EMERGENCY UNIT: The emergency unit operates for 24-hours shift duty and is fully utilized for new patients. All the new patients are registered at the unit. The majority of registration takes place in emergency unit by direct inquiry with patients on his or her first attendance at the hospital. Registered patients are usually issued with a unique number on an appointment card which serves as hospital number to the record of the patient.

Registration Procedure:

• Health records staff gives prescription booklet, request form and out-patient continuation sheet to the doctor on duty.
• After the payment of N2, 500 (two thousand five hundred naira only) for registration by the new patients.
• Health records staff will also open a case note for the new patient by using mental history booklet in line with other booklets, an appointment card (containing the registration number, patient’s name, consultant name, clinic day and time) will be given to the patient/relative.
• After proper documentation the case note will be passed to the nurses section for vital signs and nurses will take the case note to the doctor for consultation.
• After the consultant, doctor will write the date the patient will visit the hospital on the appointment card which will be taken to appointment unit in health records department.
• After the doctors must have seen the patients, the health records staff goes to the consulting rooms, packs all the files with out-patient continuation sheets.
• At the end of the day, the health records staff on afternoon duty will sort and arrange the case notes numerically for proper filling to the health records library and attend to the patient that comes while he/she follows the same procedure.
• All registered information are checked at every attendance and updated where and when necessary.

Referral Letter: The health records officer at the emergency unit will file the patient’s referral letter into the case note before passing it to the nurses section and record it for future purpose.

Booking Appointment: A calendar is usually prepared by the health records officer at the appointment unit before the arrival of the patient from the consulting room. When a patient finishes with the consultant he/she goes straight to the appointment unit to book for the next visit. The health records officer will collect the appointment card from the patient in order to give the correct appointment date.

Clinic Preparation:

• Health Records Officer will go through the appointment unit in the library to prepare the case notes - the patient’s name, registration number, appointment date.
• After the necessary documentation, they are sorted and arranged numerically for easy filling.
• While retrieving the case notes from the shelf, the tracer card will replace the position of the case note immediately on the shelves/cabinet.
• The tracer care serves as a mirror to locate the movement of the case note and destination.
• The case notes moved to clinic areas by the health records staff on night duty, arranged on the clinic table at the out-patient clinic for easy retrieval on clinic hours.

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[OUT-PATIENT CLINIC]

This is a place where patients come in for follow-up of their treatment after they have been given appointment at the emergency unit and outpatient clinic.

Our activities here include:-

• Collection of cards from the patients to retrieve their files on the table which is already arranged in alphabetical order,
• After the collection of the appointment card, a number is given to the patient. This has been of help to reduce waiting time and also create a sense of orderliness among the patients,
• For patients that have appointment date, their files would be retrieved from the sorting table and passed to the stamping table.
• The patient’s appointment card will be used to tick the patient’s name from the appointment list in order to indicate the number of patients that attended the clinic. The appointment clinic list helps to indicate the particular number of patients booked for a particular clinic day,
• The stamping table is where patients’ files will be arranged and outpatient continuation sheets will be added into the case note which contains names, registration number, date and clinical note space,
• Then the case note will be transferred to the Nursing section for vital signs and from nurses to the consulting rooms for consultation,
• After consultation, the patient will come back to health record department with the prescription sheet to book next appointment date. This will be documented in the appointment jacket according to the consultant in order to reduce waiting time.
• At the end of the clinic day, the records staff will pack the patients’ files from the consulting rooms, sort and arrange them numerically for easy filing at the library unit.

Procedure for Admission and Discharge:

• When a patient comes for admission, the health records officer will direct him/her to pay for consultation fee.
• The patient’s case note is retrieved from the health records library and out-patient continuation is added with date. Patient’s name, registration number must be written on it, before sending it to nurses unit for vital signs and from the nurses to the consulting room.

Discharge:

• Proper discharge summary must be written by the consultant in the ward.
• The nurses must discharge the patient from their register which will be signed by health records officer at the out-patient.
• The health records officer will calculate the number of days the patient spent on hospital bed.
• Appointment will be given to patient for continuity and treatment finally the case notes will be taken to the library for proper fillings.

Health Records Library is where all the patients’ case notes are filled and kept for easy access. The numbering system in health records library is straight numerical and also centralized filling system is maintained case notes are retrievable 24hrs/7days to allow prompt treatment of patients’ in attendance.

The filling retrieval, sorting, arranging and research are done here to ensure strict confidentiality of unauthorized staff. If any case note is requested by the doctors or health professions there is a register to sign before collection.