Document Sample
					Hunter Area Health Service
Operational Policy Statement
                               Clinical Information

1. Description of Unit


Clinical Information Department is located on Level 1, Eastern Aspect of The
John Hunter Hospital.


The Clinical Information Department liaises closely with Admissions, Outpatient
Clinics and the Emergency Department for the two-way movement of medical
records (approximately 28,000 per month).

The John Hunter Hospital is the central focus point for Clinical Information
Services in the Greater Newcastle Sector. This involves the provision of services
at: John Hunter Hospital, Royal Newcastle Hospital, Belmont District Hospital,
CAYHNet, GNS - Community Health Services, Rankin Park Hospital, Wansey
Centre, Toronto Poly Clinic, Nelson Bay Poly Clinic and, the records of hospitals
that have been closed at: Western Suburb Hospital, Wallsend District Hospital,
and Nelson Bay Private.

Function includes:
 Management and storage of clinical records,
 Provision of medical records for clinical care,
 Medico-legal reports and management of Subpoenas,
 Responding to Release of Information requests,
 Responding to Freedom of Information requests,
 Clinical Coding/Casemix,
 Undertaking Audits on clinical coding and medical record documentation,
 Providing education on documentation,
 Management of HOSPAS including staff training and audit trails analysis,
 Assisting in the designing of forms,
 Provision of clinical information for research, quality assurance and audit
 Completion of the Death Register for John Hunter Hospital,
 Assist in policy development for HAHS on Clinical Information Issues,
 Involvement in the implementation of new technology eg. PAS, POCCS,
 Representation for the HAHS on the state committees for the new UPI, EHR
  and POCCS,
 Active involvement at State level for new legislation for the HAHS eg, Privacy
  and Child Protection,
 Encourage staff to continue further education and maintenance of skills,

Hunter Area Health Service
Operational Policy Statement
                               Clinical Information

Function includes: (continued)

   Culling of medical records as per the retention period,
   Provide staffing across the HAHS in line with changing workloads,
   Collect and analyse statistics to indicate activity levels and adjust staffing
    accordingly, and
   Provide advice to areas on medical record issues, storage, retention,
    documentation, clerical support services and information systems.

Emergency Department: Medical records are requested and retrieved as the
patient attends. The Clinical Information Staff deliver the records to the
Emergency Department individually or in bundles of 2 or 3. The Emergency
Department staff identify the priority of the request. A record transfer system will
be used to deliver the medical records to this area (Approximately 130 per day).

Admissions / Delivery Suite: Medical records are delivered to these two areas
the day prior to the patients admission for booked admissions. For unplanned
admissions the records are delivered as the patient presents. The CID Staff
deliver records to the Admission Unit. Records required for Delivery Suite and
The general wards are retrieved by the CID staff and delivered by the wardsmen.
(Approximately 140 per day).

Outpatient Clinics: Medical records are pulled 48 hours in advance and placed
in the appropriate trolley or collection bay awaiting collection by the Outpatient
Clerk of each clinic. Clinic staff collect these records 24 hours prior to
attendance. Records required for unplanned presentations are retrieved as
requested and collected on an individual basis by the Outpatient Clerk.

Outreach Clinics: Records are retrieved for: Nelson Bay Polyclinic, Toronto
Polyclinic, Belmont Antenatal Clinic, North Coast Renal Clinics, Wansey Centre
and the Wallsend Child & Family Clinic, These records are pulled the night
before, packaged and delivered to the transport department on the morning of
the clinic for delivery and are returned at 5pm each day.

Research/Audits/QA: All records are pulled in a priority order and placed in the
record review room for the requesting clinician review.

Clinical Staff: Regularly attend to discuss research requirements, coding and
casemix issues, chart review and to discuss other clinical information related
issues eg, documentation, release of information, confidentiality, medico-legal
etc. All overnight reports are ready for collection on a daily basis or as required
for staff to commence work for that day.

Hunter Area Health Service
Operational Policy Statement
                                   Clinical Information

Function includes: (continued)

Other Departments needing to visit the Clinical Information area are:

CSU’s Clerical Staff: Some attend daily to file correspondence.

Outpatient Clinic Nursing Staff: Some attend regularly to file investigation

Aboriginal, Ethnic and Pastoral Services: The daily reports are available for
collection after 7am each day.

