Download Health Information Records Service

HIRS – location and hours
of operation
Level 1, G Block
(Beneath Emergency)
Department is staffed 24/7 – after
hours access by arrangement
Accessing Health Care
Records
o All information contained in a
health care record is CONFIDENTIAL.
o Health care records are sent to
ward ONLY for patient care.
o Clinicians are NOT to remove the
health care record from the Hospital
(i.e. taken home, put in car).
Accessing Health Care
Records
Health care records can be viewed
in our research room for the
following purposes:
o Research
o Case Reviews
o M&M Meetings
o Peer Review
o Quality Audit
o Complaints
Clinical Documentation
Documentation must be sufficiently
detailed to allow other health care
personnel, of the same discipline, to
assume care of the patient or to
provide ongoing care at any time.
Clear, accurate documentation is
also of critical importance for clinical
coding and assignment of DRGS, or
other casemix classifications as well
as review in clinical, research and
legal settings.
o Legible and in English or accepted
clinical terms
o Accurate, precise, objective and
factual
o Timed (using a 24 hour clock) and
dated (day, month and year)
o Signed by the author and include
their printed name and designation
o Electronic systems require
appropriate identification e.g.
electronic signature
o Written in black ball point pen
(for handwritten entries)
o Fluorescent markers, textas or
gel pens must not be used
because of reduced
reproducibility and durability
o Must be sequential where
possible without space between
or within entries.
o Must only use abbreviations
and symbols approved by the
area. Refer to the area
procedure on ‘Approved
Abbreviations for use in the
Health Care Record’
o Entries by students must be
countersigned by their
supervising clinician
o Details omitted from an entry
and subsequently recorded
should be made under the
heading of ‘ADDENDUM’. The
entry should record the date
and time of the omitted event
and date and time of the
addendum.
o An original incorrect entry
must remain readable,
correction fluid is not to be
used. No alteration or
correction of records is to
render information illegible.
o A correction may be made as a
single line through the original
incorrect entry or ‘strikethrough’
text in electronic records, record
“written in error”, followed by
person’s name, signature and date
of correction.
o Privacy laws permit a patient to
request a health service to amend
their health information
All entries should be made as close
as possible in time to the events
and actions they record. Where
there has been delay between
events and the documentation of
them in the health care record the
time of events must be noted and
the entry must be noted as being
made “in retrospect”.
Acute Care Settings
oMedical staff must make an entry
o on initial presentation
o on admission
o Monday to Friday at minimum
daily
o at least once on a weekend
o on discharge
o Other clinicians should make entries
to reflect their level of assessment and
intervention
Long Stay or Residential Settings
o Clinicians should make an
entry in the health care record
o twice per week
o on discharge.
Discharge summaries are required
for:
All admissions over 24 hours
including deaths.
If a health care record is returned
to the HIRS department without a
discharge summary, staff will page
you to complete what is required. If
you do not adhere to this the issue
will be referred to your Manager
oAll discharge summaries/front
sheets should commence at the
start of the episode and
completed as the patient is
discharged from the health service
but must be completed within
48hours of patient separation and
immediately sent to the intended
recipient(s)
oThe completion of discharge
summaries and front sheets remains
the responsibility of the relevant
medical team.
oPlease be aware that your
termination paperwork will not be
signed off if there are any
discharge summaries waiting to be
completed
What should be included in a
discharge summary?
oPatient identification data including
unique identifier i.e. MRN – Medical
Record Number
oName, address and telephone
number of facility
discharging/referring patient
oName of the VMO attending the
patient
o Suitable clinician’s name, title
and telephone number(s) for
follow up contact
o Intended recipients name,
address and contact telephone
number, facsimile or email
address
o Episode start (admission) and
end (discharge) dates
o Presenting problems
o Diagnosis/es
o Major interventions
o A note on the patients progress,
complications and co-morbidities
during the episode of care
o Results of major investigations and
instructions for follow up pending
results, including telephone numbers
of diagnostic departments as
relevant.
o Discharge medications and
changed or ceased medications
with reasons for changes
o Patient alerts e.g. allergies, adverse
drug reactions, advanced care
planning
o Patient needs e.g. interpreter
o Medical specialist and other
clinician contacts and appointments
o Final diagnosis
o Follow up plans
o Community health contacts
o Community service provider
contacts
o Author of discharge
summary/referral including name,
title, date and signature
When documenting in an
electronic record;
o Use upper and lower case
letters. Entries must not be typed
in all upper case or all lower
case
o Use correct sentence structure
and punctuation
o The system default font size /
font type is to be used and must
not be changed
o Use only the abbreviations
and symbols approved by the
area.
o Do not use bold or italics
unless this is the default
A sample of records are audited
each month across the area to
ensure compliance with the
clinical documentation policy.
These results will be published on
the intranet by hospital.
For further information refer to
the area ‘Procedure on Clinical
Documentation in the Health
Care Record’
An expert certificate is evidence
of a person’s opinion stating that
the person has specialised
knowledge based on his or her
training, study or experience, as
specified in the certificate and
sets out an opinion that the
person holds and that is expressed
based on knowledge.
oExpert Certificates are processed by
the HIRS department
o The HIRS department will ensure the
correct consent has been obtained
before you complete an Expert
Certificate
o An Expert Certificate may be
presented instead of your
attendance at court
o It is important when writing a police
statement for assault to include
lacerations, bruising, fractures, pain,
etc
o It is also important to be detailed,
for example how deep the
laceration is
o When a police statement is
requested, it is always requested
from the most relevant/discharging
team. If the police are not satisfied
with statement they may request a
statement from another doctor (e.g.
surgeon)
The following information is regarded
as sensitive:
Hepatitis status, HIV / AIDS related
information, information relating to
third party, sexual assault, domestic
violence, genetics, IVF and artificial
insemination program, and child at risk
* Mental health information is not
considered sensitive if it is for ongoing
health care
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