medical records in practice

Transcription

DEPARTMENT OF HEALTH
iAl
"
•iii
I
U
H-328
-
New Zealand Department of Health
LIBRARY
Box 5013Wellington
Accession Nq....................
Classification: .............................
Location: ...........................................
A
Pose, R.J. Public Health Statistician, National Health
Statistics Centre
Sindlen, A.T. Secretary-Manager, North Canterbury Hospital Board
Blood Transfusion Service, formerly Medical Records Officer,
Princess Margaret Hospital and Hon. Secretary, New Zealand
Medical Records Officers' Association
Stuart, J. Medical Records Officer, Palmerston North Hospital
Thomson, Miss N. Medical Records Officer, Ashburton Hospital and
Hon. Secretary, New Zealand Medical Records Officers'
Association
Tiller, T.J. Medical Records Officer, Wellington Hospital
Vincent, L. Admission Officer, Waikato Hospital
Wakely, Gerald. Medical Records Officer, Auckland Hospital Board
and Editor, 'New Zealand Medical Record'
Wilson, Peter, Medical Records Officer, New Plymouth Hospital
and Vice-President, New Zealand Medical Records Officers'
Association
3231
wx 173
NEW ZEALAND Medical Records
Officers' Association.
.Med4Gal ....reoo .r4 5 ... praGtlO .. ... in
.......................
WX
J1
32318
STACK
io
'S
/ ( MEDICAL '
Contributors
Medical Records Practice in New Zealand
CONTRIBUTORS
Although each chapter was written by one author, or, in some
cases, in collaboration, during the editing process each
chapter was referred to various authorities - medical, legal
and.other - and also to fellow contributors. What has emerged
is a combination of the original material and alterations
arising from suggestions.
The following wrote the chapters shown:
Chapter 2: J.R. Clayton; Chapter 3: Peter Wilson, Gerald Wakely,
Miss M. Thomson; Chapter +: Ian Davies;. Chapter 5: A.. H. Mulford,
Gerald Wakely; Chapter . 6: Max Powell; Chapter 7: L. Vincent;
Chapter 8: AT. Sindlen; Chapter 9: Dr. John Cairney;
Chapter 10: F.H. Foster; Chapters 11 and 12: T.J. Tiller;
Chapter 13: J.R. Clayton; Chapters 14 and 15: J. Stuart;
Chapter 16: Gerald Wakely, George Riddiford; Chapter 17:
P.J. Rose; Chapter 18: J. Stuart; Chapter 19: A.H. Mulford,
Gerald Wakely; Chapters 20 and 21: Gerald Wakely;
Chapter 22: R.J. Rose; Editor: Gerald Wakely; Production:
Miss P. Blucher.
Owl
Particulars of contributors:
Blucher, Miss P. Stenographer, Auckland Hospital Board Medical
Records Office
Cairney, late Dr. John, C.M.G., M.D. , F.P.A.C.S. Formerly
Superintendent-in-Chief, Wellington Hospital Board and
Director-General of Health. Died in 1966
Clayton, J.P. Cancer Statistics Officer, North Canterbury
Hospital Board, formerly Medical Records Officer,
Christchurch Hospital, President, New Zealand Medical
Records Officers' Association
Davies, late Ian. Formerly Medical Records Officer, Auckland
Hospital. , Died 1967
Foster, F.H. Deputy Public Health Statistician, National
Health Statistics Centre
Mulford, A.R. House Manager, Te Kuiti Hospital, formerly
Medical Records Officer, Waikato Hospital,
Powell, Max. Medical Records Officer, Wanganui Hospital
and Hon. Treasurer, New Zealand Medical Records Officers°
Association
Riddiford, George, N.Z.R.N. Medical Records Officer, Masterton
Hospital .
iL
Index
WORKERS' COMPENSATION
Workers' Compensation Act, 1956
X-ray filing, equipment for
X-ray reception and filing, functions of
X-ray reception, equipment for
X-ray reports, procedure for dealing with late
X-rays, retention of, discussed
4$.
15
15, 1 et seq
3.7.8
1.' 3.2.7
3.7.7
• ,. 2.3
1 9,8
Syndrome, defined
Synonymous terms
System, defined
TB clinic appointments method
Telephone exchange names, recording of
Tendon, described
concept
Terminal digit filing and the
of staff organisation
Terminal digit filing method
Termination of pregnancy, consent to
TERMINOLOGY, MEDICAL
TERMS, GLOSSARY OF
Tests, Rubins, pre-operative admission for
Time clocks, advocated
13
2 '11
9,1.
1.2.2
5.1
Z
.23
'
•,. 4.1
•,5,2
2. 1 6.6
13
23
7.8
16 1 5
3.7.6, 3.7.7
.1'.
• Tissue, defined
9,
2.1.6.
Titles, treatment of, in indexfiling
Lng:
1 2 1•4.
Tonsillectomy, in relation to operation cod
1.
Tools required for making drafts of, forms.
Tracer methods
39:.
i, 6
Tracing patients
2: .
Transfers, as affecting daily census
Trays, slide-out, in fixed shelving
'Treatment', in relation to cancer, defined
4.5.3
20,
Trial run, desirability of, for forms
Tubal insufflation, pre-operative admission for.71 7,8
. .2,3.:
Tuberculosis Act, 191+8
14 1 Appx. A.
Tuberculosis Regulations, 1951
1+, 7
Tuberculosis notifiable
Type defined
Type faces, defined
4.1
Unit numbering system described
3•3•
Urinary systems explained
.2,9:
"2
USES OF MEDICAL RECORD
Ventricles, described
9, .5
2,6,
Violence, coding of
r2 1 .8
Waiting list census
Waiting lists
7,. 7.6
Waiting time criteria
1,1,2:
Waiting time survey, how to conduct
To 7'
War Pensions Act 1954
War Pensions Appeal Board, information
4, ' , 4
required for, from medical records
7;:,4...,
War Pensions Regulations 1956
Appx0 A..
Ward bed report, example of
"Appx. C
Ward bed state, example of
Wardso admissions by
2?.5.k
Index
Shelving needed for medical records in
current use
Shelving space needed for terminal digit
filing, how determined
Similar terms
Skeleton, explained
Social Security department, lists for
Social Security, entitlement to, in relation
to admission
Space needed for medical records, how to judge.
Spacing allowances on forms, handwritten and
typewritten copy
Specialties, names of, in larger hospitals
Specifications for forms, points to be
covered in
Spelling of medical terms
Spirit duplicator
Staff coverage, outpatient and A & B departments
Staff levels, for planning purposes
Staff, medical, full-time, admissions by
Staff, medical, visiting, admissions by
Staff, organisation of
Staff qualifications
1,
Skin cancers excluded from Central Registry
Stage, in relation to cancer classification,
defined
Staging, in relation to cancer classification,
defined
'Standard Nomenclature of Operations and
Diseases,' mentioned
Stationery, use of coloured tabs for follow-up
Statistical study, for cancer, how to do
STATISTICS, HOSPITAL MORBIDITY
Statistics, in relation to admissions,
discharges, deaths etc.
Statutory Regulations on disclosure of
medical information
Stems, in relation to medical terminology
Still-births, procedure regarding
Storage
Storage and protection of medical records,
factors regarding
Storage methods
Straightnumerical filing method
Strip index, for use as waiting list
Suffixes
Suffixes, indicating surgical procedure,
defined
Survival checks, for cancer
40
•,2.1
.2'5.2.1
i,9
9, 2
, 5
Z 5.2
•,2.1
Appx. A.
7
13 9
5
5
20, 2.3
6
21 9 3.5
7.5.3
7.2.3
If
6.1
3,
6.-i
1.3.1
1.4.2
1.4.2
10,/
17,
22
Z ' ?. 5
!L'Lf.1
1 3s 3
7
!4 9
.1L'3.8.2
•,2.1
.2' 5.1
27.6.1
2.3
2.4
1..Z
PROCEDURES, OUTPATIENT AND ACCIDENT &
EMERGENCY DEPARTMENT
-16
Proof correcting, symbols for
20 9 Appx. B
Protoplasm, defined
9,1
Punched card method of indexing
3.1
Punched cards used in cancer registry
17, 2.3
Qualifications of Specialist Medical Staff
13, 7
Questionnaires, design of, for ad-hoc studies
22,9.1
Quotations, desirability of calling, for
printing
20, 4.3
Pace, required for admission
Z' 5
Re-admission, explanation of, for MS18
statistical card
22, 6.2
Re-admission, explanation of, for hospital
purposes
23
RECORD, MEDICAL AND ITS USES
2
Referral sources, Accident & Emergency
department
16,2.1
Referral sources, outpatients
1.1
Referring doctor, to be noted for admission
5.2
Register, admissions and discharges
7.4
Report forms, late, procedure for dealing with
3,
2.3
-g
Report, ward bed, example of
Appx. A
Reports to be initialled by Medical Staff
3, 2.3
Reproductive or generative system, explained
9,10
Resection, abdomino-perineal, pre-operative
admission for
,7.8
Residence in New Zealand, length of, qualifying
for Social Security on admission
Z' 5.2
Respiratory system, explained
.27
RETENTION OF MEDICAL RECORDS
19
Returns, daily, admission office
Z7.
Returns, daily, outpatient attendances
Z7.5.5
Rubins tests, pre-operative admission for
, 78
Ruling, pen, use of, for forms
4.3
Rural delivery, insufficient for address for
admission purposes
z, 5
Schools, boarding, consent for treatment for
patients from
, 62
Seamen, visiting, necessity to record ship and
owners/agents at admission 79 5.2
Section 62, Hospitals Act 1 957, quoted4, 4.1
Self-employed, Workers' Compensation 15,
Septum, described
91
Serial numbering system described
Serial unit numbering system described 51
Services, effect on planning 21,
Sex, as a classification of admission
Sex, importance of, in recording bed availability ,
Shelving, considered, in planning 21,
6.1
2
5
3.1
3.2
3.1
4.1
1
3.7.2
qn
Index
Operation list, distribution of7, 7.5.5
Operations, authorisation for
.:'6
OPERATIONS, CLASSIFICATION OF
12
Operations, gynaecological, pre-operative
admission for
7.8
ORGANISATION OF A MEDICAL RECORDS DEPARTMENT
3
Organisation of staff
4
Organisation of staff, 'team' concept in
4.1
I
Organs, defined
.2'
OUTPATIENT AND ACCIDENT & EMERGENCY DEPARTMENT
PROCEDURES
16
Outpatient booking office, functions of 21, 3.2.4
Outpatient booking and reception, equipment for 21,
3.7.5
Outpatients, returns of attendances7, 705.5
Outpatient survey, how to conduct221 7
Outpatients, Workers' Compensation, procedure' 159 2.1
Paper, choice of, for economy with forms 201 4.3
Paper, described
20
3
Paper, factors in deciding suitability for job20
3
Paper, sheet sizes
20
3
Paper, weights
20
3
Patient index
3, 2.5
2.1
Patient index, never to be destroyed 19, 9
Period in hospital, method of calculating 229 6.2
Phonetic indexing, described
2.1
Physical planning
219 4
Physician's Index
.2 • 4
PHYSIOLOGY AND ANATOMY
9
PLANNING A MEDICAL RECORDS DEPARTMENT 21
Plasma, defined
91 5.1
Platelets, defined
5.1
Population, effect on planning 21, 3.1
Poisonings, coding of
11, 2.5
2.6
Poisonings notifiable
149 3
Poisons Act, 1960
14, 3
Post mortem, importance of
Tg, 2.3
Pre-admission procedure 79 3
Prefixes and suffixes
13, 4
Prefixes, treatment of, in index filing
2.1.2
Pregnancy, termination of, consent to7, 6.6
Pre-operative admissions
7.8
Pre-registration, of admissions7, 3
Printing processes, explained 201 2
Prisons, consent for treatment to patients from72 6.4
PROCEDURE, ADMISSION OFFICE
7
Procedure manual, necessity for 3,
4
Procedures, definition of, for planning purposes 219 3.4
PROCEDURES, INDEXING
42
Microfilmed medical records, procedure regarding admissibility as evidence in Court 49
Minor, consent for treatment to, who may give. 7,
Mf-il-hio in terminal diit filin g . common
errors
Monotype, explained
Morbidity statistics, explained
MS17 summary card
11,
MS18 statistical card, care of
MS18 statistical card, described
12,
Ms18 statistical card, operation details on
MS18 statistical cards as an index
—,
MS38 cards, when to complete
Mucous membrane, defined
Muscular system, explained
13,
Names of diseases
'N' code
Neotlasrn, suspected, ruled out or unconfirmed,
coding of
Neoplasms, coding of
99
Nervous system, explained
'New Plymouth' numbering system described 51
Next-of-kin, recording of, for admission purposes 79
New Zealand cancer case registration 17,
211
Noise level
Nomenclature and classification, differences
between
4,
Non-disclosure of medical information
Non-infectious notifiable diseases
Nosology, defined
14
NOTIFICATION OF DISEASES
Notification of diseases, forms for
14 9
II,
Nucleus, defined
Number, allocation of
Numbering system for outpatient and Accident
& Emergency departments
flumbering systems
Nursing staff reffering to medical records,
policy regarding
Obstetrics, in relation to coding
Occupation, necessity to record., for
admission purposes
Occupational diseases notifiable
Offset lithography, explained
Operating schedule
Operation Code
Operation Index
Operation index, retention policy
8
6,1
5.2.4
2.1
2.2
6.4
2.9
6,2 et seq
4
3.1
4.2
1
3
10
2.5
2.2
2.2
4.
3,3.2
5
1.3
3.8.5
4
4.1
2.2
1
2.1
2.3
3
1
3
4
3
3,
14,
7,
2.3.2
2.3
5
4
2.2
7.8
2.3.1
2.3
9.2
Index
Medical Records department, function of
3,2
21, 3,2.1
Medical Records department, hours of
coverage for
.e3
Medical Records department, indexes of,
described
2
MEDICAL RECORDS DEPARTMENT, ORGANISATION OF
MEDICAL RECORDS DEPARTMENT, PLANNING A
21
Medical Records department, policy regarding
access to, out of hours
,3.
Medical Records department, procedure for
obtaining records out of hours
Medical Records department, purpose of
.,7
Medical Records department, relationship with
other departments
, 5
Medical Records department, responsibility
for daily census
2.2
Medical Records department, scope of, for
planning
21,2
Medical records, factors regarding storage.
and protection
• 2.1
Medical records, how to judge space needed for
2.1
.39
Medical records in current use, need of..
shelving for
,3.1
Medical records, knowing exact location of
•,. 2.2
Medical records, outpatient and A. & E.
department, decentralised or centralised,
discussed. '. . 16193
MEDICAL RECORDS, RETENTION OF•
Medical Records Officer, recommended as
controller of hospital cancer registry .17' .3.1
Medical Records Officers place in compilation . ..
of the medical record .2, 5
Medical staff, admissions by. .•• •. .. 7 9 7.5.3
Medical staff, notes to••. : 3 9 2.3.1
Medical staff, to initial reports.39 2.3
Medical Superintendent, permitted to give
consent for treatment in certain cases
•7, 6
Medical Superintendent, relationship with
Medical Records Officer
.,5
MEDICAL TERMINOLOGY..
13
Medical typists, functions of.
3.2.1
MEDICO-LEGAL ASPECTS OF MEDICAL RECORDS KEEPING
k
Meninges, defined.
99 4
Menstruation, date of, affecting booking
for Operations
, 7.8
Menstruation, explained
910.2
Mental Health Act 1911
,5.1
Mental Health Amendment Act 1928
Mental hospital, admission to
.j,5.1
Mental hospital, consent for treatment to
, 6.5
patients from
4"
Laparotomy, to be avoided as a term
Lay-out of forms, spacing requirements in
Lay-out of forms, to be consistent
Ledger card, treatment for accident at work
LEGAL. MEDICO-LEGAL ASPECTS OF MEDICAL
RECORD KEEPING
Letterpress, explained
Liability, Workers' Compensation
Lighting, power and heating requirements
Linotype, explained
Location index cards, different types described
List, operation
List, waiting, medical
List, waiting, surgical
Lists, waiting
'Luhn' numbering system described
Lymph, described
Lymph nodes, described
Lymphatic, or lymph vascular system, explained
Machine recording
Maiden names, treatment of, in index filing
Male reproductive system, explained
Maori, definition of, for admission purposes
Mark-sensing explained
Married persons may give consent for treatment
irrespective of age to self, spouse or child
Medical Officer of Health, diseases notifiable
to
Medical record, access to, procedure regarding
MEDICAL RECORD AND ITS USES
Medical record a privileged communication
Medical record and case notes, differentiated
Medicalrecord, confidential nature of
Medical record, compilation of, Medical
Records Officer's place in
Medical record, completed, composition of
Medical record, contribution of to
medical research
Medical record, defined
Medical record, divulgence of information from
Medical record in Court
Medical record, ownership of
Medical record, policy regarding use of, for
study and research
Medical record, procedure for patient seeking
information from
Medical record, use of
Medical record, use of after patient's
discharge or death
Medical Records Committee, discussed
121 4
20 Appx. A
20,4.2,
15, Appx. 2
4
2.1
1.9
3.8.4
2.1
2.2.1
7.5.5
7.6.2
7.6.1
7.6
3.3.3
6
6
9, 6
3
2.1 .7
10.1
5
22, 6.3.1
,6.1
14, Appx. A
'1•
2
.,3
.,I
.3'2.4
.,5
.,4
2,6.1
2, 2
i, 3
',4.1
4, 8
4, 2
3,
2.3.2
4, 2
199 2
5
Index
Heart, described
Hernia, hiatus, pre'-operative admission for
H.I.D.6 weekly return
9,
jt,
tg
Historical importance of medical records
Hospital cancer registry, operation of
HOSPITAL CENSUS TAKING
HOSPITAL MORBIDITY STATISTICS
'Hospital Statistics Handbook', referred to
17,
22
lit
11 9
II,
11
Hospital terms
Hospitals Act, 1957
Hours of coverage, suggested
Husband and wife required to sign consent for
termination of pregnancy
Hydatids notifiable
I.C.D.A., described, in relation to operation
coding
I.C.DA. , mentioned
Imprest supply of stationery, advocated
Incidence of cancer, data on, use made .of
Incomplete diagnoses or terms, instanced
Index cards, criteria for
Index, patient
Index, requirements defined
Indexes, considered, in planning
Indexing, disease
Indexing, simple, explained
INDEXING PROCEDURES
Infant, admission of
Infectious diseases notifiable
Infectious diseases, procedure for obtaining
information from wards
Infectious diseases, purpose of notifying
Infirm, admission of
Injuries, coding of
Inter-departmental relationships
Intercommunication
INTERNATIONAL CLASSIFICATION OF DISEASES
'International Classification of Diseases',
application of, to disease coding
Laboratory report forms, •procedure for
dealing with late
407
9
21,
5
7.8
I
2.1
3
Lf
2
3
2.2
2.3
2.5
2.8
2.9
6.
6
3.5
3
6.6
2.2
12,3
-., 2.3.2
21, 3.8 • 2
17,I ./+.1
I I',2,8
Lf
3, 2.5
I
3.7.2
10, 2
2.2 • 1
5
2.1
2.1
5.
5
11, 2.5
3, 5
21, 3.3
21,3.8.1
25, 3.7.1
10
ill2
•,2.3
emale reproductive system, explained
Piles required for hospital cancer registry
Filing margin, width of
Filing, order of, in index
FILING SYSTEMS
Flow of traffic
Follow-up and cancer registration
Follow-up cards, for cancer, details required
Follow-up, definition of
Follow-up, District Nurses' role
Follow-up in connection with dietetics
Follow-up, Medical Social Workers' role
FOLLOW-UP METHODS
Follow-up of inpatients
Follow-up of outpatients
Follow-up, reason for
Food poisoning, notifiable
Foreign names, treatment of, in index filing
Form, evolution of, steps in
Form, for consent for termination of
pregnancy
Form of Consent for operations
FORMS, DESIGN PF
Forms for notification of diseases
Forms, revision of, procedure
Forms, Workers' Compensation, Form 2'
Forms, Workers' Compensation, Form 3
Fractures, coding of
Function of outpatient department
Functional planning
Functions of departments
Gastrectomy, pre-operative admission for
Generative, or reproductive, system,
explained
Glands, explained
Government departments, procedure regarding
giving information from medical records to
Graft, corneal, pre-operative admission for
Group indexing, explained
Gynaecological patients pre-operative
admission for
Haemoglobin, defined
Haemaglobin, low, pre-operative admission for
Haemorrhoidectomy, pre-operative admission for
Health Act, 1956
9,
17,
20,
5
10.2
3,3
Appx. A
2.1.2
21,
3.6
17,
3.3.2
1T 9
T,
Tg,
IT
Tg,
Tg,
14,
-,
20,
5
1
2,1
1
2,2
2
3
1
2.2,
2'. 1 .3
5
6.6
1,
20
Appx.A & B
14,.•
14,.
2,3
3
11,
2.5
21,
.3
3.2
2.1
6
15, i.8
15,, J..8,
I
7.8
•,10
1
4
, 7.8
, 2.2.2
7, 7.8
5-1
7, 7.8
7' 7.8
4,
4
4, 5.1
4,
7
1.
2
Health (Infirm and Neglected Persons)
Regulations, 1958
5
tJb
I
Dictating machines, to be Considered in
planning
21 9 3.7.2
Digestive, or alimentary, system, explained
.2. 8
Digit numbering system, described
5, 3.31
Discharge note, use of
2
Discharge of patient, regulations concerning
7
Discharges, daily list, distribution of
2. 7.4
Discharges, daily return of
7, 7.5.1
Discharges, for daily census
3
Discharges, totalled for MS18 statistical cards
6
Disease coding, application of 'International
Classification of Diseases' to
11,2
Disease Index
2.2
Disease index, retention policy
.i29.2
Disease indexing
10 1 2
DISEASES, CLASSIFICATION OF
11
Diseases, infectious, notifiable
.1.: '2.1
14, Appx. A
Diseases, infectious, procedure for
obtaining information from wards
2.1
Diseases, infectious, purpose of notifying
5
DISEASES, INTERNATIONAL CLASSIFICATION OF
10
Diseases notifiable
149 Appx. A
Diseases, notifiable, other than infectious
2.2
Diseases,notifiable, pattern of
iLt, 5
DISEASES, NOTIFICATION OF
14
Diseases, occupational, notifiable
14,1
Doctor referring patient for admission
5.2
Documentation of patients
.7,
Duct, defined
., I
'E' code - accidents, poisonings and violence
I!, 26
Employer's liability, Workers' Compensation
1.9
Endocrine glands, described
9, 11
Endothelium, defined
1
Enquiry Office, equipment for
3.7.4
Enquiry Office, functions of
3.2.3
Enquiry Office, responsibility for daily
census
8,
2.2
Epithelium, described
1
.2
Eponymic terms
10
Eponymic terms, cited in 'Code of Surgical
Operations! Manual
2.2
Equipment, considerations of, for planning
21, 3.7
Evidence Amendment Act, 1952
7
Factors effecting accuracy of statistics
5
Fees, rates for inpatient treatment
1.1
Fees, rates for laboratory services
1.4
15,
Fees, rates for outpatient treatment
1.2
Fees, rates for physiotherapy
1.5
Fees, rates for surgical appliances
1.5
Fees, rates for x-rays
1.3
Fees, recovery of by Board where right of
action by patient exists
Yof
Classification, clinical stage, of cancer
CLASSIFICATION OF DISEASES
CLASSIFICATION OF DISEASES, INTERNATIONAL
Classification of diseases,historical review
CLASSIFICATION OF OPERATIONS
Clinical attendance, responsibility of
clerical staff during
Clinic booking methods
'Code of Surgical O p erations' Manual,
described
Coding of operations, procedure
Colour, as applied to forms
Colour coding in terminal digit filing
Colour, use of coloured tabs, in connection
with cancer follow-up
Combination terms, coding of
Committals
Composition of completed medical record
Confidential nature of records
Confidentiality, necessity for, in relation
to cancer registration
Consent for operations, form of
Consent for treatment, who may give
Corneal grafts, pre-operative admission for
Coroner, procedure in regard to deaths.
Counter, split-level recommended
Cremation, procedure regarding
Cremation R egulations 1 939 (reprinted 191+9)
Cross indexing, explained
Daily bed state
Daily returns, admission office
Daily returns, outpatient attendances
Days stay, discharged patients
Death certificate, matching cancer registration
with
Death of patient, regulations concerning
Death of patient, use of medical record after
Deaths, daily return of
Deceased patients, days stay
Decentralised filing system
Deposition before Coroner
Derivation, principles of
Design criteria for forms
Design dimensions for forms
DESIGN OF FORMS
Diabetic conditions, pre-operative
admission for
Diagnoses, incomplete, instanced
Diagnoses, suspected, to be coded as if
certain
Diagram, follow-up appointments, suitable for
.1,1.4.2
11
10
2' 1
12
16,
1.1+
1.1+
2.4
4.1
5.2.3
5.
il l2.4.
5.
=2
6
j,:.1.::
4,4px. A & B
7 .,.
7.8.
3.8.3
t, 7
4,7.
2.2.1
,
•Z, 7.4
z,. 7.5.5...
7.5.2.
17, 22
4,
2,6....:
27.5.1.
7,7.5.2
,4.1
20 1
2
4
.?.2Appx.A
20
7, 7.8
2,8
11,3
Yot
Index
Blood vascular or circulatory system,
explained
Boarding Schools, consent for treatment
for patients from
Bone marrow, described
Bones, classified
Bookings, bed allocations for
Boys employed, Workers' Compensation
Bracelets, identity, use of, on admission
Brain stem,-described
Breastcancer, male, MS38 card for
Built-in-fitments, not recommended
Business reply envelope, use of in
pre-admission procedure.
Cancer, basic facts
Cancer case follow-up
Cancer follow up
CANCER CASE REGISTRATION AND CANCER STATISTICS
Cancer case registration, necessity for
Cancer case registration. procedure,
Central Registry
Cancer case registration, purposes of
Cancer registration and follow-up
Cancer site registers
Cancer staging
Cards, location, index, different types
described
Case notes and medical record,
differentiated
Case notes, good, what they should contain
Case notes, who takes to ward on admission
Cell, described
Census, daily, distribution of
Census, daily information required
Census, daily, patients not influencing
balance
Census, daily, period covering
Census, daily, responsibility for
Census, daily, time at which taken
Census, daily, obtaining relevant information
CENSUS, HOSPITAL
Census, national hospital
Central nervous system, defined
Centralised filing system
Cerebellum, described
Child, as category of admission
Children's age, importance of, for admission
Circulatory, or blood vascular, system,
explained
Classification and nomenclature, differences
between
V
V
9, 5
.2'
2
6.2
2
2
2
7,7.1
4
4.1
21, 3.8.3
3
1.1
17, 2.4
17
5
1.2
17, 2
17,1.4, 1.5
5
3.3.3
17, 4.5.4
3,2.2.1
2,1
2,
7, 7.2
1
7, 7.4
2
8,2.1
2
2.2
2
2.2
22, 8
9, 4
5, 4.2
9, 4
4.1
7, 5
.9 15
10, 4
Admission Office, responsibility for
•,2.2
daily census
Admission office routine
Z' 7
Admission of patients, statutory
provisions regarding
, 5
Admission particulars
Z' 5
Admissions and discharges, for daily
census.
.,3
Admissions by visiting, and full-time staff
Z7.5.3
Admissions by wards
Z ' 75.4
Admissions, classification of, by sex,
•,4•
type and category
Admissions, daily list, distribution of
Z '7.'+
Admissions, daily return of
Z ' 7.5.1
2
Admissions, definition of
Admissions, discharges, deaths, daily
return of
7, 7.5.1
Admissions, pre-operative
7.8
Adult, as category of admission
,
Adverse reactions to injections, infusions
2.7
etc. coding of
11,
22, 6.2
Age, method of recording
Age, of children, for admission
7, 5
Aids to location in index filing
•,2.1.4
Alimentary or digestive system, explained
,8
ANATOMY & PHYSIOLOGY
9
Annual list for each hospital of
morbidity data
4.3
Aorta, described
9, 5
Appointment booking methods
1.2
Appointment clerk, outpatient,
importance of
i,3
Appointments for Accident & Emergency
department follow-up treatment
L6 1 2.6
Appointments, outpatient, calculation
of dates for
-i8,3
Armed Forces, consent for treatment to
7, 6.3
Arrangement, of files
5, 5.2.2
Artificial limbs, fees for
1.6
Artificial limbs, replacement of
1 .6
15,
Assault cases, recovery of fees
15,1
Atria, described
9, 5
Baby, admission of
5
Bed report, ward, example of
Appx. A
Bed state, daily, distribution of
7.4
Bed state, ward, example of
Appx. C
Bed-time Index
4.3
Births and Deaths Registration Act, 1951
4, 5
Births in hospital, policy regarding
admission
Blood, described
7
5
5.1
J,1Z
Index
INDEX
Entries in CAPITALS refer to chapters, other references are to
paragraphs within chapters.
Chapter references are underlined and are followed by the paragraph reference.
Individual pages are not numbered; to locate a reference look
for the chapter number in top right hand corner of recto pages,
then locate paragraph within chapter.
Example: Maiden names, treatment of, in index filing6, 2.1.7
Locate the figure 6 at the top right hand corner which will bring
you to the chapter dealing with 'Indexing procedures'; paragraph
2.1.7 in this chapter deals with this subject.
Abbreviated lists in 'international
Classification of Diseases'
Abbreviations used in case notes
Abdomino-perineal resection,
pre-operative admission for
Abstracting of cancer cases
ACCIDENT & EMERGENCY, AND OUTPATIENT,
DEPARTMENT PROCEDURES
Accident & Emergency department
reception, equipment for
reception, functions of
record, requirements for
Accident at work, admission
Accident details, to be recorded
Accident, motor, admission
Accidents at work, scope of Workers.'
Compensation Act covering
Accidents, coding of
Account, treatment for accident at work
Act, Poisons, 1960
Act, Tuberculosis, 1948
Act, Workers' Compensation, 1956
Administrative statistics., defined
Admission, acute, definition of
Admission, booked, definition of
Admission office, equipment for
Admission office, functions of
ADMISSION OFFICE PROCEDURE
10, 5
,7.8
17, 4
16
3.7.6
1.'
3.2.6
16, 2.2
7, 5.2
2.2
5.2
1.9.2
15,
11,2,6
15, Appx. 1
14, 3
2.3
Appx.
A
iLL,
15,
1 et seq
2.1
7, 2
2
21, 3.7.3
21, 3.2.2
7
4th mt. CongressThe Proceedings of the Fourth InterReport:national Congress on Medical Records,
October 21-24, 1963, Pick-Congress
Hotel, Chicago, Illinois, U.S.A.
(Chicago, 1964)
References
Nursing Mirror:Nursing Mirror & Midwives Journal,
Iliffe Technical Publications Ltd.,
Dorset House, Stamford Street,
London, S.E.1., England. Weekly
Nursing Research:
American Journal of Nursing Co.,
10 Columbus Circle, New York 19, N.Y.,
U.S.A. 3 times a year
Nursing Times:
Royal College of Nursing. Macmillan &
Co. Ltd., St. Martin's Street, London,
W.C.2., England. Weekly
Office:
Office Publications Co., •232 Madison Ave.,
New York 16, N.Y., U.S.A. Monthly
Office Magazine:
Current Affairs Ltd., Box 109, Davis
House,. 69-77 High Street, Croydon,
Surrey, England. Monthly.
Office Methods &
Machines:
new title of Office Magazine
Radiology:Official journal of The Radiological
Society of North Ameria Inc.,. 20th &
Northampton Streets, Easton, Pa.,
U.S.A.. Monthly
Official Organ of the Institute of
The Hospital:
Hospital Administrators, 75 Portland
Place, London, W.1. England. Monthly
1st mt. CongressThe Proceedings of the First InterReport:national Congress on Medical Records,
King's College, London, 8 - 1-2 September 1952, under the auspices of
Association of Medical Record Officers,
London, (1953)
2nd mt. CongressThe Proceedings of the Second InterReport: national Congress of Medical Records,
October 1 - 5, 1956, Shoreham Hotel,,
Washington, D.C., U.S.A. (Chicago 1957)
3rd mt. CongressProceedings of the Third International
Report: Congress on Medical Records, Assembly
Rooms, Edinburgh, 25 - 29 April 1960,
Edited by Elsie Poyle Mansell, F.M.R.
& Norman V. Jackson, A.M.P. Edinburgh,
Livingstone, 1960
Hospital Topics:Hospital Topics Inc., 30 W Washington
Street, Chicago 2, Ill., U.S.A. Monthly
Hospitals:Journal of The American Hospital Association, 8k0 North Lake Shore Drive,
Chicago 11, Ill., U.S.A. 1st and 16th
of each month
Jnl. AAMRL:Journal of The American Association of
Medical Record Librarians. Bimonthly by
the Association at 211 East Chicago Avenue,
Chicago, Illinois 60611, U.S.A.
Jnl. American535 N Dearborn Street, Chicago,
Medical Association:Ill. 60610, U.S.A. weekly
Lancet:
The Lancet, 7 Adam Street, Adeiphi,
London, W.C.2. Englandweekly
Medical Record:
The Medical Record, official journal of
the Association of Medical Records
Offióers, 108 Brooksby Road, Ti'lehurst,
Reading, Berks., England
New title, of Jnl AAMRL from 1962
Medical Record News:
Medical Statistics • now National Health Statistics Centre,
Branch, Department of Box 6314, Te Aro, Wellington
Health, Wellington:
Modern Hospital:The Modern Hospital. ' Monthly by The
Modern Hospital Publishing Co.: Inc.,
1050 Merchandise Mart, Chicago 5+,
Ill., U.S.A.
National Hospital:Journal of Australian Hospital Assn.
Australian Trade Publications,
243 Elizabeth Street, Sydney, N.S.W.,
Australia. Bi-monthly
N.S.W. HospitalsNew South Wales Hospitals Commission,
Commn.Sydney, N.S.W., Australia
N.Z. Hospital:
New Zealand Hospital, the official
journal of the New Zealand Hospital
Boards and Hospital Officers' Association, Box 981, wellington. Quarterly
N.Z. Medical Record:
New Zealand Medical Record. • Journal
of the N.Z. Medical Records Officers'
Association (Inc.) Editorial 'address:
Box 2656, Auckland. 3 issues a year.
to I
References
REFERENCES
Explanation of references (where these are not fully described
under 'References' or 'Further reading')
Anaesthesia:
Anaesthesia & Analgesia. International
Anaesthesia Research Society, Wade Park
Manor, E 107th & Park Lane, Cleveland 6,
Ohio, U.S.A.Bi-monthly
Canadian Hospital:
Canadian Hospital Association,
25 Imperial Street, Toronto 7,
Canada,Monthly
Canadian Medical
Association Journal:
1 5 0 George Street, Toronto 5, Canada.
Weekly
H.M.S .00
Hospital Abstracts:
Hospital Administration:
Her Majesty's Stationery Office,
3 9 High Holborn,, London, W.C.i.
England
A monthly survey of world literature
prepared by The Ministry of Health,
London, H.M.S.O.
Horwitz Publications Inc. Pty, Ltd.
39 Martin Place, Sydney, N.S.W.
Australia. Monthly
Hospital Administration and Construction:
1+50 Don Mills Road, Don Mills,
Ont., Canada
Hospital & HealthVictoria House, Masona Hill, Bromley,
Management: Kent, England. Monthly
Hospital & Social 27-9 Furnival Street, London, E.C.1+.
Service Journal:England
Hospital Forum: Hospital Council of Southern California,
4747 Sunset Blvd., Los Angeles 27,
California, U.S.A.
Hospital Progress:Journal of Catholic Hospital Association
of The United States & Canada, 1438 W Grand
Blvd., St. Louis Lf Mo., U.S.A. Monthly.
23
Paediatric BedsBeds assigned for regular, use by
patients other than newborn who
are not classed as adults by the
respective Hospital Board
Patient
A person receiving physician,
dentist or allied services in a
hospital
Patient DayThe unit of measure denoting
facilities provided and services
rendered to one inpatient between
the census taking hour on two
successive days
Patient Identification FormThe sheet of the papers relating
to the inpatient treatment on
which are written the patient's
sociological data
Patient IndexThe index maintained at the
hospital of those who are either
in the hospital or have been
admitted to the hospital and
subsequently discharged
Pre-admission FormThe form on which a booked patient
is requested to give information
prior to his admission to hospital
Re-admission(1) For hospital purposes: a case
that has previously been
admitted to the hospital and
is re-admitted to the same
hospital for any reason.
(ii) For MS18 statistical card
purposes: a case that has
previously been admitted to
a public hospital and is
re-admitted to any other public
hospital in New Zealand on
account of a continuation of the
same illness or injury.
Ward BulletinThe form which is filled in regularly by ward staff for the information of staff answering telephone
enquiries regarding patients
406
Medical TypistTypist employed exclusively on the
typing of letters and reports for
medical staff
MS18 Statistical CardThe IBM punch card made out for
each hospital inpatient and sent
to the Medical Statistician
Outpatient One who attends the clinical
service of the hospital for diagnosis or treatment on an ambulatory
basis in a formally organised unit
of a medical or surgical speciality
or sub-specialty
Outpatient Attendance The formal acceptance by the
hospital of the patient who is
not to be lodged in the hospital
while receiving physician, dentist
or allied services at the hospital
Outpatient Case Notes The papers relating to an outpatient's attendances at hospital
while a patient
Outpatient DepartmentThe department responsible for
allotting booking times for
outpatients and for the reception
of outpatients
Outpatient Medical RecordThe completed case notes relating
to an outpatient's attendance at
hospital after final treatment
Paediatric AdmissionThose accepted for lodging in a
child bed facility
(If the distinction is made:No. of inpatient beds regularly
maintained in areas intended for the
Paediatric Bed Establishment)
lodging and full-time care of
children and infants other than
newborn, during periods of normal
operations. This classification
would be maintained only by those
hospitals providing separate
paediatric facilities
23
Daily Average Occupied BedsThe average no. of inpatients
•.maintained in the hospital each
•
day for a given period of time
Daily Bed StateThe no. of beds actually occupied
by patients in the hospital at a
given time.
Discharge
The termination of the granting of
lodging and the formal release of
an inpatient by the hospital.
Disease Index.The index maintained by the Medical
Records Department of patients
treated under the diagnosis of the
patient
Emergency OutpatientOne who attends the Accident &
Emergency or equivalent service of
the hospital for diagnosis and
treatment of a condition which
requires immediate physician,
dentist or allied services
Enquiries
The department of the hospital
responsible for answering
enquiries regarding patients'
condition
Inpatient
A patient who is given 'lodging
in a hospital while receiving
physician, dentist or allied
services in a hospital
Medical Admitting Officer The medical officer responsible
for arranging for the admission
of patients
Medical Record• The completed case notes relating
to an inpatient's stay in the
hospital after discharge
Medical Records Clerk(s)The staff member(s) responsible
for the day to day routine work
of medical records.
Medical Records DepartmentThe department of the hospital in
which medical records are housed
Medical Records Officer The staff member responsible for the
department housing inpatient records
Average Days' StayThe average no. of days of service
rendered to each patient discharged during a given period
Average Occupied Beds The ratio of actual patient days to
the maximum patient days as determined by bed capacity during any
given period of time
Bassinettes Beds assigned for regular use by
infants newly born in the
hospital and which are maintained
in areas allotted for newborn
infant lodging
(If the distinction is made: No. of inpatient beds regularly
maintained in areas intended for
Bassinette Establishment)
the lodging and full-time care of
newborn infants during periods of
normal operations
Bed
Space regularly maintained in a
hospital for the use of patients
Bed EstablishmentNo. of beds regularly maintained
for inpatients in a hospital
Births
Those newly born in the hospital
and accepted for lodging in a
newborn bed facility
Case Notes The papers relating to an
inpatient's stay in the hospital
while a patient
Census
(i) The daily count of patients
occupying a bed in hospital
taken at the same time each day
('Daily census')
(ii) The annual count of patients
actually occupying a bed in
hospital taken for the Department of Statistics as at midnight on 31 March.
(iii) The quinqueninal count of patients
actually occupying a bed in
hospital taken for the National
Health Statistics Centre
4..;
23
GLOSSARY OF TERMS
Term used
Definition
Accident and EmergencyThe office responsible for the
Department reception of emergency outpatients
Admission
Formal acceptance by a hospital
of a patient who is to receive
physician, de'ntist or allied
services while lodged in the
hospital
Admission OfficeThe department of the hospital
responsible for the admission
of patients
Admission Officer The non-medical member of the
staff of the hospital responsible
for the department dealing with
the admission of patients
Admitting Officer See 'Medical Admitting Officer'
Adult Admission]hose accepted for lodging in
adult bed facility
Adult Bed
Beds assigned for regular use by
inpatients who are regarded as
adults, according to the age
specified by the respective
Hospital Board
(If the distinction is made: The no. of inpatient beds
Adult Bed Establishment)regularly maintained in areas
intended for the lodging and
full-time care of adult inpatients (even though in some
instances utilised by children)
during period of normal operation
Available beds Number of beds equipped and
staffed for immediate use by
patients
Whereas most inpatient hospital morbidity studies are
confined to information about patients as they leave hospital
in a given time (usually a calendar year) in an inpatient cohort
study a group of patients is selected at the time of admission
and its subsequent history in terms of readmission, illnesses
and treatments over a period of time is recorded and later
analysed.
References: 10.
Hospital Statistics Handbook, Wellington, Medical Statistics
Branch, Department of Health (1963)
Heasman (Dr. M.A.) Manualon Hospital Morbidity Statistics.
Draft issued by W.H.O. National Committee on Vital and Health
Statistics, 1963
Hospital Statistics of New Zealand 1 Wellington, DirectorGeneral of Health, annually
International Classification of Diseases, 2 vols. Geneva,
W.H.O. 1957
Elderly Persons' Accommodation Needs in New Zealand,
Wellington, Department of Health. Special Report Series
No. 10 (1963)
Report on the Medical Statistics of New Zealand Pt. I
Mortality & Demographic Data, Part III - Hospital and
Selected Morbidity Data, compiled by the National Health
Statistics Centre of the Department of Health, Wellington.
Wellington, Government Printer, annually
Maori Patients in Public Hospitals, Wellington, Department
of Health, Special Report Series No. 25 (1965)
Further reading: 11.
Diagnostic summary sent yearly to each hospital, Special
Report Series issued by Department of Health
Moroney (M.J.) Facts from Figures, Pelican A236.
Harmondsworth, Penguin Books, 1960.
ii
I
expense.Obviously while more accurate answers to questions can
be obtained from controls in a medical care environment it would
be much more preferable to have comparisons made with people who
were not sick i.e. the general population. Smoking histories are
an example of this preference because it has been shown that
hospital controls invariably yield a higher proportion of smokers
for each sex than controls of comparable age drawn from the general
population. This points to the fact that smokers have higher
admission rates.Tuberculosis, various respiratory diseases and
coronary artery disease have all been shown to be associated with
a long smoking history and the use of patients with these diseases
as controls could easily lead to missing the association with
smoking history. However, as cancer of the lung is so very strongly
associated with heavy cigarette smoking, the use of hospital controls even with the disease mentioned will only yield underestimates
of the degree of the association.
The person assigned the job of selecting controls mus.t avoid
interview bias which could either obscure or exaggerate an assôciatjon. There is an admitted difficulty in the smaller hospitals
that a suitable control may not be readily available; for. ±nterview:
at the particular time the diagnosed case is available. However,
the problem can always be handled by anticipating that controls of
certain ages and sex will probably be required some day and a
sensible approach could be the building up of a reference list of
patients already interviewed with their histories recorded.
In a New Zealand co-operative hospital survey, acute myocardial
infarction in Maori women (a high risk group) is compared with the
same condition in a control group of European subjects. Stage 2
of the project includes a follow-up examination of each person in
the study to obtain the further history. It is not unlikely that
Medical Records Officers will in future become involved in the
recording of the data for these enquiries so that not only comparisons can be made with cases of any disease in New Zealand hospitals,
but also with people of different races in hospitals in other
countries of the world. These comparisons are designed to identify
racial and environmental (including dietary) causes of disease.
9.6
The cohort study
A technique combining aspects of both prospective and retrospective studies of a special type has become popular during
recent years. This is known as a cohort study. The term cohort
means people banded together.
22
association of the disease with the factor relative to the risk
of those without the factor.
With factor Free of factorTotal
With the disease--Free of the disease --A routine statistical test of association can be applied to the
figures entered in this sample table to show whether there is a
significantly greater incidence of the disease among those with
the factor.
We have in New Zealand a collection of data in respect of
every cancer of the lung case diagnosed, the object being to
uncover the features which led to the development of this
disease in these unfortunate persons. If we know that 95 per
cent or more of persons who have lung cancer are smokers shall
we conclude that smoking in itself brings on lung cancer?
Clearly without some knowledge of the background of persons who
do not have lung cancer we have no way of deciding whether the
proportion of smokers with the disease is unusually high or low.
Therefore in order to arrive at any valid conclusions we must
plan to have controls who differ in no known way except that of
the suspect factor. This system is called "pairing" and it
involves the selection of another patient in the hospital of
the same age and sex, race, country of birth and social circumstances as the lung cancer victim. In fact, the ideal match for
a control would be the identical twin of the patient with the
disease if such existed and was available. The ideal control is
quite impracticable due to the difficulty of locating a control
subject.
Doll and Hill in their study of the connection between
tobacco smoking and cancer of the lung analysed the results not
only by amount of smoking, duration of smoking, method of
smoking and type and site of the cancer, but also compared the
test and control groups in a variety of factors which might
influence the observed association between smoking and lung 'cancer.
The two groups were compared with respect to sex, age, occupation,
social class, place of residence, exposure to different forms of
heating, history of previous respiratory disease and residence
near gas works. Smoking was the only factor which showed a highly
significant association, the testing of the other factors mentioned
serving to add strength to the findings. In actual fact hospital
patient controls are not ideal for this type of matched experiment
and are only used because Of easier accessibility and lesser
'9,
forward enquiry has been the dental caries incidence of children
in different areas in New Zealand, one group using fluoridated water
and the other a non-fluoridated supply. In the same way the subsequent development of babies born prematurely and babies born at
term may be compared. The principal data on the death rates of
smokers of various types and of non-smokers came from seven large
studies of men who were followed-up and whose death certificates
were obtained if they died during the period of the survey.
Prospective studies, it should be noted, need not necessarily
involve a subsequent period of waiting. Provided the information
is in the notes one can reconstruct a population as at some past
date and study the experience with respect to the occurrence of
some event after that date.
905 The retrospective study
The retrospective inquiry starts with the event e.g. the
patient with a specific disease, and the investigation is an
attempt to identify the factors which influenced the development
of the disease. The past history method of investivation of
causal factors goes back to the time of Hippocrates. With
diseases of low incidence the controlled retrospective study may
be the only feasible approach. For example, the association
between German measles in a pregnant woman and congenital malformation in the child born to her could only. be investigated by
a retrospective enquiry since the proportion of women who contract
rubella during the early months of pregnancy is so small that a
prospective study would be ruled out because of lack of significant numbers to compare with the mothers who had not contracted
measles (controls). This retrospective technique is used at
Podwell Park Cancer Hospital, New York, for research into causal
• factOrs in cancer of various sites, a team of trained interviewers
recording the answers to questions put to the cancer patient
concerning diet, living habits, general environment, etc.
9.5.1 Choice of a control group
When we have details of a group of patients with a particular disease and we are searching for the factors which may be
responsible for its development, then the need arises for the
selection of yet another group of persons who do not have the
disease, so that we can compare the relative occurrences of the
suspected causal factors. From comparison of the two groups we
produce a table like this showing us clearly the strength of the
3t
22
total cases from which they were drawn. In other words, when
doing an ad hoc survey complete coverage of all cases is not always
possible or required and is frequently wasteful.
Suppose we wished to learn whether the average haemoglobin
of the blood of Maori children was the same as that for non-Maori
children then obviously it would be impossible to take the
haemoglobin value for all Maori and for all non-Maori children.
Consequently the question would have to be answered by samples.
Hospital statistics in England and Wales are collected on a 10
percent sample basis which is quite understandable when it is
realised that discharges per year number 31 million.
When carrying out a survey by sampling methods it is
inevitable that sampling errors of •a statistical nature are
introduced. The organiser must strike a balance between the
outlay in terms of time, staff, etc. and the amount and quality of
information required. No specific rules can be laid down as to
what constitutes a good sample and a number of facts must be
considered before an answer can be given. Just as individuals
within a group vary from each other so do groups as a whole vary
from one another. If, for example, successive groups of children
are examined for their haemoglobin level, not only ouid the
individuals differ as to haemoglobin values but the mean values
would not be identical.
For all practical purposes what is known as a quasi random
sample is adequate for hospital survey purposes. To pick a
sample it is only necessary to use the terminal digits for the
serial number to select the requisite records for analysis..
For example, to pick a five percent sample those ending in, say,
14, 34, 54, 74 and 94 could be selected.
Tables are published in text-books on statistics to determine
the size and adequacy of samples under a variety of conditions,
and it is necessary to consult the statistician for a decision on
their application to any particular project.
The prospecive study:
9.4.
A prospective or forward study starts with a defined group
of people who are kept under observation over a period of years
to determine the frequency with which some disease occurs. A
questionnaire is designed to record the same amount of information
as regards those who develop a disease and those who do not. This
method-has been employed in wide variety of studies. A typical
Ui
The box' type of question runs as follows Pace:
European
J
N.Z. MaoriJ
Asian
J
Pacific IslanderOther
1
State
Against this particular method of completion is the fact
that it is rather wasteful of space and it may be preferable to
use the traditional type of answer where simple answers such as
the age of the patient or the number of weeks on the waiting list
are required.
A lot depends on the purpose to which the answer is to-be
put. For instance it is futile to have little boxes to be ticked
for the recording of the period on waiting list in broad groups if
the average period is to be calculated.
The positioning of the questions should follow a rational plan
and as far as possible should be broken into sections which are.
plainly distinguishable. Space should be available along the left
or right hand margin of the form for code numbers to be inserted.
Self-coding forms are those in which the code numbers are placed
against the various alternative answers and it will be necessary
to transfer the number marked into the coding margin, unless of
course the coding boxes themselves are inserted in the coding margin as is done with the Cancer Statistics collection cards.
9.2
The pilot survey
When it is thought that the questionnaire is ready for use
it is always preferable to get a dozen or twenty peopleto answer
it before starting the collection proper. It will generally be
found that several questions are ambiguous or not clear and these
need to be rephrased.
9.3 Sampling
Sampling is the selection of a smaller number of cases which
are representative of the whole and an examination of the cases
selected so that conclusions drawn from them may. apply to the
2?
we mean only New Zealand Maoris and do not include persons
of the same race who have their origins in the Pacific
Islands.
When the questionnaire is filled in during an interview
a most satisfactory way of recording the information is
to ask for tyesI,11noll "dont' know" answers • For
instance, if it is necessary to find out if the person
interviewed had a history of epilepsy it would be preferable to ask this question and record the answer as
"no", "dont' know" rather than to ask "State Whether
there is a history of epilepsy" and ,leave .a blank space
for the answer. If the "yes" "no" "don't know" method is
used it is possible to separate those cases where , it is
known there is no history of epilepsy from those cases
where it is not known whether there was Ia history of
epilepsy or not. If the blank space method is used,
there is usually a fairly large proportion of cases which
either have not been answered or have been answered in
such a way that it is not possible to interpret the answer
with any degree of confidence.
To take a hypothetical example, if five perceiit of the
respondents in such a. survey said they had a history of epilepsy,
20 percent said there was no history of epilepsy and 75 percent
did not answer at all, no worthwhile conclusion could be made
from the data collected because of the impossibility of interpreting the 75 percent of "nil" responses.
The detail concerning each person should be recorded on
a.separate form or card. In this way the person and his
numerous characteristics which have been recorded can be
manipulated into groups of "like with like". Unless a separate
form is introduced for each case, it is necessary to use
columns in a register and columns cannot be physically shifted
about and sorted..
All the categories in the answer which can be expected
should be entered on the form. This is best achieved by
providing alternative answers where suitable. When this method
is adopted the answer can be given by ticking small boxes, by
deleting alternative answers or by circling the required answer.
as a consequence stifled at birth, the would-be investigator
realising that he does not after all require a mass of information
or even if he collects the information he will not find it as
useful as he imagined.
The seond stage is to frame the questions so that they conform
to the following criteria The questions must be written in such a way that the
people supplying the answers understand what is required.
For example, if expectant mothers were asked to supply
information about their diet it would not be advisable
to ask questions about proteins and carbohydrates but
about meat, cheese, bread and so on.
Questions must be unambiguous. The writer of the
question might have a clear picture of what information
he wants to collect but unless the question he asks
cannot be misconstrued he cannot be sure that he will get
the right answer. For example, if in a study of the
harmful effects of working with x-rays, radiographers were
asked, "How many years do youintend to work as a
radiographer?", some would probably interpret this as
"How many years longer do you intend to work as a radiognapher?" while others would probably interpret this as
"How many years do you intend to work as a radiographer
including those years already worked?"
Another example of ambiguity concerns smoking habits.
It would not be much use asking "Do you smoke?" because
apart from the great differences there would be in the
amount smoked of those answering "yes", the man who had
never smoked in his life and the man who had given up
smoking only six months ago or perhaps even days ago
after smoking heavily for 40 years would both answer
"no".The greatest safeguard against ambiguity is to
refer the questionnaire for comment to as many people as
practicable before the survey proper is made. This
procedure is known as a pilot survey and is discussed
further below.
Special terms should be defined where possible. For
instance, if information about Maoris and non-Maoris is
being collected the definition of Maori should be given.
For some purposes the definition might be a person of
half Maori blood or more. Again when we talk of Maoris
/
22
The need arises from time to time for morbidity information
which is unobtainable from routine statistics. In such instances
a special one-purpose, one-time analysis of hospital notes would
need to be conducted. For example, information may be desired
either at a local level by hospital administrators or at a
national level by the Department of Health as to the type of
admission (emergency or waiting list), period On waiting list,
distance travelled to hospital, type of discharge (for rehabilitation purposes), types of treatment carried out for certain
conditions and their outcome or even in respect of problems of
nursing or personal care. One survey of this kind to shed light
on the respective roles of hospital and home in meeting the
medical and social needs of the elderly is documented in a Health
Department Report "Elderly Persons' Accommodation Needs in New
Zealand" (Department of Health Special Report, Series No. 10,
April 1963).
•It is conceivable that in the future there will be expansion
into new subject areas, in which the answers will not be contained
in the patient's notes. The question here will have an epidemiological purpose, background information to the hospitalised
sickness being sought in the war of living and eating habits,
occupational status of patient, past sickness episodes, etc.
In this type of interview survey, probe questions have to be put
to elicit the required answers.
An ad hoc survey cannot be carried out on the spur of the
moment and much careful planning is required at the onset. In
particular does this warning apply to the design of the questionnaire or collection form although the necessity for both consultation with a statistician and a trial run are emphasised before
the ad hoc study gets under way.
The design of . the questionnaire or transcript form: 9.1.
The very first move must be to write out the aim of the ptudy
and to specify the topics about which information is needed. Too
many ad hoc studies are carried through to the point where results
have been tabulated from punch cards only to . find that the
answers obtained still do not provide answers to the questions
that prompted the study in the first place. If on the other hand
the aim and topics are written down at the onset the person
wanting the information must clarify his own thinking and by
putting his thoughts on paper can critically evaluate what he has
written.If this procedure is followed some ad hoc studies are
The information collected at the time of the census in 1966
was Name of hospital
Name of patient
Sex
Marital status
Age
Race:Maori/non-Maori
Domicile
Date admitted
Diagnosis (principal disease or injury for which admitted)
Speciality (of physician or surgeon under whose care
patient was at time of census, e.g.
orthopaedic, E.N.T.j psychiatric)
Was this a waiting list admission: yes or no
For the 1966 waiting list census the information obtained was:
Name of hospital
Name of patient
Sex
Age (at time name was placed on waiting list)
Date last contacted
Principal condition (for which treatment to be given)
In most hospitals the night nurse or ward sister in charge Of
each ward was the person delegated to fill in the return as at
midnight on the date chosen which was 22 March 1966. An analysis
of the returns received in 1951 is contained in two tables in the
Medical Statistics Report - Part II Morbidity, 1961, One table
covers occupied beds in private hospitals and the other beds in
public hospitals by disease groups and ages. The analysis shows
that the public hospitals are utilised more by persons in the
younger age groups. This is evident for every age group up to 65
years, thereafter the private hospitals show the greater proportion
of older patients.
9.The ad hoc study
There are certain types of investigation and statistical
activity in which the Medical Records Officer may become involved
other than routine national collections of patient data.
p91.
22
The procedure suggested is that as case records are
returned for filing the record clerk makes an entry in the
appropriate place on a working sheet, one of which is provided
for each column in the final table. At the end of each period
the figures for the period are written on the final form which
is then transmitted to the central office.
Tabulation
Lack of flexibility severely limits the tabulations and they
can be no more than summaries of the information provided forthe
whole area covered by the survey, or for different parts of it.
Pates can be calculated if the respective populations are available. A series of successive returns can be used to produce time
trends for particular aspects or can be summarised to produce a
single return for the whole period.
National hospital census taking inpatients and waiting-list patients: 8.
The routine collection furnishes us with a great deal of
information obtained after the discharge or death of the patient.
We are able to obtain from our routine statistics for any
hospital and for all hospitals combined, a measure of the
relative incidence of broad groups of diseases, by sex, age,
period in hospital and average stay. These data are sufficient
for most purposes but because the records are processed only
after the end of the patient's stay, it can be a very long time,
in the caseof chronic cases, before particulars of a case in
hospital come into the statistics. It is through this influence
that the bed requirements for pulmonary tuberculosis of 12 per
cent appears from the figure of discharges and deaths to be only
2.7 percent.
A census taken of inpatient population involves the completion of a card on a particular day for each patient either in.
hospital or on the waiting list for hospital admission. This
type of study gives us a cross-sectional picture of both old
occupancy and the unfulfilled demand for hospital beds. by type
of sickness. This census information is essential for hospital
planning on a national basis and for comparison of trends of
hospitalisation over a long term. By taking a census at
intervals of five years changes in trends of the causes of
hospitalisation can be measured and bed requirements for broad
groups of diseases can be forecast.
STATISTICS OF OUTPATIENT CONSULTATIONS
Period ended.............. 19.....,
Name of hospital........ ....
Return for MALES/FEMALES*
.................o...
New casesOld cases
Department
-P0 Ho0 xi
(tHC.r1
cd
+o
Ho0 J1. co 10 All
-'O1C.rI5•rl
-0)-1
(I) Cu 00 C5 Q
a) •d 44
Cu (1) .d
H ESeS.
ESa5
Ed'dOOOP Edd 000
Ci.r-1 Cu
43
U)
Cu
U)
co Q Cu
a)CtiCHOZC)110
-H CZ
General medicine
Paediatrics
Infectious disease
Diseases of the chest
Other medical specialities
Chronic sick
Geriatrics
General surgery
Ear, nose and throat
Traumatic and orthopaedic
surgery
Ophthalmology
Other surgical specialities
Gynaecology
Obstetrics. .
Special care babies..
Other, specialities' ...
General practice units
Maternity
Other medical
Dentistry
lUTALi
*Delete whichever is not applicable
C
r1C
a)_ZO-
cases
22
(c) Disposal For administration purposes, it is important
To make some estimate of the number of admissions likely
to result from outpatient consultations. To this end
it is suggested that new and old cases each be further
subdivided as follows
(i)
(ii)
(iii)
(iv)
for immediate admission;
for eventual admission;
for further consultations;
no further consultation likely.
(d) Sex It is preferable to differentiate between the
sexes of patients.
(e) Age While it is desirable to record' the age of patients,
broad age-groupings will usually be sufficient. This
item is one which can be dispensed with if it is desired
to keep the work of the records clerks . to a minimum.
(f) Other items Among these can be counted area of
residence, occupation, detailâ of how patient came to be
seen, e.g. on recommendation of general practitioner,
from another hospital, on patient's own account, etc.
If any of these factors are included, then others, e.g.
age, will probably have to be dropped.
For the normal outpatient survey the following factors
will be the maximum if the summary method is to be used:
type of case (new or old), sex, department or diagnosis,
disposal, or another factor, e.g. age • If more
information is required, then a more detailed method
should be used.
Form design
On the following page is shown a suggested design of a
form for the survey described above.
• Collection of data
With the number of. items on this form it is suggested that
weekly returns should be made: if less information is required,
i.e. if one axis of classification is not desired, then it may be
possible to lengthen the period between returns.
14
most that can be expected in any statistical investigation
is that some small entry be made as each patient's notes are
filed away. It is therefore necessary that the organisation
of an inquiry into outpatient morbidity should be highly
selective, and with definite aims in view, although certain
statistics of a general nature may also be collected. It is
necessary with outpatient statistics to distinguish the "new"
from the old cases, and it is probably fairly simple to do so.
The number of follow-up attendances for any one illness may
be quite large but very often old patients attend different
sessions to new patients, this making separation easy for
statistical purposes.Although epidemiological uses-of
outpatient statistical data are many, they are not developed
enough for routine use at the present, and therefore the
suggestions given below for form design will be centred mainly
on routine medico-administrative uses.
Data to be collected
(a) Total outpatient attendances This should be subdivided
into new and old cases. A workable definition of a new
case is a patient attending the outpatient department of
the hospital for the first time for advice or treatment
of a particular condition.
(b) Diagnoses or departments Whether a diagnostic hat should
be compiled is problematical. Many patients seen are not
diagnosed completely on first attendance. They may require
several consultations or even inpatient care before a firm
diagnosis is made, and therefore any diagnostic list must
necessarily be a rather crude one. On the other hand, a
list of departments or specialties with number of attendances at each, gives little indication of the diagnosis.
Nevertheless, for most medico-administrative needs such a
list is probably to be preferred.
It is suggested that departments be classified, so that
addition is facilitated into four major 'specialties,
medicine, surgery, obstetrics and gynaecology and.
paediatrics.
Thus, medicine may include the departments of cardiology,
neurology, diseases of the chest, psychiatry, haematology,
endocrinology and geriatrics as well as general medicine.
116,
22
Outpatient analyáes:
7.
Outpatient and Accident and Emergency department procedures
are described in chapter 16. Some statistical analysis of outpatient attendances at clinics is carried out in each hospital
but nothing appears to have been done in this country in the way
of a statistical analysis on a national scale.
Statistics obtained from hospital boards show attendances
at outpatient clinics numbered 2 9 80 7,456 including 66,611
attendances for dental outpatients, in the year ending 31 March
1966. With such large numbers involved there is a need to resort
to sampling methods if an anlysis in depth were to be attempted.
Dr. M.A. Heasman, author of the "Draft Manual of Hospital
Morbidity Statistics" issued by the World Health Organisation, has
the following to contribute on the subject of outpatient
statistics. He recommends the use of the summary method of
reporting to a central authority:
" There are certain aspects of general morbidity which may
be worth investigation from the viewpoint of outpatient
statistics. Some conditions are very often peen in outpatients and yet only rarely admitted to hospital. For
example, in well-developed countries most diabetic patients
probably attend a diabetic clinic at, one time or another;
many patients with varicose veins will have them injected
or ligatured in the outpatient departments; much sighttesting is done there, and yet with these conditions it is
only rarely that inpatient treatment is necessary.
There are, therefore, aspects of morbidity which can be
investigated by a study of hospital outpatients, but it is
to medical administration that we must turn for the greatest
uses of the data. In the design of outpatient departments
it is of value to know the distribution of cases between
one consultant and another, to know the number of cases
requiringradio_therapeutjc treatment or some form of
operative treatment. Further, it is of value to know the
number of patients who require admission and the number who
are returned for treatment under their own doctors. There
are, therefore, a large number of uses for the data, but by
its very nature the problem demands simplicity of treatment.
Too many people are seen in the average outpatient department
for any detailed statistical data to be collected relating
to individual patients, without special arrangement. The
#7
It will be noted that hospitals can send in the statistical
cards on either a quarterly of a monthly basis, whichever is
preferred.
Filling in the card: The figures entered on the MS17 Summary
Card do not include normal maternity cases or normal nurslings
unless these cases occupied general instead of maternity beds.
Line 1 Enter the number of patients in hospital at the
beginning of the period
Line 2 Enter the number of patients admitted during period
Line 3 is the sum of lines 1 and 2
Line Lf Enter the number of patients discharged ,ortransferred during, the period
Enter
the
number of patients dying during the 'period
Line 5
Line 6 is the sum of lines Li and 5
Line 7 Enter the number of patients in hospital at the
end of the period .
.. The figures in line 7 will be carried forward to be entered
on line 1 of the MS17 card for the next period.
Before the statistical return is sent in the MS18 Statistical
Cards must be checked with the totals on the MS17 card. The
numbers shown in lines 1 4 and 5 must agree absolutely with the'
number of MS18 Statistical Cards that are sent in. Another check
that must be made is that the figures entered in line 3 agree with
the sum of those entered in lines 6 and 7. If there is not
complete agreement between these two sets of figures then there is
a mistake in the return.
The MS18 Statistical Cards should be sent in, in four groups
sorted thus:
1. Male deaths
2. Female deaths
3. Male discharges and transfers together, and
14. Female discharges and transfers together
Note: The forwarding of a monthly or quarterly return must not be
delayed because a small num1ierof case notes have still to be
written up. In this eventuality insert the number of cards which
make up the full return in lines 4 and 5 with the words "see over"
under line 6. Then write the serial numbers and patients' names of
the omitted cards on the back of the MS17 Summary Card.
3,';
22
Filling-in the MS17 Summary Card:
A copy of the MS17 Summary Card is reproduced below.
HOSPITAL STATISTICS
IL—U.S. 17
SUMMARY CARD FOR MONTHLY OR QUARTERLY RETURN
(11 it is more convenient, hospitals may arrange with this oca to send in their
returns on a monthly basis.)
This card (together with the M.S. 18 statistical cards)is to be not to the Medical
Statistkisn Boa 6314 Wellington C. 2 immediately alter the end of the month or quarter.
Name of Hospital:._.
*Monh/ Quarter ended:
.. ....
l9....
Nom—The figures entered on this card must not include normal maternity
cases or normal nurslings.
Males f Females I Total
1.Patients in hospital at the beginning
of month/quarter*
2. Patients admitted (or readmitted)
during month/quarter*
3.
Total.
4.Patients discharged or transferred
5.Deaths- 6. M.S. 18 cards sent in must agree with
the figures entered against this (6)
heading.
Total
7.Patients remaining in hospital at
end of month/quarter*
Nora—The figures entered in (3) must agree with the sum of tines 6 and 7.
Delete whichever does not apply.
(Signed)--3,00018/63-74957 W
Medkal
6.4.
(ii) Sex: Mark M for males, F for females
(iii) Period in hospital: Mark all three columns, e.g. for one
day in hospital mark 001; for 22 days in hospital mark
022; for 333 days in hospital mark 3334
1,000 to 1,999 days: Mark the '1' in the cage above the
first column, and the appropriate numbers in the three
columns, e.g. 1,162 days should be marked '1' and '1' in
the first column, and 1 6' and 1 2' in the second and third
columns.
2,000 days and over: Mark the 1 2' in the cage above the
first. column, and the apprppriate numbers in the three
columns, e.g. 2,162 days should be marked 1 2' and '1' in
the first column, and 1 6' and 1 2' in the second and third
columns,
(iv) Disease A, and Accident Details:In all cases where
there is no fourth digit in the code number the 'X' must
be marked in the fourth column, e.g. diabetes mellitus
should be marked 1260X'.
(v) Discharged, Died, Transferred: Mark the appropriate
category in the last column on the front of the card.
(vi) Disease B, Disease C, Occupation, Domicile, Operation. A
and Operation B: These columns are not to be marked.
(vii) First admission: Mark 1. or 2 on column 9 on the bacI
of the card.
(viii) Race: Mark 1, 2 or 3 (Maori, Pacific Islander or other)
in column 8 on the back of the card.
(ix) Operations: Mark 1 0' in the unlabelled column .7 on the
back of the card according to the instructions below. For
statistical purposes it is necessary to distinguish between
on the one hand, operations for the, principal disease or
for a complication of the principal disease and on the
other hand, minor operations and diagnostic techniques.
The 1 0' should be marked for an operation to the principal
disease or for an operation to a complication of the
principal disease. . A complication in this sense is a
condition arising out of the principal disease. Please
do not mark doubtful cases. These will be decided upon
in the National Health Statistics Centre. Operations
for conditions other than the principal disease or its
complications are not to be marked at all.
;fq.
22
may nevertheless be composed of discontinuous lines,
none of which will be sufficient to complete the circuit.
(ii) Pass through the centre of the figure inside the cage.
(iii) Stretch across the cage from bracket to bracket. A
short mark may fail to join up the brushes.
(iv) Not extend beyond the cage: If the mark projects outside the cage it tends to encroach upon the adjacent
column and the brushes may sense the mark in a column
where it was not intended to be.
(v) Be made with the card resting directly on a hard
surface. Plastic tablets are provided by the National
Health Statistics Centre for this purpose. A wooden
table top or blotting pad will not do, nor must the top
card of a stack of cards be marked on the stack.
Unless the card is rested on a hard surface the paper may
be dented so that the pencil mark lies at the bottom of
a shallow groove. As the card passes through the machine
the brushes will ride over the groove and fail to make
contact with the mark.
(vi) Be done with a soft lead pencil. The pencil must leave
enough black lead in the mark on the card to ensure
completing the circuit. Therefore the pencil must be a
soft one, preferably 2Bor a 'Black Beauty' pencil, or
one of those specially provided by the National Health
Statistics Centre. An HB pencil must not be used.
(vii) Errors may be rubbed out with an ordinary soft rubber, but
care must be taken that this is done cleanly and that the
surface of the card iè not broken. Smudges may act as
conductors and cause false punches.
Note: On no account should anything be written in lead
pencil on the marking section of the card, because of the
possibility that the machine will mistake the pencil
writing for nrkirg and punch holes in the card in places
where no holes were intended to be punched.
Detailed instructions for marking:
(i) Age: Mark both columns for
six in each column; for age
column and 6 in the second;
mark 00; for ages 100 years
333
6.33.
age; e.g. for age 66 mark
six years mark 0 in first
for ages under one year,
or over, mark as 99.
When a patient is transferred from Hospital A to Hospital
B for treatment of the same illness the MS18 card from
Hospital. B should show the patient as a readmission even
if the admission is the first the patient has made to
Hospital B.
(xvii) Race: Encircle the figure in front of the category which
applies. A patient is reported statistically as a Maori
if he is of half Maori ancestry or more and as a Pacific
Islander if he is of half Pacific Island ancestry or more.
A patient of half Pacific Island and half Maori ancestry
is to be reported statistically as a Maori. All other
patients should be reported as , 'other'.
6.3
Pencil-marking 'the MS18 'Statistical Card
6.5.1 The mark-sensing process
The information recorded on the MS18 Statistical Card: is
translated onto numerical codes and holes are punched onto the
card to correspond to these figures by a special machine 'in the
National Health Statistics Centre. The link between the codes
and the punched holes is provided by pencil marks which are made
in indicated places on the MS18 Statistical Card.
Once the cards have been marked, they are passed through,
the machine under a line of electrified metal brushes which ,sweep
the surface of each card. As soon as the brushes pass overa
pencil mark, a circuit is completed and the machine punches a
hole in the card. Once the holes have been punchedthe.marking
has no further use, the cards later being sorted and counted
according to the holes.
It is important to remember that the marks are not to look
at but are to serve as 'switches.' to work the punching machine.
The black lead in the mark acts as an electricity conductor
between the brushes at the time the mark passes under them.
The system is ingenious and works very well if the marks are
well made.
6.3.2 The criteria of good marking
Each mark must:
(i) Be continuous: A bold pencil stroke back and forth
across the cage (i.e. the space between the brackets
enclosing the number) is the best way to do this.
Pressure should be firm and even. , Do not try to shade
in the area, for although shading may look very neat it
UZ
22
(xii) Any other disease influencing length of stay: There is no
need to record any condition here unless it modified
treatment of the principal cause or led to extra or
less time being spent in hospital.
(xiii) accident details:
A.
How:State as fully as possible the circumstances
under which the accident occurred, not
forgetting the agent involved, e.g. lawnmower,
axe, fall from ladder. etc.
B.
Where: State where the accident occurred so that
the following code can be applied 0.Home
1 1Farm, orchard
2.Mine, quarry
30Factory, workshop, mill, construction job
4.
Playground, gymnasium, park, school-playground
etc.
Road, highway
5.
6.
Public building, office, schoolroom
Resident institution, hospital
7.
8.
Other places - river, beach, mountain, bush
(xiv) Operations: Insert operation descriptions and the dates.
(xv) Patient discharged died, transferred: Indicate the
category that applies by encircling the figure in front
of it.
Died means died while staying in hospital.
Transfer means transferred to another public hospital which
sends hospital cards (Ms 18) to the National Health
Statistics Centre. Discharged means all others not
died or transferred.
(xvi) First admission: The purpose of this question is to
differentiate between those patients who are admitted
to a public hospital for the first time for an episode
or injury and those patients who are readmitted to a
public hospital for a continuation of an . illness or
injury. In general another attack of an acute condition
such as bronchopneumonia is not to be regarded as a
continuation of an earlier infection but the reverse
would be the case with a chronic condition such as
arthritis, heart disease, multiple sclerosis, bronchitis,
tuberculosis, etc.
391
(viii) Date admitted, date of departure, period in hospital:
Period in hospital can usually be counted by simple subtraction, e.g. admitted 1st June, discharged 13 June,.
period in hospital 12 days, Do not include in the total
the day the patient was admitted as well as the day of
discharge.. If a patient is admitted and discharged on
the same day record the period in hospital as one day.
A table for calculation of period in hospital is included
on page 8 of the Hospital Statistics Handbook.
(ix). Waiting list admission: Emergency admission: Encircle the
figure in front of the category which applies. Emergency
admission includes all cases not admitted from the waiting
list. Waiting list includes surgical, geriatric and
investigation cases.
(x) Principal disease or injury for which admitted:
When two or more diseases are recorded on the case notes
all may be entered on the card but only the most important is to be coded in space A. The following points should
be used as a guide for selection:
(a) If one condition is symptomatic of an other, code the
underlying condition e.g. admitted f or retention of
urine caused by pros tatic hyperplasia - select
prostatic hyperplasia.
(b) Do not record a provisional diagnosis when a final
diagnosis is available.
(c). Current injuries and acute poisonings are usually
regarded as principal causes except when (i) a
serious disease results from a minor injury, as
tetanus or septicaemia from a superficial injury,
or (ii) a poisoning represents a reaction to
therapeutic procedures, in which case the disease
under treatment is selected as the principal cause.
Reactions from immunisations and other prophylatic
procedures are usually sole causes.
(d) For multiple injuries a general order of preference
is internal injuries, fractures, burns, open wounds,
dislocations, sprains, contusions and superficial
injuries. Always state.both the nature of the injury
and the site.
(xi) Principal complications of A: This space is to be used for
complications, that is to say additional illnesses
following from the same cause, and not merely conditions
which are otherwise associated and which should be
entered under 'C'.
580
22
Note: If a baby born in hospital needs treatment for any
condition (except preventive circumision) it then becomes
(statistically) a patient in its own right and a statistical
card should be prepared giving full details.
(i) Hospital: Insert name of hospital
(ii) Serial No.: Insert the number under which the medical
record is filed. This number will be quoted on query
forms and on medical research questionnaires. It will
enable medical records staff to extract medical records
from the files without referring to the index.
(iii) Surname: Christian name: Names supplied often need to
be transcribed onto another form or indexed in a
chronic disease register. Write the full name with
correct spelling and write clearly.
(iv)
: Insert the age in complete years at time of
admission. For ages under one week show as 1/365,
2/365 etc., for ages one week and under four weeks
show as 1/52, 2/52 or 3/52; for ages four weeks and
under one year show - as 1112, 2112 and so on. Do not
also show half weeks or half months or half years.
Where age is not known always write, an estimated age
and do not write 'not known'.
(v) Sex: Write M for male and F for female
(vi) Occupation: Industry: When an occupation such as engineer, labourer, or machinist is only meaningful when linked
with the industry add the industry data (e.g. marine,
building, clothing) to the occupation space. Never write
'retired' or 'pensioner' but supply former occupation.
