Health Records Department

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DEPARTMENT OF MEDICAL RECORDS

QUALITY OF CARE POLICY AND OPERATIONAL GUIDELINES

NHA/CD/QOCP/MER/001

ADIO R.A

HEAD OF DEPARTMENT

1.0   INTRODUCTION

The Department of Medical Records, National Hospital Abuja was established in 1999 to be responsible for the creation, maintenance, keeping and retrieval of patients’ records, thereby assisting in the delivery of quality medical care. The department is also involved in training of corps members and students on industrial attachment.

1.1    Vision Statement

To be among the best departments in Nigerian tertiary hospitals endowed with the provision of simple, measurable, accurate, reliable and timely information (data) for development and support for the best possible care, good clinical judgments, administration, research, education and training.

1.2    Mission Statement

To provide prompt and reliable Medical Records and information services to all our patients and other teeming users of health care data/information in a friendly and conducive environment.

2.0    QUALITY ASSURANCE POLICY

The Department of Medical Records, National Hospital, Abuja in line with the mission and vision of the hospital is committed to:

  • Total customer satisfaction and compliance to our objectives.
  • Ensuring patient confidentiality and client satisfaction
  • Ensure proper patient Medical Records keeping.
  • Tracking of patients’ records for prompt service delivery
  • Audit the process and procedures of services
  • Regular training including on the job training
  • Control of access through password and other security measures

3.0   STRENGTH OF THE DEPARTMENT

The Department of Medical Records has competent personnel who are committed to efficient service delivery and management of quality information to facilitate patient/client care.

There are Health Information Management professionals by an Assistant Director, who is a Health Information Manager with relevant Health Information Management qualifications from reputable institutions including PHD (in view) and supported by other Assistant Directors, Chief Medical Records Officer, Assistant Chief Medical Records Officers, Principal Medical Records Officers, Senior Medical Records Officers, Medical Records Officer 1 & 2, Medical Records technicians   and other nonprofessional staff.

Specialized services offered in the Medical Records Department include:

Registration Areas (A&E, GOPD, EPU, TRAUMA, NHIS)

  • Filling of Master Name Index card.
  • Entering all the registration details in the system.
  • Documenting the details in the outpatient register
  • Move the patient folder from the registration point to the nurses’ station.

 

Consultative Outpatient Department

This unit processes information regarding patients visits by receive patients/clients (new or re -attendance), recording visit, dispatch case note when needed and compile associated statistics

III. Admission and Discharge Unit

This unit handles documentation of in-patient admissions and discharges and associated statistics.

 Library unit

This unit is responsible for sorting and filing of patient records and as well as clinical lists.

 Coding and data classification unit

This unit is responsible for coding and indexing of patient diagnosis and compilation of statistics. It also assists in research.

Research and statistics unit

This unit collates, analyses, present and interpret data. It is involved in Disease Surveillance and Notification.

 

VII. Accident and emergency unit

This unit is responsible for documentation of patient visits at the accident & Emergency on 24 hours basis.

VIII. Medical records secretariat unit

This unit is responsible for Correspondences, Maintenance of Birth, Death and Sick-leave registers and other registry records.

 NHIS/retainership service

 

This unit is responsible for documentation of patient visits via the NHIS platform. It also compiles data on NHIS.

 Radiology services

This unit is involved in documentation of radiological services.

Cancer registry

The Registry is simply the database of cancer patients in Abuja and not just National Hospital, Abuja.

 

XII. Monitoring and evaluation

This unit is involved in using indicators to measure the progress or decline of services and following analysis provides reports of the evaluation.

4.0    OPERATIONAL GUIDELINES

The guidelines are to ensure that all departmental services are carried out with the highest sense of commitment to appropriate quality and efficiency. In this regard:

  • The Department receives patients as work–in or booked cases.
  • The work–in patients are registered to create records for further services.
  • The booked patients are given access to receive service and re-booked for new future appointments or are guided to referred clinics.
  • The patients going for admission are given admission access and their information updated after discharge.
  • Requests for release of patients’ data or information are granted through the formal application to the Chief Medical Director, attention the head of Medical Records Department.
  • Request of patients record for clinical presentation and researches within the hospital are granted by formal application to the Head of Medical Records Department routed through the head of applicant’s department or the consultant.
  • Request for change of information or data in patients’ record should be made through formal application to the CMD or his designate and this should comply with the change of information guideline of the department.

