medical records department

overview of medical records department in parash hospital patna

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OVERVIEW OF MEDICAL RECORD DEPARTMENT IN PARAS
HOSPITAL IN GURGAON


Submitted in requirement for the partial fulfillment of
BACHELOR IN HOSPITAL MANAGEMENT
FROM
NSHM COLLEGE OF MANAGEMENT AND TECHNOLOGY, DURGAPUR
UNDER
MAULANA ABUL KALAM AZAD UNIVERSITY OF TECHNOLOGY, WEST
BENGAL

Submitted by:
ABHIJEET ROY
BHM-015
Reg. No. 1576002

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ACKNOWLEDGEMENT

I, ABHIJEET ROY a student of NSHM at Durgapur West Bengal, would like to sincerely
express my heartfelt gratitude to:
· Mr. MOHIT BAKSHI, senior executive, HR for granting me the opportunity for training.

· Mr. MOHIT KUMAR, senior executive, MRD, PARAS HOSPITALS for granting me
the opportunity for summer training and assigning me my project in the Medical Record
Department.

· Mr. KAPIL CHAUDHARY, senior executive, MRD, PARAS HOSPITALS, for being
my mentor for my project in the Medical Record Department.

· Ms. MADHU, junior executive, MRD, PARAS HOSPITALS, for invaluable help with
my project and also guide for the entire period of my training, for helping me to improve
the quality of my work and for helping me identify areas where I lack and what
characteristics I must develop in myself for a future as a hospital administrator.

· Dr. NILOY SARKAR, Dean, Academic, for his invaluable inputs and guidance for my
project, as they helped me to develop a line of thought for how to shape my project.

· Mr. KRISHNENDU CHAKRABORTY, my mentor at NSHM DURGAPUR, for his
support and guidance, without which this training would not have been possible.

· Lastly, I would like to thanks my college, NSHM DURGAPUR, for providing me with
an opportunity to learn from and work with the best personnel in the Hospital Industry,
and for helping me gain an appreciation of where I currently stand as an administrator
and how much work I would need in order to meet the quality specifications that the
hospital industry seeks.

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TABLE OF CONTENTS

Sl. no. Title page no.
1. INTRODUCTION 4 - 12
2. OBJECTIVE OF STUDY 13 - 14
3. LITERATURE REVIEW 15
4. NEED OF STUDY 16 - 18
5. RESEARCH METHODOLOGY 19 - 22
6. FINDING & ANALYSIS 23 - 28
7. RECOMMENDATION 29 - 30
8. SCOPE OF THE STUDY 31 - 33
9. CONCLUSION 34
10. REFRENCES 35

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INTRODUCTION

Paras Hospitals, Gurgaon is the 250 bedded flag ship hospital of Paras Healthcare. It is a state
of the art multi super specialty hospital providing a complete spectrum of advanced medical and
surgical interventions with a comprehensive mix of inpatient and outpatient services. Since its
inception in 2006, Paras Hospitals has been moving forward with the vision to provide
competitive, innovative and accessible medical care to its patients. The hospital offers around 55
super specialties under one roof and is supported by a team of doctors of international and
national repute.

Paras Hospitals, Gurgaon, is also the first NABH accredited corporate hospital of Haryana. It is
also the first hospital of the region to have a NABL accredited laboratory.
Paras Hospitals initiated with focus on Neurosciences, Joint Replacement and Mother & Child
Care. Today there are around 55 specialty departments including Minimal Invasive Surgery,
Gynecology and Obstetrics, Ophthalmology, Dermatology, Endocrinology, Rheumatology,
Cosmetic and Plastic surgery, to list a few.

