Patient information & Record requests
Patient Information
The Change of Patient Details & Identification of Duplicate UR number forms have been developed to facilitate staff in Health Information Services to update IBA with accurate patient information.
Change of Patient Details form
This form can be used to update either one or all of the following patient details:
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Surname
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Given name
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Address
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Date of birth
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Telephone number
Please note, when requesting a change of name on IBA, a Medicare card or change of name documentation must be sighted.
Change of details form (PDF 20KB)
Identification of Duplicate UR number
If you have discovered a duplicate UR number please use this form to identify which UR numbers require merging. H.I.S staff will merge the patient UR numbers and combine any documents.
Duplicate UR Number form (PDF 20KB)
Patient Registration
Registration involves allocating a Unit Record (UR) number to a patient which can be used as a unique identifier across a range of systems at RCH including IBA and CLARA. Patient information allocated to this UR number includes: demographic and contact details; past, current, and future visits; pathology and medical imaging results; and location of documentation.
There are several departments responsible for registering patients. The Patient Registration flowchart (PDF 20KB) illustrates the registration process and multiple locations where patients may present to be registered.
Research and Data Requests
Health Information Services maintains an accurate database of all Hospital separations and medical records are managed in accordance with the Public Records of Victoria (PROV) standards. Patient records are maintained either on microfilm or in hard copy; since 1993 all admitted patient records have been kept in hard copy form only. HIS have disease classifications dating back to 1921; this information is stored on index cards, microfilm, or electronically.
Approval for data requests
Requests for hospital data can be made for a variety of purposes, and the reason for the request will determine the process followed.
If data is required for research purposes, then full RCH ethics approval will be required.
If data is required for clinical auditing/quality assurance purposes, then a clinical audit form must be completed and sent to the RCH Ethics & Research Office for approval.
Ethics approval is not required for the following:
- De-identified data
- Ongoing patient care
- Maintenance of approved clinical databases
A copy of RCH ethics/clinical audit approval (if required) must be provided to HIS before a search for the data will be conducted.
Requesting a data extract
Considerations when requesting data:
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Information required in the report e.g. unit record number, name, date of discharge etc.
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Timeframe of the search e.g. for the last 10 years. HIS can retrieve data for admitted patients from July 1993 and outpatient information from February 2002. Information required prior to this date will be forwarded on to ICT services. Data not held electronically can be found on microfilm or on the manual card system. Please note that this may lengthen the time taken to complete the request.
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Data on diagnoses are retrieved according to assigned ICD codes. Researchers should be aware that there will not always be a specific code for a particular diagnosis, and extracted reports may provide data irrelevant to their study. Also, codes have changed over time; the most significant change in coding occurred in July 1998, when the classification system changed from ICD-9 to ICD-10. As a consequence, searches stretching back beyond 1/7/98 will require codes to be mapped, and while generally this can be done, sometimes it is not possible. Classification books are available in HIS if researchers wish to confirm the codes to be used in capturing the data for their study.
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Report format: hard copy or excel format. Excel reports can be emailed but only to an RCH email address.
Requesting medical records
If the corresponding medical records are required, these can be ordered via IBA.
Hospital staff can view records in HIS or in their own department. Please note that there is limited space to hold records in HIS, so staff are encouraged to view their records as soon as possible once available.
Record requests are processed in the following way:
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1-3 Records: Up to 3 records can be requested by a user in one day. These requests are entered as a Single Record Request. You will receive these records to view in the same day. These requests can be entered via IBA, Single Record request. Click here for instructions on requesting records via IBA (PDF 62 KB)
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>3 and <15 Records: </span/>Requests for records less than 15 are requested via the Bulk Request System on IBA. HIS endeavours to complete these requests within 48 hours.
- Greater than 15 Records: Requests for a large number of records can be requested via the Bulk Request System on IBA (PDF 82 KB). Bulk requests for records are completed in a 1 week turnaround. It is important that HIS receives your request on the Tuesday as bulk requests are only completed on Wednesdays and Thursdays. Due to the number of bulk record requests received each week, HIS can only retrieve a maximum of 30 records per person per week. This may be negotiable in exceptional cases.
HIS does not provide a courier service for delivery of research records. It is the responsibility of the requestor to collect and return all records to HIS.
Any records unavailable at the time of request will need to be re-ordered at a later date.
All hospital staff requesting records must have a role in patient care or other appropriate access rights; hospital identification must be worn when collecting records.
Chargeable research
In accordance with the Finance Department cost retrieval process, Health Information Services has implemented a charge for research requests where financial grants have been allocated. Therefore, retrieval costs are as follows:
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$6 per record stored on-site
- $8 per record stored off-site
If retrieval of records also involves copying of information, the charges will be:
- $8 per record stored on site
- $10 per record stored off site
If a patient information listing is also required based on a particular diagnosis or procedure, an added cost of $50 will be charged.
Contact
If you have any queries regarding requesting records please contact Rosanna Unmack on extension 6978 and for queries relating to research and data requests, please contact Allison Lusher*
