On a typical Operation Smile international mission, there are anywhere from 2-4 medical records team...

On a typical Operation Smile

international mission, there are

anywhere from 2-4 medical

records team members, with the

most experience volunteer being

the lead.

The lead and assistants work

together with local volunteers and

translators to

fulfill their duties.

WHAT ARE THE RESPONSIBILITIES OF PAPER MEDICAL RECORDS?

DUTIES OF MED RECS VOLS

Organizing Chart Forms

Keeping Charts Accessible

Verifying Forms Completed

Report Accurate Info & Stats

NOTE: Please reference the

Checklist provided on the Paper

Medical Records manual for a day-

to-day guide of what should be done

on the mission.

WHAT SHOULD BE DONE AT THE FIRST TEAM MEETING? INTRODUCE yourself to the team so

they will be familiar with you & your role. This will help later when you may need to get complete signatures.

Make sure that TRANSLATORS have been arranged to assist during screening, introduce yourself and give them information about their role in the medical records process. Answer any general questions they have about the forms.

Talk with new medical team members about the FORMS and SIGNATURES. Ensure all medical volunteers know where they have to sign throughout the chart. Answer any general questions about the forms. If you are unsure, ask the mission coordinator or team leaders.

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WHAT SHOULD BE DONE AT THE FIRST TEAM MEETING?

SIGNPRINT

Collect printed name and signatures from all team members. This will help later when we need to link a signature on the chart with the identity of the team member whose signature it is.

WHAT SHOULD BE DONE BEFORE SCREENING? Instruct the medical records volunteers to complete

each form in legible handwriting in ALL CAPITAL LETTERS (if possible) so each specialty can read them.

Instruct the translators to write answers down on forms in English (or, in Latin characters) as well as native language. Especially for countries such as China (Pinyin), Vietnam, Cambodia, Morocco, etc. This is important both on the mission for patient safety & for later data entry and research.

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HELLO

Potential patients are screened for approximately two days at the beginning of a mission, either indoors or outdoors. Screening is organized into different stations – medical records should always be station #1

WHAT SHOULD BE DONE AT SCREENING SETUP?

WHAT SHOULD BE DONE AT SCREENING SETUP? IMPORTANT: Make sure the coordinators obtain the keys & unlock

the medical records trunks before screening starts.

The setup of the medical records

stations should be such that there is

room for translators,

medical records volunteers, and the patients /

parents / guardians.

REVIEW: BEFORE SCREENING

Introduce yourself to the team

Meet the translators

Complete signature sheet

Make sure trunks are unlocked

Help setup station one

WHAT HAPPENS WHEN SCREENING BEGINS?

Patients will arrive for the first day of screening and gather in the waiting

area. Screening will start when the coordinators see that everyone at station

one (Paper Medical Records) is ready.

Medical records volunteers should complete with the patient/parent guardian: CONTACT INFORMATION, CLEFT QUESTIONNAIRE, and the screening part of the CONSENT form.

After the patient is finished answering the

screening questions and has signed the consent

form, enter their information into the left side of

the Log Sheet, so we have their contact should we

need it.


The PATIENT INFORMATION LOG is important for two main reasons: if a chart goes missing because a patient has taken it, we have their contact information written down. Also, part of the duties of paper medical records is to tally the number of patients screened, surgeries, etc. This log is a quick reference to do that.

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WHAT HAPPENS WHEN SCREENING BEGINS? A screening sticker with the chart number written on it is placed on the

patient, in the event that they are separated from their chart & for quick reference of what number they are. For babies, place the sticker on their back or somewhere they will not pull it off.

045

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WHAT IS THE CHART ID PHOTO?

Medical records volunteers take a photo of each patient with their chart number visible,

print the photo & place it into the chart to ensure the patient is properly identified during

screening, scheduling, and surgery week.

This photo is important because for large missions, surgeons screen hundreds of patients. They need a visual reference during surgery scheduling to

remember patients they wished to place on the schedule.

It is also an important PATIENT SAFETY tool, to

ensure the correct chart is with the correct patient

during screening and before surgery.


Use the digital camera printer to

print photo, then write Operation

Smile chart number and patient’s

name on the reverse (blank) side of

photo.