Supported with expertise and cutting edge technology, Paras Hospitals, Gurgaon has one of the
leading Neurosciences centres in the region with all the facilities under one roof. It is also one of
the few centres where deep seated tumours are operated upon. Moreover, it is the first private
hospital in Delhi NCR to have a standalone Image Guided Tumour Navigation Surgery
Technology.
Paras Hospitals understands and abides by its motto-Partners in Health– and aims at becoming
the ultimate care giver for the community. The hospital with its remarkable patient care services,
excellent community interface & quality healthcare provides affordable services to the society at
large.

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Paras Hospital, Gurgaon
Address: C-1 Sushant Lok- 1 Sector-43
Phase- I Gurgaon,
Haryana 122002 (India)
Contact Number: [phone]
Emergency Number: [phone]
Email id: [email protected].
Paras Healthcare was established in 2006, with the mission of providing specialized tertiary
medical care services at affordable prices to underserved communities across the country. This
private healthcare provider stands apart from others in its vision of making healthcare for all a
reality for ordinary people in rural and remote regions. Every single individual working in a
Paras Hospital from doctors to nurses and the management- is united in the endeavor to deliver
top quality healthcare to all. Paras Healthcare is a leader in establishing specialized hospitals in
places that lack access to healthcare, specifically super specialty tertiary care.

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Paras Healthcare was established in 2006, with the mission of providing specialized tertiary
medical care services at affordable prices to underserved communities across the country. This
private healthcare provider stands apart from others in it’s vision of making healthcare for all a
reality for ordinary people in rural and remote regions. Every single individual working in a
‘Paras’ Hospital- from doctors to nurses and the management- is united in the endeavor to
deliver top quality healthcare to all. Paras Healthcare is a leader in establishing specialized
hospitals in places that lack access to healthcare, specifically super specialty tertiary care. Each
of it’s initiative is based on three tenets of healthcare- Affordability, Accessibility & Quality.
What do we aim for in the future?
The expansion strategy of Paras Healthcare has been broken into two Phases; Phase 1 is from
2015 to 2020 and Phase 2 is from 2021 to 2028. Expansion will primarily be in Tier 2 cities of
the North Indian Hindi-speaking belt. “Our target is cities with a population of 2m+ that have a
Medical College,” highlights Dr. Dharminder Nagar, Managing Director, Paras Healthcare. The
focus will be on establishing tertiary care centers that focus on Oncology, Cardiology,
Orthopedics and Neurology. These will evolve into specialized transplant centers.
By 2020, Paras Healthcare intends to establish tertiary healthcare facilities in other Tier 2 and
Tier 3 cities too, to bridge the gap between demand and supply. “Five years from now we will
have a bed strength of 1500. This year we expect to have the group revenue cross 500 crore, and
that should become 1000-1200 crores within the next 5 years with additional beds, services and
hospitals being added,” says Dr. Nagar. Partnerships with private and governmental
organizations are in the offing. “We are in talks with many governmental agencies for a chain of
cancer institutes and tertiary care centres and also with private companies keen on collaborating
in operations and management of hospitals,” he says.
At the moment, Paras Healthcare is strictly focusing on its new chain of specialized mother and
child care centres – Paras Bliss. The aim is to provide specialized maternity and neonatology
care in areas where the same is deficient. Our units in Panchkula, New Delhi highlight the 3
tenets of Paras Healthcare – affordability, accessibility and quality. Keeping the same in mind

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Paras Healthcare shall be expanding its footprint in the next 5 years in 6 important cities of North
India.
For setting up a new unit, Paras mainly adheres to its three tenets of healthcare – present
accessibility of healthcare in the region, presence of affordable healthcare at the location
and last existence of a specialized quality healthcare provider. If any of the aspects can be
addressed, Paras Healthcare participates in providing exceptional healthcare facilities that can
touch the lives of millions and improve the health infra of the state/region.
Paras Healthcare works on the principle of bridging the gap. By providing exceptional medical
expertise, infrastructure and technology to areas that lack the same, Paras is able to initiate a
healthcare revolution in the rural areas. Paras Patna, Paras Darbhanga, Paras Guragon along with
Paras Panchkula are examples to highlight the same.

