Facilty Code: 223/2010, Date: 20-22 Jan 2010

HEALTH INFORMATION MANAGEMENT SYSTEM

SURVEYOR COMMENTS
Standard No.: 07
7.1
Organisation and Management
Health Information Management System is managed by the Medical Records Unit which
is situated on the first floor of the administration block. This unit receives, checks, stores,
reproduces medical records in a confidential manner. This unit also creates statistical
reports using various computer applications. Statistical reports are made use of by the
Hospital Director to improve the management of the hospital.
The unit is well organized and managed. There is an active medical records committee
which regularly meets to improve the health information management system.
7.2
Human Resource Development and Management.
The Medical Records Unit is headed by an Assistant Medical Records Officer. However
there was no evidence of appointment of Head of unit. He is directly answerable to the
Hospital Director. There are 4 clerks and an attendant in the unit. The staff attendances at
courses have been recorded. However there was no evidence that the new staff were
informed of confidentiality of records.
7.3
Policies and Procedures
Policies and Procedures have been updated. There is a single record for each patients
data from ward or emergency department. The discharged patients records from the
wards are sent to the record office in locked bags. Consent obtained before release of
medical reports. The records can be retrieved any time even after office hours but this is
not made use of by the clinical staff.
7.4
Facilities and Equipment
The department has 2 stores one of which is a cargo container. The space was inadequate.
The records are stacked up to the ceiling and near the lights. This could be a fire hazard.
The unit head manages the space by regular writing off of older records. Safety of active
medical records needs to be improved in the main record office.
7.5
Quality Improvement Activities
There are quality improvement activities. 15% of the BHTs (Bed Head Tickets) were not
returned within the stipulated 72 hours of discharge. This is partly because the incomplete
records were rejected for corrections
7.6
Special Requirements
The contents of the patient records were adequate for the care of patients. The
confidentiality was maintained. Drug allergies were also noted on the cover of records.
Surveyor: Dato Dr. Ziaudin

Facilty Code: 223/2010, Date: 20-22 Jan 2010

SURVEYOR RECOMMENDATIONS
Overall Rating For Standard: Substantial Compliance (SC)

Surveyor: Dato Dr. Ziaudin