ABSTRACT

The patient record system has the potential to bring huge benefits to patients and is being implemented in
health systems across the developed world. Storing and sharing health information electronically can speed up
clinical communication, reduce the number of errors, and assists doctors in diagnosis and treatment. The
patient record system aims to use advanced database technology and user friendly graphical user interface
(GUI) which can efficiently help the hospitals to manage the patient’s information history without the need to
rely on the massive manual job from doctor and nurse. The patient record system consist of components like
HTMLs front end, the back end database. Analyses were done in choosing the right database systems and web
programming language to develop the user interface MYSQL database, PHP, Java Script programming
language where used in designing the system.

GENERAL INTRODUCTION
1.0 INTRODUCTION.
Granting patients the statutory right to have access to their medical records is relatively recent, having its
foundation in the access to health records act 1990 which came into force on 1 st November, 1991 As a
result of this act, subject to certain safeguards, patients were allowed to see their own manual health
records made after this date and earlier records if they were necessary to understand the later ones.
A patient record, health record is a systematic documentation of a patient individual medical history and
care. The term ‘medical record’ is used both for the physical folder each individual patient and for the
body of information each comprises, the total of each patient health history. Patient records are intensely
personal document and there many ethical and legal issues surrounding them such as the degree of third-
party access and appropriate storage and disposal.
General Automation plays an important role in the global economy and in daily experience. The Patient
Information Management System (PIMS) is an automated system that is used that is used to manage
patient information and its administration. It is meant to provide the Administration and staff, with
information in real-time to make their work more interesting and less stressing.
1.1 BACKGROUND OF STUDY
 The scope of the service in Adamawa Specialist Hospital, Yola is basically curative and preventive and is
offered in clinic unit X-ray/ultra sound, laboratory and dental unit in the hospital. Other services include
admission (ward) inpatient where drugs are issued, physiotherapy and family planning.
The hospital others 24 hours services to its staff and the entire population. The records of patients in
Adamawa Specialist Hospital have over time been run down due to large number of patients. This led to
poor record keeping since it’s a paper based system.
Reason why the current system used is manual has led to a variety of problems and these include;
unnecessary duplication of the data especially for inpatients and outpatients, inconsistence, may occur
since data is held more, that ones and it’s hard to analyse the data hence difficult to trace the flow of
patient past medication data. There are several department in the new extension of Adamawa Specialist
Hospital which include medicine, surgery, psychiatry, public health, ear, nose, eyes and throat, casualty,
obstetrics and gynecology among others.
Patient record and disease pattern documentation is concerned with documentation of information
obtained from patients and their particular health system in order to function properly. If this information
is not documented perfectly, causing some data to get misplaced, the health system will not be efficient.
The inpatient record using a computerized database system with a secure procedure for accessing if one
of the unit of the std/aids control progam (STD/HCP) a server doctor at consultant level who is assisted by
3 doctors, a secretary, 5 medical assistance, 7 nurses, trained consolers and part-time statisticians and 2
laboratory technologist head of unit. The various disease managed at the unit include the following:-
syphilis, molluscus, scabies, public lice, gonorrhea, trichomoiasis, gentle mart etc.
Patient information past and present is extremely vital in the provision of patient’s care which guides the
physicians in the making of right decision about the diagnosis.

1.2 OBJECTIVE OF STUDY

Several possible advantages to automated patient medical records over paper record have been proposed.
But there is a debate about the degree to which these are achieved in practice. Because of the relevance of
project to Adamawa Specialist Hospital later the following are the objective of this project.
a. Improve quality of care:- The implementation of patient medical record can help lessen the patient
sufferance due to medical error and the inability to analysis to access quality. The automated medical
records are claim to help reduce medical by providing the health care workers with decision support.
 b. Record keeping and mobility:- Automated patient record has the advantage of being able to connect
too many electronics medical records system.
c. Promote evidence based medicine:- Automated patient medical records provide access to
unprecedented amount of hospital and clinical date for research that can accelerate the level of
knowledge of effective medical practices. These benefit may be realistic sense only of the automated
medical records are interoperable and wide spread so that various system can easily share
information.
d. To provide useful and flexible program that will add value existing system in Adamawa Specialist
Hospital Yola .
e. To automate the processes and report base on information entered that can reduce the work load you
can expect to run the medical processes in a non-computerized environment.