OUR MISSION
Our mission is to provide the best quality medical service with utmost responsibility and
compassion. Our management ensures that every patient gets the best possible treatment whether
preventive or diagnostic.

OUR VISION
Paras Hospitals aspires to be the preferred healthcare partner for the community. We will initiate
all our endeavors based on the 3 tenets of healthcare – Affordability, Accessibility and Quality.
Paras Healthcare believes in penetration and association with the community at the grass root
level. We believe that quality care should be uncompromised and affordable. We move forward
with the vision that doctors, nurses, management together act as the torch bearers of quality
healthcare delivery-symbiosis of all entities ensures that excellence is achieved and delivered.

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 First corporate hospital of Gurgaon
 First Hospital of Gurgaon to be NABH accredited
 First NABL accredited lab and blood bank in Gurgaon
 Paras Hospitals , Gurgaon is the first neuroscience centre in the region that operates on
deep seated tumours.
 Paras Hospitals, Gurgaon is the first private hospital of Delhi NCR region to have a stand
alone image guided tumour navigation surgery technology.
 Paras Hospitals, Gurgaon is the only hospital of the region to advocate Transradial
Interventional cardiology
 First to successfully perform India’s first day care angioplasty
 Awarded the Best Healthcare Campaign for Breast Feeding Rooms in Public Places at
Six Sigma Healthcare Awards Function 2015.
 Dr. (Prof.) V.S.Mehta, Director Neurosciences, Paras Hospitals, Gurgaon awarded
“Lifetime Achievement Award” at 6th MT India Healthcare Awards 2016 presented by
Medgate Today
 Paras Healthcare has the vision of providing establishments set on the principles of
competence, commitment, compassion, convenience and effectiveness. We through our
outreach aim at redefining the meaning of healthcare and its dimensions. We believe in
being the true ‘Partners in Health’- for the community, ensuring that along with guidance,
attention and care, expertise is delivered with cutting edge technology and precision.
 Fostered with the strength of its flagship hospital- Paras Hospitals, Gurgaon, the aim of
Paras Healthcare is a pioneer in transpiring realities of healthcare- providing expert care
where the same is inaccessible and inadequate. Our footprints in Patna, New Delhi,
Panchkula, Darbhanga and Noida reinstate our mission of providing affordable,
accessible, quality healthcare to underserved areas.
 We at Paras Healthcare believe that the journey of success needs forces of passion &
dedication. These are imperative for growth and quality performance and we want to
evolve as a corporate with a ‘conscious’.
 Paras Healthcare also aims at being the pioneer in changing the perception that quality
healthcare provided by private hospitals is beyond the reach of common man, with choice
of cost effective care and a wide range of services and facilities to choose from.

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 At Paras Healthcare you can access the medical services for – Neurosciences,
Orthopaedics & Joint Replacement, Cancer Treatment & Radiotherapy, Urology,
Nephrology, Kidney Transplant, Aesthetic Sciences, Minimal Access Surgery, Obstetrics
& Gynaecology, Nenatology & Pediatrics along with Cardiology & Cardiac Surgery.
Paras Healthcare shall ensure that rare specialities like Endocrinology & Rheumatology
are also provided to all. We also assure that our medical endeavours shall always be
abreast with the latest developments in the scientific field as we understand that today’s
tomorrow may become yesterday.
 For us, our accomplishments and our happy moments shall encompass from saving lives
and making every patient who walks into the portals of Paras Healthacare healthy and fit.

Specify internal and external clients
According to the findings, internal and external clients in Coding, Statistics, Admission, and
Archive units were as follows:
Clients of admission unit
 Internal client: This unit has no internal client
 External clients: External clients of the Admission unit in the Ayatolah-Kashani Hospital
include the patients going to be admitted in the hospital. The needs of these patients are
to receive the MRs and get their gown.
Clients of coding unit
 Internal clients: Internal clients of the cutting unit in the Ayatolah-Kashani Hospital are
researchers, professors, and students of medicine and geriatrics courses who study or
work at the hospital or university
 External clients: External clients of the cutting unit in the Ayatolah-Kashani Hospital are
researchers who are referred from out of the hospital to study the MRs.

