Hospital Registration System PDF

# REGISTRATION SYSTEM ## Definition of Registration The term registration is used to describe the initiation of the patients hospital records and the allocation of hospital number to such records. The registration desk is the patient first point of contact with the hospital and majority of registr...

# REGISTRATION SYSTEM ## Definition of Registration The term registration is used to describe the initiation of the patients hospital records and the allocation of hospital number to such records. The registration desk is the patient first point of contact with the hospital and majority of registration take place in the outpatient or casualty (accident and emergency) department of hospitals by direct enquiries with the patient in his or her first attendance of hospital. ## Registration Procedure The following data are normally recorded for each patient: * **For Out-Patients:** name in full, age/sex, address, name and addresses of next of kin and his/her relationship with the patient, occupation, home town, state of origin, nationality, ethic group of the patient. * **For In-Patient:** date of admission, name of the consultant or specialist under whom the patient is admitted and ward in which the patient is admitted are usually recorded in addition to all identification data as recorded for outpatient. 1. It should be noted that, hospital number must be assigned to the records of each patient during or before registration. 2. All information collected from each patient can be firstly recorded in the register and then be transferred into the treatment card/folder or vice-versa. ## EQUIPMENT FOR REGISTRATION The following are some of the equipment being used for registration of patient in the hospital * Registers * Folder/treatment card * Patient reference hand card * Tracer card * Stationaries like biro, ruler etc ## Pre-Registration This means a completion of registration before the arrival of the patient who are to come to the hospital at a fixed date for medical care. All necessary information about the patients are usually collected through letters or telephone. It could also be given to patient's to fill while they wait to be called. This is done to limit overcrowding. ### Advantages of Pre-Registration 1. It reduces patient waiting time in the registration or appointment unit of hospital before seeing the doctor. 2. It can overcome the problem of overcrowding in the registration/appointment unit of the hospital. Pre-registration is a pre-condition for an effective appointment system. If the pre-registration is properly done, patient needs not wait for more than three minutes before leaving the appointment office for the appropriate clinic. ### Disadvantages of Pre-Registration The main disadvantages of patients are: 1. It leads to wastage of stationery by the patients who fail to turn up for their appointments. 2. It also leads to wasted effort on the part of the registration clerk in the appointment office of the hospital, if the patients fail to turn up for their appointments. # VARIOUS REGISTERS THAT ARE BEING USED IN THE HOSPITAL'S HEALTH RECORDS ## DEPARTMENT A Register is a book that is made in form of bound which is being used for recording of some relevant data about each patient who is attending the hospital. The various registers that are being used in the health records department of hospitals include the out-patient register, birth and deaths register, in patient/admissions and discharges register and accident and emergency register. These register are developed and maintained in the various service departments of the hospital as references and control to basic information. Any department wishing keep basic data to monitor their work load should maintain a register. The registers already mentioned in the above shall be discussed as follows. ## Out-Patient Department Register The outpatient register records details of patient identification data in this register, each row contains information about each patient for tracing of individual patient within the health facility. The out-patient register should contain the following unit number, name in full, age, sex, occupation, religion, hometown, ethnic group, name and address of next of kin, etc the information contained in the out-patient register will facilitate easy tracing of individual in the hospital and at the same time very useful for medico-legal cases it is also useful for collation of statistics of attendances of the hospital of both the new and the old outpatients. The treatment card is used in the outpatient department and it contains the same data as the outpatient register. | S/N | Unit No | Name in full | Age | Sex | Occupation | Religion | Home town | Ethnicity | Name & Address of next of kin | |---|---|---|---|---|---|---|---|---|---| | | | | | | | | | | | ## In-Patient/Admissions and Discharges Register The Admissions and Discharges Registers are expected to be maintained in separate bound volumes, but they are usually combined for convenience purpose into a single bound volume. Information recorded in this register should be kept to the useful minimal and to meet legal requirements. Is should include only the items needed for quick reference and must be easily obtained from the source. Items which might be included in such a combined register differ from what are obtainable from the out-patient register and these are: - * **For Admission:** Unit number, Names in full, date of birth, date of admission, referred from, ward admitted into etc. * **For Discharge:** Date of discharge or death, discharged to diagnosis, Name of the attended physician, etc. ### ADMISSION AND DISCHARGE REGISTER (ADMISSION COLUMN) | S/N | Unit No | Name in full | Sex | Date of Birth | Date of Admission | Referred from | Ward Admitted into | Name & Address of next of kin | |---|---|---|---|---|---|---|---|---| | | | | | | | | | | ### DISCHARGE COLUMN | | Date of Discharge or Death | Length of Stay | Discharge to | Diagnosis | Name of Attended Physician | |---|---|---|---|---|---| | | | | | | | This register maybe used to control the assignment of numbers to patients. Each line in the admission column will contain information about one patient and it will list the number assigned to him or her. To avoid confusion in assigning numbers to the patients, the name and other information should be recorded immediately in the admission column, as soon as the patient is admitted. This will prevent assigning the same number to two patients. ## Births and Deaths Register It may not be possible to keep the copies of births or deaths certificates in the Health Records, but information from birth certificates may be copied into the register of births and information in the register of births are as follows Hospital number, mother's name in full, age, type of delivery, sex of the baby, etc. ### BIRTH REGISTER | S/N | Hospital Number | Mother's Name in Full | Age | Time/Date of Delivery | Type of Delivery | Sex of Baby | Weight of Baby | |---|---|---|---|---|---|---|---| | | | | | | | | | ### DEATH REGISTER | S/N | Hospital Number | Name of Deceased | Sex | Age | Address | Date of Admission | Date of