The Medical Archive Unit is the unit where files created for patients hospitalized in clinical services are collected, preserved and made available for service. In terms of the quality of health service, each patient receiving inpatient treatment in our Hospital is assigned a separate archive file number for each hospitalization.
As a patient file, a wire file structure made of cardboard with colored strips on the edges according to numbers in A4 dimensions specified in the Medical Record and Archive Services Directive of Inpatient Treatment Institutions is used. This file structure is preferred due to its ease of use, expandable feature and advantages in terms of placement.
Following the patient's discharge procedures, archive file number records are created in the HIMS for patient files created in the services, the forms included in the file are processed into the Content Form, recorded and controlled in the Archive Unit. The use of patient files and Archive services is carried out in line with the Archive Operation Procedure.
PATIENT FILE USAGE
Patient File Usage for Treatment and Examination Purposes
An archive file number is assigned to each patient receiving inpatient treatment. According to the archive operation, undefined files are delivered to the service secretary in groups of 100 in exchange for signature and the responsibility of the file is given to the service secretary until it enters the Archive. File definition procedures are limited to service authority, and for files that are not opened on time, the Unidentifiable File Notification Report created with three signatures must be filled out and delivered to the Archive Unit.
In cases where the file number needs to be cleared due to reasons such as hospitalization cancellation, non-generation of documents, the patient taking the documents with them, etc., although the definition has been made, the Defined File Clearing Report created with three signatures must be filled out and delivered to the Archive Unit.
Requests for file/document examination for treatment or examination purposes are made in line with the Treatment Purpose File Delivery Report and the file is examined within the Archive or accompanied by an Archive Unit employee.
Patient file creation is carried out in line with the Hospitalization-Based File Content Control Procedure, and patient file usage is carried out in line with the Patient File Usage Instruction. After discharge procedures, the printed documents created during the patient's hospitalization procedures are checked by the relevant personnel in the service in terms of completeness (collection of all produced documents) and completeness (complete filling and signing), then organized by the service secretary and delivered to the Archive Unit, and control and reuse procedures are performed by Archive Unit employees in line with these procedures.
In cases where the deficiencies of patient files are not completed, a Document/Signature Deficiency Detection Report is prepared within the Patient File and the patient file is sent to the Archive.
In Hematology, Neurology and Chest Diseases Services, in chemotherapy course, Multiple Sclerosis, IVIG etc. specific term follow-up treatments, after the completion of the treatment, all clinical application documents assigned to the patient should be organized within a single patient (Archive) file and the application numbers assigned to the patient should be recorded with the TA.YD.17 Treatment Documents Delivery Report and the application numbers should be written one by one in the Explanation field within the Content Form and sent to the Archive.
In order to ensure the integrity of treatment documents belonging to applications opened due to admission-discharge procedures required for the patient to receive procedures at another health institution for diagnosis or treatment purposes during the patient's service hospitalization period, a single patient (Archive) file should be assigned to the patient and all treatment records should be organized completely, the application numbers assigned to the patient should be recorded with the TA.YD.17 Treatment Documents Delivery Report and the application numbers should be written one by one in the Explanation field within the Content Form and sent to the Archive.
After the patient file is created in the service and approved by the Archive Unit employees, documents belonging to the patient that were forgotten in the service or came to the service later are delivered to the Archive Unit by hand with the Missing Document Delivery Report to the Archive signed.
Forensic Case-Administrative Investigation-Educational Purpose Patient File Usage
Patient files requested by judicial or administrative authorities for various reasons are used in line with the official letter coming to the Archive Unit. In forensic case, administrative investigation and educational purpose patient file requests, the original of the file is not given, its photocopy is delivered to the requesting unit/investigator with the Forensic Case-Administrative Investigation-Educational Purpose Patient File Photocopy Delivery Report.
Research Purpose File Usage
Patient files are primary data sources in medical research. An appropriate environment is created to help doctors who want to conduct research and usage is recorded. For research purpose patient file usage, Selçuk University Clinical Research Ethics Committee / Non-Interventional Clinical Research Ethics Committee decision and Chief Physician approval are required. After the files requested by the researcher are prepared within the Archive Unit, the examination is carried out by the researcher within the Archive. Research Purpose File Delivery Report is used for research purpose file usage.
Photocopy Requests from Patient Files
Photocopies of medical documents belonging to patients treated in our hospital are occasionally requested from the Archive Unit. In line with the Patient Rights Regulation and the Medical Record and Archive Services Directive of Inpatient Treatment Institutions, the following items are applied regarding meeting document requests from patient files:
Note: Epicrisis requests from patient files are not met. The patient is directed to the relevant department.