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Clients of archive unit
 Internal clients: Internal clients of Archive unit at the Ayatolah-Kashani Hospital
includes the head and manager of the hospital, clinical personnel such as physicians,
nurses and those individuals dealing with patients’ treatment, accounting staff at the
hospital, insurance officials placed in the hospital, researchers, and students related to the
University of Medical Sciences
 External clients: External clients in this unit include the patients who need their own
medical information to continue their treatment or need other demands such as rename,
and also some organizations such as Military Exemptions and Public Duty Organization,
Organization and Martyr Veterans Affairs, Islamic Revolution Court, Insurance
Organizations, Charity Organizations, Iranian Legal Medicine Organization, The Medical
Council of Iran, Department of Education, Welfare Organization, Bureau for Aliens and
Foreign Immigrants and the researchers out of the Ayatolah-Kashani Hospital in Isfahan.
Clients of statistics unit
 Internal client: Internal clients on this unit include the head and manager of the hospital,
supervisor of the hospital, hospital's financial manager and technicians of surgery rooms
 External clients of this unit include the emergency department, assistance, and Statistics
unit of the IUMS, Local Registry Office, Health Center of the province and Medicine
College and other departments in the hospital which need statistical information.
 After identifying clients in different units of the MRD, the processes based on the
customer's point of view in each unit were described.
 In general processes of the MRD, general route of the MRs is considered and illustrated
from the creation of the store by value stream mapping. The MRs are generated by
patients or those accompanying them at the reception desk in Admission unit, completed
by medical staff and delivered to the MRD after discharging in the revenue department.
At the MRD, it is registered in the computer database and after coding procedure, it will
be stored in the Archive unit. In the case that it is not complete, it is returned back to the
Coding unit to receive the proper codes and then it will be archived

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FLOW CHART OF MEDICAL RECORD DEPART MENT










IPD
DISCHARGE
FILE
COLLECTION
CLOSE
FILE
AUDIT
DEFICIENCY
CHECKLIST
CODING INDEXING
FILING

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ORGANOGRAM OF MEDICAL RECORD DEPARTMENT








FACILITY DIRECTOR
ASSISTANT MEDICAL
SUPERINTENDENT
SENIOR EXECUTIVE -MRDJUNIOR EXECUTIVE -MRD

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OBJECTIVES OF THE STUDY

 Paras Healthcare also aims at being the pioneer in changing the perception that quality
healthcare provided by private hospitals is beyond the reach of common man, with choice
of cost effective care and a wide range of services and facilities to choose from.
 At Paras Healthcare you can access the medical services for – Neurosciences,
Orthopaedics & Joint Replacement, Cancer Treatment & Radiotherapy, Urology,
Nephrology, Kidney Transplant, Aesthetic Sciences, Minimal Access Surgery, Obstetrics
& Gynaecology, Nenatology & Pediatrics along with Cardiology & Cardiac Surgery.
Paras Healthcare shall ensure that rare specialities like Endocrinology & Rheumatology
are also provided to all. We also assure that our medical endeavours shall always be
abreast with the latest developments in the scientific field as we understand that today’s
tomorrow may become yesterday.
 For us, our accomplishments and our happy moments shall encompass from saving lives
and making every patient who walks into the portals of Paras Healthacare healthy and fit.
 Paras Healthcare has the vision of providing establishments set on the principles of
competence, commitment, compassion, convenience and effectiveness. We through our
outreach aim at redefining the meaning of healthcare and its dimensions. We believe in
being the true ‘Partners in Health’- for the community, ensuring that along with guidance,
attention and care, expertise is delivered with cutting edge technology and precision.
 Fostered with the strength of its flagship hospital- Paras Hospitals, Gurgaon, the aim of
Paras Healthcare is a pioneer in transpiring realities of healthcare- providing expert care
where the same is inaccessible and inadequate. Our footprints in Patna, New Delhi,
Panchkula, Darbhanga and Noida reinstate our mission of providing affordable,
accessible, quality healthcare to underserved areas.

