Out-Patient Clinic

OUT-PATIENT CLINIC

This is a place where patients come in for follow-up of their treatment after they have been given appointment at the emergency unit and outpatient clinic.

The health record officer usually gives health talk to the patient on Monday to Friday which usually takes place within 8am to 8:30 am

1. The patient will make payment to the account section and the records staff on duty will collect the card to retrieve the files on the table which is already arranged in alphabetical order
2. After the collection of the appointment card, a number is given to the patient and  their names, registration numbers and sex are documented on a separate clinic list which comprises of batches

• The case file is arranged according to the number allocated to them. e.g 1 to 160 which gives 4 batches list ( i.e first 40 patients, second 40 patients, third 40 patients and fourth 40 patients.). This has been of help to reduce waiting time and also create a sense of orderliness among the patients

1. For patients that have appointment date, their files would be retrieved from the sorting table and passed to the stamping table.
2. The patient’s appointment card will be used to tick the patient’s name from the clinic of appointment list in order to indicate the number of patients that attended the clinic.
3. The appointment clinic list helps to indicate the particular number of patients booked for a particular clinic day.

• The stamping table is where patient’s files will be arranged and outpatient continuation sheets will be added into the case note which contains names, registration number, date and clinical note space
• Then the case note will be transferred to the Nursing section for vital signs and from nurses to the consulting rooms for consultation.

1. After consultation, the patient will come back to health record department with the prescription sheet to book next appointment date. This will be documented in the appointment jacket according to the consultant in order to reduce waiting time.
2. At the end of the clinic the records staff will pack the patient’s files from the consulting rooms and it will be sorted and arranged numerically for easy filing at the library unit.

MEDICAL REPORT

Medical report is normally dispatched by health records officer to the patient/relatives at out-patient clinic according to the patient’s consultant and it is always documented in the register which consists the following.

• Date of collection
• Destination,
• Reference no
• Names of the patient
• Registration number
• Signature of the patient/relative.

A copy of the medical report is filed into the patient’s case note for future purpose and original copy is given to the patient/relative to his/her destination.

WARDS

* The health Record staff goes to the wards to changes the entire torn patient case note.

*  We do arrange the content of patient case note in an orderly manner.

*  Patient case note that are bulky is change and label volume 2 while the new one is created with latest diagnosis and it is label volume 1

* The label volume 2 case note is filled back into the health records library which can be access to at any point in time by doctors or health professionals.

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Clinic Procedures

CLINIC PREPARATION PROCEDURE

1. HRO will pick up the clinic list of a week interval from the appointment unit to the library to prepare weekly clinic case notes
2. The patient’s name, registration number, destination, appointment date and signature are entered into the tracer cards which will indicate the movement of the case note.
3. After the necessary documentation on the tracer card they are sorted and arranged numerically for easy filling
4. While retrieving the case notes from the shelf, the tracer card will replace the position of the case note  immediately on the cabinets/shelves
5. The tracer cards serve as a mirror to locate the case note movement and destination
6. the retrieved case notes are sorted and arranged in alphabetical order  on the sorting table
7. The case notes are moved to clinic area by the health records staff on night duty, arranged on the clinic table at the out-patient clinic for easy retrieval on clinic hours
8. The appointment clinic list will be returned to out-patient clinic, which will serve as attendance to the patients that keep to their appointment  on their clinic days

PROCEDURE FOR ADMISSION AND DISCHARGE

 ADMISSION

• Admission section is concerned with effective and efficient acceptance of the patient into the hospital or formal acceptance of patient into the hospital ward.
• When a patient comes for admission the HRO will direct the patient to pay for consultation fee, and the appointment card will be submitted to the health record unit.
• The patient’s case note is retrieved from the health record library and outpatient continuation sheet is added with the date, patient names registration number written on it, then the case note will be transferred to nurses unit for vital signs and from the nurses to the consulting room. This is where the doctor will endorse the admission to the ward
• Admission unit is where the patient’s information about the admission is being documented before  patient can be moved to the words
• The admission section originates the identification portion of the health record such as: Patient Name, Hospital number, Address, phone number, birth place, diagnosis, Consultant, sex, age, marital status, religion and Next of kin etc.

Discharge

* Proper discharge summary form must be written by the consultant or doctor in the ward.

* The Nurses must discharge the patient from their register which will be signed by Health Record Officer at the out-patient clinic.

* The health record officer will calculate the number of days the patient spent on hospital bed.

* The case file will be discharged to out-patient clinic from the admission and discharge register for follow up.

* Appointment will be given to patient for continuity of treatment.

* Finally the file will be taken to the Library for proper filing.