1. HEALTH INFORMATION
MANAGEMENT
Department of Health, Philippines

2. Health Record Standard I
The hospital maintains health records that
are documented accurately and in a timely
manner, are readily accessible and permit
prompt retrieval of information, including
statistical data.
Department of Health, Philippines

3. Health Record Standard II
The health record contains sufficient
information to identify the patient, support
the diagnosis, justify the treatment and
document the course and results
accurately.
Department of Health, Philippines

4. Health Record Standard III
Health records are confidential, secure,
current, authenticated, legible, and
complete.
Department of Health, Philippines

5. Health Record Standard IV
The Health Information Management
Department is provided with adequate
direction, staffing, and facilities to perform
all required functions.
Department of Health, Philippines

6. 1. The record is sufficiently detailed to
enable:
- patient to receive continuing care
- effective communication within the health
team
- Attending Physician to have available
information required for the consultation
- other medical practitioners and health
personnel to assume the patient care
- concurrent or retrospective evaluation of
patient care
Department of Health, Philippines

7. 1. Entries into the records are made
only by duly authorized persons of
the facility and are dated and signed,
containing designation.
3. All entries, including alterations, must be
legible.
Department of Health, Philippines

8. 1. Only abbreviations and symbols
approved by the Medical Records
Committee are to be used.
5. If possible, original copies of all reports
made by medical, nursing, and allied
health professionals are filed in the
record.
Department of Health, Philippines

9. 6. Each record should at least contain the
following data:
- unique health record number or reference
- Patient’s full name
- Address
- Date of birth
- Sex
- Person to notify in case of emergency
Department of Health, Philippines

10. 7. An “ALERT” notation, for the conditions
such as allergic responses and drug
reactions, is prominently displayed on the
face sheet of the record.
8. The record contains a written admission
diagnosis by the medical practitioner.
Department of Health, Philippines

11. • The record contains a patient’s history,
pertinent to the condition being treated,
including relevant details of:
− Present and past medical history
− Family history
− Social considerations
10. A sufficiently detailed report of a
relevant Physical Examination (PE),
performed by a medical practitioner,
should be included for the purpose
of admission.
Department of Health, Philippines

12. 1. Evidence that the patient has given
informed consent is available.
12. Drug orders are written in the record by
the medical staff.
13. Therapeutic orders and orders for special
diagnostic test are noted in the record.
Department of Health, Philippines

13. 14. There is evidence in the health record that
patient care plans were made.
15. Progress notes, observations, and
consultation reports are written by
medical, nursing, and allied health staff
to record all significant events such as
alterations in the patient’s condition and
responses to treatment.
Department of Health, Philippines

14. 1. The Admission and Discharge Record’s
discharge data is completed at the time
of discharge or as soon as the relevant
information is available. It contains all
relevant diagnoses and procedures using
the terminology of a current revision of
the International Classification of Disease
(ICD).
Department of Health, Philippines

15. 17. A Discharge Summary for each patient
should be completed within 48 hours upon
patient’s discharge, with a copy remaining in
the health record. The discharge summary
should at least include the following:
− Discharge diagnosis
− Procedures performed
− Follow-up arrangements
− Therapeutic orders
− Patient instructions (when necessary)
Department of Health, Philippines

16. 18. When a patient is transferred to another
facility, a Discharge Summary should
accompany him/her.
Department of Health, Philippines

17. 19. When an autopsy is performed a
provisional diagnosis is noted in the health
record within 72 hours and the health
record is completed within 15 days
following the death. A copy of the autopsy
report is filed in the health record.
Department of Health, Philippines

18.
Health Record Identification System
Alphabetic System
The simplest form of record
identification, using the patient’s name
to identify and file the patients’ health
record.

19. Health Record Identification System
Numerical System
•has a direct influence on the filing system
•use of a Master Patient Index (MPI) to
cross-reference the patient’s name with his
or her HRN is required.

20. Health Record Identification System
Unit Number
•unique identification number is
assigned on first contact with the
health care facility, whether:
◘admission
◘ER attendance
◘out-patient
◘includes health care facility
newborn babies

21. After receiving the inpatient health records
from the Nursing Service, the HIMD
performs essential procedures prior to filing
and storage.
1. Assembly of Health Record
The forms are arranged in the order
upon admission of the patient.

22. 2. Analysis of Health Record
•The most important function of the
HIMD is the health record analysis to
ensure maintenance of quality
documentation.
•Analysis is the process of evaluating
and/or checking health records to
ensure completeness, accuracy and
adequacy of documentation.

23. •In cases where the patient wants some
data corrected especially on the
demographic/sociological data, it shall not
be done in the original entry, but should
appear as an amendment only.