1.3 SCOPE OF STUDY

This project work, design and implementation of an automated patient medical record is limited to
Adamawa Specialist Hospital Yola . This became necessary because it will be easy to me to present a
comprehensive software only if it is confirm to limited area.
1.5 LIMITATION OF THE STUDY
The basic challenges and limitation I encountered during this project work, design and implementation
of automated patient medical record, A case study of Adamawa Specialist Hospital Yola are:-
 Time constraint:- Due to the nature of work in the hospital, was unable to me with the medical
doctor, because he is very busy, and he don’t keep up to appointment. It is also stressful for my
project supervisor, because she is always busy during examination period.
 Lack of text book:- The lack of text book and a standard library also contribution to challenges I
face during this project work, due to high cost of transportation, browser (going for research) online
which is also money.
 Virus:- Virus can affect computer system, which can lead to the lost of the project materials.
1.4 SIGNIFICANCE OF STUDY
The automated medical record is of a great impotence, considering the information compliment existing
surveillance programs by accessing the large majority of episode illness for which no etiologist agents
are identify. Additional significant includes:-
 a. Sensitivity, Uniformity and efficiency, since detection of event do not depend on clinicians to
actively report diagnosis.
b. Timeliness, the data are available within a day of clinical event.
c. Ease of information into automated surveillance system. These features facilitate early detection of
condition of public health importance including regularly occurrence, such as bioterrorist attack that
first manifest as respiratory symptoms.
1.6 DEFINITION AND TERMS
Computerization: This is to control and process data by the use of computer. It help to spore problems
and solution easier.
Hospital:- Is define as the entity that provides the medical services to the patient in questioned of a
given period of time which is basically curative and preventive and is offered in clinic unit X-ray/ultra
sound, laboratory and dental unit in the hospital.
Patient Record Management System:- It is a system that can manage multiple administrators and can
have the track of the right assigned to them. It makes sure that all the administrators functions with the
system as per the right assigned to them and they can get their work done in efficient manner.
Medical Form:- Is refers to the medical document describing the patient initials, diagnoses and
treatment of particular patient in question that can be used for future reference in case of no
improvement on the health condition of the patient hence the changes can be carried out accordingly.
Consultation Fee:- is the money paid by the patient in question at the receptionist desk before any
medical attention.
Order and prescriptions:- Written orders by a medical provider are included in a medical record. These
details the instructions given to other numbers of the health care team.
Test result:- The result at testing such a blood test (complete blood count). Radiology (X-ray),
pathology (biopsy result), or specialized testing (pulmonary function testing) are included.
 CHAPTER TWO
2.1 LITERATURE REVIEW
This Chapter provides a review of literature that address the design and implementation of an electronic
patient record. Then explore the current Health Care in Nigeria, following by the current scenario of the
Manual-base medical record and the benefit of an automated patient record. It also throws the light on
factor in the design of an automated patient medical record.
According to Karm in (2008), that different term are used in literature to explain electronics health care
data, such as electronic health record (ERH) , electronic patient record (EPR), electronic medical record
(EMR), computer patient record (CPR), and computerized medical record (CMR). These names are
given from time to time in different nations and in different health care environment.
According to Abdul in (2008) argued that Health electronic record (HER) is different from an
Electronic patient record or electronic medical record (EPR/EMP). That is longitudinal and not site
specification in Short Health electronic record (HER) is patient care software while electronic patient
record or electronic medical record are health providers center.
According to Murphy in (1999), he defines an automated medical record as any information relating to
the past, present or future of physical health of any individual existing in an electronic system which is
use to capture, transmit, retrieve, receive, store and manipulate data for the main purpose of providing
health care and health related services.
Electronic patients record/electronic medical record (EPR/EMR) can be define as the record of patient,
providing care design mainly for a particular health sector.
According to Harman in (1999), he described an electronic patient record (EPR) as an essential tool for
collecting an integrating medical information in order to improve clinical decision making.
2.2 CONTEXTUAL ASSESSEMNT
According to Swarfout and Moare (1993), from University of Olio, stressed the need for hospital; for
prescription of drugs and diagnosis measures but does not state how programmable computer should be
