Future Development &
QUESTIONNAIRE FOR HEALTH RECORD MANAGER/MEDICAL RECORD OFFICER
DATE OF DATA COLLECTION:
PLACE OF DATA COLLECTION (ADDRESS):
NAME OF RESPONDENTS (OPTIONAL):
ADDRESS: POSITION (OPTIONAL):
NO OF YEARS EMPLOYED IN THE HOSPITAL
1. Patient Identification:
1.1.Do you use distinctive patient identifier at your hospital? If yes, what is it? If no, what method you use to identify patient?
1.2.Does your hospital have problem with patient identification? If yes, what are the main problems? If no, please explain.
2. Health Record Numbering
2.1. Are all the health record forms the same size at your hospital?
2.2. Who is responsible for the designs of health record forms in your hospital and who is responsible for approving the introduction of a new form? How often does it change?
2.3. Are the health record forms placed in a health record folder after discharge of the patient?
2.4. Who is responsible for the health record related service at your hospital?
2.5. Are Health record numbers given to the patients at your hospital? If yes, how are they assigned and what are they named? If no, please explain why?
2.6. Are number registers kept at your hospital? If yes, where are the number registers kept? If no, how are patient’s health records recognized?
2.7. Does your hospital keep an admission register? If no, how are you able to know the daily number of admissions at the hospital?
- 78 - 3. Discharge / Death
3.1. Do you receive discharge list on daily basis?
3.2. Do you have a death register system in your hospital? If yes, what kind of informations do you record in death register? If no, please explain why?
4. Questions regarding Policy on Retention of Health Records
4.1. At your hospital how long Health records should be kept after the last visit of the patient?
4.2. Are the rules different for children’s health records or similar to the adult’s record?
4.3. If health records are not kept, how the records are destroyed?
4.4. Are there any precise diseases for which health record of the patient should be kept for lifetime?
4.5. What are the penalties for breaking the rules regarding Health records?
4.6. Who is responsible for approving the destruction of Health records?
5. Data management
5.1. Does anyone use health records in your hospital for the purpose of research? If yes, do you have index of a disease? If no, how do you discover health records for a specific disease?
5.2. How are coded date used in your hospital?
5.3. Does your hospital have electronic Disease/ Procedure index?
5.4. Do you have centralized or decentralized health record system?
5.5. What filing methods do you use straight numeric or any other number?
5.6. Do you have a sorter or place to pre-sort the health records? Do you consider it effective?
5.7. Who is responsible for filing the health records? I.e. one clerk or medical record department staff?
5.8. Do you have any problems with missing health records file? If yes, how do you think it can be improved? If no, please explain.
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5.9. Do you have sufficient filing space? If no, what is your major problem regarding filing space?
5.10. Could you mention if the problem could be solved?
5.11. Does the hospital have any policy on retention of health records? If yes, how long the health records are kept at your hospital? If no, please explain why?
6. Legal paperwork
6.1. Are you responsible to perform any medico-legal work at your hospital? If no, who is responsible for performing legal paperwork?
6.2. Are the informations on health record released at your hospital? If yes, to whom and in what situations? If no, please explain why?
6.3. Are you the person responsible for medico-legal correspondence?
6.4. If no, who is accountable for it and how are you involved?
6.5. Does your hospital have many appeals from lawyers seeking the release of information regarding health records?
6.6. If yes, what are the main procedures to deal with the appeals? If no, please explain why?
6.7. Are you aware of the laws concerning the release of data or information at your country?
6.8. Does your hospital send any health records to the court when needed?
6.9. If yes, does the legal system in your country use court order? If yes, what is it called?
If no, how the system works in your country?
7. Patient Access
7.1. Are patient permitted to check their health record?
7.2. If yes, what are the procedures that need to be followed when patients check their health records? If no, please explain why?
7.3. Do you have any written policy regarding the procedure for checking the health records?
7.4. What medical information can be released to the patients?
- 80 - 8. Health/ Medical Record Department
8.1. Does your hospital have a health record committee? If yes, who are the members and how many members do you have in the committee? If no, please explain why?
8.2. If your hospital does not have a health record committee, do you think it needs to be established?
8.3. If yes, who would be able to establish it? If no, please explain why?
9. Quality Assurance & Control
9.1. Does the hospital perform any quality control studies regarding the work of the Health Record department? If yes, what and how are they performed? If no, please explain why they are not performed?
9.2. Does Health record department perform quality control studies/research on the content of the health records? If yes, what kinds of the health records are studied/
researched? If studies are performed, what do you do with the results? If no, please explain why are research not performed?
9.3. Does the Health record department staff conduct quality checks on coding? If yes, what action is taken with regard to the results? If no, please explain why?
10. Electronic Health Record
10.1. What type of system you think would require meeting the apparent need of an electronic health record for your hospital?
10.2. Is there available funding for the introduction of new system?
10.3. Does the hospital have sufficient and reliable resource to support the electronic health record like electricity supply, enough space etc.? What are the possible problems in the context of resource availability?
10.4. Does the hospital have sufficient trained staffs that are qualified to use new system?
10.5. If not, what is the provision for training new staff?
( WHO, 2006)
11. Would you like to share about any issues that are of interest to you?
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RESEARCH STUDY ON HEALTH RECORD MANAGEMENT IN HOSPITALS OF NEPAL