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Studies over many years have shown “Lean to have a wide range of applications in hospital
operations ranging from:
 Reducing inappropriate hospital stays
 Improving the quality and financial efficiency of trauma care
 Reducing the cost of temporary staff
 Improving operating room and emergency department efficiency
 Improving radiology processes
 Reaching better strategic decisions affecting marketing and capacity management, among
other uses of Lean leading to improved hospital profitability.

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LITERATIRE REVIEW
Health care in India as in many other countries is confronted with growing demand for medical
treatment and services, [1] due to factors such as a graying population and higher standard for
the quality of life. Miller [2], say that health care has been an issue of growing importance for
national government. Many national and regional health care plans have been developed in the
past decades, in order to control the cost, quality and the availability of health care for all
citizens.
Brown [3], opined that the application of electronic clinical information system (ECIS) has
generated useful insight into the quality of data accuracy and health care provision in primary
care settings. This is partly one of the adapted style and approach to data entry influenced by the
design presented by the recent structure. They further emphasize, that there is a great need for
improved education and protocols for consisting data entry in the (ECIS) and also subsequent
follow up of patient clarification on the policy for duration and frequency treatment.
Laubbel [4], define medical, health record, or medical documentation of a patient’s medical
history and care as “medical record” used both as the physical folder of patients and for the body
of information which comprises the total of each patient’s health history. Medical records are
intensely personal document and there are many ethical and legal issues surrounding them such
as the degree of third-party access and appropriate storage and disposal. The key advantage of
shifting to computer-based patient record is the opportunity to strengthen the link between the
hospital records and management information system so that resources uses and quality of care
can be analyzed using Hospital database which increase physician efficiency and reduce costs, as
well as promote standardization of care.

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NEED OF THE STUDY

In the present era of globalization and advanced technology efficient record keeping cannot be
overemphasized. Imagine the scenario when the manual processes and manual modes of
instruction get replaced with electronic systems. One of such replacement can be done in the area
of patient’s database management system within a hospital. Developing patient database
management system software would benefit the hospital management who can have effortless
access to the data securely and more easily. Libraries keeps information on how many books are
in the library, how many are been loaned out and to whom they are loaned and also the date and
time this books were loaned or given out. School also keeps student’s information or records.
These records of students could include student’s personal data such as name, sex, date of birth,
level etc.
Hospitals are not excluded in record keeping. The records kept include patient data, which help
to maintain patient’s medical records. The medical records must have correctly all of the patient
medical history. Physicians must maintain flawless records, because this document serves a
number of purposes. It serves as a communication tool. As an important source of patient
information, the medical record facilitates the transfer of data to other physician involved in an
ongoing treatment of patient or the transfer of patient to another physician outside the office of
the attending physician. It also facilitates the transfer of data to health care establishment or to
any other organization or individual such as insurance company or employer. Well- kept records
usually reflect the level of care given to a patient by the physician. Therefore medical records
can be used as an evaluation tool. The more complete the record, the better they will serve the
physician and the patient in the event of any action. Every patient’s medical record must include
the following specific information. Patient’s identity which includes the patient’s first name, last
name, sex, age, address, etc.
In spite of the important function of medical record, it has come under severe threat that by the
manual system of medical record keeping. This system involves taking down patient data on
pieces of papers, which are then put in to the files and filed in cabinets.