Staple photo on left side of patient folder with smooth side of staple on outside of

folder.

NOTE: Unfortunately we cannot give extra photos to patients or family since we have very

limited resources, so if you are asked by the patient/parent/guardian for a photo, politely

decline.

Ask the parent to hold the patient or have the patient

stand if they are older, holding the chart with their

chart number visible, and use the digital camera to take

the photo.

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MARIA FLORES

The ID photo is different from the Patient Imaging Technician (PIT - station 2) photo, which is a technical photo for the purposes of post-surgical evaluation.

CHART ID

PHOTO →Shows face,

adequate for

recognition

Follows strict

technical parameter

s for

precision

← BETTER PHOTO

Can’t see entire face of patient

which is necessary for identification

and surgeon’s use (BAD PATIENT

SAFETY)

Can see whole face,

still has chart number

visible (patient safety)

PIT PHOTO →

← BAD PHOTO

X


NECESSARY EQUIPMENT:

Camera SD card Canon photo

printer Color ink Photo paper

HOW DO I PRINT THE CHART ID PHOTO?

Instructions:1. Remove printer from camera

case.

2. Plug in photo printer, press ON button

3. Remove cartridge of ink from box, open & insert into left side of printer.

4. Open printer tray, place paper inside with glossy (printed) side facing up, close tray.

5. Insert paper tray into front of printer. The top panel of the tray must be open.

HOW DO I PRINT THE CHART ID PHOTO?

HOW DO I PRINT THE CHART ID PHOTO?6. Insert camera SD card into

front slot of printer.

7. On the printer menu, go to PRINT SETTINGS, and choose PAGE LAYOUT. Select the layout which allows 4 photos to print at a time.

8. On the screen showing each photo, navigate to the photos you want to print by hitting the next button.

9. To select that photo, hit the up button. The printer will add 1 copy to print.

10. When finished, hit the green print button. Each sheet of 4 photos will take around a minute to print. Allow enough space in front of the camera for the paper to move forward.

WHAT SHOULD I DO AFTER THE PATIENT FINISHES STATION 1?

Remind patient/parent not to leave with their chart. Have them wait to see the next station (PIT photo). Inform patient/parent when surgery schedule will be posted. Take the next chart number and begin the next patient. Once a patient has gone through all of the screening stations and the Electronic Medical Record volunteer has entered their information, you should receive their chart back. File it back into the trunk (or box) in numeric order. Track the charts to be sure all have returned at the end of the day.

Continue this process until the end of screening day. Begin again on day 2.

WHAT ARE SOME REMINDERS FOR SCREENING? The most important thing to

remember is that you are part of a team. One person alone cannot accomplish all of the tasks required by medical records. Delegate specific tasks to people, and use guest participants, local volunteers, student volunteers, etc. to help. Focusing each person on a specific job will keep things moving faster!

HOW TO ORGANIZE VOLUNTEERS:· Divide the work into tasks

· Give clear instructions & expectations

· Use name tags to identify each other

· Assign specific volunteers to each task

· Be aware of individual strengths when

assigning tasks – language, photography,

handwriting, etc.

· Allow for short breaks, water, meals,

restroom

· Maintain communication & progress

updates

· Encourage, praise & thank volunteers for

their hard work!

WHAT ARE SOME REMINDERS FOR SCREENING? If the patient/parent/guardian does not know the answer to a specific

question: There are times where even the most basic demographic questions

will not have a clear answer. Some parents may not know the exact birthdates

of their child. In certain countries, addresses will correspond with a landmark

or nearby locations rather than homes, or they might be vague or unusual.

Every attempt must be made to

receive accurate and clear

information. Use the local

volunteers’ knowledge of the

culture to help estimate

birthdates (example: around

certain holidays/times of the

year) or obtain other

information. Ask the program

coordinator or Clinical

Coordinator if you are unsure

whether something can be

missing.

REVIEW: SCREENING

Have translators complete pages one, two & three Enter patient info on left side of patient log Place round sticker with chart number on patient or parent Take the chart ID photo

Send patient to station two, begin next chart

Collect all charts after screening

WHAT SHOULD I DO AFTER SCREENING ENDS?