5.0    WEEKLY ACTIVITIES AND SCHEDULES

TIME MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
8:00am – 4.00pm Registrations of patients/Record visit/Out Pt Documentation Registrations of patients/Record visit/Out Pt

Documentation

Registrations of patients/Record visit/Out Pt

Documentation

Registrations of patients/Record visit/Out Pt Documentation Practical
Admission and Discharge Entries Admission and Discharge Entries Admission and Discharge Entries Admission and Discharge Entries Dept Presentation
Collection and entry of bed statement Collection and entry of bed statement Collection and entry of bed statement Collection and entry of bed statement Clinic and Library reconciliation
Out-Patient statistics Out-Patient statistics Out-Patient statistics Out-Patient statistics Library Audit
In-Patient Statistics In-Patient Statistics In-Patient Statistics In-Patient Statistics Coding Audit
4.00pm – 8.00pm CALL DUTY CALL DUTY CALL DUTY CALL DUTY CALL DUTY
24 HRS Emergency /Shift Areas (A&E, EPU, TRAUMA, Radiology, NHIS) Emergency/Shift Areas ( A&E, EPU, TRAUMA Radiology, NHIS Emergency/Shift Areas ( A&E, EPU, TRAUMA, Radiology, NHIS Emergency/Shift Areas ( A&E, EPU, TRAUMA, Radiology, NHIS Emergency/Shift Areas ( A&E, EPU, TRAUMA, Radiology, NHIS

6.0             ORGANIZATIONAL CHART

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7.0    HEALTH AND SAFETY POLICY

The Department of Medical Records is committed to supporting the implementation of the National policy on safety by doing the following:

  1. To ensure proper booking of appointment in the clinics to prevent overcrowding which can lead to spread of diseases.
  2. To encourage the wearing of face mask, frequent washing of hand/hand sanitizing by all staff and visitors to reduce the risk of work place hazard.
  3. To ensure proper waste segregation and disposal within the department.
  4. Orient and train all staff in safe work practices and procedures in compliance with established rules and regulations and safety manual.
  5. Advocate for sufficient resources to provide and maintain safe and healthy working conditions
  6. Training in health and safety as well as first aid/fire drills
  7. Collecting and analysing data on accidents, sickness and injury

 

8.0    MINIMUM STANDARDS POLICY

The department would maintain a framework through which all staff are accountable for continuously improving the quality of our services and safeguarding high standards of care, by creating an environment in which excellence in Medical Records practice will flourish. The department will specifically maintain the following minimum standard policies:

  1. Operate in conformance with the requirements of the quality management system and procedures
  2. Free access of all staff to all departmental policy documents and standard operating procedures.
  3. Prompt service delivery and best practice procedure.
  4. Ensure good inter-personal and intra/inter-professional relationships to ensure optimal outcomes

9.0    LIST OF STAFF AND QUALIFICATIONS

The current members of staff of the Department of Medical Records and their respective qualifications are listed as follows:

 

S/NO

 

NAME

 

DESIGNATION

 

QUALIFICATION

1 Adio Rasaq Adetona. ADHR BSC,MSC HIM, PhD in view
2 Terah Ayuba ADHR HND,BSC HIM
3 Rita Okonna ADHR HND,BSC,MSC HIM
4 Enwerem Stella CMRO HND,BSC HIM
5 Obayaji Ahmed Rufai CMRO HND,BSC HIM
6 Ayoola-Awi Adefunke CMRO HND,BSC HIM
7 IIupeju Yemisi CEO BSC GEO MSC MED PHY
8 Adejoke Salami

