Every patient seen at the Clinic is allocated a unique registration number, and their medical records are kept to ensure continuity in follow up care. It’s a big task, but our Registration and Records team does an excellent job.
The function of the Registration/Medical Records Department is to create, file and be able to quickly retrieve any one of more than 100,000 medical records. Every person coming to Mae Tao Clinic first goes to the Registration Department where they are given a unique registration number that will follow them for all subsequent visits. In addition to serving as the medical record for the patient, records are the source for quality assurance and case reviews. Being able to retrieve the patient records of those who, for example, had fatal outcomes from malaria or came from a specific area of Burma, entails identifying the patients through the Health Information Systems and then reviewing the care they received.
There are formidable constraints in the Medical Records Department that are unique to a health care facility that serves migrants and displaced persons. Due to security concerns, some patients may give a different name or address on successive visits in order to remain anonymous. Others feel it is necessary to throw away their registration card before returning to Burma so as to not have any incriminating evidence of their visit to Mae Tao Clinic; for others it may be that they actually do not know their date of birth or even the name of their village. For Moe Oo, head of the Medical Records Department, and his staff, the difficulties then lie in translating the information from Burmese or one of the many ethnic languages into English, which leaves room for many different spelling variations.
Beginning in mid-2007 new patient registrations were directly entered into the HIS database. In less than 2 years, the Registration/Medical Records Department has entered more than 130,000 patients into the HIS database and is adding patients at a rate of 40,000 to 50,000 each year.