(vii) Domicile: It is important that this item be supplied
with some precision in order that the twofold purpose of
identification and allocation for disease incidence may
be fulfilled. Each case must be able to be allocated
according to the districts as set down in the census
enumeration. For city dwellers enter name of suburb
(Herne Bay, Miramar, Sumner, etc.) If within a borough
or township enter name of borough, but for patients who
live close to a borough boundary but not actually
within the boundary insert the name of the locality but
not the borough or township. If the address is rural
write in full as, say, 'Waimate R.D.2. 1 . Where applicable write 'overseas visitor' or 'overseas seaman'.
n9
(ii) Babies born in hospital (normal nurslings) who are discharged
before they are 15 days old. When a baby born in hospital is
formally admitted on the 15th day a statistical card should
then be prepared for it. The diagnosis should be shown as
Boarder'.
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22
Section 62. Non-disclosure of medical information.
(i) Subject to the provisions of the section, no person
employed by a Board (whether as an honorary or part-time
medical officer or otherwise) shall give to any person not
employed by the Board any information concerning the
condition or treatment of any patient in any institution
without the prior consent of the patient or his representative, whether the patient is still in the institution
or not
(2) Nothing in this section shall apply with respect to (f) Information required by the Director-General of
Health for statistical purposes.
Section 82. Duty to furnish information.
(1)
The Director-General may at any time, by notice in writing,
require any Board to furnish to him such returns or other
information as may be specified in the notice, and in such
manner as he may from time to time require, with respect to
any institution or service under the control of the Board,
or to the management thereof or any matters connected
therewith, or generally with respect to the affairs of the
Board.
(2)
It shall be the duty of the Board so to furnish the returns
or other information specified in the notice within such
time as may be specified in the notice.
The information collected by the National Health Statistics
Centre under the authority of the Hospitals Act is used solely
for statistical purposes and is regarded as highly confidential
by the Department.
Filling in the MS18 Statistical Card: 62.
page.
The M18 Statistical Card is illustrated on the following
An MS18 Statistical Card is prepared for each patient,
except those shown below, admitted to public hospitals.
Exceptions:
(i) Normal maternity patients who occupy beds designated as
'maternity' beds whether in a ward, annexe or separate
hospi al.
5.2 Selectivity - by the patient
There are other factors such as ignorance of disease symptoms
and distance from hospital which must be taken into the reckoning
in interpreting hospital statistics as an index of communal health.
The need for a patient to attend at hospital must be associated
with a desire to attend unless the decision is to be taken out of
the patient's hands. While they are undoubtedly extreme cases,
health surveys taken out in Maori rural communities have shown that
much serious illness goes untreated and that all too often acute
pain from symptoms and handicapping disabilities are stoically
endured. This attitude does not always arise out of poverty and
one example was that of a prosperous Maori famer in his forties
who had a congenital cleft palate which he had never considered
having treated.Club-foot is another relatively common condition in Maori school children, which it is sometimes difficult to
persuade parents to have treated. In a number of cases distance.
from hospital and the cost and inconvenience involved results in
a postponement of hospital admission. It should be noted that
resistance to hospital treatment for reasons stated is not confined
to Maoris and the same factor, if only to a lesser extent perhaps,
would apply to our non-Maori population.
Patients living on the perimeter of a hospital board district
may be able to choose whether they are treated at one hospital or
another.While convenience of access, especially by the patient's
visitors, may be the dominant factor such intangiblesas p'ersonl
prejudice and hospital reputation may affect the decision.
6.In-patient
statistical returns
Information contained in this section is a summary of the
Hospital Statistics Handbook issued for the use of medical records
personnel in all public hospitals. The Handbook gives definitions
which cover each item and category on the MS18 statistical card.
In addition, the method by which medical data contained in the
notes is transcribed into the small spaces provided on the combined
written-punch card is set out in detail with examples. Also
explained is the way in which accident, homicide and suicide
detail is to be furnished in cases of injury.
6.1
Legal authority to collect returns
The Director-General of Health is empowered under the
Hospitals Act 1957 to collect from hospital boards information for
statistical purposes. The relevant sections of the Act are:
176
22
The study of . hospital morbidity has the advantage that records
of diagnosis, although by no means perfect, are likely to be the
most accurate. obtainable. With few exceptions, all cases will be
seen by medical practitioners. In addition, all the routine aids
to accurate diagnosis (e.g. radiology) will usually be available
in a New Zealand hospital. The quality of diagnosis would be
higher in hospital records than in those of the family doctor.
We thus have in hospital statistics an easily defined basic
concept of hospitalisation, a high standard of diagnosis, but a
yield of experience which is by no means representative of the
total sickness in a community, although often related to it.
Selectivity - by the hospital: 5.1.
The first qualification to hospital morbidity collections is
the one of selection of patients for admission because of lack of
bed space. The 1966 census of hospital patients showed that
31,540 patients were on the waiting lists of all public hospitals
throughout New Zealand. Despite the ever-increasing turn-over of
patients and heavy expenditure on construction, many hospital
boards are faced with an insatiable demand for bedsand there are
long waiting lists of people needing treatment. Obviously the
severer types of illness are' given priority and this produces an
element of bias.
New Zealand has a freely available hospital service with
hospital situated to serve district needs. Hospitals placed in
rural areas, because of the advent of rapid and convenient
transport, will tend to remain small, catering only for emergency
cases or disorders of a minor or routine nature with the larger
base hospitals, equipped as they are with a wide range 'of treatment
facilities, accepting cases on transfer or by other 'specific
direction.Furthermore, the very largest of our urban hospitals
have established units which specialise in the more intricate
techniques such as brain, thoracic and plastic surgery. Asa
consequence they draw off a significant proportion of the total
cases appearing in the whole country. The , effect of all this is
that statistics confined to a single hospital or to a group of
hospitals under the same board may be selective in character and
can present a misleading picture of local or area levels of sickness.The problem is overcome on a national compilation basis by
tabulations according to the domicile of the patient, the incidence.
rates for each disease being calculated on the denominator of
the population as shown at the five-yearly census. Of course
re-admissions must be excluded from disease incidence tabulations.
A
(iii)
(iv)
(v)
(vi)
Number of discharges and total days stay
Number of transfers and total days stay
Number of cases having an operation and total days stay
Number of readmissions
From this tabulation the following data can be extracted by
the hospital about patients treated each year (i)
The number of discharges and deaths for each disease
(ii)
The number of days beds were occupied for each disease
(iii)
The number of deaths and the diagnosis of thoedying
(iv)
(v)
The number of patients transferred for each disease
The number of new cases and readmissions for each
disease
The summary also provides, the data for such calculations as
the proportional hospitalisation ratio, the hospital death ratio,
the case fatality rate and the average stay of patients for each
diagnostic group.
5.The
limitations of hospital morbidity statistics
It is well to be cognisant of the deficiencies of public'
hospital statistics so that the conclusions we draw from them may
not be misleading.
A person to be hospitalised is usually ill, physically or
mentally, and this illness has reached a stage where his medical
advisers consider that a period in hospital is advisable. The
universe of hospital patients thus consists of only a proportion
of all those persons who are unwell, many others who may have
required hospital treatment being either unable to do so or not
wishing to obtain it. This proportion varies according to the
particular condition under consideration; patients with some
conditions are nearly always hospitalised, others only rarely.
The severity of the illness before hospitalisation becomes
advisable, also differs considerably with each condition. Some
patients are virtually well, yet admission to hospital is advisable
in order that the optimum condition be present for treatment, such
as a minor operation to correct some trifling abnormality.. At the
other extreme, a patient with another condition may be admitted
only when domiciliary treatment has been tried and has failed and
the patient is seriously ill.
'1
22
by general practitioners. New drugs have not only reduced the
incidence of tuberculosis but they have also shortened the duration
of treatment and reduced hospital stay. Some years ago, the
demand for hospital beds for tuberculosis cases caused plans to
be drawn up for a special tuberculosis hospital in the Horowhenua area. Close to two million dollars was to have been spent
on this project, but the dramatic reduction in tuberculosis cases
eliminated the need for this sanatorium before it was built.
It is necessary that the changing needs and uses of hospital
accommodation be kept continually before the planning authorities,
and one of the most important, and indeed often the only method
of observing these changes is by the intelligent use of hospital
based collections of data. For this purpose the Operational
Research Unit has been set up within the Department of Health,
its objectives being to make the most efficient use of hospital
facilities and skilled medical staff. This unit shows how
hospitals can be built more scientifically, taking into account
the changing functional requirements of outpatient departments,
wards, clinical services, laboratories, theatres and all the
other components of our present-day hospitals. National statistics routinely compiled have limited uses for this unit and it
commonly makes ad hoc studies within selected hospitTs to obtain
the basic data.
The National Health Statistics Centre prepares a table each
year which contains dignostic and length of stay information
about patients discharged from or dying in each public hospil;al.
A copy of this table is sent to the hospital concerned and has
proved to be an extremely valuable research and administrative
document. Each year's cases are presented for each of the 806
three digit categories of the International Classification of
Diseases. The title to each of these categories has been
abbreviated so that it can be accommodated within the limited
space available on the printed sheet used by the tabulating
machine. The International Classification of Diseases code
number is printed alongside each title; thus, if further
information is needed about the scope of the title, reference
can easily be made to Volume I of the International Classification
of Diseases.
Against each of these disease headings the following data
are printed (i)
(ii)
Number of discharges, transfers and deaths combined,
and the total days stay
Number, of deaths and total days stay
On applying the relevant average to the number of patients
with particular conditions in the different hospitals we obtain
the length of time that this group would ordinarily have spent in
hospital had they been kept therein on the average for the same
length of time that similar •patients were kept in all class I or
all New Zealand hospitals depending whether the hospital being
considered fell into class I or class II. From this figure it
is easy to tell the variation between hospitals, condition by
condition, and when the totals are struck there is produced a
composite figure which takes into account many conditions in
terms of the length of stay to be expected on the average. The
Bed-time Index is then calculated by dividing the observed stay
by the expected stay and multiplying by 100,
The Index is a measure to some extent of the rapidity of
turnover of patients in a hospital. It must not of course be
concluded that rapid turnover, however, is of necessity good and
an indication of an efficiently run hospital, for there must come
a stage when over enthusiasm in this regard will lead to patients
being discharged so soon that they come to harm or their prognosis
is made worse.On the other hand there must be an optimum time
for discharge after which no further benefit follows longer
hospitalisation, and so far as the Bed-time Index takes into
account the average practice obtaining in a wide diversity of
hospitals for a considerable number of common conditions, the
figure of 100 may be regarded as approximating to such an optimum,
with a bias (if it exists) being rather towards a longer stay than
is really needed, than the other way round. Certain hospitals
with a high index may argue that they cater for .a widely scattered population and that they are unable to discharge many of
their cases as early as they would wish , because they are doubtful
about their after care in a backblocks area. In practice this
argument is not so strong as it may seem for few people live in
great isolation..
The advances that take place in both preventive and curative medicine will all have their effect on hospital administration, and often the scientific significance of the advance
is out of all proportion to its repercussions on the need for
hospital facilities. The introduction of new methods of diagnosis
or treatment may increase the demands on hospital care, they may
change its type or they may decrease the need. For example, the
introduction of thiouracil in the treatment of thyrotoxicosis first
reduced the requirement for surgical, and increased the need for
medical beds; then as familiarity with the use of the drug
increased, the overall requirement was reduced as more and more
patients could be treated effectively as outpatients or at home
22
The Bed-time Index first appeared in the 1953 Medical
Statistics Report, In the previous year a comparison had been
made between large and small hospitals in terms of length of
stay in hospital for a number of groups of conditions. These
conditions, however, were predominantly surgical and it was
felt that greater use could be made of the Index if medical as
well as surgical conditions were included. For the next nine
years the method of compiling the Index was unchanged. In
1963, however, two important developments occurred in that
patients who had been transferred out of hbspital were excluded
from the calculations and the selected diagnoses on which the
calculations were based were made more representative of all
patients treated in general hospitals.
The Bed-time Index consists of two groups of hospitals:
class I or those having in the particular year reviewed a daily
average of over 200 occupied beds, and class II or those having
a daily average of between 100 and 200 accupied beds. The Index
for the class I hospitals is 'based on the average length of
stay of cases in this class only but that for class II hospitals
is based on the overall New Zealand averages. This was thought
to be fairer to the class II hospitals in any comparison with
class I hospitals as it offset to some extent the improved staff
and equipment enjoyed by class I hospitals.
The method of calculating the Index is simply to apply the
average length of stay for class I or all New Zealand hospitals,
as the case may be, to the number of patients admitted to
individual hospitals with those conditions chosen for the construction of the Index. People dying in hospitals are excluded
from this analysis so as to overcome the objection that a hospital
where a high fatality rate prevails might for this reason alone
have a better index than one where life is more effectively
prolonged. In practice this is not found to be an important
factor in respect of conditions covered in the Index but nevertheless it is thought better to exclude deaths on rational grounds.
Similarly, patients are excluded who were transferred out of
hospital to another public hospital for further treatment of the
condition for which the original admission was made, . In some
hospitals it is policy to transfer cases after surgery to a
convalescent hospital under . the control of the hospital board.
In such cases the days stay of patients in the convalescent
hospital was taken into account when the index for the parent
hospital was being computed.
110.20
Treatment
Institutional administration 1.6.00
Heat, light, power and water.12.80
50.80
Household
Buildings and grounds8.30
0.10
Miâcellaneous
198.20
If hospitals are to be run efficiently then information is
required as to the use being made of 'the hospital beds. The populatipn of the catchment area from which each hospital draws its
patients is known by age, sex and race so , that proportional
hospitalisation rates can be calculated showing the pattern of
disease in each area. Hospital construction needs to be examined
against the use which would be made of the accommodation in the
immediate future as well as in the light of the future load*'. A
simple illustration is the need to provide more geriatric beds
because of predictions that higher proportions of New Zealand's
population are likely to be found in the.,upper age brackets in
future years.
Facilities of a specialised and costly nature need to be
similarly examined against the numbers of expected cases and th
demands of the future. Examples are in connection with the installation of super-voltage equipment and the location of specialist'
cardio-thoracic and neuro-surgical units as well as 'cent'res for
the treatment of spinal injury.
It is desirable that length of stay in hospital should be
kept to a minimum consistent with the welfare of the patient, in
order that waiting lists can be reduced and as many patients as possible treated. A compariBon of the length of stay of patients
with the same disease in different hospitals may show that one,
hospital discharges patients either earlier or later on the average
than the other. This can point the way to better methods of
treatment. Differences in stay between individual diseases may
be so small as to prevent conclusior being drawn from them and it
has been found preferable to select certain groups of conditions
that are likely to give some indication of the efficiency of a
hospital in terms of the response to treatment and the length of
hospitalisation which that treatment has entailed. A popular
term for this is "medical auditing" and the end result of the
arithmetic calculation is known in New Zealand as the Bed-time
Index.
22
As four-fifths at least of all illness hospitalised come
into the New Zealand collection scheme an estimate of the
incidence of many diseases can be arrived at and the disease
itself can be examined in relation to racial, economic
(occupation), geographical and climatic factors and thus
assist research on pathogenesis and aetiology of disease.
The efficacy of health education and preventive measures can be
gauged by changes in the rate of hospital admissions.
The effect of changes in treatment can be studied by changes
in incidence of hospitalised illness, duration of stay and case
fatality ratio. Indeed, with special planning the results of
different forms of treatment, including types of surgical
operations, can be studied in relation to the characeristics of
the patient.
Educational uses of accident material: 1+,2.
Very extensive use is made of the statistics of admissions for
accident both by New Zealand and overseas agencies. Most of the
enquiries come from government departments as well as the many.
societies concerned with accident prevention on the road, in the
home, on the farm, and in the factory. In addition to this the
New Zealand Standards Institute, the Consumer Institute and
sundry manufacturers are supplied with information on request
about injuries received while appliances such as electric radiators, washing machines, tractors and types of power equipment
were being used or in respect of clothing materials which present
fire hazards. The figures of poisonings from the use of sprays,
disinfectants and other chemical preparations in homes, market
gardens and factories are also closely scrutinised. Health
Education Officers of the Health Department throughout the country
make very extensive use of accident statistics for propaganda
purposes while the World Health Organisation issues New Zealand
statistics for use by other countries which do not have this
type of information available.
Administrative uses, national and local:
43,
The hospital system is generally an important unit in a
nation's health service. It is also an expensive one, the
average daily expenditure for each individual inpatient treated
in a New Zealand general hospital being, in 1965-6 close to
$13. 00 . On the average each patient costs the taxpayer just
under $20100 in 1965-6 made up as follows -
At the time of the taking of each population census (every
5 years) statistics are obtained of each patient under treatment.
Census methods of collecting hospital material are described in
section 8 which follows.
From time to time special purpose studies in depth are carried
out linked to the routine public hospital collections. The
methods employed to carry out a study of hospital case notes or
of patients while in hospital are described in section 9 which
follows.
k. The uses made of hospital morbidity statistics,
As mentioned in an earlier paragraph, hospital statistics
cannot provide information about the incidence and prevalrice of
all types of illness in the community, but they can. give substantial information about many of-the chronic diseases and
impairments of a more serious nature.
1+.1 Medical research and epidemiological uses
As, under the New Zealand system, the punch card isalso
the collection card, when filed away these form a mechanised
index to diseases treated. This index is at the disposal o
any clinician who is investigating a disease and who wishes t
use it. Lists of names, hospital and hospital number.can be
supplied to the research clinician concerned.
For a selected group of chronic diseases on which particular
attention is focussed such as hydatid disease and multiple
sclerosis, small registers are maintained. Each treatment
undergone over the years is recorded and through this follow-up
system the progress of the patient can be studied. This method
is sometimes described as longitudinal analysis of sickness
ecperienced; for conditions which occur frequently such as
myocardial infarction these follow-up studies may be done on a
sampling basis.
Information, including incidence data, is routinely supplied
to overseas medical units which may be carrying out intensive
research into severe but relatively uncommon diseases. New Zealand
offers an almost unique opportunity to establish the true
incidence of many of the severe types of disease because a high
percentage, if not all cases, which occur come into our
hospital morbidity collection.
of
22
Hospital morbidity statistics: 2.2.
Hospital morbidity statistics consist of information
collected concerning the individual patient: the items fall
under three headings (a)
Personal characteristics, e.g. name, sex, address,
occupation, age, race.
(b)
Administrative particulars, e.g. date of admission,
date of discharge (or death), duration of stay, type
of discharge. In some countries such data as type of
bed, department in which treated, type of admission
(emergency or other) are recorded and it is hoped to
extend the New Zealand collectioi scheme along these
lines in the future,
(c)
Medical details, e.g. principal disease for which
admitted, complications, other diseases treated,
details of operations performed. In some countries
items such as nature of other treatment, medical
investigations, etc. are covered.
The collection of information may relate to either inpatient
or outpatient treatment. In the majority of instances the
statistical treatment of these two types will be widely
different. Outpatients are very much more numerous than
inpatients and are likely to become very much more so as
domiciliary care services develop to conserve the use of
hospital beds for acute cases and to encourage the care of the
sick as far as possible in their own homes. Because of their
numbers, time and staff are not usually available for more than
the recording of the briefest details concerning outpatients.
Details concerning inpatients are much more easily collected
than details concerning outpatients. For this reason, and, more
important still, because the most costly part of hospital
treatment is that of the inpatients, most of the development
in hospital statistics is in the inpatient field.
Private hospitals and solely maternity hospitals do not
forward statistical returns for individual patients. Indeed, very
little in the way of case-notes are kept in private hospitals,
most of the information concerning the patient being in the
possession of the surgeon or physician in charge of the patient.
Statistical returns are received from all public hospitals.
The coverage is about 80 percent of all inpatient treatment.
1.
Introduction
In order to reveal our health problems and to carry out
measures for disease control it is essential to have some idea
of the kind and extent of ill-health in the community. Hospital
statistics go some way towards meeting this requirement in that
while they are largely confined to the severer types of illness
(90 percent of sickness in a community is treated outside of
hospital) they do cover a wide range of illness, injury and
disability. New Zealand, with its free public hospital system,
is able to produce hospital statistics which have much more
coverage of the population than those produced by most other
countries. As a result our hospital statistics do indicate the
true incidence of many forms of disease.. New Zealand is a
welfare state and the cost of hospital treatment is paid out of
taxation. Each day spent in hospital costs the equivalent of
a day's stay in one of the country's most luxurious hotels. For
this high cost reason hospital statistics are of value to the
administrator in making the best use of hospital beds in terms of
patient-movement and days of care for specific diseases.
Statistics of discharge by diagnosis and length of stay as measured
by. the Bed-time Index show variations between hospitals which may
be due to factors such as attitudes of physicians or lack of home
nursing and other extramural hospital services.
2.
The types of hospital statistics
Hospital statistics readily divide into two distinct groups
with different applications (i)
(ii)
Hospital administrative statistics which relate to.
the hospital.
Hospital morbidity statistics which relate • tc the
patient whether inpatient or outpatient.
2.1 Hospital administrative statistics
Hospital administrative statistics are not usually the concern
of a medical records department. Such data are assembled locally
by the secretarial and accountancy departments, while on a national
level the Hospitals Division of the Department of Health collects.
returns from Hospital Boards supplements these with data relating
to its own institutions and presents all this information in a
publication entitled "Hospital Statistics of New Zealand". The
volume is issued as a supplement to the Report of the Department
of Health which is presented by the Director-General to the House
of Representatives each year..
22
HOSPITAL MORBIDITY STATISTICS
1.
Introduction
2.
The:two types of hospital statistics
2.1 Hospital administrative statistics
2.2 Hospital morbidity statistics
3.
The source of our hospital morbidity data
14• The uses made of hospital morbidity statistics
4.1 Medical research and epidemiological uses
4.2 Educational uses of accident material
4.3 Administrative uses, national and local
5.
The limitations of hospital morbidity statistics
5.1 Selectivity - by the hospital
5.2 Selectivity - by the patient
6.
Inpatient statistical returns
6.1 Legal authority to collect returns
6.2 Filling-in the MS18 Statistical Card
6.3 Pencil-marking the MS18 Statistical Card
6.3.1 The mark-sensing process
6.3.2 The criteria of good marking
6.3.3 Detailed instructions for marking
6.4 Filling-in the MS17 Summary Card
7.
Outpatient analyses
8.
National hospital census taking - inpatient and
waiting list patients
9.
The ad hoc study
9.1 The design of the questionnaire or transcript form
9.2. The pilot survey
9.3 Sampling
9.+ The prospective study
9.5 The retrospective study
9 . 5.1 Choice of a control group
9.6 The cohort study
10. References
—'----1-i-i— Further reading
Wr
Coulam (N.R.) Economy of effort in
Medical Record keeping
Medical Record, Feb.
Denver (J.C.) Thoughts on the
open office
Office Methods & Machines,
May 1965, pp 353-5
1963, pp 615-25
Griffiths (C,M.) People matter
Aug. 1965, pp 615-6 1 630
Heat, humidity, noise, lighting,
colour. 1+ steps to efficiency:
conference reports
March 1967, pp 19-21
Johns (E.) The Medical Record
Librarian: 3. of tomorrow
Jnl AAMRL, Dec. 1961,
(Lincoln & Naylor) Record department administration, physical
plant, functional organisation
and other factors
end mt. Congress Report,
PP 150-67
'Medical Records'
N.Z. Hospital, June 1952
Moores (N.M.) Computors and
Medical Records
Medical Record,.Feb. 1963,
Schenthal, Sweeney, Nettleton &
Yoder. Clinical application of
Electronic Data Processing
Apparatus. III. System for
processing of medical records
Jnl. American Medical Assn.,
Oct. 12, 1963 pp 101-5
p 257
p6
pp 61+0-i
3"-
21
Holmes (C.N.) Planning a newMedical Record, Nov.
Medical Records Department - 11957, pp 283-4
Huffman (Edna K.) Manual for Medical U.S.A., Berwyn, Ill.,
Reôord Librarians, pp 458-63
Physicians' Record Co.,
('Planning a Medical Records
1 959, xxx +604, illus.
Department for a specific
situation')
Knapp (K.N.) Planning a new Medical
Records Department - 2
McWilliams (Gordon) Who will
plan your department?
Medical Record, Nov.
1957, pp 285-6
• Medical Record News,
Dec. 1965, pp 327-30,
373-k
Mansell (Elsie Royle) A new
Medical Records Department
Medical Record, May
Mellem (P.) Planning the medical
record department
Hospitals, Oct. 16,
196 2 1 pp 37-42;
Hospital Abstracts,
March 1963 p 130
Medical Record News,
Aug. 1964, pp 142-5,
Ramsey (Sister M.E.) Five years
to success
.1962 9 p. 514-19
172
Report of a Committee of Medical
Records in N.S.W. Hospitals
Seymour (E.L.) Filing and disposition of records
'Space-saving work stations' in
'Methods at work', pp 64-8
N.S.W. Hospitals Commn.,
H
1960,5+ pp.
1st mt. Congress
Report, pp 91-103
London, Current Affairs
Ltd., 1962, 101 pp
Stone (J.E.) Hospital organisation and management, pp 814-15
London, Faber, 1952,
Tiltman (P.c.s.) Practical aspects
of a Medical Records Department
,Medical Record, May
1951, pp 136-9
Jnl AAMRL, April 1961,
PP 56-8
Wolney (E.c.) A practical guide to
the cost of equipping a Medical
Record Department
xxii + 1722
Background: 6.2.
Clarke (K.W.) The group organis- •1st mt. Congress
ation in Medical RecordsReport, pp 117-27
(i) Define the departments for which you are planning.
(ii)
Establish anticipated load on these departments.
(iii)
Define the functions of departments, their interrelationship and relationship to other departments of the hospital.
(iv)
(v)
(vi)
Think out procedures.
Define coverage of departments and the staff
needed.
Establish flow of traffic both between departments and within them.
(vii) Plan the equipment required.
(viii)
Specify special points in design and planning.
These steps represent the foundations and are the basis on
• which the architect draws his plans. When these are received go
over them by trying out work situations, making scale models or
actually chalking them out and checking that everything will work.
Be prepared to argue hard for what you think is necessary, but in
so doing, make sure that you have facts to back up your requirements. Finally, be realistic. There is no reason why Medical
• Records should always be in the basement but its location must
be where it is best placed functionally, not just where the view
is nicest.
6.Further reading
6.1 Basic
Balmer (Marjorie L.) It's time to Medical Record News,
join the planners•Aug.. 1966, pp 223-6,
268-70
Biglow (L.A.) Planning a MedicalJnl AAMRL, April
Records Department from a Medicalpp 45-8
Record Librarian's point of view
1958,
Dunne (J,H.) Planning a new Medical Medical Record, Nov.
Recordè Department - 3
1957, pp 286-7
Farmer (Ellen L,) Foresight and Medical Record News,
knowledge
Aug. 1964, pp 138-4O
Hargrave (A.) Application of WorkMedical Record, Feb.
Study to Medical Records Services 1962, pp 478-86
761
21
Having got hold of a copy of the plans for these departments,
see if they will work by:
(i)
Taking actual work situations, such as suggested in 3.4
above and following them through on the plan. In doing
this take into account other activities going on in the
department at the same time.
(ii) Making cut-outs of desks, fittings etc. to make sure that
there is adequate working room. This is a safety precaution since the architect should haveensured that
there is adequate working space. However, you and your
staff are the ones who will suffer if there is not.
Acquire a scale rule - this saves much unnecessary
conversion since, depending on the scale, you can read
straight off the measurements in feet.
(iii) Checking traffic flow in departments and between departments and how this is effected by doors, for.instance,
(iv) Checking elevations to ensure that details requested
are included, e.g. clear glazing above a certain height
etc.
(v)
If in doubt about the practicability of an area measure
it out somewhere in actual size. If necessary chalk
in desks and other fittings and then try out 'work
situations in this setting.
(vi) Checking vertical as well as horizontal relationships
by superimposing floor plans by reference to common
features such as columns. (It can be misleading simply
to place one sheet above another)
At the risk of being called awkward or worse insist on
further drawings until you are satisfied that you have got as
near to what you want taking other reasonable requirements into
account.Your lack of pertinacity here could result in a
poorly working department for the next 25 or more years.
Summary: 5.
As with a building th main work in planning goes into the
part that cannot be seen. In either case if the foundations are
badly done the result will be useless. It is necessary, therefore, to:
I
3.8.8
O.P. booking and reception
Split-level counter for part that is to deal with further
bookings following a clinic. What arrangements for 'phone bookings?
Will these be done by the same or a different person? (This will
depend on anticipated number of bookings). Where will intercommunication equipment be? Chime/light system advised for 'phones.
3.8.9
Accident & Emergency department reception
Split-level counter is recommended. Where will indexes and
records be in relation to this? And intercommunication? A
power point will be necessary for time clock if used. What will
be needed for provision for booking for return visits? Chime/
light system advisable for 'phones,
3.8.10
X-ray reception
Split-level counter is recommended. Provision for intercommunication with filing area? Relationship to index to be
stated. Power point necessary if a time clock is used. Provision for counter and 'phone bookings. Chime/light system for
'phones.
3.8.11 X-ray
filing
State relationship desired to medical records filing if it
is expected to cover both departments after hours.
If fixed and mobile shelving are to be used indicate how
much of each.
Specify intercommunication location both for oral/written
communication and for despatch of films.
4.Physical planning
If the functional planning has been well done the drawings
that come from the architect will be much what you wanted, although
there will obviously be compromises which will be necessary
because the departments with which you are concerned are not the
only ones in the hospital.
If machine addressing equipment is to be located in this
area specify the sort of room required and shelving needed.
(This should be such as to allow of holding stationery in
original packs and holding some in the order in which it is run
through the machine, together with receiving area, assembly
working space and despatch trays).
Provision must be made for shelves for holding records for
various purposes because even the best system needs a halfway
house.
In the typists' area provision of power points for dictating machines needs to be mentioned, also spaces for photocopier, duplicating machine if located here, envelope bank,
etc. It is wise to mention the need for sound-absorbent
treatment. Are individual machines to be used or tele-dictation?
In addition to dictating cubicles prOvision • needs to be
made for medical and nursing staff to peruse notes without
taking them out of the department. (For policy regarding this
refer chapter 3, para 2.3.2)
Admitting: 3.8.6.
Specify the type of counter required. Are patients to sit
or stand? If pre-registration has been carried out for booked
cases then a standing position should he sufficient since all
that would be necessary would be for the patient's identity to
be established, time of arrival noted and for him to be asked
to sit down until escorted to the ward. In emergency admission,
however, a desk may be necessary, depending on the system in use.
Where should the intercommunication be located? What
arrangement is needed for calling orderlies or porters to escort
patients to wards? (A callback system to the Head Orderly's
office possibly)
Provision has to be made for waiting lists, typing and working desks depending on the procedure used. Chime/light system
is advisable for 'phones.
Enquiry office:3.8.7
A split-level counter is recommended and, unless information
on the condition of patients is duplicated, easy access to this
information which will chiefly be the concern of the person
answering telephone enquiries regarding patients.
get up every time a person comes to the counter with consequent lengthening of the time it takes to settle down
to work again;
(iii) it is better for the public in that they have immediate
contact with the staff concerned instead of having to
attract their attention.
3.8.4 Lighting, power and heating
In filing areas staff working must have good light so that they
do not find the shelvesshadowing them. Since, however, flexibility
of shelving is required overall lighting is required - ensure that
it is not in rows.
Similarly, there must be a good light source over indexes.
On the other hand, the photocopier requires to be away from bright
lighting.
Power points will be required for dictating machines and other
equipment.
Heating will not normally be dealt with in this context but
care needs to be taken to ensure that radiators are not planned
for spaces where shelving or equipment is to go.
3.8.5 Medical Records
If fixed shelving is to be used there should be provision for
slide-out work trays, or for trolleys with a small table on which
charts can be put easily for pasting in reports. etc. For fixed
shelving greater provisionmust be made for circulation. In the
case of mobile shelving a space is required for every 5 units.
Consider the noise level likely in the department. This could
be reduced by having telephones on a chime and/or light system
instead of bells. If machine addressing is housed in this department it should be in a soundproof room. Dictating cubicles will
need to be soundproofed and protected against noise coming into
them. As some staff will be doing work such as coding that
requires a high degree.of concentration noise producing factors
should be mentioned so that the architect can specify suitable
sound absorbent material.
Indicate location of patient index in relation to phones and
other equipment. It will be necessary to mention what non-architect supplied equipment is planned so that space can be provided
for it.
Kp
21
Storage:
3.8.2.
If stationery is supplied on an imprest system then it is not
necessary to provide for statinnery cupboards. (You should ask
for such a system since it is the best method to guard against
the use of outdated stationery, both in offices and wards). If,
however, each department has to requisition at set intervals for
its stationery then provision has to be made in each department
for storage.
Are any of these departments responsible for, (or do they
naturally attract) the return of crutches, walking sticks etc.
even as a halfway house? If so, and one cannot see an Accident
& Emergency department not doing this, provision must be made
for this.
Are parcels left by patients or visitors at Admitting,
Enquiries, Accident & Emergency or Outpatients, for instance?
The Board's attitude to this should be ascertained. (Claims
for loss could.arise). However, whatever the attitude it is
probably inevitable that some things will be left and it is'
therefore necessary to ask for some provision for this..
Built-in fitments: 3.8,3.
It is often tempting to ask for various built-in fitments
which ideally suit the procedure in use in a certain 'department..
This, however, totally overlooks the fact that procedures change.
It is better, therefore, to think in terms of movable fittings
and, if a special fitment is required, to make sure that space
is reserved for it but to have the 'fitment itself made up
separately.
However, there is a great deal to be said for specifying
split-level counters where there i s' direct contact with the
public. At a split level counter the public part is at normal
counter height whilst the staff part is at desk height with a
small recess under the counter part. This has the following
advantages:
(i)
(ii)
it saves space since it is not necessary to take up
room with a desk;
it makes for more efficient use of staff since they
can have their work at the counter without having to
3.7.6.
Accident & Emergency reception
What equipment will be needed for filing of reports and for
indexes? What will be required for bookings for dressings? A
time clock is advisable for recording time of arrival of patients.
Where will forms regarding Worker's Compensation be kept?
3.7.7.
X-ray reception
What equipment is required for indexes and reports? What
is required for bookings? Here again a time clock is recommended
for recording patients' actual time of arrival.
3.7.8. X-ray filing
What sort of shelving? If terminal digit filing is used
with the hospital number then fixed shelving will be required.
Where x-rays are filed straight numerically mobile shelving
can be used. It should be motorised. Assuming maximum x-ray
size of 17" x ik", the unit should have 4 openings, 15"
between shelves vertically, shelves 18" deep, with buffer 3"
to 6" dpending on how far shelf guides stick out and therefore need to be protected.
3.8
Special points in design and planni ng
Although the preceding paragraphs have covered the theoretical aspects of functional planning fully there will be certain
points that need to be noted in any planning submissions made.
These will arise, not only from the general nature of the
particular department concerned, but also from local factors the number and type of beds, outpatient services, methods and
equipment used, etc. Some general points follow:
8.1 Inter-relationship
Where possible easy horizontal or vertical access should be
asked for. It is suggested that clear glazing of partitions is
preferable to solid partitions - it is easier to work with
people you see all the time than ones who are hidden away, but
noise is a factor to be considered here. Handy stair access
will be required if the departments are to be on different floors
and are to be covered by minimum staff after hours. There should,
however, be one office in these related departments where
privacy can be obtained - this could be an interview room as
part of the Admitting Office,
cc
Medical Records: 3.7.2.
(a)
shelving. What filing system is to be used? If
terminal digit, then fixed shelving will be required.
You will need to work out how much will be required in
fixed shelving. If straight numerical filing is used,
then mobile shelving is suitable. (Refer chapter
para 5.2.1. for method of working out shelving
required). If 12 11 shelving is used in mobile shelving
a 3" buffer should be allowed for each side.
5,
(b)
Indexes. What indexes do you hav? Consideration
should be given to using deep drawer cabinets - they
are easier to use and make better use of space but
they do mean concentration of the index in one place.
How would this effect your procedure?
(c)
Dictating machines. What system is to be used?
How about after hour coverage?
(d)
Other equipment. Consider the use of such equipment
as photocopiers, small hand printers for envelope bank,
developer/printer for microfilm etc.
Admitting:
3.7.3.
Will machine addressing be used, if so, what sort? Should
it be located in Admitting or Medical Records? (Where is
your patient index kept? The functional progression is from
Admitting, O.P. booking etc. to patient index to machine
addressing which would make this logically a part of Medical
Records). How will waiting lists be kept?
Enquiry Office:
3.7.4.
How will cards for patients' condition be kept? What other
equipment is needed for additional functions of the Enquiry
Office?
O.P. booking and reception:
3.7.5.
What equipment will be needed for bookings? Will what you
envisage be able to be copied for Medical Records without rewriting (i.e. photocopy or carbon)? How much filing will be
required? (Generally speaking, this should be a minimum).
3.6
Flow of traffic
In conjunction with 3.2, 3.3 and 3.4 above it is necessary, to
indicate the flow of traffic both between departments and within them.
This needs to take into account patients, staff and paper. If the
function, inter-relationships and procedures have been worked out
then the flow of traffic will follow logically from this. Obviously,
this statement or series of diagrams must be so expressed that the
architect has no difficulty in seeing the points between which
there is the heaviest traffic and arranging for them to be in close
relationship. To take an obvious example, no one who was familiar
with the routine of a Medical Records Office would place the phone
at the opposite side of the room to the patient index. Your flow
chart must indicate this conclusion.
307 Equipment
Certain equipment - shelving, built in fittings, intercommunication - is usually part of the building contract and therefore the
concern of the architects. Other equipment - desks, filing, cabinets
addressing or printing equipment etc. - is supplied under arrangements made by the Board, for which a special Ministerial.. Consent is
obtained. Whatever the source of supply, however, equipment to be
used must be considered when planning.
Information o n equipment and factors governing its choice,
occurs from time t o time in 'New Zealand Medical Record'. What
follows are some questions for which answers will be required
in your planning.
3,7.1 Intercommunication
As has been seen these departments are closely related. What
will be the nature of communication between them:
(a) for paper charts, x-rays etc. Should you ask for a dumb
waiter (this could be practicable if there will be vertical
relationship) or pneumatic tube? Or will there be an
efficient messenger service?
(b) Oral or written? If telephone connection, is this to be
direct or will dialling be necessary? (If phone is used
this involves transcription at the other end and consequent possibilities for error). In some cases a talkback
is appropriate, e.g. between x-ray reception and filing
for immediate requirements,
21
One should not be prepared (where the size of the hospital
warrants it) to have these departments covered by staff who are
completely unfamiliar with the work or who cannot leave their
posts, e.g. in the first instance, orderlies, and in the second,,
telephone operators.
- The argument has been made above that one of the causes
of inefficiency in the departments under review is the
'them' and 'us' attitude. Where the size of the hospital
allows a supervisory position is indicated to ensure
practical day-to-day co-operation. The cost of this will
be justified through better service to patients who will
be the more likely to be contented and co-operative and
through improved staff relationships and a reputation for
smooth working. In the smaller hospital this function
should be assigned to an individual whether the Medical
Records Officer or the Admitting Officer with the necessary authority. How can you plan such an arrangement for
your hospital?
-Is clerical work being done by clerks? In most hospitals
far too much essentially clerical work is being carried
out by medical and nursing staff. New staffing patterns
should plan for this work to be done by clerical staff,
thus freeing other staff to do what they have been
trained for.
- Many routine jobs that are now done during the day could
well be done by night staff on roster, e.g. daily filing
of cards.
-What are requirements for research and teaching - now,
and likely to be in the future? Provision should be made
for staff under this head alone.
If you produce statistics now by adding up columns in a
book, for how long will this be adequate? Should not staff
and space be planned for against the day when this
information might be on data processing equipment?
-If you employ part-time staff and their duties overlap
this must be included in your planning since space will
be required for the maximum at work.
(iii) An emergency accident case is brought into the Accident &
Emergency department and it is decided to admit him. How
is he identified? What is the procedure for admitting?
Who checks on old records and x-rays and sees that they go
to the ward?
3,5 Staff
Having determined procedures the next step is to estimate the
staff needed to carry them out. Then get this staffing pattern
accepted since it is pointless planning for a department to be staffed
to a certain level if, when the hospital opens, less staff are allowed,
Here again there will be different requirements in different sized
hospitals. However, the following questions and considerations may
serve as a b'sis on which to plan for staff:
- For what hours is coverage of the department concerned to
be given? Where all the rest of the hospital works on a
21+-hour day, 7-day week it is archaic and inefficient for
the departments under review to work a 71 hour day, 5 day
week. As a guide which could be modified for smaller hospitals the following pattern is suggested:
Day
o
Hours
Yj
/çLY
el
•3(JCJ
XV
ly
Mon- 0830-1700
1
X I x x x xx
xx I
II
day1700-1900X I X
X I X 1XX I
X Ix
Ixx
1900-2300Xx
I
300_0830
Where
physicallyl
possible
coverage
to
include
2
1
FridayMedical Records ,l Admitting, Enquiries, A. & E.
-reception, X-ray rece p tion and filing
Sat-o830-1200X
XX I X IXX
urday 1200-2300X
X
XX
X I
As
da y -Frida y 2300-0830
12300-0830
Sun- 0830-1700
X
sw•w:
day1700-2300
As Monday-Friday 2300-0830
12300-0830
1
Art
21
-
What duplication is there? How many people are not
gainfully employed part or all of their time because
they are checking the work of others? (Some checking
is necessary, much continues unnecessarily; determine
what is essential and what is not).
To what extent do present procedures represent the whims
of individuals in charge of departments rather than
functional, logical ways of doing a jpb?
-• What is the Board's policy regarding retention of records?
If Medical Records are to be retained indefinitely will
there . be storage for them or should provision be made in
these plans for microfilming after a certain period?
(Refer chapter 19)
-If, to take a hypothetical situation, the staff of a
department were all killed or in hospital after a
bus crash could the department function efficiently
with a completely new staff? (i.e. are duties clear,
logical and well defined?)
The practical part of looking at procedures can be done by
thinking through what would happen in given situations. Here are
three situations; others will suggest themselves; every one of
them must be capable of logical, simple and straightforward
solution
(i) A general practitioner's nurse rings the hospital for an
appointment for a patient for the Chest Clinic. What does
she write down? On what? What does she do then? How are
records checked to see if one is held for the patient?
What is the arrangement for ensuring that records go to
the clinic when the patient attends? What is the arrangement for the doctor in charge of the clinic to dictate a
letter regarding the case and to arrange for admission?
(ii) This patient arrives to be admitted as a booked case. What
papers are ready for him and how was this done? Do any
have to be made out then? How does he get to the ward and
how does his chart go? What other departments are told
that he is in the hospital and how?
4f
-What is the nature of each of the relationships indicated?
(For in,tance, that between O.P. reception and Medical
Records involves the passage of charts from Medical
Records to O.P. reception before a clinic and their
return, possibly with dictating machine tapes to the
medical typists following the clinic. On the other
hand, the relationship between . Medical Records and
Enquiry Office is mostly a telephonic one).
3.4
Procedures
If planning is to be effective procedures must be thought
through. It may well be that equipment will become available
that will enable streamlining of procedure but it is essential
to examine existing procedures and decide how they can be
improved.
It is suggested that this can be done in two parts:
theoretical and practical.
The theoretical part of the definition of procedures requires
answers to such questions as:
-What can I anticipate as the overall national picture?
(For instance, it is reasonable to assume that, within
two decades, it will be possible to obtain basic medical
history for any person in the country wherever he is at
a moment's notice. This could come about regionally
within a decade. Thus, any system put into a new hospital
should be capable of fitting into this picture).
-How will the figures obtained in 3.1 above affect present
procedures?
-Is the organisational structure of these departments such
as to lend itself to the answers that seem right for the
first two questions? (If not, work out a new one which
must be so obviously right that it will be seen to be
necessary to fit in with the planning.)
-Are medical staff, or nursing staff in particular,
carrying out procedures that could and should be carried
out by clerical staff?
-Are present procedures basically sound or have they, to
a large extent, been forced onto the hospital through
inadequacies of buildings, equipment, staff?
U-',
21
Inter-relationship of departments and relationship to
other departments of the hospital: 3.3.
The degree to which departments are dependent on each other
obviously affects the physical planning. It is therefore
necessary to define this so that the physical relationship
necessary can be the better understood.
It can help to put this first diagramatically:
Ward
ay reception and
filing
Adr.
O.P. booking
En q U i r i e
O.P. reception
A.
Outside agencies
The degree of interdependence can be indicated
thin lines.
by thick
or
From this one can then go on to define the nature of these
relationships. As local conditions can affect this no attempt
will be made to do so here. It is suggested that what is necessary
is to examine this diagram and pose the following questions to
oneself:
-Does this represent the inter-relationship in this
hospital: (a) now
(b) in the future?
(If not, then redraw it to do so)
I
3.2.k Outpatient booking
To arrange for all outpatient clinic bookings, co-ordinate,
bookings where attendance at more than one department is required
and to ensure that copies of booking, lists are sent to Medical
Records and other departments concerned at least 48 hours
before clinic.
3.2.5 Outpatient reception
To receive patients for outpatient clinics, receive their
records for clinic, to ensure that they are called at the
booked times (dependent on emergencies etc.) and to supervise
dictation of notes and letters regarding clinic visit and subsequent return of records to Medical Records with tapes etc.
• (In most cases these departments will be one and the same.
It should be recognised, however, that there are two sets of
functions).
3.2.6 Accident & Emergency department reception
(i) to receive emergency outpatients, establish identity,
check on known medical history and raise record;
(ii) To book patients for return visits for dressings;
(iii) To receive patients returning for dressings at booked
times (as advocated in chapter 16, para 2.6);
(iv) To maintain A. & E. records. (This should include
passing information on attendance to Medical Records).
3.2.7 X-ray reception and filing
Insofar as the X-ray department's function affects Medical
Records and related departments it should pass information to
Medical Records regarding attendance so that the function defined
in 3.2.1 (i) can be carried out. It is also desirable that the
same number be assigned to x-rays as to medical records and the
same system of filing be used.
21
(ii) to be a repository for medical records that are not in
current use;
(iii) to code information on records for local and national
statistics;
(iv) to produce records required for research and teaching;.
(v) to provide a typing service for all clinical departments
of the hospital;
(vi) to produce operation lists and similar regular information.
Admitting: 3.2.2.
Ci) to arrange for the admission of patients:
(a) for booked cases off the waiting list by
pre-registration;
(b) for emergency cases by getting information
required from patient or escort on arrival;
(ii) to receive patients on their arrival for admission,
arrange for their escort to the ward and for the chart
to accompany patient to ward in the case of a booked
patient;
(iii) maintenance of waiting list.
Enquiry Office: 3.2.3.
The answering of enquiries on patients' condition, either by
phone or over the counter, the receipt and sorting of mail, flowers
etc. and the daily bed state. (In many hospitals the daily bed
state is produced by Medical Records. Is this functionally
correct? Is it not reasonable that the department that is
required to know who is in the hospital should also be able to
produce the daily figures showing how many people are in and were
admitted, discharged etc? If the information, normally produced
by the Enquiry Office is not satisfactory for Medical Records the
corrective is to improve the quality of information not change the
department producing it and incur costly duplication, )
(iv) Outpatients A projection will be necessary taking into
account anticipated population and new services. Availability of transport and anticipated moves in this direction
may also play a part here in that it is not realistic to
plan, for instance, for patients to arrive at a clinic at
41- • hour intervals if public transport only comes every
-- hour.
(v) Accident & Emergency department A projection on anticipated population is necessary taking into account also
if these are expected
anticipated industries and schools to increase substantially attendance at the A. & E,. department will be higher than for ordinary residential growth.
(vi) Special factors such as specialist units, research and
teaching, emergency precautions, all of which result in an
extra load on most of the departments under review,
3.2 Functions of departments
• It is worth the time and trouble to state what may appear to be
very obvious: what each department is supposed to do in round terms.
This then gives you a base line to which you can refer any of your
headier flights of fancy by asking: 'Is this a function of the
department?' The following are suggested as functions of the
departments under review. Smaller hospitals will telescope the
functions of various departments together. The important thing
is to be able to see a pattern similar to this in these departments.
3.2.1 Medical Records department including
medical typing
(1) To be able to answer the question: 'what is known about
this patient?', to produce the records giving this information.immediately, to raise • a record for any department
of the hospital where cases are new to the hospital and to
• up-date information for old cases. (The integration of inand out-patient notes, if not yet accomplished, should be
an aim in all new planning. However, it is questionable
whether this should include Accident & Emergency, x-ray,
laboratory and physiotherapy outpatients because of sheer
weight of numbers.This is discussed in chapter 16,
para. 3);
21
However, having said this one must point out that the person
in charge of the department should do the detailed planning.
This chapter should be read in the context of giving thought to
the functions of Medical Records and related departments with the
object of making the 'medical clerical' side of the hospital
function as an integrated whole.
Functional planning:
3.
This is the process of assessing the anticipated load and of
examining the functions and inter-relationships of the departments
concerned, not in terms of what is adequate for today but of the
demands that will be made in 25 years' time. It is probable that
needs beyond this period will be met by the provision of new
hospitals when the problem becomes twofold but still governed by
the principles put forward here: planning the new hospital and
integrating it with other hospitals.
Anticipated load: 3.1.
Before any review of functions is made it is necessary to get
an idea of the numbers for which you are planning. 'This involves
answers to these sort of questions:
(i) Population What is the population of the district served
by the hospital? What is its rate of growth? What,
therefore, is the anticipated population in 10, 15, 25
years' time? This will give you a proportion from which
other projections can be made. It is not, however,
sufficient to take births only into account. Other factors
occur such as immigration, anticipated new industries,
towns, housing areas and other developments which will
attract population, or similar developments in a nearby
area which might result in a relative standstill in
population.
(ii) Services What new services are proposed? A new clinic,
for instance, will involve extra movement of records,
extra staff etc.
(iii) Inpatients The increase will depend on the number and
type of beds and the anticipated increase in population.
6.
Further reading
6.1 Basic
6.2 Background
1, Introduction
The object of this chapter is to indicate how to go about
planning a Medical Records Department. It stresses the necessity
of thinking out the function and inter-relationships of the department and other departments of the hospital. It involves looking at
existing procedures, questioning them, looking for better ones and
thinking through the upshot of any changes contemplated.' It is then
necessary to put this in writing. If your statement is clear, logical
and reasonable then your requirements are the more likely to he met,
and the architects will understand what you want and be able to
translate it into a functional building. If you dodge the issue
and surrender to the temptation to play around with plans your
department, will find that its requirements are cut and you and your
successors will be left with the consequences of your sloth for a
long time.
2. Scope
• What, is the scope of the Medical Records Department as far as
planning is concerned? Is it merely concerned with the department
that has 'Medical Records' on the door? It is suggested that one
of the main causes of inefficiency in the 'medical clerical' side
of hospital administration is the departmentalising of interdependent offices. When opportunity is presented through new planning to co-ordinate the working of these departments it should be
taken.
This chapter assumes, therefore, that in planning a Medical
Records Department plans for the following related departments will
be included: Admitting Office; O.P. Booking and reception; Enquiry
Office; A. & E.reception; X-ray reception and filing. Although
laboratory is not included in this chapter the possibility of its
inclusion in the 'medical clerical' side should be investigated.
Some or all of these departments may have separate heads or the planfling of their offices may be considered to be part of another department - X-ray and Accident & Emergency, for instance. Insofar as
their relationships with' Medical Records are important the criteria
to make these smooth and efficient 'should be put forward with a
view to integration with the plans made by individual departments.
F
"I
21
PLANNING A MEDICAL RECORDS DEPARTMENT
1. Introduction
2,
Scope
3,
Functional planning
3.1 Anticipated load
3.2 Functions of departments
3.2.1 Medical Records Department including medical typing
3.2.2 Admitting
3.2.3 Enquiry Office
3.2.4 Outpatient booking
3.2.5 Outpatient reception
3.2.6 Casualty reception
5.2.7 X-ray reception and filing
.3.3 Inter-relationship of departments and relationship to
other departments of the hospital
3.4 Procedures
3.5 Staff
3.6 Flow of traffic
3.7 Equipment
3.7.1 Intercommunication
3.7.3 Admitting
3.7.5 O.P. booking and reception
3.7.7 X-ray reception
- 3.7.8 X-ray filing
3.b Special points in design and planning
3.8.1 Inter-relationship
3.8.2 Storage
3.8.3 Built-in fitments
3.8.4 Lighting, power and heating
3.8.6 Admitting
3.8.8 O.P. booking and reception
3.8.10 X-ray reception
3.8.11 X-ray filing
4.
Physical planning
5.
Summary
SAMPLE PROOF CORRECTED
ART TRAINING needs today to be co-ordinated with workshop practice.
The artist is apt to deplore the absence of good taste in the workman and
technician, and the technician, in turn, is irritated by the artist's ignorance
of the technical processes for which he is designing.. The artist is too
ready to design with but a vague idea of technical limitations and possibilities. The workman, in acquiring technical training, gets little chance
of cultivating good taste or artistic judgment. What is needed is art
training based on a knowledge of workshop practice; shop-trained artists,
not studio-trained craftsmen. Art training can only define principles,
stimulate imagination, teach appreciation of abstract lines and forms.
A basis of technical experience for practical and constructive work is
needed. The counterpart of the skilled technician in the school of art
and industrial design is the student of design working in the factory—
if necessary on a voluntary basis—so that he may acquire the necessary
knowledge of the process for which he intends to design.
Printing is the chief means by which messages are multiplied and
disseminated. There is no point in multiplying a message if it is not
easily understood. It is useless to say a thing three times with a mouth
full of marbles or to shout in a language that your listener does not
understand. The cultured accents of a pleasantly readable type effect
their object where the asthmatic raucousness of a type face with meaningless frills or obesities fails.
The essential considerations cannot be decided without careful
thought. For this task it is necessary to acquire some familiarity with
type forms which express the words, appreciation of apt illustration, and
ability to arrange these elements into a comprehensive and logical 'design
which will express the thought so that it will lose nothing of its effect
and informative content.
Every printed item has a job to do. . Its purpose should be the first
thing to consider. Green ink on green paper, for use under artificial
light; rattling paper at a classical concert; cumbersome menu , cards that
fall into the soup—such are examples of failures on the part of printers,
examples where the printer was not thinking of the purpose of the work.
These pitfalls, these waste-paper-basket fillers, can only be avoided by
visualising the intention of the finished work before deciding the first.
detail of its format.
—From the preface to How to Plan Print,
by John Charles Tarr.
Crosby Lockwood and Son Ltd.
20
SAMPLE PROOF TO SHOW PROOF-READER'S MARKS
,4 gc.rt training needs today to be co-ordinated with workshop practicej 0/
4The artist is apt to deplore the absen/e of good taste the workman and 9/
c/technifian, and the technician, in turn, is irritated by the artis4 ignorance
of the technical processes forjswhichl designing. The artist is too
/
ready t© design with but a vague idea of technica1imitations and possi- I
bilities. (he workm/n, in acquiring technical training gets little chance
4ultivatinoo ast xtrtistiudgment.What L is Lneeded L is Z art
training based on a knowledge of workshop practice; shop-trained artists,
not studioJle craftsmen. Art training can only define principles,
stimulate imagination, teach appreciation ofa abstract lines and forms.
A basis of technic4xperience for practical and con–structive work is
o #% needed/ The counterpart of thkilled technician in the school of art
and industrial design is the student of design working in the factory—
if ncfrssary on a voluntary basis--so that he may ac'uire the necessary
knowledge /of itheL process L for / which /he j intends L to /design.
ne.'/z LPrinting is the chief means by which messages are multlPlIeU and
disseminate?. There is no pointØin multiplying a message i it is not =
easily understood It is useless to say ajgg .tistiT] w1th a m ii ,(4o/===
-full of marbles or to shout in a language that your listener does not - understand. The cultured accents of a pleasantly readable type effect
their
object where the asthmatic raucousness of a type face with meanir
/
/less frills or obesities fails.
The essen/al considerations cannot be decided without careful
/
thought)
For this task ijj11 necessary to acquire some familiarity with
type forms which express the words, appreciationf at illustration, and
(%abty to arrange these el/ements into a comprehensive and logical degn
which will express the thought so that it will lose nothing of its effect ff/
and informative content.
Eprinted item has a job to do. Its purpose youlcl be the first
thing to consider. Green ink on green paper, fi use under artificial
light/erraulinat a classical concert; cumbersome menu cards hat
fall into the soup/ such are examples of failures on tbe®a rt ofrinters, x/X/
i/ examples 4re the printer was not thinking of the purpose of the work.
These pitfalls, thee waste-paper/basket fillers, can only be avoided/
visualising the intention of the finished work before deciding the first
detail of- it!& format.
bf
Pq
No.Marginal Mark
Meaning
49. /Substitute semicolon
so
Insert period
51
Substitute period
Corresponding Mark in Text
/
/
/
52..Insert colon
53 .
Substitute colon
54
Insert question mark
.55
Substitute question mark
.56
Insert exclamation mark
57
Substitute exclamation mark
/
Insert parentheses
( /4 )
Insert (square) brackets
59
[ ,(]
Insert hyphen
60
,
Insert en (half-cm) rule
61
58
62
/4
63..2..1 ,
64-
Insert one-em rule
A'
A'
-A'
A'
Insert two-em rule
Insert apostrophe
65
Insert single quotation
marks
66
Insert double quotation
marks
7
A'
/
A'
I -
Insert marks of ellipsis
A'.
xx
A'
68
Insert leader
/
69
Insert shilling stroke
/
.70
Refer to appropriateEncircle words, etc., that
authority anything theare queried
accuracy or suitability of
which is doubted
I
2
Marginal Mark
Meaning
J
9
Place in centre of lineIndicate position
30
Indent one ern
31
Indent two ems
32
Corresponding Mark inText
L
J
33
Move to the left
Move to the right
34 Take letter or word from
end of one tine to beginning
of' next
35 Take letter or word from
beginning of one line to end
of preceding line
36
I
Raise linesover lines to be
moved
37
Lower lines
38
Correct the vertical
alignment
39
Straighten lines
under tines to be
moved
through lines to
be straightened
Push down space
40
/through space
-
/affected
Begin a new paragraph
41
before first word
of new
paragraph
n€iáa4
L
42
No fresh paragraphhere
43
The abbreviation or figure Encircle words or figures to
to be spelt out in fullbe altered
44
Insert omitted potion of-
lou-t
4,6W
-
between
paragraphs
NOTE.—The relevant seelion of the copy should be
returned with the proof, the
omitted portion being
clearly indicated
45/after matter(Caret mark). Insert
/omittedmatter indicated in margin
.15
1
46
Insert comma
47
Substitute comma
48/
Insert semicolon
-
No.Marginal Mark
Meaning
11.j' Change to italics ________ under letters or
words to be
-
altered
12
Underline word or words________ under words
affected
-
13
Change to romantypeEncircle words to be
altered
14
Wrong fount; replace by Encircle letter to be
letter of correct fountaltered
15
}
Invert type
16
Replace by undamagedEncircle letter to be
altered
character
17
Substituted letters or signs Cross out letters or signs to be
Encircle letter to be
-altered
which this is placed to altered
/under
be ' superior
18
.Inserted letters or signs
/under which this is placed to
I
be 'superior'
19
1
Substituted letters or signs Cross Out letters or signs tobe
over which this is placed to altered
be ' inferior'
Inserted letters or signs over
20..-,
this is placed to be
/which
' inferior
/
21Pabove theUse ligature (e.g., flu) or,-.above the letters
to be altered
ligature ordiphthong (e.g., ce)
diphthong
required
22
Write out separate,
letters followed by- /
Substitute separate letters/through ligature
for ligàtureor diphthong7ordiphthong to
he altered
Close up—delete space
linking words or
between letters -....._-letters
Insert a space
23
24
Space between lines or
25
>paragraphs required; the
of space may be
iT amount
indicated
Make spacing equal
26
2.7
74t
Reduce this space
Transpose
z
/
between words
between words
between letters or
(numbered when
necessary)
20
SYMBOLS FOR CORRECTING PROOFS AND MARKING NEW COPY
(Words printed in italics in the marginal-mark column below are
instructions and not part of the marks.)
The standard symbols and marks shown below are the only ones. that
should be used when proofs are corrected. They may also be used for
correcting copy before it is sent to the printer. Do not use anymTks;bt her
than these standard ones, for strange marks of uncertain meaning may easily
lead to errors and increased costs.
Author's alterations should be made in ink of a different colour from that
used by the printer's reader.
The symbols and marks should be studied in conjunction with the sample
of a corrected proof. In copy other than tables every correction or alteration
should be made in the margin, not in the body of the printed matter. An
appropriate mark is placed in the text to show the printer where the
correction is to be made.
No.Marginal Mark
Meaning
1/Sign to show that marginal
mark is concluded2
c9J
Delete (take Out) Cross out letter or word to be
-deleted--
3
Delete and close
4
through
Delete character and leave
character to be
space
/deleted
-
Leave as printed
5,o'tet
7
8
/cclftl
/
-
''
above and below
letters to be taken
/Out
under letters or
• • • words to remain
Change to capital letters
under letters or
words to be
altered
Change to small capitals
under letters oC
words to be
altered
Use capital letters for initial
and small capitals for
& 4/;. letters
rest of words
Change to lower case
Change to bold type
under initial
letters and
- under the rest of
the words
Encircle letters to be
altered
-under letters or
words to be
altered
20
APPENDIX A.Spacing requirements in forms
1.
For handwritten copy: As a general rule allow 8 characters
to the inch horizontally and " per line vertically for
hand written forms. It may be necessary to allow a
little more than this if forms are to be filled in by non
clerical people, but over generosity seems to encourage
bad handwriting.
2.
For typewritten copy: Typewriters normally type 10 or 12
characters to the inch; check which yours does.
Allow 6 lines to the inch, or multiples thereof,
vertically.
Allow a minimum margin of " at the bottom of a
form to give typewriter rollers sufficient area to grip
the paper. Where possible allow 1" margin at the top of
the paper to allow paper holder to hold paper down.
3.
Filing margin: Filing margins should be at least " but
can often be used to accommodate information which does
not need to be read when the document is filed.
Li. Further design points
Sequence. Wherever possible information should be
entered in a 'natural' left to right sequence; this
applies particularly to handwritten forms but also
affects the number of times the tabulations indexes
•and carriage returns are required in typing.
(a)
Transcribing. If information is to be transcribed
routinely from one form to another ensure that each
•is in the same sequence.
(b)
(c)
Puled lines. When it is necessary to have a great many
ruled lines on the form whether vertical or horizontal
break up the mass by having heavy lines dividing out
natural or arbitrary sections to reduce eye strain for
those using the form.
(d)
Punch holes. If the forms are eventually to be filed
using a punch hole method then the punch holes should
be put in in the printing process.
20
Background: 8.2.
Shoemaker (C.o.) How forms
control can cut paper work
Ryder (J.) Teach yourself printing for pleasure
Hospitals, May 1, 1961, pp
81-4, 111; Hospitals Abstracts,
Aug. 1961, p 512
London, E.U.P., 1957, 1+2
pp, illus.
Associative: 803
3;c
Hollinworth (J.) Kardex in a
psychiatric Hospital
10 Patients' records
Nursing Times, April 28, 19619
pp 520-1; Hospital Abstracts,
Aug. 1961, pp 513-4
Bennett (A.C.) Methods improvement in hospitals. Chapter 17
U.S.A., Philadelphia, J.B. Lippincott Co., 1964, xi ± 157,
Wagner (Prof. G.) The development of the standardised
medical record in Germany
The Medical Record, Nov. 1965,
illus.
pp 183-8
Guide to the organisation of
a Hospital Medical Record
Department' pp 31-5
Hargrave (A) Application of Work
Study to Medical Records
'Services
U.S.A., Chicago, Ill.,
American Hospital Assn., 1962,
vii + 83
Medical Record, Feb. 1962,
pp 478-86
U.S.A., Berwyn, Ill., PhysicHuffman (Edna K.) Manual for
ians' Record Co., 1959,
Medical Record Librarians, pp
33_1+ ('Order in which to
xxx + 604, illus.
assemble the Medical Record')
35-100, ('Basic records'),
1+64-5 ('Quality of record forms')
'Is that form essential?' in
'Methods at work' pp 93-4
London, Current Affairs, Ltd.
1962, 101 pp
MacEachern (M.T.) Medical Records
in the Hospital, pp 60 -70 , 87110
U.S.A., Chicago Ill., Physicians' Record Co., 19371
'Medical Records & Secretarial
Services' Hospital 0 & M Service
Report No. 2 pp 7-12
xvi + 374, illus.
H.MS.O., 1959 32 pp
Oldham (K.W.) Anaesthetic andAnaesthesia, April 1963, pp
operation records: a description213-6; Hospital Abstracts,
of a new type of combined formJune 196 3, pp 331-2
'Paper making'
Medical Record, August 1951,
Report' of a Committee on Medical
Rogers (L.C.) Take advantage of
paper
Medical Record, Nov. 1960,
PP 346-49
Shoemaker (D.J.) California's
new fast record
Aug. 1 9 6 5, pp 200, 2021.
pp 218-22
1960, 51+ pp
203, 233-5
xxii +
Stone (J.E.) Hospital organisation and management, pp 112932, 148015 1+1 9 1542-9 1 1611
London, Faber, 195 2 ,
The design of forms in government
departments
H.M.S.O., 1962 9 173 pp.,
1722
illus.
'lit
20
(v) Observe these criteria: uniformity, comprehensibility,
economy.
(vi) Spend time on a form before you send it to the "printer.
Further reading: 8.
Basic:8.1.
Anna (Sister) Pediatric records
Hospital Progress, April 1961,
Sept. 1961, pp 583-1+
Berkbuegler (J.w.) Too much
paperwork in medical records?
Hospital Progress, Jan. 1963,
pp 60-1, 100; Hospital
Abstracts, July . 1963, p 396
London, Blandford Press 1961,
Biggs, (J.R.) An approach to type
136 pp
Bothwell (P.w.) Routine, records
and research. Pta, I - III
Medical Record; Aug. 1960,
pp 2 9 8 -302 ; Nov. 1960 pp
320-7; Feb. 1961, pp 359-61+
Breadmore (R.G.) Paperwork
simplification, 2. Designing
an efficient form
June 1966, pp 1+41-41+4
Clarke (K.W.) A practical index
for clinical notes
Medical Record, May 1958,
p 351
Champer (J.) Weiss Memorial cuts Hospital Topics,'April 1962,
admitting time in half with new pp 1+1-3; Hospital Abstracts,
forms, simplified procedureSept. 1962, p 567
Coulam, N.R. Economy of effort in
Medical Record Keeping. Section
on 'Design of forms' pp 621-2
Garner (P.) & Hollings (D) Forms
for beginners; initial review
Office 'Magazine, Sept.
Garner (P.).& Hollings (D) Forms
for beginners: layout and design
Office Magazine, Oct, 1963,
pp 615-25
pp 699-700
pp 798-9
Government Printing Office Style
Wellington, Government
Book: a guide addressed to all
Printer, 195 8 , 1 71 pp
writers, editors and public
servants who prepare manuscripts
for publication by the New Zealand
Government Printing Office
1963,
(ix) When you receive the corrected proof back go over it to
make sure there are no errors - transpositions, misspelling, wrong founts, capitals in place of lower case
and so on. Make your corrections, and those of the
initiator of the form, in ink using the correction marks
for printers' proofs shown in Appendix B. (These are
taken from 'Preparation of Copy' in New Zealand Government Style book by kind permission of the Government
Printer)
(x) Give the corrected proof back to the printer and, if you
have not already done so, give him instructions regarding
keeping copy standing etc.
(xi) When a reprint of the form becomes due - say, 3-'-f months
before you expect your stocks to run out - refer the
form to all those using it for suggestions for revision.
If necessary, make a "mock-up" of the revised form and
refer it to those concerned before taking it to the
printer.
6.
Revising a form
If your forms do not live up to the criteria given above of
uniformity and comprehensibility you will need to revise them
Again, you may need to revise them as suggested in the last
paragraph.
Unless the revision is a radical one involving changes of
type face and lay-out use the existing form as much as possible.
As part of your tools of trade you should have a hobby knife, a
steel rule and a gum bottle. Take a sheet of plain paper the
size of your form and cut up an existing form where either the
same lay-out or the same type face is to be used; paste in
position. Use pen for the parts that are to be changed.
7.
Summary
(i) Any object is well designed that is suitable for the job.
(ii) Is the new form , necessary?
(iii) Know the printing processes - see them in action, if
possible.
(iv) Know the different sorts of paper and the sizes that
it comes in.
20
form with him making sure that you know exactly what
it is to do and what the originator has in mind.
(iv) Block out a rough copy in pencil to make sure that
the copy will fit on the forms
(v) Do a copy in pen the size of the proposed form with
lettering the same size as it will appear on the form.
If there is any doubt about legibility of words (medical
terms, drugs etc.) do a larger copy to make this clear.
(In the same sized copy I use a blue ink for light or
medium print, capitals or lower case, and black ink for
bold. This is easier for the printer to follow and
gives one a reasonably good idea of the finished article.
Lower case = small letters)
(vi) Show your draft to the initiator of the form. Ask him
to make any corrections now and accept the necessity
of redrawing the whole form with as good a grace as
possible l Before giving or sending copy to the printer
give the form a name and number and preferably, alao
month of printing. (Keep a register of form names and
numbers)
(vii) Take the form to your printer and, discuss it with him paper, type faces, colour of paper or print - and ensure
that he understands your copy. Ask him to let you have
a proof and sample of paper. Confirm in writing what you
have discussed, ensuring that you give your printer
specifications and keep a copy of what you write. Although
this is not an exhaustive list it will show some of the
questions that should be covered in a standard specification: size of paper. Is form single or double sheet?
Is it to be punched, if so precisely where? Write out
clearly any words that may not be plain. State order of
leaves for more than one page • Is form to be numbered'?
Where and how? Is it to he padded or gummed? (Both add
to cost and are frequently unnecessary). If form is to
be made up in books is it to be interleaved with blank
white or coloured stock? How many forms are to be
packed together? How are they to be labelled? Where
are they to be delivered and when?
(viii)
When the proof is received give it to the initiator of
the form asking him to make any corrections necessary in
pencil. Also show him a sample of the paper for his
approval.
Consider whether the number of copies of the form that
are to be used justify setting the copy in print. Could
you use lithographed typewritten copy? (The paper used
presents a good surface for writing; your own typists
produce the copy for photographing). Many forms used
internally could well be produced in this way.
Get alternative prices for the job. In this way you will
be getting more experience and knowledge directed onto the
problems of doing your work as well and as economically as
possible. (If printing resources are limited it is worth
considering printers in other towns or cities. Some, for
instance, specialise in particular lines of work). Having
more than one head on the job may suggest alternative, and
better, ways of doing it - few jobs are so simple that they
allow of only one approach.Consider whether another
Board's forms may not be suitable. Preparatory costs might
be saved by using the body of another Board's form with
your heading by dealing with the other Board's printer.
5.
Steps in the evolution of a form
Everyone has their own way of going about things so one can
only put this forward as a suggested procedure which has been
evolved over the years and works reasonably well:
(i) A doctor comes to you in great excitement with much
scribbling-and a few lines on a piece of paper completely
different in size to your normal forms. This. is a new
form which he must have immediately. You ask him
whether this has been tried out as a duplicated form.
If not, suggest to him that he do this. This will give
him the chance to judge the practicability of it and
change it accordingly without much cost. (Because
duplicating paper does . not take ink satisfactorily it
should only be used for trials or for forms that are
little used but still considered essential)
(ii) If he has tried this out as a duplicated form, ask him
whether the Medical Superintendent and his colleagues
agree to it being printed.
(iii) Assuming that this and similar obstacles have been
cleared and that you have checked that no existing form
does, or can be changed to do, the same job go over the
20
- Use one colour ink only where possible. The use of a
second colour involves putting each form through the press
• a second time and can involve an increase of cost of up to
20 %. A general rule is that a second colour should only
be used where it is clinically essential, e.g. the normal
on a temperature chart. It is often possible to use. a
reverse block to give prominence to a heading instead of a
different colour.(A reverse block is one where the
letters appear as the colour of the paper against abackground the colour of the ink).
- Choose your paper from a sheet size that will give the
minimum of cutting to waste, not forgetting that you
normally need a blank binding margin. (A. good printer
will do this but you should be 8ure. that you are choosing
a paper that is economical)For instance, suppose that
your form size is1-" x 8--" (medium 4to); this will
cut economically out of double medium, 23" x 36 11 , but
wastefully out of double large post, 21 11 x 33". You pay
for the waste.
- Choose the right paper for the job. If you choose too
good a paper you will be paying more than you should; if
you choose a poor paper you will probably find that the
users of the form are dissatisfied with itand insist on
it being reprinted immediately on better paper.
On any job involving duplicating paper remember that it is
a more expensive paper than a bond and that its cost in
relation to the total cost of the job is far higher.
Therefore, if your form is one-sided use a lighter weight
paper; only use a heavier duplicating paper where copy
is to go on both sides. .
- Make sure that your draft of the form is clear and
unambiguous for the printer to follow. His misinterpretations of your draft will cost you money.
-. Make sure. that corrections are done to the draft of the
form before it goes to the printer. Changing the printer's
proof is known as 'author's corrections' and can be costly.
- Many forms require pen ruling which is a separate process
often carried out by another firm. Do not have the form
pen ruled until the printed copy has been approved.
be provided and there should be no doubt to which choice
it .refers
- Space. Use space intelligently; you do not have to fill
every part of the paper. It is usually better to use
smaller type with space left around it than filling up
the comparable space with printing.
Layout. Keep this consistent,Most forms ask for sex,
ward, name, number. Make sure that they do this in the
same order on each form. If the form is to be used with
a typewriter, ensure that it is spaced vertically so that
the typewriter platen does not have to be adjusted, by hand
every other line. (Refer Appendix A.for spacing' measurements for forms)
Type. A form, and even a notice, is a communication
between two people. Be sparing in your use of bold type
and capitals. When you design a form read the copy aloud
to someone the other side of your desk, Emphasise capitals,
raise your voice to a public speaking level every time you
have bold type and to a shout when it is in bold capitals.
Having done this, recast the copy with more thought for
good manners!Underlining type is ugly and unnecessary.
You can often make the point as well by using a larger'
size of type or even using a different type face - your
object is to gain the reader's attention but not his
animosity.'
4•3 Economy
Good printing does not have to
of thought and preparation on your
between you and your printer. Some
be economical in the production of
be expensive, it is the fruit
part and mutual understanding
suggestions follow on how.to
printed matter -
.- Trial run. Try to persuade whoever initiates a form to
have a trial run of, say, two months as a duplicated'form.
This will let him see, in practice, how his form works
out. He will then be able to give you a . form for printing.
which should be good for a year.
Long runs. Remembering that the main charge in printing
is in composition ensure that the number of forms printed
each time is the maximum compatible with possibilities of
change etc.
20
Unless you go consistently to the same printer and insist
that he stick to one or two type faces for your job you
will find it very difficult to maintain uniformity with
a serif face. Many printers do the equivalent in type of
putting two clashing colours together. If you specify
sans serif faces this is less likely to happen since the
choice is less. The overall effect of a choice of sans
serif faces only for your forms is to help to make them
easier to read and tidier. Printers like to mix serif
and sans serif; if you have decided on sans serif don't
let them introduce a serifed type.
- colour, Colour can be used to achieve, difference whilst
maintaining uniformity in size, weight of paper and type
face. For instance, you might like all forms relating
to examinations (as opposed to treatment, operations etc.)
to be prominent.You can either do this by using a
coloured paper or coloured ink. Differences in coloured
papers have been mentioned; you will be careful which
you select.
Coloured inks can be more exactly defined by reference
to an ink maker's colour code book. However, in choosing
a coloured ink choose one of a definite enough colour to
take all the printing on your form; the use of a colour
and black on a form is uneconomic and adds anything up
to 20% to the cost of the job. Colour can also be used
effectively in the form of a band or a coloured edge - but
the form should be printed overall in the same colour.
Similarly, red should normally only be used in conjunction
with black print as a 'danger signal'.
Comprehensibility: 4.2.
Form filling can be difficult; your job is to make it as
easy as possible, usually by persuading the initiator of a form
that you can set it out so that it's plain and uncluttered.
Here are some important points Instructions. Make them simple, easy to see and short.
Don't be afraid to use a symbol if it can replace a
sentence. Where possible, let the form-filler indicate
appropriate entry by a tick rather than having to write
something, but ensure that it is clear in a multiple
choice question whether he is required to tick, underline
or circle. If ticking, a box or short dotted line should
bondover 15 lbo in weight in colour and few manifold or air
mail banks in colour.