to carry the work of prescribing the detecting diseases in humans.
According to Ferguson (1995) from University of California, he stated how computer should be used
for diagnosis, seining and surgeries but close not pomt out how it can carry out such task. Therefore,
after considering some of the lapses in the research work above, the lapses will be rectify in my system
development.
According to Ikerenwu (1996), from Delta State University, stressed that maintaining the reliability of
the computer memory to store information and how a computer should be programmed for all works of
thousands doctors but does not pass worded if provide security.
With this research “automated patient medical record” we meant to understand that health institution
can hope to encompass a patient record. Ideally, it is to create or enable each patient’s personal health
record so that it should be accessible at all point of care. Two main impediments stand in the ways of
this ideal. Firstly, most health care despite technical feasibility; they show little willingness to share
data with their competitors. Secondly, patients are becoming increasingly anxious about the privacy
about medical records. Such concerns seem justified when consider that under current low area practice
identification medical data are routinely share with insurances companies, government, research
employers, state biredus of vital statistics, pharmacy benefit managers. Also, it is understood that two
doctrines to guide the development of electronic, medical report are proposed: firstly, the record system
should be designed so that they can exchange all their stored data, according to public standard and
secondly, that patient should have control over and permission. Building software complaint with
public standard will enable connectivity and interpretability even of diverse system.
 CHAPTER THREE
3.0 METHODOLOGY AND ANALYSIS OF THE PRESENT SYSTEM
This is a description of method chosen to achieve the objective of the proposed system. It will go on to
describe the technique of data collection that will be employed in the research study of the proposed
system. The methods that will be applied to achieve the specific objectives are namely; Literature
review, oral interviews, system analysis, system design, data modelling and black box testing. The tools
that will be used to implement the system are wamp server, MySQL, HTMLs, CSS and PHP.
3.1 USE OF THE FOLLOWING METHODOLOGY
The methodology that is used is structured system analysis design method (SAADM) which proposed
in actually an automated system where data are collected and store in the program design for this
purpose, the automated patient record is intended to replace the existing system of computing in
Adamawa Specialist Hospital Yola . In the proposed system computer system and well trained
employees are required for effective implementation of the automated system.
3.1 ANALYSIS OF THE PRESENT SYSTEM
Adamawa Specialist Hospital Yola has its own way of study analysis, design, strength and weakness
of the present system, context level diagnosis, entity relationship diagrams, Architecture design. Its uses
computerized method of processing patient record, but still there are some challenges encountered by
the system at the hospital, the speed of recording and retrieval of patient information is made very fast
and easy.
This project will be achieved by gathering materials from difference source, one of the valuable source
of data was oral interview, which I conducted with staff of Adamawa Specialist Hospital Yola , and
also the Doctors and Nurses who assisted us by providing some key technical facts, especially on issues
that border around the hospital.
3.2 HISTORY ADAMAWA SPECIALIST HOSPITAL YOLA
Adamawa Arad specialist Hospital formally called Nasarawa state specialist hospital grew from a
General hospital to its present status. The General hospital was constructed and commissioned by the
Military governor of Benue/Plateau state Late Police Commissioner Joseph Gomwalk in June 1970.
When Nasarawa state was created on 1st October, 1996 by the Military head of state, late General Sani
Abacha, the hospital was then reconstructed and upgraded to Specialist Hospital status.
On the 9th of April, 1999 the Hospital was commissioned by the Military Head of State of the Federal
Republic of Nigeria, General Abdulsalam Abubakar.
The Hospital has been designed as one of the centres for HIV/Aids screening, and international project,
it is a centre for training of Doctors on Expanded Life Saving Skills (ELSS) and midwives on Life
Saving Skills (LSS) programmes, organized by united nations fund for population activities (UNFPA).
Adamawa Specialist Hospital as a training ground for students nurse from school of nursing Yola and
student of school of health and technology on practical experience. Presently, the hospital has a bed
capacity of one hundred and thirty eight (138). Move department are being constructed e.g the dialysis
centre, the news laundry unit and expansion of the Radiology department.
The hospital has a government board with the late Dr. Adamawaas its first chairman.
AdamawaSpecialist Hospital became autonomous of the state hospital management board on 8 th May,
2000. The hospital was rename AdamawaSpecialist Hospital Yola on 23 rd January, 2002 in his
memory.
 ADAMAWA SPECIALIST HOSPITAL ORGANIZATIONAL CHART
3.3 Adamawa State Ministry of Health

