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:
- To ensure proper booking of appointment in the clinics to prevent overcrowding which can lead to spread of diseases.
- 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.
- To ensure proper waste segregation and disposal within the department.
- Orient and train all staff in safe work practices and procedures in compliance with established rules and regulations and safety manual.
- Advocate for sufficient resources to provide and maintain safe and healthy working conditions
- Training in health and safety as well as first aid/fire drills
- 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:
- Operate in conformance with the requirements of the quality management system and procedures
- Free access of all staff to all departmental policy documents and standard operating procedures.
- Prompt service delivery and best practice procedure.
- 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