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Life underground: spotlight on Records Management

Tammy Ozero (left), clerk, and Linda Khera, manager, records management & registration, are part of the small but mighty team th
Above photo: Tammy Ozero (left), clerk, and Linda Khera, manager, records management & registration, are part of the small but mighty team that processes a staggering 1,500 patient charts every day.

Spotlight on Records Management 

Location: Heather Pavilion, tunnel level (A Floor), room 108
How many staff do you have? 29
Hours of operation: 24/7
How many files do you process per day? The team processes approximately 1,500 patient charts each day.

What is the Records Management Department?

As soon as a patient enters the hospital, their record (also known as their chart) begins to be compiled. It will continue to be updated until the patient leaves the hospital.

Once the patient finishes treatment in-hospital, the record comes down to the Health Records Department where the team reviews it to ensure all of the paperwork is filled out and signed off, and that nothing is missing or pending. The team then files the chart so that if the patient returns, the record exists and the medical history is all there.

“We get a lot of charts every day," says Linda Khera, manager of Records Management & Registration for Vancouver General Hospital (VGH) and UBC Hospital (UBCH). “In one month alone, the Emergency Department sends us approximately 8,000 patient records and we receive approximately 9,000 outpatient records from DHCC [Diamond Health Care Centre] and other VGH outpatient clinics."

What do you do?

“When a patient is discharged from the ward, the chart is in a binder," says Amy Yu, Health Records clerk. “We bring the chart here and put the pages in the right order so that the next time the patient comes in the information is there and easy to find."

In addition to maintaining and filing charts, the team and manages requests for patient medical information, such as when patients request copies of their charts. Lawyers, police officers, insurance companies and other agencies also occasionally request patient records information; these requests are assessed on a case-by-case basis. To maintain patient privacy, there are many restrictions on how and when a patient chart can be accessed.

How do you support the delivery of quality patient care?

Health Records ensures that all patient records are complete and accounted for. Their work ensures care providers have all of the historical and current information necessary to make clinical decisions for patient care.

“If a physician didn't have that chart history, patient allergies, previous diagnoses and other vital information may not be otherwise available – especially if the patient presents unconscious or otherwise unable to communicate," says Linda. “Physicians need that information and will even postpone surgery until they receive the patient record."

How do you support innovation in health care?

Though the team uses paper charts, they input some of the data, such as procedure codes, into the Pacific Coast Information Systems (PCIS) and other programs to ensure all critical patient information is stored correctly and can be accessed appropriately.

Indirectly, the team supports innovation in health care by providing data for clinical research and decision support.

What else happens in the Records Management Department?

Information from the charts is also collected for statistical analysis, research and decision support.

“Once we have assessed the chart and see that it's complete we send it to Coding and they input the diagnoses into a code," says Tammy Ozero, Health Records clerk. “For example, if a patient comes in with a heart attack, there is a code for that; this code is used to produce statistics and note complications, which can be useful for research and funding."

The team also inputs treatment codes from the charts so that the coding department can bill the ministry to ensure physicians are paid for the treatment they provide.

“It's a busy place," says Linda. “In many ways we are the foundation of the hospital."

Did you know?

  • VGH has approximately half a billion patient charts. 
  • Until their transition to CST, VGH patient charts remain 100 per cent paper.
  • Health Records stores three years' of patient charts, which occupy three large rooms onsite.
SOURCE: Life underground: spotlight on Records Management ( )
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