Document Sample
					                                                                                                    PROVINCE OF KWAZULU-NATAL
     Department of Paediatrics              C l i n i c a l     R e c o r d s                            HEALTH SERVICES

                                                                                                      ISIFUNDAZWE SAKWAZULU
       P ie t er m ar i t zb u r g                                                                            EMPILO
          Me tr op o l it a n
      Hos p it a ls Com p lex                                                                        KWAZULU-NATAL PROVINSIE

               S TAN D A R D I S E D PA E D I ATR I C RE CO R D K E E P IN G
           Toward improving the quality of care that children receive, and the efficiency of
                                healthworkers working with them

                quality improvement, uniformity, efficiency, holistic, child-friendliness, region-wide

Project Aims
1)    Develop a set of forms that enable improvement in the quality of care that we deliver to children
2)    Make uniform the records across the paediatric department and throughout the KZN inland health region, which
      improves efficiency of clinical personnel (doctors and nurses)
3)    Move towards a single (and chronological) patient medical record, which reduces duplication and therefore
      unnecessary expenditure of money and time, and separate from inpatient/admission records
4)    Develop a user-friendly system for access to and ordering of the forms
5)    Make the system sustainable, which will improve job satisfaction for health personnel working with children

Paediatric Patient Record: set of records usually completed and continued by a doctor, used to ensure comprehensive
care in continuity
Administration Record: data capture sheet(s) used for statistics and billing (inpatient – the case sheet or No 23-
38704/N26053/04.05/Alert Stationers, and outpatient - the Yellow File as below)
Inpatient Records: the set of Observation and Monitoring Records, used during admission for recording patient
observations and treatments, including the nursing process
Prescription Records: charts used for prescribing drugs, and documenting nursing orders
Yellow File: 23-27608/C0716764/11.02/NPP
Brown Sleeve: 23-58901/O.No.N0000116236/11.2004

            The Paediatrics Department of the Pietermaritzburg Hospitals Complex is responsible for children’s health both
            in Pietermaritzburg and in the Western half of Kwazulu Natal.
            This has been determined by the National and Provincial Policies on the Primary Health Care Approach and on
            the District Health System framework.
            The department, in partnership with District and Hospital managers would like to respond to this challenge.
            A core area identified for quality improvement is Clinical Record Keeping

Current Practice and Problems
There are a number of different kinds of records kept for each patient:
1) Administration and clerical records
2) Clinical/medical records (doctors notes)
3) Records of investigations
4) Observation and monitoring records
5) Prescription records

A number of problems follow:
1) Administration/clerical records are at times not distinguished from clinical records (viz the “Case Sheet”)
2) Clinical notes are not chronological
3) Clinical notes are kept in at least two different places (an outpatient file and an inpatient file) If the child has been
    admitted more than once then there are further and separate clinical/medical records for each admission. The
    different sets of notes are not available with the child at each consultation. There cannot by definition be continuity of
    care, if records are kept in this way
4) There is extensive duplication:
         outpatient notes must be copied into the “Case Sheet” if a patient is admitted
           information previously elicited and documented must be re-elicited and redocumented, if previous clinical
           records are not available or there is choronolgical disarray (it takes less time to elicit and document the
           information than to go through a file that is a shambles)
           information that does not change, such as birth history, vaccination records e.t.c., must be elicited and
           document each time a child is seen if the previous records are not available
           because results of investigations are not documented in the clinical records or are not available when they have
           been because they are in a different file, investigations (some very expensive) are repeated unnecessarily, or
           results of investigastions are not responded to, both to the detriment of the child
5)    Duplication in this way is inefficient, more expensive, time-wasting, and as a modus operandi leads to an accepted
      ethos of sloppiness and indifference. Furthermore, it leads to poor quality of patient care through incorrect and at
      times extremely dangerous clinical decision making and prescribing
6)    The forms used for clinical records are outdated and often inappropriate to the task they are being used for
7)    The forms used for clinical records are often photocopied into illegibility, and look sloppy and unprofessional
8)    Different wards use different forms for the same purpose (this occurs within institutions as well as throughout the
      region). Doctors and nurses must learn different forms when they move from ward to ward

1)    Create a set of forms for clinical record keeping that is smart, professional and appropriate to the needs of sick
2)    Standardise the set of forms for use within institutions and throughout the health region
3)    Separate Administrative/clerical record keeping forms from Clinical record forms
4)    Have a single set of clinical/medical records (doctors notes) in a single file in which the standardised clinical record
      set is kept for each patient, and this set is used both in the outpatient and inpatient settings. This standardised set of
      clinical records must be kept up to date and chronological
5)    Develop a catalogue system for easy ordering and storing of forms at ward level
6)    Insist on adherence to the agreed upon system at all levels of hospital management
7)    Conduct regular document audits to monitor implementation and compliance

What needs to be done?
a.    General Rules
1)    Where “Date of Birth” is required, “Age” must NOT be used
2)    Staples must not be used in the Medical Record (or anywhere else). File fasteners are the tools for binding records

b.    Hospital Administration: Clerks
1)    The responsibility for placing medical forms into the folder must be moved from the clerks to clinical personnel
2)    The “Yellow File” must be used for the complete set of clinical/medical records This becomes the Paediatric Patient
      Record and is used wherever the patient goes in each institution, i.e. outpatients, inpatients, special investigations,
      rehabilitation services e.t.c. (see “Gold Standard” Paediatric Patient Record).
3)    The “Brown File/Sleeve” must be used for filing inpatient and administration forms (see Gold Standard Inpatient
4)    Which form to use for patient administration: either the front of the “Case Sheet” or “Inpatient Admission” form No
      23-38704/N26053/04.05/Alert Stationers, must be decided