24. •The health records shall contain all
original copies of examination results,
operations, and other required forms.
•Anesthesia record
•Report of operation
•Nurses' notes

25. 2. Coding
•It is a process of assigning numbers to
represent diagnosis or problems and
surgical procedures.

26. 1. Indexing
• Disease Index is a listing on a card for
specific disease based on standard
classification/nomenclature, arranged
according to code number.
• Operation Index is a listing on a card for a
specific operation according to standard
classification/nomenclature, arranged
according to code numbers.

27. 5. Collection of data for hospital statistics

28. 5. Filing of Health Record
A filing area that will ensure the rapid
location and retrieval of health records
must be maintained.

29. Alphabetical filing system
•All records of discharged patients are
filed in strict alphabetical order from A
to Z.

30. Numerical filing system
There are two systems of filing records
numerically:
• Straight Numeric
• Terminal Digit
For terminal digit, a six-digit
number is used and divided into
three (3) parts.

31. MEDICAL RECORDS
DISPOSITION
SCHEDULE

32. Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Retention Period Disposition
Description Authority/Remarks
a. Active b. Storage c. Total
1 Emergency Room Records 25 years 25 years
/Blotters and other records of
prospective medico-legal
significance
•Gun Shot Wounds
•Mauling of any Nature
•Poisoning Cases
•Stab/Hacking Wounds
•Sudden Death of Unknown &
Suspicious Causes
•Vehicular Accidents

33. Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Retention Period Disposition
Description Authority/Remarks
a. Active b. Storage c. Total
2 Certificates
•Birth (Not Official Copy) Retain until patient
reaches the age of
maturity (18 yrs.)
•Death (Not Official Copy) 15 yrs. 15 yrs.
Medical All Health Care Facilities,
irrespective of its category
and classification shall
dispose of medical records
Medico- legal beyond (15 yrs.)
Non Medico- legal Health Care Facilities
attached to teaching
training/research
institutions may keep
medical records beyond
fifteen yrs. (15 yrs.) if
deem necessary

34. Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Retention Period Disposition
Description Authority/Remarks
a. Active b. Storage c. Total
3 Consent to involvement in 1 year Dispose 1 yr. after
Medical Trials completion of medical
trial. If product of
confinement, follow the
disposition schedule under
Item No. 2 for Non-
Medico-legal records
4 In- Patient Chart 15 years All Health Care Facilities,
Basic Medical Records irrespective of its category
and classification shall
• Clinic and Graphic
dispose of medical records
Record/Graphic Chart/TPR Chart
beyond fifteen yrs. (15
•Consent to Hospitalization yrs.)
•Cover sheet/Face
sheet/Admission-Discharge
Health Care Facilities
Record
attached to
•Discharge Summary teaching/training/research
•Laboratory Record institutions may keep
•Nurses Notes/Nursing Records medical records beyond
15 yrs., if deem necessary

35. Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Retention Period Disposition
Description Authority/Remarks
a. Active b. Storage c. Total
•Personal History
• Physical Examination
•Physicians/Doctors Order Sheet
•Progress Records/Progress Notes/
Doctor’s Progress Notes
Supplemental Records
• Anti-Coagulant Therapy Record
•Autopsy Report
•Blood Transfusion Record
•Consultation Report
•Delivery Block
1.Labor Room Record
2. Newborn Record
3. Pre-natal Record
4. Summary of Parturition

36. Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Retention Period Disposition
Description Authority/Remarks
a. Active b. Storage c. Total
• Diabetic Record
• Dialysis Record
• Dietary Record/Report
• Discharge against Medical
Advice
• Electrocardiogram (ECG
Block)
1. Report
2. Tracing
• Fluid Intake and Output Chart
• Inhalation Therapy Record
• Intravenous Fluid Sheet
• Medication Board

37. Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Retention Period Disposition
Description Authority/Remarks
a. Active b. Storage c. Total
•Operation Record
1. Anesthesia
2. Informed Consent for
Surgery, Anesthesia
and other Procedures
3. Operating Room
Record
4. Operative Technique
5. Recovery Room Record
6. Tissue/Biopsy Record
• Parenteral Fluid Sheet
• Pulmonary Laboratory Blood
Gas Analysis
• Radio Therapy Record
• Referral Slip
• Rehabilitation Record
• Tissue/Organ Donation
• Vital Signs Record

38. Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Retention Period Disposition
Description Authority/Remarks
a. Active b. Storage c. Total
5 Indexes PERMANENT For agency reference.
• Disease
• Master Patient Requirement from all
• Operation tertiary hospitals and in
• Physician some secondary hospitals
w/
teaching/training/research
components.
6 Registers
• Electrocardiogram (ECG) PERMANENT For agency reference.
• Family Planning (Sterilization) PERMANENT For agency reference.
• Laboratory Dispose 2 yrs. After the last
1. Bacteriology entry provided to item is
subject of a medico legal
2. Blood Chemistry
case.
3. Clinical Microscopy
4. Hematology
5. Hispathology
6. Specimens

39. Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Retention Period Disposition
Description a. Active b. Storage c. Total
Authority/Remarks
6 • Live/Still Birth PERMANENT For agency reference.
• Medical Records Service Dispose 1 yr. after the last
(Incoming Medical Records from entry.
Wards)
• Medico- legal For agency reference.
PERMANENT
• Radiology For agency reference.
PERMANENT
1. C-T Scan
2. Ultrasound
3. X-Ray (Routine/Special
Procedure) For agency reference.
PERMANENT
• Surgical Cases
7 Medical Records of Employees Dispose 10 yrs.after
Working in a Health Care Facility separation/voluntary
resignation or retirement
from the facility.

40. Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Retention Period Disposition
Description Authority/Remarks
a. Active b. Storage c. Total
8 Out- patient Records Dispose 10 yrs. After last
(Ambulatory Service) consultation/visit.
9 Psychiatric Records 25 yrs. 25 yrs.
10 Records of Infants Delivered in Retain until patient
a Health Care Facility reaches the age of
majority (18 yrs.)

41. Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Retention Period Disposition
Description Authority/Remarks
a. Active b. Storage c. Total
11 Registers PERMANENT For agency reference.
• Admission and Discharges
• Birth
• Death
• Delivery Room
• Emergency Room
• Labor Room
• Operation Room
• Out- patient
Service/Department
• Prescription of Patients
(Prohibited Drugs)
• Tumor (Special Registry Book)

42. Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Retention Period Disposition
Description Authority/Remarks
a. Active b. Storage c. Total
12 Reports
• Census
1. Daily 1 yr. 1 yr. Dispose 2 yrs. After
2. Monthly preparation of annual
report.
• Consumption and Inventory of
supplies Incident (Nurses and 2 yrs. 2 yrs. All Health Care Facilities,
others) irrespective of its category
and classification shall
dispose of medical records
beyond fifteen yrs. (15
yrs.)
Health Care Facilities
attached to
teaching/training/research
institutions may keep
medical records beyond
fifteen yrs. (15 yrs.) if
deem necessary.

43. Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Retention Period Disposition
Description Authority/Remarks
a. Active b. Storage c. Total
12 • Notifiable Diseases 1 yr. 1 yr.
• Statistical
1. Annual Permanent
2. Monthly 1 yr. 1 yr.
3. Semi-Annual 1 yr. 1 yr.
13 Results/Reports of All Health Care Facilities,
Examinations/Procedures/ irrespective of its category
Tests and classification shall
• ECG Report/Result and dispose of medical records
Tracing beyond fifteen (15 yrs.)
Health Care facilities
attached to
teaching/training/research
institutions may keep
medical records beyond
15yrs. If deem necessary.

44. Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Retention Period Disposition
Description Authority/Remarks
a. Active b. Storage c. Total
13 • Laboratory For all laboratory, X-Ray,
1. Bacteriology ECG and other
2. Blood Chemistry examinations requested as
a product of
3. Clinical Microscopy hospitalization/
4. Hispathology confinement, the original
5. Parasitology copy must be incorporated
in the medical records.
The first duplicate must
be maintained by the
service concerned as
“Official File”.
If the result is a product
of an OPD Consultation,
then the original must be
incorporated with the OPD
Record.

45. Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Retention Period Disposition
Description Authority/Remarks
a. Active b. Storage c. Total
14 Requests Attach to Medical Records,
• Access to Clinical Information all Health Care Facilities,
from Medical Records irrespective of its category
and classification shall
dispose of medical records
beyond fifteen yrs. (15
yrs.)
Health Care Facilities
attached to teaching/
training/ research
institutions may keep
medical records beyond
15 yrs. If deem necessary.
•ECG
Dispose 1 yr. from date/
release of official report/
result.

46. Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Retention Period Disposition
Description Authority/Remarks
a. Active b. Storage c. Total
14 • Laboratory Dispose 1 yr. from date/
1. Bacteriology release of official report/
result
2. Blood Chemistry
3. Hispathology
4. Parasitology
5. Urinalysis
• Release of Information Attach to Medical Records
and follow disposition
authority under Item No.
14
•Research Dispose 1 yr. after date of
receipt.
•X-Ray
1. C-T Scan Dispose 1 yr. from date/
2. Routine release of official report/
result.
3. Special Procedures
4. Ultrasound

47. Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Retention Period Disposition
Description Authority/Remarks
a. Active b. Storage c. Total
15 X-Ray Films All Health Care Facilities,
• With Court Case irrespective of its category
and classification shall
dispose of medical records
beyond fifteen yrs. (15
yrs.)
Health Care Facilities
attached to teaching/
training/ research
institutions may keep
medical records beyond
15 yrs. (15 yrs.) if deem
necessary.

