Medical Records

Written by WVSU Medical Center | PDF 

GOALS

To create and maintain a health record system aided with advanced and extensive techniques and manned by competent professionals working as a team to further promote quality health care service, training and research.

OBJECTCIVE

The Medical Records Section aims:

  • To provide quality maintenance and control of all patients records at WSUMC ensuring accuracy, privacy and confidentiality of information for patient service, training and research.

FUNCTIONS

The Medical Records Section has the following functions:

  • Receive, code as per ICD-10, encode, disease index, folder making and file all medical records of patients admitted and consulted in this hospital.
  • Assemble and performs qualitative and quantitative analysis procedures on medical records received for accuracy and completeness of documentation to meet established standards as well as statistical needs.
  • Develop an effective system of assigning hospital numbers to all admitting units.
  • Retrieval of medical records for legitimate use and quality patient care and releasing information to authorized persons only.
  • Prepares monthly statistical reports to meet medical ancillary and administrative needs.
  • Prepares and process all birth certificates of deliveries and transmit to Local Civil Registrar for registration.
  • Maintain, safe keep and dispose of medical records I accordance with laws and statutes.
  • Process, prepare and issues medical certificates to legitimate/authorized persons.
  • Attend court appearances as per subpoena duces tecum.
  • Maintains registry books of admissions, discharges, births, deaths, transaction logbook and logbook of all medical records received from each department.
  • Development of medical records policies and procedures.
  • Authenticates copies of documents for insurances/claims.
  • Prepares certificates of confinement requested.
  • Processing and releasing of death certificates and medico legal certificates.
  • Sequesters and safe keep medical records of patients still admitted in the hospital upon request from the Main Attending Physician, Head Nurse and/or suspicion of irregularities in documentation.
  • Assist researches in the retrieval and filling of medical records for researches approved by the hospital Research Committee.
  • Encodes sentinel reports in PIDSR for submission to Department of Health.