ACMRO

HND,BSC HIM
9 Wada Aliyu ACMRO HND,BSC,MSC HIM
10 Mohammed Umaru ACHRO HND,BSC HIM
11 Harrison-Osagie Gloria ACHRO HND,BSC HIM
12 Lawal Jamilu ACHRO HND STATISTICS
13 Rakiya Husseini ACEO NCE
14 Anyanwu Calista Fidelis ACEO BSC FRENCH
15 Shakirah Ishola Quadri. PMRO HND HIM
16 Salman Sheriff PMRO HND,BSC HIM
17 Muazu Suleiman PMRO HND,BSC HIM
18 Enahoro Christiana PMRO HND HIM
19 Obichie Racheal PMRO HND HIM
20 Abdulrahman Siyudi  Usman PMRO HND HIM
21 Akinseye Folasade Modupe PMRO HND,BSC HIM
22 Gajere Nikre PMRO HND HIM
23 Shittu Safiya PMRO HND,BSC HIM
24 Onoweya Evelyn PMRA OND HIM
25 Chukwubuike Chinyere SMRO HND HIM,BSC ECO
26 Iliya Wakili SMRO HND HIM
27 Okoro Grace SMRO HND HIM
28 Eunice Harrison Udoudom SMRO HND HIM
29 Ani John SMRO HND HIM
30 Aliyu Garba SHRO HND HIM
31 Ojo Olayemi Idowu MRO1 HND HIM
32 Okeke Kaodilichukwu MRO 1 HND HIM
33 Ogwehi Faith MRO 1 HND HIM
34 Akingbade Joseph Akinbode MRO 1 HND HIM
35 Nafisat Murana MRO 1 HND HIM
36 Echero Omotejohwo Sylvia MRO 1 HND HIM
37 Njoku Edwin Chidi E.O.R HND  B/ADMIN
38 Tanko Yunana MRO 1 HND HIM
39 Maduekwe Chinenye Ngozi MRO 1 HND HIM
40 Leke Funmilayo MRO 1 HND HIM
41 Adebayo Akinwumi Green MRO 1 HND HIM
42 Salman A. Oluwatoyin MRO 1 HND HIM
43 Ajiboye Titilope Ruth MRO 1 HND HIM
44 Adebanjo Olanike Adeola MRO 1 HND HIM
45 George- Ngwu Joyce MRO 1 HND HIM
46 Nnamdi- Akuche Chioma  Maryann MRO 1 HND HIM
47 Peter Umoru E.O.R BSC,MSC STATISTICS
48 Dahiru labaran  HSO BSC STATISTICS
49 Jibrin Mercy

HSO I

HND STATISTICS
50 Julie Ezenwa MRO I OND HIM BSC P/ADMIN
51 Victoria Odinkemena Adejo

HSO I

HND STATISTICS
52 Abdulrasaq Omallo MRO 11 HND HIM
53 Odoemena Ngozi MRO 11 HND HIM
54 Olukoju Florence MRO 11 HND HIM
55 Ogunji sarah O.

E.O.R

NCE HOME ECON
56 Oswald Deborah HRT OND HIM
57 Musa Aisha A EOR ADVANCE DIPLOMA
58 Ibrahim  A Yakubu CCO(REC) OND HIM
59  Okike Ifeoma CCO(REC) OND HIM
60 Ibrahim Tijani. Isah HRT
61 Elizabeth Ajayi HRT
62 Joy Idimogu HRT OND HIM
63 Abayomi Rukaiyat Odunayo HRT HND HIM
64 Nanman Dogo Dawam HRT HND HIM
65 Simon patient Chantwas HRT HND HIM
66 Haliru Usman Suru HRT HND HIM
67 Eze Augustina Nkachi HRT TECHNICIAN HIM
68 Bushirat Ajike Olayinka HRT
69  Wosilat  I. Jummai HRT
70 Ajayi Oluwatosin Elizabeth HRT
71 Umar Abdulrahman HRT
72 Emmanuel kadiri HRT
73 Patience Yakubu HRT
74 Alao oriade tosin HRT
75 Ajayi  Tosin HRT
76 Suleiman Fatima Talatu HRT
77 Ramatu  Mohammed CCO(Rec.) LOA
78 Oyewole Ademola CCO(REC) BSC P/SCIENCE
79 Hadiza Musa CCO(REC.) BSC P/ADMIN
80 Isiaka H Ogbe CCO(REC) BSC  ACCOUNTING
81 Isah Suleiman Aisha CCO(REC.) LOA
82 Olayemi O. Bolanle CCO(REC) BSC
83 Yusuf Mairiga CCO(Rec.) SSCE
84 Abdulwahab Ayuba SMRC
           85 Ugwu Victoria SMRC
86 Abubakar Garba Waziri CHA
87 Hauwa Mohammed CCO(REC)
88 Kabiru Shuaibu Hospital Asst.
89 Hamza yusuf CCOR
90 Musa Abdullahi PRC II
91 Muhammad Gaddafi HA
92 Nneka Faith Osuji HA

KEY

HIM: HEALTH INFORMATION MANAGEMENT

P/ADMIN : PUBLIC ADMIN

P/SCIENCE : POLITICAL SCIENCE

HOME ECON : HOME ECONOMICS

ECO : ECONOMICS

GEO : GEOLOGY

MED PHY : MEDICAL PHYSICS

LOA : LEAVE OF ABSENCE

SL    : STUDY LEAVE

 

 

Contact email:  hod.medicalrecords@nationalhospital.gov.ng