+. The three criteria of design
Our three design criteria are uniformity, comprehensibility
and economy. Uniformity is needed aesthetically and for ease of
handling and storing. Far too many forms are difficult to
understand; your job is to see that the form is made up so
that it is easy to fill in and to read.. 'Economy is obvious.
Now let us see how these criteria can be applied.
4.1 Uniformity .'..
From the practical and aesthetic angles you should aim at
uniformity in your forms - not only should they be the same size,
or related proportionately but they should look as if they belong
together. These requirements are considered under
- size. All forms that go into the notes should be the same
size, except for ones thatare held :onbacking.
sheets (x-ray and lab. reports) when. thebacking
sheets themselves should' be the same: size as 'the
others. Daily notes kept by.the nurses which
usually go into a pocket holder formof fixture'
are the exception since their. àize is dictated
Different' sizes:
by the holder, usually 8" x
have their advocates; the, important things is
that all should be the same ' size - any waste, of
paper will be made good by the facility with
which the whole bundle of notes can be 'handled.
5".' .
- weight of paper. Consistency in weight of paper makes for
ease of reference; it is difficult to flick through
different thicknesses of paper,
- type face. For our purposes type faces can be divided
into two sorts: serif and sans (without)' serif. The
serif is the little cross-line finishing off a stroke
of a letter thus:
serjfII'GiA
sans
serif.I
C A.
20
weights of ledger paper since the flat sheets are
in up to 20 different sizes).
- newsprint, which is usually porous and therefore
unsatisfactory for our purposes.
- special purpose papers such as duplicating, the
paper used for offset lithography, gummed, papers
and so on.
The printer receives his paper in different sized flat
sheets.
The banks and bonds come in three different sizes: 21" x
33" ('double large post'); 23" x 36" ('doubLemedium');
1 7" x 27" ('foolscap'). The weights quoted for banks and bonds
are based on a large post sheet. We shall see later that the
sheet sizes have a relation to the sizes of our forms because
it is uneconomic to choose a sheet size which will result in
waste.
In deciding on the paper for a job consider what it is to
do. Is it to carry handwriting? (Most of ours will). Try all
sorts of pens and inks to see whether ink smudges 'easily and
whether it blurs. Does the paper tear too easily? Is it the
right thickness? Will carbon copies be required? - if so, is
the paper thin enough to allow of copies being taken? Will it
stand rubbing out? Will it be too thick and cause unnecessarily
bulky notes if several sheets are together? Other questions
will occur to you as you consider what the paper is to do.
Finally, a word of warning regarding coloured papers.
Colour is, as I shall indicate later, an important tool in the
good design of forms. It is, however, on the whole easier to
obtain consistency of ink 'colour rather than paper colour.
Therefore, be very sure that the colour you choose is a consistent one before you decide to standardise on it for a certain
use. Anything including red in its make-up is unreliable.
For instance, "salmon" can be any one of a different number of
shades in different batches of paper. All colours are of
varying strengths, thus giving one yellow which is a strong,
positive colour and another which is anaemic. Coloured papers
also cost more and restrict one's choice of paper. In a long
printing run paper can absorb 3Trd of the cost. of the job; an
extra 2c. or 3c. a lb. for a coloured .paper is obviously going
to make an appreciable difference. Currently, there are no
14 -to
3,Paper
As anyone who has seen a paper mill in action (or even done
a social studies project on one) knows paper is formed from wood
pulp after it has gone through various "cooking" processes with
different chemicals; some of these processes differ depending
on the type of paper that is required.
Paper, for our purposes, comes in these forms:
Firstly, boards or cards:
- board, such as is used for file backs.
- paste - or pulp - boards (described as 1, 2, 3,
k, 6, 8 or 10 sheet), as used for some index cards.
- card,
pulp
used
flat
which is a better quality than paste - or
- board and mainly termed index boards and
for index cards (described by weight of 100
sheets: 110 lb., l LfO lb., 170 lb., or 220 lb.)
- manilla, as used for file covers.
Paper as used for forms et.c:
- bank, divided into:
- manifold bank (up to 8 lbs./ream of flat sheet described as 11 8 lb.") - flimsy paper
- air mail bank (7-10 lb) - flimsy paper of better
quality than manifold
- lightweight (ii lb.: 'D.P.L.22 1 ) - used for
copy paper, x-ray and pathology reports,
single sided forms etc.
- bond, divided into:
- 15 lb ('D.p.L,301) - a super grade bank of better
quality and therefore slightJr dearer
- 18 lb. ('D.P.-L.361) - suitable for double-sided
forms
ledger paper, which is usually produced in azure or buff
and is any paper heavier than a bond but not a board or,
card - it can go in weight up to 82 lb. which is machineposting ledger paper. (The patient identification form
of a medical record is often on a 54 lb. ledger paper.
There is little consistency in the description of
20
2.2 In offset lithography copy is photographed and transferred to a paper or light aluminium plate which is then put on
a printing machine which works on the principle of the incompatibility of water and oil - the parts to be printed retain the
printing ink, a film of water on the blank areas prevents them
from being printed.Offset lithography allows of greater
versatility in that it can be used for typewritten, even
handwritten, copy and much copy can be made up by pasting
letters onto a white background. It has the advantage that
once a plate has been made it can be used again and can be
renewed from the original negative or by making another plate
from one of the forms - and, in the latter case., changes can
be made quite easily, if necessary. Plates can be stored easily
and for nothing. On the other hand there are disadvantages in
this method.If your final job is to be in type (rather than
reproducing type- or handwritten copy) then the :letterpress
process has to be gone through to produce, one good print which
can be photographed. New developments, such as the use of
the "headliner" and varityper, are making the use of a full
letterpress "pull" unnecessary in many cases but their effect
on cost has yet to show a pronounced saving.Offset lithography
lacks the clarity of imprint of letterpress because in letterpress ink-carrying metal is biting into paper whereas in offset
lithography the paper picks up ink from a rubber roller which
has picked it up from the flat surface of the plate (i.e. it is
set off from the rubber roller onto the paper).Depending on
the process whereby the copy is transferred onto the plate the
image can come out in varying degrees of fuzziness; this can be
particularly noticeable where small print is used.
2.3 Most readers will be all too familiar With the
duplicating process.It should not be forgotten, however,
that the spirit duplicator is included in this type of equipment.
The spirit duplicator is a simple machine that can produce copy
in different colours from a typewritten or handwritten original.
Its permanency cannot, however, be guaranteed.
These are the three main proôesses of getting copy onto
paper; letterpress is the most commonly used and, as we shall
see, abused
The Medical Records Officer is the only person in the hospital
who has an overall view of medical records forms; you must
ensure that there is nothing that is already doing the job or could easily be made to do it - before going ahead with a
new form. On the other hand there is no point in trying to
make an existing form do when it obviously won't.
Before examining the criteria given below it is necessary
to take a look at the tools for doing the job: type and paper.
What follows is an extremely simplified description of two
complicated subjects.
2.Type
In general, printed matter is produced in one of three
ways: letterpress, offset lithography or some form of
duplicating.
2.1 In letterpress the copy is made up into type metal
which is put on a printing press, inked and produces an image
direct onto the paper. The type metal is either set by hand which is a long and therefore expensive process - or by one of
two machines: a linotype or monotype. The linotype produces
a line of type in a slug which is fitted into place by hand.
The monotype casts each character separately; it is thus more
versatile and often more appropriately used in form work. It
is, however, a more expensive process though less so than handsetting. The question of which process is used will be decided
by the printer who will be guided by availability, cost and
practicability. Type metal can either be left standing or
distributed after the job is completed; if you go to the same
printer you should let him know whether you want the type kept
standing or not. If type is to be kept standing you will pay
for it - the current rate is lc per lb. of metal a month;
this covers the cost to the printer of the type metal and the
space that he has to keep for it. On the other hand, if type
is distributed it will have to be set again if the same copy
is to be reprinted - and setting, or composition, is the most
expensive part of the printing process.
20
DESIGN OF FORMS
1.
Introduction
2.
Type
2.1 Letterpress
2.2 Offset lithography
2.3 Duplicating
3.
4.
Paper
5.
Steps in the evolution of a form
6.
Revising a form
7.
Sumrhary
8.
Further reading
8.1 Basic
8.2 Background
8,3 Associative
The three criteria of design
1+.1• Uniformity
Lf 2 Comprehensibility
1+.3 Economy
Appendix A. Spacing requirements in forms
Appendix B. Symbols for correcting proofs and
marking new copy
Introduction: 1.
The Medical Records Officer is in the middle of the chain
in the business of producing a form. In the design of forms
your job as a Medical Records Officer is to interpret the
ideas of medical staff so that they meet the criteria of form
design: uniformity, comprehensibility and economy. Different
people will have differing ideas on the make-up of their forms
and will put them forward vaguely, minutely or as a compromise
between the two; your job is to apply criteria to each draft
so that the end product will form a well-designed part of a
series.You should not hesitate to suggest a new form if you
consider this is necessary but beware of spawning too many
forms - unfortunately, there is no closed season for this
activity and you must, therefore, always examine the necessity
for a form before going ahead with its design. This duty of
examination applies irrespective of the source of the request.
To microfilm or not to microfilm (in 'What do YOU do?')
June 1 965, pp 121-4, 126,
128
14.2 Background
Doran (M.T.) The need for research
in Medical Record methods
1st mt. Congress Report,
pp 129-41
Document disposal: details of
office shredding machines
Office Magazine, Nov.
19 6 3, p 1004
pp 583-4
Dudley (H.A.F.) The consultant's
need for Medical Records
'Into the W.P.B. with safety'
in 'Methods at work' pp 11-16
Luck (J.H.) Work study as
applied to Medical Records
Londo,, Current Affairs Ltd.,
101 pp
'Medical Records'
N.Z. Hospital, June 1952,
p64
3rd mt. Congress Report,
pp 88-106
14.3 Associative
Benedon (w.) Records management
Jnl AAMRL, Aug. 1957,
pp 145-8
(Flavian, Hoovler, Murphy &
Nuss) 'We need more space'
(in 'What do YOU do?')
Medical Record. News, Oct.
1962., pp 220-1
19
Further reading:14.
Basic:lk±-i.
Bernhardt (P.) How long must
medical records be kept in
the hospital?
(Translation from German;
abstract)
Hospital Abstracts, Aug. 1963,
p
Bothwell (P.w.) Routine,
records and research
Pt. III
pp 359-6k
Eastham (G.),. Formy (E,w.)
& Brown (R.J.) An
investigation into the
demand for old records
pp 269-7k
'Guide to the organisation
of a Hospital Medical
Record Department'
PP 59-60
American Hospital Assn.,
1962, vii +83
McBride (D.M.) Ohio's clean
sweep (Record retention)
Medical Record News, June
1963
MacEachern (M.T.) Medical
Records in the Hospital.
pp 33_4, 198
U.S.A., Chicago', Ill.,
1937, xvi + 374, illus.
Nemec (F.C.) Microfilming
techniques
3rd Int. Congress Report,
pp 193-206
Pajala (A.M.) & Brody (S.A.)
Mistakes in microfilming
Oct. 1 9 6 3, pp 199- 2 00, 220
Medical Record, Nov, 1961,
pp k3-52.
Ready (J.B.) Microfiche
Report of a Committee on
Medical Records in N.S.W.
hospitals
1960, Skpp
Retaining records: how long?
Feb. 1 963, p 9
S.pringei (E.W.) Retention
of the record
August 1964, pp 166-7
London, Faber', 1952,
xxii + 1722
Stone (J.E.) Hospital organisation and management,
pp 791-2, 797-8
wI
45
(ii) Shredding. By this process paper is cut up into strips
varying from -a" to 1/16" wide and up to 6" long. Theit
shredded paper is used for packing material. Even
strips are not wide enough to convey any significant
information and the strips are so tangled that attempting
to reconstruct a sheet would be virtually out of the
question.
Shredding can be done on contract by a firm dealing
in waste paper. In this case destruction will have t.o
be supervised by a member of the Medical Records department.
Alternatively, there are office shredders which could
be installed in the Medical Records department. The
price range would be $120- 2 5 0 ; these could cope.with
all types of medical records and most do not require the
prior removal of staples, pins etc.
Under no circumstances should destruction be unsupervised by Medical
Records staff.
12, Conclusion
Finally it should be remembered that much effort is expended
in securing the medical record of the patient and many departments
of the hospital organisation are concerned with its production;
all this effort is wasted unless the record is preserved in such.
a manner as to be readily available when required. What is
preserved depends on legal, medical and sociological considerations;
how it is preserved is largely a question of economics.
13. References
Huffman (Edna K.) Manual for Medical Record Librarians, 1959
edn. pp 19 1 - 2 ('Numbering and filing medical records')
2nd International Congress Report.
Medical Record News, Feb. 1963
Medical Record, May
1958, November
.1959
The Standardisation of Hospital Medical Records. Report of
the Sub-Committee of the Standing Advisory Committee of the
Ministry of Health of England and Wales. London, H.M.S.O.
1965
19
U
Disease index & operation index: 10.2
These would be needed for as long as records kept for
research, probably longer because they do give certain basic
information about the incidence of disease.
Patient summary cards: 10.3
These give identification data, date of admission and discharge, final diagnoses and operations. They are mainly of
value after discharge as an alternative to the record shou:L1,
this not be available for ascertaining final diagnosis, ope:ra-.
tions etc. If kept in chronological order they can replace tthe.
admission and discharge register and, as such, should be kept
indefinitely, though this could be on microfilm. If, however,
they are merely an additional card they should be destroyed
after 2-3 years.
Means of destruction: 11,
Medical records are confidential. It follows that much
care must be taken to ensure that, when they are destroyed,
destruction is complete,
(i) Burning. Unless this is done in a furnace it is
useless. Incinerator type destruction can result
in charred, but still legible, records being left
around the incinerator site or going up the chimney
partly burned and being blown over the surrounding
countryside.
Destruction in a furnace when it is fully
operational is absolute. However, steps must be
taken to see that records are unloaded straight
into the furnace and not left lying around near
it. This method may become less available as boilers
are converted to automatic stoking and fueling.
Some local bodies provide destructor services
where documents in bulk can be destroyed under
supervision, which would he by a member of the
Medical Records staff.
3r
Until a local survey has established whether a significant
enough proportion of A. & E. patients are part of the 'hospital
population' it seems that policy should be retention for a
minimum period of 7 years and a maximum period to be fixed locally
depending on storage facilities, and the views of the medical
staff on the value of A. & E. cards over 7 years old.
'A local survey' is written advisedly. If a hospital is in a
primarily residential area, serving possibly several schools but
little industry, then the likelihood of A. & E. patients being
general hospital patients also is high; conversely, a department
in a central city hospital or one in an industrial area is more
likely to attract patients who would go elsewhere for general
hospital treatment.
9.
X-rays
Storage of x-rays - as long as the majority are the 17" x
1 5" size - presents a bigger problem than storage of medical
records. If mobile shelving is used it must, generally
speaking, be motorised; if not motorised, a bay must not be
more than 6' wide otherwise it is too heavy to move.
It is generally agreed that x-ray report cards should be
kept indefinitely or as long as clinical records are kept. The
time that x-rays are kept depends largely on storage available.
The English report already quoted considers that they can be
destroyed after 6 years, maintaining that the majority are of
ephemeral interest, such as simple fractures.
A compromise between destruction and indefinite retention
is to mark each x-ray in one of three categories: to be kept for
7 years, 15 years, indefinitely. This depends on radiologists
making a decision at the time the x-ray is taken, which they may
not be prepared to do.
10.
Medical Records department indices
10.1 Patient index
This should never be destroyed. Even if the patient is
dead it is often of value as establishing that a person was at
a certain place at a certain time.
34 6
19
Nursing notes: 6.
The nursing notes are the ones made by nurses in the ward
during a patient's time in hospital. They record what actually
happened to the patient.
There has been a great deal of discussion as to the value
of the nurses' section of the medical record after it has served
its immediate usefulness, and the necessity for preserving it
temporarily or permanently. The report quoted in para 3.1
above considered that they should be classified as primary
records and therefore kept for 20 years after the date of last
attendance. The Auckland Hospital Board considers them clinical
records which should therefore be retained indefinitely. The
value of microfilming them is, however, questiohabie.
Outpatient records: 7.
If, as recommended in chapter 16 ('Outpatient and A. & E.
department procedures'), the outpatient records are integrated
with the inpatient notes then the one policy will cover both.
If, however, they are kept separately in clinics physical considerations, allied with the interest or otherwise 'of the
clinicians in the material in the notes, will be the deciding
factors.
Accident & Emergency department records: 8.
The question of retention of A. & E. records is discussed
in chapter 16 para 3.2 ('Outpatient and Accident & Emergency
procedures').
Some American hospitals, and at least one in Australia,
consider that the A. & E. record should form part of the
patient's unit medical record.
The English report quoted in paragraph 3.1 above states:
'Because the majority of patients will be seen only in the
Accident & Emergency department for incidents having little or
no significance in the patient's future medical care we agreed
that this department should have separate records with a series
of numbers separate from the unit system of numbering for the
rest of the hospital records'. No recommendation was made on
retention.
3'c
(iii)
(iv)
(v)
Protection. Film cannot be easily tampered with.
Misfiling risk, Misfiling of a chart after it has been
put on microfilm is impossible. (This is not the case
with microfiche, nor with microfolio or aperture cards,
obviously)
Saving of time. Filmed records held in the records department eliminate the necessity of having to go to outside
storerooms for charts.
A study of the two methods - microfilm or microfiche - has
shown that a big advantage is obtained with the microfiche. The
great advantage of this system is that the whole of a normal
patient's file may be recorded on one card. Hard paper copies of
an old record - or part thereof- can be made for attachment to
a new record on readmission if this is considered necessary.
The disadvantages are as follows -
Ci) Inconvenience for study purposes. This is not easily
done if records are microfilmed, although this depends
on the equipment available for viewing or the production
of hard paper copies.
Not being able to keep a patient's record under one
file. On readmission of a patient it would be necessary
for the doctor to see the films through a viewer unless
a reader-printer was available to print a hard paper
copy.
(iii) There is a marked aversion to consulting microfilmed
records even where a hard copy can be made available
easily. The report on 'The Standardisation of Medical
Records in England and Wales' stated that there was
'a slump in recall rate which seemed to follow the
limitation of recalled records to micro-filmed copies
even when copies enlarged to full size were available.
This seemed to indicate that micro-filming inhibits the
recall of records which might-otherwise be useful.'
(ii)
(iv)
Stationery should be designed with microfilming in
mind otherwise the preparation of material can be
time-consuming and therefore expensive.
3,
19
Microfilming: 5.
Definitions: 501.
Microfilm is a 16mm film onto which full-sized pages have
been reduced. Microfilm has the main disadvantages that the
whole reel has to be •gone through to get the record required
and the record cannot be updated - a necessity with a unit
record system. On the other hand once on microfilm a record
cannot be lost, short of losing the whole film.
Microfiche is a 6 x + card of transparent mylar with longitudinal pockets which will take pieces of microfilm cut off
in. lengths. Microfiche is adaptable to the unit system and
can be easily updated. Strips of film could, however, get
lost.
Microfolio is a 5 x 3 clear acetate card with up to 60 microfilmed images of Lito sheets (as part of the card as opposed
to the microfiche which holds the cut-up film in a pocket),
being only one thickness of acetate ittakesup less space
than microfiche and its size is more convenient. It is less
convenient than microfiche to update.
Aperture card is a punch card into which a 35mm film is
inserted, the film carrying reduced copies of original papers up to 8 foolscap sheets. Aperture cards have the twin
convenience of being capable of use with punch card machinery,
(since they can be punched) and with microfilm viewers and
reproducers.
.
Microfilm reader is an illuminated groLLnd glass screen onto
which the image of a document is projected in its original
size from the microfilm. .
Hard paper copy is a permanent copy, in the original size, of
a document on bond-weight paper magnified from the microfilmed
copy.
Reader-printer is a microfilm reader incorporating an automatic process for producing hard paper copies in 6-10 seconds*
Advantages and disadvantages: 5.2.
The advantages are as follows (i)
(ii)
Saving of space. 3,000 pages of records can he photographed on 1 100 foot roll of 16mm film, or if microfiche is used about 60 exposures may be reduced to the
size of an ordinary index card. . .
Accessibility. Microfilmed records can be stored in the.
department itself and are readily available.
(ii) with the advent of mechanisation methods of recording
would change and, from the accretion point of view,
a review should be made within 5 years, or possibly
earlier;
(iii) the culling and destruction of 'management' records
should be subject to local rules of the hospital but
the Medical Records Officer was to assess the percentage
of storage space that would be saved if culling was
carried out;
(iv) that modern microfilming methods should be supported'.
+.Methods
Medical records can be kept in various ways most of which are
dealt with elsewhere in the manual. Suffice it to mention the
main ways and to comment briefly:
(i)
(ii)
wooden bins - wasteful and should have been discarded
long ago;
wooden drawers - wasteful and should be discarded;
foolscap filing cabinets - wasteful of, space and money
for general record storage; only to be contemplated in
exceptional circumstances where the need to keep
records separately and not in shelves can be justified;
,( iv) wooden shelving - takes up more space than steel, is
usually difficult to dismantle satisfactorily and is
frequently as expensive to provide as steel shelving;
there are proprietary makes of adjustable wooden
shelving which can be dismantled easily, but which
would probably be open to the first objection and
possibly the last;
(v) fixed steel shelving - best solution for current records
and essential where terminal digit filing is used;
optimum height is 7 openings, 12" between shelves, if
high shelves used then kicksteps will be necessary;
(vi) mobile sheel shelving- for older records; on chassis
mounted across rails so that the records lie in the same
direction as the rails; not more than 6 openings (12" between
shelves); if 9 ft. wide should be motorised;
(vii) microfilming - for old ' records for which there is insufficent room for the originals.
3i,
19
Type of record
Period kept
Remarks
A. & E. records
variesmedium sized hospitals
tend to keep indefinitely, unless space very
cramped, and larger
ones for 10 years
X-rays of particular
interest
indefinitelythough a few hospitals
with pressing storage
problems have to make
a time limit
of inpatients )
of outpatients)
considerablea few hospitals: particvariationularly well endow.ed with
storage space keep indefinitely. Most keep for
periods from 4-15 years.
Report cards usually kept
indefinitely.
Medical Record
summary cards
variesWhen plentyof storage
space retained indefinitely but the majority
5-20 years with one
large hopital microfilming
Patient Index
Cards
indefinitely
The Auckland Hospital Board's Medical Advisory Committee
investigated this matter in 1966 and recommended the following
policy:
(i) patients notes, from the clinical and academic
point of view, should be retained indefinitely;
(ii)
(iii)
A. & E. cards should be retained to conform with
the Statute of Limitations, i.e. 7 years, and
then destroyed;
X-ray films should be retained for a minimum
period of 20 years but the reports kept
indefinitely.
The Committee also considered:
(i) that the storage problem should be measured on a
statistical basis having regard to population growth
and expansion of the hospital services;
survey showed that twenty-nine states have either no less a term
or no specific policy for the retention of medical records, five
states have established 25 years as the limit, three states 10
years and one state 21 years. Three states have decided to retain
all records permanently.
The report on the standardisation of hospital medical
records (in England and Wales) recommended that 'on the patient's
discharge from hospital all transitory documents should be discarded together with all secondary documents, where copies of
essential information would be available elsewhere for 6 years;
otherwise secondary documents would be retained in the case
folder for 6 years before discarding. Primary records except
those of special medical importance should be discarded 20 years
after the date of last
Primary records were defined as: patient identification form;
discharge summary; standard discharge letter; post-mortem report;
General Practitioner's letter of referral; history sheet and continuation sheet; operation sheet and authority for consent;
anaesthetic sheet; nursing record; social records. Secondary documents: mount sheet (for x-rays and path reports); pathology report
form; x-ray report form; E.C.G. report form; E.E.G.••repert form;
drug sheet; pharmacy request form (inpatient): pharmacy request
form (outpatient) (these mounted on drug sheet); communications
sheet (request form); other secondary documents, to be given a
suffix locally according to need. Transitory documents: temperature, pulse, respiration and blood pressure chart; other transitory
documents to be given a suffix locally according to need, such as
electrolyte, fluid balance, urine charts etc; standard envelope.
3.2 In New Zealand
A survey of representative large and medium-sized hospitals
throughout the country in 1966 indicated the following pattern:
Type of recordPeriod keptRemarks
Inpatient notes:
Medicalindefinitely
Nursingindefinitelybut some hospitals destroy because of space
limitations - one after
18 months, another after
5 years
Outpatient notes variesthe majority, indefinitely, but some 10 years
19
coming into hospital for terminal care with conditions such as
bronchopneumonia, general debility, residual hemiplegia etc.
If surveys show that these are seldom, if ever, referred to for
their medical content they could be treated as if the only
requirement was the legal one provided thereis information
retained elsewhere establishing identity and dates of admission
and death.
It is in the field of research and study that the requirements
are ill defined. If a doctor is doing a retrospedtive study he
wants records as far back as he can get them and he often wants
those parts of the record which may appear of no great moment
after the patient's discharge. In the treatment of codition A
What was the response to and what were the side effects from
drug X? This will often require consistency of recording of
factors which may have appeared unimportant at the time. However,
to compare treatment by drug X with treatment by drug Y such
information is necessary. The research workers' main complaint
is that these vital clues are missing in old notes, or are
often only to be found, or hinted at, in the nurses' notes which
the administrator would like to destroy because they usually form
the bulk of the notes. The policy that is adopted on the retention of medical records must therefore try to take this into
account and balance it against the realities of storag space and
maintenance of storage areas0
There is also an historical consideration which administrators
may not consider of much importance. However, medical records are
documents reflecting medical procedures of the time and also
social background. As such some should be kept indefinitely as
historical documents even if a policy of destruction after a set
number of years has been decided on. Depending on numbers
possibly one in every 100 or even 500 or 1000 should be kept for
this purpose. There is a cultural, obligation on us to see that.
posterity is handed down original contemporary documents.
General policy: 3
Overseas: 3.1.
In the United States of America the medical records of
patients are usually retained for clinical and scientific
purposes, either in the original or a reproduced form, for a
period of twenty-five years after discharge or death of the
patient. Even this varies from state to state. A recent
providing storage for medical records for ever and therefore some
records must be destroyed or microfilmed but nobody agrees on
which records should be kept.
2.Factors involved
The question of how long medical records should be kept is
governed by three factors (i), the length of time they must be kept to serve the
needs of the patient;
(ii)
the length of time they must be kept to meet legal
requirements;
(iii)
the length of time they must be kept for research
and study.
Serving the needs of the patient means having records available to provide information if the patient returns to the hospital
for any reason - ideally, from the cradle to the grave. They are
also required to answer enquiries about previous medical history
from other hospitals or by the doctor being consulted by the patient.
Legal requirements are governed by the Statute of Limitations
which states the period within which an action must be taken -.
normally 6 years but this -can be longer in the case of a minor.
From a practical angle the time is usually regarded as 7 years
The occasions when a person would have grounds for sue.ing for
negligent treatment while a minor after he had obtained his
majority for treatment over 7 years before occur so seldom as
to he negligible; his parents or guardian can be. deemed to have
taken care of his interests at the time.
Although hospital administrators are often reluctant to
destroy old medical records few seem to have any information about
what use is, in fact, made of these notes. A study was made at
Wellington Hospital in which information about the date the
record of first admission was commenced and the reason for
current retrieval were obtained. In one month 5,500 medical
records were retrieved, of which 107 were for admissions
occurring between 10 and 40 years previously. 33 of these were
for readmissiors, 19 for outpatient attendances, 51 for research
and + for other purposes. It is suggested that Medical Records
Officers could assist hospital administrators by compiling similar
local data so that facts are available on which storage versus
destruction decisions can be based. Studies could also be done
specifically into the use made of medical records of patients
19
RETENTION OF MEDICAL RECORDS
1.
Introduction
2.
Factors involved
30 General policy
3.1 Overseas
3.2 In New Zealand
40 Methods
5.
Microfilming
5.1 Definitions
5.2 Advantages and disadvantages
6.
Nursing notes
7.
Outpatient records
8.
Accident & Emergency department records
9.
X-rays
10. Medical Records
10.1 Patient
10.2 Disease
10.3 Patient
department indices
index
index & operations index
summary cards
11. Means of destruction
12. Conclusion
13. References
14. Further reading
14.1 Basic
14.2 Background
14.3 Associative
Introduction: 1.
Spiraling costs in the hospital field have led hospital
administrators to question the value of keeping medical records
indefinitely. If they are not to be retained indefinitely, when
is it safe and sane to destroy them? Storage of medical records
presents not only problems of space, economy and efficiency, but
also of correct atmospheric conditions, accessibility to
authorised staff and cleanliness. There is a financial as well
as the medical administrative problem,which is that of deciding
which records are to be retained and which destroyed.
The issue is not a clear cut one and can probably be summed
up as: everyone agrees that, for economic reasons, we can't go on
8.Further reading
8.1 Basic
'Medical Records and Secretarial
Services': Hospital 0 & M
Service Report No. 2.
Follow-up, p 20
H.M.S.0., 1959, p 32
8.2 Associative
Schulz (M.D.) & Wang (C.C.) A
simple method of follow-up,
disease indexing and filing
of radiation therapy records.
Radiology, Nov. 1962,
pp 8'+2-7
18
ceedings of the 1st International Congress on Medical Reàords" cancer registration and follow-up is recommended. Following up
cancer patients is done also by obtaining all newspaper clippings
of deaths and comparing them with the cancer register of the
area.For cases thought to be deceased and not listed in the
papers, a letter to the local Registrar of Deaths or to the
Registrar General, Wellington, will bring positive proof.
Tracing patients: 6.
When attempting to conduct a survey or review of selected
diseases it is necessary to forward a questionnaire to the
patient. Naturally, quite a number have moved on and it is
necessary to find forwarding addresses or by writing to the
private doctor. If these are not successful the Reference
Department of the Public Library will hold electoral rolls
(national and local), telephone directories and other directories
which could help and tracing techniques are covered in the
article by K.M. Laurence referred to below.
References:
Berkowitz (N.H.) Patient follow-through in the outpatient
department. Nursing Research, 1963 v 12,
No. 1 p. 16.22 and Hospital Abstracts,
July 1963 p 417.418
Jackson (N.y.)
Hospital discharge reports,Medical Record,
Nov. 1 959, p 191-194
Laurence (K.M.)
Tracing patients, Medical Record Feb. 1960
p 22+/231
MacEachern (M.T.) Medical Records in the hospital, p 50,52
Turnpenny (R.W.) Calculation table for follow up appointments
Medical Record, Aug. 1960 p 312
Operational Research Unit No. 1Outpatient Services
S.Y.Q.C. (Pam) OXF
Logan (Dr. W.P.D.) Cancer registration and follow up.
3$'
7.
1+ 0Dietetics
In selected diseases, follow-up of diet is most important.
This is carried out either by giving the patient a diet chart on
his discharge from hospital or by arranging an appointment at a
dietary clinic.These clinics can be held in the outpatient
department or in a suitable room in the diet department.
50Cancer Registration and follow-up
Readers will be aware of the procedure in registr.tion of
new cases of cancer in New Zealand (which is covered in
chapter 17). The question of cancer follow-up is perhaps the
most widely known form of follow-up technique. All hospitals
that maintain a consultation clinic, Radium or Therapy department
make a practice of following up all cases, 'of cancer that have
been registered in their area. This is done by the clinic
itself at regular intervals, say 3, 6 or 12 monthly: by
writing to the patient himself enquiring as to his present
state of health or by writing to the private doctor. In
practice, this latter method has proved to be the most used.
To operate such a scheme it is essential to institute an
adequate bring-up system so as not to omit any patient. A
printed form is used with a space at the bottom for the
private doctor to reply. A self addressed envelope is also
included as it helps to expedite the reply and place the
request on a sound footing. On reply by the doctor, the
details are recorded in the patient's consultation case notes
and a further bring-up is made for, say, six months. The use
of coloured tabs can come in useful here. As the letters are
despatched a coloured tab is placed on the outside of the
record.. As the letters are returned this tab is removed.
One can tell at a glance the outstanding replies. Next month
a different colour tab would be used. A suitably ruled book
in month order with an alphabetical index will suit a medium
sizehospital admirably. Once a month the letters are sent out
as stated and as they come in the names are crossed off and
particulars entered.Cancer follow-up is the only means
available in New Zealand of finding out the survival rate of
forms of cancer. By this means, the National Health Statistics
Centre can ensure the accuracy of its statistics. For. general
research within the hospital these forms of follow-up can
prove most illuminating.One may tell at a glance what the
survival rate on, say, cancer of the rectum would be after ten
years. For a wider form of follow-up page 203 of the "Pro-
18
book would be required for leap year. To compile the tables
a sheet is prepared for each month of the year, showing the
days of the month at the top and giving time intervals 1, 2,
3, 4 and 6 weeks and 2, 3 1 6, 9 and 12 months ahead down the
left hand side. A strip of x-ray film i ll wide secured to a
bulldog clip is then clipped to the sheet on the particular
day of the month and thus the calculated appointment dates
are available at a glance through the film strip.
1
2
3
1
6
2
3
6
9
1
1 2 3 47 6 7 8 9 10 11 1213 1415 16 17 18 19
May
week8 910 11 12 13 14 15 16 17 18 19 20 21 . 22 23 2425 26
May
weeks 15 16 17 18 19 20 21 22 23 24 25 26 2728 29 30 31 1 2
May
June
weeks 22 23 24 25 26 27 28 29 30 31 1 2 3, 4 5 6 7 8 9
MayJune
month 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
June
weeks 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
JuneJuly
months 26 27 28 29 30 1 2 3 4 5 6 7 8 9 10 11 12 13 11+
JulyAugust
nonths 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11
October
Nov.
months 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3
Jan,
months 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
May
year7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 2324 25
(a moab1e strip of x-ray film)
To ensure the patient does not leave without making a
fresh appointment it is general to hand him a slip of paper
roughly the size of a visiting card, asking him to report to
the Outpatient department for an appointment in .......time.
All the doctor does is to fill in the number of weeks.
This subject is also covered in chapter 16, section 1.2.
completed in the ward, one copy given to the patient, the other
to Medical Records or Outpatient department or both, or else the
ward sister rings the Outpatient Department to book the appropriate appointment. Some hospitals ensure that patients are seen
before discharge when such things as O.P. appointments are
checked. It is here that mistakes can occur. Sometimes, if
sister is busy, she entrusts the booking to a nurse who might
forget to make it or else ask for a booking at the wrong clinic.
Conversely the appointments clerk may book the patient into a
wrong clinic.These mistakes may not be found out until the
records have been withdrawn for the clinic, or, worm still, when
the patient arrives at the clinic itself. Every effort should be
made to ensure accuracy at this point.
The job of appointment clerk is most important; a good
clerk, with a sound knowledge of clinic routine can save hospital
boards many pounds as well as ensuring . that the doctor in charge
of the clinic has no waste time. To achieve this, one must have
the co-operation of all from the nursing sister to the porter who
will have to carry wet films to the clinic. It is indeed a team
effort.
•Outpatient attendances have increased as a result of Health
Department policy to reduce bed stay. Many tests can be carried
out as an outpatient which, previously, were done whilst an
inpatient. To ensure coverage of these tests, a repeat appointment must be made for a date following completion of these tests.
For example..... a patient may have been referred to clinic with
symptoms suggestive of a duodenal ulcer. The visiting physician
will order the appropriate x-ray and perhaps occult blood tests
to be carried out and request the patient to return on completion
of these tests. The appointments clerk will ensure a reasonable
time for the results to come to hand and make an appointment
accordingly. All these results should be placed in the outpatient case notes before the clinic starts so that the information will be available. A further example may be, say, a chest
case with a repeat appointment in one year. Therefore, all
clinic books should be kept ruled up a year ahead. This is easy
if clinics are held only on set days and times. it is usual, at
this time, to check off the appointment dates with a calendar,
striking off those days which are public holidays, such as
Anniversary day, Queen's Birthday, Labour Day, etc. (Obviously
this would not apply in those hospitals which continue to
operate clinics on public holidays). Alternately, the diagram
below which is a calculation table for follow-up appointments
will help. This could well be used in hospitals where appointments books are not ruled up for one year ahead. A separate
18
specified period to continue treatment. This note should be done
the same day as the patient is discharged. The same applies if
the patient is ambulant and is required to attend the Accident
and Emergency Department daily for dressings. A note, similar
to the above, should be sent to the Accident and Emergency
Department. This, plus the availability of the patient's medical
record should enable treatment to be carried out.
Medical Social Workers: 2.2.
This department has grown rapidly over recent years. Its
main task in connection with follow-up is to see-that the
patient has somewhere to go on discharge, that there will be
adequate supervision of treatment, that, in the case of
unemployed, there will be a Social Security benefit or, better
still, a job to go to.In the case of psychiatric patients
the home background is investigated to ensure that the patient
is returning to a congenial atmosphere. Medical Social
Workers will pay visits to check on progress and report back
to the medical staff concerned. Most of the above can be done
while the patient is still recovering in hospital, thus
ensuring an early discharge and a happier patient.
Poet Mortem:
2.3.
Quoting MacEachern once more in the case of Reports of
Autopsy he states "In the case of death, every possible effort
shall be made to secure an autopsy. The attending physician is
the one person who can be most successful in this, but should
he not wish to take the initiative, a resident, or some other
member of the hospital personnel may be allowed to act." This
is generally the practice in New Zealand, where it is recognised
that by conducting a post mortem conclusive findings are found
of suspected diagnoses.
Outpatients:
No patient should be allowed to depart from hospital,
unless provision has been made for his future care. This may
be either by follow-up by the family doctor, appointment at an
outpatient clinic or referring specialist's rooms or by
readmission at a later date. The first has been covered above.
Reference to an O.P. clinic is done by the ward sister before
the patient leaves the hospital. The ward sister accompanies
the visiting physician or surgeon on the ward round and makes
a note when the patient is to return to clinic. A form can be
3.
covering all details of treatment etc. and does not worry about
follow-up reports except in certain cases as for research work
or for cancer which is dealt with under 'Cancer Registration'
(Chapter 17)
2.Inpatients
With short bed stay the continuation of treatment for
patients about to be discharged from hospital is necessary. The
period from discharge until an appointment either at clinic or
doctor's surgery is covered by, firstly, an interim discharge
note which is sent to the family doctor on the day of discharge
from hospital using N.C.R. (no carbon required) paper, or a pad
with carbon paper. This sheet has the bare essentials, namely:
private doctor's name, patient's name and address, diagnosis,
treatment given and treatment to be continued, house surgeon's
signature and date. The form is completed by the house surgeon
whilst on a ward round and either posted out the same day or
.handed to the patient although the latter course is not
recommended, as the patient may either lose it or forget to
deliver it. If carbon copy is made this is filed in the medical
record.
The medical record is forwarded to Medical Records for
assembly and it is usual for the house surgeon to do enlarged
notes to the family doctor, other than for certain routine
minor surgery, e.g. Ts and As, D and C etc. Some hospitals use
photostat copying apparatus, dictating machines, tape recorders,
or just plain long hand. One or two hospitals omit the interim
discharge note and send out one letter to the family doctor with
a note at the bottom that a fuller report will be furnished on
request. Whatever the scheme or method adopted, the aim is to
provide the doctor who is going to carry on treatment with some
facts on the case in the shortest possible time. Different
sized hospitals will obviously have different methods but all
will agree that whatever the method the human element counts in
the long run. The most modern equipment in the world is rendered.
useless unless used regularly and methodically.
2.1 District Nurses
• Often patients are discharged from hospital to continue
daily dressings or treatment by the District Nurse. The house
surgeon or ward sister contacts the District Nurse, preferably on
a standard form, requesting that the District Nurse call for a
00
18
Medical Records Practice' In NewZealand
FOLLOW-UP METHODS
1.
Introduction
2.
Inpatients
2.1 District Nurses
2.2 Medical Social Workers
2.3 Post Mortem
3.
Outpatients
4Dietetics
5.
Cancer registration and follow-up
6.
Tracing patients
7.
References
8.
Further reading
8.1 Basic
8.2 Associative
Introduction: 1.
The general interpretation of the above heading means the
various methods for continuing treatment for patients. Reference
to other publications cited will give access to a wealth of
diagrams, flow charts, etc. which it would be impossible to
reprint in this manual.
In most cases, when the patient is discharged from
hospital, the disease is not entirely cured, and it is necessary
to follow him through a period of convalescence of treatment.
varying from days to many years. The immediate result is known.
at the time of discharge but it is of greater importance to
know the end result. This is the correct evaluation of the
work and can be determined by a systematic follow-up. This can
be done in the outpatients department, by the Medical Soôia].
Worker, or by the private doctor.
According to'MacEachern in 'Medical Records in the
Hospital' private patients can be followed-up only with the
consent of the attending physician and the best method is to
see the patient at intervals and report the results to the
hospital where they will be incorporated in the medical record.
In general, where a patient desires to attend his private
doctor for follow-up, the hospital provides a discharge note
j4q
'
.
17
different selection of patients. Few hospitals in New .Zealand
will have sufficient cases available for this type of detailed
survival.
Crude or observed survival rates discussed in the previous
section do not take into account mortality from other causes nor
the effect of sex and age on the calculation. For example, skin
cancers such as rodent ulcers and squamous cell are not considered
particularly dangerous, yet the crude 5 year survival rate is
around 73 per cent in males. This result comes about because of
the high proportion of very old persons who suffer from skin
cancers and old people have a high risk of dying from other
causes. Ideally, it would be desirable to have survival rates
based on deaths due to cancer of the particular site alone, but
it is considered too difficult to define to what. degree the
cancer affected the outcome irrespective of the eventual certified
cause of death.
A more satisfactory way of handling the problem is to produce
a corrected or adjusted survival rate which makes allowance for
the normal processes of mortality. Under this system the skin
cancer 5 year survival rate rises to around 95 percent. Briefly,
it is calculated, for each site independently, by multiplying
the number of male or female registrations in each age—group
by a percentage worked out from the New Zealand Life Tables. This
percentage represents the probability that a person who reaches
that age will live for another interval, of three or five years,
The sum of these products gives a total of the expected number of
survivors in the site. This total is then divided by the number
of registrations or persons at risk in the site. A factor is
thus obtained which, when applied to the crude survival rates,
provides the corrected survival rate. The effect of so dividing
a crude survival rate by this corrective factor is to adjust
upward by a certain percentage.
6, References
International Classification of Diseases (1958 revision)
Hospital Statistics Handbook
Statistics Handbook for Hospital Tumour Registries.
State of California Department of Public Health
Wilson (Peter E.) Operating a cancer registry in the
Taranaki district. N.Z. Medical Record, December 1966
iq3
in the remaining groups. This is the number to be entered
in column 2 of the sample table. The rest of the living
group, that is, the (s) subgroup, plus the (a) (5 or more)
subgroup of the dead group makes up the total individuals
who survived 5 or more years. This number is entered in
column 3. The 5-year survival rate is obtained as the
number in column 3 x 100 divided by the number in column 2.
EXAMPLE OF TABLE FOR PRESENTATION OF
SURVIVAL RATES
(Source: California Tumour Registry
Handbook)
Period,TotalAlive atSurvival
years5 yearsRate
( -1)(2)(3) (i+)
520615675.7%
The same procedure can be used to obtain rates for other
years of survival, that is, the three-year survival rate or the
ten-year survival rate, as long as the appropriate group
exposed to risk is selected and the untreated cases are excluded.
It is emphasised that the simple type of survival rate'
described above while useful can be most misleading if compared
with similar figures compiled for other hospitals. The series
will comprise a heterogeneous collection of cancers in all
stages of development, some cases treated for cure, some for
palliation and some not treated at all. The hopeless cases
included in the series reported at a stage in the illness when
the physician can have little or no influence on the outcome
will have a depressing effect on survival rates, and much
depends on the extent to which a series is made up of those
cases,Thus for comparison with data from other registries,
to have some validity, it is essential that survival be
examined in the light of the stage or degree of malignancy of
the disease at first diagnosis by the intention of first course
of treatment, by the reasons for non-treatment and by the precise
type of treatment or combination of treatments undertaken and by
the sex of the patient. Only with survival information available in these breakdowns will it be possible to measure whether
differences in the rates are real or due to chance because of a
27
17
By survival we mean the probability of a group of,-patients
suffering from cancer living for a specified number of years.
The question to be posed in respect of every case included in
the series is: "Was the patient exposed to the risk of living
or of dying over the whole of the period specified - usually
three, five or ten years?"
Survival calculations are confined to new registrations
only, all recurrences or cases treated prior to registration
being omitted. Survival is calculated from the date of the
first course of treatment in treated cases and from the date
of initial diagnosis in untreated cases. It is the number of
cases alive at the end of the period expressed as. a percentage
of the total number of cases alive at the beginning of the
period.This calculation is termed the crude survival rate
and makes no allowance for cases which died of causes other
than cancer of the site in question.
The following method can be followed .1. Make out a card on which, is entered the following (a) Date of first treatment or diagnosis 'if Suntreated.
(b) Date of last follow-up report.
(c) Whether living at last report or 'dead at last
report (L or D).
(d) Interval from date of first treatment to last
report in completed years.
With a card bearing this information, proceed as follows 2. If you are compiling 5-year survivals include only cases
which , had a chance of follow-up on or after their fifth
anniversary. For example, if you are computing 5-year
survival as at 31 December 1967, exclude all cards
treated or diagnosed from 1963 through to 1967-
.3. Subdivide the remaining cards into two groups on the
item last report: those marked (living at last report);
those marked D (dead at last report).
.k. Take up these two groups (living, dead) and subdivide
each according to interval : (a) those marked 5 or more:
(b) those marked k or less. The (b) cards in the "living"
pack are untraced for the full five-year period. Exclude
cards for those untraced cases. Count the number of cards
consists of making the clbsed hole into open "V" shaped slots.
When a needle is inserted through a batch of cards correctly
stacked and the batch is raised, those cards which have been
slotted at the needled position will fall away. Cards thus
separated can then be counted. In this manner, through
passing the needle in succession through, say, four holes
marked for precise anatomical site of cancer, individuals
can be separated out and then further subdivided by age, sex,
stage, etc. Approximately one thousand cards can be needled
through any one position in one minute.The body of a
marginally punched card can be printed and used as an
ordinary record card, utilising both the front as well as
the back of the card for this purpose.
At the New Plymouth Hospital Registry a marginally punched
card printed locally is used as an abstract form to
summarise all the details of each case. The system is
described by Mr. P. Wilson, Medical Records Officer, as
follows " The Brown Punch Card contains personal details, duration
and type of symptoms, diagnosis, stage, pathology, treatment and follow-up reports. It condenses all the essential information from the inpatient medical record, outpatient medical record, x-ray department and treat 'ent at
other units (for example neurosurgery at Dunedin or
Cobalt 60 at Palmerston North).Thus there is available
a document that serves a threefold purpose - for filling
in the MS38 abstract form, as a comprehensive hospital
cross-index for cancer, and as a patient and site index.
Cards are stored alphabetically by patient's name while
the patient is alive and under follow-up. All deaths and
survivals of more than ten years (called discharges) are
stored alphabetically by patient's name in site groups.
Thus we have all lung cancers A to Z, all stomach cancers
A to Z, etc. This method keeps the current cases down to
a manageable number in a comparatively small cabinet. It
will be seen that the Brown Card is the "heart" of the
register and all other cards and forms are the means of
keeping it up-to--date. "
5.3 Calculation of survival rates at the Hospital Registry
The two most important aspects of cancer registration are
incidence and the survival experience. Incidence is a matter
for the Central Registry but the hospital registry is in a
position to measure the effectiveness of treatment for cancer
within the hospital.
17
EXAMPLE; OF CARD FOR SORTING
AGE
PATIENT
NAME
Jones, John
TYPE
Adenocarcinoma
STAGE
Growth limited
to lower bowel
DATE OF
ADMISSION
6-9-57
YEARS SURVIVED
5
59
SEX
SITE
.1. Abdominoperineal
resection
Alive
7.5.63
TREATMENT
DATE OF
LATEST
INFORMA TION
STATUS
(ALIVE . OR DEAD)
(h) Marginally punched cards,
When information is collected on a large number of items for
a large number of individuals, devices must be introduced to
reduce the burden of work. Only the Central Registry and the
very largest hospitals will have mechanical punched card
systems for punching and tabulating the individual cards for
each patient's history. However, there is another system
employed in at least one hospital in New Zealand (New Plymouth)
which can be recommended.
The marginal punched card is known as the Para-punch Card
(a proprietary name). Made of light cardboard, it has perforations along its edges. Each hole represents an item
of information and is identified by either a numbered or
lettered code.When the required information has been
entered on the card (the use of the holes is different for
each project) the relevant hole is slotted with a pair of
clippers similar to a bus conductor's clippers. Slotting
For males and females? For children and adults in
defined age-blocks?
5.2 Methods of collecting and tabulating data
(e) Sources of data to be checked .1.
.2.
.3.
Hospital case notes
Hospital Registry abstracts
The site index register
.k. Central Cancer Registry reports and data
(f) Tally sheets.
When many items are to be counted, and especially where
there are different categories which must be kept apart,
it is advisable to use a tally sheet. This system is
described in chapter 22 (Hospital Morbidity Statistics).
(g) The card system of analysis.
When the number of cases is large, or when the number of
categories into which the cases are to be grouped is
large, the process of tabulation is facilitated by transferring data onto a separate card for each individual,
each fact being indicated in the same place on each
card. The cards can then be sorted into piles according
to the age, or sex, or type of treatment, or into other
groups or classes. It is then necessary only to count
the number of cards in each pile and enter the totals
into each table. In this way the inter-relationship of
two or more factors can readily be studied.
.17
In many instances it will be more efficient and certainly
quicker to carry out local statistical studies in the registry
itself and certainly by so doing the registry worker will gain
a clearer insight into the material which he is recording from
day to day.
Some ideas on how to collect data for a statistical study
and how to express medical facts by figures are well set out in
the Statistics Handbook for Hospital Tumour Registries compiled
by the State of California Department of Public Health, This
section is an adaptation of the Californian Handbook.
Planning a study: 5.1.
(a) First of all the objectives must be stated ' in terms of
questions which could be answered with, statistical data.
Example: What is the five-year survival rate for
leukaemia patients in your register?
(b)
Investigate the availability of data. Is it possible to
obtain the information you want on all the leukaemia cases
admitted for a specific period ending at least five years
prior to the date of the investigation?
Where will the information come from - abstract forms, the
site index register, the medical record itself, or a
combination of them?
Is this information accessible and complete?
Are there enough cases to make the investigation worthwhile?
(c)
Define the population and the items to be studied.
Should you include only cases diagnosed and treated in
your own hospital and exclude cases diagnosed elsewhere
or treated previously elsewhere?
What period of time is to be included?
(d)
Describe the variables to be used in the study.
Should rates be calculated separately for acute and
chronic leukaemias?
21Z
Cases where malignancy is strongly suspected can be inserted
in the registry.The preliminary diagnosis will either be confirmed or rejected through follow-up or death information.
4.5.6 Histologic type of cancer
The precise histologic type of cancer will usually be
revealed by microscopic examination of tissue. The.pathologist's report is referred to for this detail. The code used,
fairly universally, for histologic coding is the Manual of
Tumour Nomenclature and Coding published by the American Cancer
Society.
4,5.7 Corrections and additions
The Central Registry records in respect of each case must
match up at all times in essential detail with the corresponding
record in the individual hospital registry.
From time to time further or amending information concerning a case will become available after the case has been
registered with the Central. Registry. The obligation is on
the Medical Records Officer to inform the Central Registry of
any additions or corrections to the initial report.
:5. 'Methods of tabulating data
The Medical Records Officer is in a position to provide
valuable information routinely to both medical staff and to
lay administrators in his or her hospital. By doing so he
will undoubtedly impxove his standing in the hospital. Some
part of the service he can render will come through requests
for data, but there still remains the opportunity to show a
positive approach to the job by compiling and presenting a
report on. registry activities at the close of each year.
The Central Registry will, if it is able, provide figures
covering any particular registry, and is in a position to
contrast those for any geographical area with the national
picture. However, the Central Registry has its , own list of
functions to carry out and the machine time available for
cancer tabulations is restricted by the demands for other
types of medical facts.
1-,I
17
- second, assignments to each of these three components of
a series of numbers to indicate degrees of extension or
involvement, e.g. TO, Ti, T2, etc.
- third, grouping the T.N.M. assignments into a small
number of clinical stages
Tumours occurring in five sites - breast, buccal cavity,
pharynx, larynx, and bladder have been classified and defined by
the International Union. Proposals regarding seven further sites
are now outlined and were to be considered at a meeting in July
1965. These are - thyroid, bronchus, oesophagus, stomach, colon,
rectum and corpus uteri.
The classification adopted for carcinoma of the cervix in
New Zealand is internationally recognised and there is no
suggestion that it will be supplanted by T.N.M. Actually the four
stages (see N.S.38-6) do correspond to the four degrees of T.
The staging internationally accepted for tumours of the
body of the uterus is as set down in M.S.38--7 and is really a
simple T classification. Like the stomach and colon this is not
a site at which a clinical assessment of the extent of the primary
or the involvement of regional nodes can be accurately made.
Indeed it may be difficult to say whether a growth arises from
the cervix or the body of the uterus, though the histology may
resolve this.
Confirmation of diagnosis:
4.5.5.
Cases will fall into three categories A.
B.
C.
Cases confirmed microscopically
Cases confirmed clinically
Cases not confirmed as malignant
The big majority of cases (over 90 per cent) will be confirmed
microscopically. Positive microscopic findings are revealed by
biopsy, surgical specimen, bone marrow aspirations, cytology
and blood studies. In general it will be found that cancers of
the inaccessible sites will be microscopically confirmed less
frequently than cancers of the relatively accessible sites.
Cases confirmed clinically will largely comprise far
advanced cases for which surgical removal was deemed inadvisable
and biopsy considered unnecessary.
2D
nationally accepted criteria become available these are
accepted as being more suitable. Three of the MS38 cards,
Larynx (part only), Kidney and Ureter, Other Female Genital
Organs, and General provide for the simplest of breakdowns
into three categories of stage as follows .1.
Localised- tumour that appears to be confined
entirely to the organ of origin.
.2.
Regional and/or Node Involvement - tumour that has
extended beyond, the limits of the
organ of origin (1) into regional
lymph nodes (2) into surrounding
organs or tissues or (3) a combination
of (1) and (2) and appears to have
spread no further.
.3.
Remote or Diffuse Metastases - tumour that has 'spread
to parts of the body remote from the
primary tumour. Distant metastases,
tumour tissues growing in parts of
the body remote and disconnected from
the organ of origin, are known to
reach their distant positions by
three modes of transport.These
include travel through the bloodstream, the' lymph channels, and the
body cavities.
A further category of stage which is used is that of Stage
O - In Situ - also called intraepithelial, preinvasive, noninvasive, or noninfiltrating. This is a tumour that fulfils
all the microscopic criteria for malignancy, except invasion.
The e International Union Against Cancer,. which is considered to be the authority on these specialist matters, has
evolved the T.N.M. system of classifying malignant tumours.
The T.N.M. system is in effect a medical shorthand system
of breaking down the "extent of disease" and involves three
steps - first, identification' of extent of disease by the.use
of three symbols:
T = Extent of primary tumour
N = Condition of regional lymph
nodes
M = Distant metastases
17
F. OTHER TREATMENT
Anytumour directed treatment that cannot be assigned to one
of the above categories. it
Staging: 4.5.1+.
It will be necessary to study the medical record very
thoroughly to establish the stage of the tumour. Evidence
will come from the physical examination of the patient, especially in regard to lymph nodes or other palpable organs or
masses and also from the pathology report. X-ray reports will
describe findings that may represent metastases to lungs and/or
bones, or other internal abnormalities such as organ shadows
that appear to be displaced due to pressure or increased size
as a result of malignant involvement. Other evidence may be
seen directly from procedures such as bronchoscopy, cystoscopy,
gastroscopy, oesophagoscopy and sigmoidoscopy.
Staging a case is a matter for a physician and the wise
registry worker should provide for an entry to be completed
worded precisely in the way that he requires the staging to
be assessed, rather than attempting to interpret anumber of
statements presented in narrative form.
The purpose in grading tumours is to provide a measuring
rod on which the results of treatment and prognosis of
malignant growths can be assessed and compared both as
between different regions within New Zealand and between
New Zealand and the rest of the world. The Central Registry
definition
ae is the extent to which the disease has
progressed as established at the time of first clinical
examination prior to treatment and must not be changed by any
findings at operation at any later time. It is not uncommon
to find in the case of internal cancers that the tumour is
more extensive than had been adjudged through clinical examination.However, the ruling of the Research Commission
Committee of the International Jnion Against Cancer is that
the staging categories assigned should not be changed when
the histological findings of the surgically removed tissues,
especially the lymph nodes, become available, but such
information may be used in a supplementary pathological
classification.
The MS38 abstract cards employ different staging criteria
and systems for individual sites. The systems adopted were
decided upon by New Zealand specialists, but whenever inter-
If
w
Mannitol-mustard
Phenylalanine-Mustard
Mechiorethamine
Purinethol
6-Mercaptopurine (6 MP)Stilboestrol
Methotrexate
TEM (Triethylenemelamine)
Mus targen
TEPA
Myleran
Thio-TEPA
Nitrogen Mustard (HN 2 )Uracil-mustard
Oestrogen
Urethane
D.
STEROIDS/HORMONES
Included here is any type of therapy which exercises its
effect on tumour tissue via change of the hormone balance of
the patient. Thus we have hormones, anti-hormones, steroids,
surgery for hormonal effect, and radiation for hormonal
effect. Steroids and hormones are primarily used for breast
cancer, prostatic cancer, leukaemia, Hodgkins' disease,
lymphomas, lymphosarcomas, and multiple myeloma.
Surgery for hormonal effect includes such procedures as Adrenalectomy(anysite other than adrenal)
Hypophyectomy(breast)
Oophorectomy(breast)
Oophorectomy plus adrenalectomy (breast)
Oestrogen with orchidectomy (prostate)
Radiation for hormonal effect would include such procedures
as x-ray therapy to ovaries.
E.
SUPPORTIVE PROCEDURES
Supportive procedures are not tumour directed. Provision
is made in some instances on the MS38 abstract form for
supportive procedures to be marked (e.g. colostomy on the
Colon and Rectum Card), but it is emphasised that on the
MS38 General Card box "k. Surgery" is not to be marked if
the operation could be considered as supportive only.
Examples are Surgical short circuiting of neoplasm, such as
colostomy, cholecystoduodenostomy, ureterosigmoid
transplant, etc.
Vasectomy (testes, prostate or bladder)
Blood transfusions for leukaemia
Surgical cutting of nerves for relief of pain
Removal of fluid (thoracentesis, paracentesis)
27
17
I
B. RADIATION
Radiation-Beam includes all teletherapy directed to tumour
tissue regardless of the source of radiation. Examples
are X-ray therapyNeutron Beam
Cobalt Bomb
Betatron
Cycloto:xin Spray radiation
Linear Accelerator Radiation,, not otherwise specified
Radiation - Other includes all forms of radiation therapy
other than beam therapy, such as Radium insertion
Colloidal gold
Radon seeds
Radioactive gold (Au
phosphorus P32
Yttrium
198, iodine
(1131),
In other words, all implants, moulds, seeds, needles, or
applicators of radioactive material are included in this
category.
Exception: Any radiation to endocrine glands for cancer of
another site should be considered radiation for hormonal
effect and listed under "Steroids and Hormones". (Radiation
to an endocrine gland because of a primary tumour would of
course be listed under "Radiation").
C. CHEMOTHERAPY
Chemotherapy covers any chemical which is administered to
attack or treat tumour tissue and which is not considered
to achieve its effect through a change of the hormone
balance. Substances quoted are Aminopterin Cytoxan
Amethopterin Degranol
Actinomycin D
DON
Azaserine
Endoxan
6-Azauracil
5-Fluorodexyurine
Chlorambucil
5-Fluorouracil
6-Chloropurine Leukeran
ilk
planned to be initiated within four months after diagnosis. The
first course of treatment may have been completed as an inpatient
in your hospital or may have been continued on an outpatient
basis at your hospital or may have been completed at a private
hospital or radiotherapy unit. It is extremely important that
the full course of treatment be obtained and recorded at another
hospital. Under the existing system whereby most cases treated
in private hospitals are not reported to the local cancer
registry, some cases will appear either as inpatients in public
hospitals or as outpatients in radiotherapy departments in which
the details of the original or first part of treatment are
unknown.In all such cases a note, "full treatment detail not
available", should be written across the treatment section of
both the hospital and MS3 8 abstract so that the case can be left
out of survival by type of treatment calculations.
The MS38 abstract card asks for a division to be made.
between "palliative" and "curative" procedures. There is .no
general agreement on the definition of these terms, and it is
admitted that intent is often difficult to establish from
medical records. However, most cases are clear-cut from the
type of operation or procedure carried out. "Treatment" in the
statistical sense is strictly interpreted as being aflcedures_or ther ,^yi eij which aim to modify, control, remove or
destroastic tissue,whether prima
ati C • The
following definitions are extracted from the "Californian
Tumour Registry Handbook" 'Ii
A. SURGERY
This category is restricted to surgery which partially or
totally removes a tumour (excluding a biopsy for diagnostic
purposes only).Surgical procedures where tumour tissue is
not removed, such as exploratory laparotomy, caecostomy or
cholecystoduodenostomy are not included as surgery..
Extion: Removal of endocrine glands for hormonal effect
such as oophorectomy and oophorectomy plus adrenalectomy and
hypophysectomy for breast cancer or orchidectomy and simple
adenectomy for prostate cancer would be listed on the hospital
abstract form as "Steroids and Hormones" and would be included
as this form of treatment in any statistical analysis of the
MS8 abstract form.
17
The Public Health Statistician,
National Health Statistics Centre,
Department of Health,
Box 6314,
WELLINGTON
Notes on abstracting and abstract items: 4.5,
Identifying information: 4.5.1.
Even in a Country with a small population like New Zealand
there are numbers of persons with exactly the same surname and
Christian or first name, while many others have very similar
names. Each hospital registry should have available the local
Electoral Roll(s), and this should be referred to for verification of the spelling of names, the accuracy of the address
and the correctness of the stated occupation. For medical
purposes the occupation provides a guide . to the environment
and the economic status of the patient, which means that it
is essential to elicit, in the case of elderly patients in
particular, the occupation followed for the greater period of
the person's working life.
Death information: 4.5.2,
It is a very good policy to • check all names in the death
columns of the local newspapers with the alphabetical index of
registered cases. The date of death would then be entered on
the abstract card as well as on the follow-up , reminder card so
that unnecessary letters would not be sent out. It is emphasised
that the Quarterly Death List supplied by the National Health.
Statistics Centre is issued up to six months after the date of
registration of the death and still further this list contains
:nly the names of persons whos deaths were due to the malignancy
either directly or as an associated cause of death. Deaths of
registered patients dying from causes other than cancer will not
be covered by this quarterly list.
Treatment: .405.3,
Treatment for cancer can cover a very long period of time,
and for statistical purposes at the Central Registry it is
necessary to limit any analysis by type of therapy to the first
course of treatment, which is defined to include all treatment
Z14
(a) Every case, inpatient or outpatient, public hospital or
private hospital, with a diagnosis of a malignant neoplasm
as defined in the International Classification of Diseases
is to be registered at the local hospital registry. Skin
cancer cases, basal cell and squamous cell, I.C.D. code 191,
are not required by the Central Registry but it may well be
that hospital registries will wish to cover these types of
lesion. Malignant melanoma of the skin, I.C.D. No. 190,
requires to be reported to the Central Registry.
(b) The first admission to your hospital or attendance at an
outpatient clinic with a diagnosis of cancer should, be
abstracted. Readmissions for the same neoplasm constitute
follow-up, and another abstract should not be prepared.
(c) When a patient has two or more unrelated primary neoplasms
each should be registered on a separate abstract card.
(d) Cases first discovered at post mortem with'no previous suspicion of neoplasm should be abstracted with the notation
"First discovered at post mortem" entered under "No treatment, specify reason" on the hospital abstract form. On
the MS3 8 abstract card there is already provision for this'
in a box in Section X, "Reason for No Treatment".
(e) Possible, probable and suspected diagnoses are registered
only if tumour-directed treatment is given. If tumourdirected treatment is not given and the diagnosis is suspected only, the cases should not be registered. In the
latter instance, if the patient is readmitted and the
diagnosis confirmed then the case becomes reportable for
this later admission. The previous admission should be
disregarded.
1+.3 When to abstract
Allow sufficient time for obtaining complete diagnostic and
treatment information before abstracting. The MS38 cards should
be sent to the Central Registry at the close of each quarter.
1 , 4 Where to send MS38 abstracts
Completed M S3 8 abstracts should be sent to the Central
Registry addressed -
17
used to preparereports of survival and end-results by site
groups.To take out such statistics a coding system would
need to be employed for detailed anatomical site, stage and
treatment and for this purpose, of course, the codes employed
on the MS38 abstract card would be generally the most
suitable. There are two column headings only on the
suggested site index register illustrated in Figure 3, which
are not self-explanatory.
These are, with suggested codings, as under Type of admission
Code1 - Inpatient
2 - Outpatient
3 - Private hospital case
Previous diagnosis or treatment
Code 1 - First diagnosis and treatment of case
2 - Diagnosed elsewhere earlier but no previous
treatment
3 - First diagnosis and treatment elsewhere
Directions for abstracting: 1+,
The Hospital Statistics Handbook; 4.1.
Fairly precise instructions concerning the completion of
the MS38 abstract card forwarded to the Central Registry are
contained in the Hospital Statistics Handbook, Part II. The
points mentioned here are pertinent both to abstracting onto
forms used in hospital registries as well as to the abstracting
for Central Registry purposes.
Note Ommission from Handbook: Abstract card MS38-5 was
specially designed for female breast cases. Abstract card
MS38-12 should be used for male breast cases.
Cases to be abstracted: +.2.
The following cases require to be registered in the
Hospital Registry and a corresponding MS38 abstract card
forwarded to the Central Registry -
International List No, Site
14o-148
Buccal cavity and pharynx
Oesophagus
150
Stomach
151 Large intestine (except rectum)
153
154
Rectum
Biliary passages and liver
155
Pancreas
157
All other digestive organs
15 2
9 156, 158, 159
162
Lung bronchus and trachea
160,
164,
165
All other respiratory system
Breast
170
Cervix
171 172-3
Other
parts of uterus
Ovary
175
All other female genital organs
176
Prostate
177
178-179
All other male genital organs
i8o-i8i
Kidney and bladder.
190-191 Skin. . ..
192-199
All other sites and gene±a1ised
carcinomas..
20k
Leukaemia
and A1eukaemia
200, 201, 202, 203, 205
All other Lymphatic and . haematopoietic tissues..
An alternative design of Site Index Register is the .one
illüstrate.d in Figure 6. This type is recommended to all .the
large registries in that it permits the extraction Of statistical.
data concerning the cancer load in the hospital.Patients seen
for the first time are listed by major anatomical sites, with
the following information recorded
a, the hospital number
b, the patient's name
c. diagnosis
d. date of diagnosis
e, age at diagnosis
f. stage
g. type of treatment
h. survival in years
i. date of death
The Medical Records Officer could readily prepare summary
reports by anatomic sites by age, sex, stage, and method of
treatment from this register (see section k). It may also be
SITEINDEXREGISTER— 170'BREAST
0
c4
0c
E OFNAME OF PATIENTHOSP. LDIAG
ISSION
SERIAL I SITE
NO.
YR. ILASTFIRST
AGE SEXDATE OFLATEST FOLLOWo2$
I.C.D.
INITIALTREATMENT UP INFORMATION
J
TYPE CODE NO..DIAGNS..
MO. yp : STAGE TYPE CODE YEARS AFTER TR
p.z
El
FIG.
6—
SUGGESTED SITE INDEX REGISTER
F
DEATH
INFORMATION
ATE OF YEARS OF
DEATH SURVIVAL
HOSPITAL LETTERHEAD
Name of Relative or Friend,
Street Address,
City or Town
Dear
(Date)
______
This hospital is carrying out a special study of the
state of health of patients who have been treated for some types
of disease. We have lost contact with (name of patient) and we
are seeking your help.
Would you be kind enough to fill out the requested information as set out below, and return this letter to us. We are
especially interested in the whereabouts of (name of patient), so
that we can keep in touch with him for the purposes of our study.
We are enclosing a stamped, self-addressed envelope for
your convenience.
Sincerely,
End.
Present whereabouts of:
for Medical Superintendent
(name of patient)
Street address:____________________
City or Town:
Present condition:
Apparently well
FIG.
5-
Not well
SAMPLE FOLLOW-UP LETTER TO RELATIVE OR FRIEND
17
HOSPITAL LETTERHEAD
Name of Patient,
Street Address,
City or Town
(Date)
Dear
We are writing to enquire how you have been feeling since
you were last seen at this hospital.
We are very interested in the progress of our patients
after treatment and it would be helpful if you would give us a
brief report on your Condition and return this letter to us in
the enclosed envelope.
Thank you for your co-operation,
Sincerely,
End.
1. Date
2, What is the state of your present health?
3. What doctor do you attend (if any):
Name of doctor
Doctors address
FIG. '+ - SAMPLE FOLLOW-UP LETTER TO PATIENT
271
HOSPITAL LETTERHEAD
Name of Doctor, (Date)
Street Address,
City or Town
Dear Doctoro*osoec000e
PATIENT FOLLOW-UP
Name of patient: . . . . . . . . . . . .. . . . . . . . .
Address: .
• • • • • • • • 0 • 0 0 • 0 S 0 S 0 0 S 0 S ••_0 S S 5 0
Diagnosis: * . . . . . . . . . .
Hospital No.: . . . . .
••••••••••S0000S50
• • • • 0 • • • • • • • • • • • • . .
Date of registration :.../..../..o
In order that we may keep our cancer records up-to-date
and produce an accurate composite measure of survival experience
in different sites, it is necessary to have a simple follow-up
report at yearly intervals.
I would be grateful therefore if you would furnish the
information set out below in respect of the above patient.. If you
are unable to trace this patient I would be glad if you would
return this form noted accordingly.
With thanks for your , co-operation,
Yours faithfully,
IF ALIVE
IF DEAD
1. When was the patient last1. Date of death
known to be alive? ... /.../...2 Place of death
2. Condition of patient (if
known) .....................
FIG.
3 — SAMPLE '
.../..../...
PATIENT FOLLOW-UP LETTER TO PRIVATE DOCTOR
17
F date when the patient was last seen or reported on
G the name and address of the attending physician
H the name and address of the nearest relative or
friend
Forms suitable for sending out to enquire about the state of
health of the patient are as illustrated. Figure 3 is the
type of form which is used to contact a private doctor and
Figure Lf is for contacting the patient who has not been seen
by the doctor named-on the Follow-up Card for a long period of
time (usually a year). Eventually it may be necessary to
obtain information from relatives or a friend, and Figure 5
is an example of the type of letter which could be sent.
The Central Registry does not require annual follow-up
information to be furnished to it in respect of each patient,
but in a proportion of cases only, those who cannot be traced
at the registered address on Parliamentary Election Rolls,
confirmation of survival will be required at the end of each
five-year period. In its turn, the Central Registry will
routinely supply to each hospital registry a quarterly list in
alphabetical order of persons who have died on whose death
certificate a malignant condition was mentioned. This list
allows the Medical Records Officer to enter death details on
the abstract form and remove the case from follow-up.
The site index register: 3.3.3.
This type of index in a simple form is kept in most New
Zealand hospitals for every disease treated, being termed the
"Disease Index".
The index of cancer cases may be maintained in the hospital
registry as a means to facilitate access to the full hospital
medical record so that it is ready immediately it is required by
surgeons and other medical staff. The index would be kept by
primary site in I.C.D. classification number order with provision to enter on the site card such items as name, hospital
number, sex and precise diagnosis. The following are the major
specific sites and site groups by which abstracts may be filed
according to primary lesion -
in Auckland.. Copies of their forms may be obtained from: The
Herald Centenary Cancer Registry, Box 5546, Auckland. Small
hospitals will not wish to keep detailed records, and in such
cases it is recommended that a duplicate of the appropriate
MS3 8 form be used as the hospital abstract form.
In any of the larger registries it will be found convenient
to maintain two separate alphabetical files for abstract forms one file for the live cases and the other for the dead cases.
Alternatively a card index system could be maintained with the
abstract form filed in numerical order,
3.3.2 The follow-up reminder index. . ...
The prime purpose behind this index or diary is to ensure
continuing - contact with the patient. During the first year,
following discharge from hospital, this is ideally at three,
six and twelve month intervals, depending. on theièp.t's
condition. Follow-up during the first year will often be
obtained from re-admission or outpatient records of clinical
examinations.After each patient is discharged from hospital
a follow-up card is filed, nominating a return appointment.
If the patient breaks the appointment a new date is set and
the card is removed and refiled under the advance date.
Patients breaking two or more appointments should be followed
through other means, such as home visits, etc., and encouraed
in every way to return to the hospital or clinic for check-up.
After the first year follow-up for statistical purposes is
necessary only at yeaily intervals.
Each case should be filed alphabetically by month of first
treatment or diagnosis so that the Medical Reä.ords Officer is
alerted to the requirement to either post available, follow-up
information onto the Hospital Abstract Form or to the need to
communicate with persons outside the hospital to obtain , simple
follow-up information. If the patient is no longer under the
care of a physician, then the Medical Records Officer should
obtain permission from him to communicate with the patient's
family,`
The follow-up card should contain the following items A the patient's name and address
B the patients case-note number.
C the patient's assigned abstract form file number
site of the cancer
E date of diagnosis and date of treatment
FOLLOW-UP INFORMATION
NAME AND ADDRESS OF NEAREST RELATIVE:
E4
NAME AND ADDRESS OF PHYSICIAN RESPONSIBLE FOR FOLLOW-UP:
DATE OF INFORMATIONSOURCE OFCONDITIONSUBSEQUENT.
-
CONTACT
TREATMENT OR
REMARKS
/ /19
//19
/ /19
//19
/ /19
/ /19
//19
z
//19
//19
/ /19
//19
//19
//19
/ /19
/ /19
/ /19
CLINICAL NOTES
FIG.- 213 - SUGGESTED HOSPITAL REGISTRY ABSTRACT FORM - BACK
gy
HOSPITAL REGISTRY CANCER ABSTRACT FORM •Date Abstract M.S.38
forwarded to Central
Registry
NAME:
Surname
MR., MRS./MISS
Christian Names
ADDRESS:
El
z
DATE OF BIRTH:
H
El
COUNTRY OF BIRTH:
RACE:Na OF CHILDREN:____________
(Female genital &
breast cases only)
HOSPITAL:
PATIENT'S DOCTOR:______________________________
SERIAL NO.
Date of admission Date of discharge
(Private Case)
PRIMARY SITE:
- DATE OF DIAGNOSIS:
NATURE OF GROWTH:
MICROSCOPIC DIAGNOSIS AND HISTOLOGIC TYPE (STATE)
to
STAGE (Describe): SIZE:______________________
.••CODE
NODES:___________________
H
METASTASES:_________________
RE
WAS CASE POSITIVELY DIAGNOSED AS CANCER IN ANY HOSPITAL SERVICE BEFO
THIS ADMISSION?
.
.
IF SO, DATE AND NAME OF HOSPITAL: uu
El
WAS TREATMENT GIVEN? IF SO, TYPE OF TREATMENT AND .HOSPITAL:......
4 03
PRESENTING SYMPTOMS AND POSSIBLE AETIOLOGICAL FACTORS (e.g. smoking habits):
f—M—o—
n-t h___Y_e_a_r_1Interval between 1st symptoms and diagnosis:
obDate of first symptoms:
I//
Presenting symptoms (state):
Aetiology (state):
months
..
.
INTENT(state reason if palliative)
DATETREATMENT (describe)
A.
Surgery
Radiation - Beam
Radiation - Other
D.
Chemotherapy
z
B.
C.