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Another problem is the missing of pieces of information. One standard hospital study reveals that
on the average, patient records visited, there are pieces of information the doctor could not find
in the paper file.
Physicians and their office staffs have said that, they spent more time looking for patient
information, than the time they have for the patient, as issues related to risk management is
security. The first consideration is the physical safety of the data being stored. Threats exist
externally in the form of natural disasters. The most important issue is the security involved in
patient’s privacy.
 The MRD personnel should be responsible for receiving Pathology forms from the
Pathology department, deliver it to the MRD and attach them to the MRs
 Receiving the MRs from different people should be banned; they should prepare a list of
the names who are allowed to receive these MRs and inform it to the hospital manager
for confirmation
 In general, all information about the MRs should be presented via formal request, so it is
suggested that a request form be prepared by the MRD, so those who do not have a
formal request refer to the hospital manager for confirmation and then refer them to the
MRD for their requests
 In the statistics unit, it was proposed that much of the statistical reports have to be
prepared by computers and the one who is in charge of such statistics receive them
through the hospital network
 The doctors’ credits are affected by their documentation on the MRs
 The MRD should report their activities as feedback to the attending physicians, the
interns and the residents
 The correct and standard methods of documentation should be taught to the interns and
residents, when they start their jobs in the hospitals through training workshops, by
specialists in the Health Information Management
 The accuracy of the documentation of the interns and residents, as well as their
effectiveness, should be reported to their attending physicians and the vice chancellor of
education of the hospital.

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The value activities in the units of Coding, Admission, Statistics, and Archive contain the
following:
 In the Archive unit, the MRs are given to the researchers based on the request forms to be
completed by them and approved by the attending physicians and the vice-president in
the educational affairs
 In the Archive unit, if the client is not the patient itself, needing a certified copy, a note is
attached to the file signed by the client showing that the certified copy is submitted to
him
 For the copies of the documents for the Military Exemptions and Public Duty
Organization, the phrase “for the Military Exemptions and Public Duty Organization” is
written, and a tag is stuck over it to prevent others from any probable misuses
 No answer is given to the MRs which has financial problems
 On the cover of the MRs which copies are provided, it is written that a certified copy was
submitted
 The MRs related to the Neurology ward, due to its being single-service, a summary sheet
of the MRs is provided
 SPSS training courses for staff of the Statistics unit is held
 A person who is in charge of the statistics unit prepares voluntarily different statistical
reports; therefore, when the authorities require reports, they are ready and are submitted
at once
 The hospitalization order form all physicians are the same
 The Admission unit conducts those patients who are not under any insurance to the
Iranian insurance to prevent them from wasting their time and confusion.

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RESEARCH METHODOLOGY

Data: A collection of fact on which conclusions maybe drawn.
Hospital: An institution that provides medical, surgical or psychiatric care and treatment for the
sick or the injured.
Patient: One who receives medical treatment attention care.
Medical records: It’s any data, which is collected and use to diagnose or treat a patient’s health
problem.
Database: A collection of data arranged for ease and speedy search and retrieve.
Most of the patient and administrative information that flow throughout the health care system is
still recorded on paper. According to an earlier report by cnnmoney.com, only about 8% of the
nation 5,000 Hospital and 17% its 800,000 physician currently use the kind of common
computerized record keeping system
In general, medical records may be on physical media such as film (X-rays), paper (note)
photographs, often of different sizes and shapes, physical storage of documents in problematic as
not all document types fit in the same size folder or storage spaces. In the current global medical
environments, patient are shopping for their procedures many international patients travel from
one country to the other for special treatment or to participate in clinical trial co-ordination these
appointment via paper-based record is a time consuming procedure. Physical records usually
requires significant amount of space to store to them, when physical records are no longer
maintained, the large amount of storage space are no longer required paper film and other
expensive physical media usage can be reduce by electronic record storage. Paper records are
stored in different location, furthermore, collecting and transporting them to a single location for
review by a health care provider is time consuming. Also when paper records are required in
multiple location, copying, faxing and transporting cost are significant.

