Health Records Department

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

 

 

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