                        These processes must be cleared with the Institutional Systems Manager

c.    Outpatients
1)    The Paediatric Patient Record (see Appendix 1) should be assembled in Paediatric Outpatients (or General
      Outpatients for District Hospitals) under the instruction of the Sister and Doctor in charge of outpatients
2)    The records MUST be assembled correctly, and placed (male or female) in the “Yellow File” as the patient arrives
3)    Referral letters are part of the Medical Record and must be placed with the “continuation” (history and progress)
      sheets in chronological order
4)    Before starting to enter information, the doctor should check that the Medical Record is complete and in the correct
      order. Incomplete or non-chronological records must be corrected immediately
5)    At admission, the attending doctor simply writes “Admit” as part of the care plan at the end of the clinical notes
6)    The sister responsible for admitting, should then fill in the Administration Record (either the “Case Sheet” or
      “Inpatient Admission” form No 23-38704/N26053/04.05/Alert Stationers)
7)    The “admission package” therefore contains 1. the “Case Sheet” or “Inpatient Admission” form No 23-
      38704/N26053/04.05/Alert Stationers, 2. the blue prescription sheet, and 3. the pink doctors orders card
8)    For minor ailments, all background information (history, growth charts results of investigations) must be filled in only
      if time allows. If time does not allow, it is acceptable to make a clinical note only on the continuation sheets
9)    For non-minor ailments and for admissions, all background information MUST be filled in, every time a patient is
      seen for the first time

                 These processes must be cleared with the Medical and Nursing Service Managers

Last modified: 13 June 2007                                     2                                                   For review: 2009
d.    Pharmacy
1)    For outpatients, the prescription can be written at the end of the clinical notes
2)    For inpatients, the prescription is written on the blue sheet

                                     This must be cleared with the Pharmacy Manager

e.    Inpatients
1)    Medical notes MUST remain in the “Yellow File”, and be kept in chronological order. All referral letters, consultation
      requests and replies, operation notes and special investigations reports (CT scan, MRI e.t.c) are part of the Medical
      Record and should be placed in the record in chronological order. It is the patient’s doctor’s responsibility to keep the
      Medical Record neat and orderly
2)    All laboratory results should be entered into the results sheet
3)    After entry, the laboratory forms should be signed, lined, and archived. It must be decided where to put the
      laboratory forms: Brown Sleeve, Ward Box, or Shredder.

                 This should be decided by the Clinical HoD and the Institutional Medical Manager

4)    During the admission, all Observation, Monitoring and Prescription charts should be kept in a (plastic) A4 Ring
      Binder, in a set order and should be managed according to the instructions laid out in Appendix 2. It is the Sister in
      Charge of the ward’s responsibility to keep this Ring Binder neat and orderly

f.    Discharge
1)    At discharge, the patient discharge letter/summary should be completed in triplicate. A copy goes with the patient,
      one forms part of the Paediatric Patient Record, and one should be filed on the ward in a lever arch file by date of
2)    Observation, Monitoring and Prescription records should be removed from the Ring Binder, bound with file fasteners
      (NOT staples) in chronological order and placed in the Brown Sleeve
3)    The Administration Record (either the “Case Sheet” or “Inpatient Admission” form No 23-38704/N26053/04.05/Alert
      Stationers) should be completed and signed by the doctor in charge of the patient, and placed in the Brown Sleeve.
      The Paediatric Patient Record MUST NOT be removed from the yellow file
4)    The first clinical note at the patient’s next presentation must come immediately after the copy of the discharge letter

                    This must be cleared with the Systems Manager, for the attention of the clerks

g.    Managing and Ordering Forms
1)    The catalogue and the complete record set (originals only) should be kept in the ward and in the Stationery
2)    In addition, the Child Health Resource Package compact disc, which contains all the forms, must be easily
      available and usable to all ward clinical personnel in charge of each ward, and to stationery staff
3)    The Ordering Form should be used for obtaining new forms
4)    ONLY ORIGINALS should be copied, and the copies MUST be EXACTLY the same as the originals
5)    A shelving system in each ward should be used where the form order on the shelves is EXACTLY the same as the
      order of forms in the Paediatric Patient Record and the Inpatient Ring Binder
6)    With the catalogue, each ward must keep a “Gold Standard” for the Paediatric Patient Record (Yellow File) and for
      the Inpatient Records (Ring Binder) for cross referencing
7)    The Sister in Charge of the ward is responsible for managing and ordering forms
8)    Quality control should be performed by the Doctor and Sister in charge of the ward, and non-compliance in the
      ordering, copying and managing of forms should be reported to the Hospital Manager

                              This must be cleared with Nursing Service and Hospital Managers

The Future
The intention of this department is the roll-out of this standardised paediatric clinical record system into all hospitals in
the Western half of Kwazulu Natal. This process is integral to the improvement of quality of care of children throughout
the health region.
Further forms will be developed according to need.
The Child Health Resource Package will be put onto the intranet. This will improve access to the resources, and will
enable instant use of updated resources as updates occur.

                                  COHS AS A: “all notes must be legible and chronological”
       Saving Children 2004: “Significant improvement in record keeping and archiving is required.
       Not only is the record keeping problematic with regard to statistics but it also has a negative
                                         impact on patient care.”

Last modified: 13 June 2007                                     3                                                   For review: 2009