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WELCOME TO HEALT RECORD

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Mrs Alfred-Esezobor Oluwatoyin Blessing Designation::Chief health information management

Email Address:: XXXXXXXXXXXXXXXXXXX

PROFILE

1). HND in health information and biostatistics 2). PGD n hospital management 3). B.sc in health information management 4) MSc in Health information management

  • HISTORY OF HEALTH RECORDS DEPARTMENT
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    Health Information Management is defined as the collection and analysis of healthcare data to provide information for healthcare decisions involving patient care, institutional management, healthcare policies, planning and research. 

    The name of the function changed from Medical records management to health information management as enhancements in technology expanded responsibilities from managing paper records to managing the full scope of the process of collecting and sharing electronically-captured information among desperate entities.

    The earliest forms of medical records were narratives written by ancient Greeks to document successful cures, share observations about symptoms and outcome, and teach others who provided medical advice through these case studies.  While written reports describing patients complaints and diagnose predate the records of Simeon Forman and Richard Napier-astrologers who documented clients’ medical questions and treatment, their records from 1596 to 1634 form the earliest complete collection of medical records in existence. In 1950, Lawrence L. Weed who died at the age of 93 introduced a system for organizing patient data in the 1950s that is still used today by hospitals on a global basis and developed a computerized method for assisting in the diagnosis and treatment of diseases.

    In 1960, there was introduction of Medicare and Medicaid which requires nurses to collect data to document care for reimbursement.  In 1964, El Camino Hospital in Mountain view, CA worked with Lockheed corporation to develop a hospital information system that included medical records, In 1971, the first attempt at a total, integrated health records system was implemented in a gynecology unit at the university medical center in Burlington, Vermont based on the problem –oriented medical record to provide an overview of care to see the relationship between conditions, treatments, cost and outcomes.

    In 2000, as hospitals continued to merge into large health systems, the electronics health records (EHRS) medical records.  The introduction of cloud computing for healthcare today is aimed to integrate and harmonize data to make it available to all users, for effective management of patient’s data; clinical and financial improve patient care and safety for quality healthcare service deliveries.

  • FUNCTION OF HEALTH RECORDS DEPARTMENT
    • 1. To Advice the Management.
    • 2. Manage and control acquired printed Medical Records and Stationaries.
    • 3. To initiate patient’s Records (for new, out patient, new admissions)
    • 4.. To keep custody of the out-patient and in-patient case note.
    • 5. To Store Medical Records or treatment files of patient who are either treated in the in-patient or out-patient.
    • 6. Health Records department is the custodian of patient information where all patient case note are filed and kept for easy access.
    • 7. To ensure the case note cover should provide adequate protection for the documentation contain within and should be replaced if they becomes torn or damage.
    • 8. Health records department is responsible for quick services to patient in order to reduce waiting time.
    • 9. Health records department maintain the history of services user care.
  • JOB SPECIFICATION IN EACH UNIT

    1. EMERGENCY UNIT  
    This is where documentation of all new patients is being done through the use of (EMR) Electronic Medical Record. The department runs 24hours services daily, an average of 20 - 25 patients is registered on daily basis. A total No of 5472 patients were registered during the period of this report.

    2. OUT PATIENTS UNIT  
    Out-patient unit is a place where patient come for follow-up treatment. The Health Record department ensure that patient case note are retrieved a week before the clinic day. The unit also ensure that all case note used in the clinic are packed, arranged numerically and returned back to the library for proper filing and confidentiality. A total 33,332 patients were seen and treated during this report.

    Out-Patient Runs Clinic 4 Days in a Week. 

     DAYS OF THE WEEK

     UNIT SEPCIFICATION

     CONSULTANT

    Mondays

    General Adult Psychiatrist

    Dr.Owoeye,
    Dr. Adegbaju
    Dr. Shofu Akanji

    Tuesdays

    General Adult/Substance Abuse

    Dr. Ojo,
    Dr. Koyejo
    Dr. Esangbedo

    Wednesdays

    Retention of Case Note, Locating Misfiling of Case Note and Changing of torn files at the Ward.  

