records officers 21.2 In-service training 21.3 Fomal courses 21.4 Refreshing courses

1030-1045 1045-1145

ll45-1230 1230-1400 1400-1515

25.

1515-1530 1530-1700

•

Saturday. 3 December 0900-1030 28. Group discussions* 28.1 Training curricula for hospital statisticians 28.2 In-service training 28.3 Formal courses 28.4 Refreshing training Coffee break Group picture 29. 29.1 29.2 29.3 Plenary session. Topic 3 Discussion on group reports Approval of group reports Summary Report

1030-1045 1045-ll00 llOO-1230

*Guidelines (Annex 3)

. #

- 37/38 Monday,

5 Dece'.llber 30. Visit to the Riza1 Memorial Hospital, Pasig, Rizal

0900-1200 1200-1400 1400-1515 1515-1545 1545-1'700

Lunch break ,1. Plenary session 31.1 Draft report

32. Evaluation questiormaire

33. Closing ceremony

•

•

•

- 39 ANNEX .3 GUIDELINES

Item II ll.l.l Basic records 1. Discussion of records which are iDdispensable for medical care and follow-up of both out-patients and in-patients, such as: registration record, case history (including familiar and persoual history, present complaint, physical examination and other details for use in general or specialized care, such as obstetrical, paediatric, cancer, etc.), progress notes, doctor's orders form, appoiatment card, admission record, etc. 2. Discussion of records which are complementary or supplementary for medical care and follow-up, such as: operation protocol, biopsy and other laboratory protocols,X-ray findings, immunization card, admission order, transfer order, discharge order, sociOoofinancial stu~,treatment permit, police reports, summary card, etc. ,. Disoussion of recorda indispensable or auxiliary for other than direct medical care and follow-up, such as: daily census, operations lists on different distributions; laboratory, X-ray, pharmacy reports, diagnostic index, other indices, patient's discharge list. ll.1.2 BaSic content of records 1. Data which are or- may be important for medical care, such as: identification of the patient (name, number, age, sex, address, etc.); clinical history (ecologic, familiar, personal); important symptans, findings on phySical examination, findings on ;Laboratory exam1uation, diagnosis, doctor's orders, response, follow-up, etc. 2. Data of statistical or epidemiological interest such as: age, sex, residence, diagnosis, date of onset, type of treatment (medical, surgical, ambulatory, in-patient), primary or secondary, new or old case, etc. ,. Data of interest for special studies, such as: cal, research, etc. ll.l.' Recording procedures 1 •. By who, .where (department) and when shall data be recorded. (Different types of data should be considered, such as: identification data of the hospital aDd the patient, date and time, (OPD or IP), department or speCialty sym,ptans, findings, diagnOSiS, (specific cause -of admission and others), surgical interventions, prescriptions, condition of discharge, cause of death, etc. epidemiologi-

•

- 40 Item 12 12.1 Responsibilities and scope department CTf

• i

activities of the med1.cal records

1. Should it be limited to the safeguard of patient's records? 2. Should it be broadened to include all facets of record flow, control (of the record itself and of recording of data), maintenance, summarizing and/or consolidationa, etc.?

3. Should it also control other records, such as daily census, X-ray films, disease indices, statistical reports ••• ? 4. Should it prepare periodical reports? 12.2 Record flow and control 1. Patterns of flow 01' medical records 1.1 Use of flow charts 1.2 other procedures 2. Control method of records, to ensure that all w1ll finally return to the records office. 2.1 Use of control cards (different types can be discussed here) 2.2 other procedures

3. Flow of records within the record office 3.1 Check of completeness of recording. Person{s) respons-ible 3.2 Check of completeness of records. n n 12.3 Filing system of records 1. 1.1 1.2 1.3 Identification system 01' records Name cf patient NUmber aSSigned to records others

2. Filing system of records 2.1 Alphabetic: Strict, Initial only. 2.2 Sequential order of record number 2.2.1 One number, permanent for life 2.2.2 One number, permanent for the year 2.2.3 One number, different each department, each

att~ntion.

2.3 Terminal digit 2.4 others For each case, discussion can also result on advantages and disadvantages of centralized or decentralized files with their possible variations.

•

- 41-

,. Controlaystem of fl1iD801: ~.cords ..... 3.1 IDdex cards, al.ph8bet1cally arranged . Index cards, phonet1cal~ arranged (Soundex system) 3.3 Index book 1n alphabetical order 3.4 Index book in alphabet1cal/sequential order 3.5 National identity card Hospital 1dentity card 3.1 others

,.2

,.6

Item 13 13.1 Conditions for the successful estab11shment of a medical records department 1. Policies on authority, responsibilities and procedures. 1.1 Who do records belong to! 'rbe hospital! 'rbe ~ician! 'l!he patient! 'l!he Civil Authorities! Control measures. 1.2 The confidential nature of the records. Condit10ns under which personal information could be disclosed. Personnel's responsibllity.