Health Services Management Board

Internal Audit
Chief Medical Directors

Head of Account
Chairman Medical Advisory Director of Administration
Committee
- Medical - Security
- Surgery - Catering
- Dentistry - Laundry
- OBS & Cyanear/hopaedics - Works & Management
- Nursery service
- Paediatrics Administration

- Physiotherapy
- History pathology
General Admin Plan & Dev. Estabs & Staff Dev.
- Microbiology
- Pathology (chem.) - Utilities - Rehabilitation - Pension
- Haematology - Housing - Research - Senior staff
- Radiology - Transport - Special capital - Junior staff
- Urology - Library - New capital - Training & Staff
- E.N.T - Library - Statistics
- Medical Records - Legal unit - Tenders
- Anaesthesia - P.R.O - Tenders Procedure
- Staff med/welfare
3.3.1 ORGANIZATIONAL PROFILE
Name of Establishment: AdamawaSpecialist Hospital Yola AdamawaState.
Location:- Hospital Road, Yola Adamawa State.
Number of people employed 1330.
Some of the functional departments/units include:-
1. Security Department
2. Out patients Department (OPD)
3. Admin Department
4. Accounts Department
5. Pharmacy Department
6. Medical Record Department
7. Family Planning/Antenatal and child welfare
8. Dental clinic Department
9. Eye clinic
10. Laboratory (pathology)
11. Theatre and central sterilization unit
12. X-Ray (Radiology) Ultra Sound Department
13. Maintenance
14. Catering Department (Kitchen)
15. Mortuary unit
16. Male medical/surgical and women medical gynecology maternity units
17. Pediatric unit.
3.4 WEAKNESS OBSERVED FROM THE PRESENT SYSTEM
As in the research: it is observed that manual record keeping is not meeting up with the
information required as in the updating and retrieval of the patient record.
There are many weakness or problem associated with the manual system are included below:-
1. There is a problem of storage of registers and forms/charts which are produce at different
levels.
2. Information retrieval from these sources is not easy.
3. It is evident that there is a lot of duplication in recording of reception, in the laboratory. And in
the ward different registers are kept.
 4. Some charts get lost or misplaced. This is a problem in decision making as there is inadequate
information.
5. Patients have to wait for a time as health workers are looking for their charts.

3.5 PROPOSED HIGH LEVEL SOLUTION

It is very important to get user of the system fully involved such that problem of change
management does not arise. The stakeholders, who will use the system therefore were approached
during the proposed system and the following were the findings:-
1. A system that improve on the efficiency at information storage and retrieval.
2. A system that is easy to learn and use.
3. A system that is fast in producing results which will be read at the point pf care therefore
reducing on waiting time and increasing on time to attend to the patients.
4. A system that is faster, flexible and convenient.
5. A system that restricts access to information to only authorize personnel’s.
6. A system that store data and product report timely and accurately.