Patient Transport: Delivers and returns all records daily which are required at
an outside unit for continuation of care.

Medical Record Flows – these are shown on Diagrams attached

Medical Record Flows – Diagram 1
John Hunter Hospital Request for a Medical Record

Medical Record Flows – Diagram 2
John Hunter Hospital Medical Record Number Allocation

Medical Record Flows – Diagram 3
John Hunter Hospital Return of Discharged Medical Records and Clinical Coding

Hunter Area Health Service
Operational Policy Statement
                                 Clinical Information

                                      Diagram 1
                                John Hunter Hospital
                                Medical Record Flows
                             Request for a Medical Record

      Elective admission               Emergency attendance               Audits
                                       Emergency admission                 QA
                                       Outpatient attendance             Research

     Requests received by:             Requests received by:       Requests received by:
      report generated by              printer                    telephone
        ATS 24 hrs prior                telephone                  printer
      printer                                                      fax
      telephone                                                    hand-delivered

                                      Check PMI to identify if a
                                       medical record exists

                NO                                                       YES

        Make up new chart
         and update PMI

                                        If not requested on
                                      printer, make a request
                                        on MRRT and print
                                            request slip

                                        Place slip in tracer

                                           Medical record
                                       forwarded or available
                                            for collection

Hunter Area Health Service
Operational Policy Statement
                                  Clinical Information

                                   Diagram 2
                              John Hunter Hospital
                        Medical Record Number Allocation

                                          Medical Record Number
                                          Requested by

                      Telephone                                      Fax

        Collect & log information from                       Request received PMI checked.
        requestor. Requestor remains on                      Number allocated or existing
        line while clerk checks PMI.                         number noted & requestor
        Allocated or existing number                         contacted with number
        given immediately

              Medical record chart                           Request filed in folder for 1 month
              made up if required

                MRRT updated with
               information that it is a
              new allocated number,
               Dr to be seen & clinic
              name. Tracer placed in

         Hunter Area Health Service
         Operational Policy Statement
                                          Clinical Information

                                                  Diagram 3
                                     John Hunter Hospital
                    Return of Discharged Medical Records & Clinical Coding

                                                 Inpatient Discharged

                              Medical records returned 3 days post discharge & placed in
                              the RRR returns area

                              Medical record assembly checked & also reviewed for
                              completion of front sheet and/or discharge summary.

                               Check ATS to ensure all admissions are present

                                                 Chart Completed

                        NO                                                           YES

            Medical record tracked to RRR & placed                           Medical record is
            in Dr’s pigeonhole awaiting completion                           tracked to JMRD
            of Front Sheet

             On completion of Front Sheet the
             medical record is tracked to JMRD

                                            Medical Records placed in Coding Unit

Episode coded using 3M Encoder. Codes transferred to HOSPAS DI                         DI Grouper run on
                                                                                       the 14 month

                               Coding summary printed and placed in admission notes

Hunter Area Health Service
Operational Policy Statement
                               Clinical Information

New Areas
The new area will include the following rooms:

Reception/Waiting, Interview room, Record Review room, Trolley Park,
Meeting Beverage Room, Office x6, Workstation one person x2,
General work area space for 10 people, Coding room, Staff toilets with
lockers, Equipment Microfilm room, Record Store area, Document transfer
bay, Clinic collection area, Photocopy/store room, File Sorting area,

The main reception will be located at the front door of the department. A doorbell
will be at the front door and used to alert staff in the department there is
somebody waiting in the reception area. The public will wait in this area before
being attended to by a member of the staff.

Interview room
The interview room will be located close to the waiting/reception area and used
for interviews between a patient and the clinician to discuss the medical record,
solicitors reviewing their client’s medical record with the CID staff, general public
to complete forms for release of information, aggressive visitors to be handled
away from general staff, medico-legal officers interviewing and training sessions.

Record Review Room
There will be five people working in this area to research, audit and mark through
the medical records, also assemble records into order and computer enter and
basic clerical skills.
The Record Review Room is also used by clinicians for signing and reviewing
records. The current “small” pigeonhole wall of shelving will be transferred from
the old Clinical Information Department and relocated to this room.
A coffee machine will be installed in this area with a bar fridge to encourage
Doctor's to visit this department and sign off for Coding.