,

"

2. Provisions for revision of records. 2.1 Revision Committee

3. Responsibility of the staff in tbe.recording of data as appropriate. Regulations aimed st the avoiding 01: delays. Skills or specialities.

4. 5.

Basic personnel.

Co-orditl8tion with other personnel's activities. Proportion to bed capacity, to number of discharges, etc.

6. Minimum office space, shelf space, equipment, facilities. 1. 13.2 Activities on medical records outside office hours.

Location of the medical records office ·io the hospital 1. Should it be annexed to the admitting office! annexed to the OPD'l annexed to finance office? annexed to some otheroffice~ Should it be an independent office, close to some other! Should it be on a specific site?

2.

• •

3.

- 42 -

13.3

Minimal ;personnel, equipment and space in the medical records office 1.

Number and category of personnel (a) (b) ec) (d) In In In In proportion proportion proportion proportion to to to to the the the the hospital size? (number of beds) number of beds and bed occupancy? admissions (discharges)? person days-stay?

2.

Equipment.

Type and capacity.

(a) (b) (c)

(d)

Filing cabinets? Shelves? open? Drawers? Transportation of records. The patient? messenger? conveyor belt? basket? dumb-waiter?

3.

Space (a) (b) Filing space Office space

13.4

Time limit for keeping records in the file 1.

1.1 1.2 1.3 1.4

Purpose Medical follow-up Research regal Others

Item 17 17.1

Sources of hospital statistics 1. 2.

3. 4.

5. 6. 7.

8. 9. 17.2

Admission record Clinical history Discharge record Summary card Admission and discharge record Register book Dai4r clinic record Protocols Dai4r census

Personnel's participation and responsibility 1. 2. The receptionist The admission clerk. Personal and administrative data. The medical records officer. Direction-s~rvision.

3.

• ..

- 43 ,

4. The nurse. Record med1.eal data of her participation 5. The physician. Rec~ medica,l data of his participation 6. other technical and non-technical personnel" ' 17.' Minimal data that must be recorded for effective records and statistics 1. Minimal data necessary for statistics or information (Review could be made of data which should be tabulated, which are mentioned in reports and which are used for specific tasks). For For For For periodical reports special reports research SPecial studies

.

'

1.1 For routine tabulations 1.2 1.3 1.4 1.5 2.

Need of minimizing repetition of data recording (Discussion on advantages and disadvantages or repeating information in several records, particularl3' index-cards and hospital da~.ly census)

• !

Item 18

18.

Statisticsneeded'athospital level

1.

2.

3. 4.

5· 6. 7.

For medical care For planning pre"\l'entive and medical work (morbidity and mortality. Most frequent causes, population groups, etc.) To assess personnel needs To assess bed and other equipment needs (patients prevalence, bed occupancy, length of s:taY") To assees yield of each department For teaching and research For overall assessment of hospital activities , ,

18.2 1. Morbidity. Cause of call to the hospital. Cause of admission. Subsequent d1agnos~s. Use of the International Classification of Diseases (ICD) and otherl1sts. Morbidity tables. Age/sex distribution. Grouping. International recommendations. Special local needs. Mortality.Underl3'1ng cause of death. Mortality tables. Use of the ICD.

2.

•

3.

- 44 4. Special tabulations of morbidity and mortality

4.1 Maternsl causes, especially deliveries, caesarian sections 4.2 Accidents, poisonings and violences 4.3 Diseases peculiar to the neWborn and the infant 4.4 Foetal deaths 4.5 Operations, post operation infections 4.6 others

5. Consolidation of hospital statistics at national level. (Discussion should revise both in-patients and out-patients).

Item 19 19.1 Uses and users 1. of

hO!pital statist1cs

Hospital personnel

1.1 Physicians. Group review. Research. 1.2 Hospital adm1nistrator. For guide 1n day-by-day administration. For planning. 2. Health authorities

•

2.1 Local health officer, to learn main health problema and the role of the hospital in meeting them. 2.2 National health authorities, to learn health problems of national interest, treatment potentialities, hospital programme evaluation.

3.

others

3.1 International organizations concerned with health and medical work. 3.2 students 19.2 Link of hO!pital statistics to national vital and health statistics 1. Component ot special interest in the national morbidity and mortality

1.1 Advantage ot diagnostic facilities 1.2 Disadvantage of selected sample 1.2.1 Special illnesses 1.2.2 Special severity 1.2.3 Patients of special socio-economic 2. Independent information on hospital care

gro~

2.1 Data on preventive work

• 2.2 Data on treatments 2.2.1 OUt-patients 2.2.2 In-patients

- 45 -

Item 20 20.1 Due recognition of the vaUdity of the medical reOOl'ds-otticer

1.