Z
E. Steroid-Hormone
El
El
-
F. Supportive only
G'. Other
NO TREATMENT . (Specify reason)
z CONDITION AT DISCHARGE: Alive
Dead
IF DEAD, DATE AND CAUSE OF DEATH
FIG. 2A - SUGGESTED HOSPITAL REGISTRY ABSTRACT FORM - FRONT
m'p
21
17
(iii)
To make readily available to medical staff analyses
and statistical reports concerning the management
of cancer cases in the hospital. These reports'
should cover the details of treatments used, the
survival as from the date of such treatment, broken
down according to the stage at which the disease
was diagnosed. Figures of stage at which disease
was diagnosed and the trends in the percentages
diagnosed early provide an evaluation of the
results of educational activities in the area.
(iv) . To make readily available to physicians and
research workers the relevant detail about particular types of cancer so that studies in depth can
be carried out.
Filing and indexing: 3•3•
No specific system for maintaining a registry is to be
laid down. However, certain basic files must be maintained in
order that the objectives, or at least some of the objectives,
set out in section 3.2 may be achieved.
A register of cases must of necessity he maintained in
alphabetical order so that all cases can be checked for
duplication. This can be done in two ways, (a) by filing the
detailed hospital cancer case abstract forms in alphabetical
order or (b) by employment of an index card system giving
access to filed numbered hospital case abstract reports.
The hospital registry abstract form file: 3.3.1.
A suggested design of hospital registry abstract form is
illustrated in Figures 2A and 213. The file of cancer registry
abstracts is the most important element in all cancer registry
programmes. It is a concise summary of significant data
derived from the full hospital medical notes. It should not be
a duplicate of details concerningsyrnptoms, diagnostic techniques
and particulars of medical procedures.
The form illustrated provides what is considered to be the
minimum of recorded information, and yet lends itself to being
summarised still further onto the specific site MS38 abstract
card forwarded to the Central Registry. Clearly no standardised
method of documentation will be capable of answering every
question which may be asked. A more complex type of Hospital
Abstract Form is in use in The Herald Centenary Cancer Registry
112
3.
The operation of a hospital cancer registry
The base on which our national cancer scheme rests is the
individual hospital registries. Registries as an entity in
themselves are a feature of most large hospitals in America,
Canada and Europe. The hospital cancer registry, located in
a separate room (or corner) should contain the special cancer
records of all cancer patients attending at the hospital
either as inpatients or as outpatients. The hospital registry
forms the active file of pertinent information on the diagnosis,
treatment follow-up and end-results of all cancer patients0
3.1 The control of the hospital registry
The key person in the operation of a hospital registry is
likely to be the officer who acts as secretary and abstracter.
The most obvious person advantageously placed to carry outall
the necessary clerical functions and to maintain a liaison
with the Central Registry is the hospital Medical Records
Officer. In the larger hospitals where the volume of the
cancer load warrants it, and especially in those where Consultation Clinics operated by the Cancer Society of New Zealand
exist, then aPegistrar would probably need to be appointed. The
Registrar's duties would in general be to co-ordinate the
gathering in of records from the Consultation Clinic, the
radiology department, the pathology department and from outside
doctors. The Registrar would also act as advisor to the
records of
on medical queries in the filling in of the
abstract cards.
A trained Medical Records Officer should have no difficulty
in carrying out the day-to-day operations of a registry in conjunction with his main hospital duties provided that he has the
continuing assistance and guidance of a physician registrar and
the co-operation of the medical staff.
3,2 The functions of the hospital registry
The fundamental reasons for the existence of a cancer
registry in each hospital are threefold (i)
(ii)
To provide continuing supervision and patient care.
To
of
to
in
routinely furnish accurate statistical summaries
each case registered to the Central Registry and
work closely with the Central Registry so that it,
turn, can achieve its objectives,
27/
INFORMANTS
PUBLIC HOSPITALS CANCER CONSULTATION . PRIVATE HOSPITALS
..
CLINICS
ABSTRACT CARDSFORWARDED
MATCHED WITH REGISTER TO SEE WNETHER PREVIOUSLY REGISTERED
N5i8 HOSPITAL
RETURNS CHECKED AGAINST CENTRAL REGISTRY
ABSTRACT CARDS TO SEE WHETHER RETURN HAD BEEN FORWARDED
PATIENT PREVIOUSL'iJ
NEW CASE
NEW CASE
REPORTED
INFORMATI ON I INFORMATI OJ\FOR WHICH
ADEQUATE JINADEQUATE
ABSTRACT SENT FOR COMCARD NOT PLETION OR
FORWARDED LETTER OF
ENQUIRY SENT
(PICKED UP
FROM MS 18)
ABSTRACT CARD CORRECTED . ABSTRACT CARD INSERTED IN INDEX AND
- IF NECESSAI ..
jREGISTRATION NUMBER GIVEN
ANNUAL CHECK WITH DEATH CERTIFICATES
AND POST MORTEM DETECTED CANCER CASES
INSERTED IN REGISTER
1.
NEW REGISTRATIONSDEATH DETAILS
COMPLETELYPUNCHED INTO
PUNCHED,OLD CASE
(LIVE AND DEAD).REGISTRATIONS
4,
.4-
[CARDS ARE HANDLED BY
THE PUNCH-CARD MACHINES
COMPLETED STATISTICS
ARE PRODUCED
Fig. 1 - schematic presentation of the Central Pegintry organisation
.z7o
2.4 Survival checks and follow-up
In all overseas registries a yearly follow-up report is
obtained on each case. This is done by forwarding a followup list of names to each contributing hospital with provision
for the recording of the latest information. The advantage
of this system is that it stimulates periodic medical checkups of the cancer patient, acting as a reminder to call in
cancer patients for an annual examination.
At the inception of the cancer collection scheme in New
Zealand a yearly follow-up system was carried out but this
turned out to be the rock on which the scheme nearly came to
total destruction. In practice, many hospitals and clinics
found themselves unable to cope with the volume of work
involved.It was decided then to take advantage of New
Zealand's isolation and the smallness of its population and
to depend upon a careful check of the death registers along
with periodic references to the electoral rolls. No record
of death and an entry in the electoral roll can be taken as
proof of survival, but in the absence of the roll entry and
a death entry there are other possibilities. These, are (1) Patient died under another name or under an alternative.
spelling of the furnished name;
(2) In the case of a female patient, has married or remarried;
(3) Patient has left the country.
To check on these possibilities it is necessary to refer
a small percentage of the total cases surviving in each site
back to the hospital or clinic for confirmation of survival.
Another reason for the referring back of cases.is where
.the patient is known by the Central Registry to have survived
and yet at the time of diagnosis the prognosis was unfavourable. In a high proportion of these cases the diagnosis
proves to have been an incorrect one and it is necessary to
remove the case from the series.
2.5 Schematic presentation of the Central Registry
Organisation
In figure 1. is sketched in diagram form the consecutive
steps taken at the Central Registry from the time the abstract
form is received through to the production of statistical reports.
i4f
17
death or as an associated cause of death (in Part II of the
International Death Certificate).
A copy of this Quarterly List of Cancer Deaths is forwarded
to all clinics and will be sent to any Hospital Registry on
request. The second step. is at the close of the year when all
post-mortem reports received into the National Health Statistics Centre
have been examined and those cases detected after death are
also added to the register.
Clearly-the majority of cases in the register found at the
routine matching will be deaths from intercirrent conditions,
although, of course, there will also be instances of death
from malignant disease where the original cause of death was
amended as a result of post-mortem findings coming to hand
after the death certificate was filled in; on the other hand,
there will be, of course, cases where the death certificate
was provisional and recorded malignant disease which was confirmed by the post-mortem findings. Still further, the postmortem results not infrequently alter the primary site of
invasion.
One very valuable result of the matching of cases on the
register with death certificates and post-mortem reports is
the establishment of the primary site of the cancr, as there
is frequently disagreement as between the various records.
Some sites where incompatability between records is encountered
are rectum and colon, oesophagus and stomach, cervix and body
of conditions of the lymphatic and haematopoietic tissues.
The punched cards: 2.3.
• Except for the current year, a punched card is in existence
for every case registered since the inception of the scheme in
1948. When not in use for statistical analysis, those cards are
maintained in registration number order in the groups 'alive,s'
and 'deads'. The punched cards are readily available for
amendment, for cancellation or for the insertion of additional
detail in order to conform with the abstract card in the Index.
As soon as •possible after the end of each year (delays result
from the non-receipt of outstanding. returns from a few hospitals)
death details are punched into all previous registered cases
who have died during that year and the information on all new
registrations is transferred to punched cards. All registrations
are then available for the compilation of statistical reports,
special studies and in response to requests.
(c) Each patient's card with a diagnosis of cancer, sent in under
the routine system operated in New Zealand since 1873 by
which returns are supplied by the public hospitals for all
inpatients no matter what the disease for which the patient
was admitted, is checked with the register to verify whether
the cancer abstract card has been forwarded in respect of
that patient.
(d) All new cases are checked with the names on the Parliamentary
Poll for the district in which domiciled as a check on the
spelling of the name and the accuracy of the address.
(e) All information on the abstract card not already self-coded
is then coded, the site by the W.H.O.. Classification of
Neoplasms according to the Anatomical Location of the
Lesion (an adaptation of the International List) and the
pathological nature of the growth by the Manual of Tumour.
Nomenclature and Coding, published by the . American Cancer
Society. The address of the patient is coded according
to Hospital Board District and the individual hospital.
making the diagnosis is coded by a devised code.
(f) The card is filed away in the alphabetical index of
cases constituting the 'live' or action series in the
National Cancer Register. A series of dead cases other
than those in the current year's series is maintained in
a separate filing cabinet. . .. . .
2.2 Matching with death certificate.
The matching of all cases on the register with death certificates is undertaken every year. This is a very tedious
task, as all alternative spellings of names must be tested.
Maori names present a special problem in this respect. The
system involves the sorting of the certificates of all deaths
totalling close on 23,000 per year into alphabetical order and
the matching of these with 50,000 names on the 'live' register.
By this means, other details besides name which all assist in
the identification of the patient, such as address, age, date
and cause of death are visible to the searcher, which would
not be so if working from an index of names such as is available at the Registrar-General's office. In practice, the
procedure reso] . s itself into two steps. Each quarter in each
year the records of deaths are perused and a list made of all
cases where cancer is mentioned, either as the direct cause of
17
survival related to early and late diagnosis, and the
diagrammatic presentation of cases occurring in the community
are only three aspects of the cancer problem which lend
themselves to education uses by field workers.
Confidentiality: 1.6.
The methods and practice of safeguarding the confidential
nature of the information about individual patients suffering
from cancer at all points in the registration scheme must be
kept under constant review. It is a recognised principle that
information can be reported by a hospital inrespect of an
individual patient to the National Registry without that
patient's consent, but all such information must-always be
maintained as a matter of confidence between the Department
and the reporting hospital.
Case registration procedures
at the Central Registry: 2,
The central registry is a section of the National Health
Statistics Centre which is in the Ford Building, Courtenay Place,
Wellington. The central registry staff includes a senior clerk
and two female assistants. Medical Consultation is provided by
physicians with the Department, The National Health Statistics
Centre is equipped with I.B.M. machines.
Case regisration and indexing: 2.1,
(a) The abstract card is received from the clinic or hospital'
for each first or new cancer patient who attended at a
cancer consultation clinic or who was admitted to the
hospital.
(b) The abstract card is checked against the alphabetical
register of live cases to verify that the case is a new
case, and if so, is given a sequence registration number,
as well as being stamped with the year of registration.
If the case is found to have been already registered by
some other hospital, details of any further treatment
administered are transferred onto the existing registration card and the record brought up to date.
I .5.2 Epidemiologic investigations
Registry data can be used to investigate possible relationships between cancer and environment and living habits.
Eminent authorities overseas consider that epidemiology is the
line we should take in New Zealand because of the advantages we
possess in being in close touch with treating hospitals and in
not having too wide a range in our social structure.
Epidemiologic investigations call for special surveys based
on a hypothesis or "hunch". The hypothesis once formulated
can be tested by taking a group of cancer patients and questioning them in regard to the likely causative factors. The findings
are then compared to the occurrence of the same factors in a
group of controls which are matched with the cancer patients in
certain chosen respects.A collection of this nature has been
in New Zealand in connection with the cancer of the lung,
sponsored and carried out by a group of thoracic surgeons.
Specific items covered in the collection include-smoking habits,
occupational history, pre-existing respiratory disease and
presenting symptoms. There is much scope in New Zealand for
investigation into the high incidence of cancer in the stomach
in Maoris of both sexes, and of course of the lung in Maori
women.
1
.5.3
Genetic studies
The material of a cancer register may also be helpful in
genetic studies on the existence of possible •inherited traits
and the occurrence of particular types of cancer.
1,5. 4
Local cancer control
The register of cancer patients allows for an examination of
the various factors important to those concerned with local
cancer control, e.g. the proportion of patients receiving treatment, the stage at which they were diagnosed, the reasons for
delay in the diagnosis of cancer, the waiting period before
treatment, and the type of treatment given, and where.
1
.5.5
Provision of facts for educational use
Cancer registration data when suitably presented have in
many instances a great deal more impact than mortality data.
The probabilities of developing cancer in various sites,
lif
17
and are not usually part of the planned first course of therapy.
New Zealand has a collection form for most of the specific
sites in each of which the common treatments are set out in
terms of the operation or operations performed or the kind and
quantity of radiation given, or the other therapeutic agent or
agents used. This differs from the procedure adopted in most
registries oversease where the treatment categories are
generally grouped under four broad headings: surgery,
radiation, surgery and radiation and other or none reported.
The treatment headings adopted in New Zealand were selected
and grouped according to the decisions of a group of New
Zealand specialists. Where a patient is not treated except
for palliative treatment it is essential that the principal
reason for this be noted on the abstract card.
Other purposes of cancer case. registration: 1.5.
A cancer register offers very much more than its use for
comparing the efficacy of different methods of treatment or
for measuring trends in incidence. There istoday an awareness that various circumstances combine in many cases which
trigger off the process known as cancer. Evidence of this is,
of course, the considerable variation in the incidence of many
of the common cancers, not only as between the various countries
of the world, but also as between different parts'of the same
country.
An investigation into the possible underlying causes of
cancer comes into the field of epidemiology.
Clinical and Laboratoty studies: .1.5.1.
The register is used as a source of information, enabling
studies in depth to be carried out by research workers into
certain types of malignancy. All leukaemia cases reported are
passed on to a research centre set up under the aegis of the
Cancer Society in Christchurch. The specialist centre for
cancers of the cervix is in the Postgraduate School of
Obstetrics and Gynaecology in Auckland. Each year details of
rare types of cancer are supplied to physicians who are making
a contribution to the medical literature of their particular
interest.
dition. To take a realistic view, besides knowing the best
results obtainable by surgery and radiotherapy, we also want
to know the average prospect for patients living in different
regions of the country who are receiving such treatment as is
available to them in respect of cancer of each site. Only a
small proportion of cancer patients in the whole country can
hope to be treated at the best institutions or be operated
upon by the surgeons with outstanding experience. Statistics
of results of treatment from one hospital or a group of
hospitals in any particular area can be misleading.
•The selection of the type of treatment given to a prticular patient depends, of course, upon many things: age and
general condition of the patient, stage of disease, site of
origin, location of the tumour, histological type of tumour,
and other complicating conditions.
In planning therapy a very important decision which has
to be made in many cases is whether to try to cure the
patient of his disease or simply to prolong life and relieve
symptoms. These two concepts, the concept of cure and the
concept of palliation, are exceedingly important in the
management of cancer cases. Especially is this so when
radiation therapy is introduced, for upon it will depend not
only the patient's chance of survival, but also his degree
of comfort and disability resulting from treatment. It is
important to observe whether treatment is confined to surgery,
radiotherapy, hormones, or chemotherapy directed to the
destruction, removal or delay in growth of malignant tissue.
Treatment under one or combinations of these headings can be
divided into whether the intent was for cure and complete
eradication of the growth or merely to prolong life and delay
the inevitable progress of the disease. Treatment does not
include methods, surgical or otherwise, concerned with the
relief of symptoms.
Treatment refers to the first treatment or series of
treatments received by the patient, whether as an inpatient
of a hospital or as an outpatient. In general it covers all
treatments within four months of the date of the admission
for treatment. The reasons for limiting first course of
treatment to a specific time period are that (1) cases for
whom treatment has been delayed are not comparable to cases
treated shortly after diagnosis and (2) additional treatments
begun after a greater lapse of time generally represent
treatment for a recurrence or an initial treatment failure
17
as "the apparent extent of disease" when the patient is
examined clinically and "staging" as the division or classification of cancer cases into groups or categories by
degree of apparent extent of disease, according to some
agreed plan. What is needed is simply an agreement for
each site on the recording of such precise information on
the extent of disease as to make possible the combination
or re-combination of cases ac'ording to any agreed plan.
The objectives of staging cases at time of diagnosis
may be defined as (1) Aid the clinician in the planning of treatment
(ii)
Give some indication of prognosis
(iii)
Assist in the evaluation of the results of
treatment
(iv)
Facilitate in the exchange or comparison of
information between treatment centres or
nationally over periods of time -
(v)
(vi)
Provide an evaluation of the effects of
detection compaigns designed to diagnose
cancer at the earliest possible stage
Enable studies to be carried out on the
correlation between early diagnosis and
the survival rate
Data about treatment survival after treatment: 1.+.3.
The primary objectives of cancer therapy are to eradicate
the disease and to prolong the life of the patient. There is
a need in every country for more exact knowledge of the outcome of treatment for cancer than we have at present. A
cancer register offers the material for evaluating the
relative merits of different types of treatment. Central cancer
registries, posting the data from hospitals all over the country,
are better situated to make comparisons on treatment than are
certain centres or groups of centres. Notwithstanding that
large numbers of patients may be involved inevitably each
centre will constitute 'a selected sample, and biases will be
introduced.. Some cases of cancer never present themselves at
particular centres or, if seen, will be sent off for treatment
elsewhere; others are not treated for various reasons;
amongst those treated the typeof treatment given will at times
be influenced by factors quite apart from the malignant con-
26Z
A question is asked about the occupation of the patient partly for identification purposes. The occupation is also
coded and related to the data supplied by the Department of
Statistics showing the numbers of males at risk in each occupatient. The question to be answered here is Q . Are there hazards in respect of the development
of cancer in particular occupations?
1.4.2 Data about the extent of the disease
(Clinical Stage Classification)
The extent of the disease at time of first diagnosis must
be classified in some way before it can be used for statistical
purposes - that is to say, before it can be grouped .with data
from other cases so that conclusions about categories of
patients may be drawn in contradistinction to conclusions'about
individual patients. There are now internationally accepted
criteria established for classifying the extent of disease for
a number of particular sites put forward by the International
Union Against Cancer. The International Union has, through its
Committee on Clinical Stage Classification and Applied Statistics,
produced draft recommendations in regard to the breast,, the
pharynx and larynx and the urinary bladder and is considering a
further group of sites.These are thyroid, bronchus,. oesophagus,
stomach, colon, rectum and corpus uteri. New Zealand has been
quick to adopt internationally accepted staging systems and we
are using these in classifying breast, cervix, body of uterus and
larynx. In all the other sites the criteria has been established
by specialists in the particular anatomical area of .the body.
In no other area of cancer registration is there so much
difference of opinion as there is concerning the classification
of malignant neoplasms. This is because data about the extent
of the disease at the time of diagnosis are a static concept and
present a snap-shot picture of a chronologically continuing
process. The malignant condition is a dynamic phenomenon proceeding with varying speed at different times in different
individuals. This is well recognised from a clinical point of
view, and is only dwelt on here for its significance from the
statistical angle. The unpredictability of certain forms of
cancer is evidenced to anyone dealing with large numbers of
cases of cancer of the breast in that cases with apparently
good prognosis die of cancer quite soon after operation and
others whose chances appear poor survive for many years. These
qualifications are best expressed if the word "stage" be defined
21,01
Once private hospital cases were included the coverage would be
almost complete as it is assumed that almost every case of
cancer (skin cancers other than melanomas are not collated)
would sooner or later be admitted to a hospital for treatment.
Those cases not treated or which were discovered at postmortem would be picked up from the official death certificate.
The uses made of registry data: 1.4.
Data about the incidence and prevalence of cancer:
Data in the cancer registry are used to show the incidence
(i.e. number of fresh 'cases a year) and the prevalence (i.e.
total number of cases present in the population at a particular
time) of cancer of different sites according to the age, sex,
domicile and race of the patient. Figures on incidence and
prevalence are needed to show the public health authorities
and the Cancer Society the cancer problems of the population
of New Zealand. When the data can be given separately for
various sub-groups of the population, such as occupational
groups, or for different geographical areas of a country, they
will help ensure a national distribution and utilisation of
diagnostic and treatment facilities and personnel. They will
also indicate high-risk groups in the population for which
preventive measures or special case-finding programmes, such
as mass screening, may be required. Again, the study of
incidence data, their time trends, and their variation between
different population groups, may often serve as the starting
point for research into the aetiology of cancer.
Incidence data can only supply an accurate assessment of
the position if it has complete coverage. Provided an
accurate count can be made, the following questions are able
to be answered Q . How many cases of cancer of each site occur at
particular ages and in each sex in this country?
Q . Are there differences in the occurrence of cancer
in certain sites as between districts, which
would suggest that environmental factors could
be responsible?
Q . Are there any marked differences in the occurrence
of cancer in our Maori and European populations?
260
and as more and more people are getting cured of cancer or are
surviving for longer periods of time then death figures become
of less and less value for incidence assessment purposes. For
comparisons of trends over a period of time or for international
comparison purposes something better than death statistics is
needed. Just as an example, three reasons would present themselves for an explanation of a fall in the death rate from a
particular form of cancer: (a) an improvement in therapy, (b)
an increased proportion of earlier or curable cases presenting
for treatment and (c) a decrease in incidence (number of new
cases coming forward).
1.3
The New Zealand case registration scheme
There exist here in New Zealand ideal conditions for the
establishment of a Cancer Registry on a national basis at very
low cost. The foundations for a central registration scheme
have long existed in the shape of the public hospital inpatient
return furnished routinely to the Nalional Health Statistics Centre
(MS18 statistical card). Still further there are in each of our
large regional hospitals cancer consultation clinics established
and controlled by the particular local division of the Cancer
Society of New Zealand. In addition our population is small,
making for a handy-sized registry, while our geographical
isolation makes for stability in that a high proportion of
cases remain in the country under supervision and very few are
lost to follow-up because of crossing with adjacent countries
or states.Finally, we have a strong and active Cancer Society
which is vitally concerned with the production of comprehensive
statistics.
1 ,3. 1
Public Hospital and Private Hospital cases
As has already been said, the registration of public hospital
cancer cases is obligatory. The registration of cases seen at
outpatient Consultation Clinics is carried out by arrangement
with the Cancer Society. These two sources provide an overall
coverage of about four-fifths of all cancer in this country (it
varies as between sites). Added to this, a number of privately
treated cases are reported voluntarily by interested surgeons.
With the backing of the Cancer Society of New Zealand preliminary
steps are being taken to devise legislation so that surgeons
would not be committing a breach of confidentiality in supplying
details of their patients treated in all private hospitals.
rq
17
exposed to the cancer risk. Indeed, in most important sites
the death rates are on the decline; in some other sites the
rates are fractionally higher, but whether this is a reflection
of a decline or increase in true incidence or a reflection of
improved methods of therapy is not able to be stated with
certainty in the absence of reliable and complete case reporting.
It is true for certain that the incidence is rising in cancers
of the lung and bronchus, while on the other hand stomach
cancer incidence and uterine cancer incidence is clearly on the
decline.There is a tendency also for types of cancer in the
leukaemia and lymphosarcoma groups to increase at the older ages.
In summary, although the absOlute numbers of deaths from
cancer will continue to: increase because of the increasing proportion of old persons in the populatiori,we may reasonably anticipate a substantial reduction in the death rate from cancer in
the next decade. The reasons for this expectatioi are lowered
incidence, more effective treatment, recognition of pre-invasive
cancers and development in virology. We must be in a position
to measure these changes..
The organs and tissues of the body which are : affected by
cancer in the first twenty years of life differ strikingly from
those most susceptible during the later years of life,: These
differences and others indicate that we.are not correct in considering cancer as one disease. The many forms that tancer
takes is itself an indication that the disease is:one of
multiple aetiology.
Why we need case registration: 1.2.
The World Health Organisation hasset up a Sub-Committee on
Cancer Statistics comprising a number of the world's experts on
this speciality. This committee has stressed the need for the
establishment along uniform lines of national cancer registers
in all countries, in order that comparison may
possible
between the cancer experience in various parts of the world.
At the present time there exist cancer registries in all the
advanced countries but very few: indeed are population based,
i.e. cover all cases occurring in the whole country or in a.
defined area of that country,
•.One of the important reasons for case registration in cancer
is the limitations of death statistics. If everyone who was
affected by cancer died from the malignancy then and only then
would death figures tell us the true incidence of these forms
of disease, • Fortunately this is far from being the position,
4 •5. 1+ Staging
4.506 Histologic type of cancer
1+.5.7 Corrections and additions
5.
Methods of tabulating data at the hospital registry
5.1 Planning a study
5.2 Methods of collecting and tabulating data
5.3 Calculation of survival rates at the Hospital
Registry
6.
References
FIGURES
Figure 1- Schematic presentation of the Central Registry
Organisation(2.5)
Figure 2A - Suggested Hospital Registry Abstract Form - Front (3.3.1)
Figure 2B - Suggested Hospital Registry Abstract Form - Back. (3.3.1)
Figure 3- Sample Follow-up Letter to Private doctor (3.3.2)
Figure
Lf-
Sample Follow-up Letter to patient (3.3.2)
Figure 5- Sample Follow-up Letter to relative or friend (3,3.2)
Figure 6- Suggested Site Index Register (3.3.3)
1. The background to cancer case registration
1.1 The basic facts about cancer
Malignant disease accounted for 3,657 out of 22,861 deaths
in New Zealand in 1964, one sixth of the total mortality. At
old ages cancer is quite expectedly the second leading cause of
death to heart disease, but it is rather surprising to find
malignant conditions to be the leading disease cause of death
(accidents rank in first place) among children at pre-school
and school ages (1 to ik years).
In 1962 a total of 9,860 inpatients were treated in our
public hospitals (4,896 males and 4,964 females); the aggregate days stay of these hospitalised cancer patients was
229,352 days.
While the number of cancer cases diagnosed and the numbers
of persons dying from cancer are increasing in absolute numbers,
they are not doing so out of proportion to the population
2S7
17
CANCER CASE REGISTRATION AND CANCER STATISTICS
1.
The background to cancer case registration
1.1 The basic facts about cancer
1.2 Why we need case registration
1.3 The New Zealand case registration scheme
1 .3.1 Public hospital and private hospital cases
1.4 The uses made of registration data
1.4.1 Data about the incidence and prevalence of
cancer
1.k.2 Data about the extent of the disease
(clinical stage classification)
1.4.3 Data about treatment and survival after
treatment
1.5 Other purposes of cancer case registration
1 .5.1 Clinical and laboratory studies
1.5.2 Epidemiological investigations
1.5.3 Genetic studies
1 .5, 4 Local cancer control
1 .5.5 Provision of facts for educational use
1.6 Confidentiality
2.
Case registration procedures at the Central Registry
2.1 Case registration and indexing
2.2 Matching with death certificates
2.3 The punched cards
2.4 Survival checks and follow-up
2.5 Schematic presentation of the Central Registry
organisation
3.
The operation of the Hospital Cancer Registry
3.1 The control of the Hospital Registry
3.2 The functions of the Hospital Registry
33 Filing and indexing
3.3.1 The Hospital Registry Abstract Form File
3.3. 2 The follow-up reminder index
3.3.3 The site index register
+. Directions for abstracting
4.1 The Hospital Statistics Handbook
+.2 Cases to be abstracted
4.3 When to abstract
Lfk Where to send MS38 abstracts
+.5 Notes on abstracting and on abstract items
4.5.1 Identifying information
4.5.2 Death information
4.5.3 Treatment
Welch (J.D.) Appointment
systems in hospital outpatient departments.
(Abstract of pubin.)
Hospital Abstracts, Sept.
1963 9 pp 514-5
9.2 Background
'A visit to outpatients'
Hospital & Health Management,
Nov. 1962, p 1023
Ball (A.M.) The general
hospital outpatient
department
Jnl. AAMRL, April 1959
'Clinic accommodation':
Abstracts of Efficiency
Studies in the Hospital
Service, No. 17
H.M.S.O., 1961, 2 pp
pp
55-7 9
79
Takahashi (N.) Storage and Hospital Abstracts, July 1962,
filing of outpatientpp 423-4
medical records.
(Translated from Japanese:
abstract)
z'
c4
16
'Maternity department:
appointment system for
clinics': Abstracts of
Efficiency Studies in the
Hospital Service, No. '+k
H.M.S.O. 1962, 2 pp;
Hospital Abstracts, May 1963s
Morgan (J.H.) Medical
Records Departments: the
Cardiff Royal Infirmary
Medical Record, April 1951,
'Outpatients Appointment
Systems' (at 3 hospitals)
pp 90-5
pp 439-4 3, 460
Piddiford (George H.)
New Zealand Hospital, May,
Masterton Hospital Survey
.1966, pp 5-19
of patients waiting time in
outpatients and casualty
departments
Rossiter (W.J.c.) Registration and reception of
outpatients
The Hospital, June 1959,
Ryan (J.A.) Seven guides to
better emergency department records
Hospitals, March 16, 19639
Schankula (H.J.) Identification cards for outpatients
Canadian Hospital Sept.
1962, p 56.; Hospital
Abstracts, Jan. 1963,.P 51
Hospital Administration,
Nov. 1960,;pp 22 9 25;
Hospital Abstracts, April
Spence (A,R..w.) The duties
of the outpatient clerk
call for many qualifications
pp
'+79-83
pp 66, 68-9,71;
Hospital Abstracts,
Sept. 1963 9 p 537
1961, p 272.
Stone (J.E.) Hospital organ- London, • Faber, 1951,.
isation and management, xxii +1722
pp 198-245 9 805-6,
15k2-9
Turnpenny (.w.) Calcu-Medical Records Aug. 1960,
lation table for follow-.pp 312-3
up appointments
Villegas (E.L..) OutpatientHospitals, April, 16, 1967,
appointment system savespp 52-71 120
time for patients and
doctors
Walker (P.M.) Outpatient
waiting time or 'Why are
they waiting?'
Weilerstein (J.,) Outpatient record development
Medical Record News, April
pp 67-71
1962 9 pp 55-7 9 87
Brockis , (R.J.) Pre-Registration - is it worth it?
(Pre-Registration for
O.P. clinics)
Camille (Sister Mary) Emergency room records
Medical Record News, Oct. 1962,
Carr (Mary Beth) & Finnigan
(Pita). Controlling outpatients and emergency
loan records (in 'What to
YOU do?')
Medical Record News, Feb. 1965,
Eastham (G.) Out-patient
Waiting Time
Fraser (N.A.) Consultant's
view of medical records
Medical Record News, Nov 1963,
Gibbins (c.H.) & Cashmore
(V.F.) Control of appointments and records
pp 1+02-5
pp 9 9 11-12
pp 1+87-97
pp 583-8
pp 201-6
'Guide to the organisationU.S.A., Chicago, Ill.,
of a Hospital MedicalAmerican Hospital Assn.,
Record Department' pp 1921+ 1962, vii + 83
Hill(P,A.) Public relations Hospital & S ocial Service
in the out-patient depart-Journal, No, 3, 1961,
ment
pp 1277-8;
Hospital Abstracts, Feb. 1962,
p123
Hinds (n.J.) Appointment
survey pinpoints causes of
clinical delays
Hospital Topics, Dec. 1962,
pp 1+2-5; Hospital Abstracts,
June 19 6 3, p 331.
MacEachern (M.T. )Medical
Records in the Hospital,
pp 173-87
(Marshall, Wright, Booker,
Bald & Fieber) O.P.
diagnosis & operations
indicies (in 'What do
YOU do?')
1937, xvi + 371+ illus.
pp 282-/+
'Maternity department:H.M.S.0., 1962, 3 pp;
appointments system for Hospital Abstracts, Aug. 1962,
clinics': Abstracts of p 519
Hospital Service, No.29
16
While it is true that our hospitals do attempt to have an
organised appointments system, there is always room for improvement
so it is advisable 4 in the interests of the patient, to conduct a
periodical survey no matter how time consuming this may be. The
Medical Records Officer, however hard pressed, should treat: this
as a matter of priority and when the facts are before him face up
to them,particularly when it is found that part of the cause for
delays is due to inadequacies within his own department.
References:
Waiting in Outpatient departments. Nuffield Hospital.
Trust, 1965
Manning (D.P.) & Pugh (w.v.N.) A casualty appointment
system. Lancet,-14 March 1964, 601-03
Tatham (c.) Experience with an appointment system in a
Casualty Department. Lancet, 28 May 1966, 1201-03
Further reading:
9.
Basic:9.1.
Anspach (M.) The hospitalMedical Record, May 1953,
service in Belgium with pp 154-61
special reference to the ..
administration of a Records
Department
'Appointments system for H.M.S.O., 1962, k pp
(Maternity) Clinics':
Abstracts of Efficiency
Studies in the Hospital
Service No. kk
2fZ
Betts (B.H.) Waiting in
Outpatient Departments
Sept. 19571 pp 322-4
Bott,(T.H.) New systems,
new equipment speed clinic
appointments
Hospitals, Feb. 1, 1962,
June 1962, pp 352-3
Brockis (n.J.) Casualty
records
Medical Record, July 19519
pp 189-90 , 205
The form is arranged primarily for ease of completion and extraction of the necessary information from which tables can be complied
to give the required information, i.e.
Table 1.1 Total time in minutes spent at hospital
1.2
Minutes between reporting time and start of
consultation
1.3 Duration of consultation time in minutes
Table 2.1 Total time in minutes spent in Accident &
Emergency Department
22 Minutes between arrival and start of examination
2.3 Duration of examination
Table 3.1 Time in minutes spent in dressing clinic
Table
3.2
Minutes between reporting time and start
of treatment in dressing clinic
3.3
Duration of treatment in minutes in dressing
clinic
3.4
Minutes between appointment time and start, of
treatment in dressing clinic
Lf
Diagnosis of patients treated in Accident &
Emergency Department
Table 5.1 Transport of patient to hospital by domicile
5.2 Domicile by category of patient
These tables give a break down for each clinic for each day that
the survey is conducted. This then allows one to see if an atypical
distribution occurred on any one day which affected the overall
pattern of that clinic.
Transport to hospital and domicile by category of patient is
necessary in order to determine whether the arrival time differed
to any' great extent from the appointment time as these are factors
which must be taken into consideration when making appointment
times so as to reduce overall waiting time.
As all medical records and appointments lists are prepared in
advance for clinics, particulars on the form, numbers I - 10 and
12 - 16 can be filled in at the same time thus being in readiness
for when the patient reports, and as a time saver during the
actual survey.
16
- HOSPITAL
WAITING TIME SURVEY
Note: In multiple choice answers please encircle the
figure in front of the category which applies
Name:
1Address:___________________________
2 - 5Serial No.:
6-7Age:
8Sex:1 Male2 Female
9-10 Date:
/1
11 Transport to hospital:I Ambulanôe
i--I
•
-U 1
2 Public transport 3 Other
(includes taxi)
FOR OUTPATIENTS
12 Clinic:
13 Was this consultation booked? 1 Yes 2. No
14 -. 16 Time of appointment:
17 - 19 Time of arrival at patient reception:
• 2021 Time consultation began:
• 22 - 24 Time consultation ended:
FOR ACCIDENT & EMERGENCY PATIENTS
25 Was patient referred? 1 Yes 2 No 3 Don't know_________
26 - 28 Time arrived at A. & E. Dept.:
29 - 31 Time examination began:
32 - 34 Time patient left A—& E. Dept.:
35 Was patient admitted? 1 Yes2 No
36 - 38 Nature and site of injury:
2 rd
I
(i) Patient Participation
In this case patients are given a form which they are
requested to take with them and present it to the various
staff, who will insert the appropriate details.
(ii)Direct Observation
The movement of each patient is recorded by staff
stationed at vantage points in the department and the
form completed as above.
Method
For outpatients clinics - direct observation is the more practicable0 During the clinic session a clerk should be stationed in
the outpatients reception area where all patients should beinstructed to report to on their arrival, and again on their departure,
each patient being given a form on which the necessary data
required is recorded. If there is more than one clinic. session
being held at the same time then a clerk should 'be. stationed near
each clinic. For Accident & Emergency department pattents,:and
outpatient dressing room attendance 's, this information can be
recorded by the nursing staff on duty.
Information Form
It is necessary to design a form to record the information.
The following would meet the requirements of most hospitals:.
2q
16
Staff coverage: 6.
Outpatient department clerical staff coverage is normally
between 8.30 a.m. and 4 .3 0 or 5 p.m. though if clinics are held
outside these hours it is desirable that clerical staff should
be on duty.
Similarly, clerical staff should cover the Accident &
Emergency department for as much of the 24 hours as possible.
The determining factor will probably be size of the departments concerned so consideration should be given in planning new
hospitals to making the departments inter-related with the
Admitting department so that one person can cover both Admitting
and A. & E. reception during the evening or night hours.
When nursing staff do the clerical work in the absence of
clerical staff procedures must be simple and capable of easy
checking by clerical staff when they come on duty.
Clerical staff qualifications: 6.1.
It will be obvious that, particularly in the Accident &
Emergency departments, personal qualities required in the
clerical staff are important and can be summed up as:
(a)
Calmness and efficiency in dealing with patients
and emergency situations.
(b)
Tact in dealing with relatives and friends.
(c) Ability to understand and carry out instructions
quickly.
Condudting a waiting time survey: 7.
The conducting of a successful survey, can only be
achieved by tackling the problem as a team. In this case such
a team would normally consist of medical, nursing, medical
auxiliary, portering and clerical staff, but the size of the
team would naturally depend upon the size of the institution.
A survey can be done, either by patient participation or
by direction observation:
24
doctor when filling in the •record whereas a car accident with ?
concussion and extensive abrasions face and arms would be permanent.
Temporary records could be kept. in the A. & E. department for 7
years to comply with the Statute of Limitations whereas permanent
ones would be filed in the Medical Records department once their.
visits in connection with the first attendance had finished. In
each case an index card would need tobe kept indicating into which
category the patient came should he return to the hospital.
Other systems will suggest themselves. The important thing
is that they must be in the best interests of patients whilst being
practical to operate in the hospital.
k.Numbering
The method of numbering records will depend on whether they
are centralised or decentralised. If centralised it is obviously
desirable that one number only should be used for each patient
otherwise the confusion of trying to trace a patient through a
succession of numbers would undo much of the advantage of having
a central record.
If the records are decentralised then each clinic or department will probably run its own series of numbers which will be
meaningless and will tend to confuse through duplicating othet'
departments' numbers if used outside the department.
If, for reasons of local hospital politics, decentralisation
is insisted on blocks of numbers or prefixes which could distinguish
departments or clinics should be advocated.
5.Time of arrival
It is particularly important that' this be recorded accurately
in the Accident & Emergency department. The majority of complaints
about the A. & E. department concern the amount of time that a
patient was kept waiting before seeing a doctor. It is therefore
preferable to have a time clock for recording time of arrival of
the patient since this disposes of any arguments concerning the
accuracy of the clerk's recording of time of arrival.
16
therefore present no more difficulty for the Medical Records
department in providing the record than a booked readmission or.
an outpatient clinic attendance.
At the other extreme a card is made out for the A. & E.
patient on first attendance and kept in the department until
the visits in connection with that attendance have finished when
it is filed numerically or alphabetically serially or by year of
attendance. For all practical purposes it can only be found
again if the patient remembers when he attended previously.
Few, if any, hospitals in New Zealand haie•madé a survey
to establish the relationship between A. & E. patients and those
attending other departments of the hospital as outpatients or
inpatients. Are the majority of A. & E. patients'oncers' Or are
asubstantial proportion part of the 'hospital population',
visiting this department or that fairly regularly? If the
latter is the case then visits to Accident & Emergency are
obviously as important as other outpatient attendances in the
overall helth picture of the patient and should be so regarded.
If, however, most A. & E. patients only attend the hospital for
genuine accidents or emergencies and are otherwise looked after
by their own doctors and do not therefore usually come near the
hospital is one justified is going to much trouble over the
records for only a minority?.
A large number of patients come to the Accident & Emergency
department and the sheer physical job of filing and pulling a
medical record for each on each visit would call for extra staff
and extra filing space in Medical Records with doubtful
benefits to patient or hospital. On the other hand virtually
'writing-off' a patient because be cannot remember when he last
attended could have serious consequences.
Some hospitals overseas maintain that surveys have shown
that 35% and more of patients attending the Accident & Emergency
department of the hospital are referred to other services,
either as inpatients or outpatients and that this justifies
treating A. & E. records as normal outpatient ones. Until a
local survey has been done it seems. that a compromise is called
for.
Depending on the seriousness of the accident or. emergency
the. record:could be regarded as permanent or temporary. For
instance, a schoolboy referred for abrasions (L) knee and contusion (L) upper arm would be marked 'temporary' by the examining
lqb
3.Records - decentralised or centralised?
If records are decentralised this means that each clinic or
department maintains its own records and there will not, generally
speaking, be any reference on inpatient notes to indicate that the
patient has been attending an outpatient clinic. On the other
hand centralised records are those maintained in the Medical Records
department for all attendances of the patient at the hospital
whether as inpatient or outpatient.
31 Outpatients
There can be no argument on which is preferable for general
management of the patient as a whole person. The central record,
showing outpatient as well as inpatient, treatment gives a complete health picture.
The policy should therefore be to register a patient on his
first attendance at the hospital, whether as an outpatient or
inpatient, and to raise a medical record for him then. This record
should be in the same format as that for . inpatient notes so that a
chronological history of the patient can be made and easily
referred to.
The objection to this policy put forward by those against it
is that it is inconvenient - if the records are kept in the clinic
or department they are immediately available to answer questions
by referring doctors or. for research whereas having to ask the
Medical Records department for the record means delay. There is
validity in this argument only if the patient is looked on as 'a
case' belonging to that particular clinic or department, but all
the information including possible drug reactions, obtained by
that clinic is wasted if it is not immediately available should
that patient be treated elsewhere in the hospital.
3.2 Accident & Emergency patients
In principle the same argument applies but practical considerations may force a compromise.
Ideally, an accident & emergency patient should receive a
number as for a normal hospital admission on his first visit, the
record of treatment should be in the same format as the inpatient
notes, immediately following treatment the notes should go to
Medical Records and begot out from Medical Records for each
successive follow-up visit which should be by appointment and
16
Referrals to other departments: 2.4.
Most referrals will be to the X-ray department. Some
hospitals have a mobile x-ray machine in the A. & E. department.
As with outpatients it is important to see that patients are
brought or sent back from another department and that they are
attended to when they return to the A. & E. department.
' Further treatment: 2,.
This should normally be carried out by the patient's , own
doctor, the job of the Accident & Emergency department being to
cope with the initial accident or emergency and to complete
treatment following from the first visit. There may, however,
be further treatment required, such as physiotherapy, which
would be arranged by the hospital who would not
the patient's
own doctor by letter from the medical officer in the A. & E.
department,
Follow-up appointments: 2.6.
Opposition to an appointment system for follow-up appoint-,
ments in an Accident & Emergency department dies hard. Experience has shown, however, that an appointment system can work and
helps to spread the 'peaks and valleys' if devised having regard
to local factors such as the experience of when the department
is normally most crowded, convenience for patients as far as
transport and working hours are concerned,other staff commitments,
how long patients are kept waiting at different times of the day
etc.Before an appointment system is introduced a survey must be
done to establish the above factOrs. This is 'something which
clerical staff can do on their own initiative as part of the
reception process. With the facts of what actually happens in
the department (as opposed to what people think happens) medical
and nursing staff should be more ready to try an appointment
system for follow-up cases which will make their work easier.
However, the very nature of the department means that
there are liable to be interruptions and doctors are likely to
be called away to emergencies, it is essential that clerical'
staff be 'aware of what is going on and explain to patients with
bookings who are delayed the cause of the delay.
1Wi
clerical staff is normally responsible for obtaining this information.
The record should show':
(i)
(ii)
(iii)
(iv)
(v)
(vi)
Name and address, sex, age and occupation,
What patient is complaining of, e.g. 'lacerations face
and CE forearm'.
The time the patient arrived
The time the patient was seen by a doctor and by whom
The patient's own doctor
If an accident at work, the employer's name and address
Allythe above would normally be filled in by clericalstaff.
(vii)
(viii)
Details of the accident, including location. (This is
normally filled in by medical staff as part of the
medical examination of the patient. As, however, this
information is needed for coding should the patient be
admitted there is much to be said for including headings
which will ensure that the information required is given).
Diagnosis, notes of first and any subsequent treatment,
x-ray and other reports.
The clerical staff are, as with Outpatients, responsible for
recording figures of attendances at the department.
It is important that accidents at work are not overlooked.
It is good practice to put 'accident at work' with a rubber stamp
in a space provided for this on the form. This will help ensure
that the information is transcribed for revenue purposes.
2.3 Notifying relations
The clerk taking particulars from a patient following an
accideht should find out if the patient wishes anyone to be notified that they are at the hospital. If the patient is admitted
and/or transferred to another hospital the next of kin should be
notified.
2i3
16
Referral sources: 2.1.
(i)
Accidents. Traffic or domestic accidents or accidents
at work coming straight to the A. & E. department.
Accidents at work are covered under the
Compensation Act which is explained in chapter 15
('Workers' Compensation'). Most domestic accidents are
covered by Social Security unless it is an obvious case
of assault when the proàedure below applies.
Where it can be shown' that another person is to blame
for an accident* - and this applies mostly to traffic
accidents - the onus is on the injured person to
recover hospital costs from the person injuring him.
If the injured person declines to do this he must be
warned that his hospital costs are not covered by
Social Security' and that he can be. held'responsible
for paying them.
In practice, these costs are usually met by insurance
in traffic cases. The point to note, however, is that
the patient no longer 'has the option, where blame for
an accident, can be established,.
the costs being met
on Social Security by default and the responsibility
is on clerical staff to explain this.'
(ii)
General practitioners, Usually for domestic accidents.
(iii)
Hospital emergency admissions. In some hospitals all
emergency admissions are admitted through'the Accident"
& Emergency department before being sent to a Ward.
This ensures that the patient is examined by a doctor
immediately on arrival in the hospital.
(iv)
Other organisations. Schools, sports clubs, other
institutions bring accident cases to the A. & E.
department.
Records: 2.2.
The Accident & Emergency department record must give sociological as well as medical information. By its very nature it is
apt to be badly filled in but, conversely, because of the likelihood of legal. and insurance claims it is all the more important
that it should be completed accurately. Furthermore, where there
is an admission as a result of an accident the details of the
accident will be required for the MS,18 statistical card. The
and he is handed a numbered disc. The board for these discs is
kept on the table of the Sister in charge of the Clinic. Appointment cards are handed to the Sister, who calls the patients into
the Clinic from these cards. When the patient answers his numbered
disc is taken from him and placed on the board on the Sister's
table so she can then easily see if any numbers are missing and
find out the reason.
If a patient has been referred to another department from
which a report is required for the patient's next visit the
clerical staff, when doing the pre-clinic check of records, must
ensure that the report is available.
1.6 Further treatment
The patient is told by the clinician what the arrangements
for further treatment are; if an appointment with another department of the hospital is required the outpatient clerk should either
arrange this or explain to the patient where togo to make the
appointment.
1.7 Doctors' reports and letters
During or following each clinic the clinicians either dictate
entries for the patient's records or write them in long-hand. They
also dictate a letter to the patient's doctor stating what they
recommend for the patient. Alternatively, a form letter can be
completed in long-hand, stating the essential facts: patient;
when seen; diagnosis; disposal; any further remarks •and whether
a fuller letter is to follow. In each case a copy of the letter
should be filed as part of the patient's record.
2.Accident & Emergency department
The name of the Casualty department was changed to "Accident
& Emergency" to stress its function: to care initially for
accidents and genuine emergencies, because patients had got into
the way of regarding 'Cas.' as a free version of the doctor's
surgery, which moreover, was open 24 hours a day. Although most
Hospital Boards have a rule requiring that all people presenting
themselves at an Accident & Emergency department must be seen by
a doctor clerical staff should bear in mind the function of the
department and try to impress this on those who are trying to use
it frivolously.
ziti
16
Hospital
Clinic:
Mr/Mrs/Miss
Hosp. no.:
To return in
time
For admission. Priority:____________________
Medical Officer
Where the bottom line is filled in the slip should not be given
to the patient to take to the office since it is liable to give
rise to unprofitable discussions on the interpretation of priority.
As explained in chapter 18 it is important that the outpatient clerk turn up the date required immediately if, say,
another appointment is tobe booked in 6 weeks time. If a
system incorporating pockets (1.2.1 (iii) and (iv) ) is used
there is no difficulty as it is easy to count pockets. If, however, a book is used in addition to the methods mentioned in
chapter 18 a simple method for use with a loose leaf system is
to have pieces of card long enough to have 2 punch holes for
holding in the fixture and also to protrude above the booking
sheets marked "1 week", 11 2 weeks", "1 month", "3 months" etc.
putting them in the relevant position in the book and moving
them up one each morning.
Referrals to other departments: 1.5.
Where patients are sent to another department, e.g. x-ray
or laboratory, it is the responsibility of the clerical staff
to see that they are not 'lost sight of' and that they are seen
again when they return although, here again, the remarks made
above regarding co-operation between nursing and clerical staff
apply.In some . hospitals with large clinics hostesses are
employed to take patients to other departments and to maintain
liaison with them.
A method which is used at one large hospital to overcome
patients 'getting lost' or being overlooked: when the patient
reports to the Clinic, his appointment card is taken from him
Igo
relieving professional staff of work of a non-medical nature.
Obviously, as with many other procedures described in this manual,
this is a dual effort of co-operation between clerical and medical
or, in this case, nursing staff. Clerical staff are also responsible for producing statistics regarding clinic attendances required
by Administration.
Where mechanical patient documentation is in use for outpatients it is assumed that labels only will be printed to allow
the clinic to use them on successive visits and for different
purposes, e.g. heading-up forms, laboratory or x-ray requests etc.
Depending on the size of . ,the clinic, the accessibility of the
hospital or whether a phone call is a toll the procedure, for
obtaining the information required for the label will needto be
varied. There should be astandard form the lay-out of which
corresponds to the label and which can be sent to the patient's
octor or used internally. If the clinic booking is some time
ahead a booking can be made and the doctor or his nurse can be
asked to fill in the O.P. booking form which would previously
have been supplied in pads; the form needs to be designed so
that it incorporates business reply post (payable by the hospital).
If there is insufficient time the information required can be taken
by the booking clerk on the phone on a form for internal use with
the same lay-out. If neither of these methods is possible or
practical then the patient would be asked to attend j hour before
the clinic appointment for documentation. It is stressed, however,
that this is a poor solution from two points of view: it keeps a
patient waiting; it makes bad use of the machinery inIthat it
requires that what should be done at a slack period as routine
has to be treated as an emergency and, consequently, a genuine
emergency might be delayed.
Following the clinic visit it is the responsibility of the
clerical staff to book the patient for a further visit if this has
been requested by the medical staff or to put him on the waiting
list for admission. A simple form (which can be duplicated) is
used between the clinician and the outpatient clerk along the
following lines;...
234
16
3rd Notice: Health Dept. Copy
eeoeoee.eo•eo....e,.
Mail to M.O.H., Blanktown,
Don't use Window Envelope
As the previous appointment was not kept, a re-appointment for Chest Clinic for the above has been made for
between
to 3 p.m. on Friday, the
.....,,i96.....
(pink copy)
No more reminders will be sent to this patient
Records:
1.3.
The requirement of an outpatient record is that it should
clearly record progress where there are several visits. Whether
this should be done by keeping.separate records in the clinic
or integrating them with inpatient records is discussed in para.
3 below.
Where mechanical documentation is in use it will be
necessary to decide whether this is to be used for outpatients
and, if so, to what extent and the procedure to be followed.
This is covered in the following paragraph.
Clinic attendance: 1.4.
The responsibility of the clerical staff is to receive the
patient on arrival for a clinic and to check identity. It
should also be the responsibility of the clerical staff to ensure
that patients are seen as near their appointment time as possible
as it is usually the clerical staff who bear the brunt of the
complaints if clinics are running late or patients are taken out
of turn. In many hospitals this is the responsibility of the
Sister-in-Charge. Whilst medical or nursing staff must always be
able to make changes for clinical reasons the clerical staff
should keep control of the situation, informing patients of delays
and the reasons for them (emergencies etc.), seeing that the
appointments system is not abused by patients being seen in
order of arrival rather than by time of appointment and otherwise
20
. . •....I I • •I•••S. - I
2nd Notice
REMINDER: Your Chest Clinic appointment is for
2 to
3 p.m.
on Friday, the......,196.....
It is in your interests to keep this appointment becaus
(old gold copy)
The report on your x-ray film was:
If the patient still fails to attend the Public Nurse Health
has statutory power, in the case of a TB patient, to compel
attendance. The patient is rebooked using the following forms;
by agreement with the local Medical Officer of Health the onus
can be placed on the Public Health Nurse to ensure attendance as
soon as she receives the pink copy:
BLANK HOSPITAL.BOARD
Blank Hospital,
Hospital Pd. Blanktown
....../..../6.....
3rd Notice
As you did not
appointment has
BLANK HOSPITAL,
2to 3
keep your last appointment, another
been made for you at the CHEST CLINIC,
between
p . m. on Friday, the 0 ........ ,i96.....
DON'TBREAKTHISDATES(yellow copy)
Z7
16
at one writing by varying the copy on the forms, ensuring that
the part regarding time and date registers through the different
forms, having them either on different coloured stock or printed
in different coloured inks; the second notice is sent out about
a week before the clinic:
HOSPITAL
Blank Hospital,
Hospital Rd. Biankto.wr
/
- list Notice
An appointment has been made for you to attend the
CHEST CLINIC, BLANK HOSPITAL,.between
2 to 3 p m. on Friday the ...... , 1960
If you want to change this booking, please ring
Outpatient Office NOW ('phone 123k5 or 56789)
The report on your x-ray
Sputum tests:
• • OS 00
eiee S S SO • S 0 10 • • • S •S • SO IS • •
e copy)-:
(white
Advice:, . . . . . ...... . . • . . . . . . . . • . .(whit
............
•0•OSS S S • SO 0SS•S•CS IOIOSQS000SSI 0•0 0I0000I•S9000
S•••ISIS••SS•S05505•05S 5 0 I 5055•IS•SS•S
-
Sister-in-Charge, Outpatient. Clinics
(perforation)-----____
list Notice: Health Dept. Copy
Mail to M.O.H. -B-ia•nktown.
Don't use Window Envelope
Thest Clinic appointment has been made for
he above for
2 to 3 p.m. on Friday, the .........,i96....
T.B. Cases only. Non-TB., destroy this copy.
The following is report on this case given
to patient:
(green copy)
X — Ray. . . . . . . . . . . . . . . . 0 • • • • • . . . . . . . . . . . . -. . . . .
Sputum tests:
.•••••• S.
•OI555SSS• SO •ISIS
There should be a limit set to the number of new patients
seen and the number of follow-ups for each clinic and this limit
should only be exceeded with the agreement of the consultant. It
is important that the outpatient booking clerk insist on this to
avoid the odium of booking patients into an over-full clinic
unnecessarily. Where the transition is made from a 'first come,
first served' clinic to one with proper appointment times patients
who come early expecting to be taken 'in turn' must not be seen
ahead of someone who has come later but in time for a booked
appointment.
A copy of the clinic list will be required by the Medical
Records department for getting out records beforehand.
Where patients ask for an 'urgent' appointment the patient's
doctor must either endorse the note 'urgent' or this must be said
by him or his nurse when making the appointment and no such appointment should be given until either the doctor's note or his phone
call has been referred to the Consultant's registrar or other
appropriate medical.officer.
1.2.2 For the patient
The essential is that the patient knows where to go and when.
Where a patient is returning regularly to a clinic it is usually
better to have a card with his name and hospital number. The
instructions regarding the clinic are printed and space is left for
appointments to be entered following each clinic visit. The card
itself should be about 3" x 2-i-" folded or single - not too large
to fit into a pocket or wallet comfortably, not too small to get
missed in a handbag.
For clinics where the visits are usually single ones or at
long intervals it is preferable to give the patient a form, a
carbon of which can be sent to the Medical Records department with
the clinic list for records. The form needs to be laid out so
that it not only tells the patient when to come and where but also
gives sufficient information about the patient for the Medical
Records department to use the carbon copy to identify the patient
if he has been to hospital before or to prepare new papers for him
if he is a new patient. (See also chapter 18, 'Follow-up methods')
In some cases, such as TB clinics, it is usual for the
hospital to work closely with the Public Health Nurse to ensure
that patients come to hospital when they are supposed to and it
is usually good practice to send reminders of appointments since
those concerned tend to be casual about dates. This can be done
16
will tend to make the carbon copies very dirty); NCR paper
could be used, depending on the supply position, although
similarly the .•lower copies will tend to get marked.
(iv) Separate 8 x 5 sheets which can be held in pockets in
'Papidex' type books or, less conveniently, 'Kardex' type
trays.As with the book system depending on the organisation of the clinic there is a separate bOok for each
clinic and possibly each consultant. The sheets held in
the pockets project sufficiently under a celluloid
protector to show date, consultant, time (assuming a
separate book for each clinic,e.g. one book for Allergy
Clinics, another for Hypertension etc.):
This system has the advantages of the loose laf book one
with the added advantages that the sheets are easily held
in the fixture and the fixture is convenient. It has the
disadvantage that the sheet is small for a Large clinic.
Another firm has metal cabinets with up to 9-drawer trays.
Each tray contains 45 holders which can be filled by
specially printed forms and dated for subsequent clinics.
The dates are visible when the tray is opened, as above.
The forms fitted into each holder can be 2-, 3- Or 4page with carbons as required and an overall size of
13" x 9 11 . Headings across the paper could be:
Reporting Surname Christian or Age Address If new patient
timefirst nameswrite N.P.
Previous X-rays
Previous records
required?
Required? Supplied Returned
ExistingNew hosp.
hosp. no. no.
(old patients)
(new patients)
irp
9 September 1966 Mulcahy
Dr:
Hosp. no
Address
TimePatient
N. P.
17 Fanfrolico St.
8.30 a.m. Mrs. Edna Morris
Makatana R.D. N. P.
Mrs. T.J. Stone
Date.
10.30a.m. Mrs. J. Bell
3428
Mr. F. Ladden
1562
Miss B. Cumming
4265
The main disadvantage of this method is its inflexibility.
If more people come to the clinic than usual there is 'oftenno room to write them in tidily, consequently the whole page
becomes very difficult to read. It does, however, have the
advantage that reference.can always be made immediately to
previous clinics, although this is often a time-wasting
method of getting information that could be got quicker elsewhere. A bound book also has the further disadvantage that
lists required for medical records wanted for the , clinic
have to be transcribed. Specially printed and bouñdbooks
are expensive and do not justify their cost.
(ii) A loose leaf book. This has the advantage that extra leaves
can be put in if clinic arrangements are 'changed. The lay .out would be similar. It has the further advantage that
sheets can be easily photocopied for Medical Records to draw
''the records required. Loose leaf books tend, however, to get
untidy, the holes enlarge and frequently the pages tear out.
This can, to a large extent, be overcome by having the pages
tightly held which, however, results in an .uneven writing
surface; if held in a ring binder paper reinforcing rings
can be used to guard against tearing. Specially printed
pages will be needed but thought has to be given to type and
weight of paper and printing method, e.g. most people use
ballpoint pens which write satisfactorily on duplicating
paper. Should you not have your sheets run on the hospital
duplicator instead of sending them to a printer?
(iii) A printed pad in triplicate. One copy is sent to the Medical
Records department, one to the clinic concerned and the
bottom copy is kept in the outpatient booking department.
These pads can be assembled with one-time carbons (although
the considerable amount of handling which they will receive
V.;
-16
however, one has to qualify it by emphasising that appointment
times must be realistic - if there is only one bus service an
hour then inevitably many patients for the clinic are going to
arrive hourly.
Booking for clinics is done either by telephone, personally
or by letter.
Phone bookings may be done by the patient or someone on
his behalf, the general practitioner or specialist or his nurse
or other wards, departments, hospitals or organisations. If
the Ward Sister makes an appointment for an inpatient to return
to clinic following discharge it is essential that this be
done through the appointments clerk.
Counter bookings are usually made by the patient himself
for follow-up visits but, depending,on how convenient it is
to get to hospital, the patient may make the first booking
himself.He must have a •note from the doctor 'referring hIm
stating the purpose for which he is referred.
In general, it is preferable for all, clinic bookings to be
done by one department. This enables visits to be co-ordinated
and also means that the same method can be used for all clinic
bookings. It is recognised, however, that certain 'clinics may
have a case for doing their own booking and alsothat hospital
lay-out often precludes a centralised booking system.
For the information of the hospital: 1.2.1.
When a phone call is received or the patient comes to the
counter to, make a booking the outpatient booking clerk must be
able to refer to a book or fixture from which an appointment time
can be given.
The following methods may be used:
(I) A bound book which may be an exercise book, a larger and
thicker book with ruled, cross lines or a diary. The name
of the clinic is on the outside. Different lay-outs will
be needed depending on the size of the clinic and the
number of medical staff running it; medical staff usually
prefer to bring new patients in at the beginning of the
clinic, setting aside more time for them.
The lay-out of a day's clinic sheet could be:
Outpatient departments serve a double function either for
pre-admission assessment to determine whether a patient is to be
admitted and, if so, to determine urgency for waiting list
purposes or to continue treatment for which a general practitioner,
would not have facilities and which saves the patient being
admitted as an inpatient. In some cases certain pre-admission
procedures are also done on an outpatient basis to improve bed
utilisation and allow the patient to be admitted nearer the date
of his operation.
Outpatient follow-up is covered in para. 3 chapter 18 ('Follow-up methods').
1.1 Referral sources
(i)
General practitioners. The main source of referrals
to the outpatient department is from general practitioners either direct or through a specialist.
(ii)
Wards. Following discharge the ward may arrange for
a patient to attend a clinic for follow-up visits.
(iii)
Other departments of the hospital may arrange for a
patient to attend a clinic.
(iv)
Other hospitals may refer outpatients or discharged'
inpatients to the outpatient department either because'
the hospital to which the patient is referred has more
specialised facilities or because it is more convenient
for the patient, although there may be local arrangements of 'zoning' which limit this.
(v)
Other organisations such as Medical Officers of Health,
Public Health Nurses, mental hospitals, prisons, the
Armed Services refer patients direct to the outpatient
department.
1.2 Appointment booking methods
It is assumed that all outpatient departments operate an
appointments system bringing patients in in 'blocks' of so many
to a quarter or half hour. Anything less than this should not
be tolerated. The British Ministry of Health's criteria are
that 50% of patients should be seen within 15 minutes of their
appointment time, ',)5% within half an hour and less than 3%
should wait for more than half an hour. Having said this,
2;,
OUTPATIENT AND ACCIDENT & EMERGENCY DEPARTMENT PROCEDURES
Ii
1.
Outpatient department
1,2 Appointment booking methods
1.2.1 For the information of the hospital
1.2.2 For the information of the patient
1.3 Records
1.4 Clinic attendance
1.5 Referrals to other departments
1.7 Doctors' reports and letters
2.
2.2 Records
2.3 Notifying relations
2.4 Referrals to other departments
2.6 Follow-up attendances
3,Records
- decentralised or centralised?
3.1 Outpatients
3.2 A & E patients
1•Numbering
50Time of arrival
6.
Staff coverage
601 Clerical staff qualifications
7.
Conducting a waiting time survey
80References
9.Further reading
9.1 Basic
9.2 Background
Outpatient department: 1.
It is in the outpatient department that most patients make
their first contact with the hospital. It therefore follows
that it is one of the busiest and that care should be taken to
see that it is also one of the most efficient. Much of the
success or otherwise depends on the clerical staff who make the
first contact with the patient.
'4.)
to
Hospital Regd.
Id
.r4
(tia)
Patient's.Christian or
Name: .........• o..0.O... ...00First Names:,,,
Address: 00• •.. ••
Employer:
E4
0000000000
0 0000 ass • a a a a ..o,000
••
000 00050
0000010050000000 000000 000500050•00005•0OG
• . Date First Attended:
0Dept. : ..00000 .Occupation.:
Employer's
How did Accident
Address: ......••••.... 0 0ccur: ..........
00 0 00000000.050..5550
0 0 00000000000000 0 •SS0 0$ 000
.•. 0000090005050..0,.
I nsurer: . . • . . . . . . . . • 0 • 0 • • • • • 0 • • • •• • • • • • • . . 0 0 0 • • • 8 • • • • • • • • • • • • •
LEDGER CARD
No0 000
oa.•••••••a•••
0•••••
No. 5588
Month and
Department
1 2 3
123
1 23
1 23
k 5 6 7 8 9 10 1112 13 14 15 16 17 18 19 25 2123 24 25
26 27 28 29 30 . 31BALANCE
9 10 11 12 13 1+ 1516171819 20 21 22232k 25 26272 9 . 3031- - 1+5 678 9 10 11 12 13 14 15 6 1718 19 2o 21 2223 2+ 25 26 27 28 2931
1 56 78 910 1112 131k 15 16 1718 192J 2122 232k2526 27 28 29 30 31
,
k567 8
Medical Certificate0......,i&t visit•,,.....,.
Emergency and Accident Dept. .....0......vlslts@$1.5o .... .......
Diagnostic X-ray...0 ...
Physiotherapy Dept.
.......,..055............,..... ............05...00..
0 000000 00 0005
•00•000
•, ...•.
•.......... . •....... ....
visits @ $1.50 •0.....o .. ........ .. ....
......
a ••S0•000 00 0050500 05 0050
TOTAL$
Hospital Regd.
Co
Ha)
'H
aia)
Patient's Christian or
Name: ...................... ..-.....First Names:
Address: .
e • •. • •.•, •.o.....
No00....,..,.,.,
o.....,.,....o..o...,..,,,o,.00000.o,0000
•• • • •. •. ., .Date First Attended: • • ••,•,•
55,05,0000
Employer: 0000 0 , • 000•S• • • •..... . Dept. : . .. ....... .Occupation: •.... . .
Co
a)
E-I
Employer's
How did Accident
Address: • , •• S • • , •, • 0 0 0 0 • • • • , • • • Occur : . . • • . . . . • • • • • • o
Insurer: , . . . . . . . . . . . • • • • • • • •0 • • • • • 5 0 S I • S 0 0 0 I 0 5
0000I0
0 0 0 0 0 0 I 0 0 S S I 0 0 0 0 0 5 5 00
0050•5550505S00•0I00S000SI50
Dr. to - AUCKLAND HOSPITAL BOARD
Phone 32-690 P.O. Box 5546, Auckland, C.1.
When communicating please return this account or quote name of Patient and Account No.
5588
TO TREATMENT OF THE ABOVE PATIENT ON THE DATES SHOWN Month and
Department
2 3 Lf 5 6 7 ö 9 10 11 12 13 14 1 5 16 17 16 19 20 21 22
19 20 21 22
2 3 1 5 6 7 8 9 10 11 12 13 ILF 15 17 -1-7-177
Ii 2 3 + 5 6 7 b 9 10 11 12 13 14 15 16 17 16 19 20 21 22 23 2
Medical Certificate issued by ....,.........1 visit © $2.50
SSSISSSSSSSO 00555
Emergency and Accident Dept. ................ visits @ $1.50
S.I.I00000.. 50005
Diagnostic X—ray. . . .. . . os-.. . . . 0 5 • • SO 0 00 0 II SOS 0 5 I I 0 5S• S
050000I006SS 00555
Physiotherapy Dept. ........o.....00.000...00 visits1.50
S S S S S • ••S • S S S I S S S S S S S I 5 0 It0 0 0 0 • S S5 0 5 SI 0 5 0 0 S • S 55 5 • S S I S I S I 0
-
-
-
.-.
I'
TOTAL$
t:x1
b
Stone (J.E.) Hospital Organisation and Management.
London, 1952.
Further reading:.1.
Background
Hess (A.E.) Can he work or not?
Your work holds the answer
Jnl.AAMRL, Aug. 1961,
Information to insurance
companies (in 'What do
YOU do?')
August 1 963, p 170
pp 160-i
sheet for accounts staff or in some way, such as by preparation
of card or entry in register for inpatients, records the
admission for future costing.As stated earlier the daily
rate for inpatients is based on the annual accounts of the
individual board.
Some very ticklish problems occur on this side such as
hernias, occupational diseases such as lead poisoning,
leptospirosis, poisoning etc. In all these cases, it is not
within the sphere of a Medical Records Officer to determine
whether or not the claim is in order. The principle is the
same as with outpatients queries: make out a Form 2 to the
insurance company and argue later. In practice it will be
found . that if the insurance company is in doubt, it will
request a special report.
3. Conclusion
When one considers the total number of accidents at work•
treated each year in one's own hospital one realises the
substantial source of revenue this provides to hospitals. In
a few of the major hospitals there are special claims departments set up solely to implement the Act from the hospital
angle. However, the majority of hospitals generallyrely on an
accounts clerk to devote some of his time to this work each
week.The largest amount of work required from Medical
Records personnel is to keep the medical record up to date by.
inclusion of all reports and by direct contact with the
insurance company when further progress medical certificates
are required. Indeed, one can generally tell when the
insurance company intends paying out by the number of rings
requesting further reports.
No mater.,what the job is, whether it be routine filing or
the preparation of a comprehensive report, accuracy is
essential so that a true and correct record is always available.
Remember, this is one of the few sources of income for
hospitals, and errors mean lost money..
kReferences
Partridge
(J0S0)
Some thoughts on Workers' Compensation and
Public Liabilities affecting Hospital Boards.
N.Z. Hospital, Dec. 1955-
zz6
record plays its part. The record should always be kept up to
date, complete with all x-ray and laboratory results, dates of
outpatient attendances and finally whether or not the patient
is cleared for work or had to return at some future date; if
the latter, this should be stated in the account. Naturally
some accounts extend over several months and sometimes it is
preferable to forward an interim account to the insurance
company.
During the time the worker is off work, a medical certificate must be completed certifying his incapacity for work. The
Form 2 is good only for the estimated time stated by the doctor
examining for the first time. Thereafter certificates should
be made on Form 3, until the final clearance which is given on
Form 3.It has been found that most insurance companies
insist on the final Form 3 before they pay out on an account.
A further point crops up in the nature of special reports.
These usually originate from the company or firm of lawyers
requesting a detailed report on the injuries sustained. These
reports are chargeable at a higher rate and may be paid in
full or in part to the doctor or specialist providing such
report.
In larger boards considerable paper work can be involved
in workers' compensation cases and also in folloing treatment
for patients. A method has been evolved to cut down the paper
work. It consists of an 8 x 5 sheet padded with a similar
card and with carbon paper in between (refer appendixes 1 and
2)Whilst the patient is still receiving treatment both
parts of the form go to the department treating him and
attendances are noted. When the treatment is finished the
complete form is sent to the accounts department in the board
office, the upper part is sent out to the employer or
insurance company as the account and the lower part becomes
the accounts department ledger card, thus saving a considerable
amount of transposing and unnecessary record keeping. Such a
system could also be used in smaller hospitals.
Inpatients: 2.2.
This is usually originated in the Admission Office. Among
the questions asked of all patients is whether the admission to
hospital is a result of an accident, and, if so, what nature?
If the Admission Officer is satisfied that admission is a
result of an accident he either types a copy of the record
:zc
it6.
Boys employed on milk rounds, paper runs, Post Office1
and also those employed after school delivering
goods etc.
7 Persons working on own account but whose business is
a private Company. e.g. John Brown employed by
John Brown. All persons working for an employer
including staff of hospitals. NOTE Commercial cleaning staff are employed by Commercial Cleaners,
a separate company. Persons referred to this
hospital for treatment by a private doctor should
•have a Form 2 completed.
Form 2 should be made out whether the employee will b6 off
work or not and for persons admitted to hospital. Where
the treatment takes more than 30 minutes 1 this should be
recorded on the outpatient card.
The foregoing may be considered a general background. How
does one extract all this information? Naturally, this varies
from hospital to hospital due to size etc. Generally, however,
the best place to commence a claim is right at the start, in
the Accident and Emergency Department.
;^.1 Outpatients
The Casualty Officer or Visiting Physician or Surgeon (in
the case of an outpatient clinic) completes Form 2 in duplicate
from information obtained from the injured worker. The original
is either entered in'a register or in the case of larger
hospitals, is passed direct to accounts staff in Board Office
who invoice it and post to the employer or insurance company
concerned. The onus is not on the Casualty Officer at this
stage to determine whether or not the accident occurred in the
course of worker's employment.Now that the case is entered
on a workers debit card the subsequent treatment is watched and,
periodically, normally fortnightly, the accounts staff, or
Board Office staff in company with Medical Records personnel
extract all information from the medical record and prepare an
account for submission to the insurance company, or where this
is not known, direct to the employer.
In practice it has been found preferable to deal direct with
the insurance company whose business it is to handle compensation
accounts. As seen earlier in the chapter, all relevant services
must be extracted and costed and it. is here that the medical
15
Act, which is statute law.According to the nature of the accident a worker may commence an action in the court for Workers'
Compensation, and obtain a judgement; he can then go ahead with
his common law claim if he so desires, but in this latter claim
he must take into account what he has received under
Compensation.. Similarly, he may have-a common law claim for
full wages. (Workers' Compensation being restricted to 4/5 wages).
He may also obtain special damages for his out of pocket
expenses, medical expenses and costs.
Practical considerations:. 2.
The question of whether or not an accident comes within the
scope of the Act does not generally concern Medical Records
personnel. Most Boards work on the assumption, , and with the
Health Department's approval, that the best way is to issue an
account to the insurance company and argue later. There are many
fine points to be considered such as: workers cycling to work
(generally this would not be accepted under the Act but there
are some awards that include this provision), accidents occuring
during meal times, accidents caused through skylarking etc.
These examples would also be considered outside the Act. As a
guide to readers of this Manual, the following instructions are
reprinted from our own Workers' Compensation . Register , as a guide
for House Surgeons:The Casualty Officers should ascertain from patients on
their first visit to Casualty whether the accident happened
at work, and if so, fill in Workers' Compensation Certificate, Form 2, and enter the particulars in this Register.
Form 2 should not be given to the worker but retained in
the Register for subsequent despatch by the Accountant. The
following persons come within 'the scope of the Workers'
Compensation Act 1.
2.
3.
Jockeys and Apprentices
Sharemilkers
Boys employed by father provided they are receiving
remuneration, especially farmer's sons.
Lf Civilian members of the Armed Forces. Note:. Uniformed
members do NOT come within the Act.
All Government Departments. State name of Department
and in the case of RAILWAYS and POST OFFICE, the
Branch concerned.
5. Commercial Travellers.
Form 3
Workers' Compensation Act 1956
FURTHER MEDICAL CERTIFICATE
To ..........................
(Employer or Insurance Company)
(Address of Medical Practitioner)
(Date)
THIS
is to certify that ..........................................................................................................................................
incapacitated for it further
• is still unfit for work and will be totally
period. of ........................................................................................................................................................................
• is fit to resume work on .............................
(Date)
........................... ..........
...................i9............
Remarks.....................................................................................................................................................................
Signature:....................................................................................................
* Complete one paragraph and delete the other...
1.9 Scope of the Act .
.
Workers' Compensation insurance is compulsoryo Protection is
assured the worker, however, by a provision in the Act that the
worker will receive compensation even if the employer has failed,
to insure.There are actually three bodies of law. The Workers'
Compensation Law covers the employer's common liability for an
unlimited amount, it covers any liability which he may have in
equity, and covers his liability under the Workers' Compensation
15
Form .2
Workers' Compensation Act 1956
FIRST MEDICAL CERTIFICATE
(To be used in all cases of injuries at work and industrial diseases)
To ............................................................................................................................................................
Name and address of Employer or Insurance Company (Please Print)
Dr .............................................................................................................................................................
Name and address of Medical Practitioner (Please Print)
This is to certify that I have today examined................................................................
....................................................employed by
Hehe
states that was accidentally injured whilst at work on......../....
Sheshe
h
- 19............at................a.m./p.m. and thatceased work on......../....
she
19............at................a.m./p.m. Worker's account of accident......................................................................................................
hepartially
his
I find that - is incapacitated from following shetotally
her
occupation as a result of the following injuries.......................................................
The probable length of
his
incapacity will be...............................................................
her
I am of the opinion that the above injuries areproperly
are not
attributable to the accident in the worker's account.