48. Agency Schedule No. Page ___ of __ pages
Address Date Prepared:
# Records Series Title and Retention Period Disposition
Description Authority/Remarks
a. Active b. Storage c. Total
15 • Without Medico-legal Case 5 yrs. 5 yrs. 10 yrs. NOTE: X-ray Films of
interesting cases with
teaching and research
significance may be
maintained beyond 10 yrs.
Depending on the decision
of the hospital
management.

49. Department of Health
Memorandum Circular No. 2005-0081
dated November 17, 2005
REITERATING COMPLIANCE
WITH VARIOUS ISSUANCES
REGARDING POLICIES ON
ADMISSION AND DISCHARGE
OF PATIENTS

50. Republic Act No. 3753
Law on Registry of Civil Status
Sec. 5. Registration and Certification of Birth – The declaration of
the physician or midwife in attendance at birth or, in default
thereof, the declaration of either parent of the newborn child,
shall be sufficient for the registration of a birth in the civil
register. Such declaration shall be exempt from the
documentary stamp tax and shall be sent to the local civil
registrar not later than thirty days after the birth, by the
physician, or midwife in attendance at the birth or by either
parent of the newly born child.
It is the duty of the hospitals to prepare the Birth Certificates
and transmit to the Local Civil Registrar (LCR). The Registered
Birth Certificates should be released by the Local Civil Registrar
to the parents and not by the hospitals. The hospitals are not
authorized to collect registration fees on behalf of the LCR.

51. 2. Instruction Manual:
Civil Registry Forms (Accomplishment &
Coding)
Date and place of marriage of parents (Item 18)
• Enter the exact date and place of marriage, if
parents are legally married at the time of birth.
• If the parents have forgotten the exact date of
their marriage, enter the approximate year. If they
cannot approximate the year, enter “Forgotten”.
• Enter “Unknown”, “Don’t Know” or “D.K.” if the
informant could not supply the information.

52. B. Death Certificates
1. Presidential Decree No. 856
“The Code of Sanitation of the Philippines”
Chapter XXI – Disposal of Dead Persons
Section 91: Burial Requirements – The burial remains is
subject to the following requirements:
• No remains shall be buried without a death certificate.
• This Certificate shall be issued by the attending physician.
• The death certificate shall be forwarded to the local civil
registrar within 48 hours after death.

53. 2. Implementing Rules & Regulations of Chapter XXI –
Disposal of Dead Persons of the Sanitation Code of the Philippines
Item 2.1 Death Certificate Requirements
2.1.1 In extreme cases, where no physician in
attendance,
it shall be issued by:
a) City/Municipal Health Officer
b) Mayor, or
c) The secretary of the municipal board, or
d) A councilor of the municipality where the death occurred.
The basis of the death certificate shall be an affidavit duly
executed by a reliable informant stating the circumstances
regarding the cause of death

54. 2.1.2 If the local health officer who issues a Death Certificate has
reasons to believe or suspect that the cause of death was due to
violence or crime, he shall notify immediately the authorities of
the Philippine National Police or National Bureau of Investigation
concerned.
There is violence or crime when the cause of death was due to
but not limited to the following: stab wounds, suicide of any kind,
strangulation, accident resulting to death, actual physical assault
inflicting injuries upon a person resulting to death, or any other
acts or violence upon a person resulting to death and or sudden
death of undetermined cause.

55. 3. DOH Adm. Order No. 55 s.
2001 - Muslim Deaths
“Formulation of a Standard Operating Procedure in
Releasing Muslim Cadavers from DOH Hospitals”
All government hospitals are mandated to facilitate
the release of cadavers belonging to the Muslim
Group, within 24 hours. All existing policies
pertaining to the release of cadavers must be
revised and/or modified in accordance thereof.

56. 1. World Health Organization’s International Statistical
Classification of Diseases and Related Health
Problems Version 10 (ICD-10) Volume 2
Item 4.1. Causes of Death
In 1967, the Twentieth World Health Assembly defined the causes of
death to be entered on the medical certificate of cause of death as
“all those diseases, morbid conditions or injuries which either
resulted in or contributed to death and the circumstances of the
accident or violence which produced any such injuries.
Item 4.2 Underlying Cause of Death
It was agreed by the Sixth Decennial International Revision Conference
that the cause of death for primary tabulation should be designated
the underlying cause of death….For this purpose, the underlying
cause has been defined as “(a) the disease or injury which initiated
the train of morbid events leading directly to death or (b) the
circumstances of the accident or violence which produced the fatal
injury.”

57. THANK YOU!