International Journal of Engineering & Technology, 7 (3.

7) (2018) 232-235

International Journal of Engineering & Technology

Website: www.sciencepubco.com/index.php/IJET

Research paper

Managing Medical Records in Specialist Medical Centres

*Mastura Md Zali1, *Saiful Farik Mat Yatin1, Mohd Razilan Abdul Kadir1, Siti Noraini Mohd Tobi2, Nurul Hanis
Kamarudin1, and Nik Nurul Emyliana Nik Ramlee1

1
Faculty Faculty of Information Management, Universiti Teknologi MARA (UiTM) Puncak Perdana Campus, Shah Alam, Malaysia
2
Faculty of Business Management, Universiti Teknologi MARA (UiTM) Puncak Alam Campus, Kuala Selangor, Malaysia
*Corresponding author: Mastura Md Zali: Faculty of Information Management, Universiti Teknologi MARA (UiTM) Puncak Perdana
Campus, Shah Alam, Malaysia
E-mail: masturamdzali@yahoo.com

Abstract

A collection of facts about a patient’s life and health history of past and present illnesses and treatments is known as medical records.
The health professionals were contributing to record the patient’s care. The responsibility in managing daily records that produced by
each of department is by the Medical Records Department. It is a department under clinical support services with activities including
managing of patient records, patient information production, management of medical reports, and hospital statistics. This article aims to
discuss the challenge associated with managing medical records in the organization and how to handle and manage it with the records
management as a tool to mitigate risk. Therefore, it is likely to prompt further research by addressing existing gaps towards improving
service delivery that can contribute to the body of knowledge in the field of records management and archives generally.

Keywords: Medical Records, Records Management, Specialist Centre, Records Management Department, Medical Records Officer

Without apply a good records management in the organ-

1. Introduction izations they are lack to manage efficiently and effectively of the
daily operations as well as to use the knowledge for past and fu-
Organizations with good records management practices benefit in ture use [2]. In managing medical records, all activities done
many ways. Records management provide evidence of activities meets the standards been addressed in ensuring that the practice
or business transactions which means it is to recall the details of meet a predetermined value.
what was done or what was decided in the daily operation in the According to Hersh [3] there are several problem related
organizations. The records management also makes informed to electronic medical records which are increase time, insufficien-
decisions and formulates policy on a solid basis of knowledge. cy standards, and reveals privacy threats. Hence, it will bring dif-
Medical records considered as one of the field that consider its ficulties in retrieving medical record. As stated by Noraziani et al.,
records as critical resources in carrying specific functions. The [4] no standardization on documentation systems which there lots
medical records may have been in the paper and in an electronic of system software can be obtainable, therefore it create difference
based that also known as health records. It contains collection to the systems then cause document that is not standard. Although
patient information including health, treatments and others. The improvement has been done within creating coding standard for
government and private hospital used medical records for continu- data elements, not any appeared in the same way as complete
ing care of the patient health. Furthermore, it is also used in the standard. Inadequate funding is also an issue, which lack of fund
health care facilities and services such as management and plan- often promotes dishonesty [5]. Usually, the management of a med-
ning, research of medical, and in producing statistics of healthcare. ical centre may be restricted with inadequate fund and may not
In every organization, knowledge and experience worker is an even have health information department [6]. Some hospital in
important asset especially in Specialist Medical Centre. recent years have shown the tendency towards self-satisfaction in
Davenport [1] stated that a knowledge workers is the employee hiring unqualified hands which the staffs assigned job are from
that “have high degrees of expertise, education, or experience, and different disciplines other than records management in term of
the primary purpose of their jobs involves the creation, distribu- managing the organization records [7].
tion or application of knowledge”.
Specialist Medical Centre whose staffs with excellent knowledge
and experience are their utmost priority in order to finish the en-
3. Purpose of the Study
tirely given task. However, Specialist Medical Centre also con-
fronts several difficulties involving in managing medical records This conceptual paper is intended to discuss the prob-
in Medical Records Department. lems of inadequate proper system for managing medical records in
Specialist Medical Centre, to know the factors that cause the prob-
lem in managing medical records such as inadequate funding, and
2. Problem Statement to suggest some strategies to overcome the problems of unaware
staff in managing this medical record.
Copyright © 2018 Authors. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly cited.
International Journal of Engineering & Technology 233