I shall see him/her again on ............................................................................................. 19
at..........................................a.m./p.m.
.
Remarks: ......................................................... ; .................... I ....................... ..........................................
............
Date:.......................................Signature............................................................................................
1.2 Outpatient attendances
$.2.50forthe first visit, $1.50 for the second and each succeeding visit with a proviso .that anything over thirty minutes
shall be charged at 50c for each fifteen minutes.
1 .3 X-rays
The amount chargeable for X-rays is double the charges
prescribed in the schedule of the Social Security Regulations
(X-ray Diagnostic Services) as being the relevant fee payable
to Radiological Specialists. In practice, x-ray fees vary, but
the standard fee payable for, say, an x-ray of the armor leg is
$i+.
1.4
Laboratory services
Same as prescribed above for x-rays, but not double.
1.5
Other services
Physiotherapy treatment, artificial aids, teeth, loss of
clothing, splints, boots are all chargeable as set out in the
Act.
1.6 Artificial limbs
..
The employer is required to pay a lump sum into the consolidated fund based on age of worker at the time of accident.
This covers repairs and replacement limbs only; the worker is
then entitled to receive free repairs and replacements from the
Board.
1.7 Ambulance fees
Come under the Section of Transport Expenses.
i..8
Forms
The forms used are set out below. Form 2 is the form
used for the initial visit. Subsequent progress reports and the
final Medical Certificate are completed on Form 3. .
2W
1
WORKERS' COMPENSATION
1. Application of the Act
1.1 Inpatient treatment
1.2 Outpatient attendances
1,3 X-rays
1.4 Laboratory services
1.5 Other services
1,6 Artificial limbs
1.7 Ambulance fees
1.8 Forms
1.9 Scope of the Act
2, Practical considerations
2.1 Outpatients
2.2 Inpatients
3.
4,
Conclusion
References
Further reading
Application of the Act: 1.
The method of obtaining the information required varies from
Board to Board. The whole field is governed by the Workers'
Compensation Act, 1956, and its yearly orders. The theory of the
Act as it affects hospitals is that the medical services afforded
an insured worker as a result of an accident within the scope of
the Act, are payable by the insurance company subject to certain
limits. It is the usual policy of self-employed workers to take
out an insurance policy against accidents or sickness so that, In
the event of injury, the worker has some financial relief. This
means that any services, apart from special reports, rendered by
the Board are free to the insured. Fees are recoverable by the
Board if the patient has right of action against another for
negligence, e.g. assault cases, motor vehicle accidents and in
other cases where this right exists. A brief survey of the
chargeable items as at end 1966 is as follows Inpatient treatment: 1.1.
Amount per day is ascertained by the individual Board's Annual
Accounts. This amount varies from Board to Board and has no
maximum.
III
NOTIFIABLE DISEASES OTHER THAN NOTIFIABLE INFECTIOUS
DISEASES UNDER THE HEALTH ACT 1956
Notifiable to the Medical Officer of Health
1. Actinomycosis
20 Anchylostomiasis (hookworm
disease)
Beriberi
3°
4 0 Bilharziasis (endemic haematuria, Egyptian haematuria)
Chronic
lead poisoning
5.
6. Compressed air illness arising
from occupation
76 Damage to eyesight arising
from occupation
8. Dengue
9. Diseases of the respiratory,
system arising from occupatidn
10. Eclampsia
11. Food poisoning
13. Impaired hearing arising from
occupation
1.
15.
16.
17.
18.
19.
20.
21.
22.
Malaria
Phosphorus poisoning
Poisoning from any insecticide, weedicide, fungicide,
or animal poison met with
at work
Poisoning from any gas,
fumigant, or refrigerant
met with at work
Poisoning fromany solvent
met with at work
Poisoning from any metal or,
salt of any metal met with
at work
Skin diseases arising from
occupation
Tetanus
Trichinosis
NOTIFIABLE DISEASES UNDER TUBERCULOSIS 'ACT 19+8
Tuberculosis (all forms notifiable to the,Medical Officer of
Health)
(Correct at February 1 968,
III
11+
APPENDIX A.
NOTIFIABLE INFECTIOUS DISEASES UNDER THE HEALTH ACT 1956
Section A. Notifiable to the Medical Officerof Health and
to the Local Authority
1. Anthrax
2, Cholera
3. Cysticerosis
Lf, Diphtheria
5. Dysentery (amoebic and
bacillary)
6. Encephalitis lethargica
7. Enteric fever (typhoid
fever, para-typhoid fever)
8Infective hepatitis
90 Leptospiral infections
10. Meningococcal meningitis
11. Ornithosis (psittacosis)
12. Plague (bubonic or
pneumonic)
13e Poliomyelitis
11+. Puerperal fever involving
any form of septicaemia,
sepsis or sapraemia
15.
16.
17.
18.
19.
20,
21.
22,
23.
Rabies
Relapsing fever
Salmonella infections
Smallpox (variola,
including varioloid and
alastrim)
Taenisis
Trachoma (granular conjunctivitis, granular
ophthalmia, granular
eyelids)
Typhus
Undulant fever (brucellosis)
Yellow fever
Section B. Infectious diseases notifiable to the Medical
Officer of Health
10 Leprosy
2, Ophthalmia neonatorum
30 Pemphigus neonatorum, impetigo or pustular lesions of the
skin of the newborn infant
1+. Puerperal infection involvingany form of sepsis, either
generalised or local, in or arising -from the female genital
tract within 1 1+days of childbirth or abortion
50 Streptococcal pneumonia or septicaemia of the newborn infant
Although the schedule states 'infectious diseases notifiable
to the Medical Officer of Health and Local Authority" in practice
few cases are notified direct to the Local Authority. The District
Health Offices are aware of this and they, themselves, take the
precaution of notifying the Local Authority,
Z17
7.2. Background
Stone (J.E.) Hospital organisation London, Faber 1 19529
and management, pp 490-2 xxii + 1722
Trends in Notifiable DiseasesWellington, Department
of Health, Medical
• • •Statistics Branch,
•••Special Report Series.
No. 18
21
14
notified by the hospital and, if note why not. Secondly, the
death certificate eventually filters through the Registrar
General's office to the National Health statistics
Centre,who are able to check off the disease with their
MS18 statistical cards for comparison.
Any complicated test that cannot be performed in the hospital
laboratory, in addition to specialist's tests for viral infections
and salmonella infections, is generally forwarded to the National
Health Institute in Wellington. The results of these tests take
some time but when received back at the hospital, should be acted
upon, even though the patient may have subsequently been discharged
from hospital. All positive results are also sent to the appropriate Medical Officer of Health.. It will be seen, therefore,
that notifications should never be overlooked.
The whole purpose of notifying cases of infectious diseases
is to allow departmental and local authority staff to investigate
home conditions etc. in order to prevent the outbreak or spread
of any such disease, The Medical Officer of Health, if authorised
by the Minister, is given wide powers under the 'Act to achieve
this. For example, he has power to isolate, quarantine or
disinfect. He may order insanitary things to,
or
forbid people to leave the district, ' Besides the..mainpurpose
of preventing the spread of infectious disease, the 'notifications
also form the basis of a weekly New Zealand Bulletin (H.I.D.42)
which sets out the number of actual and suspected notifiable
diseases and the Health Districts in' which they occur,
References: 6,
Health Act 1956, Section 74 and - first schedul.to the Act
1962/76, 1964/39,
.
Poisons Act 1960/39
Tuberculosis Act 1948
Further reading: 7.
Basic: 7.1.
Benjamin (B'.) Tuberculosis 1st mt. Congress Report,
notification and registration pp 215-20
yr
cases of poisonings admitted or discharged from hospital during the
past week up to Saturday midnight, are included. The method of
obtaining such information would be the same as with the other
notifiable infectious diseases, that is, through the daily admission lists. It is suggested that poison notifications be entered
in red ink in the Infectious Disease Register whilst other notifiable diseases are entered in blue ink. This has the immediate
advantage of comparing admissions for the different diseases. It
has been found in practice, that organisations such as Women's
Institutes, clubs etc. will willingly use information of this
nature in an endeavour to bring to parents' notice the danger of
leaving poisonous objects within a toddler's reach. Where it is
undesirable for the Health Department to make further enquiries
in the case, the weekly returns of the Department should be
marked 'investigation not required' (this is covered in paragraph
2 of Health Department Circular Letter 1961/18 of August, 1961).
4• Occupational diseases
These are usually confined to the bigger cities where there is
a danger of occupational hazards such as lead poisoning or
poisoning from insecticide spraying etc. Notifications are made
on the usual weekly H.I.D.6 form.
5.
Conclusion
A perusal of the Infectious Disease Register shows how inpatient
patterns have changed in New Zealand over the past few years.. In
the early 1950s diphtheria and poliomyelitis were responsible for
a large portion of the total notifications. However, with the
introduction of immunisation programmes and public health campaigns
by the Health Department, those diseases were, largely eradicated.
Instead the pendulum swung towards infectious hepatitis, although
a few years ago there were many attacks of influenzal pneumonia
especially in young children.
It is important to follow up positive laboratory findings in
connection with deaths. There is provision on the back of every
death certificate for the disease at the time of death. This
provision has a twofold purpose. F irstly, the local Medical
Officer of Health is notified by the funeral director of a positive case of infectious disease. There is a statutory obligation
for the funeral director to do this, The Medical Officer of Health
can then check his files to see if the case has already been
1+
outpatients seen at his clinic. This form is
usually prepared at the Chest Clinic Office by
the District Health Nurse in attendance at the
Clinic and contains all information necessary
for the Health Department to maintain a Tuberculosis Control Register.
H.T.B.10 This form is. used by the Hospital to notify any
new case of Tuberculosis. For method of
notification see below.
H.T.B.11 This form is sent to the Department when a case
is discharged, died or denotified.
H.T.B.12 This form is virtually a half yarly survey, to
the Department, containing all the names etc. of
every case in hospital at that date..
The method of obtaining the new notification is the same as
with notifiable infectious diseases above. However, this group
includes all outpatient notifications so a careful scrutiny must
be made of all outpatient chest files for any new cases. In the
case of this disease it is usual to wait until clinical or , x-ray
or bacteriological proof of the disease has been established
before notification is made. Once a notification has been made
the name is entered on the T.B. Control Register in the Health
Department and subsequent follow-up is maintained by means of the
Outpatient Forms H.T,B.8. The question of new T.B.'notifications
should not be taken lightly. Once a new case has been registered,
an investigation is made not only to check contacts of the case
but also to search for the likely source of the infection. This
is usually by x-ray or laboratory tests.
The patient's name remains on the Tuberculosis Control
Register until the patient is denotified. The register serves
as the. main record within the local , office of the Health Department by which officers of the Department and the District Health
Nurse are able to check that the necessary supervision has been
given.,.
Poisonings: 3.
Under the Poisons Act (1960) there is a statutory obligation
for hospitals to forward to the Medical Officer of Health, all
cases of poisonings. As the circular does not specifically state
that it requests only cases of children swallowing poisonous
ingredients, it has been the practice for hospitals to list all
cases of poisonings, whether attempted suicide or otherwise.
Thus, on the weekly return of Infectious Diseases (H.I..D.6) all
113.
Mr.
Mrs.
Hosp. No.
Miss
( rname)(Christian name)
Age
Permanent aaress
Sex
Admitted from
Admitted byWardDoctor
Date admittedProvisional diagnosis
Date DischargedFinal diagnosis
Discharged to
Notes receivedH.D. notified
NOTIFICATION OF NOTIFIABLE DISEASE
Every Monday a complete return of all notifications is.prepared from the working book and transposed into an Infectious
Disease Register on to Form H.I.D.6 for despatch to the Health
Department. Any discharges or deaths of previously notified
cases are also recorded on H.I.D,6. This return is complete up
to the previous Saturday night. Some Health Authorities require
form H.I.D.,1 to be completed and forwarded immediately a
patient is admitted with a notifiable infectious disease.. However, this is not the general rule, the normal method being
the weekly H.I.D.6.
2.2 Notifiable diseases other than infectious diseases.
The main diseases of this group occurring in New Zealand are
food poisoning and hydatids. In the latter case the question of
domicile and maiden name in the case of a married woman play an
important part. When completing an MS18 statistical card the
maiden name of the patient is included. This is necessary.to
follow through an old notified case and also to distinguish
between town and country for notifiable cases. The campaign
against hydatids is waged on a national scale and there is no
need to enlarge on it here; . suffice it to say that all notifications must be prepared by the Health Department for use by the
National Hydatids Council and any other interested body.
2.3 Notifiable diseases under the Tuberculosis Act 1948
A different set of notification forms are used here, namely H.T.B.8This form is used by the Chest Physician to notify
the District Office, Health Department, of all
211
14
Dr.
Ward •.•..............,....
R e:•........
• . • . . •... . . . . . •
1••
Hospital No.:
The above named was admitted to your ward sulfering from —
• • S S •SSSOSSS 1001550555e0s0 •0S•S•O
If this is diagnosed as a disease notifiable under the Health
Act or the Tuberculosis Act, (see over) will you please notify
Medical Records Department. Suspected cases of cancer and
notifiable diseases should also be notified.
Date:
MEDICAL RECORDS DEPARTMENT
Note: If the patient is admitted as a suspect case of
notifiable disease the final diagnosis must be notified to
the Medical Records Department as soon as possible - also any
change from a notifiable disease to a disease which i5 not
notifiable,
REPLY:
A card index system instead of a register is also used by
some hospitals.A 5t x 3" card, as laid out below, is used —
211
2.1 Notifiable infectious diseases
This work is normally handled by the Medical Records department, mainly on the grounds of convenience. Some hospital
regulations and standing orders for house surgeons state that it
is the personal responsibility of the house surgeon to supply the
information to Medical Records departments. This is the most
desirable method but it is a counsel of perfection in many cases.
Various systems of checking new admissions are used in New Zealand
ranging from the Enquiry Office Register through to the individual
ward lists. Both systems have advantages and drawbacks but the
important thing is that whichever is used should work. By this I
mean that a new case may be admitted as a pyrexia of unknown origin
(P.u.o.) This case may turn out to be a brucellosis or just an
otitis media. The important point is, however, not to overlook
this case in the space of a few days. Experience has led me to
keep my own system of bring-ups and not to rely on nursing staff
to notify new cases to the office. This latter system may work
quite well until staff changes take place but then it is apt to
break down.
The following system could well be used in a hospital of
medium size.Daily, a perusal is made of all daily admissions
making a note in a book of any likely cases of infectious diseases.
The Ward Sister is then contacted and asked to confirm the
diagnosis. In the case of a positive diagnosis the local office
of the Health Department is rung. It is advisable to confirm,
with the local office of the Health Department that preliminary
telephonic advice is required for notifiable diseases. Where the
diagnosis is in doubt the ward is rung daily until the diagnosis
becomes positive or negative. Some of the larger hospitals adopt
a slightly different arrangement; instead of ringing a ward a
form similar to that shown below is forwarded to the house surgeon
concerned: the form is self-explanatory.
Ifo
14
NOTIFICATION OF DISEASES
1.
Introduction
2.
Diseases notifiable
2.1 Notifiable infectious diseases
2.2 Notifiable diseases other than infectious diseases
2,3 Notifiable diseases under the Tuberculosis Act 191+8
3.
Poisonings
1+.
Occupational diseases
5e
Conclusion
6.
References
7.
Further reading
7.1 Basic
7.2 Background
Appendix A. List of diseases notifiable
Introduction: 1.
Under the provisions of the Health Act 1956, Section 71+ (1),
it is the responsibility of medical practitioners to give notice
of cases of notifiable diseases to the local Medical Officer of
Health and, where applicable, to the local.authority of the
district,
.
Section 71+ (2) of the Act sets out the action to be taken
by the Medical Superintendents of hospitals. In the case of
public hospitals, returns are made weekly on form H.I.D. 6 to
the Department. This form is numbered serially,i.e. the first
return of the year would be 1/67 ending with 52/67 for the last.
Diseases notifiable: 2.
Diseases notifiable change from time to time; the list at
the date given is shown-at Appendix A. Any changes can be
ascertained from the nearest Medical Officer of Health.
jo,
16.2 Background
Quin (M.P.) Those off-beat
abbreviations can mean.
lost time, lost friends
Jnl. AAMRL. Feb. .1961, pp 10,
Gordon (B.L.) Growth of
medical terminology to
meet the day's needs
(review of 'Current
Medical Terminology')
Medical Record News 1 August,
39.
1965, pp 223- 2 4, 226, 233
2$
13
International Classification
of Diseases
Geneva, World Health Organisation, Palais des Nationa,
1957.
Hough (John N.) Scientific
Terminology
New York Rinehart & Co. Inc.,
1953
Durham (Robert H.) An
Encyclopaedia of Medical
Syndromes
New York.-Paul B. Hoeber,
1960
Basic 16.1.
Agee (Mrs. Mary L.) A medical U S A, Dayton, Ohio, Grandstudy guide and reference view Hospital, 1959,
165 +:.'23
Current Medical Terminology American Medical Association,
1966..•.
Davies (Paul M.) Medical London, W. Heinemann Medical
Terminology for Radiographers Books Ltd., 1960
'Guide to the organisation U S A , Chicago, Ill.,
of a Hospital Medical Record American Hospital Assn.,
Department' pp 77-831962, vii + 83
International Study Project:3rd mt. Congress Report,
International Glossary of pp 151-89
terms and definitions . . ,.
(Mostly 'Medical record',
rather than 'Medical'),.. .
Marks, Jean, edit. MedicalNew York, Marks Publishing
Terminology: a handbookService, 1961, viii + 822
for Physicians, Nurses,line ills.
Medical Record Librarians, .. .. .
Medical Secretaries, .
Attorneys, Insurance.
Brokers, Students
Stanton (A.I.) A dictionary.U.S.A., Springfield, Ill.,
for Medical SecretariesThomas, 1960, vii + 175
The ftirtcher Word Book: , U.S.A., Los Angelos, Calif.,
a short cut to understand-Birtoher Corpn., 1962,
ing medical and surgical 32 pp.
terminology
Ui
so that the knowledge acquired will create an ever-increasing
interest in Medical Records.
In recent years, ' medical research has become a most important factor in medical activities in New Zealand hospitals. A
well-trained Medical Records Officer, with a good knowledge of
medical terminology, and the ability to read case notes intelligently, is a great asset to medical men undertaking research
work. Specialists are the first to acknowledge the value of an
experienced layman.
Medical recording work is a worthwhile occupation and the
greater one's experience the greater interest one takes in this
useful work.
With better training facilities and fuller recognition by
medical staff and hospital authorities the more important will
the fully trained Medical Records Officer become, Already the
- demand for trained staff in many of our hospitals cannot be
satisfied. The chances of promotion to other and larger
hospitals for the fully trained Medical Records Officer can be
looked forward to in the near future.
1 5, References
Huffman, (Edna K.) Manual for, U.S.A. Berwyn, Ill.,.Physicians
Medical Records LibrariansRecord Co. 1959
Dorland's Illustrated Medical 23rd Ed. Philadelphia, W.B.
Dictionary Saunders Co. 1957
Harned (Jessie K.) Medical
Terminology Made Easy
Chicago, Physicians Record
Co. 1961
Bollo (Louise E.) Medicine
and Medical Terminology
W.B. Saunders Co. Philadelphia
1961
Roberts (Dr. Ffrangcon), M.A., London, W. Heinmann Medical
Books Ltd., 1954
M.D., F.F.R. Medical Terms
(Their Origin and Construction)
Perkel (Louis Leo) Medical
Terminology Simplified
Springfield, Ill., Chas C.
Thomas 1958
Skinner (Henry Alan) The
Origin of Medical Terms
Baltimore, The Williams &
Wilkins Co. 1949
13
The terms syndrome and disease are often unwittingly used
interchangeably although they are not synonymous.
In general, a syndrome evokes more interest and is more
challenging than a disease because its relationships are more
obscure and its etiology is less apparent. If, subsequently,
a specific etiologic factor ddes become manifest, the condition
should then be reclassified as a disease.
As an example of a relatively common syndrome we may take
purpura. This is characterised by bleeding into the skin and
mucous membranes, and from the body orifices. It is often, but
not invariably, associated with deficiences of the blood platelets0
Purpura is a syndrome which may be caused by a large variety of
diseases ranging from septicaemia to cancer, as well as by the
toxic action of drugs, industrial poisons or x-rays.
Conclusion:it-i-.
The use of medical terms from Latin or Greek may create
difficulties for the beginner, but in many cases it actually
makes for brevity and directness in preparing medical records
and articles. For example "arteriosclerosis", in one word,
conveys the same idea as the more common but longer expression,
"hardening of the arteries", "Infectious hepatitis", "epidemic
hepatitis" and "viral hepatitis" are short ways of sying
"inflammation of the liver due to virus".
It will be seen from the above how necessary it is for a
Medical Records department to keep a well-stocked library
containing books of reference - refer to books mentioned under
heading of References.
The beginner should be encouraged to read all reference
books available at the hospital where he or she has commenced
work. Few Medical Records offices possess any books of
reference other than the odd medical dictionary - a sa3 state
of affairs which should be brought to the notice of all Medical
Superintendents. If good medical recording is required, then
staff should have the tools to work with.
Medical terminology should be the first subject taught
when a person commences work in Medical Records. It will be
seen that medical terminology is largely a heritage from the
past. It is essential that the student makes an early study of
stems, prefixes, suffixes, and the derivation of medical terms
icc
In medicine Bright's disease (chronic nephritis) and Pott's
disease (tuberculosis of the spine) are examples.
A' disease may be named for the place in which it was first
or most importantly or particularly identified, as tularaemia
from Tulare County, California, Rocky Mountain Spotted Fever
was at first thought to be limited to theRocky Mountain areas
but is now known to occur throughout the Western Hemisphere..
12. Synonymous Terms
A single disease may have several names. In fact, this is
the rule rather than the exception, especially when the condition
has been known for a long time. The problem of recognising
synonymous terms is sometimes a difficult one, especially for
the beginner. ..
A condition may be called one thing by certain workers in
certain places, and something else by physicians of other times
and placesIt may be expressed as a lay, term, or in.a more.
learned and scientific fashion. The term brucellosis serves as
an example. This disease ia a generalised infection caused by a,
bacillus, Brucella, named for Sir David Bruce. While.'brucellosis
appears to be the preferred term, there are many other names foz'.
this condition, including, undulant fever, continued fever, Malta
fever, Mediterranean fever, goat fever, and Bruce's septicaemia,
The modifiers "continued" and "undulant" express the fact that the
disease is often chronic and occurs in waves of attacks. The
geographic names indicate that the fever was at first, considered
peculiar to the Mediterranean areas, but we now know that it
occurs in America and other countries. In fact it is quite
common in New Zealand. The name goat fever derives from the fact
that the condition is essentially a disease of domesticated goats,
cattle and pigs, but it can affect a person who drinks the milk'
from diseased animals,
13 Syndrome,
The word Syndrome has been in recognised use since 15 4 1 when
it appeared in Copland's English translation of Galen.
It is usually defined as a concurrence or running together
of constant patterns of abnormal signs and symptoms. A symptom
complex.'
13
Similar Terms:
9,
The following is a short list of medical terms which will
alert the student to the dangers of mistaking these terms for
one another Arthritis
Arteritis
Bronchitis
Br onch io lit is
Carbuncle
C.aruncle
Empyema
Emphysema
Hydatidiform
Hydatid
Hypertension
Hypotension
Ileum
Ilium
Perineal
Peroneal
Spondylolisthe sis
Spondylo iys is
Urethra
Ureter
Operation:
Mastectomy
Mastoidectomy
Keep your medical dictionary handy - there are'many more
medical terms Which appear similar. Never guess
Names of Diseases: 10,
The art of naming diseases has developed along with progress
in all branches of medicine.
Before so much was known of the true causes of disease,
illnesses were Often described in terms of how the patient
looked or acted, and some of these names continue tobe used.
Scarlet fever, yellow fever, smallpox, leprosy ("scaly skin")
and apoplexy ("a striking down or seizure", a "stroke") are
examples.
Eponymic Terms: 11.
Certain diseases are named in honour of the first or early
discoverers or teachers of the theories of those diseases.
Names of persons forming the base of any term are called eponyms,
205
incr.increased or increasing
I.V.P.Intravenous pyelogram
L.F.T.Liver function test
L.M.P.Last menstrual period
M.O.Medical Officer
N.A.D.No abnormality demonstrated
N.E.C.Not elsewhere classified
N.E.I.Not elsewhere identified
N.O.S.Not otherwise specified
O.E.On examination
P.D.Provisional diagnosis
P.D.Patent Ductus
P.H.Past History
Para,Parity (Para. 1, 2 or 3 = number of
children)
PN.
Post natal
P.U.O.
Pyreda of unknown origin
R.B.C.
Red blood count
R.H.D.
Rheumatic heart disease
R. S.
Respiratory system
R.T.
Radiotherapy
S.M.P.Submucous resection
S.O.B.Shortness of breath
T.N.P.N.Total nonprotein nitrogen,.''.
T.P.R.Temperature, pulse rate
Ts & AsTonsils and adenoids
V.D.Venereal disease
V.S.D.Ventricular septal defect
W.B.C.White blood count
is greater than
is less than
13
B/P
Blood Pressure
B. S.
Breath or bowel sounds
B.U.N.
Blood, Urea, Nitrogen
C
with
C.H.D.
Congenital heart disease
c/P.
Complains of
C.N.S.
Central nervous system
C.S.F.
Cerebrospinal fluid
C.V.D.
Cerebrovascular disease.
C.v.s.
Cardiovascular system,
C . Xr.
Chest X-ray
D. & C.
Dilatation and currettage
D.O.A.
Dead on arrival. . .
decr.
diminished or decreased
Diagnosis
disch.
Discharge
E.C.G.
Electrocardiograph
E.E.G.
Electroencephalogram.
E.F.I.
Evacuation for incomplete (abortion)
E.S.P.
Erythrocyte
E.U.A.
Examination under anaesthetic
F.B.C.
Full blood count
F. H.Family history
G.P.I.General paralysis of the insane
G.U.S.Genito Urinary System
Gra y .Gravida (Gra y . 1, 2 or
of pregnancies)
3
= number
Hb.Haemoglobin
H.P.House Physician
H.P.I. .History of present illness
H.S.House Surgeon
M.Rad.(T)Master of Radiology
(Radio - therapy)
M.R.C.P.Member of the Royal College
of Physicians
M.R.C.O,G.Member of the Royal College
of Obstetricians and
Gynaecologists
M.R.C.S.Member of the Ro y al College
of Surgeons
Surgery- That branch of medicine which treats
diseases, wholly or in part, by manual
or mechanical means. (see also
medicine)
Therapeutics
- The science and art of healing.
Thoracic Surgery
- The study and surgical treatment of
diseases of the thorax, inclüding
the lungs, pleura, oesophagus,
mediastinum, and heart.
Urology
- The study and treatment of diseases
of the female urinary system and of
the male genito-urinary system.
Venereology
- The branch of medicine which deals
with venereal disease.
-I. Abbreviations used in case notes
The following are some of the abbreviations used by the
medical staff in writing up a patient's case notes:abd.abdomen
adm.admission
Alim.S.Alimentary system
AN.Ante natal
A.P.H.Ante Partum Haemarrhage.
A.S.Arteriosclerosis
A.S.D.Atrial Septal defect
Ba.Barium meal
B.N.R.Basal metabolic rate
zoo
13
D. 0.
Diploma in Ophthalmology
D.O.M.S.
Diploma in Ophthalmic
Medicine and Surgery
D.P.M,
Diploma in Psychological
Medicine
F.C.Path,
Fellow of the College of
Pathologists
F.C.R.AO
Fellow of the College of
Radiologists of
Australia
F. F. A. R. C
Fellow of the Faculty of
Anaesthetists of the
Royal College of Surgeons
FF.R.
Fellow of the Faculty of
Radiologists
F.R.A.C.P.
Fellow of the Royal Australasian College of
Physicians
F.R.A.C.S.
Fellow of the Royal Australasian College of
Surgeons
F.R. C .O.G.
Fellow of the Royal College
of Obstetricians and
Gynaecologists
F.P.C.P.
of Physicians
F.P.C.S.
of Surgeons
M.Ch.Orth.
Master of Orthopaedic
Surgery
M.C.P.A.
Member of the College of
Pathologists of Australia
M.D.
Doctor of Medicine
M. P. A. C .P.
Member of the Royal Australasian College of Physicians
M.Rad. (D)
Master of Radiology
(Radio - diagnosis)
Pathology
- The study of the modifications of function
and changes of structure caused by
diseases
Paediatric
The study and treatment of children under
14 years,
Pharmacology
The study of the nature and properties
of drugs.
Plastic Surgery
- The study and treatment, by surgical
repair, of diseases and malformations
of the soft tissues, often involving
the transferring of tissues from one
part to another,
Proctology
- The study and treatment of the diseases
of the anus, rectum, and sigmoid colon.
Psychiatry
- The study. of the mind and its diorders.
Radiology
The science of radiant energy and
radiant substances; especially that:
branch of medical science which deals.
with the use of radiant energy inthe
diagnosis and treatment of disease.
Rhinology
- The sum of knowledge regarding the nose
and its diseases.
Specialist
- A qualified medical practitioner who' hs
specialised knowledge and experience in
any of the recognised specialties of
medicine or surgery. This includes
general medicine (Physicians), general
surgery, E.N.T. surgery., Obstetricians
and Gynaecologists, Psychiatrists,
Ophthalmologists, Dermatologists,
Paediatricians, Anaesthetists, Pathologists, Radiologists and Radiotherapists.
Specialists in the above subjects
usually hold one or more of the following postgraduate degrees or diplomas D.0 .P.
Diploma in Clinical Pathology
D.D.M.
Diploma in Dermatological
Medicine
D.L.O.
Diploma in Laryngology and
Otology
13
Pathological (or morbid) histology
-The histology of
diseased tissues.
Medicine
The art and science of healing
diseases by internal remedies.
(see also surgery)
Neurology
The study and treatment of diseases
of the central, peripheral, and
sympathetic nervous systems, except
those which require operative
treatment.
Neurosurgery
The study and treatment, by surgical
measures, of diseases of the
central, peripheral, and
sympathetic nervous systems.
Obstetrics
The study and treatment of women
during pregnancy, labour and the
puerperium . - (the period or state
of confinement, after labour)
Occupational
Therapy
The teaching of patients useful
occupations, such as weaving,
printing, knitting, basket-work,
etc. for remedial purposes.
Odontology
The sum of knowledge regarding the
teeth; dentistry.
Ophthalmology
The study and treatment of all
diseases of the eye and its
supporting structures.
Orthopaedics
That branch of surgery which deals
with the correction of deformities
and with the treatment of chronic
diseases of the bones, joints,
muscles, fasciae, tendons, and
their nerve control.
Otology
The study and treatment of the ear
and its diseases.
Part-time VisitingStaff: (sometimes
erroneously referred
to as 'Honoraries')
Appointments made by the Hospital
Board of specialists to part-time
positions (designated in 'tenths'
of a 35-hr week) entitling them
to beds in the hospital.
Bacteriology- The science which treats of bacteria.
Bacteriology as a term is becoming
replaced by "Microbiology", which
more correctly covers the microscopic
parasites and the viruses as well as
bacteria,
Cardiology
Cytology
- The study and treatment of the cardiovascular system and its diseases.
The scientific study of cells, their
origin, structure, and functions.
Exfoliative cytology is the diagnostic
study of cells which have desquamated
(become detached) from the external
or internal surfaces of the body as a
means of detecting cancer, estimating
the influence of hormones, and
determining sex, etc.
Dermatology
- The study and treatment of the skin
and its diseases.
Dietetics
- The science and regulation of diet.
Endocrinology
- The study and treatment of the glands
of internal secretion.
E.N.T.
- The study and treatment of diseases of
ear, nose and throat.
Gastroenterology- The study and treatment of all diseases
and conditions of the digestive
system except the anus, rectum and
sigmoid colon.
Geriatrics
- The study.and treatment of diseases
of old age.
Gyna eco logy
- The study and treatment of the diseases
of the female generative and urinary
organs.
Haematology- That branch of biology which treats of
the morphology of the blood and
blood-forming tissues.
Histology- That department of anatomy which deals
with the minute structure, composition
and function of the tissues. Called
also microscopical anatomy.
Normal Histology The histology of
normal tissues.
"I
13
another directly or indirectly.
Contagious Disease- One communicable by contact with an
individual suffering from it, or'by
contact with an object touched by
him.
Infectious Disease- One due to an infection caused by
parasites, such as bacteria, protozoa,
or fungi; it may or may not be
contagious.
Follow-up
-. The periodic examination of a patient
following disease or injury to
determine the progress being made
toward complete recovery and normal
health and to study end results. In
cancer cases "follow-up" can also
have a meaning in establishing that
the patient is still alive and
symptom free with no further need for
medical examination.
Legal Liability
Responsibility
. before t law for
reasonable care of patients and for
reasonable maintenance of facilities
for that purpose.
Medical Social
- Most hospitals employ Medical Social
Services
Workers for the sociological investigation of a patient and his environment tb ascertain any factors which
might have a bearing on the diagnosis,
treatment and after care of the
patient.
Postmortem Examination
Autopsy, NecropsyThe scientific examination of the body
after death to determine the direct
and indirect or contributory causes of
death through a study of the physiologic, histologic, and pathologic
examination of the organs of the body
and their structure.
Prognosis- The estimation of the probable course,
duration, and outcome of a disease.
Department of
- For the study of anaesthesia and
Anaesthesiaanaesthetics.
SuffixMeaningExamples
-pexyFixation ofurethropexy, orchidopexy,
gastropexy
-plastyRepairarthroplasty, oophoroplasty,
oesophagoplasty
blennorrhagia, metorrhagia,
Burst forth
-rrhagia
menorrhagia
herniorrhaphy, perineorrhaphy,
Sewing of
-rrhaphy
colporrhaphy
diarrhoea, menorrhoea,
Running from
-rrhoea
pyorrhoea
anuria, glycosuria, polyuria
Urine
-uria
5.
Spelling
The spelling of medical terms varies in different medical
dictionaries. English dictionaries usually use the Greek and
Latin spelling,-e.g. haemorrhage, diarrhoea, haemorrhoids, etc.
American usage differs from the English in such respects as
reversal of P and E, for instance fiber for fibre. The English
fibre is strictly correct.Again American spelling Of examples
shown above, e.g. hemorrhage, diarrhea, and hemorrhoids show the
suppression of a and o in the diphthongs ae and oe. However, in
New Zealand in most cases we remain loyal to the original Greek
and Latin spelling.
Probably the best all-round dictionary for use. in a medical
records department is the American Illustrated Medical Dictionary
by W.A. Newman Dorland which gives both the American and English
spelling of medical terms. The intelligent use of a good
medical dictionary by medical records staffs is essential for
accurate coding and classification of diseases.
6.
Hospital terms
The following are some of the terms most commonly used -
Normal Nursling- A normal infant born in hospital.
Communicable Disease - One whose causative agents may pass
or be carried from one person to
'ft
13
Prefix
Meaning
pyo-
Pus
Suffix
Meaning
- a e mi a
-coele
Blood anaemia, uraemia, leukaemia
Hernia rectocoele, hydrocoele,
meningocoele
Skin
neuroclernia, scieroderma,
xerodermna
Excision
gastrectomy, lobectomy,
mastectomy
Inflammation
appendicitis, bronchitis,
otitis
Science of
biology, cardiology, psychology
Mass
carcinoma, haematoma, lipoma
Examining
broiichoscopy, gastroscopy,
sigmoidoscopy
Make opening
colostomy,, nephrostomy,
into
i leo s to my
Cut
hysterotorny, laparotomy,
valvotomy
Examples
pyoderma, pyogenic, pyenephrosis
retro-
Behind retroperitoneal, retroposition, retroversion
sub-
Under subcutaneous, subarachnoid,
submaxillary
supra-
Above suprarenal, suprapubic,
supracondylar
tachy-
Rapid. tachycardia, tachylalia,
tachypnoea
thronibb- Clot
thrombosis, throniboarteritis,
thrombophiebitis
vaso-
Vessel vasoconstriction, vasodilation, vasovagal
-derma
-ec tomy
-itis
-010 gy
-oma
-oscopy
- Os t omy
-0 to my
Examples
PrefixMeaningExamples
neo-Newneonatal, neoplasm neothalamus
nephr-)
Kidneynephritis, nephrosclerosis,
nephro-)
nephrectomy
neur- )
neuro-)
Nerveneuritis, neurology, ,neuralgia
Ophthalm- )
Ophthalmo-)
ophthalmia, ophthalmodynia,
Eye
E
ophthalmoplegia
ortho-
Straightorthodontic, orthopaedic,
Correctorthostatic
osteo-
Boneosteomyelitis, osteotomy,
Os t e ama
at- or oto-
Ear
otitis, otologist, otorrhoea
pan-
All
panhysterectomy, panosteitis,
panophthalmia
para-
Beside,
Beyond
paracentesis, parametriuni,
paravertebral
pen-
Around
periapical, periarteritis,
pericarditis
phieb- )
phiebo-)
Vein
phlebitis, phlebothrombosis,
phlebotomy
p n e u mo -.
Lungpneumonia, pneumothorax,
pneumococcal
p-
Many or muchpolyarthritis, polycythemia,
polyuria
post-
After orpostpartum, postauricular,
Behindpostmenopausal
pre-
Beforepreauricular, precordial,
preeclamptic
proct- )
procto-)
Rectumproctocoele, proctoscopy,
proctospas m
pseud- )
pseudo-)
False, orpseudoarthrosis, pseudoSpuriouscyesis, pseudomucinous
psych- )
psycho-)
Of the mind
pyel- )
pyelo-)
Pelvis orpyelitis, pyelogram, pyeloKidneycystitis
psychoneurotic, psychoanalysis, psychopathology
13
enter- )
Intestinesenteritis, enterocentesis,
entero-)
enterostasis
erythro- .Rederythroblast, erythrocyte,
erythrodermatitis
extra-Outside ofextradural, extramural,
extrasystole
fibro-Fibrefibroma,, fibrositis,
fibromyositis
gastr- )
Stomachgastritis, gastro-enteritis,
gastro-)
gastroscopy
haem- )
haemo- )
Bloodhaernatoma, haematology,
haemato-)
haematopoietic
he mi One half . hemianopsia, hemiplegic,
•hemisphere
hepat-)
hepatitis, hepatomegaly,
hepato- )
Liverhepaticotomy
hepatico-)
hydro-)
hydr- )
I1I
Water
hydrocarbon, hydrocoele,
hydrocephalus
hyper-
Above,
excessive
hyperemesis, hypertension,
hyperpyrexia
hypo-
Under,
deficient
hypochondrium, hypodermic,
hypotension
infra-
Below
infraduction, inframarginal,
infrapatellar
inter-
Between
.interauricular, interphalangeal, intervertebral
intra-
Within
intra-atrial, intracranial,
intra-orbital
leuko-
White
leukocyte, leukodermia,
leukoplakia
myel- )
myelo-)
Marrow
Spinal cord
myeloma, myeloid, myeloblastoma
my- )
my o -)
Muscle
myoma, myocarditis, myotonia
bi-)
bin-)Two or twicebifocal, binocular, bisacromial
bis-)
bio-Lifebioloy, biomedicine
biosynthesis'
brady-
Slow
bradycardia, bradyplasia,
bradypnoea
cardio-
Heart
cardiology, cardiogram,
c ardioven al
chol- )
chole-)
cholo-)
Bile
cholangitis , cholelithiasis,
cholochrome
chrom- )
chromo- )
chromato-)
Colour
chromocyte, chromosome,
chromatophobia
cr an io -
Skull
craniotomy, craniomalacia,
craniospinal
cyano-
Blue
cyanoderma, cyanotic,
cyanuria
cysto-
Bladder
cystitis, cystoscopy,
cyanuria
cyto-
Cell
cytobiology, cytogenetic,
cytology
derma- )
dermato-)
Skin
dextro-
Right
dextrocardia, dextrogastria,
dextroposition
di-
Twice
Double
didactylism, dioxide,
diphonia
dys-
Difficulty
Painful
dysentery, dymenorrhoea,
dyspnoea
encephalo-
Brain
encephalocoele, encephalitis,
encephalogram
end- )
end o -)
Within
dermatitis, dermatophytosis,
dermatology
endocarditis, endocrine,
endometrium
13
is called appendicectomy? The "ectomy" terminal of the word is
from the Greek to "cut out", or "excise". Another example:
tonsillectomy - removal of tonsils. Having once learnt the
meaning of the terminal "ectomy", students will know firstly
that it applies to an operation and that a patient has had a
partial or complete removal of an organ.
Stems:
3.
" In medical terminology we are concerned mainly with the
'stems' of words, the forms to which inflectional endings,
suffixes, and prefixes may be added. By learning the meanings
of the important stems, suffixes and prefixes and by analysing
medical terms into their component parts, the meanings of many
terms become quite obvious, and the study of medical terminology
becomes a fascinating subject even for those who have no
previous knovtr ledge of Greek or Latin.
Let us take the word 'endocarditis' to illustrate this.
In this word the stem is 'cardi', from the Greek kardia, heart;
the preceding 'endo', the connective form of the Greek endon,
within, is the prefix; and 'itis', from a Greek adjectival
termination which has come to denote inflammation of. the part
indicated by the noun to which it is attached, is the
suffix. Hence 'endocarditis' signifies an inflammation of the
endocardium (the epithelial lining membrane of the heart). "
Prefixes and suffixes: +.
The following is a list of prefixes and suffixes PrefixMeaningExamples
a- (or an-)Without or notasocial, atresia, anencephalic
ab Away from
abduct, aberrant, abnormal
aden- )
Gland
adenitis, adenoma, adenocarcinoma
adeno-)
'sq
ante-
Before
antenatal, antepartum,
antecubital
anti-)
ant- )
Against
anticoagulant, antihistamine,
antiseptic
arthrarthro-)
Joint
arthritis, arthrodesis,
arthrolgia
2. The principles of derivation
At this stage I could do no better than quote from a very
useful little book written by Dr. Ffrangcon Roberts, M.A.,
M.D., F.F.R., "Medical Terms, Their Origin and Construction".
Dr. Roberts in the following lines illustrates so simply the
origin of many words in daily use in all our hospitals:
"Innumerable names are derived from resemblance to"buildings,
animals and plants or their parts, to musical .instruments,
articles of adornment, agricultural implements, tools and
weapons.
In order to illustrate the derivation of names from surrounding objects we may reflect upon domestic life, in GraecoRoman times. An open space for assembly or marketing was
called agora (hence agoraphobia, .fear of open spaces). An enclosed
space, 'if large, was called claustrum (claustrophobia, fear of
being shut in) and, if small, areola •(areolar tissue,i.e... tissue
of small spaces). . In a house the vstibuium led into the atrium
(to us synonymous with auricle). This may have been so called.
because it had a fire in the middle of the room and therefore
had blackened walls (ater black). An inner room or bedroom in
Greece was called thalmos, a term applied by (4alen .to the':in'ner
chambers of the brain. A wall or partition was called phragma
(hence diaphragm). The fireplace was called focus, hence the
modern meaning - centre of heat and light. A beam (in the roof)
.was called trabs, dim. trabeculum. Passages were called fauces.
Outside there would be via, road, fornix, arch, stylos, pillar
(styloid process). Water was conveyed by a ductus,, .fossa (ditch),
fistula(pipe), or cloaca (sewer). A large house would have a
fountain, fontana, in the court, hence fontanelle (dim. through
French), so called from the pulsation resembing bubbling.
Examples of musical instruments are salpinx, 'trumpet,
tympanum, drum; of articles of adornment, fib'ula, brooch; of
agricultural implements a vomer, ploughshare; of tools, malleus,
hammer, incus, anvil; of weapons, ensis, sword, (ensiform,
sword like).
The above examples by Dr. Roberts are sufficient to show the
strong Greek and Latin influence in medical terms.
Most laymen are familiar with the word appendix, but few would
know it is an appendage of the 'caecum. How many know that appendicitis is an inflammation of the appendix? Many people talk,
about having their appendix "out"How many know this operation
'SI
MEDICAL TERMINOLOGY
1,
Introduction 2,
The DrinciDles of derivation
odo
3 e Stems
1, Prefixes and suffixes
50 Spelling
6, Hospital terms
70 Names of Specialties met with in larger hospitals
8 Abbreviations used in case notes
9, Similar terms
100 Names of diseases
110 Eponymic terms
12 Synonymous terms
17Syndrome
11+, Conclusion
15,
References
16,
Further reading
16.1 113a&c
16,2 Background
Introduction: 1.
In an attempt to help the student Medical Records Officer to
understand something of the origin and meaning of medical
terminology, this chapter must necessarily be kept within
reasonable limitsSo I propose to write on the more elementary
aspects of the subject to enable the student to gain some
knowledge of what his or her work in a Medical Records Department will entail.
The newcomer to medical records must remember that most
medical terms have been derived directly or indirectly from
the Greek and Latin, and we are concerned here mainly with
terms of those language origins.
International Classification of Diseases, Adapted -.U.S.
Department of Health Education and Welfare
7. Further reading
7.1 Basic
Loy (Ruth M.) A code of surgical
operations
pp 28-31
7.2 Background
MacEachern (M.T.).Medical Records
in the Hospital, pp 230-33
1937, xvi374 illus.
4.
12
Summary;
5.
(i) All hospitals should keep a list of classified operations.
The necessity for a hospital to keep aclassified index of
operations may be seen from the fact that in Wellington
Hospital over a twoyear period ehare been asked to produce records for the following operations: Gastrectomy
for malignant and non-malignant condition, appendicectomies
for appendicitis with peritonitis,-vascular surgery,
adrenalectomjes, to mention but a few. We have also been
asked how many operations such as craniotomies etc. have
been performed over a given period,
(ii) How this list is kept is mentioned elsewhere in this
manual as here we are only concerned With the actual coding.
While the "Code of Surgical Operations" may seem difficult
to apply, in reality the coding process is exactly the same
as that applied to the disease from the International Classification of Diseases,
(iii) The "Code of Surgical Operations", in spite of some shortcomings, has been in use for operation coding in the
Wellington Hospital for fifteen years and is recommended
for use in all hospitals as it is well suited to New
Zealand conditions.
(iv) Operations may be classified alphabetically but this method,
while simple, can lead to trouble.
(v) "The Code of Surgical Operations" being based on a
uniform pattern throughout and also being based on a
decimal system allows of ready expansion by additional
digits to meet local needs.. The same can be said for
I.C.D.A. which has the additional merit of corresponding
to the International Classification: of Diseases. Also
included are the classification of Radiotherapy and
Anaesthetic procedures.
Referenced:
Hospital Organisation and Management - (Stone)
Manual for Medical Record Librarians - Huffman
The Code for Surgical Operations - H.M. Stationery Office,
London
6.
k, Operation details on MS18 statistical cards
Operations should always be entered .on the MS18 at the same
time as the diagnosis.
As far as possible the use of the term Laparotomy should be
avoided if other surgery was performed at the same'time An
example of this has been the recording of the term Liaparotomy
where the diagnosis was recorded as ectopic pregnancy. On reading
the operation record we find the procedure given as Laparotomy
and removal of ectopic pregnancy. It is therefore necessary to
ensure that the surgery carried out is recorded on the case notes
and also on the MS18 card with , certain exceptions as below.
As in accordance with the Hospital .Statistioe. Handbook,
certain terms are not to be marked as operations it has been found
that there is no point in coding these as operations. The list.
includes 1. Any term ending in -oscopy
2 4 Laparotomy (see above)
3. Episiotomy
k, Diagnostic procedures e.g. biopsy, lumbar punctures
5.
Washouts and aspirations
6.
Insertion Radium
7, E.U.AO
8.
X-ra y and dee p x-ray
9.
Exploration sinuses
10.
Application of plaster
11,
Injections
12,
Dressing burns
13.
Dilatation strictures
14.
Orthopaedic manipulations (other than open fractures
and elevation of fractures)
The operation of removal of Ts and As need not be coded for
the operation index as it will be shown in the disease index as
510,1 with tonsillectomy or 510.0 without tonsillectomy.
When in doubt about any coding, always ask for advice from
the Registrar or the surgeon who performed the operation.
AO
"4'
12
40Repair of hernia
+O.O Repair of inguina]. hernia except recurrent
4001 Repair of recurrent inguinal hernia
402 Repair of femoral hernia except recurrent
4o. 3 Repair of recurrent femoral henia
'+0.1+
Repair of epigastric hernia
4o. 5
Repair of ventral or inc . isional hernia
1+0.6
Repair of, umbilical hernia
4o.7
Repair of diaphragmatic hernia, abdominal approach
1+0.8
Repair of diaphragmatic hernia, thoracic approach
Other hernia repair
The alphabetical index is very compléteandit . js interesting
to note that no eponymic terms are used.
Another interesting feature, and in fact a ',. very desirable
feature, is the proyision of inclusion and exclusion notes as in
the International Classification of Diseases.An example of
these notes is the operation enteréctorny, Code. 4603.. the
inclusion and exclusion notes inthe Tabular List reading Enterectomy1+6.3
includes:Caecectomy
Duodenectomy
Enterectomy, N.O.S.
Ilectomy.
etc.
excludes:Colectomy (1+6.1+)
Diverticulectomy (1+6.2)
Gastroduodenectomy (44,2)
etc.
This code of operations, following closely 'along the lines
of the International Classification of Diseases, has much to
commend it.
The code will be found in two volumes of the International
Classification of Diseases, Adapted, Volume 1. Tabular List, and
Volume 20 Alphabetical index, published by the United States
Department of Health Education and Welfare, 1962,
1s
example, skin graft 942, but if the skin graft is after the removal
of a breast it is coded to 385. In fact, thea Index should be consulted always until the coder is wefl . con-versant with the code
numbers. The reason for this is that there are no inclusion or
exclusion notes as given in some sub-titles of the International
Classification of Diseases. A further example of the necessity
of checking the Index is the coding of the operatior Dilatation
and Curettage (D. & C.); there are two codes for-this procedure
as will be seen from the Index which reads Dilation:
Cervix:
Obstetrical.789
non-obstetrical - 732
Another example is the operation of-Hysterectomy:
Hysterectomy:
abdominal- 722
partial.- 721
radical- 723
with ealpingo-oophorectomy - 721
In brief, to code operations it is simply a matter of looking
up the Index to get the number making sure that the number chosen
fits in with the operation, as shown in the above examples.
It is not recommended that an operation code number be recorded
on a list as a means of remembering a code number as this often
leads to a case of "familiarity breeding contempt". It will be
found that once the coder becomes acquainted with the coding manual,
code numbers will be readily remembered but it is always a good
policy to consult Parts 2 and 3 of the manual-as described above..
3'International Classification of Diseases, Adapted'
(I.c.D.AJ
Although no practical application of this code has been made
by the writer, it appears tohave some advantages, over the Code of
Surgical Operations but instead of using three digit categories,
• two •digit system is used with the addition, where necessary, of
• decimal point, e.g. operation for a repair of hernia is coded
as ko with the following sub-divisions
I,z
12
Trendelenberg ' (varicose, vein)
Ramstedt'(correction of'congenital pyloric stenosis)
Wertheim(radical hysterectomy).
Bassjnj. (radical cure o' inuinal hernia.)
Gilliam,(ventro-suspension of uterus)
Suffixes: 2.3.
Some examples of suffixes indicating surgical procedure which
may be of value 'when coding are:
-ceitesis
- a punctuze or aspiration, a "pricking", e.g.
abdomino centesis - puncture of the abdominal
cavity for aspiration of fluid..
-desis
- a fusion or stabilisation - arthrodesis -. fusion of
a joint by removing the articulate surface and
securing bony union.
-ectomy
- excision, remove or cutting out, e.g.appendicectomy,
removal or appendix (code k'+i), nephrectomy,
removal of kidney (code 605),.
-lysis
-
-, st omy
-
-otomy
- a cutting or an incision. Nephrotomy - incision
into the kidney.
-plasty
- a forming or repair ,f plastic surgery, e.g.
Phinoplasty - plastic operation on nose (code 217).
-rrhaphy
- a stitching or suturing, e. g. Herniorrhaphy suture repair of hernia.
a loosening or freeing - Tenblysis - freeing of
adhesion of tendon (code 869)
denotes the making of a mouth e.g.'proctostomy,
the making of an artificial opening in the rectum.
Coding of operations: ,2.4.
Until certain where a' given operation is coded in the
Tabular List, (Part 2) it is advisable to refer to the Index (Part 3) of the "Code of Surgical Operations" first and then to
look in the Tabular list to get an idea of the contents of each
section and its layout. Failure to consult the Index first may
lead to the wrong code being given to the operation as, for
'SI
002. Leucotomy
Lobotomy
T opec to my
Tractotomy:
medulla oblongata
mesencephalon
2. 930 Incision and Drainage, Superficial
Exploration:
sinus tract
wound (operative)
Incision (and drainage):
abscess
N.O.S.
skin
boil
carbuncle
cellulitis
cyst:
N. 0.S.
pilonidal
skin
gangrene of skin
scar (skin)
ulcer:
N.O.S.
skin
unspecified
In each of these examples the use of the parentheses ( ) and
colons (:) and of the term N.O.S. (not otherwise specified) should
be noted. These have the same meaning and use as in-the International Classification of Diseases.
2.2 Eponymic terms
With some exceptions these have been avoided but those
included are provided for in the Index. Some examples of eponymic
terms used in the code are:
Biliroth(partial gastrectomy)
Caldwell Luc(Antrostomy)
Fothergill(correction of uterine prolapse)
Keller(correction of hallux valgus)
12
9.
10.
1+00 - 599
Gastro-Intestinal and Abdominal Surgery
Genito-Urinary Surgery
600 - 699
Gynaecological Operations
11,
Obstetric Operations 12.
Orthopaedic Surgery
760 - 799
800 - 899
13.
Operations on Peripheral Blood Vessels
and Lymphatic System 900 - 929
14.
Operations on Skin and Subcutaneous Tisues 930 - 91+9
Other Surgical Procedures 950 - 999
8,
15.
700 -
759
These fifteen main sections comprise Part I -List of three
digit categories of the code, and each main section is further
divided into a number of groups or sub-groups as necessary to
give more precision to the site, as fOr example 1. Neurosurgery (001 - 01+9) which is divided into:
Brain and Cerebral Meninges (001 - 019)
Spinal Cord and Spinal Meninges (020 - 029)
Peripheral Nerves and Sympathetic System '(00 - 01+9)
This order of arrangement of the three figures within each
group is broadly: Incision, Drainage, Local excision, Plastic
operation and other operations.
The Tabular list of Inclusions finds each section broken
down still further as will be seen from the following examples:
1. NEUROSURGERY (001 - 01+9)
Brain and Cerebral Meninges (001 - 019)
001. Craniotomy
Craniéctomy
Craniotomy
Decompression:
Brain
Cranial
Exploration of Cranium
Trephinatioñ (cranial)
171
Another classification of operations has been compiled in the
United States. This is an adapted version of the International
Classification of Diseases as at present used in New Zealand and
its title is "International Classification of Diseases, Adapted"
orAs well as diseases, it contains a tabular list of
operations in Volume I and in an index in Volume 2. The fact
that it can be used in conjunction with the International Classification of Diseases makes it worthy of consideration for hospital
classification and operation coding. It is further described below,
2. 'Code of Surgical Operations' Manual
This Code of Surgical Operations was first issued in a draft
form in 1950 and prepared for circulation and trial in certain
hospitals and a number of statistical offices in the United Kingdom. The draft code was based on "The Basic Diagnostic Manual of
Diseases and Injuries" prepared for use by the Medical Services of
the United States Armed Forces. Later the code was issued for
general use by the General Register Office after suggestions. and
improvements from various sources had been included. This Manual
has been in use in Wellington Hospital since 1952 and has proved
successful for the purpose of classifying operations. It is simple
to use and has the advantage of being built on a uniform pattern
throughout, and also, being based on a decimal system, it allows of
ready expansion by additional digits to meet local, needs.
2.1 The structure of the operation code
The operation code is referred to the two axes of site and
operative procedure and employs a three figure classification.
It is divided into 15 main sections according to the broad anatomical site of the operation or the surgical specialty, to each
of which is allotted a series of numbers. These 15 main sections
and code numbers are code 001 - 049
1, Neurosurgery
070 - 099
2. Operations on Endocrine System
100 - 199
3. Ophthalmic Operations
200 - 24-9
. Operations on Ear, Nose, Throat
5.
6.
7.
Operations on Buccal Cavity and Oesophagus 250 - 299
Thoracic Surgery
300 - 379
380 - 399
Operations on Breast
fly
12
THE CLASSIFICATION OF OPERATIONS
1. Introduction
2, 'Code of Surgical Operations' Manual
2.1 The structure of the operation code
2.2 Eponymic terms
2.3 Suffixes
2.4 Coding of operations
3.International Classification of Diseases, Adapted (I.C.D.A.)
1, Operation details on MS18 statistical cards
5.
6,
7.
Summary
References
Further reading
7.1 Basic
7,2 Background
Introduction: 1.
As with diseases it is frequently necessary for Medical Records
staff to produce case notes for research or study purposes on different types of operations performed. Two methods are open to
produce such records:- (1) By referring to the Operation Register
kept in the theatre, or, .(2) by referring to the classified Index
of operations kept in the Medical Records department. This can be
kept either on a yearly or perpetual basis. Except perhaps in
smaller hospitals the first method would prove to be an extremely
inefficient way of doing such a task and in the case of a large
hospital practically a hopeless one.
The classification of operations can be carried out in two
ways, one by classifying the operation alphabetically and the other
by using a classification manual similar to the International
Classification of Diseases. Whilst the first method would operate
satisfactorily for a small hospital, it is not one to be recommended
for general use as there are too many pitfalls and classification
can be somewhat perplexing at times especially with eponymic terms.
An ideal classification is one which follows close to the International Classification of Diseases, and this classification will
be found in the manual "The Code of Surgical Operations" published
by H.M. Stationery Office, London.
117
MacEachern (M.T.) Medical
Records in the Hospital,
pp 209-15
1 937, xvi + 371+ illus.
Morgan (J.H.) Medical Records
Departments: the Cardiff
Royal Infirmary
Medical Record, April
1951, pp 90 - 5
Background: 52
liv
Doran (M.T.) The need for
research in Medical Recording
methods
pp 129-1+1
Expert Committee on Health
Statistics 8th Report, W.H.O.
Technical Report Series,
No. 261
Geneva, W.H.0., 1963, 31+ pp
'Hospital Records Systems in
relation to the Statistical
Classification of Diseases
treated in Public Hospitals'
N.Z. Hospital, Sept. 1948,
pp 23-9
Kurtz (D.L.) Examples of
methods
pp 11+3-57
Lincoln (Helen B.) Disease
classification for diagnostic
indexing
pp 53-7
Hospitals
N.S.W. Hosps. Commn0
1960, 54 pp
(v)
Until certain where a given disease is coded in the
International Classification first refer to the Alphabetical Index. As one becomes familiar with the
Classification, the Alphabetical Index will be used
less frequently but it is not advisable to guess where
a specified condition will be classified.
(vi)
Look upon the Index only as a key to the 'Tabular List.
The greatest help in successful coding is given by the
inclusion and exclusion notes which are to be found
under the titles in the Tabular List.
(vii)
Code suspected diagnoses as if they were certain.
(viii)
Never make up a list of code numbers to be memorised
or to refer to.
(ix)
Coding should only be done when a final diagnosis is.
known.
k.References
International Classification of Diseases Volumes 1 and 2
Manual for Medical Records Librarians - Huffman
Hospital Organisation and Management - Stone
Hospital Statistics Handbook - N.Z. Health Department
5.
Further reading
5.1 Basic
Brown (R.J.) Disease classification
(Dunn, Baehr, Felton & Winfield)
Principles of selection and use
of morbidity and mortality
classification
1st mt. Congress Report
pp 59-74•.
2nd mt. Congress Report
pp 8Li_112
I.C,D.A: answers to
queries on
Medical Record News,.
August 1964, pp 162-4
and subsequent issues
Ingram (Prof. J.TJ Clinical
approach to the nomenclature
and classification of
diseases
3rJ.
mt. Congress Report
pp 274-84
'75-
11
Read the inclusion as well as the exclusion notes under
each number. As an example of this take the coding of
Keratitis 371+, which includes several types but excludes many
others.
If one condition is symptomatic of another then the rule
is to code the underlying cause e.g. a diagnosis of retention
of urine caused by prostatic hypertrophy - code prostatic
hypertrophy and disregard retention of urine.
Further rules for coding will be found on pages 16 and
of the Hospitals Statistics Handbook.
17
The coding or classification of diseases cn be a
frustrating or often perplexing business, and correct coding
calls for well written records, correct diagnoses and
intelligent use of the International Classification of
Diseases. For new or strange diseases, it is advisable to
refer such a diagnosis back to the initiating medical officer
for a suggested code number.
It is important that MS18 statistical cards are carefully
handled since damage will prevent them going through the IBM
machine. This is referred to in the Hospital Statistics
Handbook (page 19).
Summary:
(i)
An accurate study of disease treated in a hospital
cannot be made unless a classification of diseases
is carried out. Such classification or coding can
be carried out in all hospitals by using the
International Classification of Diseases.
(ii)
Medical Records staff should not diagnose. Never
use provisional diagnosis when a final diagnosis
is available.
(iii)
(iv)
17t
Avoid the use of incomplete or vague terms.
The numerous notes and cross references in the
Tabular List of Inclusions and the four digit
sub-categories in Volume 1 help the coder to
understand the general principles and methods
of classification underlying the code.
3.
Neuritis- state nerves involved and cause, e.g.
alcoholism.
Oesophageal stricture - state cause if known and whether acquired
or congenital.
Salpingitis
- state whether acute, chronic, tuberculous, whether followiig abortion or
childbirth.
Aneurysm
- state whether aortic, arterial, arteriovenous, or cardiac, whether syphilitic
or not.
Arthritis
- state whether acute, pyogenic, acute
infective, non-pyogenic, rheumatoid
arthritis or osteo-arthritis etc.
Bright's Disease- state whether acute, subacute, chronic
nephritis and cause if known. If
arising during pregnancy this fact
must be noted,
Cellulitis- state cause if known and whether
associated with lymphangitis.
Colic- state whether intestinal, biliary or
renal.
Dementia.- this term should not be.used
unqualified when coding. State the
disease or type of dementia e.g.
epileptic, praecon, presenile, senile
etc.
Eclampsia
- when did fit occur? e.g. before onset
of labour, during labour, or after
delivery.
Glioma
- state site, histology if known, and
whether benign or malignant, if unknown.
then state this fact.
2.9 General
When looking through both volumes of the International
Classification, the use of abbreviations, symbols and parentheses
along with age abbreviations, must be understood and references
to these will be found in the introductions to Volumes 1 and 2.
When coding look consistently in the Index under the disease
or condition and not the site,
ri
11
For coding poisonings by a drug under a proprietary name,
it is good policy to ask at the Pharmacy the nature of the drug.
Late effects of injury, poisonings and violence are brought
together under E 960 - 965 where the late effect is one year or
more after recurrence. The date of accident should always be
shown.
Always state as fully as possible how and where the accident
occurred as the information recorded on MS18 statistical cards
is the principle source for accident statistics in New Zealand.
If the place or cause is not known, use the term "N.O.S."
Coding of adverse reactions to injections, infusions etc: 2.7.
Code numbers for adverse reactions along with inclusion and
exclusion notes will be found on pages 33 0 -333, Volume 1.
Incomplete diagnoses or terms: 2.8.
A list of incomplete terms or diagnoses appears on page 20
of the Hospitals Statistics Handbook. The additional information
needed to code the term satisfactorily will be found' to the right
of each term.
A few more incomplete or undesirable terms are given below
together with further information required to .give a satisfactory
code number
Abortion- was it with sepsis? Was it therapeutic,
incomplete, complete or threatened?
Anaemia- state type if known; if not known the
diagnosis to be coded should read
Anaemia N.O.S. (not otherwise
specified)
Hepatitis- state whether infective, serum or
associated with pregnancy.
Laryngitis- state whether acute or chronic (note
acute laryngitis is coded 474, chronic
laryngitis is coded 516). State also if
due to infection e.g. syphilitic or
tuberculous etc.
Leukaemia- state type e.g. lymphocytic, myeloid,
monocytic.
172
Falls (accidental)
Other accidents
Complications due to non-the rape utic
medical and surgical procedures
Therapeutic misadventures and late
complications of therapeutic procedures
Late effects of poLsonings and injury
Suicide and self inflicted injury
Homicidal and injury purposely inflicted
by other persons
Injury from war operations
E 900 - 904
E 910 - 936
E 9+0 - 946
E 950 - 959
E96O - 965
E 97 0 - 979
E 980 - 985
E 99 0 - 999
Before actual coding is commenced, it is again necessary to
read through the section on 'E' coding to obtain a general
background and the layout.
An alphabetical index is given in Volume 2. on pages 4.70-510
plus an alphabetical index to place of occurrence of nontransport accidents on pages 511-512.
The place of occurrence should be shown by the fourth digit
for injuries etc. coded under numbers E 870 - 936. The fourth
digit classification will be found on pages 264-266 Volume 1 as
well as in Volume 2 as above.
Examples of the 'E' Code using 4th digit
Burnt in fireat homeE 916.0
Bitten by dogat farm926.1
Cave in of earthquarry910.2.
Caught hand in machineryat factory912.3
Fall from "jungle jim"school ground902.4
Fall on footpathstreet903.5
Cut hand with knife
while cutting meatbutcher's shop913.6
Fall same levelhospital903.7.
Exposure to coldon mountain9328
For all other I E I code numbers use X e.g. E 979X. For
example:suicide, by jumping in front of a train E 979X..
For all poisoning cases the coding must be qualified by the
term accidental or suicidal as these are different codes: e.g.
Nembutal poisoningAccidentalE 871
Nembutal poisoningSuicidalE 970
171
11
In coding fractures, a fracture dislocation should be coded
to the bone involved in the fracture. Occasionally when cQding
orthopaedic diagnoses, the term fracture of condyle, fracture of
ramus etc. is used. These terms merely indicate the portion of
the bone fractured and are not the names of the bones involved.
When coding pathological or spontaneous fractures it should be
remembered that they must be coded to the condition causing the
fracture (e.g. metastase.s of neoplasm, multiple myeloma etc.)
The following example is taken from the Hospital Statistics
Handbook, page 16:
A patient with osteitis deformans fractures his femur in a
fall at home.
Disease A is coded 73 1 X (osteitis deformans)
Disease B is coded N821X
along with the appropriate accident code.
When looking up a single fracture in the Index, make sure
that it is a single fracture site and not 'fractures multiple'.
The instructions at the beginning of each chapter and the
inclusion and exclusion notes in the Tabular List are of
particular importance when using the 'N' code.
The 'H' Code - accidents, poisonings and violence: 2.6.
This section of the International Classification has a dual
classification according to the external cause (E) and to the
nature of the injury (N). When both classifications are employed
simultaneously for primary cause tabulation, each case must be
included in both lists, numbers E 800 - E899 and N800 - 999,
e.g. a patient admitted with a fractured neck of femur sustained
by being knocked off a pedal cycle by motor vehicle would be
coded and recorded Fracture neck femurN 820x
Knocked off pedal cycle
by motor vehicleH 813X
Here again when using the 'H' code, it is necessary to read
and apply the inclusion and exclusion notes and also the
definitions and examples given on pages 2+3 - 250, Volume 1.
Transport accidents are coded by numbers E 800 - 866
Accidental poisonings by solid and liquid
substances
E 870 - 888
Accidental poisonings by gases and vapours H 8 90 - 895
lb
so the required code number for the coding of a diagnosis influenza
with pneumonia is +80. The code for chronic bronchitis with
emphysema follows the same way:
Bronchitis
chronic502,1
with emphysema 502.0, which is the required
'number
In short, when coding multiple diagnoses look up the index to
see if they are coupled together as in the above examples.
In the section Diseases of Early Infancy, code numbers 760each category is divided into two sub-categories designated
.0 without mention of immaturity and .5 with mention of immaturity.
776,
2.5 Coding of fractures, injuries and poisonings
(the 'N' code).
The most difficult section of coding is probably. this section
dealing with accidents. The 'N' code is quite comprehensive and
as it cannot be memorised as easily as the remainder of the.
classification, there is, perhaps, a greater tendency to. guess at
the wanted number.
.
Code numbers for fractures, injuries and poisonings.are
prefixed by the letter 'N' e.g. N800X N931+X etc. and :will be found.
in the alphabetical portion of the term describing the type of
injury e.g. fracture appears under F with the codenumbèrsfor the
various anatomical sites and bones fractured. As an example:.
Fracture of hip N820X..
Similarly "wound open" appears under 'W' followed by a list
of anatomical sites. To code such diagnoses as cut finger,
laceration leg, etc. the coder will be directed in the alphabetical
index as follows:
"cut (external), see also wound open", "laceration, see also
wound open"
Where multiple sites of injury are to be coded, the word
"with" indicates involvement of both sites. The word "and" in
all these titles indicates that either one or both sites are
involved e.g. N813X fracture of radius and ulna, N823X fracture
of tibia and fibula, fracture nose, with either bone, N802X etc.
'11
11
An undetermined primary site can be coded to 199.2 and codes
for metastatic sites can be located under 199 by referring to the
amendment which will be found on page 96, Volume 1 and page 22 of
the Hospit'al Statistics Handbook. It should be noted that the
fourth digit should not be used for coding on statistical cards
sent to the Health Department, but can be used for local needs if
necessary.A suspected neoplasm ruled out or unconfirmed should
be coded to 793.1.
Obstetrics: 2.3.
A comprehensive arrangement for disease that frequently
complicates pregnancy, childbirth and the puerperium is listed
under "pregnancy, delivery and puerperal". The diagnoses under
these terms are listed also under the disease name with codes for
both those of puerperal and those of non-puerperal origin.
All uncomplicated deliveries are coded to 660.0 (660.5 if
caesarean section). This number should not be used where a complication covered by code numbers 6 7 0 -678 exists, A caesarean
section would be coded by the addition of the fourth digit .5 to
the code number e.g a diagnosis of delivery complicated by placenta
praevia and caesarean section would be coded to 670.5; delivery
complicated by uterine inertia and a caesarean section performed
would be coded 675.5, etc.
New born infants delivered in hospital would be included in
the code Y20-Y29 e.g. normal nursling, Y20. These code numbers
are, however, for internal hospital use only. As far as the MSI8
statistical cards are concerned the International Classification
of Diseases ends at y18.
Other notes for coding obstetric diagnoses will be found in
Hospital Statistics Handbook, page 17.
Coding of combination terms: 2.4.
In the alphabetical index will be found a considerable number
of categories in the classification which include a combination of
two closely related diseases, or a disease with frequent complications such as influenza with pneumonia, chronic bronchitis with
emphysema etc. The alphabetical index records these codenumbers
as:
Influenza 481
with pneumonia (all forms) 480
ibS
(3) Looking up T for Tonsillitis, chronic, this leads us to
the choice of two code numbers 510.0 and 510.1. Looking up 510.0
in Volume 1 we note that this reads "without mention of tonsillectomy or adenoidectomy" and 510,1 reads "with tonsillectomy and
adenoidectomy", as in this case. 510,1 is therefore the code
number.
(4) To code perforated gastric ulcer we look up U - ulcer
not under perforation or gastric (see note in (2) above) and
under, ulcer 'gastric we find the code 540 which is sub-divided. .0
without perforation and .1 with perforation.' In this case the
code number we require is 540610
Other examples of coding which require reference to inclusions
and exclusions will be found in many sections of Volume 1 and
these must be read and applied'.
From the foregoing examples it will be noted that when
using the index look under the disease or condition and' not the
site e.g. to code anal fistula look under fistula, tuberculosis
of hip, look under tuberculosis and chronic bronchitis, look up
bronchitis and not chronic,
2.1 Eponymic terms
These will be found listed under "disease" followed by the
name of the person after whom the disease is named, e.g. Bright's
Disease (chronic nephritis) will be found under disease, Bright's,
similarly, for Pott's Disease etc.
2.2 Coding of neoplasms
While terms such as carcinoma, sarcoma, and epithelioma
appear in their own alphabetical places in the index along , with
their code numbers, it will be noted there is an instruction
"see Neoplasm, malignant", where the complete listing of anatomical sites appears with the code numbers. Benign tumours are
indexed in the same way except that they have the reference "see
also neoplasm, benign". Sites are listed alphabetically with the
appropriate code numbers shown against them in , three columns,
depending on whether the neoplasm is malignant, benign or
unspecified on pages 75 - 78 1 Volume 1.
1•1
which, before a code number is applied, must be stated whether
associated with childbirth or not. The code number for
breast abscess is 621.0 but if associated with childbirth its
code number becomes 689.
An example of the application of the International
Classification to coding may be shown as follows. Suppose we
are to code the following diagnoses from the medical record
(1) Right Inguinal Hernia
(2) Acute Appendicitis
(3) Chronic Tonsillitis (with Tonsillectomy)
(k)
Perforated Gastric Ulcer
these being the final and correct diagnoses.
(1) Turn up the alphabetical index, Volume 2, and under
"H" we find hernia and this refers us to the number 560 in the
tabular list Volume 1. We find that 560 is divided up into
five sub-divisions: .0 (inguinal .1 (femoral), .2 (umbilical),
.3 (ventral) and .+ (other specified site). As the hernia we
are to code is an inguinal type and there is no mention of
gangrene., incarceration, obstruction or strangulation, then the
code number is 560,0.
If, on the other hand, the diagnosis to be coded was
strangulated inguinal hernia, then the code number would be
561,0 as obtained from looking up the alphabetical index and
referring to the note given on page 214 "Code as below all
hernia with mention of gangrene, incarceration, irreducability,
obstruction or strangulation".
(2) Turning up the alphabetical index under "A" we find
appendicitis which refers us to the code 550 in the tabular list
Volume 1, This code number is sub-divided into .0 (without
mention of peritonitis) and .1 (with peritonitis). As the term
peritonitis is not included in the diagnosis to be coded, the
requisite code number is 550.0. If, however, the recorded
diagnosis was recorded as appendicitis with peritonitis, the
code would be 550,1. Chronic appendicitiswould be 552 but the
word "chronic" would have to be included in the diagnosis.
Note:- If instead of looking up 'appendicitis' we looked for
acute - this would read "see condition" which means that the
disease name is to be looked up rather than the adjectival
modifier (see note On page xiii, in the introduction to Volume
2, Alphabetical Index),
16
The structure of the International Classification is described in chapter 10 and its relatively simple numerical code of
three digits which cover the major categories or titles, with
four digit sub-divisions in some instances to permit classification of greater detail, make it simple to use, provided that
the Index, (Volume 2), is used in conjunction with the , main
volume - Volume 1,'and that the inclusion and exclisionnotes
are understood and applied.
2.The application of the International Classification to
disease coding
Before the manual is applied to disease coding it is
advisable and necessary to read the introduction to both
volumes. In Volume 1 will be found the general principles of,
classification, the difference between a nomenclature and a
classification, a general description of the manual, together
with certain aspects of classification. Also to be noted in
Volume 1, page 44, is a note on the use of parentheses, colons,
etc. This is of particular importance and should be read 'and
understood before disease coding is attempted.
The introduction to Volume 2 (Alphabetical Index) is
particularly important as it contains the structure and use of
the alphabetical index, criteria for assigning a given code,
number, how to use the index to find code numbers, adjectival
forms and modifiers, eponyms, the indexing of combination terms
and once again the special use of parentheses. Also of importance
in the introduction to Volume 2, are the details of abbreviations,
symbols and other devices used in the Index.
In order to carry out coding itis necessary that all the'
above be understood which will lead to both volumes of'the
Classification being used efficiently and will make the location
of code numbers simpler.
Before actually coding a disease it is important that the
diagnosis must be final and complete e.g. the diagnosis on the
notes may read abdominal pain and an appendicectomy performed,
the pathological report reading acute appendicitis. In such
cases the matter should be brought to the notice of the appropriate Registrar or Surgeon in a diplomatic manner. In practice,
experienced Medical Records staff will be trusted by medical staff
to pick up and code correctly such inconsistencies but they must
always be sure that what they are doing is within their competence.
In such a case code acute appendicitis and disregard abdominal
pain. Another example of an incomplete diagnosis is breast abscess
16
11
THE CLASSIFICATION OF DISEASES
1.Introduction
2,The application of the International Classification to
disease coding
2.1 Eponymic terms
2,2 Coding of neoplasms
2,3 Obstetrics
2.k Coding of combination terms
2.5. Coding of fractures, injuries and poisonings
(the 'N' code)
2.6 The 'E' 1 code - accidents, poisonings and violence
2.7 Coding of adverse reactions to injections,
LnIusions etc.