Should he be considered a clerk or a professional?' Could he Qe entrusted technical responsibility1 Could he be substituted by any office clerk?

2. ,. 20.2

Salary scale camaensurate with knowledge and resll9nsibllities 1. 2. ,. Should salary be within office personnel scale?

Should salary be within professional scale? Which shOuld be the cOllU;l8.rative category for salary? A Career?

20., !

Medical Records. 1. 2.

Should medical records officers be given career appo1J;l.tment? Should the. medical records officer career be stimulated?

,.

Which should be the scheme of work for medical records personnel?

Item. 21 21.1 Organization and develgPment of statistical work in a hospital 1. 2. ,. The place of medical records office in the hospital. Recording of atatistical data since the first call of the patient to discharge. Bed c_lement by service or department. This is a point at wbich the seminar coUld discuss the definition of hospital bed, hospital admission, new case, old case, routine attention, special attentIon,. length of stay in the hospital( in the ward (personS. admitted snd discharged the same day), daily prevalence, transfer (to other department, to other hospital) hospital discharges, readmission • Diagnostic index' Operation index

•

•

4. 5.

- 46 6. 7. 8. Localization of patients in the hospital Statistics of admissions statistics of discharges

• l

Item 22.1

22

Organization and development of a national system of hospital statistics 1. Goverment hospitals

1.1 standardization of record forms

1.2 Standardization of periodical reports 1.2.1 Accomplishment at hospital level vs. acc~lishment at national level. Personnel involved. 1.2.2 Source of data for acc~lishment of reports. 1.2.3 Sa~l1ng vs. universe reports. 2. lines.

Private hospitals

The Seminar may like to discuss f'ollowing sane of the above

Item 26 26.1 Qualifications of the medical records officer 1.

t

:Basic background may

The Seminar background on: 1.1 1.2 1.3 1.4 1.5 1.6

like to discuss the need and level of'

General instruction Filing methods Medical terminology Classification of diseases and causes of death Use of' the ICD Definitions of terms used in hospitals such as admission, hospital bed, diagnOSiS, hospital census, discharge, transfer, etc. 1.7 Definitions of different rates and ratios and other constants used 1n analyzing hospital work~ 1.8 ~utation of rates, ratios and other constants. 1.9 Other knowledge or background 1nstruction (knowledge on statistics could be considered here).

.. !

2.

3.

Elcperience in office work. leVel. Experience in medical records work.

• ltells27and 28

27.1 Same

Training curriculum for medical records officers ~ Seminar may like to suggest end discuss major topics. examples (by no means considered exhaustive) are as follows:

1. Purpose and uses of medical records. Definitions: hospital patient, hospital bed, patient bed, patient day, census, occupation, treatment, minor and major operation, etc. 2.

The medicel record

3. Terminology

4. Record-keeping systems 5. OUt-patient reception, appointment and follow-up

6. Admission and discharge procedures 7. Form design 8. 9. !

Case-history routine.

Daily Census routine, other routines

Recording at data. Participation and responsib1lity at the doctor, the nurse, etc. Classification of diseases, injuries and causes of death other patient I s classifications Coding, sorting and consoli"t1ation of data Filing system. Numbering system. Control system.

10. 11. 12. 13. 14. 15. 16. 17. 18. 27.2

Summary, microfilming and storage of records

standards and policies Priooiples of administration Analysis at hospital operation Biostatistics. Misuse of' statistical data

In-service training 1. 2. Orientation on the work of medical records Practice on admission and discharge procedures Recording routines

3.

- 48 -

4. Filing, indexing routines. Arranging and binding of records.

1

5.

Summarizing routines

6•. Record control routines

7. Indexing 8. 9. 10. 27.3 Classification of diseases, injuries and causes of death Coding C~tation

of statistical constants

Refreshing training 1. Content - duration - periodicity.

At the end of the discussion of each item, the rapporteur presented a summary of the discussions.

- lj.9 -

• I. 1. 2. ,. Iu!!&:EiRENCES CITED IN THE TEX'l

ANNEX 4

Thailand, Depsrtlllentof Medical Services, Min1stry of Public Health, (1965), statistical Report, 1964 Thailand, Women' 8 and Children's Hospital, (1966), Stati-stical BePQ1't:,].964 Thailand, Faculty of Medicine and Siriraj Hospital, University of Medical SCiences, (1966), statistical Report, 1964 Diseases, Geneva

4. World Health Organization, (1955), International Classification ot

II.

BIBLIOGRAPHY

AMERICAN HOSPITAL ASSOCIATION Guide to the organizatioQ of a hospital medical record' department. Chicago, A.B.A., 1962. 831>. AMERICAN HOSPITAL ASSOCIATION Hospital accreditation references.

