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Office for Medical Records Administration
Our office is responsible for storing and organizing the huge quantities of medical data produced by the NCCHD on a daily basis. Using the “one patient, one record” system we efficiently collect and collate all patient data using our one single independent information system.
ICD-10 based diagnosis coding
Health information managers review all admission records and designate each with an ICD code appropriate to their cause of admission. Records for the Diagnosis Procedure Combination (DPC) and Per-Diem Payment System (PDPS) are also prepared by our office.
Audit of medical records
Our office provides quantitative and qualitative audits of medical records. We also manage the practice of mutual auditing among medical staff, whereby staff internally peer-review each other’s electronic medical records.
Management of discharge summary and performance indexes
The office encourages physicians to complete discharge summaries quickly. Several clinical indicators are extracted from the data warehouse.
Cancer and other disease registration
For diseases that require additional registration, our health information managers either assist physicians or independently fill out registration forms to ensure accurate record keeping.
Manuals, guidelines and other documents are collected and listed by the office.