Health Information Management & Financing – Session 10 Recording Departmental Registers

DENTAL NTA LEVEL 4 • STUDY NOTES

Health Information Management & Financing – Session 10 Recording Departmental Registers

Read the complete lesson in an organized slide-by-slide format. This topic contains 15 learning sections from the source presentation.

Study tip: Use the contents below to jump to any section. Read one slide at a time, then continue using the Next Slide button.
LESSON CONTENTS — 15 SECTIONS
LEARNING SECTION 1CONTENTS ↑

Session 10

Recording Departmental Registers

LEARNING SECTION 2CONTENTS ↑

Learning Objectives

Learning Objectives

By the end of this session, students are expected to be able to:

  • Describe recording of departmental registers (Laboratory, Blood bank, Physiotherapy, Pathology, X-ray, and Mortuary)
LEARNING SECTION 3CONTENTS ↑

Filling Laboratory Registers

Each facility providing laboratory services will require a laboratory register for recording services rendered

Every section of the laboratory will have its own register depending on the type of tests done. Important data from the registers will be recorded as follows

LEARNING SECTION 4CONTENTS ↑

Filling Blood Donor Registers

Health facilities with blood bank services should keep records concerning this service

There will be not less than two registers in this department

Register for blood donors

Register for blood recipients

LEARNING SECTION 5CONTENTS ↑

Components of the Register for Blood Donors

Column (1): Date

Date blood donated

Column (2): Serial number

This will be the serial number of the blood donor

It will begin with 001 each month

Column (3): Name

Name of blood donor

Write the name accurately

Column (4): Age

Age of blood donor in completed years

LEARNING SECTION 6CONTENTS ↑

Column (5): Sex

Write sex of blood donor

Write ‘KE’ if female and ‘ME’ if male

Column (6): ABO

Blood group of blood donor

Column (7): Rh-Rhesus status of blood donor

Column (8): Serology

Serology for HIV/VDRL

Write results of the test as follows (+ HIV/+VDRL) or (- HIV/-VDRL)

Use codes if provided by the hospital

Column (9): Hb

Write the haemoglobin of the blood donor

Column (10): Amount

Write amount of blood donated in millilitres

LEARNING SECTION 7CONTENTS ↑

Column (11): Bottle number

Write the number indicated on the bottle

Column (12): Patient’s name

Write the name of patient donated for

If the blood donor is not donating for any particular patient then write (-)

If more than one donor donate blood for a patient then a patient name should appear under each donor

Column (13): Ward

Number or name of the ward where they patient is admitted

Column (14): Relationship

Write the relationship between patient and blood donor, e.g. uncle, husband, wife, sister or (–) if not related

LEARNING SECTION 8CONTENTS ↑

Blood Recipients Register

Used to collect information on blood group and cross matching results of both the patient and donor.

It will enable to obtain information on patients who require blood transfusion from wards, departments or other health facilities.

If recorded correctly, it will also enable to obtain information on patients who require blood transfusion but could not get.

Remember to record information on blood returned from the ward because of ‘reaction’ in remarks column.
LEARNING SECTION 9CONTENTS ↑

Components of the Blood Recipients Register

Column (1): Date

Date when blood sample was received in the Laboratory e.g. 20 Feb

Column (2): Serial number

Each sample should be given a number starting from 001 at the beginning of each month

Column (3): Health facility number

Health facility number as shown on the patient’s file

Column (4): Patients name

Write patient’s name accurately and neatly

LEARNING SECTION 10CONTENTS ↑

Column (5): Age

Age of the patient

If the patient is below one year then write age on twelve months basis e.g. for a child aged five months write ‘5/12’

If a patient is aged one year or more then enter age in complete years

Column (6): Sex

Write sex of patient

Write ‘KE’ if female and ‘ME’ if male

Column (7): Ward

Write number or name of the ward where the patient is admitted

Column (8): ABO

Patient’s blood group

LEARNING SECTION 11CONTENTS ↑

Column (9): Rh

Status of Rhesus e.g. (+) or (-)

Column (10): X-match

Fill in cross matching results

Column (11): Amount given

Write amount of units given to the patient

Column (12): Bottle number

Write the number shown on the blood bottle given to the patient.

LEARNING SECTION 12CONTENTS ↑

Column (13): Name of technician

Column (14): Name and signature of blood collector

Should fill in name and signature

Column (15): Remarks

Write if reaction has occurred and blood was returned, and any other comments

LEARNING SECTION 13CONTENTS ↑

Filling Physiotherapy Services Register

Each health facility providing physiotherapy services should use a register to collect all-important data concerning the services provided.

This register is used to record patients attending as both outpatients and inpatients. This will help in following up of patients attended in the department throughout the year.

Patients who are not admitted should pass through the OPD before being attended at the physiotherapy department.

The total number of diagnosis from physiotherapy services should be recorded in the departmental data book.

Total number of attendances and re-attendances should be recorded.

LEARNING SECTION 14CONTENTS ↑

Filling Pathology and Mortuary Register

Pathology Register

Health facility with pathology services need to have registers to collect information on activities occurring in the department.

Laboratories will continue to use the existing registers.

The following are to be included in the register

Identity number

Date specimen received

Patients name

Patient’s sex, address and patient age

Clinical diagnosis

Histo-pathological findings

Date when specimen results were sent to originating office

LEARNING SECTION 15CONTENTS ↑

Refers to the module

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SUPPLEMENTARY LEARNING

Additional Study Notes

This section is separated from the source slides to make the lesson easier to revise.

Supplementary learning: For health information topics, follow the information cycle from data collection and recording to checking, compilation, analysis, interpretation, reporting, storage and use for decision-making. Data quality depends on completeness, accuracy, timeliness and consistency. Patient information must also be handled confidentially.

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