Chicago, A.H.A., 1964.. 211p.

AMERICAN HOSPITAL ASSOCIATION . . Medical record administration. A collectton of readings selected fran the literature in the field. Chicago, A.H.A., 1948~ 267P. AMERICAN HOSPE'AL ASSOCIATION Medical records toms for hospitals: A.H.A., 196,. illus.

Gul.de to preparation.

Chicago,

AMERICAN HOSPITAL' ASSOCIATION Uniform chert of accounts and definitions tor hospitals. A.H.A~,

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AMERICAN HOSPITAL ASSOCIATION UDitormhospita1detinitions.Chicago, A.H.A., 1960. 5Op. AMERICAN HOSPITAL ASSOCIA!rICIf . Uniform hOspital stattstics.

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,

FRENAY, Sister Mary Agnes Clare Understanding medical terminology. 3rd ed. St. Louis, Miss., The Catholic Hospital Assoc., 1964. 246p. GORDON, Burgess L. & TALBO'l"r, John H. Current medical terminology. 2nd ed. Chicago, American Medical Association, 1964. 346p. GREAT BRITAIN. Ministry o"r Health The standardization o"r hospital medical records. Report o"r the SUb-committee set up by the Standing Medical Advisory Committee. London, HMSO, 1965. 58p. HAYT, E. and HAYT, J. Legal aspects o"r medical records. Record Co., 1964. 371p.

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- 51 -

• UNITED NATIONS. Department-of Econanic and Social Af':I.'airs. Report of the Seminar on Sampling Methods, Tokyo, Japan, .30 August _ 11 September 1965. Sponsored by ~ in co-operation with the Statistical Office of the United Nations, et al. N.Y., U.N., 1966, 48p. (statistical Papers Series M, No. 42) UNI'I!EJ) m'ATES NATIONAL CEN'l'ER FOR HEAIIrH srATISTICS International ClaSSification ot Diseases, Adapted, for Indexing Hospital Records by Diseases and Operations. Washington, D.C., U.S. Department of Health, mucation, and Welfare, Public Health Service, 1965. 2 vols.

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2.

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5.

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6.

7.

8.

- 52 ARTICLES IN PERIODICAlS BIGIDW, L.A. Amrual administrative review: lQ8..114, 16 April 1961

medicsl records, HOspitals,

~:

BOURBEAU, M.T. 'lhe medical archives, Canadian Nurse, 22,:

253-5, March

1963

DUNN, L. See-at-a-glance ward records, Nursing T1mes,

29.:

673, 22 May 1964

DUXBURY, D.L. HeaUh service statistics record system, Public Health Report, 1 - 10, January 1960 FOSTER, J. T • How oneamall hospital standardized its records, HOspitals, 45-7, 1 January 1963

12.:

21:

HAWKINS, N.G. Social data: its place in the medical record, Hospitals, 71-6,16 October 1959 HERSHEl, N.

~:

Medical records and the nurse. llQ-2, February 1963

1. American Journal of Nursing. ~:

HERSHEI, N. Madical records and the nurse. 96-7, March 1963

2. American Journal of Ifursing, ~:

HOLLAND, W.W., et ala Inpatient records: an investigation of their content and handling at st. ThaDas's Hospital. lancet,!: 819-21, II April 1964

JaRES, E.E., et al. New

records of an old service, Nursing Outlook, E,: 49-51, June 1964

KOREIN, J. et al. COIIqlUter processing of medical data by variable-field-length . JAMA, 186: 132-8, 12 October 1963 .. LAIRD, Onalee M.

Medical records, McKIl'fNEI,

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109-15, 1 April 1966

s.

Trends in medical records, Hospitals,

21:

131-6, 16 April 196, Hospitals,

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22,:

37-42,

!

- 53 MYERS, B.S. . .. A- diirebarge-sUomary can save time far physician and hospital.

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2&:

130, April 1961

.

MXERS, B.S. . Here are three steps to maintai.n indexes of operations 'aQd diseases. Modern Hospital, 2,1: 122" October 1961 MIERS, B.S.

History and physical examination record should be clear, conqise. lobdern Hospital, 22,: 127-8, February 1961 MmRS, R.S.

PhySician's signature needed for added legal Modern Hospital, 2!t,: 126-8, March 1960 MIERS, R.S.

protectio~

Single form would facilitate medical record progress report. lobdem. Hospital, 22,: l,a, March 1961 . MmRS, B.S. & SlEE, V.N.

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22:

g,:

32-~,

4 Jul..61/.

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PHADUF,

M.C~

A nursing audit method.

Nursing Outlook,

g:

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Ma)"

1964

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11:

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Z1:

•

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1964

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2!t,:

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WERNECKE, H.J., Jr. Making the most of personnel history cards. 50-1 1 November 1960

2!t,:

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