4. Literature Review records. However, there are more serious consequences if the
Shepherd [8] has stated in her studies, records that are properly records are not maintain properly.
well managed and known as records management program can
support business with efficiently, consistently deliver services, Factors that cause problems - Inadequate funding, cost
support decision making as well as make clear policy creation etc.
besides make sure continuous in implementation of policy and Records are vital information in any organization that
others. Nandalal [9] stressed that it is vital for medical records as needs a secure and good custody from the authorized person. It
it roles to deliver the information of the patient’s health. Further- should be keep properly so that it cannot be reaching by intruders
more, it gives useful information such as disease epidemiology and can only use by authorized person for specific purpose. In
that is important to the country’s health system and in the way of order to maintain a good recordkeeping, an organization should
nation’s health. The government and private hospital need to keep prepare an adequate financial to support cost needed to spend for
their medical records properly to deliver proof which can help buying any equipment for recordkeeping maintenance. To have a
within keeping the legal significance related to the patient, physi- good recordkeeping and maintenance, organization should have a
cian and healthcare institution. good staff to manage all the records. Organization should hire
person with qualification in records management field as they
Problems in managing medical records of inadequate sys- understand more about the procedure of managing the records
tem which can improve records management of organization. To en-
As stated by the Government of Alberta [10] infor- suring the useful and well-organized of managing of medical rec-
mation is vital as one of strategic asset towards the government or ords, the hospital must have records personnel who have essential
private and valuable to people and technology. Similar to other abilities in managing records that have been created in the course
organization, it is important to manage information and records. of their business [16].
Some organization is generates records and information and there Smolji and Dun [17] had said that managing patients’
records need to be keep for future use. The organization keeps health records is an accurately as well as timely is vital element in
records to meet legal requirements in support of business opera- the process of decision making. For example, the inadequate of
tion as well as protect the right by took the administrative, histori- patient health information will cause to medical errors and impre-
cal and archival reasons [11]. Unfortunately, some issues have cise of decision making. By providing access of details of medical
existed in managing medical records department that are lack of history of the patient is hard to the physicians. In addition, to reach
adequate and appropriate space, lack of sufficient budget, and lack the adequate and valuable information is challenging. The concept
of staff. In addition, they also have no effective way to managing to support that balance of the efficient medical records is by the
their records that created by organization. Burns et al., [12] indi- Personal Health Record and Continuity of Care Record.
cated that there is virtually no money in the budget of many organ- Besides that, medical records are collection of patient’s
izations to train records staff that leads to lack of staff and inap- information health. When a patient has a record such as records in
propriate training towards managing records. paper based, the patient by this time have a basic personal health
Health Port [13] stated that there are many practices that record. The patient perhaps faced the problems of paper records
are easy such as by providing suitable record storage. In fact, the [18]. In preparing medical records, the practitioners must keep in
medical practitioners stated that patient’s charts are not being mind that he is generating the documents that are reflecting his
discovered in 30% of visits because the results are not accessible personal findings and management of patient’s diseases. In some
[14]. time, these medical records can be needed by the patient and the
courts in matters of laws and litigation [19].
Medical records are supposed to return in the Med-
The Chief Executive Officer (CEO) or Medical Director
ical Records Division after being use [15]. In most of the Health of the healthcare was responsible to keep the privacy and confi-
Care organization, the problems of managing the medical records dentiality of medical records. Moreover, medical records need be
which make difficult because the records creator were not aware kept in secure rooms to ensure it is well protected even it is not in
in managing records effectively when creating the records. The use. The medical record should be protected from any harmful
situation of poor records keeping practices such as fail to hire threats such as vermin, weather, and others. It is also need to be
competent and qualified staff in records management field, inade- easy access when it is needed and returned in a complete form by
quate storage accommodations, consequently staff lose discour- the users after they use it.
agement and enthusiasm, and fail in the implementation of good Even though the electronic medical records have posi-
records management. tive effects towards healthcare and medical practices, the imple-
There are staff including administration, clinical, nurses mentation process become crucial issues. The implementation of
and health professionals must aware with the Medical Records EMR requires cooperation from hospital management. A good
Department as this department responsible to provide good rec- knowledge on EMR such as system features and system workflow
ords of patient information. There are significant numbers of pa- is the important element to ensure an effective implementation.
tient are harmed from their health care that results in permanent Mohamed Khalifa [20] stated that lack of knowledge is one of the
injury, increase length of stay (LOS) in hospital and death. factors on the unsuccessful implementation of EMR.
From the lesson from the previous, the bad incident hap- The hospital management must find proper solutions to
pen not because bad people purposely hurt patient but the improve and enhance the process of implementing EMR. Besides
healthcare system nowadays is complicated. Therefore, the suc- that, the management should hire technical expertise in order to
cessful treatment and results for each patient depends competence implement effective EMR. Difficulties to accept electronic medi-
of healthcare providers. It will make it difficult to make sure the cal record (EMR) comprise inadequate of technical skills and
safe care of the system of care is designed to enable timely and illiterate of computer knowledge [21-22]. In comparing with other
comprehensive information and thoughtful by all the healthcare industries, the information technology in healthcare is still slow. It
professionals including doctors, nurses, pharmacists, and others. showed that there are limited available in organize applications,
Medical records is important source of evidence in the which resulted steep learning curve for healthcare organization.
hospital and it supposed to be keep and preserve the records for Moreover, training on EMR is needed to avoid difficulty
evidence of business transactions. The hospital where the records in retrieving medical records. Hospital management supposed to
are not manage properly, it can cause to be inadequate when it is deliver continuous training for all staff on effective usage of EMR.
needed by the users, records easily lost and even records was de- The hospital management does not provide training for staff on
stroyed prematurely and maintained inappropriately. Besides that, using EMR. Thus, it will cause the problems on accessing medical
too much records retention will lead problems during accessing records. In addition, in create modules on training such as to use
the applications because of illiterate of computer knowledge, the
234 International Journal of Engineering & Technology