    All Health Record Staff

    Thursdays

    Forensic/General Adult
    Psychiatrist

    Dr. OluwaniyI,
    Dr. Awesu
    Dr. Maitanmi

    Fridays

    Geriatric/General Adult Psychiatrist

    Dr.Adebayo,
    Dr. Oduguwa,
    Dr.  Nkem Ndionoka

    Emergency

    Emergency Psychiatrist

    Dr.Omotojesi,

    Community /Harvey Road Clinic

    FamilyMedicine/Minor Surgery

    Dr. Adegbite

    Amenity Clinic

    VIP Clinic

    Dr. Raji

    Sleep Clinic

    Dr. Obembe

  • OTHER UNITS

    3. OUT-PATIENT UNIT OSHODI ANNEX 

    The unit runs 24 hours services on daily basis and also runs out-patient clinic on Mondays, Tuesdays and Thursday, which is mainly for adult especially for those who reside within the area where the hospital is located. A total no 5474 were seen and treated during this report.

     

    OUT  PATIENT CLINIC DAYS AND THEIR CONSULTANT          

     CLINIC DAYS

     UNIT SPECIALIZATION

     CONSULTANT

    MONDAY

    Adult Psy./Rehabilition Centre

    Dr. Kajero

    TUESDAY

                 “

    Dr. Nyamali

    THURSDAY

                 “

    Dr. Akinola

               

    4.         CHILD AND ADOLESCENT 

    This unit provides services for children and adolescent between the ages of 0 to 18.  Their clinic days are Tuesdays and Thursdays.  The health record department is in charge of registration of new patient, retrieval of patient case note and filing of all used case note after every clinic, as well as booking of appointment for patient and any other job assigned to them for example participating in research work whenever the need arises.  During the period of this report, a total number of 7,343 patients were seen and treated.

    CHILD AND ADOLESCENT CLINIC DAYS & CONSULTANT IN CHARGE

     CLINIC DAYS

     UNIT SPECIALIZATION

     CONSULTANT

     

    MONDAY

    Clinical Presentation/New Cases

    Dr.Ogun,Dr.Bello-Mojeed & Dr. Ijarogbe

     

     

    TUESDAY

    Child & Adolescent

    Dr.Ogun/Dr.Bello-Mojeed

     

    WEDNESDAY

    New Cases

    Dr.Ogun/Dr.Bello-Mojeed &

    Dr. Ijarogbe

    THURSDAY

    Child &Adolescent

    Dr. Ogun /Dr. Ijarogbe

     

    FRIDAY

    New Cases

    Dr.Ogun/Dr.Bello-Mojeed &

    Dr. Ijarogbe

     

     

     

  • MORE UNITS

    5.         APPOINTMENT UNIT  

    This unit is responsible for the interpretation and booking of new appointment for the patients after seeing the doctor on each clinic day and even those registered at the emergency for the first time booked their appointment here as well and those that have been discharge from admission, also appointment is booked Electronica through the use of Electronic Medical Records.  In the unit we have what is called Appointment Jacket in which each consultant maintained one depending on their clinic day.  This unit is always busy due to the nature of services rendered.

     

    6.         HEALTH RECORD LIBARARY  

    It is located within this Records department and responsible for storing active patient health care files of this hospital. The Library also manages a number of other different record types e.g. LASTMA CASES, Prison CASES, FORENSIC CASES etc.

    The Library supplies Health case files for all emergency and elective patient activity in the hospital, including ward admissions and out-patient clinic appointments.

    To protect the serenity and confidentiality of patient Health care files, Access to the Library restricted to only authorized staff.  

     

    7.         ADMISSION AND DISCHARGE UNIT  

    Collection and Compilation of patient information/data of patient who are on Admission and those who are discharged is done in this unit.

     

    8.         STATISTICS AND RESEARCH UNIT  

    This is where compilation of patient data is done, weekly, monthly, quarterly and yearly in a figurative form to give a more meaningful, interpretation which the hospital uses for planning, evaluation and research.

     

    9.         AMENITY CLINIC  

    The unit runs only one shift i.e. morning duty from 8.00a.m. to 4.00 p.m. they retrieve, book appointment and filed back all used case note after every clinic, except on weekend. Admission to ward is also done here. During the period of This report a total number of 2259 were seen and treated

     

    10.       COMMUNITY CLINIC   

    This unit provides services for Sick staff, Relatives and the Neighborhood, these services includes Cardiology, Neurology, Dietician and Physician. The unit runs two shifts, morning and afternoon.  During the period of this report a total number of 3121 were seen and treated.

     

    11.       SLEEP CLINIC  

    Is a unit that handles patient with sleep-wake disorders, it operates on Tuesday.  The most common is insomnia, nightmare disorder. The consultant in charge is Dr. Obembe.

     

    12.       GERATIC CLINIC  

    It is meant for Adult from 60 and above and the clinic is run on Fridays, The consultants are Dr. Adebayo and Dr. Oduguwa.  The total number 2,228 were seen this year.