HEALTH INFORMATION MANAGEMENT

Brief history of Department with recent achievement

Health information management services are provided by registered health information officers and registered health information technicians. Health information management professionals oversee health records system and manage health related information to ensure that it meets relevant medical, administrative and legal requirements. In a nutshell, health Information professionals act as data brokers in OOUTH, Sagamu.

So far, the department has been able to acquire series of achievements but the frontline of it all is computerization of Health Information Management, which is designed primarily to support users by providing accessibility to complete and accurate data, alerts, reminder, clinical decision support systems, links to medical knowledge, encoder and other aids.

Other relevant information to showcase the activities of the department and hospital.

1.       OUT-PATIENT SERVICES:
The department rendered medical records services at the following out-patient units of the hospital.
1.         General Out-Patient Clinics Department
2.         Consultant Out-Patient Clinics such as:
            *          Autho/Trauma
            *          Antenatal Clinic
            *          Gynaecology Clinic
            *          Medical Consultant Clinic
            *          Surgical Consultant Clinic
            *          Paediatrics Consultant Clinic
            *          CMPC Clinic
            *          Child Survival Clinic
            *          ENT
            *          Virology
            *          PNS
3.         Accident & Emergency Department
4.         Staff/NHIS Clinic

At the various out-patient units mentioned above the foregoing medical records services were rendered during the year:

Electronic Registration and documentation of new patients
Documentation of their subsequent visits
Electronic Booking of appointment of patients attending consultant clinics
Prior preparation of patient medical records before appointment day
Retrieval, filing and storage of patients Health Records for treatment, research, teaching and planning
Extraction, compilation, collation and presentation of daily statistics in all clinics
Requisition and collection of medical forms for the documentation of patients’ treatment.
Providing accessibility to complete and accurate data, SMS alerts, reminders and other aids.
Assigning diagnostic codes to diseases by the use of encoder.
Electronic reminder of patients’ appointment.

2. IN-PATIENT SERVICES:
In-patient services were rendered to all patients admitted, discharged and deaths by the department.

STATISTICS UNIT: This unit, which was manned by an Asst Medical Records Officer with the assistance of a Medical Records Technician. These staffs are responsible for collecting, compiling, collating, analyzing and presenting, adhoc, monthly, periodic and annual statistical returns of the activities of the hospital. In addition to this, the unit also attended to request from other health facilities, SMOH (e.g. FMOH), on matters such as monthly disease surveillance and immediate notification of certain diseases, to mention few. With the integration of computer information system, many of these types of statistics are generated authomatically.

ADMISSION AND DISCHARGES UNIT: Inpatient census data collection. Electronic and manual documentation of all admissions, transfer, discharges and deaths and proper maintenance of appropriate registers for the storage of in-patient information were ensured. This unit ensure effective quantitative records analysis is refers to a review of the Health Records. The content of the health records complete with appropriate documentation that complies with accreditation and practice requirements.

CODING AND INDEXING UNIT: Clinical coding is another important function of HIM department. Code numbers are assigned appropriately using a classification system to patient diagnosis, procedures and service code. This is normally carried out in a retrospective process; the health record is coded after patient discharge. The use of information technology such as encoder is also used to guide the coder to determine the appropriate diagnosis. The diagnosis coding are used for the purpose of research, claims submission and quality of care study. Encoder has increased coding quality.

MEDICAL RECORDS LIBRARY SERVICES: Health Information Department is the custodian of patient health information. Two system are used for storing health records, we have the paper storage system such as filing shelves which is the manual and the electronic format method. The following functions were discharged during the year:
Storage, retrieval and filing of patients medical records and other medical documents
Maintenance of archives containing in-active medical records
Maintenance of efficient tracer system of all medical records in circulation
Weeding and shift back of inactive Health Records to archives.
Printing, storage and supplies of medical forms
Proper storage of used registers and documents.

3. FORMS CONTROL UNIT: Form design and management is another critical HIM function. Good forms are developed whether in paper or electronic format which is an important part of high quality health records content. This section track and manage forms, establishment of forms standard, implementation of forms numbering and tracking system.

Weekly Activities

DAY	EVENT(S)	TIME
MONDAY	Electronic registration of new patients	Operate 24hrs
	Retrieval of patients Health Records for consultation
	Documentation of the patient visit
	Electronic booking of Patients appointment
	Extraction of diagnosis and compilation of daily statistics
	Coding of outpatients diagnosis with the use of an encoder
	Filing and proper storage of Patients Health Records.
	Prior preparation of Patients Health Records for next day appointment
TUESDAY	As above	As above


WEDNESDAY	As above	As above


THURSDAY	As above	As above


FRIDAY	As above	As above


SATURDAY	As above	As Above


SUNDAY	As above	As above