costs maintaining servers and software updates must be considered

[23]. Lakbala, Lakbala and Inaloo [24] stated staff might hesitant
to use EMR for a few reasons. Good plans for extensive training
to use EMR are essential to prevent the lack of training.
After that, hospital management should give support in
implementing EMR. As mentioned by Vu [25] the acceptance
among staff towards EMR is decreased. For that reason, an imme-
diate action must be set up to get supports. The hospital manage-
ment needs to give encouragement to use EMR and must be ex-
tensive support from the whole organization. The encouragement
from hospital management must be practically with the intention
to use EMR consistently.
In healthcare delivery the use of EMR can increase the 6. Methodology
efficiency with the development of information technology. The
information technology definitely gives the huge usage towards A qualitative method research design will be adopted. The re-
the changes especially in healthcare today. By having EMR, it will searcher will use purposive sampling. This study also include
be one of the solutions to address some issues of medical records. semi-structured and face-to-face interview will be used to obtain
Someday, EMR will give the practitioners new approach the information. There are 6 respondents will be identified which
when patient that is treated have allergic on medication, thus it from Medical Records Department. They will be given some ques-
give the newest research related to the treatment modalities hence, tions to investigate the challenge of managing medical records,
it can organizing the volumes of information of patient’s chronic their duties and responsibilities, to determine inadequate proper
condition. EMR also be able to modified information of the pa- system, to determine the inadequate funding and to determine the
tient accessibility through tools for example when get connected awareness of effective records management among staff. The data
with World Wide Web (web services). This proficiency will allow will be analyzed using ATLAS.ti and using the thematic analysis
retrieval the information at any time. for data analysis.
Moreover, EMR help to smooth the activities directly
through the friendly interface such as decision support quality
management and results of the reports because it has capability to
7. Conclusion
create a comprehensive record.
In conclusion, in managing medical records in Specialist
Medical Centre is essential in daily operations which improve the
Strategies for staff unaware of effective records manage- performance of healthcare and increase productivity especially in
ment Medical Records Department. All of the actions are under Head of
Uwaifa [26] stated that the vital element of records man- Department (HoD) of Medical Records Department responsibili-
agement is necessity of created records to maintain for future use. ties in managing medical records. Medical record must according
It is needed to have proper storage and filing system to assist easy with the policy and standard required to keep records in effective
retrieval of records. The storage facilities such as shelves, rack, ways. With the good practice of records management, carries sim-
cabinets and others must in a good condition. Furthermore, the ple of administration tasks.
successful records management can support the organization to
overcome the unexpected event like audits and disasters.
Acknowledgements
Additionally, it helps to keep stakeholder’s interest such
as staff, client, policy makers and others. It aid fulfilling the audit
requirements, gives evidence for legal action and preserves organ- This article is financially supported by Conference Support Fund,
izational memory. Records management cover the scope of rec- Institute of Graduate Studies (IPSis, UiTM), Fundamental Re-
ords, content, context, requirements in access, use, risks assess- search Grant Scheme (FRGS), Ministry of Higher Education
ment, safety and others that gives advantages in managing records (MoHE), Malaysia. (Ref. No: FRGS/1/2016/SS06/UITM/03/1)
[27]. and Academic Development Trust Fund (TAPA), Faculty of In-
A broad record management practice in the organization formation Management, UiTM
must create filing system in storage area by using alphabetical,
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