Organize the charts into stacks by Priority Number:

31 NOT A CANDIDATE4 52

Ensure the forms have been completed properly & signed.

Verify that each patient received a chart ID photo.

Verify that each patient received a priority label.

Verify that each patient received a PIT photo.

Verify blood work is written into the patient’s chart if run.

At the surgery schedule meeting, the team leaders will use the Patient Priorities to come up with the schedule for each day. Write down this schedule in the Surgery Scheduling sheets, including the patient chart number, name, age, weight, sex/gender, hematocrit (HCT), hemoglobin (HG), procedure to be performed, estimated surgery time, and whether there will be any dental work in the OR.


Organize charts by surgery day, table, and order. Keep in mind the schedule will change, so focus on the next day’s charts. File the charts for patients not scheduled back into the trunks in numeric order.

MONDAY TUESDAYWEDNESDAYTHURSDAY

Give the Dental Patient Log to the dentist. This is so they may document patients they see in the dental clinic, which runs during surgery week.

FRIDAY


WHAT ABOUT LAB WORK?

EXAMPLE – CAIRO, EGYPT:The lab printout clearly indicates both hemoglobin and hematocrit in the correct units, so it can be entered for this patient. Be sure the printout has the correct patient chart number, and the names & ages match. Because lab results are used to determine whether a patient gets surgery, this must be accurate.

Different countries run lab work differently. Most only run labs for patients once they are identified as candidates for surgery & cleared for surgery. Others run labs for each screening patient. Most countries run labs in batches. Usually lab results are delivered as computer print outs. It might not be delivered to you until after screening, but it must be written into the PHYSICAL EXAM & MEDICAL HISTORY form as the hospital keeps the original copy.

WHAT SHOULD BE DONE BEFORE SURGERY WEEK? Prepare the charts for the next

day’s surgeries by moving the screening forms to the left side of the chart, collating & adding the operative forms to the right side.

Obtain PATIENT CODE SHEET from the EMR volunteer, place it in the charts.

Complete the patient info at the top of each surgical form. Some forms require more information than others depending on what specialty uses them:

The new screening forms have page numbers at the bottom, indicating the order they should be placed in. Pages 1-4

(CONTACT INFORMATION, CLEFT QUESTIONNAIRE, PATIENT CONSENT, and PHYSICAL EXAM & MEDICAL HISTORY) are on the

left side, pages 5-9 (PRIORITY & ELIGIBILITY, PATIENT DIAGNOSIS, DENTAL ASSESSMENT, and SPEECH PATHOLOGY)

are on the right side.

SCREENING CHART

WHAT IS THE ORDER OF THE FORMS?

As with the screening forms, each surgery form has a page number

indicating where it should be placed in the charts. Even the Patient

Code Sheets, which are printed by the EMR volunteer, have a page

number indicating where they go. For surgery charts, move the

screening forms to the left side of the chart, and place the surgery

forms on the right side in numeric order. The ADDITIONAL NOTES

page is the only optional surgery form, as it is only placed in the chart

upon request.

SURGERY CHART

WHAT IS THE ORDER OF THE FORMS?

WHAT SHOULD BE DONE BEFORE SURGERY WEEK?

Place the PRE OP ASSESSMENT label on the outside of the charts.

Complete ID BRACELETS, place inside of each chart.The patient ID bracelets are included with the charts prepared for the next day’s surgeries by the paper medical records volunteers. To prepare these:

1. Write each patient’s chart number and priority number at the top of the ID bracelet 2. Write their name in the center of the bracelet 3. Write the age, labs results (usually hemoglobin), gender and weight at the bottom

Give PATIENT CARE BOOKLETS to the Pre/Post Nurse to give to patients after surgery Give the following day’s charts to the Pre/Post NurseFor patients with medical allergies: the allergy bracelet is placed on patients who are allergic to medication or medical materials they will encounter in the hospital, such as latex. The specific allergy should be clearly written on the bracelet.


Separate the original copies and carbon copies for non surgical patients. Start with those NOT A CANDIDATES. Wait until later in the week for high priority patients and patients on standby, as they may receive surgery. Staple the yellow carbon copies together for each chart and leave them in-country. Re-stuff the white original copies into the folders and file them in the trunks in numerical order.