CHAPTER FOUR
4.0 SYSTEM DESIGN
4.1 OBJECTIVE OF DESIGN
The objective of the design is to make sure that the problems involved in automated patient record
system are overcome. This project will also go a long way to solve the problem encountered in using
php/html and wamp server which is user friendly that enable the program to run properly.
4.2 CONTROL CENTER (MAIN MENU)
The control center tells more about mode of operation of the program and it will help to ensure that the
purpose of the program is achieved, they include:
a. User Login: The user login enables the user to gain access to the webpage.
b. Login: The login webpage enable the user gain access to the main program menu.
c. Password: The password helps you to secure your software programs from unauthorized users.
d. Lab Test: The lab test menu enables the user to gain access and input the patient’s lab data.
e. Treat Patient: This menu enables the user to gain access to patient treatment results and also to add or
edit the information.
f. Search Patient: The search menu enable the user to locate a patient information in the program data
base.
g. Patient Information: The patient information webpage enables the user to gain access to any patient
information being store in the database.
4.3 OUTPUT SPECIFICATION
The desired outcome of the system designed is to be able to accept data and produce
Desired output. It should be able to accept and be able o give out the required information for any patient
record using the appropriate programming, php/html and wamp server platform shown below.
USER LOGIN
User Name:
Password:

4.3.1 DATA BASE SPECIFICATION

LOGIN
FIELD NAME DATA TYPE NULL KEY
USER NAME VARCHER (30) NO PRI
PASSWORD VARCHER (30) NO PRI
PATIENT INFORMATION
FIELD NAME DATA TYPE NULL KEY
PATIENT NO VARCHER (30) NO PRI
FIRST NAME VARCHER (30) NO PRI
LAST NAME VARCHER (30) NO PRI
ADDRESS VARCHER (30) NO PRI
SEX VARCHER (30) NO PRI
DATE OF BIRTH VARCHER (30) NO PRI
DATA VARCHER (30) NO PRI

4.3.2 PROGRAM MODULE SPECIFICATION

a. User Login: Page under this, there are two basic menu namely:
i. Username: This enables the user to access their names without any difficulties to access their
information.
ii. Password: This enables the user to secure their personnel information from any unauthorized user.
b. HOME PAGE MENU: Under this menu we have sub menu namely
i. Login: login webpage enable the user to gain access to the main program menu.
ii. Patient Information: The patient information webpage enables the user gain access to any patient
information.
iii. Lab Test: The lab test menu enable the user to gain access and input the patient lab test.
iv. Treat Patient: This menu enables the user to gain access to the patient’s treatment result and also to
add or edit the information.
v. Submit: This control, allow the input data more to the data base so that another entry can be made.
vi. Search Record: The search menu enables the user to locate a patient information in the program data
base.
vii. Display: This enables the user to display all the information in the patient record system.
4.3.3 INPUT AND OUTPUT FORMAT
USER LOGIN
Username:
Password:
INPUT FORMAT FOR REGISTRATION OF PATIENT INFORMATION
 Patient No.
First Name:
Last Name:
Address:
Sex:
Date of Birth:
LAB TEST SPECIFICATION
Patient No.
Ward No:
Specimen:
Test:
Result:

INPUT FORMAT FOR TREATMENT INFORMATION

Patient No:
Ward No.
Bed No.
Diagnosis:
Treatment:
Doctor ID:
Clinic Note:

OUTPUT SPECIFICATION
Search Patient
Enter Search Term

Search

4.3.4 OVERALL DATA FLOW DIAGRAM OF THE SYSYTEM

 START

LOGIN

IS
LOGIN
VALIDATED

PATIENT INFORMATION

PROCESS PATIENT
INFORMATION

STOP

4.3.4 CHIOCE AND JUSTIFICATION OF PROGRAMMING LANGUAGE PLATFORM.

In the design phase of any computer application, the programming language to be used is one of the
problems. But for accuracy, flexibility and competent of the design work. The research uses PHP and
MYSQL (structure query language) for the database design, DREAM WEAVER, HTML and JAVA
Script for designing the webpage and suggested the use of PHP script to link the website to the database.
Below are some of the justification of using these programming languages.
 PHP website are considered more secure to window supported language such as ASP and Net.
 With PHP, your website can include pages which are created automatically, dynamically using
information available in the MySQL database.
 With PHP you can make your webpage more attracted in MYSQL database.
 PHP/MYSQL web hosting is cheaper than windows supported hosting.
 The computer that host your site run the PHP code, which create HTML for the page.
  PHP/MYSQL does not require and license for fees unlike window supported language than
windows supported host.
 MYSQL/ as the database and PHP are the scripting language.