2,8 Incomplete diagnoses or terms
2,9 General
30Summary
k,References
5 °Further reading
5.1 Basic
5.2 Background
Introduction;
1.
In order that Medical Records departments may readily, be
able to produce information about diseases treated in a
hospital, it is necessary that a disease index be kept. This
index, or as it is sometimes called, the Classified Index of
Diseases, is described in chapter 6 of the manual and here we
are only concerned with the classification or coding of
diseases so that they may be entered in the correct section of
this Index or Register.
There are many ways of classifying diseases and for hospital
purposes the most efficient classification is one which permits
the location of a maximum number of pertinent records with the
review of the least number. A classification system for a
disease index should anticipate most requests for patients'
records in all hospitals and the present classification manual
in use in all public hospitals in New. Zealand, "The International
Classification of Diseases, Injuries and Causes of Death",
together with the Alphabetical Index, suits the purpose admirably,
.'Efficiency in hospital
indexing of the coding
systems of the International
Statistical Classification
and Standard Nomenclature..
report of a collaborative
study
Jnl AANRL, June 1959, pp 95-11,
129
Expert Committee on Health
Statistics. 8th Report,
W.H.O Technical Report
Series* No. 261
Geneva, W.H.O., 19631 31+ pp
International Study Project 1: 2nd mt. Congress Report.,
Diagnostic Indexes andpp 59-83
Classifications
Kline (Dr. H.M.) World Health
Problems and Programs
2nd mt. Congress Report,
pp-35-46
Olsen (F.E.) Use of the International Classification of
Diseases for reporting
hospital morbidity
Jnl AAMRL, Feb. 1960, pp 11-159
37
Hospitals
1960, 54 pp.
(
163
10
Moriyama (Iwao M.) The International Classification of
Diseases4th mt. Congress Report, pp 130-37
Rolleston H.D. "The classification and nomenclature of
diseases with remarks on diseases due to treatment",
Lancet, May 22, 1 9 0 9, pp 1437-43
Sutherland I. "John Graunt: A tercentenary tribute" Journal of the Royal Statistical Society - Series A.
Vol. 126. Part 4 pp 537-56
Further reading:
Basic: 9.1.
Hospital Statistics Handbook
Wellington, Medibal Statistics
Branch, Department of Health
( 1 963) 36 Pp
Huffman (Edna K.) Manual for
Medical Record Librarians
PP 266-9, ("Grouping by
International statistical
classification number"
under "Indexing Procedures),
PP 319- 24 "International
statistical classification
of diseases, injuries and
causes of death" under
"Collection of statistical
data") -
U.S.A., Berwyn, Ill,, Physicians
Record Co., 1959, xxx + 604,
illus.
Knight (J.) The InternationalMedical Record, Feb. 1956,.
Statistical Classification ofPP 25-28
Diseases and its uses in
diagnostic indices
Background: 9.2.
Cakrtova (Dr. M.) The value
of medical records to the
World Health Organisation
Mot
Pp 29-39
6.
Revisions
The International Classification of Diseases is revised every
ten years.The revision is undertaken by the World Health Organ-.
isation which calls together committees of experts for this
purpose.
To give an illustration, there was a certain amount of dissatisfaction among psychiatrists with that section i the International Classification of Diseases dealing with mental disorders.
A committee of experts , from several countries was appointed under
the chairmanship of a leading authority. Alternative classifications were collected and studied. From these deliberations the
better classifications were selected and distributed to member
nations for comment. The comments were considered by the committee and a final classification of mental disorders agreed upon.
7.
Additions and amendments
From time to time it becomes necessary to accommodate newly
recognised conditions within the framework of the International
Classification of Diseases. Sometimes the question originates
from a Medical Records Officer, sometimes the query arises in
the Health Statistics Centre. It is the usual practice to
consult such references and authorities that are available and
then to acquaint hospitals with the decision of what code number
should be used to classify the new condition.
This is perhaps a suitable place to mention that, if in
retrospect it appears that more appropriate code numbers could
have been selected than those to which some of these new conditions were allotted in the past, it should be remembered that
the circumstances under which the decisions were made were not
ideal.When new diagnostic terms first find their way into
medical records there is often very little known about the terms.
Sometimes an article in a journal is the sole reference. Moreover,
at this stage there is frequently conflicting evidence about
etiology. If the findings of subsequent research were available
at the time the decision must be made then the task would be much
easier.
8.
References
International Classification of Diseases (1955 Revision)
Volume 1 pp ix - xviii
I','
10
indexing diseases and injuries than that provided for in the
Classification, certain titles have been expanded within the'
framework of the existing Classification so that it is
possible to show finer shades of difference. The need to make
such modifications, however, has been infrequent.
In North America the Standard Nomenclature of Operations
and Diseases is used in many hospitals to classify medical
records. Its capacity for showing detail seems to be both a
strength and a weakness because so much of its usefulness
depends upon the skill of those who use it. It has been
reported that so much time must be spent in training staff in
the use of the nomenclature that medical records systems have
been. in danger of breaking down completely when confronted by
unexpected changes in staff. As a consequence many hospitals
have now turned to the International Classification of
Diseases for indexing medical records on the grounds that
although the Classification might not be so fine an instrument
as the Nomenclature it is at least easier to-keep it operating.
Abbreviated lists:
5.
In Volume 1 of the International Classification of Diseases.
three special tabulation lists are shown which are useful for
preparing special summaries. List A. is known as the
"Intermediate" list and consists of 150 titles. It has been
designed for both morbidity and mortality tabulations. List B.
is the "Abbreviated list of 50 causes and is for mortality
tabulations. List C. is the "Special" list of 50 titles for
both morbidity and social security purposes.
The three figure • code numbers that have been assigned to
each title in these three lists are specified, so it is an easy
matter to decide which of these tabulations is the more
appropriate for any particular purpose.
In addition to special tabulations, the list A has been
used in some hospitals in New Zealand as a basis for the
disease index. The hospitals concerned have found that
although there was no need to have an elaborate or very
detailed index there was a need to have some means of quickly
locating medical records when information about certain disease
groups was required. List A. can easily be modified to meet
the needs of such hospitals.
160
3.2 Statistical
In New Zealand the International Classification of Diseases
is used by the Social Security Department, the Department of
Statistics, and the Armed Services, as well as by the Department
of Health. The prime advantage of using the Classification i
of course that it enables comparisons to be made with a precision
which would be otherwise lacking. If one classification was used
to code all the deaths registered at the Registrar-General's
Office, and another to code admissions to public hospitals, and
a third for admissions to mental hospital--, little imagination is
necessary to visualise the complications that would accompany
attempts to get the national picture of conditions such as
alcoholism, epilepsy or psychotic illness. In spite of this it
is not uncommon to hear pleas for the production of classifications tailored to meet the particular needs of different
disciplines. For example, the psychiatrist finds that although
most of the statistical headings with which he is concerned are
grouped together in one section of the Classification he must
venture out of this group of code numbers everytime he diagnoses
a case of psychosis due to syphilis or following encephalitis or
of puerperal origin. Similarly, the researcher in cause of death
statistics finds little interest in statistical headings such as
those relating to the musculo-skeletal system or to fractures and
open wounds or to symptoms. It is only when it is vital to have
information about diseases as a whole that the necessity of using
a standardised classification is fully realised. Apart from
death, public hospital and mental hospital statistics the
International Classification of Diseases is used to classify
post mortem reports, causes of stillbirth and cancer statistics0
k.Differences
between a classification and a nomenclature
The prime aim of a classification is to bring together like
conditions.The scope and limits of each group of like conditions
are known and are precisely defined. On the other hand the
function of a nomenclature is to list every single known variety.
A nomenclature must of necessity be constantly growing in size
as each newly recognised conditior is added and new code numbers
allotted.
In New Zealand the International Classification of Diseases
is in general use. The Classification meets the needs of the
hospital service very well. In a few hospitals where it was felt
that there was need to have a more detailed method of cross-
1',F9
10
contain ill-defined conditions and conditions infrequently
reported. To some extent the "other and unspecified"
titles is a "wash-up" group.
To many of the titles and sub-titles included in the list
notes have been added for the guidance of the coder. These
notes define the scope of the particular heading and direct
the coder to other titles which might be more appropriate for
a particular case.
Uses of the International Classification of Diseases: 3.
The two main uses of the International Classification of
Disease.s that concern us here are disease indexing and
statistical.
Disease indexing: 3.1.
The purpose of disease indexing is to have a means of
readily locating all the cases of a particular disease. It is
important that all the cases of that disease., no matter by
what terms they are at times described, should be included
under the one heading and not distributed by chance among
several headings.For instance, if we want to trace all the
cases of measles we do not have to look for cases under each of
the three headings, morbilli, rubeola and measles. By using a
classification we know that all cases of measles, no matter
which of these three diagnoses may have been chosen, will have
been indexed under a particular heading and that we do not
need to be concerned about the possibility that some cases of
measles could have been indexed elsewhere.
It is sometimes claimed that the International Classification of Diseases is not detailed enough to enable fine shades
of difference to be shown between similar, but nevertheless
slightly different, conditions. The answer to such criticism
is that for a very few purposes no classification, or nomenclature either for that matter, has yet been designed that
would be detailed enough to provide the material required
without some preliminary selection of cases. The largest
hospitals in New Zealand have found that a disease cross-index
based on the International Classification of Diseases is
satisfactory to meet the demands made on it to provide
medical records for both specialist and general enquiries.
This topic is discussed under 'The Classification of Diseases'
(chapter -ii).
9.
Diseases of the digestive system
10.
Diseases of the genito-urinary system
11.
Deliveries and complications of pregnancy, childbirth
and the puerperium
12.
Diseases of the skin and cellular tissue
13. Diseases of the bones and organs of movement
1k 0 Congenital malformations
15. Certain diseases of early infancy
16Symptoms, senility and ill-defined conditions
17.
Accidents, poisonings and violence (external cause)
18.
Accidents, poisonings and violence (nature of injury)
19.
Special admissions without sickness
Each section is divided into sub-sections which in turn contain between one to 27 statistical headings or titles to each Of
which a three figure code number has been allocated. Some of
these statistical headings are further sub-divided by the
addition of fourth digits and sub-titles. To illustrate, the
section dealing with diseases of the digestive system has six
sub-sections 1. Diseases of buccal cavity and oesophagus
2 Diseases of stomach and duodenum
3. Appendicitis.
k. Hernia of abdominal cavity
5.
Other diseases of intestines and peritoneum
6.
Diseases of liver, gallbladder and pancreas
The third sub-section contains four statistical headings acute appendicitis, appendicitis unqualified, other appendicitis,
and other diseases of appendix, one of which (acute appendicitis)
is further divided into two sub-groups by means of four digits .0 without mention of peritonitis, and .1 with peritonitis.
This structure has been used throughout the classification..
Some conditions are specified and shown out separately, usually
because they are frequently encountered or because they are of
particular clinical interest. Other conditions are grouped
together under an "other and unspecified" title. These usually
1c7
10
This is sufficiently elaborate but his original nosology
further gave subheadings of the species, for example 0. Dentitionjs
(a)
(b)
Lactantium; cutting the teeth or shedding teeth
Puerilis;cutting the second set or permanent
teeth
(c)
Adultorum; cutting the adult or wise teeth
(d)
Senilium; cutting teeth in advanced life or
old age
The need for a uniform classification of diseases for
international use was recognised more than a hundred years ago.
The first International Statistical Congress, held in 1853,
requested William Faar and Marc d'Espine to prepare a uniform
classification of causes of death applicable in-all countries.
This action and subsequent developments eventually led to the
adoption of the International List of Causes of Death in 1893.
After the first revision in 1900, the International List of
Causes of Death underwent successive decennial revisions until
1948 when a classification suitable for classifying causes of
illness as well as causes of death was adopted. This dual
purpose classification, known as International Ciássiuiéatjon
of Diseases (I.C.D.) was modified only slightly in 1955.
Structure of the International
Classification of Diseases: 2.
Nineteen sections of the International Classification of
Diseases are currently used in New Zealand. They are 1.
2.
3.
Infective and parasitic diseases
Neoplasms
Allergic, endocrine system, metabolic and
• nutritional diseases
+. Diseases of the blood and blood-forming organs
151,6
5.
Mental, psychoneurotjc and personality disorders
6.
Diseases of the nervous system and sense organs
7.
Diseases of the circulatory system
8.
Diseases of the respiratory system
often even that of the varieties, I hold to be a necessary foundation of every plan of physic, whether dogmatical or empirical,"
said Cullen in his First Lines of the Practice of Physic (1776).
The system devised by him came to be a predominant one, although
many other systems were presented.
An example of one of these early nineteenth century classifications is that of John Mason Good, a London physician. His
classification published in 1822 contained six clases (1) Coeliaca, (2) Pneumatica, Diseases of the Respiratory System
(3) Haematica, Diseases of the Sanguineous Function, including
the specific fevers, visceral inflammations, supperations, (k)
Neurotica, Diseases of the Nervous Function, (5) Genetica,
Diseases of the Sexual Function and (6) Eccritica, or Diseases
of the "Excernent" Function, included under this last heading
are corpulency, dropsy, tumours, and skin diseases. Each class
has orders, genera and species, as shown by the first page of the
table of classification Class 1.Coeliaca.
Diseases of the Digestive Function
Ord. 1.Enterica.
Affecting the Alimentary:Canal
Gen. 1.Odontia
Misdentition
Spec,1.0. Dentitionis
Teething
2.
Dolorosa
Toothache
3.
Stuporis
Tooth edge
4.
Deformis
Deformity of the teeth
5.
Edentula
Toothlessness
6.
Incrustans
Tartar of the teeth
7.
Excrescens
Excrescent gums
10
Lethargy
14
Livergrown
20
Meagrom and Headach
12
Measles
7
Murthered and Shot
9
Overlaid and Starved
45
Palsie
30
Plague
68 ,596
Planne t
6
Plurisie
'15
Poysoned
1
Qu ins i e
35
Pickets
557
Rising of the Lights
397
Rupture
34
Scurvy
105
Shingles and Swine Pox
2
Sores, Ulcers, broken and bruised limbs
82
Spleen
14
Spotted feaver and Purples
1,929
Stopping of the Stomack
332
Stone and Strangury
98
Surfiet
1,251
Teeth and Worms
2,614
Vomiting
51
V Venn
1
Although few of these terms are likely to find their way
onto a contemporary death certificate most of them will at least
be meaningful to the present-day reader, who might perhaps
pause and reflect with sadness upon the passing of such
colourful terminology as rising of the lights, purples and
griping in the guts.
By way of explanation calenture is a term for tropical fever
or delirium, the chrisome means a child's white robe at baptism
used as a shroud if it died within a month, the lights were the
lungs, Kings Evil was scrofula or tuberculosis of lymphatic
glands, and impostume was a purulent swelling or abscess. This
statement then is an early tabulation of causes of death made
up largely of symptomatic or descriptive terms which are
arranged in alphabetical order.
Nosology, or the scientific classification of diseases, was
cultivated zealously a hundred and fifty years ago, and was
believed to be a necessary part of the knowledge required for
the practical treatment of disease. "The distinction of the
genera of diseases, the distinction of the species of each and
bills of mortality were weekly statements in which were shown the
number of christenings and burials in each parish in London, together with a statement of the causes of death. The causes of death
were reported by searchers who were (to quote Graunt)
Matrons, Sworn to their Office (who) repaired to the place where
the dead Corps lies, and by view of the same, and by other
enquiries, they examine by what disease or casualty the Corps
died, Hereupon they make their report to the Parish-Clerk". The
most famous bill of mortality is that for 1665, thq year of the
Great Plague. The following list of causes of death has been
taken from that bill Abortive and Stiliborne
Aged
Ague and Feaver
Appoplex and Suddenly
Bedrid
Blasted
Bleeding
Bloody Flux, Scowring & Flux
Burnt and Scalded
Calenture
Cancer, Gangrene and Fistula
Canker and Thrush
Childbed
Chrisomes and infants
Cold and Cough
Collick and Winde
Consumption and Tissick
Convulsion and Mother
Distracted
Dropsie and Timpany
Drowned
Executed
Flox and Small Pox
Found dead in streets, fields etc. .
French Pox
Frighted
Gout and Sciatica
Grief
Griping in the Guts
Hangd & made away themselves
Headmouldshot & Mould fallen
Jaundies
Impostume
Kild by severall accidents
Kings Evil
Leprosie
617
1,514
5,257
116
10
5
16
185
8
.3
56
111,
625
11258
68
134
4,808
2,036
5.
1,'+78
50
21
655
20
86
23
27
46
1,288
7.
il+
110
227
46
86
2
10
INTERNATIONAL CLASSIFICATION OF DISEASES
1,Historical review
2.
Structure of the International Classification of Diseases
3.
Uses of International Classification of Diseases
3.1 Disease indexing
3.2 Statistical
4.
Difference between a classification and a nomenclature
5.
Abbreviated lists
6.
Revisions
7.
Additions and amendments
8.
References
9.
Further reading
9.1 Basic
9.2 Background
Historical review: 1.
An excellent account of the development of disease classification is given in the Introduction to the International
Classification of Diseases. The account describes how an
internationally accepted classification was gradually evolved
and names those nosologists who made substantial contributions
to its development. It is pointless to repeat here the information, already available in the code books themselves but some
acquaintance with the precursors of the International Classification of Diseases is necessary before a worthwhile evaluation
of the Classification can be made.
The following notes are designed to supplement the
information contained in the historical review and it is thought
that they will be of particular interest to the, reader who does
not have access to those publications in which reference is made
to earlier classifications.
On page x of the Introduction reference is made to the
work of John Graunt who pioneered the statistical study of
disease. John Graunt was a London draper who, in 1662, published
• book entitled "Natural and Political Observations Mentioned in
• following Index and made upon the Bills of Mortality". The
j57.,
K
IIj
H'
J_tp___
co
.1
6
z
C1
FR
I
It
orP.
) rp
ON
Gq
'n.
t
I
of
S
2
I:
9.
S.V.0PULMONARY
VEINS
VPVV
'AORTA -- -i---c CAPILLARIES
RCULATION
CAPILLARIES- -- .-CIPULMONARY
CISYSTEMI
RCULATIC ON
Fig.
141
If.
Fig. 3.
SCAPI
31CR
Fig. 1.
VE
HIP BO
IA
BRAL
ISPHERE
STEM
LLUM
L CORD.
Fig. 2.
RAL CANAL
147
9
Reference': 12
Cairney (John) and Cairney (J.)
First studies in Anatomy and
Physiology
Christchurch, N.M. Peryer
Ltd. 1963 V + 223
Further reading: 13
Turner (A.E.J,) A Preliminary
Introduction into the study of
Anatomy and Physiology
Medical Record: Feb. 195+
pp 280-3, 295; May 1954,
pp 305-11,3 2 0; Aug. 1954,
pp 347-+9, 58; Nov. 1954,
PP 384-7, 390; Feb. 1955,
pp k20-3
Illustrations by courtesy N.M. Peryer Ltd., Christchurch
44
The testis contains groups of cells called interstitial cells,
between the seminiferous tubules; collectively they constitute the
endocrine part of the testis, and they secrete a hormone called
testosterone.The ovary produces two hormones: oestradiol,
secreted by the ripening follicles, and progesterone, secreted by
the corpus luteum. Testosterone in the male and oestradiol in the
female are responsible for the changes that take place in the body
at puberty, while oestradiol and progesterone are responsible for
the changes that occur in the endometrium each month throughout the
reproductive years.
The pancreas has groups of cells called cell islets, or the
islands of Langerhans, scattered through its substance. Collectively
they constitute the endocrine part of the pancreas, and they secrete
the hormone insulin, which is essential for the utilisation of
glucose by the tissues and also facilitates its storage in the liver.
The thyroid secretes a hormone called thyroxine, which regulates
the metabolism of the body generally.
The parathyroids secrete a hormone called parathormone, which
regulates the metabolism of calcium and phosphorus.
The adrenal cortex produces two principal hormones, cortisol.
and aldosterone. Cortisol, in contrast with insulin, tends to raise
the level of glucose in the blood. Aldosterone controls the
excretion of sodium and potassium by the kidneys, thus maintaining
their proper concentration in the body.
The adrenal medulla produces two hormones, adrenaline and
noradrenline.The production of adrenaline is a physiological
response to an emergency; it increases the heart rate, raises the
blood pressure, mobilises glucose from the liver and so on. The.
role of noradrenaline in the normal working of the body is not yet
clear, but it is probably concerned with the control of the circulation and especially with maintaining the blood pressure at a proper
level.
The anterior pituitary secretes (a) a group of hormones which
stimulate other endocrine organs - the thyroid, the adrenal cortex,
and the gonads; . (b) the lactogenic hormone, which stimulates the
mammary glands to secrete milk; (c) the growth hormone.
The posterior pituitary has two hormones: (1) the anti-diuretic
hormone, which acts on the kidneys to control the quantity of water
put out in the urine, and (2) the oxytocic hormone, which acts on
the uterus at the end of pregnancy to help expel its contents.
11W
9
The Fallopian or uterine tubes, of which there are two,
each extend from the ovary to the uterus, and each serves as a
duct for the corresponding ovary. When ovulation occurs, the
ovum immediately enters the tube, by which it travels to the
uterus. Union of the ovum and a spermatozoon to form a zygote when this happens - occurs in the Fallopian tube, and the
zygote then continues the journey to the uterus, where it
undergoes its further dévelopment
The vagina is a tube of non-striated musc]e lined by mucous
membrane, leading from the uterus to the vulva,,
Menstruation is periodic physiological bleeding from the
body of the uterus, occurring at intervals of approximately four
weeks. Every month from puberty to the menopause (except during
pregnancy) the endometrium undergoes a series of. changes in
preparation for the possible arrival of a zygote, and the completion of these changes coincides with the time when a zygote,
if there is one, is due to arrive. If the ovum discharged from
the ovary at ovulation is not fertilised and therefore no zygote
reaches the uterus, there is no means by which the changes in
the endometrium can be reversed, and it now becomes necessary
to shed the prepared endometrium and start anew. This is the
explanation of menstruation.
The endocrine glands: 11.
The endocrine glands are glands without ducts. The products
which they manufacture are called hormones, and these are carried
in the blood to various parts of the body.
The endocrine glands which exist as separate organs are (a)
the thyroid, in the front of the neck, (b) four parathyroids,
immediately behind the thyroid, (c) two adrenals, each at the
upper end of the kidney, and (d) the pituitary, occupying a
hollow in the interior of the base of the skull. The adrenal
and the pituitary each consist of two parts with different
functions; in the adrenal they are an outer part called the
cortex and an inner part called the medulla; in the pituitary
they are an anterior lobe, often referred to as the anterior
pituitary, and a.posterior lobe, often referred to as the
posterior pituitary. In addition, the gonads (ovary and testis)
and the pancreas have endocrine functions as well as their other
functions,
genitals; in the male they are the penis and the scrotum, and in
the female they are known collectively as the vulva.
10.1In the male (See Fig.
7.)
The testes, right and left, are each situated in the corresponding half of the scrotum. They consist essentially of a large
number of fine tubes called seminiferous tubules, the function of
which is to form spermatozoa; this commences at puberty and is
thereafter a continuous process till it comes to an end with
advancing years. A fully developed spermatozoon is a single cell
of a specialised type; it is motile, and has a long tail which
acts as a propelling mechanism. When eventually discharged by
ejaculation from the urethra, the spermatozoa are contained in a
fluid called semen.
The duct of the testis consists of two parts: (a) the
epidiymis, a long thin tube coiled on itself to such an extent that
the epididymis as a whole forms a relatively small structure along
the posterior border of the testis, and (b) the vas deferens,. a
thick-walled tube extending from the lower end of the epididymis to.
open into the posterior urethra...
The auxiliary glands of the male reproductive system. are (a)
the two seminal vesicles, situated behind the bladder, and (b) the
prostate, surrounding the posterior urethra. They secrete most of
the fluid part of the semen.
.
10.2 In the female (See Fig.
8.)
The two ovaries, right and left, are situated in the pelvic
cavity, one on either side. They are composed of fibrous connective
tissue in which are embedded a large number of special structures
called ovarian or Graafian follicles, each containing an ovum.
Ovulation consists in the discharge of an ovum from the surface of•
one or other ovary; it commences at puberty, and thereafter occurs
once every four weeks (except during pregnancy, when the process is
suspended) until the menopause. Every month a group of follicles
commences to undergo a ripening process; ordinarily only one of
them completes the process, and the others degenerate. The one that
completes its ripening approaches the surface of the ovary, where it
ruptures and discharges the ovum; the ruptured follicle is thereupon converted into another structure called a corpus luteum, which
persists until the next menstrual period is due.
'Li3
The kidneys form urine by extracting substances from the
blood. They act as a kind of "blood inspector" whose duty it
is to maintain the proper composition of the plasma. In the
performance of this function, they excrete (1) water in such
quantity as will ensure that the water content of the body remains
more or less constant, (2) nitrogenous waste, principally in the
form of urea, though a smaller amount of it is uric acid, (3)
inorganic salts to the extent necessary to keep their concentration in the plasma at its proper level. The items just
enumerated are the important constituents of normal urine.
The kidneys are situated on the posterior wall of the
abdomen, one on each side of the vertebral column. The ureter
emerges from the medial borderof the kidney; the commencement of the ureter is funnel-shaped and this part is called the
Lelvis - strictly speaking, it is the pelvis of the ureter, but
it is commonly referred to as the pelvis of the kidney.
The bladder, situated in the pelvic cavity, is a hollow
organ, with its wall composed of non-striated muscle lined by
mucous membrane. The urethra emerges from it below, at a
region called the neck of the bladder. The urethra has two
sphincters surroupding it, an involuntary or non-striated
sphincter at the neck of the bladder, and a voluntary or striated
sphincter in the pelvic floor. The female urethra is about 1-iinches long, with a direct course from the neck of the bladder
to the exterior.The male urethra is about 8 inches long and is
divided by the striated sphincter into two parts: (a) the
anterior urethra, which traverses the, and (b) the
posterior urethra, which is surrounded by the prostate.
The reproductive or generative system: 10.
The reproductive or generative system differs in the two
sexes.
Reproduction depends upon the union of a male germ cell or
spermatozoon with a female germ cell or ovum.The two unite to
form a single cell called a fertilised ovum or zygote, and from
it are produced all the organs and tissues of the future child,
known early in pregnancy as the embryo and later as the foetus.
The organs which house the germ cells are a pair of genital
glands or onads; in the male they are called the testes, and in
the female the ovaries.The parts of the reproductive system
which are situated on the surface are referred to as the external
1,z
There are four digestive juices: (1) saliva, secreted by the
salivary glands, (2) gastric juice, secreted by numerous glands of
microscopic size in the wall of the stomach, (3) pancreatic juice,
secreted by the pancreas, and (+) intestinal juice, secreted by
numerous glands of microscopic size in the wall of the small intestine. The digestive juices contain enzymes which carry out the
digestion of proteins, carbohydrates and fats. Bile is not a
digestive juice; it contains no enzymes, but it assists in the
digestion and absorption of fats.
The digestive process splits proteins into amino-acids, carbohydrates into glucose, and fats into glycerol and fatty acids. The
absorption of these end products (as well asof other substances
which do not need digestion) takes place in the small intestine,
and practically the only absorption that occurs in the large
intestine is the absorption of a further quantity of water. The
amino-acids and glucose are absorbed into the venous blood and are,
carried by a vein called the portal vein to the liver. Glycerol
and fatty acids, on the other hand, are re-constituted into fats
during their passage through the intestinal wall, and are carried
as fats by the lymphatics to enter the veins at the root of the neck.
Glucose and fat are used by the tissues for the production of
energy and heat. Surplus glucose can be stored in the liver as
glycogen, which can be converted back to glucose as. required.
Glucose which is not needed can also be converted into fat, and
surplus fat can in any case be stored as adipose tissue in various
parts of the body.
Amino-acids, on the other hand, cannot be stored. They are
used for building the proteins of the tissues, not only during
growth but also to make good the wear and tear that goes on all
the time throughout life. Unwanted amino-acids (which come from
the breakdown of tissue proteins as well as from any surplus in
the food) are dealt with in the liver, where the nitrogenous part
is converted into urea (a waste product, for excretion by the
kidneys), while the remainder can be converted into glucose0
9.The urinary system (See Fig. 6.)
The urinary system is-concerned with the excretion of urine.
It consists of '(a) the two kidne, right and left, in which the
urine is formed, (b) two tubes called the ureters, one from each
kidney, which convey the urine to the bladder, (c) the bladder,
where the urine is temporarily stored, and (d) a passage called
the urethra, leading from the bladder to the exterior.
9
The alimentary or digstive system: 8.
(See Fig. 5Y
The alimentary or digestive system is concerned with the
digestion of food stuffs (proteins, carbohydrates and fats) and
with the absorption not only of the products of digestion but
also of other substances (water, inorganic salts, and vitamins)
which do not require digestion.
The system consists of (a) a tube called the alimentary
canal, which runs right through the body from the mouth to the
anus, and (b) various glands which discharge t1ieir secretions
into the alimentary canal.
The part of the alimentary canal above the diaphragm
comprises (1) the mouth or oral cavity, (2) the pharynx,
situated behind the nose, the mouth, and the larynx, and (3)
the oesophagus, which begins in the neck as a continuation of
the pharynx, runs down through the thorax, and finally through
the diaphragm to open into the stomach. This part Of the
alimentary canal is mainly concerned with the mechanical
functions of mastication (chewing) and deglutition (swallowing).
The glands associated with it are three pairs of salivary
glands, the ducts of which open into the mouth.
The part of the alimentary canal below the diaphragm
comprises (1) the stomach, a dilated part of the alimentary
canal which enables us to take meals, (2) the small intestine,
so called because it is smaller in calibre, though considerbly
longer, than (3) the large intestine. The whole of this part
of the alimentary canal is conveniently referred to as the
gastro-intestinal tract. The glands associated with it are
the liver, which secretes bile and has a duct called the bile
duct, and the pancreas, which secretes pancreatic juice and
has a duct called the pancreatic duct. The bile duct and the
pancreatic duct open into the upper part of the small intestine.
The gastro-intestinal tract is a tube of non-striated
muscle lined by mucous membrane. The function of the muscular
wall is to propel the contents onwards, which it does by waves
of contraction called peristalisis. The muscle is in two
layers, longitudinal and circular, and at several points the
circular layer is thickened to form sphincters, which regulate
the passage of the contents.
the intake of air for respiration can be regulated. With the vocal
cords brought together in the middle line, they can be caused to
vibrate in a blast of expired air, and this is how sound is produced; variation in pitch is brought about by varying the tension
of the vocal cords.
The lung consists essentially of an enormous number of minute
air-sacs or alveoli, together with a system of tubes connecting them
to the main bronchus. After entering the lung, the main bronchus
undergoes repeated subdivision, and all its branches within the lung
collectively constitute the bronchial tree. The larger branches
are still called bronchi, but the smallest ones are called
bronchioles.
To facilitate the exchange of oxygen and carbon dioxide
between the air in the alveoli and the blood in the pulmonary capillaries, the barrier between the two has been reduced to a minimum
and consists of practically nothing more than two layers of flat
cells - the endothelium of the capillaries and a single layer of
flat epithelium forming the walls of the alveoli. Because the
pressure of oxygen is higher in the alveoli than in the capillary
blood, oxygen passes from the air in the alveoli to the blood in
the capillaries; and for a similar reason, carbon dioxide passes
in the opposite direction. In consequence of these exchanges,
(1) the air which is expelled at expiration contains less oxygen
and more carbon dioxide than does inspired air, and (2) the blood
which leaves the capillaries to enter the pulmonary veins has lost
a proportion of carbon dioxide and gained a proportion of oxygen,
and has thus become arterial blood.
Inspiration is carried out by the action of muscles which
raise the ribs and lower the diaphragm, thus increasing the capacity
of the thorax. Because the capacity of the thorax is increased,
air is drawn into the lungs through the air passages. In expiration
the thorax returns to its former size and in consequence air .is
expelled from the lungs. In,a general way, the action may be compared with drawing air into a pair of bellows and forcing it out
again.
The muscles that we use in respiration are voluntary muscles:
the diaphragm, supplied by the two phrenic nerves, right and left,
and muscles called intercostal muscles (between the ribs), supplied
by nerves called intercostal nerves. Though we can, if we wish, stop
breathing for a short time, respiration normally proceeds automatically and in a rhythmic manner, and this isdue to a nerve
centre in the hind brain called the respiratory centre.
with by the histiocytes.
The respiratory system: 7.
(See Fig.
l)
The respiratory system exists to replenish the oxygen in
the blood and to enable the blood to get ridS of its unwanted
carbon dioxide.The air we breathe mis called inspired airs
is ordinary atmospheric air and contains about 20 5 01 oxygen
and only atrace of carbon dioxide, whereas the air we breathe
out, called expired air, contains about k% more of carbon
dioxide and about 476 less of oxygen.
Air normally enters and leaves the body through the nose,
but we can of course also breathe through the mouth. In either
case the air also traverses a tube called the pharynx, situated
behind the nose and the mouth. The respiratory system itself
begins with the larynx,which opens off the front of the
pharynx, below the back of the tongue.
The respiratory system consists of (a) two air reservoirs,
the lungs, situated in the thorax, one on either side of the
heart, and (b) a series of air passages, by which the air is
conveyed to and from the lungs.
The air passages comprise (a) the larynx, (b) the
trachea, which ends by bifurcating into (c) two main bronchi,
one for each lung. The main bronchus enters the medial surface
of the lung (i.e. the surface which looks towards the middle
line), and is accompanied by the pulmonary artery and two
pulmonary veins; this whole group of structures constitutes
the root of the lung.
The air passages are lined throughout by mucous membrane,
and outside this the walls are formed by pieces of cartilage
together with fibrous tissue and muscle (skeletal striated in
the larynx, and non-striated below this). The cartilage serves
to keep the tubes open at all times.
About half-way down the larynx, two folds of muc.ousmembrane, one on each side, project like shelves into its cavity.
In the free border of each is a band of elastic tissue (so
called on account of its elasticity), and these are the vocal
cords; the space between them is the glottis. By moving the
cartilages of the larynx on one another, we can move the voc-al
cords nearer together or further apart; in other words, the
size of the glottis can be varied by muscular action, and thus
called lymphoid tissue. Corpuscles and platelets, at the end of
their life span, are destroyed by cells called histiocytes, which
are present in bone marrow and lymphoid tissue and also in other
situations such as the liver and connective tissue in various parts
of the body. The histiocytes in the spleen (which is also a
lymphoid organ, and as such forms lymphocytes) play an important
part in the destruction of worn-out red corpuscles.
The plasma makes up rather more than half of the total
volume of the blood. When blood escapes from the blood vascular
system, it coagulates or clots, this being Nature's attempt to stop
or minimise the bleeding. The process of coagulation is started
off by the disintegration of platelets when they come into contact
with damaged tissue, but what eventually happens is that fibrinogen,
one of the proteins of the plasma, is converted into an insoluble
substance called fibrin; this forms a network in which the corpuscles are entangled. The solid part, or clot, now consists of
fibrin and corpuscles, while the fluid part which is left 'consists
of plasma minus its fibrinogen, and is called serum.
6. .
The lymph vascular or lymphatic system
The lymph vascular or lymphatic system contains a colourless or
faintly yellow fluid called lymph, which is discharged into large
veins at the root of the neck.
The tissues of the body are permeated by a fluid called tissue
fluid, which acts as an intermediary for the exchange of substances
between the blood in the capillaries and the tissue cells. It is
constantly being renewed from the plasma in the capillaries, and it
is constantly being removed from the tissues (a) by going back into
the capillaries and (b) by being drained away by the lymphatic system.
The lymphatic system commences in the tissues as numerous blind
lymphatic capillaries, the contents of which come from the tissue
fluid. From them the lymph is drained away by lymphatic vessels or
lymphatics, which join up to form larger and larger vessels, until
eventually there are only two, the thoracic duct, which opens into
the veins at the root of the neck on the left side, and the right
lymphatic duct, which does the same on the right side.
Situated on the course of the lymphatics are small oval or beanshaped structures called lymph nodes, through which the lymph percolates. They consist of lymphoid tissue, which forms new 1tnphocyte,
but they also act as filters and remove from the lymph any materials
of an injurious nature, such as bacteria, which can then be dealt
Ii
9
Of this time, atrial systole occupies Oal second, ventricular
systole occupies 0.3 second, and for the remaining 0e 1+ second
the whole heart is in diastole.
Blood:. 5.1.
The blood is the medium by which various substances are
conveyed from one part of the body to another.
Blood consists of a fluid called 1. 1asma, in which are
suspended (a) a multitude of cells called blood corpuscles,
which are of two kinds, red and white, and (b) other
structures called platelets. ..
Red corpuscles, or erythorcytes, number . 5 million to 6
million per cubic millimetre.They are cIrcular .bio-concave
discs without nuclei, and their protoplasm contains a pigment
called haemçglobin.Their special function is the transport
of oxygen, which is carried in chemical combination with the
haemoglobin. In venous blood, when a certain amount of oxygen
has been given up to the tissues, they also carry part of the
carbon dioxide. The rest of the carbon dioxide, and everything
else that the blood transports, is carried in the plasma,
White corpuscles, or leucocytes, number 5,000 to 10,000 per
cubic millimetre. They are nucleated cells, and are divided
into several classes according to their appearances in a stained
blood film.In the first place there are two main classes,
granular andaccording to the presence or absence of
granules in the protoplasm of the cell. The granular leucocytes are mostly neutE2janhils. which make up about 70% of the
total leucocytes, and the agranular •ones are mostly lymphocytes,
which make up 20% or more of the total. The granular
leucocytes constitute one of the defence mechanisms of the body;
in inflammation, they migrate through the capillary walls into
the tissues, where they ingest bacteria and destroy them a
process called phagocytosis.
The platelets number between 200,000 and +OO,OOO per cubió
millimetre. They are minute fragements of protoplasm without
nuclei, and they are of importance in connection with the
coagulation of blood.
Corpuscles and platelets are constantly being renewed, and
old and worn out ones are constantly being destroyed. Red corpuscles, granular leucocytes and platelets are formed in the red
marrow of bones, and lymphocytes are formed in a type of tissue
The systemic circulation begins with the aorta, a single large
artery carrying arterial blood from the left ventricle. From the
aorta are given off a number of named arteries, which, by branching
into smaller and smaller arteries, convey arterial blood to all
parts of the body. The smallest arteries are called arterioles,
and these open into the capillaries of the various organs and
tissues. In the capillaries the blood gives off oxygen to the
tissues and takes up carbon dioxide from them; it thus becomes
venous blood. From the capillaries the blood is collected by veins,
which join to form larger and larger veins. The venous blood is,
eventually poured into the right atrium by two large veins called
the superior vena cava and the inferior vena cava.
The pulmonary circulation begins with a single large artery,
called the pulmonary artery, carrying venous blood from the right
ventricle. This soon divides into two pulmonary arteries, right and
left, one for each lung. Within the lung, the artery divides into
smaller and smaller arteries, and the smallest of them open into the
pulmonary capillaries. In the pulmonary capillaries the blood takes
up oxygen from the air in the lung and gives off its surplus carbon
dioxide; it thus becomes arterial blood. From the pulmonary
capillaries it is collected by veins, which unite to form larger
veins; it is eventually poured into the left atrium by four
pulmonary veins, two from each lung.
The wall of the heart consists of cardiac muscle, lined on the
inside by endothelium and covered on the outside by serous peri '
-cardium.Theusclarw isoftenpk ofasthemypcardium,
and the endothelial lining is called the endocardium.
At both ends of the ventricles the cardiac pump is provided
with valves, produced by folding in of the endocardium, and
permitting the flow of blood only in one direction. The valves at
the atrio-ventricular orifices are called atrio-ventricular valves;
the one on the right side is the tricuspid valve, and the one on the
left side is the mitral valve. The valves at the outlet from the
ventricles are called semilunar valves; the one at the opening into
pulmonary artery is the pulmonary valve, and the one at the opening
into the aorta is the aortic valve.
Each beat of the heart consists of simultaneous contraction of
the two atria, driving blood into the ventricles, followed by simultaneous contraction of the two ventricles, driving blood into the
pulmonary artery and aorta, Contraction is called systole, and the
relaxation which follows is called diastole.
If for convenience of calculation we take a heart rate of 75
per minute, the time corresponding to each heart beat is 0,8 second,
IW
The blood vascular or circulatory system:
(See Fig. 3.)
The blood vascular or circulatory system distributes blood
to all the organs and tissues of the body and brings it back
again to the heart.
The system consists of the heart, which acts as a pump,
and the tubes called blood-vessels. The blood-vessels are of
three kinds: (a) arteries, which convey blood from the heart
to the tissues, (b) veins, which return the blood from the
tissues to the heart, and (c) capillaries, which are numerous
very fine vessels, microscopic in size, situated in the
tissues themselves and forming the means of communication
between the arteries and the veins. All the blood in the body
is contained in the heart and blood-vessels.
The heart, situated more or less in the middle of the
thorax (two-thirds of it are to the left of the middle line),
consists of four chambers: two atria, right and left, and
two ventricles, right and left. The atria are receiving
chambers; each receives blood from veins, and when it contracts,
expels the blood into the corresponding ventricle. The
ventricles are distributing chambers; each receivesblood from
the corresponding atrium, and, when it contracts, expls the
blood into arteries.
Each atrium communicates with the corresponding ventricle
by an atrio-ventricular orifice, but there is no communication
between the right and left sides of the heart, which are
separated from each other by a partition or septum. The left
side of the heart contains blood which is bright red in colour;
it has in
a high proportion of oxygen and a relatively low
proportion of carbon dioxide, and is called arterial blood.
The right side of the •heart contains blood which is bluish in
colour; it has in it a higher proportion of carbon dioxide
than in arterial blood and a relatively low proportion of
oxygen; it is called venous blood.
The blood that leaves each ventricle returns to the heart
by entering the atrium of the opposite side. There are thus
two systems of blood-vessels: (1) the systemic circulation,
connecting the left ventricle to the right atrium, and (2) the
pulmonary circulation, connecting the right ventricle to the
left atrium.
5.
In sections of the brain or spinal cord there are two kinds of
nervous tissue, which are called grey matter and white matter
according to their appearance to the naked eye. Grey matter consists of an aggregation of nerve cells, and white matter consists
of an aggregation of nerve fibres. Outside the central nervous
system, the nerves consist of nerve fibres, and any collection of
nerve cells constitutes a ganglion.
In the peripheral nerves, fibres which carry impulses to the
central nervous system (for example, from the skin) are called
afferent fibres, and fibres which carry impulses from the central
nervous system (for example, to the voluntary muscles) are called
efferent fibres. A nerve may be entirely afferent or entirely
efferent, or it may contain both afferent and efferent fibres and
is then called a mixed nerve.
Afferent fibres from the skin convey impulses which, when they
reach consciousness, give rise to the sensations of touch, pain,
warmth, and cold. There are also afferent fibres from muscles and
tendons, and the impulses which they carry give rise to sensations
which enable us to be aware of such things as the position of any
part of a limb and whether an object held in the hand is heavy or
light; such sensations are covered by the term muscular sense.
Associated with the nervous system are the organs of the
special senses of sight, hearing, smell, and taste. These are (1)
the(2) the ear, (3) a specialised part of the mucous membrane
of the nose called the olfactory region, and (Lt) the taste buds,
microscopic in size, in the mucous membrane of the tongue.
When the spinal cord is followed upwards (see Fig. 2), it
becomes continuous with a part of the brain called the brain stem,
and this ends above at the base of the two cerebral hemispheres
(right and left), which make up the greater part of the brain. The
outer layer of each cerebral hemisphere consists of grey matter
called the cerebral cortex, and the cerebral cortex is the only part
of the brain concerned with consciousness and with initiating
voluntary movements. Projecting backwards from the brain stem,
below the cerebral hemispheres, is another part of the brain called
the cerebellum; it has nothing to do with consciousness, and its
function is .to act as a centre for co-ordinating muscular movements
which have been initiated by the cerebral cortex.
The brain and spinal cord are surrounded by three membranes or
meninges, which, in order from without in, are called the dura, the
arachnoid, and the pia. Between the arachnoid and the pia is, the
subarachnoid space, filled with a fluid called cerebro-spinal fluid.
1
called nerve impulses, which cause the muscle to contract.
As seen under the microscope, a muscle consists of
contractile units called nerve fibres, each of which is really
an elongated cell. This type of muscular tissue is often
referred to simply as voluntary muscle, but t because the
muscles are mostly attached to the skeleton and because the
fibres show a characteristic cross-striation when seen under
the microscope, it is also called skeletal striated muscle.
We may note here that there are two other types of
muscular tissue, and that these are not under the control of
the will. One type (which has no cross-striation) is called
involuntary or non-striated muscle; it is found in the walls
of hollow organs like the stomach and the bladder, and in the
walls of tubes, including the arteries. Its nerve-supply comes
from a part of the nervous system known as the involuntary or
autonomic nervous system. The other type is found only in the
wall of the heart, and is known as cardiac muscle or cardiac
striated muscle. It is remarkable in possessing the property
of automatic rhythmic contraction, by which, throughout life,
it maintains the circulation of the blood; its nerve-supply,
from the autonomic nervous system, is purely a regulating
mechanism.
The nervous system: +.
The nervous system comprises the brain and, the spinal cord,
together with all the nerves of the body. The brain is situated
inside the skull and the spinal cord inside the vertebral
column; together they constitute the central nervous system.
The nerves arise from the central nervous system as 12 pairs
from the brain, called cranial nerves, and 31 pairs from the
spinal cord, called, spinal nerves; together they constitute the
peripheral nervous system.
The unit of structure in the nervous system is called a
neurone, and a neurone consists of a nerve cell together with
a long process of its protoplasm which has been drawn out to
form a nerve fibre. The whole nervous system is made up of
neurones, and might be compared with an extremely complicated
system of electric wiring, in which each single length of wire
represents a neurone. The function of neurones is to convey
messages called nerve impulses, and nerve impulses travel along
I
the neurones in much the same way as an electric current travels
along the wires in a wiring system.
elsewhere red marrow persists throughout life. Red marrow is one
of the blood-forming tissues, but yellow marrow consists almost
entirely of fat.
3.The muscular system
The muscular system comprises all the voluntary muscles of the
body, that is to say, the muscles which are under the control of the
will.
The outstanding property of muscles is their power of contraction, so that the two ends of the muscle are brought nearer to each
other. The majority of muscles are attached at both ends to bones,
and pass over at least one joint. When such a muscle contracts, it
moves one bone on the other, the movement taking place at the
intervening joint. Every voluntary movement that we carry out in
any part of the body is brought about by the contraction of muscles.
Muscles make up the greater part of the substance of the limbs,
which is not surprising when we reflect that the usefulness of a
limb depends upon its capacity for movement. The diaphragm, which
separates the thorax from the abdomen, is a muscular partition;
and the walls of the abdomen are mostly composed of muscles.
While the majority of muscles are attached at both ends to
bone, this is not the case with all of them. In the face there are
muscles which are attached at one end into the skin, and which
produce changes in facial expression. The tongue consists of a
mass of muscle covered by mucous membrane, to which the muscles
are attached, and all the changes in the shape and position of the
tongue are produced by the action of its muscles.
The attachment of a muscle to bone may be a direct one, or it
may take place through a cord-like or band-like structure called .a
tendon, which is a white glistening structure composed of fibrous
tissue. In the region of the wrist and ankle, the muscles of the
forearm and leg have given place to tendons, and these tendons are
surrounded by sheaths of fibrous tissue lined by synovial membrane
and lubricated by synovia, so that the tendon can glide smoothly
within its sheath. Muscles which are broad and sheet-like (as in
the abdominal wall) have tendons which are likewise broad and
sheet-like, and such tendons are called aponeuroses.
Every voluntary muscle has a nerve-supply, and by this we mean
that a nerve reaches the muscle from either the brain (in the case
of the muscles of the head) or the spinal cord (in the case of the
rest of the body). The nerve conveys the messages from the brain,
15 1
9
Though many cavities and tubes are lined by epithelium,
there are some which are not. The internal lining of the heart
and blood-vessels is a single layer of flat cells called
endothelium, not epithelium. The heart beats inside a fibrous
pericardium, and both the outer surface of the heart and the
inner surface of the fibrous bag are lined by a smooth membrane
called the serous pericardium;. this kind of membrane is a
serous membrane, not a mucous membrane, and it consists of a
layer of flat cells called mesothelium with a backing of fibrous
tissue. The other serous membranes are the pleura, lining the
interior of the chest wall and covering the lung, and the
peritoneum, in the abdomen. Each of the serous membranes is
moistened by just sufficient of a serous fluid'to prevent
friction between the apposed surfaces.
The osseous system or skeleton: 2.
(See Fig. 1.)
The osseous system orskeleton comprises all the bones of
the body.
Any place where two bones meet is a joint, and there are
three types of joints: fibrous joints, cartilage joints, and
synovial joints. In fibrous joints, as in the upper part or
vault of the skull, the bones are connected by fibrous issue,
and such joints (here called sutures) are quite immovable.
Cartilage joints occur in the vertebral column (or spine), where
there is a series of superposed segments called vertebrae,
connected by discs of a gristly substance called cartilage;
each such joint allows a slight amount of yielding or "give".
Synovial joints are typified by the large joints of the
limbs, which are freely movable. Here the bone ends are
covered by a smooth layer of cartilage, and there is a joint
cavity surrounded by a cylinder of fibrous tissue called the
capsular ligament. The capsular ligament is lined on its deep
surface by a glistening layer called syn.ovial membrane, which
secretes a stickyfluid called synovia for lubricating the joint.
Bones are classified, according to their shape, into long
bones (as in the limbs), short bones (such as the vertebrae),
flat bones (as in the vault of the skull), and irregular bones.
The interior of bones is occupied by a tissue called bone
marrow, of which there are two types, red and yellow. At birth,
all the marrow is red marrow, but by early adult life most of
the marrow in the long bones has changed to yellow marrow;
PO
If we make a thin section of any organ and examine it under
he microscope, we find that it consists of units called cells.
Each cell is composed of a living substance called protoplasm,
and a small part of the protoplasm, near the centre of the cell, is
different from the rest and is called the nucleus. A cell then,
is a circumscribed mass of protoplasm containing a nucleus.
From this point of view, the body consists of myriads of
cells. The cells are in turn arranged in tissues, and a tissue
is an aggregation of cells which have specialised to carry out a
particular function. In all tissues there is a certain amount of
material between the cells, and this is referred to as the intercellular substance.
There are various different kinds of tissues, but two of them
which are widely distributed throughout the body, and which form
parts of many organs, are fibrous connective tissue and epithelium.
Fibrous connective tissue, often spoken of simply as connective
tissue or as fibrous tissue, has a large amount of intercellular
substance in proportion to the cells, and the intercellular substance has thread-like structures called connective tissue fibres
running through it. Fibrous tissue forms tendons and ligaments,
and a variety of it which is looser in texture forms a kind of
packing between muscles and around blood-vessels and nerves.
Epithelium, by contrast, consists almost entirely of cells,
with only a minimum of intercellular substance. It might be said
to resemble brickwork with the smallest possible amount of mortar
between the bricks. It covers the external surface of the body,
and it lines many hollow organs and tubes. In these situations it
has a backing of fibrous tissue called the corium. On the, surface
of the body, the epithelium and corium (here also called the
epidermis and the dermis), together form the skin; lining hollow
organs and tubes, the epithelium and cerium together form a
mucous membrane.
The organs known as glands also consist of epithelium, which
here has the power of.extracting substances from the blood and
manufacturing from them a new product called a secretion. Examples
are the salivary glands, which secrete saliva, and the liver,
which secretes bile. The tube by which a gland discharges its
secretion is called its duct. There are also glands of microscopic size, such as the sweat glands in the skin and glands in
the mucous membrane of the stomach, which secrete one of the
digestive juices.
It
9
ANATOMY AND PHYSIOLOGY
10Introduction
2,The osseous system or skeleton
3.
The muscular system
4.
The nervous system
5 0The
blood vascular or circulatory system
5.1 Blood
6.The lymph vascular or lymphatic system
70
8.
The respiratory system
The alimentary or digestive system
The urinary system
9.
100
The reproductive or generative system
10.1 In the male
10.2 In the female
11.
The endocrine glands
12.
Reference
13.
Further reading
Figure 1.
The skeleton
2,
The brain and spinal cord
3.
The circulation
4.
5.
The respiratory system
The alimentary canal
60
The urinary system
7,
80
The male reproductive system
The female reproductive system
Introduction: 1.
The body, when examined by dissection, is found to consist
of a number of structures called organs, such as the brain, the
heart, the lungs and the stomach. The internal organs are often
spoken of as viscera. The organs are for the most part arranged
to form systems, and a system consists of a group of organs which
co-operate in carrying out particular functions.
Id
8
APPENDIX C
AVAILABLEBEDREPORT
As at Midnight.. ........
WardWardTotal OccupiedAVAILABLE BEDS
Number TypeBedsBedsSingle Male Female Total
Room
1Medical20151225
2Surgical2020---Thoracic106
3Gynaeco-3028
logical
1Surgical30251
22
135
5Medical2020---Research1082 2
6Medical3030---7ISurgical2020----
TOTAL119011721 41
7171, 18
APPENDIX B.
..HOSPITAL
•Census for 24 hours ending midnight on . ../.../6..
(filled in by Medical Records) Admission and Discharge Lists attached
Ward Number in ward Number admitted in Number transferred Number die- Number died in Number of
•at last censuslast 24 hours-ToFromcharged inlast 24 hours patients in
last 24 hrs.ware at midnight
(1)(ii)(iii)(iv)(v)(vi)(vii)(viii)
2
LI
14
15
17
18
22
TOTAL
NOTE: Total cola. (ii) and (iii) lesc total cola. (vi) and (vii) must equal col. (viii) and
total col. (iv) must equal total col. (v).Col. (ii) must be the same as yesterday's
col. (viii).
Visiting Staff:
TOTAL:
WARD BED STATE:WARDBEDSTATE
APPENDIX A (2)
......
AT MIDNIGHT
..25..2..1966....
No.ADMISSIONSDISCHARGES AND DEATHS No.TRANSFERS
Remaining New Transfers from Discharges Transfers to Remaining BETWEEN
fromAdmissionsOther Wardsand • Deaths Other WardsfromWARDS AND
Previous Day..
.HospitalON LEAVE
1
5
- 16Mrs. J.
Brown
from
El
NAMES OF PATIENTS ADMITTED
(Omit Transfers between Wards)
SurnameChristian Name
NAMES OF PATIENTS DISCHARGED AND DECEASED
Case Note No.SurnameChristian Name
JonesWilliam.
123-61.Smith. Alfred
314-19 Soap.Joseph
BrownMary
016-22.AbleWilliam
SmithJane
ClarkWaka
315-18
11 3-2 1
JohnsonDawn
ClarkRichard
WARD BED STATE:WARDBEDSTATE
APPENDIX A (1)
............. WARD
AT MIDNIGHT.....
No.ADMISSIONSDISCHARGES AND DEATHS No.TRANSFERS
H
Remaining
Remaining
BETWEEN
R
NewTransfers from
I
to
K DischargesTransfers
H
from
InWARDS AND
AdmissionsOther Wardsand DeathsOther Wards
Previous DayI
Hospital ON LEAVE
19
2
NAMES OF PATIENTS ADMITTED
Surname
Christian Name
20Mrs. J.
1
Brown
to A 2
NAMES OF PATIENTS DISCHARGED OR
DECEASED
Case Note No.SurnameChristian Name
DannClare
0 63- 1 9
DunnMabel
142-27FordJoseph
DavieFlOrence
DaviesRichard -
BunnMary
M.S.18 statistical cards: 6
At the end of each month the total number of male and
female discharges (irrespective of age) and the total number
of deaths, male and.female, also irrespective of age, are
totalled and M.S.18statistjcal cards for each must be available
to be sent. to the National Health Statistics Centre, The number to
be saitis determined by a progressive day-to-day total being
maintained on,the bed states, and the figures arrived at on the
last day of the month in this respect must total the actual
discharges and deaths.
References: 7,
Huffman (Edna K.) Manual for Medical Record Librarians pp 365-71
(U.S.A., Berwyn, Ill.) ('The census and rates computed from it')
Stone (J.E.)Hospital Organisation and Management p 195
(London-Faber, 1952)
Symposium:The Daily Count of Patients N.Z. Medical
Record, p 8, p 16, March 1963
Furth'er reading: 8.
Basic:8.1.
Dawson (J.F.) Medical Records
Departments: South Devon and
East Cornwall Hospital
pp 7-14, 34
Eldridge (K.J.) Admission procedure and registration of
inpatients
Richardson (A.J.) Bed states,
admissions, discharges and the
S.H.3
pp 519-24
pp 181-3
Rivers (J.S.) The 'Hymn Board' Medical Record, Feb. 1951,
Bed State
pp 8-1, 35
Tiltman (P.c.s.) Practical aspectsMedical Record, May 1951,
of a Medical Records Department
form to receive the information from the ward. Others do it by
telephone and others may extract it front ward bed state. The
latter is not satisfactory in the case of mixed wards as the bed
state will not normally show the sex or type of bed available.
The first essential is to know the bed establishment in the
ward, then it is necessary to know the type of ward - medical,
surgical, thoracic, gynaecological, psychiatric or mixed surgical/
thoracic, mixed medical/psychiatric, etc. - and the available beds
in each category. In the case of mixed sex wards, it is essential
that the numbers of female and male beds available are clearly
shown. On obtaining the information this is passed to the
Admission Office, the Accident and Emergency department (when acute
admissions are done through this department), the Matron and
Medical Superintendent. The distribution of the information may
vary front hospital to hospital as well as the lay-out of the form
used to relay the information, but as an example the style set
out in Appendix C may be used.
+.1 Classification of admissions by sex, type and category
In order to have data available to complete various hospital
returns, it is necessary that a record be kept of the sex of.
patients admitted, the type of patients (medical, surgical, etc.)
and category (adult or paediatric). This information is normally
extracted at the time. of balancing admission slips and can be
recorded day by day and totalled at the end of each month. In
determining category of admission (adult or paediatric) the age
for each category will be determined at the discretion of the, local
hospital board or Medical Superintendent. The essential factor
to be considered is that the age so determined remain consistent.
5.Social Security lists
Most hospitals are required to notify the local Social
Security Department of all adult admissions and discharges. These
lists may, in some cases, be prepared by Medical Records Office
from data provided to complete the daily census. Where it is
necessary to supply full names, age, address and Social Security
Benefit the patient is receiving, this information can be
extracted from admission slips.
Discharge lists can be copied from the hospital bed state.
12Z
ro
2nd day of month
1st day of month
DischargedDied
Line M F NP FP M F ' NP FP
1
DischargedDied
Line F NP FP N F MP FP
1631211
2631-21
242-32-
3631-21
3 10 51
-53
1
It will be seen that on the first day of the month only
patients discharged on that day will be shown (line 2) and total
(the same number) carried down to line 3. On subsequent days
the previous day's total goes to line 1. The day's discharges
into line 2 and new total into line 3. This continues to the
last day of month when the bottom line (3) will show the total
male and female adult and child discharges and deaths for the
month.
On the reverse of the hospital bed state may be shown the
daily ward bed states with totals of admission, discharges,
transfers to other wards and total remaining in hospital, this
becoming the permanent record of individual ward bed tates.
On this form, too, is a record of the total admissions to date,
as from 12 midnight 31st March each year. Also included is the
total patient days for this period.
One form which has been found satisfactory for both large
and small hospitals is shown at Appendix B. This is
accompanied by the admission and discharge lists thus making
it unnecessary to write in individual names. It will be seen
also that it is self-balancing. It can be varied by putting
headings for specific information at the bottom. For instance,
in the case of a maternity hospital the names of visiting staff
might be replaced by numbers of mothers and babies, births
during past 24 hours etc.
Information regarding available beds:. 140
In addition to showirg just who is in hospital, and what
movements have taken place, it is essential to know at all
stages just what beds, the type and sex, are available for the
day's admissions, and this information is also extracted at the
time of taking the day's census. Some hospitals use a separate
121
MORE ADMISSIONS THAN DISCHARGES:
Example (1)
Patients remaining
at start of period
AdmissionsDischarEes
(as in A above) (as in B above)
25
4 65
20Plus
New Balance
5. Admis- sions
+70 Total
- in
hospital
MORE DISCHARGES THAN ADMISSIONS:
Example (ii)
Patients remaining
at start of period
AdmissionsDischarges
(as in A above) (as in B above)
20
465
25Minus
New Balance
L+65
5 Discnarges
-f6O Total
- in
hospital
Having obtained a balance of ward bed states, the next stage
is to complete a hóspitalbed state on which is shown the names of
all patients admitted to hospital (including transfers and the
consultant under whom admitted). Also shown is a list of all
discharges, deaths and transfers to other hospitals.
Discharge list will show (a)
Hospital number
(b)
Patient's full name
(c)
Patient's age
(d)
Number of days in hospital
(e)
Discharged or died
On the hospital bed state is shown the total number of discharges and deaths from day to day, both adult and paediatric
(this information on a monthly basis). While the lay-out of this
may vary from hospital to hospital, the following will serve as
examples:
8
Discharges are checked against a discharge list supplied by
a central hospital source. This is compiled either from
discharge slips for each patient or from notification direct to
Enquiries by ward staff.
Transfers to other hospitals will normally be shown on the
discharge list with the name of the hospital to which transferred.
Deaths will also be shown on the discharge list but
annotated deceased, and if a mortuary list is supplied this is
used as a double check.
Transfers between wards are checked on the ward transfer
list also supplied from the central hospital source.
Actioning ward bed states:
3.
On receipt of the ward bed states all items have to be
checked and the balance corrected. The first essential check
is to ensure that the figure shown as patients remaining in the
ward at the start of the 24 hour period is as shown on the last
ward bed state received as patients remaining after previous days
admissions and discharges had been actioned. Thisis checked
against the previous ward bed states. All admissions, discharges,
deaths and transfers (to other hospitals) must be checked against
lists, and any discrepancies on the ward r?turns checked with the
Ward Sister by telephone.Transfers between wards must be
checked on the list supplied and also on bed states of both wards
involved.
When all bed states have been checked and balanced, the
following takes place A. All admissions (including transfers from other hospitals)
are totalled,
B. All discharges (including deaths and transfers to other
hospitals) are totalled.
The balance between (A) and (B) above, are either added or
deleted as applicable from the previous day's hospital total to
give the new balance.
'9
A suitable ward bed state is shown at Appendix A.
2.1 Patients who do not influence balance
(i) Patients dead on arrival
(2)
Still births
(3)
Foetal deaths who do not breathe or show any signs
of life.
None of the above are admitted to hospital and therefore are
not discharged and will in no way affect hospital totals.
2.2 Obtaining relevant information
From the medical recording point of view .- apart from ward bed
states which appear more or less standard in all hospitals - different sources of information will be found from hospital to
hospital, but in all cases it is essential that information supplied
by the ward is accurate. Where there are discrepancies a check
must be made with the ward.- although the person answering the
telephone will inevitably have been off duty when the report was
prepared!
.,.........,
The question of whether the daily census is . compiled. .in. the
Medical Records department or by Enquiries is an open one which,,
should be decided in the light of local conditions. In some
hospitals it is compiled in the Admission Office. The requirements
of the departments differ. Medical Records and Admission Office
primarily require to know numbers whereas Enquiries must know,
individual people and is not so concerned with balancing adrnissipns
and discharges against those in hospital. This balance is,
however, the sum of individuals. What has to be decided for each
hospital is: is it better to partly duplicate the work done by
Enquiries by Medical Records or can the information required by
Medical Records be effectively and consistently produced by
Enquiries?
Admissions can be checked if Medical Records Office is
supplied with duplicate copies of all admission slips and by a
hospital list of all admissions (the latter usually maintained by
Orderlies' Lodge).
Live births in a maternity ward are not an admission but they
are admitted if transferred to a general ward (refer as above).
IM
8
(B)(1)
Patients discharged during the 24 hour
period, including -
(2)
Patients who have died,
(3)
Patients transferred out to other hospitals,
(4)
Patients transferred out to other wards.
When all ward bed states have been obtained, they are
totalled to give the overall hospital picture of (a) (1) Total number of patients in hospital at
start of 24 hour period,
(2)
Total number of patients admitted during
the 24 hour period, including -
(3)
Total number of live births during the
24 hour period,
(4)
Total number of patients admitted on
transfer from other hospitals,
(5)
Total number of patients transferred
between wards.
(b) (1) Total number of patients discharged during
the period, including (2)
Total number of, patients who have died
during the period,
(3)
Total number of patients who have been
transferred to other hospitals,
NOTE: Still births are not recorded as either
admissions or discharges. Refer 'Medicolegal aspects of medical recordkeeping'
(chapter +). for policy regarding admissions
of babies born in hospital.
It will be seen that, by adding all admissions (including
transfers in from other hospitals and live births), to the total
number of patients in hospital at the start of the period, then
subtracting the total number of discharges (including deaths and
transfers out to other hospitals) the new total will be the
number remaining in. hospital for the start of the next 24 hour,
period.
Patients transferred between wards in the same hospital do
not affect the figures, as they are neither admissions nor
discharges.
117
of little use, as a breakdown in the continuity of the return will
cause near chaos.
Information gathered at the time of taking the census will be
the basis of many returns, some of which may not be prepared for
weeks or months later.
The actual method of collecting the data will vary from
hospital to hospital, but the methods described in this chapter
may be taken as general principles on which to base a method
suitable for the reader's own hospital.
Some hospitals may collect only the information required for
the actual . census, while others may, at this time, extract extra
details which are "stored" until required to complete reports and
returns.
2.Information required
There are basic requirements that will be the same in all
hospitals, and the period over which the census is taken - 2+
hours -.also appears standard in all institutions. How the information is collected, recorded and checked will, however, be
dependent on the method best suited to the individual hospital.
The actual time for start and finish of the 24 hour period may
vary from place to place, though 12 midnight to 12 midnight seems
the most favoured. There is no set time actually laid -down . , but
it is essential that it remain the same every day.
The data to be obtained are first gathered from individual
ward bed states, hospital admission slips, discharge and death•
lists and hospital transfer notices. They are then totalled to
give the overall picture of occurrences, bed states and hospital
totals.
Ward bed states will show the following (A)(1)
Number of patients in the ward at the start of
the 24 hour period.
(2)
Number of patients admitted during the 24 hour
period, including -
(3)
Live births,
(4)
Patients transferred in from other hospitals,
(5)
Patients transferred in from other wards.
Jib
8
HOSPITAL CENSUS TAKING
1.
Introduction
2.
Information required
2,1 Patients who do not influence balance
2.2 Obtaining relevant information
3.
Actioning ward bed state
Lf,Information
regarding available beds
4.1 Classification of admissions by sex, type
and category
5.
Social Security lists
6.
M.S.18 statistical cards
7.
References
8.
Further reading
8.1 Basic
Appx. A. Ward Bed State
Appx. B. Census Form
Appx. C. Available Bed Report
Introduction: 1.
In considering the requirements of hospital census taking,
one must consider all aspects of the need and have available a
simple but efficient method of carrying out this important duty.
There can be no room for mistakes. Information gathered is
going to show how many patients have been admitted, been born in
hospitals, transferred from other hospitals, transferred from
ward to ward, been discharged, transferred to other hospitals
or have died.The information will first be gathered on an
individual ward basis, then assembled to give overall hospital
totals. In short, all occurrences involving in_patients
movements , during 24 hour periods will be noted, co-related and
assembled to produce a census of the activity for the period.
It is essential that the method used to collect the data
is as easily understood as possible and that as many persons
as possible in the department be able to perform this duty. It
must be carried out every 24 hours for every day of the year.
A complicated system, understood by only one or two persons, is
Webb (J.) Waiting list procedure
pp 323-5
10.2 Background
'Admissions service at Archway'
Nov. 1962, p 1013
Lefebvre ( p .) & Issartel (M.)
Reception and humanisation of
the hospital (Translation from
French; abstract)
Hospital Abstracts, Nov. 1961,
p729
Luck (J.H.) Work study as applied 3rd mt. CongressRêport,
to Medical Recordspp 88-106
10.3 Associative
Nursing Times, April 28,
Hollinworth (J.) Kardex in a
1961, pp 520-1;
psychiatric hospital.
Hospital Abstracts, Aug.
1. Patients records.
1961, pp 513-4
lilt,
Services' Hospital 0 & M
Service Report No. 2.
Appointments systems: pp 17-19;
follow up: p 20; registration
of patients: pp 21-2; waiting
lists: pp 22-3
HOM.S.O, 1 959, p 32
Montmarin (J. de) The mechanisa- Hospital Abstracts, Aug.
tion of admission procedures 1963, p
(Translation; abstract)
Morgan (J.H.) Medical RecordsMedical Record, April,
Departments: the Cardiff Royal1951, pp 90-5
Infirmary
Myson (J.G.) Addressing machine
system at the London Hospital
pp 29+-7
Quilter (Peter) Mechanical documentation
pp 220-8
Rivers (J.S.) The 'Hymm Board'
Bed State
pp 8-11, 35
Ross (D..H.) They get the right
patient in - and out
Modern Hospitl, March
1962, pp 85-7; Hospital
Abstracts, June 1962,
p353
Sibley (E.M.) The non-profes-Hospital Forum, June 1961,
sional in the admitting office pp 22-4; Hospital
Abstracts, Oct. 1961
p666
Thielmann (C.F.) A methods
improvement case study: four
departments, one aim: find a
better way
Hospitals, June 1, 1961,
pp 40....3; Hospital
Abstracts, Oct. 1961,
p 652
Tiltman (RCS.) Practical
aspects of a Medical Records
Department
PP 136-9
'Waiting list systems' (at
hospitals)
1
Webb (J.) The nurse and the
medical records office (Nurses'
responsibility re admitting)
U!'
Medical Record, Aug. 1955,
pp Lf7280
Nursing Mirror, July 27,
1962, pp 319- 2 0; Hospital
Abstracts, Dec. 1962,
p 748
Dudgeon (w.J.) Admission Procedure and registration of
inpatients: In a hospital for
the treatment of mental illness
Eastham (G.) 'Offset litho' for
patient documentation
The Hospital, Sept. 1961,
PP 576-9; Hospital Abstracts,
Jan. 1962, p 31
Eldridge (K.J.) Admission procedure and registration of inpatients: In a general hospital
pp 526-8
pp 519-24
Hospital Abstracts, June 1961,
'For patients and visitors at
the Rikshospital, Oslo' (Trans.
p 394
from Norwegian; abstract)
The Hospital, March 1962,
Frazer (E.) Mechanisation in
Hospital
hospital medical records
pp 16
5-9;
Abstracts, June, 1962,
Heel (E.M.) Admitting
p353
Medical Record, Feb. 19651
pp 811,83-85
Hill (P.A.) Admission procedure.Medical Record, Nov. 1955,
and registration of inpatients: PP 524-6
In a specialised hospital
Hospital Forum, June 1961,
Horton (E.E.) The professional
22-4; Hospital-Abstracts
nurse in the admitting office
pp
Oct. 1961, pp-665-6
London, King Edward's
'Information booklets for
patients': Report of an enquiry by Hospital Fund for London,
the Division of Hospital Facilities 1962, 24 pp
London, Institute of Hospital
Institute of Hospital Admini
strators Study & Research
Administrators, 19 6 3, 37 pp;
Committee. Hospital
waiting
Hospital
Abstracts, June:
lists: a report
19 6 3, p 331
Jackson (N.V.) Mechanical
registration at low cost
pp 633-9
Modern Hospital, Feb. 1961,
Lake (R.) & Gilliam (T.R.)
Name plates system strips red
July 1961, p 462.,
tape from addmissions
HM.S.O., 1963, 3 pp .
'Mechanical registration of
patients': Abstracts of
Efficienty Studies in the
Hospital Service, No. 49
Mitchell (Edith N.) Pre-admission Medical Record News,
questionnaire (in 'What do
June 1964, p 86
YOU do?')
%J1,,
7
Laurenson (J.o.) Discussion: N.Z. Hospital, Dec. 1952,
'Admitting Systems'pp 52-9
MacEachern (M.T.) Medical Records U.S.A., Chicago, Ill.,
in the Hospital: pp 111-17 Physicians' Record Co.,
1937, xvi + 374, illus.
Stone (J.E.) Hospital OrganisLondon, Faber, 1952,
ation and Management, pp 196-8, xxii + 1722
778-83, 806-78
Basic: 10.1.
'An Addressing Machine System':
Abstracts of Efficiency Studies
in the Hospital Service, No. 12
H.M.S.0.,1961, 3 pp
Anspach (M.) The hospital
in Belgium with special reference to the administration of
a Records Department
PP 154-61
Brockis (n.J.) Records developments at Southend-on-sea
Hospital (Mostly concerns
admitting procedures)
pp 272-5
Brown (A.M.) The hospital preadmission system
Hospital Forum, June 1961,
pp 19- 2 1; Hospital
Abstracts, Oct. 1961,
pp 22-4
Champer (J.) Weiss Memorial
cuts admitting time in half
with new forms, simplified
procedure
Hospital Topics, April
1962, pp 41-3;
Hospital Abstracts, Sept.
1962, p 567
Hospitals, Dec. 1, 1961,
May 1962, p 306
Croder (D.M.) & McManus (M.C.)
Information manual smooths
admission procedure
Dawson (J..F.) Medical Records
Departments; South Devon &
East Cornwall Hospital
pp 7-14, 34
Dickinson (Miss N.D.) AdmissionMedical Record, Nov. 1955,
procedure and registration ofpp 529-32
inpatients: In a Mental
Deficiency Hospital
Ui
Miller (R.E.) The index for Medical Record news,
roentgen diagnosis Oct. 1962, pp 20-6
22+, 226-9
(Wallace & Fullmer) Tumour
registry (in 'What do YOU do'?')
Jnl. AA1'iPL, Aug.
1961, p 27
MacEachern (M.T.) Medical Records U.S.A., Chicago, Ill.,
in the Hospital, p 177, pp 205-09, Physicians' Record Co.
2 15-19 9 222-36
1937, xvi + 374,
illus.
Service Report No. 2
Diagnostic index: p 25
H.M.S.0. 1959
Pedelty (N.) A Scottish Master
Index
Medical Record, May 1959
pp 104-5
Report of a Committee on Medical
N.S.W. Hospitals Commn.
1960, 54 pp
Serviata (Sister Mary) Expanding
the name file
Medical Record News, Feb.
19629 pp 13, 36
Stone (J.E.) Hospital organisation
and management, pp 792-3
London, Faber, 1952,
xxii + 1722
Wood (D.B,) The diagnostic and
operation indices in a teaching
group
1953, pp 264-9
6.2 Background.
methods
1st mt.. CongressReport,
pp 129-41
Dudley H.A.F. The consultant's
need
1962, pp 584-6
International Study Project 1:
Diagnostic Indexes and Classification
pp 59-83
Kurtz (D.L.) Examples of research
in Medical Recording methods
pp 143-57
6.3 Associative
Booth ( p . j .) The poisons index
PP 520-22
Houghton (Dr. L.E.) and Jolley
(J.L.) A successful experiment
in Medical Research: Feature
cards applied to the analysis
of response to chemotherapy
Medical Re 'cord, May 1961,
pp 403-8
6
(Marshall, Wright, Booker,
Bald & Fieber) O.P. diagnosis
and operation indices (in
'What do YOU do?')
N.Z. Standard Specification
1 4 96:1959 'Alphabetical
arrangement'.
Schulz (M.D.) & Wang (o,C.) A
simple method of follow-up,
disease indexing and filing
of radiation therapy records.
N.Z.Standards Institute, Private Bag,
Wellington.
Radiology, Nov. 1962,
pp 282-k
pp 8k2-7
Further reading: 6
Basic: 6.1.
Barrowman (R.D.) Diagnostic
indices for the smaller
hospitals
1 95 6 , pp 31, 38
Blankenburg (I.S.de) Patient
indexing in hospitals in
Venezuela - use of the
family index
Jnl. AAMRL, June 1958,
Collison (R.) Colour, shape and
form
Office Magazine, Nov.