Trolley Park
For storage of trolley when not in use and will hold up to 5 or more trolley at one
time. Located near the reception area for the return of records from clinics.
Records are to be transferred from the OPD clerk’s trolley to the return trolleys.

Meeting Beverage Room
This area will be located central in the department with access to a small
kitchenette area within the room. This area will also be used for holding meetings
where larger numbers of people are involved. This area will have access to a
private outside courtyard.

Hunter Area Health Service
Operational Policy Statement
                                Clinical Information

There are six offices and x2 one-person workstation. These offices are to be
used by the following persons:
GNS Manager, GNS Deputy Manager, Assistant Manager, Office Supervisor,
Medico-legal Report Officer, Medico-Legal Secretary, Audit Clerk,
Coding Auditor Manager.
All offices will be of similar size depending of the amount staff in each office and
have external views for natural lighting.
Office area will be lockable and workstations will have a secure area for private
items and documents.

General Work Area
There will be open plan work area for all staff primarily involved in record retrieval
and filing. There will be space for 10 persons working in this area each having a
workstation of there own.

Coding room
There will be 8 people working in this room. The Coders are responsible for using
the 3M Encoder for coding all discharged records by the Area Coding Deadlines.
Completion of Cancer Notification occurs on line in the HOSPAS system.

Staff Toilets & Lockers
Two unisex toilets are located in the far end of the main record store.
Staff lockers will be located in the anteroom off the toilet area for staff to put
small personal items.

Equipment/Microfilm Room
This room is a storage area for: microfilm computer, microfilm reader, microfiche
reader, printer and shredder.

Record Store area
Large area with open shelving for storage of both active and archival files.

Document Transfer Bay
This area us for the receiving and transferring of medical records via an
automatic case system

Clinic Collection area
This area is for ”extra” records required for clinics. Clinic staff will access this
area to collect records via reception area.

Hunter Area Health Service
Operational Policy Statement
                               Clinical Information

Photocopy/Store room
Used to house large equipment: photocopier, fax and clerical supplies and
storage. Located close to reception area/clerical area and the main entrance to
allow delivery of stores easier.

Filing Sorting Area
This are two areas on is close to the main record area and used to sort files
which have been returned on the tracking system and are ready for filing, the
other is located near the back of the record area for storage of covers and
dividers which make up the medical record.


Staffing numbers – 30.8 FTE               Categories AO1 – A06
                  10.0 Casual staff       Categories AO1 – A06
This department provides a 24 hour service and Staff start at selected times
throughout the whole 24 hours.

3. Hours of Operation

The Unit operates 24 hours/7 days

4. Waste Disposal

Waste materials will be sorted into appropriate containers at their point of use
and disposed of by the housekeeping services department.
Confidential paper/documents will be placed in a lock secure Sulo Bin marked
confidential waste and when full taken and a return empty bin exchanged.

5. Supplies Services

The Supply Services Department will provide supplies via Corporate Express and
delivered during working hours.

6. House Keeping Service

The House Keeping Services Department will provide cleaning Services.
Clinical Information Unit require a daily service which would include emptying of
bins in all offices, work areas and lunch room, removal and replacement of the
security shredding bin, dusting, mopping and vacuuming.

Hunter Area Health Service
Operational Policy Statement
                               Clinical Information

7. Occupational Health & Safety

The Clinical Information Department will provide:
 appropriate trolleys for the staff to move records,
 adequate foot stools and ladders,
 climate and moisture controlled environment as per document storage
 designated area for the dot matrix printer to reduce the potential for noise

8. Security

Security of this area is required
The front entry will have a visual panel and be lockable from the inside. There will
be a doorbell at the front entry and the side door access will need to be locked
after hours.
A security officer will accompany afterhour’s staff when retrieving a record
outside the main department or ward areas as offices and clinic areas are locked.
The security officer also accompanies the staff member to Byrne House, Hunter
Rehab, and Rankin Park as well as to Doctor’s officers to search for and retrieve
medical records.
Staff property will be stored in lockers located in the change room off the toilets in
the main department.
All offices will be locked with lockable desk drawers and cabinets.


Lingjuan Ma Lingjuan Ma