Every time a patient is treated at Almonte General Hospital (AGH), a chart is created to record the health care professionals’ observations, diagnosis and treatment decisions, as well as vital signs, test results and other data about the patient’s condition.
Once a patient leaves the Hospital, the Health Records Department takes over responsibility for the chart. Health Records is responsible for maintaining medical records in a standardized and professional manner in order to support a high quality of care for patients, and is also responsible for keeping the health information private and secure in accordance with federal and provincial regulations.
AGH’s Health Records Department includes Health Information Specialists who provide coding and abstracting of the diagnosis, Health Records Clerks who make sure that the charts are complete and filed correctly and Transcriptionists who type and prepare more than 12,100 reports dictated by physicians each year (e.g., discharge summaries and operative notes). Other duties include the release of information to authorized recipients, such as insurance companies, and completion of monthly and annual statistics.
The abstraction phase involves reading the chart and analyzing the information to determine what condition(s) the patient had, what caused it and how it was treated. Data from the Emergency Department, Day Surgery and Inpatient records are submitted to the Canadian Institute for Health Information (CIHI).
CIHI publishes reports that help AGH monitor its own performance, as well as other statistics and reports that provide regional, provincial and national information about health status, use of the health care system and efficiency of the system.
Health Records staff also produce reports for use by the AGH management team, physicians and Board that describe volume of service, types of service provided and statistics, such as the average length of stay of inpatients. This information, along with the CIHI reports, helps us understand what is working well and identify areas where improvements may be needed.
- Between April 1, 2013 and March 31, 2014 the Health Records Department processed:
- 15,000 Emergency records * 1,900 Out Patient Clinic records * 1,350 Inpatient records * 790 Day Surgery records
- 150 Medical Day Care records
The dedicated Health Records staff work behind the scenes at AGH, ensuring that patient records are stored safely and securely and providing information that helps to improve the quality of patient care.
Heather Graham is Director of Health Records, Brian Burns is Vice President, Finance, and Mary Wilson Trider is President & CEO of AGH.