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IMPORTANT: The consent forms (both English & local) and Patient Code sheet must go with the white copies back in the chart. If the hospital needs a copy, work with

volunteers to make them.


Get the SURGERY SCHEDULE from the EMR volunteer. Give this to the Team Leaders for following day of surgery.

Tally the number of patients, priorities,

age groups, and genders screened, and

compare these numbers with the EMR

volunteer. Reconcile any discrepancies.


Sort charts into stacks by priority number

Complete the surgery schedule sheets Sort charts into stacks by day, prepare next day’s surgery charts Ensure lab results written into charts

Collate operative forms & place into charts for surgery

Put pre op assessment label on front of surgery chart

Write patient info onto bracelets

Begin separating yellow copies

Give pre op nurse charts, bracelets & patient care booklets

Give dentist the dental log sheets

Tally screening numbers, make sure they match the EMR

REVIEW: BEFORE SURGERY WEEK

WHAT SHOULD BE DONE DURING SURGERY WEEK?

Record any changes to surgical procedures (from the discharged patients’ charts) on the SURGERY SCHEDULE print out.

Fill out the second half of the MEDICAL PATIENT LOG from the patients’ charts directly.

Confirm schedule for next day with Clinical Coordinator each night.

For surgical patients, continue to move screening sheets to the left side of the chart. Continue to collate and stuff operative packets on the right side of the chart. Track the going in and coming out of surgery on the surgery schedule sheet. Update the EMR volunteer about any changes. Collect the discharged patients’ charts from the Pre/Post Nurse starting the second morning of surgery.

Fill out the MISSION TALLY SHEET using the Patient Log, OR boards, and charts After every chart for the previous day of surgery returns, confirm & record the number of procedures on the Tally Sheet:


During the week of surgery, patients

will continue to come to the hospital to

be screened. Ask the team leaders and

clinical coordinator how they want this

part of screening to work.

Pull next unused chart in numerical

order as you screen patients.

Complete the screening forms.

Make sure that a PIT photo is taken.

Arrange for all the specialties to see the patient.

The patient will be placed on the surgery schedule at the team leader’s

discretion.

If the patient is selected for surgery, let the patient know when to return, if

applicable.

Should the patient not be selected they will be notified at the time of

screening.

If patients show up on the last day of surgery, collect information and

provide it to the local in-country Operation Smile Manager.


END OF SURGERY WEEK: All charts have returned after surgery Right half of patient log sheet completed Yellow copies separated from all charts Dental log received back from dentist Tally sheet completed Surgery numbers reconciled with EMR:• Total number of surgery patients • total males & females• Priority numbers• Age groups• Procedures performed

WHAT SHOULD BE DONE BEFORE THE END OF SURGERY WEEK?

WHAT OTHER INFORMATION SHOULD I BE AWARE OF?

• Often doctors and nurses will make a note about a patient (ex: when a patient’s surgery has been cancelled) on the outside of their chart, and the information will not be relayed to the form. Please pay attention to the front of the chart, and what is written on it. • Always pay attention to whether information is getting completed, and how it is being filled in. Although you are not a medical team member, you should have enough familiarity with the forms to know where signatures go, and what boxes need to be checked.

• If a surgeon or anesthesiologist does not complete a form, wait until the they are not in the OR with a patient, and please ask them to complete the form. If you are unsure of which surgeon because of a lack of signature, consult the Clinical Coordinator’s surgery schedule boards to identify the surgeon.

WHAT LABELS ARE USED ON THE MISSION?

WHAT ABOUT OFFICE SUPPLIES?2-HOLE PUNCHCLIPBOARD

LARGE BINDER CLIPS

LEGAL PADSHIGHLIGHTERS

SHARPIESPAPER CLIPSPENCILS &

SHARPENERBLUE/BLACK &

RED PENSPOST IT NOTESLARGE RUBBER

BANDSRULERS

SCISSORSSCOTCH TAPE

INK PADSTAPLER & STAPLESSTAPLE

REMOVERWHITE OUT

Office supplies are a seemingly small detail, but VERY important to get the medical records tasks completed. These should be included with the medical records supplies.

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On a typical Operation Smile international mission, there are anywhere from 2-4 medical records team...

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