Death | Diagnosis | Cause of Death | Name of Attended Physician | |---|---|---|---|---|---|---|---|---|---|---| | | | | | | | | | | | | Information contained in the deaths register are as follows Hospital number, name of the deceased in full, sex, age, address, date of admission, date of death, diagnosis, cause of death, name of the attended physician, etc. All the above information are contained in the registers of birth and deaths and identification data recorded depends on individual hospital usage, as information required in the state Hospital may be different from what is obtainable in Teaching Hospital, where training of medical students and research works are carried out. The purpose of these registers is to keep them readily available for whoever may need it in future and for: - * Compilation of statisties of births, foetal deaths. * Hospital data analysis as a step for Hospital planning by the health authority. * Registration of births and deaths for census purpose. ## Accident and Emergency Register Accident and emergency register is a bound volume book, just like any of the out-patient and Admissions and Discharges registers. In many hospitals, separate register is maintained, for recording necessary information of all patients that come to the casualty section of Accident and Emergency department for treatment of minor cases, e.g. Abrasion, minor laceration, foreign body in the eye or oesophagus, bruise, etc. such cases often require only one treatment after which the patient will not call at the Hospital again. The information to be contained in the Emergency/casualty register include-serial number, Name of the patient in full, Address, sex, age, Marital status, Religion, Occupation, ethnic group, date, etc. this same register is in most cases many hospitals sub-divided into two, based on age categories, e.g. Adult emergency register, children/paediatry emergency register, But, the information contained in both are the same. ### ACCIDENT AND EMERGENCY REGISTER | Patients Name in full | Address | Sex | Age | Marital Status | Date | Religion | Occupation | Ethnicity | Next of Kin | |---|---|---|---|---|---|---|---|---|---| | | | | | | | | | | | ### ACCIDENT AND POLICE REGISTER | Name in full | Age | Sex | Marital Status | Address | Religion | Occupation | Time of Arrival | Nature of Accident | Name & Receiving Physician Surgeon | No of Police | Name & Address of next of kin | |---|---|---|---|---|---|---|---|---|---|---|---|---| | | | | | | | | | | | | | | On the other hand, a complete separate register is maintained for the patients that come to the accident and Emergency department with serious cases such as Road traffic accident, work accident, etc. and any cases that require police intervention e.g. gunshot, rape. Such register is called accident and police register and it always contains the following data: serial number, time of arrival, date, Names in full, Age, sex, Marital status, religion, occupation, home address, nature of accident, receiving physician/surgeon, name and number of the police, name and address of next of kin, etc. # WAITING LIST SYSTEM ## Definition Waiting list is the list of patients who though need to be admitted into the hospital wards, but cannot be admitted immediately, because there are no sufficient beds. The category of urgency is usually stated on the waiting list card and is written in form of "soon, urgent and very urgent". A patient's name is usually entered on waiting list after he had been an out-patient. The doctor who made the decision that the patient should be admitted into the ward writes an appointment instruction on the patients' case note and this instruction becomes the authority for placing the patient's name on the waiting list. At the end of the consultation, the patient who now requires admission should be interviewed by the medical social workers or admission clerk and given as much information as possible about the Hospital, when he may expect to be called for, and how much notice will be given. Information about the hospital such as the visiting time, etc will also be supplied to the patient. It may be that, the patient can come in at every short notice and thus should be recorded. The patient's phone number if any and contact address should also be recorded, otherwise, bed are wasted by patients who cancelled at the last moment and cannot be replaced. ## DUTIES OF OFFICER IN CHARGE OF WAITING LIST The officer in charge of the waiting list is known as the waiting list officer. He is usually a senior health records officer. He should work in close relationship with the admission clerk not only for effective arrangement for patient's admission, but in notifying all appropriate officers of these arrangements. His functions may be summarized as follows: To maintain lists of all patients who are waiting for admission and to notify patients for admission into the hospital as required by the medical staff or as there are vacant beds. 1. To maintain an index to the waiting list, which should be, checked daily with the admission lists to remove acute cases. 2. To ascertain by routine following letters to know whether patients still wish to remain on the list. 3. To bring to notice of the appropriate medical staff those requiring priority in admission. 4. To enable regular returns for the information of committee and medical staff of the number of those awaiting admission in each section of the list. 5. To deal with correspondences arising from out of the waiting lists. ## MAINTENANCE OF WAITING LISTS Waiting lists may be maintained in a number of ways. The principal methods employed are as follows: * **Register (Bound or Loose Leaves):** Until fairly recently, the method was used almost universally. It can be effective in small hospitals, but its disadvantages particularly in large hospitals are that, it is inflexible and unless the detections are recently made, it is in-efficient. Secondly, cases will move from the lists remaining to the register so that quite often one finds a few active cases scattered over many pages of entries. * **Visible card index:** Visible card index over lapping principle may be convenient if it desires that a case synopsis should be included. This is not desirable, but it is sometimes call for by the medical staff. Otherwise, although convenient in use and efficient, visible cards are not economical in this particular application and it is therefore not recommendable. * **Visible strips index:** The strips are supplied in belts, which are parked nearly into single strip after typing the data each. Each belt has 20-30 strips according to the width of the strips used and it is designed to fit typed writing lining space. It is the best system recommendable for maintenance of waiting list because, it enables the doctors who select patients for admission to see the waiting lists as a whole and assess priority with the visible strips system. * **Vertical card index:** Another method of maintaining waiting lists is by the use of vertical card index, which is an index in which it has cards filed horizontally in steel tray or panel with the edge of one over lapping the edge of the next card.