Coulam (Miss N.R.) Indexing of
disease coding systems
Curtis (M.R.) The comprehensive
card in the long-term hospital
Jnl. AAMRL, April
1 9571 pp 57-60, 80
'Efficiency in hospital indexing
of the coding systems of the
International Statistical
Classification and Standard
Nomenclature....': Report of
a collaborative study
Jni. AAMPL, June
'Guide to the organisation of
Department' pp 43-50
U.S.A., Chicago,
Knight (J.) The International
Statistical Classification of
Diseases and its uses in
diagnostic indices
pp 99-101, iik
1963,-Pp 961-3
1960 9 pp 222-3
1959, pp 95-111,
129
Ill., American
Hospital Assn.,
1962, vii + 83
195 6 , pp 25-28
Office equipment is properly dealt with elsewhere
but a few pointers are pertinent to the present section. Cards
will always play a major part in index systems, and they should
be of tough, durable paper while not being too thick, bearing in
mind the tendency of card files to grow rapidly. It is not good
practice for staff members to have to bend down too low to gain
access to the bottom drawer of the cabinet; it is bad for working
and can be detrimental to accuracy in filing and searching.
Assuming that a perpetual card file is in use or will be
chosen for the Patient index it is recommended that cabinet construction be of metal to reduce fire danger to vital information,
and that the card size be kept as small as possible as this index
is the most rapidly growing of all. Ensure, however, that no
information that is vital to identification of the patient or to
the location of his medical record is left off and that there is
reasonable space to type or write in. The card should have the
capacity to record dates of at least a dozen admissions to
hospital before a continuation card must be made out.
Finally it is recommended that this section be read in conjunction with the chapters on 'The International Classification of
Diseases' (chapter 10), 'Classification of Diseases' (chapter ii),
and 'Classification of Operations' (chapter 12) which are closely
related and to a certain extent interwoven topics.
5.References
Anspach (N.) The hospital service
in Belgium with special reference to the administration of a
Records Department
Medical Record, May
Collison (P.) Filing and indexing
Pt. 4 Cards
Office Magazine, April
Gogan (I.) Automatic indexes for
medical evaluation
Hospitals,. Aug. 1, 1961,
Medical Record Librarians
pp 2+5-308 ('Indexing procedures')
U.S.A., Berwyn, Ill.,
1 953, pp 154-61
.1963, p 294
Physicians' Record Co.
1959 xxx + 604,
illus.
Inglis (S.) Indexing and cross- •National Hospital, Feb.
indexing of disease and1961, pp 21-4;
operations
Hospital Abstracts,
July, 1961, p 440
6
recorded with great rapidity and can later be sorted and
evaluated with equal facility by other machines by means of
the punched holes, doing work that would represent . a considerably greater outlay in labour by manual methods.
Machine processing of medical information is done in
Wellington by the National Health Statistics Centre using
MS18 statistical cards which add up to a punch card index
for public , hospitals throughout the country. Hospital
Boards, and even individual hospitals, could use the same
methods to maintain their own disease, operation or physician's
indices, although the determining factor here would be cost.
A central office could use computers to receive, amass and
interpret information from all hospitals in New Zealand to help
determine such seemingly unrelated requirements as the number
of bedpans likely to be required ten years henäe to the optimum
treatment for allergies. Here again cost will determine when
this becomes a fact.
Conclusion: k.
As mentioned in the introduction, indexing is a very
important section of Medical Records Office procedure, and
great care must be exercised in the setting up and maintaining
of each index. Whatever systems are adopted must be adhered
to without variation, and it is important that staff occupied
in this activity fully understand procedures and the. need for
accuracy. Vital information can be lost in the files for
ever and the overall value of the department to the hospital
reduced if full and intelligent attention is not paid to this
job.
The watchwords with any index are 'Adequacy' without undue
'Excess'. Provided it can meet all demands made upon it,
then it can be assumed that sufficient attention is being
paid to detail. It is not properly the function of the
Medical Records Officer to decide on what should or should
not be recorded. However, it is definitely a responsibility
of such officers to keep abreast of the trends , and shifts of
emphasis in medical research so that he or she may play his
or her.proper role in consultation with doctors in ensuring
that the diagnostic index is kept alive and accommodating
to changing conditions.
tt
Operation cards may be kept in a loose leaf binder with dividing cards denoting the group and subgroup headings or they may form
a visible card file. The latter is as always the more easy to use,
but can become embarrassing as it grows larger. By using the
former method of keeping operation cards, they may be gathered
into years and bound in book form for reference.
2.4 The Physician's Index
As mentioned earlier in this chapter, this index may be required
by some hospitals. It is simply a record of the work done by each
physician or surgeon of the institution, and enables him to
evaluate and analyse the results of his own work if he should
desire. No hard and fast rules govern this index, which may be
loose leaf or of the visible card style, with a card for each
doctor arranged in alphabetical order.
Detail on the card is simple, having provision for the hospital
number, the disease or operation and the end result, i.e. cured,
relieved, died etc. Totals-may be taken out at the end of each
year.
This index may be considered over and above essential office
routine and would normally only be kept if it became the policy
of the hospital, after requests from the medical staff for the
information to be recorded.
3.Machine recording
Automation has, as with most other areas of human activity,
found its way into the medical record field. This is, of course,
by no means a new fact and automatic indexing and sorting and
evaluation of medical information by machine process has proved
well adapted and of immense value in many parts of the world.
3.1 The Punch Card method of indexing
Almost everyone is today familiar with the punch card and its
uses in many fields and none more so than coding staffs of public
hospitals throughout New Zealand who work every day with the
MS18 statistical card. There is no need to go into the intricaciep of the machinery involved to grasp 'the essentials of punch
card indexing.Holes are punched in the card in determined
positions according to the code number of' the disease being
recorded, by a, special machine designed for this function. The
information, i.e. the diagnosis or operation, is thus permanently
61
Any modifications made to the use of the International
Classification should not be made without careful consideration and consultation with the medical staff.
At the back of Vol. 1 of the International Classification
of Diseases there are lists for special tabulations which
would be suitable for the small hospital.
7The Operation Index: 2.3,
As far as general principles are concerned, the fundamentals
of operation indexing are the same as for Disease Indexing.
Local conditions may, however, be said to play a larger part in
determining how wide the classification is to be, and what form
the index is to take.
The Operation Code: 2,3.1,
If a nomenclature of operations with code. numbers is to be
employed in the hospital, then a card index similar to that
described for use in Disease Indexing will be employed; cards
will again be filed in numerical order according to code number.
and entries made in the same way on a similar card format.
Small differences to note are that the column headed Physician
on the disease card will become 'Surgeon' on the operation card,
and 'Associated Diagnoses' would become 'Associated Operation'.
Operation Indexes other than
a Coded Nomenclature: 2,3,2.
In its simplest form, the index may be purely alphabetical,
that is all operation names that begin with 'A' being grouped
together and so on. This is a method that will be found adequate
in only the smallest of hospitals.
It is preferable for the grouping to be anatomical or
systemic, and is covered in more detail under 'The Classificatio
of Operations' (chapter 12). The actual degree of subgrouping
will be determined by consultation with the medical staff,
taking into account the variety of surgery performed and its
quantity, and the demand that is likely to be made on the
records for research. A complete operation classification is
given in the International Classification of Diseases adapted
for Hospitals, (I.C.D.A.)
CODE 385
CATARACT
HOSI?ITAL NO. ASSOCIATED DIAGNOSESIDAYS STAY RESULTI DOCTOR
7293260X(10)
(9) 433.1(ii)
560.0 (12)
CODE 560.0
HOSPITAL NO. I ASSOCIATED D
7293260X(ik)
( 1 3)433.1(15)
1 385X(16)
15
Cured I Smith
INGUINAL HERNIA
NOSES
M
56
DAYS STAY
115
RESULTI DOCTOR
Cured ISmith
The decision whether to carry out cross indexing or simple
indexing must be carefully made and due consideration must be given
to the question of whether, in fact, the amount of research done
in the hospital is sufficient to warrant the extra time involved.
Modifications can of course be envisaged whereby, in a case with
multiple diagnoses only the principal disease and principal
complication be cross indexed and the remainder simply indexed.
2.2.2 Group indexing
In countries where the Standard Nomenclature • (an alternative
to the International Classification) is in common use, some hospitals employ what is known as Group Indexing where this nomenclature
has been found too detailed for local use. Under this system
diseases which are related topographically and etiologically are
grouped together under a modified code number. The advantage is
mainly that indexing becomes simpler because there are less code
numbers to deal with and there are consequently less cards in the
index.
Although most hospitals will find the International Classification of Diseases suitable for indexing some small hospitals may
find it desirable to modify the I.C.D. by broadening the grouping
a little further, where the amount of classifying and indexing is
small and of less variety. Such grouping would of course apply
only to internal classification in the hospital, and not to
statisti'cal cards prepared for the National Health Statistics
Centre.
19
6
If a patient is admitted suffering from a number of
diseases, then as stated, his hospital number will ppear on
the individual card for each of his diseases. The choice may
be made depending on local conditions, whether or not to employ
cross indexing, whereby reference is made beside each entry
10 cards of other conditions.
In hospitals where little research is done or doctors are
not in the habit of requesting a combination of diagnoses for
study, that is, they are only interested in a particular disease
and not others that the patient may also have suffered on the
same admission, then a considerable amount of time may be saved
by NOT cross indexing. For example, by not cross indexing a case
with four diagnoses, only four entries, one on each card, will be
made against sixteen entries required if the case is cross
indexed, when each card will have its own entry-PLUS reference
to the other three.
Example of Cross Indexing
Patient is diagnosed as suffering from the following four
conditions 1.
2,
3,
+.
Diabetes Mellitus
Atrial Fibrillation
Cataract
Inguinal Hernia
Cross indexing will be carried out as follows, demonstrating
how 16 entries are necessary for four diagnoses -
CODE 260
HOSPITAL NO,
7293
(i)
CODE 433.1
HOSPITAL NO.
7293
(5)
DIABETES MELLITUS
ASSOCIATED DIAGN0SES IJ DAY5 STAY
4 33.1 (2) 385X(3)
I
RESULT JDOCTOR
15Re-Smith
lieved
560.0 (4)
ATRIAL FIBRILLATION
ASSOCIATED DIAGNOSES AGE DAYS STAY RESULT DOCTOR
260X(6)
385X(7)
560.0 (8)
5615Re-Smith
lieved
irovide space for the following items:(a) the hospital number corresponding with the patient index
(b) the patient's name
(c) the patient's sex
(d) the patient's age
(e) the number of days stay in hospital
(f) the physician's name
(g) whether patient survived or died
(h) disease manifestation
(1) associated conditions (for use if full cross indexing
employed - see below)
One further column may be added if desired by the medical staff:
(j) Result i.e.: Cured (C); Relieved(R); or Un-relieved(U)
Savings can be made by using devices such as: instead of
recording sex and age as two separate entries have two columns printed
on the card headed M and F respectively. Write in the age under
the correct heading, for example:
MF
32
23
18
19
Medical staff vary in their opinions as to what is considered
necessary to be recorded, butthought must be given to including
information likely to be required later for medical research or
education. Before a decision on the composition of the disease:
index is made current and likely future requirements should be
thoroughly discussed with medical staff.
Indexingf diseases
Indexing of diseases can be defined as "recording on a card
all essential data on each patient suffering from a particular.
disease for which that card is kept.
2.2.1 Indexing and cross indexing
Simple indexing (that which is not cross indexing) involves
recording the data according to (a) to (j) above on the individual
disease card for each condition the patient was diagnosed as
having, separately and without reference one to the other.
6
there is no card in the index, is made. The consequences of
failure in this way are, to say the least, highly embarrassing when one is proved wrong, and could be fatal in a serious
emergency.
Proportion of names to letters of alphabet: 2.1.9.
Finally, in planning the space to be allotted to each
letter of the alphabet in an index, it is worth remembering that,
in general, there are twice as many W's as A's; twice as many
B's as G's and that about one name in every five begins with
the letter M or S while it is 'obvious that few begin with X or
Q or even I.
Whatever filing rules are laid down must be adhered to and
understood by all staff if the patient index is to be the
trusted servant it is supposed to be.
With regard to the patient index generally, it is
important that, only, information relating to identification should
be recorded therein and nothing of a medical or confidential
nature as the patient index, unlike the medical records
themselves, is open to other non-Record staff for various
reasons, and such untrained persons could unwittingly give
away medical details relating to a patient which could give
rise to medico-legal difficulties.
The Disease Index: 2.2.
The first essential in establishing and maintaining a
disease index is the possession of a thorough knowledge of the
nomenclature employed and a sound familiarity with coding and
medical terminology. This chapter should be read in conjunction
with those dealing with Classifying of Diseases and Operations
(chapters 11 and 12) because indexing is simply the practical
application of a disease operation classification. 'The
International Classification of Diseases' is universally used
throughout New Zealand and is discussed in chapter 10.
The Disease Index iE usually a card file of one type or
another containing as many individual cards as code numbers
including fourth digit sub-categories decided upon, assembled
in numerical order following the scheme of the classification.
Each card will be headed with the year of admission of the
patient and the title of the disease according to the Classification, together with the appropriate code number. The main
body of the card will then be divided into columns that should
Acourt, Adcock, Ainsworth, Allard, Anderson, Attlee, etc. The
number usdd will depend on the size of the index. Too many will
be a nuisance and too few of little value. Examination of your own
index would suggest the proportion.
2.1.5 More than one card
There is usually one card per patient but of course some, by
reason of many admissions, will run to two or more. It is best to
arrange these in chronological order with the card showing the
first admission nearest to the front of the drawer.
2.1.6 Titles
Titles such as Dr., Rev., or Father, Sister etc. are not taken
to be part of the surname for filing purposes, but may be placed
before the first or Christian names on the card as long as they do
not take part in the sequence of letters.
2.1.7 Maiden names, etc.
The legal name of a married woman is always the one used for
filing though if desired for additional identification, her.
husband's first name may be shown in brackets, e.g.. Mrs. Wilma
Blank (James).If a women's surname changes by virtue of.1
marriage or remarriage between admissions, it is.wise to maintain two cards in the file with the later one referring to the.
card bearing the previous name, e.g. Blank, Joan (nee Williams).
A full cross index is provided by noting also the first card
with the words 'see floW t as with: Williams, Joan (see now
'Blank'). Dates of admission will also be transferred to the new
card.This procedure safeguards against the not too infrequently
met occurrence of a woman patient choosing to resume her previous
name.Patients of both sexes will be encountered who are known
by more than one name and are wont to alternate them between.
admissions. A similar type of cross reference to that just
described will be of value. It is definitely unwise to erase
a prior name, substituting the new one, and filing the card elsewhere in the index.
2.1.8 Different spellings
In searching the master index, it should always be kept in
mind that there are many and various ways of spelling some names,
and as many possibilities as can be thought of by everyone in the
office should be investigated before an arbitrary decision that
6
In case of doubt,, refer to the N.Z. standard specification.
Foreign names:
2.1o5r
Some degree of difficulty and or confusion may be expected
over the indexing of some foreign names, particularly of
Asiatics or Pacific Islanders,
Ignoring the intricacies of foreign name structures and
dealing only with the manifest results, it will be found that
such patients may reverse the order of their names between
admissions so that what was the 'surname' on one occasion
may become or appear as the first or Christian name or names,
on the next. This situation can also arise as a result of
language difficulty, when the Admission Officer may find it
impossible to communicate what is meant in English by the
term 'surname' to the patient.
While it is not feasible to suggest that all foreign
names appear re-arranged at some future date, it is essential
that all discovered instances be FULLY CROSS INDEXED in the
Patient File.
The Index must therefore contain either:
(a) A duplicate card for each name variation known
and each having a notation stating "SEE ALSO" and
thereafter listing the others. With this method,
each card must be brought up to date on each
admission.
or(b) One master card covering all details of admissions
and discharges etc., under a selected name variant
and 'dummy' cards for the others, each having a
reference to the master card.
Aids to location in filing:
A worthwhile refinement to arranging index cards is to
insert at regular intervals in each drawer taller cards bearing
the surname to which they are adjacent. If the names on your.
standard cards are typed near enough to the top this can be
done by taping or stapling them onto a 'standard card i ll or so
from the bottom. By providing a quick guide to the relative
alphabetical positions within the drawer they save a great
deal of time in needless thumbing through cards. For example,
in the 'A' section a guide card could be set up at the names
2.1.2 Order of filing
The cards must always be arranged in strict alphabetical order
as in a dictionary or telephone directory. It is a matter of choice
if a special drawer is. maintained for the Mc's and Mac's, otherwise these are placed in their appropriate position with other
names begining with MAC....
Prefixes are treated as part of the name, e.g.
Thomas A'Kempisfile as AKEMPIS, Thomas
DATH, George
George d'Ath
Leonie de Brett DEBRETT, Leonie
Maisie de la Rue DELARUE, Maisie
Alexander du CroixDUCROIX, Alexander
Ramon El Cortez ELCORTEZ, Ramon
Helene L'Africe LAFRICE, Helene
Michael la Roche LAROCHE, Michael
LEFEVRE, Joan
Joan le Fevre
TEPAA,
Ngaire
Ngaire Te Paa
VAAFUSU,
Maatsu
Maatsu Va'Afusu
VANBERGEN,
Hermien
Hermien van Bergen
VANDENBERG,
Rex
Rex van den Berg
VANDERWAL,
Thelonius
Thelonius van der Wal
Hermann von SturmerVONSTURMER, Hermann
M' and Mc are treated as Mac, e.g.
Angus M'Tavishfile asMACTAVISH, Angus'
MACDONALD, Flora
Flora McDonald
St. is treated as if spelt in full e.g.
Gordon St. John
SAINTJOHN, Gordon
The ones very seldom met with are best filed under the
main name, e.g.
Dilys ap Morgan
MORGAN, Dilys ap
In the case of Chinese names ascertain which is the
surname or family name and file it as usual, e.g.
FONG, Tom
Tom Fong
HOY, Fang
Fang Boy
There will be many instances of the same surname appearing in
the index. This presents no problem and serves to illustrate the
wide flexibility of the card index if the strict alphabetical sequence
is simply carried on through the first names. Filing of cards is
made generally easier and more accurate if the names themselves are
ignored as such and simply regarded as "onesuccessionofletters".
Ignore the hyphen in compound surnames.
M.
filing cards according to the sound of the name and not
according to the spelling. It is in limited use in smaller
hospitals in countries like the U.S.A. where there is an
enormous variety of surnames - a prime reason for its use;
in New Zealand, however, where there are relatively fewer
surnames phonetic filing will not be found of great use and is
not recommended, although a modified form of this system is in
use in some hospitals and in the National Health Statistics Centre.
Certain names are filed together, e.g. Gray and Gray, Johnson
& Johnstone, Reid, Read and Reade. If the Greys and Grays are
filed under Grey, a marker card is filed under Gray pointing
out this fact. An advantage of this system is that the lazy
researcher is more likely to find a previous reference —to 'a
wrongly spelt name this way.The visible card file needs no
explanation these days but it is worth noting that it has been
described as 'the most flexible way of organising information
yet invented' and is indeed an indispensable servant as long
as it remains comparatively small. It can become an embarrassing burden as it grows ever bigger. This factor is, however,
heavily outweighted by the advantage it holds over the old
bound book system of indexing,. in which it is possible to
group only surnames beginning with each letter of the alphabet.
With the card index, however, it is possible to arrange every
surname under each letter in a predestined and rapidly located
position when the cards are filed in strict alphabetical order,
that is, following the alphabet letter by letter through the
surname and on through the first names to a fine degree of
subdivision. The possible positions are therefore virtually
endless.
Assembling of patients' index cards in separate groups
according to the year of admission is not recommended, and is a
method that has been replaced by the perpetual index which
contains the cards of all patients irrespective of when they
were admitted and is by far the less cumbersome. It is
difficult for patients to remember sufficiently exactly when.
they were last admitted," therefore any system based on the year
of admission is a poor one.
The following points should be borne in mind when operating
a patient index:
Surnames: 2.1.1.
The surname should always appear first on the card, followed
then by the Christian or first names.
it
proportion of the entries against the time consumed in entering •a
great many more that will never be used. Added to this basic
problem is the complication, particularly in a medical index, of the
very rapidly shifting emphasis on the type of demands made upon
it, due to advances in medical discoveries. Early workers in
this field may have been carried away in their first flush of
enthusiasm with the notion of indexing everything and anything.
However, over the years as techniques have developed and been
refined in the hard school of experience, it has now become more
a matter of tailoring the system to fit the needs of the hospital
in which it is used. It is obvious, therefore, that there are a
number of variables to be taken into consideration in establishing
an indexing programme for a particular department in a particular
hospital. An index that meets less than the demands that will be
made upon it will be unsatisfactory as will the over-elaborate
and top heavy system that requires a vast amount of labour to
maintain but has few demands made •upon its resources.
It has been said that the final test of an index is whether
in fact it satisfies the medical staff who have to use it.
Once an indexing procedure has been decided on, the prime
concerns become completeness and accuracy within the adopted
framework. A Medical Records department will invariably be
judged by the manner and ease with which the information stored
within its archives can be released for practical use by doctors
and others, and this factor will vary in direct relation to . the..
degree of skill and attention that is applied to this section of
office procedure.
.
2.Indexes of the Medical Records department
i.
2.
3.
+.
The Patient index
The Disease index
.1.
The Operation index...
The Physician's index. (Not always required to
be kept by many hospitals but can be of great
value to medical staff)
The Patient index
,This index is the key needed to locate medical records and
any other information relating to a patient held by.the Medical
Records department. It is usually an arrangement of cards kept
in a vertical file in strict alphabetic order, or, if desired,
filed by the phonetic systems It is not proposed to describe
phonetic filing in detail in this chapter. Briefly, it means
7,
INDEXING PROCEDURES
1.Introduction
Indexes of the Medical Records department
2.1 The patient or file index
2.1.1 Surnames
2.1.2 Order of filing
2.1.3 Foreign names
2,1.+ Aids to location in filing.
2.1,5 More than one card
2.1.6 Titles.
2,1.7 Maiden names etc.
2.1.8 Different spellings
2.1.9 Proportion of names to letters of alphabet
2,2 The Disease Index
2.2.1 Indexing and cross indexing
2,2.2 Group indexing
2.3 The Operation Index
2 .3.1 The operation code
2,3.2 Operation indexes other than a coded
nomenclature
2.4 The Physician's Index
3.Machine recording
3.1 The punch card
k.. Conclusion
method of indexing
5,References
6.Further
reading
6,1 Basic
6.2 Background
6.3 Associative
Introduction: 1.
The indexing of files, diseases and operations may well be
described as a corner stone of Medical Record Office procedure.
Medical records are by their nature a mass of statistical
information, which must be sorted, classified, and recorded in .
such a way as to render it quickly and easily accessible to
doctor and research worker, who must in turn be able to rely
on a high degree of accuracy.
-Maintaining an index of any kind is very much a problem
of balancing the time saved in finding a relatively small
methods
pp lLf3_57
(Lincoln & Naylor) Record
department administration,
physical plant, functional
organisation and other
factors
PP 150-67
'Medical Records'
N.Z. Hospital, June
p 61+.
Wakely (Gerald) 'What's your
name and number?'...
pp 213-216
8.3
1952,
Associative
Schulz (M.D.) & Wang (C.C.)
A simple method of follow-up,
disease index and filing of
radiation therapy records
Radiology, Nov. 1962
pp 81+2-7
b9
S
Luck (J.H.) Work study as
applied to Medical Records
Hill (Peter A.) Work study and
the clinical record. 3. Filing
McWhirter (Prof. P.) The
Medical Record Service and
malignant disease (includes
remarks on unit system)
pp 88-106
pp 207-211
1966,
PP 57-70
'Medical Records & Secretarial H.M.S.O. 1959
Service Report no. 2 p.12-14
Morgan (J.H.) Medical RecordsMedical Record, April 1951
Departments: The Cardiff Pp 90-5
Royal Infirmary
Pedelty (Neil) The Copenhagen
N.Z. Medical Record, Dec. 1966
County Hospital medical records pp 2 7-31, 14, 46
system
Seymour (E.L.) Filing and
disposition of records
Seymour (E.L.) Visual Automatic
filing
Medical Record, June, 1951
PP 91-103
Pp 156-59
Wakely (Gerald). A question of N.Z. Medical Record,
identity: a hospital identi-Sept. 1 9 6 7,
pp 21 -33, 45
fication system for New Zealand
Wolstejn (Mrs. E.) Medical records
in hospitals in the General N.Z. Medical Record,
Federation of Labour in Israel Sept. 1967,
P p 1 3-20, 45;
PP 10-13
Background: 8.2.
Clarke (K.W.) The group organisation in Medical Records
Doran (M.T.,) The need for
methods
PP 117-27
pp 129-41
Dudley (H.A.F O ) The Consultant's Medical Record, Nov.
1962
need for Medical Records PP 580-86
Fraser (Dr. A.) A Consultant's Medical Record, Nov. 1963
view of Medical Records pp 582-8
'Future use of Medical Records' Medical Record, Nov.
(three views) PP 433-42
1961,
8. Further reading
8.1 Basic
Balmer (N.) Colour in serial Medical Record News, Oct. 1963,
numbering
pp 197-9
Bothwell (P.w.) R outine, records Medical Record, Aug. 1960,
and research Pts I - III pp 298, 302; Nov. 1960,
PP 320-7; Feb. 1961,
pp 359-6k
Britton (D.B.) Filing systems - Medical Record, May 19629
aids to efficiency pp 523-30
I
Brockis (R.) Supervision ofMedical Record, Nov. 1958,
filing procedurespp 44-47
Brockis (R.) Tracing system Medical Record, Feb. 1956,
pp 14-15, 37
Collison (R.) Filing and index- Office Magazine, April 1963,
ing Pt. 4 Cards
Collison (R.) Filing of
tomorrow
Dec. 1964, pp 1025-7
Collison (P.) The secrets of
successful filing
Office Magazine, March 1964,
Chamberlain (J.) Finding the
misfiles in a terminal digit
system
Jnl AAMRL, Aug. 1961,
Coombes (PS) Getting more
files into the same space
Ferguson (P.) Supervision of
filing procedures
Medical Record, Nov. , 1958,
'Filing by the terminal digit
method' in 'Methods at work'
London Current Affairs Ltd.,
1962, 101 pp.
Gibbins (C.H.,) & Cashmore (V.
F.) Control of appointments
and records
'Guide to the organisation
or a Hospital Medical Record
Department' pp 11-17
Hadlett (E.A.) The ideal.
hospital filing system
Hunt (C.A.) A simple tracing
system
N.Z. Medical Record,
Dec. 1964, p 13
Kurtz (Dorothy L.) Culling
Medical Record News, Dec.
pp 1-7
pp 396-8
pp 159, 177
p 257, 262.
pp 47-8
pp 201-6
1962, vii + 83
pp 489-91.
1964, pp 247-50
4
5
Medical Records department').
Summary and conclusion: 6.
(i)
(ii)
(iii)
(iv)
(v)
(vi)
A good filing system ensures that records can be
produced when wanted,
Identification can be: alphabetical (not. recommended)
or numerical.
Numbers should be given on admission in preference to
discharge or by diagnostic classification.
Numbering can be: serial (not recommended); serial
unit (where space is at a premium); unit (recommended).
The unit number can be a digit number, or the 'New
Plymouth' system or the 'Luhn code'.
Filing systems are decentralised or. centralised
(recommended) or a combination of both.
(vii)
Shelf filing can be straight numerical or terminal
digit.
(viii)
Advantages of terminal digit are uniform expansion,
easier filing and facilitates 'team' organisation
of department.
(ix)
Arranging files up and down rather .than across makes
for easier reference. .
The unit number system and terminal digit filing are recommended as experience in overseas hospitals has proved their worth
which has been confirmed by those New Zealand hospitals using the
system.
.
References: 7.
Huffman (Edna K.) Manual for Medical Record Librarians.
Physicians' Record Co., 1 959, pp 16 7- 1 90 ('Numbering
and filing medical records')
Proceedings of the 1st Conference of N.Z. Medical
Records Officers' Association, 1965
N.Z. Medical Record, August 1966
5.2.3 Colour coding
As a guard against misfiling the record container can be
colour coded. Advertisements in overseas journals advocate multiple
colour coding. However exciting this might be for the decor of
the department it is not practicable under New Zealand conditions.
Colour coding should therefore be for the terminal digit of the
primary number, i.e. 0 -9. The colours chosen should be ones which
will be legible since not more than one printing should be done
(refer chapter 20 'Design of forms' para 4.3).. Obviously dissimilar
colours must be used for numbers which are liable to be confused at
a first glance e.g. 3 and 5 or 8, 6 and 9, 9 and 0. 'Coloured
adhesive tape can be used for the second digit in the primary pair
and/or for the terminal digit in the secondary pair. However, tape
is liable to come off and there is no point in, operating an elaborate
taping system if it takes more time than searching for a misfile.
Similarly, colour coding containers which stay on the shelves
whilst the contents travel is pointless; it merely shows that the
envelope was correctly filed in the first place. If the envelope
travels with the record inside then it should be colour coded to
guard against misfiling when it returns and is put into file; if
the envelope stays on the shelf and the contents travel then the
latter should be coloured. A folder, colour-coded, would be cheaper.
5.2.4 Misfiles
Edna Huffman quotes the following:
(1) Look for transpositions of the last' two digits of the
number, or of the hundreds or thousands digits.
(ii) Look for misfiles of t31 under '5' or 1 8' and vice
versa; and of '7' or 1 8 , under' '9'.
(iii)
(iv)
(v)
Check for a certain number in the hundred group just
preceding or following the number as 485 under 385 or
585, or under other similar conibinations.
Check for transpositions of first and last numbers.
Check the folder just before and just after the one
needed. It sometimes happens that a folder is put
into another folder rather than between two folders.
5.3 Tracing records
Methods of recording the whereabouts of records removed from
file are covered in chapter 3, para 2.2 ('Organisation of a
5
Conversion back to total running feet - 58 x 3 x 7 = 1218 ft
will indicate that there is more shelving than was originally
asked for, i.e. 1218 ft total instead of 980 ft. or 12.18 ft per
primary number instead of 9.8 ft. It will be recalled that this
was described as the ideal situation and it will be apparent that
the extra shelves, whilst not lending themselves to use for the
terminal digit filing, will not be wasted.
In practice, what usually happens is that one is given an
area and a compromise has to be reached between shelving wanted
for the ideal time for which records are to be kept and the
shelving that will fit in the area. Therefore, as indicated
above, , the compromise will include some fixed shelving for terminal digit and some mobile shelving for straight numerical
filing.
How to arrange files: 5.2.2.
Filing is made easier if done from top to bottom rather than
along since this avoids always having to get up or bend down for
one primary number. Thus assuming four 3 ft bays with 7 openings,
filing along the shelves:
but up and down:
-z
4
z 4 ;
4
01—,7- , -,> 0____
0)
03
6L.
10
Example: Records to be kept in terminal digit filing for 7 years.
Average anticipated discharges per year = 7000
Average number of records/ft = 50
•'. Running feet of shelving required = 7 x 7000 altogether
50
or7x7000
100 for each primary
50
number
=
9.8 ft
Nearest multiple of 3ft above= . 1 , 2 ft
.'. No. of 3ft bays required =12 x 100
3
No. of units 7 openings high
=
400
=
400
7
571/7
=
i.e. 58
This requirement is then worked out in terms of the filin g
suitable for the area. If all are free standing and can therefore.
be assembled back to back they might be in units . 9 ft. or 12 . ft
. long so that access is easy: .... . '..
Units:, .3' . x !?.
shelves
WOMM
16
M=M"
16
mm
^
IMMMMI
14
12
58
0
Any hospital that contemplates changing over to this method
of filing would have no difficulty in doing so. It is not
necessary to convert old records to the system; all that is
required is to set a 'deadline' and commence your new system
and as readmissions are made convert the old records as required.
To summarise the advantages of terminal digit filing;
(i)
all sections expand uniformally;
(ii)
annual transfer of files to storage is eliminated;
(iii)
filing is evenly distributed among filing clerks;
(iv)
reduces misfiling to a minimum.
Determining how much space is needed: 5.2.1.
The ideal situation is described first.
Decide: for how many years are records to be kept in terminal
digit filing.
Calculate: (i)
(ii)
average anticipated discharges/year
average no. of records/ft. of shelving
Formula: Years of storage X average
discharges- Total running feet of
Records/ft.- shelving required
then:Punning feet shelving
- required- No. of feet required for
100- each primary number
This is then taken up to the nearest multiple of 3ft. (the
standard shelving unit)
.. No. of 3' bays required = Nearest multiple
of 3ft
x 100
But shelving is so many openings high (7 recommended for
fixed shelving), therefore calculate the number of units required
3ft long x 7 openings high.(Specifying 'openings' rather
than 'shelves' is preferable as less ambiguous; 'shelves! could
include the top, unused shelf)
it can be seen that all files on each shelf must end with the
primary number, as example the file quoted above would be on shelf
42. This also tends to decrease the chance of files being misfiled. Therefore, on the shelf labelled 42, assuming that numbering
started at 000001, the first files will be 000042, the next 010042,
and so on to 2400 1+2; the next will be 0001+2, 0101 1+2 ... 240142,
000242, 010242 ... 240242 and so through the changing secondary
numbers to 006642, 016642, 026642 .... 236642, 246642. There will
not be another record placed in the 1+2 shelf for another 100
numbers and not another in the 66 division of the +2 shelf for
another 10,000 numbers.
With terminal digit filing the shelves on average fill
equally rather than at the end as is the case with numerical
filing.
It is essential to be able to locate a file as soon.as possible and under this method it is only a matter of seconds, once
the number is known, to do this. The clerk is able to go to the
right shelf and the right divider straight away and it is then
easy to find a number of two digits; this is not possible in any
of the other systems.
Another advantage of this method is explained in detail
in chapter 3 ('Organisation of a Medical Records department').,
Briefly, because each section is added to equally it is possible
to distribute the work in the office equally by making different
clerks responsible for blocks of numbers of records - the "team'
concept.
The system has the disadvantage that space must be kept free
for expansion and this is very difficult to do where' space is
limited. The method is not suitable for use with mobile shelving
and, if used where space is limited, it involves continual culling
to take records not in use out of the system and into less convenient storage. This, however, does mean that each record must be
looked at and long-standing misfiles can be picked up in this
way. Therefore, because space is seldom unlimited, it will usually
be more realistic to keep the more immediately needed records
in terminal digit filing and older ones in mobile shelving or less
accessible shelving filed numerically. The aim should be to have
7 years' terminal digit filing but if only 3-4 years can be kept
terminal digitally the system is still worthwhile. Below this,
however, it needs to be ascertained that much moving to and fro
will not be involved.'
S
Shelf filing methods:
5.
There are two ways medical records may be filed numerically
on the shelves in Medical Records departments:
Straight numerical method: 5.1.
Firstly, there is the conventional numerical method, which
has been in use by hospitals for many years. Using this method
the records are filed in numerical order with a guide at least
every 500 charts. If filed annually then guides should indicate
where each year starts. This method has the disadvantage that
current filing activity is concentrated on one or two shelves
causing congestion in a large department where several people
pull and replace records. It is easy to make errors by transposing
digits.
Terminal digit method: 5.2.
Secondly, there is the less conventional method known as
the terminal digit system. This method of filing has been very
successful particularly in larger hospitals. Terminal digit
filing is a simple but speedy and accurate method of filing.
This method eliminates many possible filing errors, as it
practically does away with the transposition of numbers, the
commonest of errors in filing. . When filing under this method
the clerk only need keep two digits in mind at the time of
filing.
The details of terminal digit filing can be described as
follows: on admission the patient is assigned a number which
is broken down into digit groups for reading from right to left.
The first two digits, on the right hand side are called the
primary number, the next two numbers on the left of the primary
numbers are called the secondary numbers. Taking a hospital
number as an example, 2 1-f66 1-f2, the number is first divided into
three parts 24-.66-. - 2. The last two digits constitute the
primary number. As there will be a large number of files
ending with 42 this needs to be subdivided first to the
secondary digits - 66 - and then according to the third group.
Thus a patient with the number 246642 would be filed in the
division 66 (secondary numbers ) of the 42 section (primary
number) in the sequence of the third group of digits. If the
terminal digit system is used, it is advisable if space permits,
to have 100 filing, shelves in sets of 10. If this is practicable,
connectionbetween the files; if the patient is transferred from
one department to another the record is obtained by way of loan.
As an example, when a patient visits the Outpatient department,
the record is filed in that department. If the patient is subsequently admitted to hospital the record for that hospitalisation
is filed in the Medical Records department. The patient on discharge may revisit the outpatient clinic for further treatment,
in which case the record previously made by the outpatient clinic
is brought forward but is not combined with the record held in
Medical Records. Such a method could be detrimental to the
patient and hinders efficiency, as all records concerning the
patient are not immediately available at all times. Records are
inclined to become duplicated which not only increases operating
costs but in most cases takes up valuable filing space. For
these reasons this method is being replaced by the centralised
system in the majority of hospitals throughout the country.
4.2 Centralised system
Under this arrangement all the medical records of the patient
whether inpatient or outpatient, are filed together in . the.one
department. Under the centralised system any method of numbering.
as outlined above may be used. It has the advantage that all
records are together.Those who prefer to keep records decentralised say that the centralised system ,means that they cannot
immediately answer telephone enquiries from private practitioners
about patients who have attended at their departments. This
again is a matter of administrative inconvenience which is outweighed by the clinical importance of having all records in one
place,
Specialist departments (e.g. neurology, cardiology, teaching
and research units) argue strongly that they should 'keep their
own records. Generally accepted practice overseas which is , equally
applicable to New , Zealand is that there is nothing to prevent a
department doing this within reason provided that these records
are copied (not physically abstracted) from the main record.
To what extent this is done will depend on staff .and.other
facilities available but the object would be to accumulate
material for research and teaching and not to substitute departmental notes for the patient's medical record.
Whether or not centralisation should include Accident &
Emergency department records is discussed in chapter 16 ('Outpatient and Accident & Emergency department procedures').
the same month, would be impracticable in a large hosp4t•ai (over
200 beds)
The 'Luhu' system: 3.3.3.
This system, devised by a member of the staff of IBM,
utilises the first i-i- letters of the surname, first two initials,
the birthday (day of month and month and unit of year) and a
machine-generated check number. If the patient is a woman 5
is added to the first digit of the day of birth. it is ' claimed
to have a duplication rate of only 1 in 10,000. Thus John
Montmorency Smith, born 18 August 1 938 , might have the number:
SMITJM18889, the last figure being the check number. This
system has to be used with data processing equiment with an
attachment to generate the check number, which is a device to
check against transposition or writing a wrong digit. If, for
instance, the number had been written SMITJM 18389 the machine
would query the number because this combination would not
provide the check number 9. The system has the disadvantages
that it relies on the correct and consistent spelling of a
consistent surname (though a computer could be programmed to
search for alternative spellings) and accurate and consistent
birth dates. It is not suitable for terminal digit filing.
Both the systems relying on the use of names as part of the
number are particularly unsuited for hospital admission numbers
in New Zealand because of the number of unmarried mothers using
false surnames for social reasons, the tendency of Maoris to use
Maori or Pakeha names at will and of Islanders to interchange
surnames and Christian or first names and the difficult>rthat
predominantly pakeha clerks have in spelling these names.
Filing systems: 4.
Systems of filing, apart from the numbering system, fail
into two categories: decentralised or centralised, Cr S
combination of both.
Decentralised system:+.i.
Under this arrangement the inpatient and outpatient departments have their own records and file them independently within
their own department. Unless a central summary card of all
attendances both inpatient and outpatient, is kept, there is no
number how many patients have been in during the year. Detractors
of this system stress this disadvantage, which is purely one of
administrative inconvenience at the expense of the advantage of
having all notes in one pack, which is a clinical one.
There are different methods of allotting a number which are
suitable for the unit system; these are discussed below.
3.3. 1
Digit number
A single number of +, 5 or 6 digits is allotted, depending
on the size of the hospital. As 6 digits can be difficult to
remember one letter could be introduced, and would thus have the
effect of adding 26 extra digits. This would still lend itself
to terminal digit filing (see para 5.2 below) as long as it
preceded the primary and secondary numbers. Errors in transcribing
numbers can be lessened if they are treated as pairs of numbers 36 75 06 - as with the terminal digit filing system rather than
one long number - 367506.
3.3.2 The 'New Plymouth' system
This system, used satisfactorily at New Plymouth Hospital,
employs the first three letters of the patient's surname, the
month and last two figures of year of birth. Where any numbers
are missing an X is substituted. Thus, John Smith born in
August 1938 would be given the number SM1838.
The advantages of this system are that as soon as the
patient's surname and month and year of birth are known he can
be given a number, the system is easy to operate and the records
can be found if index cards etc. are missing. A further advantage is that a number can be issued by any department of the
hospital as soon as name and month and year of birth are known.
However, this is offset by the disadvantage that variations in
spelling of surnames will involve looking in different places
(Gray, Grey, Smith, Smyth etc.) and consequently the patient
index has to be consulted.Further disadvantages are that the
system assumes constancy in surnames which is not the case
particularly with Maoris and Islanders and after a woman has
married requiring reference again to the patient index for birth
dates, addresses etc.; reliable dates of birth are frequently
difficult to obtain. This system is not suitable for terminal
digit filing. Furthermore, the system, by requiring one to
search out the John Smith who was born in August 1938 from amongst
all the Charles, Federick, James and Montmorency Smiths born in
57
old envelopes/tracers have to be renumbered; if
'readmitted' then reference has to be made to the index.
Whichever is done this takes longer than referring to a single
once-fo-al number, and chances of error increase.
However, where the number of people under the same name in
the patient index is not too many, reference would be from the
Disease Index to the patient index and thence to the latest
admission. It is good practice in this and other method 's to
maintain a summary sheet at the front of the record pack showing
dates of admission and discharge, diagnoses, operations and,
under the serial unit numbering system, the hospital number.
Although the serial unit numbering system is considerably
used in New Zealand it is being replaced by the unit numbering
system which is a better system.
Unit numbering system:
3.3.
The patient is given a number on admission or first
attendance at the in- or out-patient department of the hospital
and retains that number for all subsequent admissions to any
department or ward with the possible exception of the Accident
& Emergency and X-ray departments. If this method is employed
the filing shelves must not be filled to capacity as the record
is continuous and additions will be made following each readmission.
The main advantage of this system is that all the records
of the patient irrespective of the type of disease or disability
are kept together so that the doctor treating the patient may
consider the patient as a complete identity. Considered a
disadvantage by those used to the serial unit system with
records in annual blocks is the absence of an indication of
year in the number. Consequently, it is not possible to
extract records for a certain year for filing elswhere
merely by looking at the number. This, however, can be an
advantage in that it means that each record has to be looked
at individually and random misfiles can then be picked up.
This means a readjustment in work habits whereby culling is
done methodically day by day rather than in an orgy at the end
of the year.Another disadvantage (by comparison with the
number allotted on each admission starting from 1 each year)
is that one cannot see at a glance from the current hospital
ment which the previous records require him to get. This disadvantage can, to a certain extent, be overcome by keeping an index
card on which all the numbers are recorded; this should also show
the diagnosesFurthermore, a summary card of inpatient and outpatient attendances should be used. It still involves, however,
going to several-different places for previous records. It should
be clear that this method is not recommended.
3.2 Serial unit numbering syste.m
By this method the patient is assigned a new number on each
admission and all previous records are brought up to the latest
number on each readmission. If this system is used and the records
for all admissions are combined, the same •procedure may be followed with the patient's index card, by showing all the previous
admission numbers on the index card, and not creating a new card
for each admission. When this method of numbering is used the
filing shelves may be filled to capacity as the records are
complete when filed. This is one of the advantages of this method
of filing. It is also a disadvantage in that the temptation is,
when moving records for filing elsewhere, to take an entire shelf
without checking individual records which is the only way that
long-standing misfiles can be found.
The main disadvantage comes in referring to these records from
the disease index.. To take an example: cases of chorea in
females of childbearing age are required. These will be •few and
therefore spread over many years. If one is found who was admitted
10 years ago and has subsequently been admitted for other reasons
the latest number has to be found. As the Disease Index usually
only lists surnames, initials and sex (refer chapter 6, : para 2.2)
it is not practicable in the larger hospitals to search the
patient index until the patient's card with the latest number is
found. It will therefore be necessary to work forward from
admission to admission until the latest one is found. To enable
this to be done the following procedure has to be carried out for
all records where there is a readmission:
(i)
(ii)
the original envelope or a tracer has to be left in
place of the number shown in the disease index;
this envelope or tracer has to have either the following
number, the latest number or 'readmitted' on it. If
it has the following number then one looks at each
succeeding envelope/tracer until the current one; if the
latest number is put on then for every redmission all
5
and the unit method-s.
Before determining which to use it must be decided how the
number is to be allotted to the patient. This can be:
(i)
(ii)
(iii)
admission numbers. A number is allotted to a patient
on admission or first attendance. This is the generally
accepted method, since, for positive identification,
a patient must have a number throughout his hospital
stay;
discharge number. The number is allotted on the
patient's discharge;
diagnostic classification code numbers allotted in
accordance with the classification of the final
diagnosis. Neither this nor the previous method
is recommended because the patient does not
receive a final number while he is under treatment.
In the case of the diagnostic classification number
system a temporary number is given while the patient
is in hospital and this is changed to the diagnostic
classification number for filing purposes. Thus
there is no positive identification of the patient
because there could be confusion between the two
numbers.
Serial Numbering system: 3.1.
In this method the patient is assigned a new number on each
admission, regardless of the number of readmissions, the number
always being the next unused number in either the patient's
register or the number index. Some hospitals using this method
prefix the number with the year and begin at number 1 at the
beginning of each year.
The disadvantage of this system is that the patient's record
is filed in one or more places in the filing depending on the
number of times the patient is admitted. One advantage of the
system is that filing takes less time, as it is not necessary to
look up and bring forward previous records. This advantage is
heavily outweighed in that, when the records are disturbed in
this manner, more time is required for collecting all the
previous notes together should they be required by the physician
or surgeon. This makes the doctor reluctant to ask for all the
records, and in such cases the patient may not receive the treat-
(i)
(ii)
(iii)
The medical records should be able to be produced when
and where required in the minimum amount of time and
with the minimum amount of effort;
the system should provide safe and confidential custody
of the records and be as foolproof as possible;
the best use should be made of available space.
2Method
As the medical records are .wanted 'for future reference' it
follows that:
(i)
(ii)
there must be a way of identifying them;
they must be so located and arranged that they can
be found.
Identification can be:
(i)
alphabetical. By this method the records are kept
in order one behind the other in alphabetical sequence
of surnames. Because so many names are the same this
has not been found a reliable method for medical
records; it is,. however, necessary for indexes
(refer 'Indexing procedures' - chapter 6)..
(ii)
numerical. If each medical record, or all those
relating to one person, is given, a number, the number
can be ascertained from the index and the records can
be filed numerically as explained below.
By 'location' is meant the choice between decentralising having records relating to a patient in different places depending
on the reason for which he attended the hospital - or centralisation - having all the records relating to a. patient in one place,
normally the Medical Records department. These choices are
discussed below.
How the records are arranged means the way in which they are
physically arranged on the shelves - should they be in straight
numerical order or by some other method? . . This is disOussed in
para. 5 below.
..
3.Numbering systems
The methods of numbering which are accepted as adequate in
medical records practice today are the serial, the serial unit,
5
FILING SYSTEMS
1.
Introduction
2,
Method
3.
Numbering systems
3.1 Serial numbering system
3.2 Serial unit numbering system
3.3 Unit numbering system
3 . 3.1 Digit number
3 . 3. 2 The 'New Plymouth' system
3.3.3 The 'Luhn' system
k.
Filing systems
4.1 Decentralised system
4.2 Centralised system
5.
Shelf filing methods
5.1 Straight numerical method
5.2 Terminal digit method
5.2.1 Determining how much space is needed
5.2.2 How to arrange files
5.2.3 Colour coding
5.2.4 Misfiles
5.3 Tracing records
6.
70
80
Summary and conclusion
References
Further reading
8.1 Basic
8.2 Background
8.3 Associative
Introduction: 1.
Medical Records staff should use the following information
as a guide to establishing an individual policy which would be
realistic for the requirements of the patient, the doctors and
the individual hospital. Some of the factors which should be
considered are dealt with later.
'Filing system' is defined as the way in which you put
away papers for future reference.
are:
Fz
The requirements of a filing system for medical records
Appendix B (Continued)
CONSENT FOR MINOR
I, .s.s...s...o.....s..s... of.......... .... ......... ......
hereby consent to the submission of my child
............
to the
operation of..........................., the effect and nature of
which have been explained to me.
I also consent to such further or alternative operative
measures as may be found to be necessary during the course of such
operation and to the administration of a local or other anaestheticfor the purpose of the same.
I understand an assurance has not been given that the
operation will be performed by a particular surgeon.
(Signed).. . . . . . •.s.. • • .
DATED this . . . . . •.,*,,****'day of........ . . . . • 1 • . 19., . . . .
(Read over and explained to the signatory, who stated that
he/she understood the same and affixed his/her signature in my
presence)
. .
(Witness) . . . . . . . . . . . . . . . . . . . . . . . . • 1
(Medical Officer)
CONSENT BY PATIENT APPENDIX B.
-Ie.,soe,s,,s.,,000
.0.00000
of.
•............ •• ••...'. .......
hereby consent to undergo the operation of
the effect and nature of which have been explained to me. I also
consent to such further or alternative operative measuresas may
be found to be necessary during the course of such operation and
to the administration of a local or other anaesthetic for the
purpose of the same.
I understand an assurance has not been given that the
operation will be performed by a particular surgeon.
DATED this * ........ * day of..........,.............19........
(Signed).. . . . . . . . . • . • • • • • . • . • • 0• •
(Read over and explained to the signatory, who stated that
he/she understood the same and affixed his/her signature in my
-presence).
.
(Witness). . . . . • .. ..• . . . . . .... . . . .-. .
(MediOal Officer)
CONSENT BY RELATIVES
•..,............. a...,. .s.so
of.............,... .
•ss • • •o.o.
the ........................of the above name- d, hereby also
consent to such operation.
DATED this. •........ .... day of........ ....
o
•.19....... • • 5O
(Signed)... . ... . •. . . .... . . . .
.HOSPITAL BOARDAPPENDIX A
FORM OF CONSENT BY PATIENT
I,.... .. . •oo...... ..
S.. •ISIS•SS•S• . . . . .. . .. I • • • •• •• •I • S S
o f............................................. hereby consent to
t he operation of . . . . . . . . . . . . . . . . . . .
6 . . . . . . . . . . . . . . . . . . . . . . . .
• . . . . . . . • . • . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . to be performed
upon
•.....SS.sS.SS.So.SSS.,.Se.SS.. •5•SSI• •.••.S•I•
I acknowledge that the nature and effect of the operation
have been fully explained to me. I also consent to such further
or alternative operative measures as may be • found necessary during
the course of such operation or during the treatment period subsequent thereto and to the administration of a local or other
anaesthetic for the purpose of such operation or operations.
I acknowledge that no assurance has been given that the
operation will be performed by any particular surgeon.
DATED the. . . , . . . . . . . . . . . . .of. . . . . . . . . . . . . . . . . . . . 190 • . . .
Signed:....*
.• .................
PATIENT, PARENT, GUARDIAN,
RELATIVE
This consent was read over by me to the signatory who
acknowledged to have understood it fully and signed the same
in my presence.
Witness (Medical Officer) : . . . • . . . . . . . . • . . • . . . • . . . . . . . .
49
Levitt (Dr. W.M.) Infants and .Medical Record, Nov. 1951,
consent to operationspp 266-7
Stone (J.E.) Hospital organisa-London, Faber, 1952, xxii +
tion and management, pp 796-7,1722
1611
Background: 11.2.
'Guide to the organisation of
Department' pp 51-8
1962, vii + 83
McSwiney (B.A.) Hospital ethics
with special reference to legal
implications
Medical Record,, May 1961,
pp 393-7
Regan (W.A.) A lawyer evaluates
the Medical Record
Jnl. AAMRL, April 1961,
pp 53-5
Hospitals
1960, 54 pp
Springer (Eric W.) You, the
computer and the law
Medical Record News, Feb.
1965, pp 15-16, 18
For Rubins' tests, tubal insufflation: patients admitted 2021 days after onset of previous menstruation. There are exceptions to (b) in the case of post-menopausal bleeding and persistent unceasing per vagina bleeding.
It will be found, in most cases, that surgeons have, as a whole,
their own individual whims which a booking clerk must take into
consideration when working with them and making bookings for
operation sessions.
8.
Conclusion
Generally speaking admissions to hospital come during the daytime, although there is always the extra rush in the early evening
which normally is due to general practitioners making their rounds
during the day, finding it necessary to send patients to hospital
and invariably it is evening before they arrive for admission.
Evening in admission office is a very busy time, going through
the lists of admissions, checking with wards regarding discharges,
and completing lists of both admissions and discharges for distribution throughout the hospital, and it is at this time that particular care has to be taken to ensure that all discharges are
accounted for by number as well as name and that there are no
discharges missed by the individual wards. It is usual to make
a definite patient count with individual wards at, say, 8.30 9 o'clock each evening, by which time there will have been sufficient time elapsed to allow the wards to check their admissions and
all discharges.
In conclusion, the admission office duties as broadly outlined
here, are not to be regarded as hard and fast, but a guide for the
requirements of any particular hospital. Much admission office
work is unsupervised, presents daily problems demanding initiative
and good public relations and calls for the little extra beyond
the normal call of duty. It will be a challenge with which the
clerk who has a sense of duty and the welfare of the patient at
heart will cope and thereby achieve a sense of satisfaction in a
job well done.
9,
References
Medical Record Librarians,
PP 39-0 ('Record of
U.S.A., Berwyn, Ill.,
xxx + 604, illus.
admission,-)
110
7
major cases of surgery, most surgeons admit cases one day before
operation as preliminary investigation at a clinic will have
revealed any unusual features which could necessitate extra
investigation time before surgery is possible. However, some
common cases as outlined hereunder require extra time (a) Haemoglobin low but surgery necessary by a certain
-day: 7 days pre-operative admission,
(b)
Diabetic condition for ordinary surgery: 3-4 days
pre-operative admission, normally sufficient to enable
the diabetic condition to be stabilied. Diabetic
conditions for cataract extractions, however, are
normally given 7 days pre-operative treatment before
surgery.
(c)
Corneal grafts are always admitted two to three days
pre-operatively for bed rest and antibiotic treatment.
(d)
Hiatus hernia: 3 days pre-operative treatment for
physiotherapy instructions or breathing exercises
before surgery.
(e)
Gastrectomy: normally have a 3 day pre-operative
bed rest and preparation, blood tests etc.
(f)
Abdomino-perineal resection: usually admit 4.- 5
days pre-operatively for bowel preparation and
bed rest.
(h)
Some surgeons prefer to do haemorrhoidectomy after a
2 day bowel preparation but generally most surgeons
admit one day pre-operatively.
(i)
Major gynaecology operations are invariably admitted
at least 2 days pre-operatively for bed rest, blood
tests etc.
Care is necessary when booking female patients to ensure as
a general rule, that they are clear of their menstrual period
for the following types of operation (a)
Major Gynae. done per vagina
(b)
Minor Gynae. done per vagina
(c)
Haemorrhoidectomy
(a) Varicose Veins
(e) Tonsillectomy
too
operation list for a surgeon.
7.6.2
Medical waiting list
There is usually prompt admission, if hospitalisation is deemed
necessary, after the preliminary investigations are done. Unlike
surgical problems, medical problems cannot often wait for an
empty bed, so it is unusual to have more than a few cases waiting
to be admitted under a medical category.
7.7 Bed allocations for bookings
Bed allocations for surgeons and physicians vary from hospital
to hospital, but generally speaking there is a nominal bed allocation per doctor or team of doctors and they are expected to work
within it and only admit booking cases under their care if they are
within the allocation, whether it be 10 beds or a whole ward. A
surgeon or team of surgeons have a set number of operating sessions
available each week ' and it is necessary for the clerk responsible
for bookings to work in close co-operation with the surgeon to
ensure that sufficient booked cases are available for these
sessions and to avoid, where possible, wasteage of operation time.
Close co-operation is necessary to ensure that any cases
requiring surgery, already in wards from acute admissions, are
taken into consideration when making bookings for routine operation sessions, otherwise these can be overlooked resulting in
more cases than can be dealt with in a session, thereby causing
unnecessary patients in a ward and thus inconvenience to a patient.
In all cases, the surgeons and physicians take their turn on
acute admissions and must make provision prior to their turn to be
in a position to absorb acutes within their working beds.
To ensure that any particular surgeon or team of surgeons do
not admit more patients than is their normal quota, the daily
booking state is a very helpful guide to the booking clerk to
enable him to keep the surgeons and physicians advised of the
position.
7.8 Operating schedule
Where it is necessary to fill an operation schedule by any
surgeon, on any day, it is necessary to arrange for prior admission of the various booked cases. Generally speaking, except for
It'$
7
practitioners in the area. These cases are vetted and possibly
preliminary x-rays and laboratory tests done before the case is
recommended for the waiting list.
In all cases, any patient who required urgent surgery would
be admitted direct to a ward, as an acute, and dealt with
immediately. Other cases will be, as a general rule, assessed
as semi-urgent or routine and placed in the appropriate
categories on the waiting list.
For efficient control, and to ensure that the cases longest
on the list are the first ones admitted, it is wise to prepare
two index cards with essential details from the clinic cards;
these are filed in separate drawers, one in date order, and one
in alphabetical order. The date order drawer is the working
list used when making up an operation list. The alphabetical
order is for control of the list should it be necessary to locate
a person by name. Where a person is booked from a date order
card, it is essential to withdraw the alphabetical card at the
same time tb keep the list correct. Strip indexes as described
in the chapter on equipment provide a good visual method of keeping
this part of the waiting list since not much information is
required , the second part, described below, having the main
information.
The waiting list index card should carry the surname, in
capitals, with all Christian or first names across the top and
the name of the surgeon and priority, that is, routine or semiurgent, together with the date of coming onto the waiting list.
Full address and telephone number and the provisional diagnosis
together with any special admission details such as availability,
date, clear chest x-ray before admission, check haemoglobin up
to standard before admission etc.
Separate compartments should be allocated for various
surgeons and subdivided male, female, with 'semi-urgent' or
'routine' under each category. Children would be treated in a
similar manner.
With specialised lists such as microscopic ear surgery,
submucous resection, T's and A's the cards can be grouped.
With a gynaecological waiting list, beside semi-urgent
or routine the cards can be subdivided under major or minor
surgery as well.While the above details may appear to make
a complex operation of maintaining a waiting list they do allow
of efficient operation and are time saving when compiling an
107
responsible for the various surgeons' patients record the next
day's operation list by early evening. The layout of such a list
hereunder is quite self explanatory.
MR.LANCERTHEATRE
1
8.30
a.m.
VII38099DOUGLAS Roslyn3ms,G.A. Pre-Med as chartE.U.A. Post Nasal Spaceed jhr pre-op
XIX7205
CARP Mary60
G.A. Pre-Med as chartLaryngoscopy P.O. Polyp ed at call
Vocal Cord
etc.
The essential distribution list would be MAIN OPERATING THEATRE BLOCK (several copies)
Any detached theatres e.g. ORTHOPAEDIC, EYE, E.N.T. etc.
All wards concerned
Orderly Office
Transport Officer (to arrange ambulance transfer of.
patients if there are any detached wards concerned)
(f) Surgeons' change room
(g) Theatre Charge Sister
(h) Medical Records
(i) Medical Superintendent
(j) Matron
(Ic) Nursing Supervisor
(1) Enquiries
(a)
(b)
(c)
(d)
(e)
The next-of-kin of any patient going to the theatre next day
is advised of the fact by telephone during the evening.
7.6 Waiting lists
Quite a considerable amount of work is involved in keeping an
accurate and up to date waiting list and this, too, is most often
administered in the Admission Office.
7.3 .1
Surgical waiting list
If the hospital has predominantly visiting surgeons on its staff,
it is likely that many names for the waiting list will be referrals
direct from the surgeon's own consulting rooms.
However, by far the most cases coming onto a waiting list will
be patients referred to hospital surgical clinic by general
JOb
oc
7
EXAMPLE:
DATE
APRIL
1967
The following is a typical list of clinics (not listed in
importance), but some hospittls will have more than this
because of local specialties or because a larger centre caters
for certain conditions on a regional basis, e.g. cardiology (a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(1)
(j)
(k)
(1)
E.N.T.
Surgical
Gynaecology
Ophthalmic
Medical
Psychiatric
Dermatology
Staff
Orthopaedic
Paediatric
Rheumatology
Consultation Clinic
Then there is the operation hat duplicated each evening
for distribution throughout the interested departments of the
hospital. Each hospital has its own system of notifying
regular operations for the next day. T his can include a
piece of paper pinned to a notice board outside operating
theatre block, a book hanging on a nail outside operating
theatre block, or a blackboard on the wall outside theatre
block. These are effective where there are only a few
operations per day but where there are 30 - 50 operations
each day it necessary to distribute duplicated sheets to
the various departments concerned.
To enable the operation list to be assembled a record
book is kept in Admission Office in which the house surgeons
(e) Medical
(f) Ophthalmic
etc.
by totalling the admissions of each doctor covering a particular
field.
7.5.4 Admissions by wards
Ward analysis showing admissions to each ward for the day and/
or transfers to the wards DATE
APRIL 1
ADMISSIONS TO INDIVIDUAL WARDS
WARD NO.
Admissions direct to ward to be shown in Black.
Transfers to ward to be shown in Red.
7
This analysis is to show the turnover of patients per ward
throughout the year.
7.5.5 Outpatients
To enable accurate returns to be made of patients seen at
various clinics each month it is important that a daily record
be kept at each clinic office and that the total be submitted to
Admission Office at the end of each month to enable statistical
returns to be recorded. (N.B. This only applies if the Admission
Office is responsible for submission of monthly statistics to the
Board Office; otherwise it would be submitted by the Clinic Office
to the appropriate department)
104,
7
Admisjons by visiting and full time
staff:
7.5.3.
Then comes analysis for (a) Acutes
(b) Bookings
and the number of each category for each surgeon or physician.
BOOKED ADMISSION
DATE
APRIL
U)
1967
zz
00
H 0 IiiU)
Z
F U) U) U) U) U)
U) U)i-1
H
:1 HZ U) U) U) t4
000 1 11U)H
U) Z i-OZ i-i U)
00 U) U) 0 <i 0 U)H U) 0
U) H H U)
U) U) U)
A ca
U)
U)
U)
U) U)
0-4
U)
-IU)
•
i—iC)C) E-iU)
-1-i +) 0
(Dc1E-1
cn
1
- -
— r—
2
3
ACUTE ADMISSIONS
DATE
APRIL
U)
Z
U)
1967
U)00 U)
U
owU)
U) U) U) H
U) U) Cl)
Cl) ,U)
Cl) f)
U)
U)
U)
HZU)U)U)E4HZ00
U)--1 C) C)
D0 00 U) U)z OHZi-i U)
i-1.iHU)
00
U)00
U)
U) <- U)-0 U) U)1-' 4) Q
<1 U) H H Cl)
U) U) U) U) U) a) a H
1
2
3
With this particular analysis it is possible to give a daily,
monthly or yearly total of admissions under any particular
specialist group., i.e. (a)
(b)
(c)
(d)
Gynaecology
Surgery
Orthopaedic
Paediatric
DAILY DEATHS
DATE
SURGICALMEDICAL INFECTIOUS T.B.
APRIL )ULT
I CHILD ADUL4CRILD
II
ADTTL4(TTTT.n tflTTT,9Ii
DAILY
friil
lciIIc.ii Iciil Tl
I-I
I,iIl-iIrjl
i,-il-I -1ITOTAL
1zIIxt . I:I
iilI ui <i çi:
Ii-.3I Ii-1
fr
fr
l
I
I
1967
IIII
I
1
2
3
Lf
Note: These can, of course, be combined into a single return.
7.5. 2
Days stay discharged patients and numbers remaining
List showing Discharged Patients' days stay
Deceased Patients' days stay
Remaining-in Patients
EXAMPLE:
I.UMVIAININU IN
APRIL
1967
I
2
3
7
(a) Male(e) Medical
(b) Female(f) Surgical
(c) Adult(g) Infectious
(d) Child(h) T.B.
EXAMPLE:
DAILY ADMISSIONS
DATESURGICAL MEDICAL INFECTIOUS T.B.
ADULT HILD ADULT CHILD ADULT HILD ADULT HILD
APRIL
NIx:!fx]
cii
I:1ci
:,
.rx
D A I LY
TOTAL
'cx:i.cx:i
1967
I
2
3
1
etc.
DAILY DISCHARGES
DATESURGICAL MEDICAL INFECTIOUS T.B.
ADULT6HILD ADULEICHILD ADUL[LHILD ADUITLHILD
P1
1967
lo
lxi
DAILY
TOTAL
3.
List to analyse number of beds in each ward under individual
surgeons and physicians, or under surgical or medical teams
whichever system is in force in the particular hospital.
Distribution (a) Medical Superintendent
(b) Admitting Officer
(c) Admission Officer
A permanent register must be maintained with the previous day
admissions recorded and the previous dayb discharges and/or
deaths noted in red with the date for each also noted. This procedure is one where extreme care is necessary to ensure accuracy.
Discharges, to be particularly checked by number as well as names.
This record is compiled from ward lists.
This register should record as a minimum: date of admission;
patient's hospital number; surname; Christian or first name;
sex; birth date; age; race (as for M.S.18 card); ward; diagnosis
(this is only recorded after patient is discharged orhas died);,
doctor under whose care the patient is admitted; date of die-..
charge or death.
For enquiry purposes it is essential to maintain an index,, in
alphabetical order, of all patients in hospitals admission to'bè
immediately added and discharges and deaths taken out as soon as..
advised from the wards. For control purposes it is an essential
to keep an index in ward order maintained as at midnight on, esob,:
day.
.
In order to assist the bed control and allocation of beds : for
admissions, both acute and bookings, it is essential to maintain.
a ward indicator. To keep this accurate, it is necessary tohave.,
the co-operation of ward staff, to advise immediately any diecharges or deaths. Admissions can be added as routine...:.,
7.5 Statistics
The sectional analyses outlined hereunder are undertaken in
order to facilitate answers to various requests for statistics by eBoard Office and the Health Department. In some hospitals part
or all of these records will be kept by the Medical Records
Department or Enquiries or by a separate statistics by office.
7.5.1
Admissions, discharges and deaths
Records must be kept of Admissions, Discharges and Deaths
analysed toindicate -
(ok,
the patient is being admitted is advised of the arrival of the
patient to ensure there is no delay in the commencement of treatment. The doctor is advised by telephone or the doctor's call
light or colour system, the former being used if the doctor's
whereabouts is known and the latter if the doctor is in circulation around the wards. It is a wise precaution to note the
time of despatch of a patient to a ward and further to note the
time the house surgeon is advised of the arrival of the patient.
In the latter case unless the house surgeon is spoken to
personally, it is necessary to indicate the fact that a message
was passed via, say a ward sister, by indicating the ward telephone
number with an M.. e.g. 703(M) 2,1+5 pm0
Daily returns: 7.1+.
The daily lists for the information of various sections are
briefly 1, Admission and discharge lists. Distribution should normally
beto(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
Medical Superintendent
Matron
Medical Records Office
Social Security Department
X-ray Department
Admission Office
District Nursing Service
Theatre
A. & E. Department
Board Office
2, Daily bed state as at midnight each day,. Distribution (a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
Medical Superintendent
Matron
Nursing Supervisor
Dietitian
Laundry Linen Keeper
Admission Officer
Board Office
Medical Records Office
(Note: There is no Health Department 'requirement for this
to be done at midnight; it can be done at whatever time the Board or hospital administration
decide. This is covered in chapter 8 'Hospital
Census Taking'),
7. Admission Office routine
71 Identification of patients
Identity bracelets for patients are in general use throughout
New Zealand; these bracelets are usually of plastic, designed to
take a small card with the patient's name and hospital number;
they are worn on the wrist and are designed to be worn by the
patient throughout his or her stay in hospital.
Depending on hospital policy the bracelet will either be put
on by Admission Office staff when the patient presents himself for
admission or by ward staff. Points for and against;
- there is sometimes objection to Admission Office staff
touching patients;
- Admission Office staff could put a bracelet on too tight
and this might not be seen for some time with possible
adverse effects;
- the bracelets are usually difficult to put on and conse• quently the operation is time-consuming; this can cause
some delay in the Admission Office on a busy morning;
- if the bracelet is not put on until the patient reaches the
ward mistakes in identity can occur, particularly if two
patients arrive in the ward at the same time;
- if a new bracelet iswanted this can easily be got and
prepared at the Admission Office whereas the ward would
have to wait for it. •
7.2 Patients' case notes
As it is necessary to check that the details on, the patient
identificationform are correct and to add the time of arrival to
this it follows that, whichever system of documentation isused,.
the patient's basic case notes will be in the Admission Office when
he arrives.
•
The patient should be escorted to the ward by an orderly who
should carry the case notes in an envelope. If it is necessary to
send the patient to the ward on his own and for him to carry the
case notes there these should be in a closed envelope.
7.3 Notification of House Surgeon
Firstly, after the patient has been despatched to the ward it
is necessary to ensure that the house surgeon under whose care
4
7
together. A specimen of an acceptable form is shown, hereunder
and is self explanatory:
NAME OF HOSPITAL
....... . •eao•ee.e..e..•..e...,. give my consent for
operation to be performed on myself, which may include —
is ....
* (1)
Termination of my present pregnancy.
* (2)
Termination of my present pregnancy and sterilisation.
I fully understand that as a result of this operation
I am unlikely to become pregnant,
* (3)
Sterilisation. I fully understand that as a result
of this operation I am unlikely to become pregnant.
' (+) Removal of one or both ovaries if it is found
advisable at the time of operation.
Signed..............,........,.,.., • D at e
Witness- ...... . . •C....,....c.....,.
c.,'..e.á.......,
Address and Occupation ...... ,.,.,... ... ....,,. ........ .,.,,.-.,
• • ••• CCC ......0•0C
Cessec OS S •000 S .........0 •CS 50CC S000000Ce
I, . . . . . . . •. . , .. . ., . . . so • , . • . . . o..G. give my consent for an
operation to be performed on my wife ......... which may include —
* (1)
Termination of my wife's present pregnancy.
* (2)
Termination of my wife's present pregnancy and
sterilisation. I fully understand that as a result
of this operation my wife is unlikely to become
pregnant.
•
* (3) Sterilisation. I fully understand that as a result of
- • •this operation my wife is unlikely to become pregnant.
(k) Removal of one or bothovaries if it 'i s
' found
advisable at the time of operation.
Signed
••0006C•0000•.*.....,O..,......
Date
Witness...........
Address and Occupation •••O•••••O•SO.....01 ...
...............................
....O.,.....
* Delete -whichever is inapplicable. Both patient and husband
- must initial each deletion.
97
Where it is impossible to locate the next-of-kin or a minor
or an unconscious person and an urgent operation is immedijely
necessary, the Medical Superintendent or his deputy can, and usually
will, authorise such treatment, after first satisfying himself that
all possible efforts have been made to locate the next-of-kin.
6.2 Patients from Boarding Schools
It is usual for the Principal or similar official to obtain
at the time of admission to their establishment, from the legal
next-of-kin, permission for authority to consent for any treatment
should it . be necessary for the person to be admitted to hospital.
Where the operative procedure is of a major nature it is usual to
obtain personal consent from the next-of-kin.
6.3
Armed Forces
In the Armed Forces, the Commanding Officer of a minor can give
permission for necessary emergency operative treatment. It is
customary for relatives to be advised promptly-when treatment is
deemed necessary and their consent obtained before commencing such
treatment,
.
6.4
Prisons
A minor admitted from Her Majesty's Prisons, and similar institutions, is placed in the same category as Armed Forces,. and the
Superintendent is permitted to give permission for emergency
operative treatment, but where possible, the next-of-kin are to
be asked for their formal consent.....
6.5
Patients from a mental hospital .
The Medical Superintendent of a mental hospital is the , legal
guardian of all patients, other than voluntary patients, and as
such, is permitted to sign consent for any operation, but he
invariably obtains consent from the next-of-kin or nearest relative
for the operative procedure. Voluntary patients in mental
hospitals are admitted to public hospitals in the normal way as
normal patients.
.
6.6
Termination of pregnancy etc.
Operations for termination of pregnancy, removal.of ovaries or
sterilisation must be consented to by both the husband and the wife
7
Another important fact to note is if the admission is the
result of . a motor accident or an accident at work. In the former
case, it is merely necessary to state yes or no. If there are
subsequent court proceedings or there is an insurance claim, the
cost of the stay in hospital may be the subject of a claim refundable to the Board.
In the case of an admission due to an accident at work or
sickness or disability, due to the nature of the work it is
essential to obtain the employer's name and address, as all cases
are covered by the Workers' Compensation Act and cost of treatment
will be the subject of a claim. (Refer chapter 15)
Particular care should be taken when completing pre-admission
details with these cases as there can be a considerable amount of
money involved to maintain a patient in hospital.
Consent for treatment: 6.
General: 6.1.
The form in use in most hospitals in New Zealand 'is given in
chapter + ('Medico-legal aspects of Medical Records Keening').
Consent may be given as follows (a) A single adult of legal age (21 years) can give such
permission for himself or herself. Where an adult is over
16 but under 21 and living away from home his or her consent
would be sufficient to a reasonable operation.
(b) A married man can. give permission for himself or his wife
or child irrespective of his age.
(c) A married woman can give permission for herself, her
husband or child irrespective of her age.
(d) Permission for treatment for operation on a minor (under
the age of 21 years) can be given by the next-of-kin and
this can be either parents, or foster parents if the child
has been legally adopted,or by the person concerned if
over 16 (see (a) above).
(e) Where parents are unavailable a brother or sister if over
the age of 21 years can give consent (but see also (a) above).
5.2 The detail of a doctor referring a patient for admission
to hospital
Many general practitioners work in conjunction with a partner
or by arrangement with another doctor to cover evening calls and/
or weekend calls and it is often that a patient will be admitted
to hospital as an acute with a reference note from a doctor other
than his. or her normal doctor. In this case, it is wise to state
clearly the name of the referring doctor as well as the name of
the regular practitioner. This necessity is to enable both
doctors to obtain a report on the patient upon his or her discharge from hospital. It is usual for the name of the doctor on
duty at the reception desk or Accident and Emergency department
to be stated on the Patient Identification form as on occasions,
he or she may have to investigate the patient before admission,
and can give information to the doctor under' whose care the
patient is finally admitted.
Various institutions have their own internal arrangements
for allocating acute admissions and bookings admitted under the
care of Specialists.
It is necessary to have the date of any previous admission,,
whether as an inpatient or an outpatient, to enable the old records
to be obtained from Medical Records and despatched to the wards
with a patient.
Another necessary point is whether the patient is ordinarily
a resident of New Zealand and, if not, the date of arrival in
New Zealand and whether he intends staying permanently in the
country or whether the stay is of limited duration. These details
are essential, because unless a person is resident in New Zealand.
for two years or more, he is not entitled as of right, to receive
free treatment in hospital under the Social Security Act. If the
intention is that the patient is to remain permanently in New
Zealand even though of recent arrival, the normal practice is
that he is treated as a resident of the country but where the
stay in the country is of short duration and unless the patient
is covered by reciprocal Social Security Benefits, e.g. from
England, Scotland, Northern Ireland or Wales, it is necessary
that the patient be charged for stay in hospital at the ruling
daily rate for the particular institution.
In the case of visiting seamen the name of the ship concerned
and the owners or agents must be obtained since the latter are
responsible for payment, even where the country concerned has
reciprocal Social Security benefits with New Zealand.
9
Ilia
7
especially acutes, there are many instances where it is necessary
to communicate urgently with the next-of-kin, checking diet, preadmission symptoms, advice of impending operation, permission
for anaesthetic etc., and it is vitally necessary to obtain this
information. Naturally, not all people havea telephone installed
in their own home, but it is unusual to find a neighbourwho is
not prepared to pass a message when it concerns a hospital matter.
There are times, however, when at short notice, it is impossible
to get a message to the next-of-kin by normal channels and it
will be found that the police are always co-operative, if the
circumstances warrant asking for their assistance. In country
districts in particular, the police know the locality and can
organise the relaying of a message promptly and efficiently.
The relationship of the next-of-kin should always be stated.