CHAPTER FIVE
5.0 SYSTEM DOCUMENTATION AND IMPLEMENTATION
These chapter emphasizes the patient medical record is a systematics documentation of a patient
individual medical history and care. The medical records also server as documenting between the
health care professional contributing to the patient care. The system was transformed from the user
requirement into a workable product. The purpose system documentation and implementation was
to make sure that the correct application is delivered to the end user.
Besides that, this chapter also employees on how the testing is done to confirm to meets the user
requirement.
5.1 HARDWARE AND GENERAL SYSTEM SPECIFICATION
This section describes the hardware component and software requirement needed for effective and
efficient running of the system.
a. The hardware requirement include:-
i. 125MB RAM and above
ii. Processor speed of 1GH3 and above
iii. At least 20GB of hard disk drive.
b. Software requirement include:-
i. Microsoft window XP and above
ii. Apache web server version 1.3
iii. Internal explorer or any other web browser
iv. MySQL server version 3.2
5.2 HOW TO USE THE SOFTWARE
 a. Load your internet browser or wamp server.
b. Then type the web address of your program http://localhost/medicalhomepage.php in order to
display your homepage.
c. Under the homepage you should input or type the password and username, then your program
environment would be open where you would be asked to fill in the necessary information.
5.2.1 SITE PREPARATION
When preparing your software you must make sure that all the software needed for all program
are properly installed into your computer system, if any of these software is not properly installed
it will hinder the normal functioning of your program.
5.3 HARDWARE AND SYSTEM INSTALLATION
The hardware and system installation describes the installation procedures for setting up the
system. This program is expected to run on Microsoft window XP service pack 2 and Pentium iv,
20GH3 hard disk space. In system installation requires you to insert disk containing the package
automated patient record system at Adamawa Specialist Hospital, Yola , in the CD-ROM drive,
then click start on the window task bar and click run.
5.4 TRAINING
In any software, before it can be used students, staff or anybody, there must be trained on how to
implement the new system and the user can gain access to their database in order to collect all the
application in each section. You also need to install wamp server 32bit to enable the software run
effectively on the system.
5.5 FILE CONVERSION
The procedure involves changing from the old system into the new system. It involves the
following:-
a. Direct Change:- This is immediate change for an old system to a new system without delay.
b. Parallel change over:- This is a change from the old system to a new system. This is a done
step by step.
c. Pilot change over:- This has to do with the process the new system is used by the users before
allowing other group to use it.
In this design pilot change over is used to change from old to new system by the group of users
using it before the other group is allowed to use it.
 CHAPTER SIX
6.0 SUMMARY
Several possible advantage to automated medical record have proposed, but there is a degree to
which these are achieved in practice, the information conformed in the medical record allow the
health care providers to provide continuity of care of individual patient, the automated patient
medical records when fully implemented will serve as the basic for planning patient care,
documenting, communication between the health care and other health professional contributing to
the patient care in Adamawa Specialist Hospital Yola .
6.1 CONCLUSION
The use of automated patient medical record should not be over emphasized because the
implementation of automated medical record in Adamawa Specialist Hospital Yola help less
patient suffering due to medical errors and the inability of analysis to access qualify. Electronic
health system in Adamawa Specialist Hospital Yola help to reduce to medical errors by
providing health care workers with decision support, fast access to medical literature and accurate
best practice in medicine hypothesized to enable proliferator of ongoing improvement in health
care efficiency.
Finally, improve usage of automated medical record achieve if the presentation on screen or on
manual record is just not longitudinal, but hierarchically or dered and layered.
6.2 RECOMMENDATION
Training of all members of staff in the hospital to get accustomed to the system would be priority.
We would recommend that the management system of the hospital educate them on how the
system will operate and how it will supplement their effort. The hospital users of the system need
to be thoroughly educated about the use of the password and the username, also not to be careless
when using them, and they should be kept confidential. The information needed to record while
tracing state of patient’s daily health should be properly recorded such as:-
 Body temperature
 Pulse rate (health rate)
 Blood pressure and respiratory rate.