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Records, quality & support

Medical Records, Coding & Registers

Chart tracking between departments, the ICD-10 coding worklist per discharged visit, release of information with consent and audit, and the statutory registers — births, deaths, notifiable diseases — with printed notifications that are frozen once issued.

For:Medical records officersCodersAdministration

Where:Medical Records › Coding Worklist · Chart Tracking · Release of Information · Births · Deaths · Notifiable Diseases

The coding worklist: discharged visits awaiting their codes.
The coding worklist: discharged visits awaiting their codes.

How to

Code a discharged visit

  1. Medical Records › Coding Worklist: visits closed without complete codes.
  2. Open the visit, review the diagnoses and procedures, add or correct the ICD-10 codes, mark Coded.
  3. Claims are built from coded visits; the dashboard shows coding completeness and turnaround.

Track a physical chart

  1. Chart Tracking › Request: who wants which chart; Out when it leaves the archive; Returned when it is back.
  2. Overdue charts are listed for the archivist.

Release information

  1. Release of Information › New: who asks (patient, insurer, court, another hospital), what, the consent attached.
  2. Approve; Released with what was given and to whom; Refused with the reason. Every step is on the audit trail.

Issue a birth notification

  1. Medical Records › Births › New: mother, date and time, sex, weight, delivery type, attending practitioner, the newborn’s name, the father’s name, national ID and nationality, plurality and order, place of birth.
  2. Issue the notification: a number and a QR are assigned; print the notification in the country’s layout (Egypt ships; the Hijri date prints beside the Gregorian date if enabled).
  3. An issued notification cannot be edited. To correct it: Cancel with a reason, then Reissue corrected — a new draft pointing at the cancelled one, issued under a new number.

Issue a death notification

  1. Medical Records › Deaths › New: patient, date and time, place, the certifying practitioner, the WHO chain — immediate cause, underlying cause (coded), contributing condition, intervals — and the manner.
  2. Issue: the notification prints with its QR; the patient file is flagged deceased and the patient card revoked.

Report a notifiable disease

  1. Notifiable Diseases › New (or from the visit when a notifiable diagnosis is coded): the diagnosis, the date, the practitioner.
  2. Reported with the reference when the authority has been notified.

See also: Patient Card & Verified Documents Patient Documents & Photo Pre-authorisation, Claims & Doctor Fees

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