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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 Zali
1
, *Saiful Farik Mat Yatin
1
, Mohd Razilan Abdul Kadir
1
, Siti Noraini Mohd Tobi
2
, Nurul Hanis
Kamarudin
1
, and Nik Nurul Emyliana Nik Ramlee
1
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 a s medical records.
The health professionals were contributing to record the patient’s care. The responsibility in managing daily records that pr oduced 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
1. Introduction
Organizations with good records management practices benefit in
many ways. Records management provide evidence of activities
or business transactions which means it is to recall the details of
what was done or what was decided in the daily operation in the
organizations. The records management also makes informed
decisions and formulates policy on a solid basis of knowledge.
Medical records considered as one of the field that consider its
records as critical resources in carrying specific functions. The
medical records may have been in the paper and in an electronic
based that also known as health records. It contains collection
patient information including health, treatments and others. The
government and private hospital used medical records for continu-
ing care of the patient health. Furthermore, it is also used in the
health care facilities and services such as management and plan-
ning, research of medical, and in producing statistics of healthcare.
In every organization, knowledge and experience worker is an
important asset especially in Specialist Medical Centre.
Davenport [1] stated that a knowledge workers is the employee
that “have high degrees of expertise, education, or experience, and
the primary purpose of their jobs involves the creation, distribu-
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-
tirely given task. However, Specialist Medical Centre also con-
fronts several difficulties involving in managing medical records
in Medical Records Department.
2. Problem Statement
Without apply a good records management in the organ-
izations they are lack to manage efficiently and effectively of the
daily operations as well as to use the knowledge for past and fu-
ture use [2]. In managing medical records, all activities done
meets the standards been addressed in ensuring that the practice
meet a predetermined value.
According to Hersh [3] there are several problem related
to electronic medical records which are increase time, insufficien-
cy standards, and reveals privacy threats. Hence, it will bring dif-
ficulties in retrieving medical record. As stated by Noraziani et al.,
[4] no standardization on documentation systems which there lots
of system software can be obtainable, therefore it create difference
to the systems then cause document that is not standard. Although
improvement has been done within creating coding standard for
data elements, not any appeared in the same way as complete
standard. Inadequate funding is also an issue, which lack of fund
often promotes dishonesty [5]. Usually, the management of a med-
ical centre may be restricted with inadequate fund and may not
even have health information department [6]. Some hospital in
recent years have shown the tendency towards self-satisfaction in
hiring unqualified hands which the staffs assigned job are from
different disciplines other than records management in term of
managing the organization records [7].
3. Purpose of the Study
This conceptual paper is intended to discuss the prob-
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
to suggest some strategies to overcome the problems of unaware
staff in managing this medical record.