Medical Records and Coding

Department Manager: Rachely Harambam

General

A medical record is a set of medical documents created to document a person’s medical condition by the people who are authorized to do so. The record includes identifying information of the patient and therapist, medical information about the treatment received, the medical history as provided, diagnosis of the current medical condition and treatment orders.

The medical record serves many purposes. It facilitates the design and monitoring of medical treatment, is a channel of communication between the physicians and other professionals involved in the patient’s care, provides written documentation of the patient’s disease, the treatment administered and results, demonstrates that the legal rights of the patient, physician and medical staff were protected; acts as a source of information for research, teaching, auditing, statistics and long-term planning.

Department Activities

• Managing databases and locating medical records.
• Recording movement of hospitalization records in the computer.
• Preparing previous hospitalization records for medical treatment and follow up, instruction, research and auditing.
• Reporting diseases that must be reported by law.
• Preparing medical documentation at the request of the patient or requests from outside parties.
• Preparing and photocopying the medical record for the Risk Management Unit.
• Marking and Coding diseases and surgeries according to ICD-9.
• Training physicians on proper recording and coding of diagnoses and procedures.
• Training medical secretaries on coding and marking of diagnoses and surgeries.
• Qualitative and quantitative review of the medical record.
• Professional consulting to the medical secretaries in the in-patient departments.
• Producing reports for research, statistics and future planning.
• Training of interns who have graduated from a medical secretary course.
• Participating in emergency drills and events.

Receiving Medical Information

• A patient over the age of 18 is entitled to receive medical information from his/her medical record from the medical institution upon presentation of identification.
• Medical information will only be provided to other parties under the following conditions: The patient has provided written consent by signing a waiver of confidentiality in the presence of an attorney; the institution is legally obligated to report such; the information is being provided to a different therapist for the purpose of medical treatment.
• Medical information about a minor will be provided when the person requesting it is one of the minor’s parents and upon presentation of identification, or the lawfully appointed guardian upon presentation of a document of confirmation from the court.
• Medical documents about deceased persons will be issued in the following cases: presentation of an inheritance order in which the person making the request is listed as the legal heir according to a court ruling, order of probate in which the person making the request is listed as the legal heir according to a court ruling, a court order mandating the medical institution to provide the medical information to the person making the request, an affidavit from an attorney stating that the person making the request is the legal heir of the deceased.
• The medical documentation will be provided for a fee determined by the Ministry of Health, except for medical treatment and upon presentation of a letter requesting such from the attending physician.

Location:

Ground floor, next to The Emergency Medicine Department 

Open to the public and Calls answered:

Sunday-Thursday, 8:30 a.m. – 1:00 p.m. 

Telephone: 04-7744261 

Fax: 04-7744682

E-mail:

Medical record requests: [email protected]

The medical documentation will be provided for a fee determined by the Ministry of Health.