WRITING A PROCEDURE

Assignment:

1. Using one of the methods for writing procedures (e.g. narrative, outline, or play script), develop a procedure for the receipt and processing of medical records of discharged patients.

2. The following activities must be completed to properly process the medical records of discharged patients:        

• Medical records of discharged patients are retrieved from the patient care units on a daily basis during the 11:00 pm to 7:00 am shift. (health information courier)
• The records are sorted by discharge date (analysis clerk)
• Partial records (records that are not complete and that have other parts of the record filed elsewhere) have to be bound by rubber bands or paper clips (analysis clerk).
• The computer has to be queried to see where the corresponding record is for all partial records. In-house partials are placed in premade folders on the "in-house" shelf. For all other partials, the corresponding record should be located and the partial placed inside it. If the record cannot be located, the partial is placed in terminal digit order on the "Partial" shelf. The location of the record in the computer system should be changed to "Recompile" (analysis clerk).
• Fetal monitor strips have to be removed from the records and placed in labeled envelopes. The patient's name, hospital number, and the date have to be recorded on the envelope (analysis clerk).
• These envelopes are then taken to "Permanent file" (File clerk).
• The coding section has discharge lists that are checked to make sure that there is a chart for each patient. Somehow the patient's name is marked or highlighted to show that a chart was received. After all the charts are checked, the lists are returned to the coding shelf (analysis clerk).
• Each record of a discharged patient is placed in a premade folder. A bar code label is made for the patient's name and medical record number and placed on the bottom of the folder. The patient's name and medical record number are also handwritten on the folder (analysis clerk).
• The location of each of the discharge records (incomplete charts, coding, etc.) is input into the computer (analysis clerk).
• The medical record is sent to the appropriate location for coding, completion by physicians, or filing (incomplete charts clerk).