Upon admission the patient states who he or she wishes to be known
as his or her next-of-kin and the hospital staff have a moral
obligation to honour this, even though, in point of fact the
person named, may not be the legal next-of-kin. At all hospitals
the next-of-kin, as specified on the pre-admission form of a
patient, can interview the House Surgeon under whose care the
patient was admitted, at certain specified times, and care
should always be taken that a person presenting himself to
interview a doctor concerning the patient is the person named
as the next-of-kin on the pre-admission form. Where the person
is not the next-of-kin and he has no written permission to
interview the doctor and yet the details seem reasonable, it
is wise to phone the next-of-kin for confirmation that the
doctor may grant an interview.
Special details regarding telephone exchange names: 51.
Many large centres have small sub-exchanges which operate
from but through the main exchange and it is essential to record
the exact name of any exchange or sub-exchange when asking for a
telephone number. In obtaining telephone numbers to communicate
with a next-of-kin it is'frequently helpful if there is an
alternative number through whom a message can be sent in the
event of the next-of-kin being unobtainable. It is also
essential that telephone numbers at work as well as at home be
recorded,
hospital be lengthy, it is likely that the age could step up a
year and not be noticed. Some hospitals insist on the birth date
being stated for all patients being admitted and this information
can often be valuable, if accurately stated, for identification
purposes, particularly if the place of birth is included. However,
for various reasons, mistakes are frequently made in quoting 'birth
dates. It is unwise, therefore, to base any system solely on this
information.
Statement of sex of a patient is essential as some Christian
or first names do not readily indicate whether the patient is male
or female.
Whether a patient is Maori, Islander or of other race is
required for statistical purposes and could be useful for
treatment. A Maori is defined as being of half blood or more.
It should be noted, however, that it is important to ask a
patient whether he is Maori, Islander or European, rather than
guessing, since considerable importance is attached to the
work done on Maori health and the health problems. of Islanders
are of increasing concern.
Marital status, that is married, single, widowed, divorced or.
separated is necessary to help determine who is the next-of-kin
and who is likely to be interested in the condition . , of the
patient should the patient, or those accompanying him, be unable
to give this information.The true importance of marital status
becomes evident upon the decease of a patient or where the condition of a patient may necessitate committal to a mental hospital.
Religion is important because most of the major religions have
a permanent clergyman attached to the larger hospitals.. These
clergymen are daily advised of members of their faith admittedto,
or discharged from, hospital. ..
While knowing the occupation of a patient may not be essential
for their treatment, it is necessary from a statistical point of
view as required by the Health Department. Industry data are
needed when occupation data are not precise, e.g. machinist,
packer, supervisor.
The date of admission is obviously essential and the time of
admission to the hospital is important to check on possible
treatment delays after the arrival of the patient in hospital.
Next-of-kin: Where possible the name and address of the nextof-kin should be accurately recorded, together with a day and
night telephone number and exchange name. With admissions,
7
Admission particulars: 5.
Details obtained by an admission clerk from a patient or the
next-of-kin of a patient being admitted to hospital form a very
necessary and important part of the records which are used
extensively during a patient's stay in hospital.
Firstly, the hospital number is essential on every form
used throughout various departments of the hospital, e.g.
(a) specimens of blood sent to the laboratory
(b) x-rays, etc,
and these forms can only be positively identified by a number.
Various institutions have special ways of numbering to suit their
individual requirements but one method becoming increasingly used,
due to its flexibility and ease of filing, once the chart is
returned to Medical Records, is the unit number, more details of
which are to be found in chapter .5 ('Filing Systems').
It is essential that all names, surnames and Christian or
first names, should be correctly recorded in order to avoid
confusion at a later stage when many similar names may be found
in the patient index. Full Christian or first names should always
be obtained and recorded. Maiden names should also be obtained.
In the case of Maoris and Islanders particularly, the question
"are you, or have you been, known by any other name(s)?" should be
asked, as often Maori and European names are used by the same
person at different times, or different family names are used.
The address from which a patient is admitted should be stated
and can quite often be useful for reference purposes after a
patient has been discharged, but it should not he obtained at
the exnense of a permanent address which should be accurately
stated on every form - number of street, road arid its name • In
country districts where frequently rural delivery numbers, e.g.
are stated, it should be borne in mind that every road
has a name or number and to state rural delivery number is really
not sufficient, one main reason being that in the event of District
Nurses having to follow-up with dressings after a patient has been
discharged from hospital, a district number does not give much
help, so a road name or number should always be insisted upon
and can usually be obtained if, the above explanation is given.
Age is
the age of
The reason
frequently
always important and particularly with children under
10 years, it is advisable to state their birth date.
is that the dosage of a drug to be administered is
based on a child's age and should their stay in
With pre-registration details as required on a pre-admission
form can be obtained when the clinic card is prepared at the time
of attendance at an Outpatient Clinic. If the admission ismade
within a matter of weeks it is usually safe to prepare the preadmission form from the clinic card details. However, where there
is some time lag in arranging a booking, to ensure accuracy, it
is preferable that the relevant details be supplied by a patient
or next-of-kin on an appropriate form when accepting an admission
date and time. Particulars of what the patient will need in
hospital, arrangements regarding custody of property, laundry,
visiting hours etc. should be sent at this time.
To ensure a . prompt reply to the offer of a booking, it is
wise to enclose a business reply envelope with each and every
notification. It should be noted, that a franked or stamped and
addressed envelope could be used, but there is always a number of
notifications not replied to and there would be a total loss of the
franking or stamp concerned. With a business reply permit envelope,
only returned envelopes would be subject to postage cost, plus one
cent each extra for the permit..
It is an advantage to arrange as many admission bookings as
possible by telephone in order to ensure that.there is a minimum
number of defaulters.When the telephone is used, it is also
possible to have a definite check as to coughs and.colds, sores
and infectious contacts, menstrual period if it applies, and
alternative dates can be arranged easily.
Even the use of toll calls is warranted for. admission bookings
in order to prevent "theatre time" wastage due to the non-arrival
of bookings.
However, it is still advisable to send written confirmation
together with information regarding admission mentioned above.
/+. Documentation of patients
Mechanical aids to assist with accurate documentation of a
patient upon admission to hospital are installed in a number of
the larger hospitals in New Zealand and their principle is outlined in the chapter on equipment. Their use should ensure
accurate identification of all papers with a particular patient
and save considerable time for medical and nursing teams in the
wards.
hospital administration will function smoothly. .At.this stage we
Will assume that admissions are being done through a central
office.
Definition of admissions: 2.
Admissions are either Booked which means that they will have been admitted
from the waiting list following attendance at
an outpatient clinic. ('Waiting list' on M.S.18)
Acute which means immediate admission. In some
hospitals all such admissions go through the
Accident and Emergency Department, (and
acute admissions include admissions from
this department); in others, admission may
be arranged by the General Practitioner with
the Registrar concerned. ('Emergency' on M.S.18)
Pre-admission procedures:
Obviously no pre-admission details can be taken for acute
cases. The information required is obtained:
(i)
(ii)
(iii)
by a clerk from the Admission Office going to the
patient and obtaining the necessary details from
him;or,
by this being done by a nurse and passed to the
Admission Office;or,
by relatives or friends accompanying the patient
coming to the Admission office and giving
patient's details. . .
In the case of booked patients, admission details: can
either be obtained when the patient presents himself for
admission or they can be got before this happens ('pre-registration
If details are taken at the time of . admission this has the
advantage that the information is up-to-date and Is extracted
from the patient by a person trained to do it. On the other.
hand, it does mean keeping the patient waiting in the Admission
Office while this is done and until the necessary papers are
prepared which have to accompany him to the ward.
3.
1. Introduction
The Admission Office in any large hospital brings staff
into close co-operation with the public, the nursing staff in
wards and medical staff. The staff of the Admission Office
therefore needs to be carefully selected and trained to enable
them to carry out their duties for the welfare of the patient
as well as co-operating in every possible way with the various
departments that exist to make up an efficient hospital. The
Admission Office is the original source of all identifying data
in Medical' Records which must be' detailed and accurate at all
times.
It should be remembered that when a patient is admitted to
hospital, legal responsibility is automatically accepted for'
the care and treatment of the individual, and safe custody of
his or her personal effects, and these facts should always be
borne in mind by all staff in their dealings with the public.
When it has been decided that a person is to be admitted
to hospital for treatment as a patient, either as an 'acute' or
as a 'booking' the next contact with the hospital will be when
the patient appears at the hospital Admission Office or receives
a form for pre-registration. It is the duty of Admission Office
staff to smooth the way by treating the patient with every
courtesy and consideration, and giving prompt attention to
necessary formalities before despatching the patient to a ward.
There is, as yet, no set system adopted for admission,.'
procedure in the various hospitals throughout the country.
Those in use are mainly based on , local requirements and 'all
work quite well in their own way. .'•' '
Naturally the requirements for a 200 bed hospital are not
going to be so detailed as for the large hospitals of 600-800
bed capacity. With the smaller hospital, admission office hours
can be restricted to 8.30 - 5 p.m. on five or six days a week
with the nursing staff filling in essentials at other times.
With the larger hospitals the admission office should be
staffed 21+ hours a day every day of the year in order to cater,
for up to an average of 1+5-50 patients per day. With such a
daily average, there could be daily totals of 80 or more
admissions depending on the spread of 'bookings' and 'acutes'.
The larger the hospital, the more departments there are to be
kept advised of daily admissions and discharges so that the
ADMISSION OFFICE PROCEDURE
1.
Introduction
2.
Definition of admissions
3.
Pre-admission procedures
+. Documentation of patients
5.
Admission particulars
5.1 Special details regarding telephone exchange names
5.2 The detail of a doctor referring a patient for
admission to hospital
6..- ' Consent for treatment
6,1 General
6.2 Patients from Boarding Schools
6.3
Armed Forces
6.4 Prisons
6.5 Patient from a Mental Hospital
6.6 Termination of pregnancy etc.
70 Admission office routine
7.1 Identification of patients
7.2 Patients' case notes
7.3 Notification of House Surgeon
7.4 Daily returns
7.5
Statistics
•7.5.1 Admissions, discharges and deaths
7.5. 2
Days stay discharged patients and numbers
remaining
Admissions
by visiting and full time staff
7.5.3
7.5.4 Admissions by ward
7.5.5 Outpatients
7.6 Waiting lists
•7.6.1 Surgical waiting list
7.6.2 Medical waiting list
7.7 Bed allocations for bookings
7.8 Operating schedule
8.
Conclusion
9.
References
10. Further reading
10.1 Basic
10.2 Background
10,3 Associative
laws of this country. Finally, it should be the aim of all concerned with the admission and discharge of patients to see that
everything possible is done to reduce the worries and fears of
patients on arrival and while in hospital. Remember that good
public relations may save misunderstanding by the patient and
unnecessary legal proceedings.
10, References
Acts: Births and Deaths Registration, 1951; Coroner's,
1951; Health 1956; Hospitals, 1957; Mental Defectives, 1911; Tuberculosis, 1948.
'Consents to Surgical Operation', New Zealand Hospital, June
1957
Hayt, Emmanuel, Hayt, Lillian R. and Groeschei, August H.
Law of hospital, physician and patient. 2nd ed. U.S.A.,
New York, Hospital Textbook Co., 1952.
Regulations: Cremation, 1939; Health (Infirm and Neglected
Persons), 1958
Searby, G.W. Consents to Operations. New Zealand Hospital,
Sept. 1960
Searby, G.W. General law affecting hospitals. New Zealand
Hospital Officers' Association lecture notes.
11. Further reading
11.1 Basic
Brown (R.J.) Some legal problems
in the practice of Medical
Records
Medical Record, Aug.
1953, pp 189-94
Haydon-Baillie (M.) Medicolegal
aspects of Medical Records
1954, pp 290-95
Medical Record Librarians,
PP 397-427 ('Legal aspects of
medical records')
U.S.A.,.Berwyn, Ill.,
Physicians' Record
Co., 1959, xxx + 604
illus.
Letourneau (Dr. c.u.) Who owns
the Medical Record?
Jnl. AAMRL, Dec. 1958,
pp 221-3 1 260
TWE
the approval, and these records will be accepted as evidence.
(See Section 5 of the Evidence Amendment Act, 1952),
Medical records are generally used in court on the
following occasions 1.
2.
Insurance cases
Personal injury suits (see also under Workers'
Compensation Act, 1956)
30 Malpractice suits
k. Will cases
5. Divorce cases
6. Criminal cases
There may be other reasons for producing the medical
records in court. This necessitates the careful keeping of
all the medical documents whether the patient was treated as
an inpatient, an outpatient or at home. The Social
Security Act 1963 provides that if a person has good grounds
to claim compensation or damages and fails without good
reason to take steps to enforce his claim, he may be
personally liable to pay the cost of his treatment at
hospital.
Summary: 9.
The Medical Records Officer must naturally look to the
Medical Superintendent of the hospital for guidance and
instruction on all matters medico-legal while the Medical
Superintendent may seek legal advice from his board. By the
same token the staff in a Medical Records department should
receive instruction from the Medical Records Officer on all
aspects of keeping medical documents and any medico-legal
problems. As custodians of the medical records, the Medical
Records staff should be fully aware of their responsibility
to the hospital, hospital board and community as a whole.
The Medical Records Officer •whose responsibility it is to
supervise the Medical Records department should ensure that
all those employed within the department are fully conversant
with the rules regarding disclosure of information.
It should be clearly understood, that the medical record
as an order of business is the property of the hospital, while
the personal data contained in the record are considered as a
confidential or privileged communication and therefore the
property of the patient. It is compiled, preserved and protected from unauthorised inspection for the benefit of the
patient, the hospital and the physician as required by the
8.The medical record in court
If a hospital record is to be used as evidence in court proceedings, it must of necessity be admitted or received by the court
and properly identified by a witness. Hospital records may be
accepted as evidence and allowed to be entered as an exhibit on
the grounds that reliance can be placed on the written memoranda made in the regular course of business of an institution,
and that there would be no reason for making false entries at
that time.
The chief value of a medical record is that it is an unbiased
statement inasmuch as the doctors and others concerned in making
the record at the time of the patient's hospitalisation have no
interest in any subsequent litigation, except, of course, when
the patient himself sues the hospital. Because of the possibility
of each patient being a potential court case, careful recording
of the medical findings is of primary importance. Notation of
the complete findings upon examination and the exact status of the
patient on admission should be set forth, together with a report
of the patient's progress while in hospital.
Occasionally mistakes are made in writing medical records.
If this is noticed at once, the error may be lined through and the
correction made immediately following. If an error has been
erased or crossed through and the correction written above, without an accompanying signature And date, there is no assurance that
the correction was not made at a later date. Thus doubt is
created as to the validity of the entire record.
When a medical record has been presented during a court
session, it will be held by the Registrar of the court while the
case is sub judice, and following judgement will be held in the
court files and will be released only upon application by Counsel
for the party requiring production of the record duly consented
to by Counsel for the other party. It must be kept in mind that
medical records may be needed in some research projects or a
further admission of the patient at the time that they are being
retained by the court. Wherepossible, and there is sufficient
time after receipt of the subpoena, photo copies should be made of
the original medical record.
To cover the admissibility of microfilmed records as evidence
in court it is necessary to have obtained an Order in Council
signed by the Clerk of the Executive Council. The usual practice
is for the hospital board to apply to the Council when it decides
on a policy of microfilming medical records and when the Order
has been approved or gazetted the original documents may be
destroyed. The Order in Council will allow the hospital board to
produce microfilmed records in court at any time subsequential to
1
If cremation is required the Cremation Form-would be completed with the Death Certificate and also signed by the
medical officer concerned. It would then be passed to the
funeral director for transmission to the Medical -Referee.
(See Cremation Regulations 1 939 (reprinted 1 9 4 9). Reference
No. 194 9/122, Clause 5, 6 and 8).
The relatives are notified of the death by the medical
officer or ward sister who also arranges for the removal of the
body to the hospital mortuary. When considered necessary or
advisable, a medical officer will request permission from the
next-of-kin for a post mortem examination. As stated previously
if the death was the result of an accident or occurred under
circumstances of suspicion a Coroner's Inquest may be required
and the Coroner's Pathologist will carry out any necessary
postmortem examination. (See Section 10, Coroners Act 1951).
In the event of the death of a patient who has been
resident in a mental health hospital, the following information may be required by the coroner:
(i)
(ii)
cause of death;
last seen alive - where, when, by whom and under
what circumstances;
(iii) who examined after death;
(iv)
was a post mortem held?
If a patient dies from infectious disease, a notation
should be made on the Death Label attached to the body and also
on the back of . the medical certificate of causes of death
issued persuant to Section 55 of the Births and Deaths
Registration Act 1 951.This enables the funeraldirector and
others to take all due precautions. It is also necessary to
notify the Medical Officer of Health or his deputy. (See
Section 70-87 Health Act 1956)
The handing over of the effects of a deceased patient can
be made only on the production of Probate or Letters of Administration or other acceptable evidence of the claimant's legal
authority. Until this authority is produced the effects should
remain in the custody of the Secretary, the House Manager, or
other Senior Administrative Staff. (See Section 15 0 Hospitals
Act, 1 957, relating to payments without probate where the
amount in possession of the deceased did not exceed £200).
44
The deponent being duly sworn saith:My name is •....(in full)..... I am a duly qualified and
registered medical practitioner employed by the ...... Board as
a ****.(state house surgeon or otherwise).....
The .....(man or woman)...., known to me as ...(name in full)
aged. . . . . . .yrs. 0s•• •of . . . . . . . (address)..... .......
was admitted to .....(name of hospital)....... time
on......... date....900 year, following an accident when ........
• • • . . . . . . .0 • • ( medical findings) . . . . • • . • . •• •0
In my opinion death was due to
Type name of doctor
Qualifications
Taken and sworn this0.....0day
of ......... 19...., at
before me.
Coroner
Note: the medical practitioner signs the deposition at the
inquest. A copy of the deposition should be kept in the
medical record.
All still-births (i.e. born dead after the expiration .of the
28th week of pregnancy) must be notified to the Registrar of Births
as required in the case of,the live birth. A still-birth is
registered in the same manner as a live birth but no entry is made
in the death register..
Where a medical practitioner is in attendance at the birth of
a still-born child he is required by Section 20 of the Births and
Deaths Registration Act 1951 to issue and deliver to the Registrar
of Births a medical certificate setting out, to the best of his
knowledge and belief, the causes of the still-birth and such other
details as the Registrar-General may require.
A medical certificate is similarly required to be issued in
respect of an early foetal death occurring after, the 20th week of
pregnancy but before the expiration of the 28th week.
It is of interest that in the case where no medical practitioner was in attendance at the confinement but a midwife was, the
certificate required to be issued under Section 20 should be
issued by the midwife. It should be noted also, that still-births
require the normal burial procedure to be completed by the parents.
Lf
would be recorded within the case notes. Hospitals which treat
patients with electric shock therapy require a consent form to
be completed for this purpose and always kept in the case notes.
Regulations regarding discharge or death of patients: 7.
Should the patient decide to leave hospital against the
advice of the medical staff concerned, he is requested to sign
a form absolving the hospital authorities from any liability
for personal damage or injury caused by this unauthorised action
or complications arising therefrom.
The Medical Officer of Health requires advice on all tuberculosis cases discharged from hospital. It is also a common
procedure to notify the discharge date of any patient who has
been treated with an infectious disease as listed under the
Health Act, 1956. (See Regulation' 17 of the Tuberculosis
Regulations, 1951).
Where a patient dies in hospital and has been attended by
a registered medical practitioner the practitioner is required
by Section 25 of the Births and Deaths Registration Act 1951
to issue forthwith a medical certificate stating the causes of
death and such other particulars as may be required by the
Registrar-General and make such certificate available to the
funeral director. If in the opinion of the medical practitioner
death has occurred under circumstances of suspicion, he should
immediately report the case to the Coroner and refrain from
issuing a medical certificate.
A medical certificate should not be issued where the
medical practitioner has reasonable cause to suspect that the
deceased person has died either a violent or an unnatural
death unless the Coroner decides that no inquest is necessary.
In the event of an inquest the Coroner may require a deposi tion from the medical practitioner who attended the patient.
The deposition should be set out as follows -
L2
6.Authorisation for operations
A written consent for operation and administration of anaesthetics should always be obtained from the patient and filed with
the medical record. Some hospitals have a consent form on the
back of the chart front or admission order and routinely secure an
authorisation on admission of all patients. If this is done,
another consent form should be completed just prior to the operaion, and after the nature of the proposed operation has been
fully explained to the patient or in the case of a minor, to the
parent or guardian.It is always a wise policy to have a
medical officer's signature as witness to the patient's authorisation.The Form of Consent as adopted by the North Canterbury
Hospital Board has now become the accepted layout by hospital
boards. An example of this form is shown at Appendix A. Alternative wording, which gives the same sense, together with consent
by relatives and consent for a minor are shown in Appendix B.
Procedure may vary in accident or other cases where the
patient is unable to give consent. Mr. G.W. Searby has fully
covered this aspect in his 'General Law Affecting Hospitals'.
In dealing with consents of patients to operations, S.R.
Speller, in his 'Law Relating to Hospitals', draws attention to
certain operations not rendered valid by the patient's consent
which he classifies as operations without medical need. He quotes
"Any operation not required on medical grounds which inflicts
bodily injury on the person undergoing it is illegal and may be
the subject of a criminal charge, notwithstanding the consent of
the person operated upon", and again "Although an operation for
sterilisation does not inflict a manifest injury, as does the
amputation of a limb, it none the less constitutes a most serious
bodily injury and one in respect of which a criminal charge may
follow unless performed for the sake of the health of the patient".
In all such cases, a surgeon who intends operating will safeguard himself by taking a second and a third opinion which should
be recorded in writing before such an operation is performed, and
the opinions held in the hospital medical record.
Where religious doctrines conflict with medical practice
such as the giving of blood transfusions, special care is necessary
in recording a consent. Other circumstances could be the termination of pregnancy or sterilisation.
Special conditions may apply when a donor, a normal healthy
person, is admitted to hospital to enable transplantation to be
carried out on a donee, or a foetal transfusion found necessary
in an unusual maternity case, and additional consent procedure
L'I
"
In those cases where a baby is transferred to the premature
unit of another hospital and the mother remains a patient
at the first hospital the baby is to be recorded as a
patient from the date of admission. H
It is strongly recommended, however, that some form of admission
procedure should be carried out for newly born infants,
expecially where a unit record is used.
It is important to
and Deaths Registration
must be notified to the
in a city or borough or
note that, under Section 10
Act 1951 a birth occurring
Registrar of Births within
within 7 days in any Other
of the Births
in a hospital
48 hours if
case.
The hospital authorities are also responsible for notifying
the Registrar where a child is born outside the hospital (say,
in an ambulance) and is immediately admitted to.the hospital.
Admission to a mental hospital: 5.
A patient may be admitted to a mental health hospital in
three ways, as a voluntary boarder, as an informal admission
or as a committal. When it is considered that a patient should
be committed to a mental health hospital application may be
made to a Magistrate by any person not under the age of 21 years,
but under the circumstances of a patient 'committed from a general
hospital, application would be completed either by a relative of
the patient or the Medical Superintendent. Two medical certificates are required to comply with the Mental Health Act and these
would be completed by the medical attendant to the patient and
another registered medical practitioner. Relatives would be
interviewed either by the Medical Superintendent or a Senior
Medical Officer. If the relatives are agreeable to the patient's
committal, the application form is completed and signed by the nextof-kin. In other cases the application would be made out and
signed by the Medical. Superintendent or his deputy. On being
signed by the Magistrate, the application form •then becomes the
reception order form. It is important to note that the application with the two medical certificates must be forwarded to
the Magistrate's Court and the application form signed by the
Magistrate within 48 hours of the patient being received at the
mental health hospital.. (See Sections 3-15 Mental Health Act,
1 911 and emergency admissions under section 8 of the Mental
Health Amendment Act, 1928)
4',
treating infectious cases. All cases must be reported even
though the disease be only suspected and not necessarily diagnosed
as notifiable.A list of notifiable conditions is always available from the District Medical Officer of Health. It will be seen
from the list that not all infectious cases are notifiable,
including venereal disease. See Sections 70/87 and 88/92 Health
Act, 1956. The procedure of advising the Local Authority is
carried out by the Medical Officer of Health unless arranged
otherwise. (Refer also to chapter 14 on 'Notification of
Diseases')
Patients may be admitted to hospital when they are found to
be infirm and have no help. Admissions in this category are known
as committals the details of which are laid down under Section 126
of the Health Act 1956 and in the Health (Infirm and Neglected
Persons) Regulations 1958. Committals under this Act are comparatively rare.Under the procedure laid down in such cases an
appropriate application is made to the Magistrate's Court •without
the necessity of giving any notice to the person proposed : to be
committed since that person is usually in a condition where notice
of the proceedings would serve no purpose. On being satisfied of
the merits of the application the Magistrate will make an order
directing that the person be committed to a named hospital. This
order cannot be questioned by the hospital and becomes the
authority for admitting the patient. The hospital is entitled to
a sealed copy of the order which should be filed with the patient's
records.
When a baby is born in hospital or is admitted to hospital
immediately after birth some form of admission procedure is necessary for administrative purposes. Health Department regulations,
however, state:Infants (except premature babies cared for in a premature
baby unit) newly born and remaining in a maternity hospital,
ward or annexe after the discharge of the mother should not
be recorded as admissions, notwithstanding that they may be
receiving treatment which would warrant their classification
as patients; but if transferred to a general hospital or
ward they should be recorded as admissions thereto in the
ordinary way.
Premature babies cared for in a premature unit should not
be recorded as patients while the mother is also a patient;
but where they are retained in a premature unit these
babies should be counted as patients for the period they
are cared for in the unit after the discharge of the mother,
although they will not be occupying 'available' beds.
(5) For the purposes of this section, the term "repre-
sentative", in respect of any patient, means his
executor or administrator or any dependant within
the meaning of the Workers' Compensation-Act 1956
if the patient is dead, or one of his parents or
his guardian if the patient is an infant; and, in
any other case where the patient is unable to give
consent, means a person appearing to the Medical
Superintendent of the hospital to be lawfully
acting on behalf of the patient or in his
interests.
•(6) Every person who acts in contravention of the
provisions of this section camiits an offence and
shall be liable on summary conviction to a fine
not exceeding fifty pounds.
Statutory provisions regarding admission of patients:
The statutory. authorities for duties relating to the
admission of patients to hospital are indirectly covered in
Sections k and 55 Hospitals Act, 1 957. It is at this stage
that the statutory requirements relating to the notification
of Infectious Disease, Tuberculosis etc., must be considered.
Following admission to a ward it is the duty of the Ward
Medical Officer to advise the Medical Superintendent or the
Medical Records Officer acting on behalf of the Medical Superintendent, of any such cases as soon as diagnoses are
suspected or confirmed. The usual procedure is for the
Medical Records Officer to check the provisional diagnosis on
all admission cards daily and on behalf of the Ward Medical
Officer inform the District Medical Officer of Health by
telephone. A written list of all suspected cases or provisionally confirmed cases is then passed to the Ward Medical
Officer for verification,The Ward Medical Officer must
return the list to the Medical Records Officer weekly to
enable details to be transcribed onto the official form which
is provided by the Medical Officer of Health for the purpose
of notification. It should be noted that it is the responsibility of the Ward Medical Officer to notify any cases within
the meaning of the regulations and the Medical Records Officer
acts only as an intermediary in all cases. Beside details of
the patient, the form forwarded to the Medical Officer of
Health must show the provisional diagnosis, the final
diagnosis if known, have a aerial number and be signed by
the Medical Superintendent. Advice forms are forwarded to
the Medical Officer of Health weekly where the hospital is
5.
(3)
(d)
Information required in the course of his official
duties by any officer of the Department of Health,
the Department of Justice, the Social Security
Department, the Navy Department, the Army Department,
or the Air Department, or by any officer of any of
Her Majesty's Forces, or by any constable:
(e)
Information required by any person pursuant to the
provisions of any Act:
(g)
Information , briefly describing the nature of the
injuries of a patient suffering from the results of
an accident, if the information is given within
twenty-four hours after the patient's admission to
hospital and is.'given by the Medical Superintendent
of the hospital, or by any other medical officer,
authorised by the Medical Superintendent, to any
person authorised by the editor or publisher of any
registered newspaper authorised by the editor or
publisher of any registered newspaper to collect
information for publication in that newspaper:
(h)
Information required by such other persons or class
of persons in such circumstances and subject to
such conditionâ as the Minister may from time to
time prescribe by notice in writing.
Nothing in this section shall be deemed to prohibit the
use or disclosure of any information concerning a
patient's condition or treatment for the purposes of the
advancement of medical knowledge or research:
Provided that where any such disclosure is made in any
publication-no disclosure shall be made of the name,
initials, or identity of the patient, and where any such
disclosure is made in any other way every person , to
whom the disclosure is made who is not employed by the
Board shall in respect of the information'so disclosed
be subject to the provisions of this section in the same
manner and to the same extent as if he were employed by
the Board.
(4)
Nothing in this section shall derogate from section
eight of the Evidence Act 1908 or any other enactment or
rule of law relating to evidence in any criminal or
civil proceeding.
57
/
If the record is to be used for purposes of research or
other scientific investigation as authorised by law, permission
is not necessary from the patient, but the use of such a
record must be subject to the statutory provisions. Where
specific cases are to be quoted in a publication, even though
identification data are not noted, consent should be obtained
from the Medical Superintendent, and also, as a matter of
courtesy, from the attending physician.
Information from the medical record is constantly asked
for by insurance agencies before paying claims to the Insured.
The hospital must have written and properly signed and dated
authorisation before releasing a report. It is the practice
of some insurance companies to have the insured sign a form
of authorisation on taking out a policy. No authorisation
dated prior to the date of hospitalisation should be accepted
by the hospital.
Statutory regulations on the
disclosure of medical information: 4.1
Hospitals Act, 1957
62 Non-disclosure of medical information - (1) Subject
to the provisions of this section, no person employed
by a Board (whether as an honorary or part-time medical
officer or otherwise) shall give to any person no
employed by the Board any information concerning the
condition or treatment of any patient in any institution without the prior consent of the patient or his
representative, whether the patient is still in the
institution or not,
(2) Nothing in this section shall apply with respect
to (a)
Information in general terms concerning the
condition of the patient on the day on which
the information is given:
(b)
Information communicated by a member of the
medical staff of the hospital to the nextof-kin or other near relative of the patient
In accordance with the recognised customs
of medical practice:
(c)
Information required in connection with the
further treatment of the patient:
should he ask for one.This eliminates the necessity of consulting the hospital record after the patient has been discharged
and facilitates follow-up of the patient in the doctor's office.
However, it should be noted that this form of disclosure must be
treated with caution, and only initiated when provision is made
by the Medical Superintendent for such a system.
Requests for confidential information concerning a patient's
records are frequently received from Government Departments.
Some of these requests are made in person by representatives and
others are received through the mail. Unless release of such
information has written authorisation or is fully covered by
statute it should not be made available. Information as to the
name of the patient, the address, and the dates of admission and
discharge may be released as such data are not usually considered
confidential.
Beside the provisions of Section 62 of the hospitals Act 1957
it should be noted that Section 13 of the War Pensions Act 1954
and Regulation 3 of the War Pensions Regulations 1956 specifically
cover any Government Officer requesting medical records on behalf
of the War Pensions Appeal Board. The records may be made
available to the Appeal Board on written demand without the
authority of the patient but the demand should show on its face
that the records are required for the purposes of the War Pensions
Act.
Numerous welfare organisations make inquiries which may be
official and solely for the benefit of the patient, but unless
they are specifically covered by statute, the information should
not be disclosed to them without proper authorisation from the
patient and the approval of the Medical Superintendent.
The Health Department is interested in the control of disease
which includes , the means of prevention of disease and injury, and
the promotion of health.In these activities the hospital is
bound by law as well as ethical responsibility to co-operate to
the fullest extent.However, when releasing any information care
must be taken to ascertain whether the record is to be used as an
impersonal document or as a personal document. If it is to be used
as personal information, authority should be obtained from the
patient and the Medical Superintendent. To give an example of
personal information, notification of a poison case may be quoted
where a neurotic patient has attempted suicide, and information as
to why the patient took the poison is passed to the Medical
Officer of Health. Such additional advice is not required under
the Health Act, 1956.
Sc
1
Privileged communication:
3.
Although statutes within New Zealand fully set out the
penalties for unauthorised release of information from a
patient's record, many persons having access to hospital
records fail to observe the principles of privileged communication. Confidential information given by a patient to
his physician must be regarded as privileged. Unless the
patient has waived claim of privilege of the medical record
by giving written authorisation for the inspection of the
record or release of information as covered by the statutory
provisions, no information may be divulged at any time. After
death of the patient the claim of privilege may be waived by
the patient's executor or next of kin.
Medical records containing identification data, diagnoses
and other pertinent data are sometimes allowed away from the
hospital for various purposes. Great care must be taken in
permitting practices which might involve a violation of the
privileged character of the medical record. The practice of
allowing medical records to be taken to homes or offices
where they may be viewed by unauthorised persons must be considered as unacceptable and condemned by those having custody
of the records.
Disclosure of medical information:
If a visiting physician requests access to the medical
record of a former patient, he is usually given the record to
peruse, but only as a courtesy by the hospital and not as a
matter of right. It must be fully accepted that medical
practitioners are well aware of the canons of professional
secrecy and that it is permitted under statute to pass on
information required in connection with the further treatment
of the patient. To be absolutely correct from the legal
point of view, a medical practitioner should maintain
personal records of his patients and these should be kept in
his office. Where a patient changes to another medical
practitioner, it is not unusual for that medical practitioner
to ask the hospital for a full report on the patient. The
information is given to the medical practitioner on the understanding that it is for the further treatment of the patient.
Some hospital medical record departments make it a practice
to send a duplicate copy of the records to the medical
practitioner in the form of a precis or summary for hisown
personal file. If the patient changes his medical practitioner
a copy of the summary is readily available to forward to him,
34.
k.
2. Property rights
Medical records are kept primarily for the benefit of the
patient but the question may arise as to who has the legal Hght to
custody.The case notes and all documents of patients treated in
the hospital are the property of the Hospital Board (or Hospital
Management Committee). They cannot become the property of the
medical practitioner making them but remain under the control of
the hospital.To elaborate further on this question, Mr. S.R.
Speller in his book 'Law Relating to Hospitals and Kindred
Institutions' quotes ".... whether it be a private or general
ward patient, it seems clear that the patient has no claim to the
medical notes or reports which are simply in furtherance of the
treatment for which he has either contracted or with which he is
being provided by the hospital". Putting it another way the
American authors Hayt and Hayt in their textbook 'Law of
Hospital' point out the property right of the hospital in the
following words " The hospital record is the property of the institution as is the register of a hotel .... records
are the property of the hospital which has the
right to their possession and custody; it is no
more the property of the patient than the merchant's
book is the property of the customer".
In addition to being kept for the benefit of the patient, the
medical records are kept as a guide to consultants, for education
and research, for the protection of the attending physicians
against claims of malpractice, and for the protection of the
hospital against criticism together with claims for injuries or
damage.
It is not in the patient's interest to see his record and any
patient requesting information should do so through his physician.
Upon receipt of written authorisation from the patient it is
permissible for the legal representative acting on behalf of the,
patient or other acceptable person, to receive a full report from
the medical record. However, the hospital may be required to
produce its records upon subpoena. Usually this is a Subpoena
Duces Tecum or a Summons to Witness to produce, which directs
the custodian of the records to appear in a given court on a date
and at an hour designated in the subpoena or summons. After
receipt of the subpoena all records specifically enumerated in it
must be produced in court at the time and place designated, or the
person subpoenaed is liable for contempt of court. When the
medical record is retained by the court it. is necessary for the
hospital to apply to the Registrar of the Court for its return.
k
MEDICO-LEGAL ASPECTS OF MEDICAL RECORDS KEEPING
1.
Introduction
2.
ProDertv rights
3.
Privileged communication
Lf.
Disclosure of medical information
4.1 Statutory Regulations on the disclosure of
medical information
50 Statutory provisions regarding admission of
patients
5.1 Admission to a mental health hospital
6. Authorisation for operations
7.. Regulations regarding discharge or .death of patients
8.
The medical record in Court
9.
Summary
.10. References
11. Further reading
11.1 Basic
11.2 Background
Appendix A Form Of consent by patient
Appendix B Consent by patient; consent by relatives;.
consent for minor
Introduction: 1.
The improvement of hospital administration during this
century has been accompanied by legislation which clearly
defines the duties and responsibilities of all staff connected with the compilation and keeping of a patient's
medical record. This is particularly so within New Zealand
where every effort has been made to cover by law all aspects
of medical jurisprudence.Hospital officers in their own
interests as well as the hospital's should be fully familiar
with the Hospitals Act and all the provisions pertaining to
medical record keeping..
File No.
Name
todate
Fig. 2.
A permanent
index card
1.-
2
APPENDIX A
File No.772240
Name of patientBROWN Joseph Robert
LocationWard 9
Date Out 12/8/65
am
pm 12120
Taken Byname of person
Fig. 1. The simple index card
These cards may be headed up to suit machine addressing.
The name of the patient may also precede that of the file
number.
Fig. 3. The 'record out' guide. Protrudes over the •end of
records on a shelf. Departments using steel
filing cabinets would design guide to protrude above
the top of the records.
83
Associative
'Controlling Staff' in London, Current Affairs Ltd.,
'Methods at Work' pp 47-511962, 101 pp
8.4
Light Relief
Pose (Ian) Robert's Rules
of Unparlimentary
Procedure
III The Phenomenon of
Records
Canadian Medical Assn. Jnl.
17 Aug. 19 6 3 9 pp 308-9
Tiltman (R.c.s.) Practical
aspects of a Medical
Records department
PP 136-9
Backround: 8.2.
Bothwell ( p .w.) Routine,
records and research
Pts. I - III
pp 2 98-30 2 ; Nov. 1960
PP 320-7; Feb. 1961, pp 359-64
Clarke (K.W.) The group
organisation in Medical
Records
pp 117-27
Clayton (J.P.) Recent trends N..Z. Hospital, March 1954,
in Medical Research and thepp 69-70
effects upon Hospital
Medical Records
Clyne (Max B.) The threeLancet,.6 June 1964,
faces of Joan: diagnosticpp 1270-2
and therapeutic levels
in general practice
research in Medical
Recording methods
pp 129-41
Fraser (Dr. A.) A consultant's view of Medical
Records
Medical Record,Nov. 1963,
Pp 583-8
Grant (John, edit.)
Work sampling
Medical Record News, April
1964 9 pp 51-2 ., 72-4
pp 143-57.
research in Medical
Recording methods
(Lincoln & Naylor) Record
department administration,
physical plant, functional
organisation and other
factors
PP 150-67
Rowan (D.J.) A working
formula for better human
relations
JnlAAMRL, Dec. .1961, p 255
Schenthal, Sweeney, Nettle- Jnl. American Medical Assn.,
ton & Yoder. Clinical appli- Oct. 12, 19639 pp 1,01-5
cation of Electronic Data
Processing Apparatus.
III System for Processing
of Medical Records
Hargrave (A.) Application
of Work Study to Medical
Records Service
pp 1+78-86
Hill (Peter E.) Work study
and the clinical record
2. Organisation, the key
to efficiency
PP 175-82
Incomplete notes: how to
deal with (in 'What do
YOU do?')
Medical Record News,.
Dec. 1965, pp 322-4
Jackson (N.V.) Departmental Medical Record, Feb. 1961,
Routine - requests
forpp 373-4
Information
Luck, J.F. Work study as 3rd mt. Congress Report,
applied to Medical Records pp 88-106
Luck (J.H.) Work study inMedical Record, Aug, 1959
relation to a Medical
Records Department
'Medical StenographersH.M.S.O., 1961,4 pp
Department': Abstracts of
Hospital Service, No. 10
Melvan (M.) Medical recordMedical Record News,
deficiency formFeb. 1966, pp 20-2
Meyer (Sister M.Y.) Methods Jnl AAMRL, Feb. 1957,,
improvement and the Medical pp 7-11, 16
Record Librarian
(Oviatt, Kurtz, Price,
April 1962, pp 82-1+, 90-1
Schultz, Mitchell &
Baumann) After hours office
supervision (in 'What
do YOU do?')
Hospitals
1960, 54 pp
Seymour (E.L.) Filing and1st mt. Congress Report,
disposition of recordspp 91-103
Sheetz O.K.) OrientationJnl AAMPL, Oct. 1960,
of the employeepp 183-4, 208-9
Stone (J.E.) Hospital organ- London, Faber, 1952, xxii +
isation and management,1722
pp 801-4, 814-18
N
3
smoothly regardless of how competent the Medical Records Officer
is himself, He/she is not a one man/woman department but. a
person who can co-relate and supervise the daily activities
and weld them into an efficient unit of the hospital service.
Developments in medicine and in the application of data
processing equipment to the medical record field demand that the
Medical Records Officer adjust his thinking to change. The next
two decades will see a complete change in methods of recording,
storing and referring to patient data; to serve his hospital
the Medical Records Officer must keep abreast of developments.
References: 7.
Huffman (Edna) Manual for Medical Record Librarians.
Physicians' Record Co. 1959- pp +31-5 8 ('Organisation
and management of a Medical Records department')
Further reading.: 8.
Basic: 8,1.
26
(Baumann, Smith, Cole &
Medziuà) Measuring
productivity in Medical
Record activities (in
'What do YOU do?')
Medical Record News, Oct. 1963
Brockis (R.J.) Tracing system
Brown (R.J.) Simple 'job,
analysis in a Hospital
'Records Department,
Medical Record, Aug. 195+,
(Carter, Chamberlain, Dunne,
Mitchell, Odam & Eugene,)
Requests for medical
records (in 'What. do. YOU
do?')
Jnl, AAMRL, April 19619
pp 80-2
Coulam (N.R.) Economy of
effort in Medical Record
keeping
pp 216-8
pp 1+15, 37
pp 350-58
pp 615-.25
hospital or to reveal certain, aspects of their medical history to
the examining practitioner because "they are afraid of what the
girls in the office might say". Fortunately in most cases such
statements are only an excuse to cover up some underlying motive;
however, they do serve to show how essential it is for all members
of the medical records staff, however junior, to display absolute
integrity. Whilst a person cannot be held responsible for her, or
his, family background this aspect has to be taken into consideration, particularly in the smaller communities, when considering
applications for positions in the Medical Records department. Also
it is wise to point out to new staff, who have not had previous
hospital experience, that non-disclosure of information includes
next-of-kin and other members of the hospital staff; this is an
important matter which is sometimes overlooked. Loyalty not only
to information regarding patients but also to the medical profession and the hospital itself should at all times, both during
working hours and in private life, be maintained.
It is also necessary for the senior medical records staff to
have an intelligent, but not presumptuous, understanding of medical
science. In the smaller hospitals it is very difficult for staff
wishing to increase their ability in this field but if personal
relationships are good most members of the medical staff are only
too willing to be helpful. Private reading and study are also most
valuable and in most cases, where there is a training school
library, tutor sisters are willing to lend books which although
written in extensive nursing detail, can be most useful.
The Medical Records Officer himself is directly responsible for
the efficiency of his department and no chapter dealing with the
present subject would be complete without assessing the abilities
and training necessary for the holding of such a position.
He will be regarded by his board as a senior member of the staff,
with a sound, complete and detailed knowledge of medical records
systems. Able to lead and supervise the department in all its
various aspects of daily work, enthusiastic and capable of infecting
his staff with enthusiasm and to command the respect and confidence
of medical staff, other heads of departments, his superiors,.'and
his own staff, he must be flexible to meet the ever changing demands
of medicine and board policy. His training, probably of necessity,
is of an "on the job" type but should be on as broad a basis as
possible not only to maintain an efficient department, but to be
able to meet additional responsibilities if necessary and to give
advice and assistance when required. Personnel selection and
management play a large part in maintaining efficiency, and only
a reliable and happy staff can keep a department functioning
3
Medical Records Officer and the staff concerned asked to meet
the committee. Such a committee can also give hacking to
Medical Records department procedures designed to keep records
available. For instance, it is a good policy to insist that
nurses requiring notes for case studies do their study in
the department and usually that not more than 20 records be taken
out at a time for research by medical staff. If a Medical
Records committee is aware of the reasons for wanting such rules
and endorses them their acceptance within the hospital will be
that much easier.
Responsibility to medical staff
and staff qualifications: 6.
During comparatively recent years the medical profesèion has
come to realise and acknowledge that specialised clerical aid in
the handling of medical records is a necessity, and to this end
the technical side Of medical records work has been handed over to
a staff of trained para-medical persons. This in turn has placed
on this staff a strong challenge to professional loyalty and created
positions of special trust within the hospital organisation. The
need for personal integrity in these positions cannot be overstressed. It is opportune to quote here from the Pledge of the
American Association of Medical Record Librarians: "Moreover, I
pledge myself to give out no information concerning a patient
from any other source, to any person whatsoever, except upon order
from the chief executive officer of the institution which I may
be serving ..... 't
The final responsibility for the completed, factual and
accurate medical record rests with the attending physician or
surgeon with the assistance of other hospital personnel. He knows
the facts and is competent to interpret them as they apply to the
person being treated. His co-operation and assistance will
produce an adequate, scientific and authoritative record. Tact,
understanding and consideration of medical staff's problems on
the part of the Medical Records department will help establish
a climate conducive to good medical recording thus laying a firm
basis for better patient care in the future and adequate statistical
data for research programmes..
This element of medical work tends if anything to be enhanced
in the hospitals serving smaller communities where unfortunately
there is a tendency for everyone to know everyone else's business.
It has been known for patients to express reluctance to enter
possibly for a day in rotation because otherwise there are too many
interruptions.
In addition, the teams would have routine department jobs
shared between them, such as census, operation lists, notifiable
disease lists etc.
This type of organisation allows each team to vary its work
according to requirements and inclinations. By making each team
responsible for certain blocks, of numbers it imposes on the team
an obligation to know at all times where the records in its section
are
5. Relationship with other departments
In a hospital as with any other complex organisation, it is
important to appreciate the problems, and the work involved, of
other sections of the staff. A Medical Records Officer may look
with dismay at an admission record that is lacking in some
personal details of the patient, and feel that the Admitting
Officer is not doing his job properly. It might not occur to him
that the Admitting Officer could have, been in the difficult
position of having to admit an unconscious patient, accompanied
by some person who could not supply all these personal details.
The reverse also applies - an Admitting Officer could feel that
the Medical Records Officer is wanting some information that is
not really required. The best way to solve these problems is to
show the reason why a certain procedure is adopted, or why a
particular set of questions require answers, by personal approach
to the people concerned.
The Medical Records Officer's working relationship is closest
with the Medical Superintendent to whom he is usually responsible
for his work even if, as a member of the administrative staff, he
comes under the House Manager. Normally, the Medical Records
Officer will discuss problems with the medical or other staff
concerned, referring to the Medical Superintendent matters of
principle or seeking his backing where necessary.
AMedical Records Committee, usually with the Medical
Superintendent as chairman and the Medical Records Officer as
secretary and with representation from part-time visiting staff
and full-time medical staff and possibly nurses is recommended.
This should meet monthly or every other month for the purpose of
examining problems in connection with medical records. Cases of
delay in completion of records can be brought forward by the
23
3
ment, and may be subdivided to allocate which jobs are performed
by particular members of the staff. This manual should be'
reviewed from time to time, as the addition of new procedures,
the deletion of others, or changes in staff may call for some
revision.
In any job, it is a good policy to be always on the lookout
for ways and means to do it better, faster and with less effort.
Medical Records is no exception to this, and the staff within
the department should be encouraged to make suggestions for ways
and means to improve any of the many -jobs that are carried out
within the department. Even the most junior member of the staff
should be asked for ideas; they may come up with something
that routine bound older members have constantly missed.
It is important to train staff to be proficient in as many
phases of medical records work as possible. This safeguards
the department in the event of staff being away due to sickness
or holidays, as the work of the department must continue. An
office whe .re the staff of equal capabilities change duties
periodically is also advantageous, as a clerk who is constantly
pulling and filing records, or indexing, can become bored with
the routine nature of such work. Such boredom can lead to lack
of care, and then mistakes occur, such as misfiling, which is
probably the most time consuming error to rectify in a Medical
Records department.
The 'team' concept: 4.1.
Mention is made in para 5.2, chapter 5 ('Filing systems')
that terminal digit filing facilitates the orgànisation of the
office in teams.
An alternative to changing clerks from one job to another
for variety of experience and interest is to make them responsible
for everything for a certain section of records. This can be done
with the terminal digit filing method by dividing the department
up into teams responsible for records ending in certain numbers.
For instance, a hospital with 12,000 discharges a year might be
divided into 3 teams, team A being responsible for charts with
primary numbers 00-32, team B 33-66 and team C 6-99.
Teams of two each are usually best; they would have
responsibility for all the operations connected with the record stacking., filing, coding, typing MS18 statistical cards etc.
although it is usually better to have pulling done by one person,
z2
In order to assist medical and nursing staff to find a
record when the department is not staffed by Medical Records
personnel, it is useful to 'have a plan displayed, showing
where to find patient index cards, where files of a certain
number are, and where to find records that may be housed in
another room. Access should only be by obtaining a key from
the Head Orderly's office on signature. An 'after hours' book is essential. In this book, a note
is made of any record removed after hours. It should show the
date and time of removal, where the record has gone' to, and who
took it. It is also necessary to have a large notice plainly
telling staff what to do when taking a record.
k.
Organisation of staff,
V
The variation of size of hospitals throughout the country
naturally makes a considerable difference in the number of
staff •required to operate a Medical Records department. In
small hospitals, one person may be responsible for admissions,
records, medical typing, and a host of other duties. Moving
up the dcale, there are separate Records departments, manned
by one person, to the major hospitals with a large staff,
including clerks who specialise in one particular sphere of
medical records work, such as coding, workers' compensation,
cancer registration, and index clerks, as well as clerks who
are responsible for pulling and refiling case notes.
The majority of jobs in a Medical Records department are
learned by experience and tuition from other staff within the
department. An exception might be a coder, who could have
attended a training course organised by the National 'Health
Statistics Centre. Next to the officer in' charge of the Medical,
Records department, the position of coder must be regarded as a
key one, by virtue' of the time it takes to reach what may be
regarded as maximum efficiency. However, this does not mean
that the coder is more important for the efficient working of a
Records department than, say, a filing clerk, as all records
staff should be regarded as part of a team.
In organising the distribution of work, the Medical Records
Officer must ensure that his staff fully understand the nature
of a particular job, how it is done, and why it is done. To
this end it is a wise policy to draw up a procedure manual.
This details all the different jobs done by the Records Depart-
Ii
3
2.5.
The patient index:
This must be accurate and correctly filed according to
whatever system is in use in.the hospital. It is a timesaving device to include all names pronounced in the same
way but spelt differently in the index together, e.g. Gray,.
Grey, Hardie, Hardy, Heard, Herd, Hird. The important thing
to note is that all staff must know what system is used and
follow it exactly. .. .
• .
An efficient department:
2.6
The work done by the Medical Recordsdepartment may vary
between hospitals. For instance, in larger: hospitals most
include the medical typists as part of the department but in
some this will be a separate department; in smaller hospitals,
medical records will be part of the functions -of the office..
Whether 'Medical Records' is a complete department or part of
one clerk it must do its job promptly and efficiently. If it
gets known as 'the filing' then it is relegated tothe status of
a dustbin - and probably looks like one. To. be'efficient a
department should look efficient. ..•..
Hours of.coveràge for
Medical Records department:
•The normal working week for the majority ofNew Zealanders
is Monday to Friday. However, many public services have to
maintain their service for twenty-four hours a day, seven days
a week, although such service may be .on a reduced scale at
weekends, and at night. A hospital issucha.service.
To assess the hours of coverage for the Medical Records
department, it is reasonable to assume that if there is a
constant call for records outside the normal working hours,
then the department should be staffed to deal with the work.
This problem is mainly one for the large hospitals. Staff may
work on a roster basis, and have regular change of shifts,
covering other departments where possible, e.g. Admitting.
PO
.3.
2.3.2 Referring to medical records
Different methods of keeping track of medical records are described in chapter 5 ('Filing systems'). However, there has to be
a policy regarding the use of medical records for study or research.
The medical record must, as we have seen, 'be quickly brought
into service if a patient is readmitted'. This cannot be done if
it is in the rooms of a member of the visiting staff, in a
resident's or nurse's room.
Therefore, a policy along the following lines should be
adopted and have the authority of the Medical Superintendent:
(i)
in a new department or one where space is available,
study cubicles should be available for medical and
nursing staff to refer to records, to study them or
to use them for research;
(ii)
generally speaking, not more than 20 records should be
put out for study or research at a time, another 20
being put out when these are returned;
(iii)
as space is usually short, a compromise has to be
reached usually with records for visiting staff being
put in their lounge, those for resident staff in their
office and nurses being required to study records in
the Medical Records department.
2,4. Confidential nature of records.
The question of maintaining the confidential nature in all
matters relating to a patient's medical record has been emphasised
in all publications relating to Medical Records practice.
All enquiries for information from a medical record for
insurance, workers' compensation, or legal purposes should be
through the Medical Superintendent. An authority to divulge
such information must be signed by the patient. Enquiries from
a Registered Medical Practitioner about past history that may
assist the practitioner in arriving at a diagnosis for a current
illness are not regarded as a breach of confidence.
'1.9
3
Hospital
MEDICAL RECORDS DEPARTMENT
Dr.
Patient:Hosp.. No.__________
Please:1. Discharge letter
2. Discharge summary
3. Sign front sheet
k Final diagnosis
5. Operation. note
6. See x-ray report.
7. See pathology report
8. See P.M. report
Put - out at your request..
• Quick action by you will help
us to give prompt service
Date
.../.../6..
The required message is circled or ticked.
2.3 Identification of reports with a patient
A number of report forms, particularly laboratory and x-ray
reports, will not be available until after the patient has been
discharged from hospital. It is essential that these reports be
seen by the doctor in charge of the case or his House Surgeon
who should initial all reports, indicating that he hasseen
them; this should be rule of the hospital. The report should
be attached to the record with a note to the doctor concerned
drawing his attention to it.
Before filing with the medical record, reports should be
identified by the patient's name as well as hospital number, as
belonging to that record. It is possible to have people with
the same name, and only one number different on a file, if, for
example, a father and son were admitted as a result of a motor
vehicle accident. We could get Reginald Brown No. 123456, and
his son'Reginald James Brown 123+57, both admitted to a hospital
for the first time, and being allocated adjacent file numbers,.
2 .3.1 Notes to medical staff
The Medical Records department frequently has to bring the
attention of medical staff to deficiencies in a medical record or
is asked to put out a record for a doctor's attention. , Nothing
looks so indicative of a sloppily run department as putting these
out with a scrap of paper with a scrawled note on it.
Any hospital Medical Records department can have a supply of
standard notes to be pinned on the front of the record, even if
these are only duplicated. The note could be along the following
lines:
11
3
A.
The guide is the same height as the folder it
replaces, and about two inches longer. It is
also advantageous to be of a contrasting colour
to the normal record folders. A plastic
pocket on the side of the guide holds-an index.
card much the same as the simple index card
(see Fig. 3, Appendix A). The guide must be
made from a durable grade of cardboard. The
main disadvantage of this type of location
check is its use in a Records department that
may have records stored some distance from the
• main working area; obviously one does not know
that the record is out until going to the file
to find it.
B.
A simple lined manilla card of contrasting
colour and longer (or higher) than the case
notes. When a medical record is removed from
the files the following details are written on
the manilla card - hospital number,, patient's
name, where the notes are taken to, and the
date taken (signature of the person taking can
be added), the card is then placed in, the
location of the record. When the record is
re-filed, the 'record out' card is removed and
a line put through the last entry, hence it is
ready for reuse. This has the advantage that
it is simple to use, inexpensive and useful
when records are filed in different places.
It has the same disadvantage as that described
under 'A' above.
(iv) 'Kardex' type
One can also use a card in a Kardex type drawer or
folder either as an individual mark-out or for,
say, 10 charts.This works quite well as a
tracer of records up until the MS18 statistical
card has been typed and action on the record has
been completed. For use with the unit system it
has been found unsatisfactory when referring to
older notes.
(b) A location index card.This system may have several
variations, and providing all staff of.the hospital who
may be called upon to remove medical records from the
Records department follow the simple procedures, an
adequate location check is . assured.
(i) A
simple index card (See Fig. 1, Appendix A)
This is a 5" x 3" card headed with the patient's
name, hospital number, location, and, date removed.
A line should also be provided for the signature. of
the person. removing the record from file, as this
procedure establishes the authority of the person
taking the record.
It is a good policy to use two cabinets for this
type of card, one strictly for admissions, and the
other for all others, such as clinics', research,
etc. After discharge from hospital, some patients
will be followed, up at clinics for . changes of
dressings, suture removal etc., and the index card
used to denote an admission for such a patient may
be transferred to the 'other records out' box.
The date of such a change should be noted on the
card. When the records are returned , to file, these
index cards are destroyed.
(ii) A permanent index' crd (See Fig : 2, Appendix A)
This card is used in the same manner as the one
previously described. It is kept under the front
of the folder of the record while the record is in
file, and may be stored in a cabinet when the
record is removed. The only advantages over the
simple' index card are (1) it may be headed up with
the patient's personal details when the original
record is compiled, thus saving a little time by
not having to make up a card each time the records
are removed, (2) it gives a brief history of the
movement of the record between different departments,
which is often useful.
(iii) The 'record out' guide
When a medical , record is removed from its place in
the file, it is replaced by a guide. Two kinds are
suggested: ..
/1
3
been taken from the department has gone to. Several methods
of 'booking out' records may be used, some of which follow Tracer methods: .2.2.1.
(a) An alphabetical indexed book
When a patient is admitted, the despatch of his or her
records to the ward is recorded by entering in the book
particulars such as, for example, in the case of a
Mr. John Adams admitted to Ward 9 on 5 July, 1965 Date & time
file sent to
ward
6/7/65
10.30 a.m.
NameFilePrevious
notes
Ward
Adams, John 123+5 .0/c
9
Date file sent to ward. This date may not be the
admission date, as the previous record may be very old,
and housed some distance from the Records department,
and not brought up to date until the following day. In
the case of an evening admission the record maynot be
despatched to the ward until the following day. Under
the column headed 'Previous notes', it is useful to
show very briefly the type of records that go to the
ward. An example of terms abbreviated can be:
(i) 0/c, an old case. This means that the patient has
old inpatient records, and they have been sent' to
the ward.
(ii) O.P.D.This means that the only previous
records cover attendance as an outpatient or the
patient was examined at a specialist clinic prior
to coming to hospital as a booked admission and
the records have been sent to the ward.
(iii) A simple. dash - could denote that the 'patient has,
no previous history of attending the hospital, and
that a new folder for his medical record has been
headed up and despatched to the ward0
Noting the ward number serves as a location checc.
records stored there; if a room has to be in another building,
an attempt should be made to select one that is close to a member
of the clerical staff in that building, so that a telephone call
to that person can recall the record into use.
The policy should be that the oldest records (i.e. the ones
where the patients have not been admitted for the greatest number
of years) should be less accessible than the more recent ones, if
two or more storage rooms have to be used. The methods used to
select the records over a.certain age can be readily worked out by
the Records staff of the hospital concerned. Tightly packed
records can lead to damage and the chance of misfiles increases.
Space requirements vary in different hospitals depending on the
degree of detail used. Instead of taking an arbitrary figure to
cover all eventualities it is better to count a few shelves to
see how many records you get per foot. You could find this varying
as much as 30 to a foot between, say, open maternity cases and a
medical admission in a teaching hospital.
When organising the working space and storage capacity of the
Records department, care should be taken to have sufficient
shelving or drawer space free to accommodate records in current
use, such as recent discharges awaiting discharge letters, reports,
coding and indexing etc. Outward and returned clinic records
should be kept in their own marked shelves for the interim period
between clinic sessions for the outward records, and the re-filing
of returns. All records awaiting action (discharge records,
clinic records) should be immediately sorted into the alphabetical
order of the surnames of the patients, or the numerical order of
the hospital numbers or filed in pigeon holes under the House
Surgeon or visiting staff. Strict observance of this procedure
enables clerical staff to be more accurate when refiling, they
can quickly locate a particular record should it be required, it
leads to a tidy office, with consequent improved morale and greater
productivity.Even the newest member of the staff will be fully
conversant with the-office routine in a short time. On the other
hand, sloppy storage of records awaiting action such as heaping
them on desks, on the floor, or in any odd space that may be
vacant, will lead to these records being mislaid,.and creates an
air of confusion in the department. Good housekeeping is a must
in a well organised Medical Records department.
2.2 Knowing the exact location of medical records
It is essential that the staff of a Medical Records department have some means of knowing where a medical record that has
13
3
(ii) To ensure that all reports and forms can be identified
with the patient to whom they apply, and that they are
filed correctly.
(iii) To ensure that the confidential nature of a patient's
medical record is maintained.
(iv) To maintain an accurate patient index (refer chapter
6 'Indexing procedures').
(v) To operate a disease index, and any other indexes
that will usefully serve the staff of the hospital,
such as operation index, radiotherapy index,, cancer
register etc. (while a disease index is essential
for all hospitals, other indexes may or may not be
used depending on the size of hospital and scope of
treatment). Depending also on the size of the
hospital the cancer register may be a part-time job
for a Medical Records staff member, a full-time job
for a Medical Records clerk or be kept outside Medical
Records by separate staff (who are, however, dependent
for their information on Medical Records).
(vi)
To enjoy the confidence of medical, technical, and
administrative members of the staff by the prompt and
efficient execution of all duties rightly assigned to
the department.
Within the broad scope of these six headings, all Medical
Records departments should operate.
Storage and protection: 2.1.
The majority if not all hospitals' Records departments reach
a stage where the volume of records becomes such that, the
rehousing, destruction or microfilming of the older records
becomes necessary. The pros and cons of microfilming are dealt
with in chapter 19 ('Retention of medical records). The question
of how long, records are to be kept is also covered in the
same. chapter.. . Rehousing can usually be achieved within
the hospital, and careful consideration should be given to the
proposed location, keeping the following important points in
mind: the new room should be clean, well ventilated, dry and
have no extremes of temperature, such as pipes from the steam
reticulation system nor be an extremely cold room. If the room
is in thesame block asthe main Records department, then the
Records. staff, are in a position to handle any calls 'on medical
it
Depending upon the size of the hospital, there will be a considerable variation in the number of people employed within a
Medical Records department. Indeed, there may be many differences.
between the duties performed by Medical Records staff from one
hospital to another. The layout of different. departments within
a building, or group of buildings that comprise the hospital,
will influence the type of work, and scope of duties of-Medical
Records personnel.
The generally accepted formula of the close proximity of
Admitting Office, Medical Records department, Outpatient department, Medical Officers' Lounge and library, is ideal. However,
many New Zealand hospitals (and those of other countries' too),
started life as comparatively small institutions, and have grown
stage by stage as the community they serve has grown. Naturally,
such buildings cannot be continuously enlarged as one structure, ..
and the end product is often a group of buildings with Medical
Records, Outpatient, Admission Office, and Medical Officers' rooms
widely separated.
• Against this background therefore, we may have a modern
hospital, with a specially designed Medical Records department,
with adequate accommodation for storing many years' medical
records;or an older type of building, with the Records
department housed in converted rooms, and 'storehouses' for
case notes situated in several different places within the
hospital. Hospitals in New Zealand vary in size from about 900
beds down to 50 beds or less in country centres. Naturally the
management and organisation of a Medical Records department' is
going to, differ greatly with such a wide variation in hospitals.
However, let us examine the function of a Medical Records department with a view to finding a 'common denominator', some basis
applicable to all hospitals regardless of size or age.
The function of a Medical Records department:. 2.
This basis is (j) To store and protect the medical records of all patients
in such a manner that they can be quickly brought into
- service if a patient is readmitted, or if the patient is
to be seen at a clinic, and to know the exact location
if out of the department.
11
3
ORGANISATION OF A MEDICAL RECORDS DEPARTMENT
1.
2.
Introduction
The function of a Medical Records department
2.1 Storage and protection
2.2 Knowing the exact location of notes
2.2.1 Tracer methods
2.3 Identification of reports with a patient
2. 3. 1 Notes to medical staff
2.3.2 Referring to medical records
.2.4 Confidential nature of records
2.5 The Patient Index
2.6 An efficient department
3.
Hours of coverage for a Medical Records department
4.
Organisation of staff
14.1 The 'team' concept.
5.
Relationship with other departments
6.
Responsibility to medical staff and staff qualifications
7.
References
8.
Further reading
8.1 Basic
8.2 Background
8.3 Associative
8.4 Light relie
.
Appendix A. Marking out cards
Introduction: 1.
This chapter covers organisation .in outline. It will be
apparent that the object of most of this manual is to cover this
subject in great detail. Specifically, the chapters covering
aspects of organisation in a Medical Records department are:
51 'Filing systems'; 6, 'Indexing procedures'; 8, 'Hospital
census taking'; 10, 'International classification of diseases';
11, 'The classification of diseases'; 12, 'The classification
of operations'; 14 1 'Notification of diseases'; 15, 'Workers'
compensation'; 17, 'Cancer registration'; 18 'Follow-up
methods'; 19, 'Retention of medical records';
21, 'Planning a Medical Records department'-.
to Social Security department concerning admissions to hospital;
dealing with enquiries about War Pensioners and letters from
G.Ps. concerning patients. This work is delegated to members
of his staff as necessary. It will thus be seen that the
necessity for an efficient Medical Records department is
essential to the successful administration of our New . Zealand
Hospitals.
8.
Conclusion
Other questions may be asked about the medical record "Who owns a medical record?"
"Who has access to a medical record?"
These questions are all answered in other parts of this manual,
and I earnestly recommend that all Medical Records Officers and
their staffs make a careful study of this manual and so qualify
themselves in the very important work they should be doing
accurately and well in our New Zealand Hospitals.
Finally, I feel this manual, with some sections dealing
with admission procedures, planning a new department, filing
systems, form design and the role of Medical Records departments
in the hospital organisation should prove of interest to
Hospital Medical Superintendents and Board Secr.etaries,.in.
. .
future planning.
The contribution of the medical record to medical research: 6.1
Hospital records are, of course, not kept for research
purposes primarily, but rather for the care of ill individuals.
Nevertheless the medical record is a storehouse of knowledge
concerning the patient. Collected together these records
contain a mass of data on all phases of morbidity. Hospital
data are able to yield important clues as to the factors
which underlie or are associated with disease. For example,
cigarette smoking associated with lung cancer was first suspected from hospital studies. It was only later that the
validity of the association was confirmed by controlled
prospective studies.. Many examples can be cited of retrospective studies of cancer in which hospitalised cases and
matched controls have been used in search of attributes
associated with disease. Hospital data, it has been
demonstrated, can be used to study associations between
various diseases appearing in the patient. To extract and
analyse medical files in hospitals and clinids is not an
easy task, demanding extra effort and imaginativeness on the
part of the Medical Records Officer. A good Medical Records
Officer should not only be able to assist medical men doing
research work, but should be thinking in terms of initiating
studies of his own after consultation perhaps with interested
medical staff.
The purpose of the Medical Records department: 7.
I have been asked "what do Medical Records staffs do?" or
"what is the purpose of running a special department for
medical records?"
. . .
I can only quote from my own fairly lengthy experience in
one Hospital Board.A Medical Records Officer in charge of
a department in a large hospital is responsible for the
smooth running of a fairly large staff. This may include
the admission office, accident and emergency department,
receptionists, all medical and surgical typists and secretaries, hospital bed census clerks, filing and coding clerks.
His responsibilities include the production of statistical
returnsto the Board's administration staff for annual
reports; supplying day-to-day data to the Superintendentin-Chief on bed states, average days stay and any other
information required that assists in running .a large
hospital; statistical returns to the'Public Health Statistician;
correspondence to insurance companies and lawyers re
accident claims and workers' compensation; daily returns
alterations to the diagnosis or findings on the case can be made.
It is the Medical Records Officer's duty to see that every medical
record contains the complete findings on the case. This can only
be done if fully trained staffs are doing this important work,
When Medical Records staffs have studied and understood the many
excellent sections in this manual the more qualified they will
become and will not only take a greater interest in their work
but will be of greater. help to the medical staffs they work with.
6. Use of a medical record after patient's discharge or death
I have often been asked what is the use of a medical record
after a patient's discharge or death?
The medical record is, of course, of the greatest assistance
in the event of the patient's readmission to hospital. To the
House Surgeon examining a. patient for the first time the particulars in a good medical record of a previous admission are
invaluable.To learn what treatment and drugs a patient has
been on previously is vital.Reference to any allergies to
drugs and antibiotics could possibly be a life saver.
I am told that in at least one hospital the reference to any
allergies isaiways written in bold marzipan ink on thecasenote
cover. This is the first thing noticed by the sister or doctor
attending - an excellent idea which should be copied by all
. . ..
other hospitals.
As mentioned above, ideally the medical record should contain
in one pack all inpatient and outpatient notes. 1t is important
that any doctor examining a patient should be able to get from
the notes all previous medical history - people's memories are
notoriously unreliable and it is poor practice to keep clinic
outpatient records divorced from inpatient ones.
The medical record is also used in connection with cases for
negligent treatment. If an assertion is made that a certain.
drug or treatment was or was not ordered or given the medica.
record, as the document written at the time, is looked at for the
answer.
New Zealand's small population and its isolation from more
heavily populated parts of the world make it an ideal country for
medical research. In recent years more and more research is
being carried out and well written medical records are of the
greatest use to medical staffs working on the increase or
otherwise of certain diseases in New Zealand.
7
2
Drugs prescribed, nursing instructions, temperature charts
and other treatment given are recorded on the appropriate forms
that go to make up-the case notes.
What a completed medical record looks like: k.
"Now what does the completed record look like?" The style
of forms used varies in different hospitals, but the general
set-up is much the same. The patient identification form shows
the full name, address and age of the patient, where born, race
(usually Maori or non-Maori), next-of--kin.The patient's
hospital number is usually shown in the top right hand corner.
Below is shown the disease or diseases diagnosed and
operations, if any. The order of diseases is set out to conform
to the Ms18 statistical card sent to the National Health Statistics
Centre in Wellington.
The continuation sheets show particulars of the patient's
illness and course of treatment from admission until discharge
or death.This record is followed by all the other forms used
to record the different tests done. The temperature chart and
nursing notes are usually the last sheets in. the patient's
case notes.
In most hospitals on the discharge or completion of treatment of a patient a summary giving a history of the course of
the patient's illness and treatment while in hospital is sent to
the patient's own doctor, with recommendations for the after
care of the patient. A copy of this letter is usually attached
to the medical record for filing. This is a good practice as a
concise summary is very useful for quick reference to the case
if necessary and will probably give enough information without
reading through all the pages of the medical record (which are
available if more detailed research is required. )
The Medical _RecordsOfficer's place in
the comLetionof the medical record: 5,
Now where does the Medical Records Officer come into the
compilation of a medical record? As a matter of fact he has
little to do with it at all. However, the trained Medical
Records Officer must be able to read the medical record intelligently and learn to look out for a missing report that may
possibly alter the diagnosis. His duty then is to take the
report, show it to the doctor in charge of the case so that any
In New Zealand patients are usually admitted under a member
of the visiting staff who is assisted by the whole time staff,
e.g. Registrars and House Surgeons. Radiotherapists, Radiologists and other members of the whole time staff are called in
as consultants in a great number of cases. All these people
make a contribution to the medical record of the patient.
3. What good case notes should contain
At this stage we must ask ourselves "What should good case
notes contain?"
The notes should show as clearly as possible the patient's
past history, both as an inpatient and outpatient, if the patient
has had previous hospital treatment.
This information should be obtained if possible from the
patient or from a near relative. The symptoms complained of
should be carefully recorded. Patients usually bring to the
hospital a letter from their own doctor, giving a history of
the illness with, perhaps, a provisional diagnosis. In the case
of acute or accident admissions the position is more difficult
and the immediate requirements for the case must be attended to
first because the patient is probably not in a fit state for
questioning.However, if relatives are present, information
can be obtained about the acute attack or accident. On admission to the ward the patient is first examined by the House
Surgeon. Following the examination, his findings are carefully
recorded on the forms that go to make up the full case notes.
Depending on the type of illness various tests are taken,
e.g. blood, urine, sputum etc. and forwarded to the Pathology
department to be reported on. All reports are sent back to the
wards and must be attached to the case notes promptly. In
number of cases requisitions are sent to Pathology, Biochemistry,
Microbiology X-ray departments and for other technical examinations for their reports on a particular case. So it can soon
be seen how the case notes are built into a fairly complete
history of any particular case. Where surgery is performed the
operation sheet should be fully written up, preferably by the
surgeon himself, showing the procedure and findings; all biopsy
or histology reports must also be attached to case notes as soon
as received from the Pathology department.
In some of the larger hospitals the operation report is
dictated by the surgeon to his secretary who types the report
on the Operation Sheet.
It
2
INTRODUCTION:THE MEDICAL RECORD AND ITS USES
I • Preamble
2.
What a medical record is
3.
What good case notes should contain
k. What a completed medical record looks like
5.
The Medical Records Officer's place in the compilation
of the medical record
6.
Use of a medical record after the patient's discharge
or death
6.1 The contribution of the medical record to
medical research
7.
The purpose of the Medical Records department
8.
Conclusion
Preamble: 1.
The readers of this manual on Medical Records Practice in
New Zealand will, or should, find the various sections of great
assistance and interest in the daily running of a Medical
Records department.When reading the different sections on
medical record keeping and other subjects, it is necessary to
consider and ask the question: "What is a medical record?"
Reference to the glossary of terms (chapter 2 9) will give the
definition of a medical record: the completed case notes,
the case notes being what is defined in the following paragraph whenreferred to whilst the patient is in hospital.
What a medical record is: 2.
The medical record is a narrative on paper of the patient's
medical history, present complaint, examination findings and
treatment given. Ideally, it contains in the one pack all
inpatient and outpatient treatment for the patient. Unfortunately, because house surgeons are often inadequately trained
in record taking, many records fall short of the ideal and far
too many are inadequate and would be of very limited use on
readmission or if another doctor took over treatment. The
content of the record depends to a large extent, also, on the
ability of the patient to give a history of past illnesses and
treatment.The doctor examining a patient has his task made
more difficult if the patient is not very intelligent.
-2-
The first reference number which is underlined refers to the
chapter number, the second to the paragraph within the chapter.
Thus:
Hospital cancer register, operation of 17-s- 3
HOSPITAL CENSUS TAKING.8
l+Finding a reference
Separate pages are not numbered,. the number appearing at, the
top right hand corner being that of the chapter,. thus permitting .
the. easy replacement of out-dated material.
Locate the chapter required. from the top right hand corner,
then the paragraph from the paragraph reference number which always
appears on the outside of the. page...
Gerald Wakely
Editor
HOW TO USE THIS MANUAL
1.
Scope
2.
Organisation
3.
Index
1, Finding a reference
I
Scope: 1.
The manual's purpose is threefold:
(a) ' a working source of reference on medical records
and related practices under New Zeálànd conditions;
(b)
a basic text for education in medical records and
related procedures;
(c)
a guide for those in charge of departments, and
others concerned, in the fields of .organisation,
equipment and planning..
As circumstances change in different hospitals the manual
is intended to-be used as a guide to working out asuitable
method for, a particular situation; it does not lay down standard
procedures to be followed in all hospitals except where all
hospitals make the same returns, e.g.. MS18 statistical cards and
MS3 8 cancer site cards. .
Organisation: 2.
Chapter headings indicate the. scope of each,chapter.
Reference should be made to the index, however, for mention of
a subject in other chapters. ... ..
Inde;,Chapter headings only are in CAPITALS, all other references
in lower case..
2.
3.
CONTENTS
How to use this manual
I
Introduction: the medical record and its uses
2
Organisation of a Medical Records department
3
Medico-legal aspects of medical records keeping
Filing systems
Indexing procedures.
Admission Office procedure
Hospital census taking
Anatomy and physiology
International Classification of Diseases
The classification of diseases
7
8
9
10
11.
The classification of operations Medical terminology
Notification of diseases Workers' compensation
5
6
12
13
14
15
Outpatient and Accident & Emergency department procedures
16
Cancer case registration and cancer statistics
17
Follow-up methods
18
Retention of medical records
19
Design of forms
20
Planning a Medical Records department
21
Hospital morbidity statistics
22
Glossary of terms
23
References
Index
-
S
Contributors-,-
S
S
C.,
7
MED:CAL-s
L.URARY
1::L(

medical records in practice

Transcription

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