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In 2016, an estimate was made that 1 in 7 hospitalizations occurred when medical records were
not available. Additionally, 1 in 5 lab-tests were repeated because results were not available at
the point of care. All these were as a result of paper-based medical records.
Hand written paper medical records can be associated with poor legibility, which can contribute
to medical errors.
Paper-based patient record hinder flow according to [5] once information has been recorded
within a set of bulky paper records, it may not be readily accessible later, effort to compile more
complete paper records are likely to make this problem worse.
Paper records can only be use in one place at a time.
The data are only as secure as the paper itself and the entire records are individual page within a
record can easily be misplace, damage lost or stolen.
This research work focus on how this method can be improved through the automation of
patient database system which convert the paper based patient medical record to computer-based
paper-based.
Suggested that if all information in paper-based records were digitized and embedded within
information system, that will provide rapid context sensitive access to the data and link to other
information in the institution. The health care delivery could fully documented information using
a variety of convectional and handheld computers equipment with keyboard, pen-based.
Structured data entry or handwriting recognition illegible or consistent entries could be caught
and corrected as they are entered in medical order, their results and all others internal
transactions could be tracked automatically Though, [6], have made a significant contribution
toward the development of a computerize medical records for medical institutions, however this
project intends to look at how medical record of a hospital would be share only within the
hospital by the staff and not across the institution.
Health information could be stored as individual indexed items of information that could be
abstracted into reports and compare among patients. Record could be accessed and easily

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duplicated when necessary. Information anywhere within the record could be access by minimal
delay. Data could be located from any one delivery medium and digital device that access them
could be designed with a wide variety of capability and capacity [7]. A page from a paper- base
patient record could be stored electronically in many different ways. The information could be
scanned and store as an image (much like a fax) that is the picture of a paper form but is not
searchable or editable document imaging system are widely available that use computer and
optical disk to store such image and make them available to clinicians on workstation with
graphic terminals. These system reduces the amount of physical storage space require for patient
record and they allow the record to be shared by clinicians and administrative officers without
physically transporting the records.
Handwritten medical record can be associated with poor legibility which can contribute to
medical error, pre-printed firms, the standardization of abbreviation and standard for penmanship
were encouraged to improve reliability of paper medical records. Electronic record help with the
standardization of forms terminology and abbreviation and data input. Digitization of form
facilitates the collection of data for epidemiology and clinical studies. Duplication of lab tests,
diagnostic imaging, and other services can be prevented by good record-keeping of any type.
However, because database records can be available at many locations at once, integration of
services and awareness of duplication can be reduced. Database management system enable
health organization to access old records instantly, thereby allowing the health work to send to
another health organization in the event of an emergency.
In the present research, the MRD Lean team offered some suggestions for the documentation of
the MRs and a reduction in their shortages. Moreover, they carefully examined the processes and
promoted the current ones and eliminated the wastes. Among the processes which were modified
and suggested in this research the processes of Admission, Statistics, and Archive units were as
follows:
 Answering the insurance companies and the Military Exemptions and Public Duty
Organization (to eliminate the physical environment waste category)
 Answering the patient's request for changing his/her name (to eliminate physical
information waste category)

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 Answering the requests of Organization and Martyr Veterans Affairs (to eliminate the
physical environment waste category)
 Collecting and sending the number of the inpatients MRs (to eliminate the process waste
category)
 Calculating the ready, empty, occupied surgery rooms (to eliminate the physical
environment waste category)
 Calculating the statistics of patients in wards and the emergency department (to eliminate
the physical environment waste category)
 Preparing and sending the reports related the cancer patients and suicide attempts (to
eliminate the physical environment waste category).
This research revealed that achieving the patients’ satisfaction as the most significant customers
of the health system, is one of the major criteria in measuring the quality of the services offered
to the people in the hospitals and the medical centers. It is also the most important goal of the
Lean management. The implementation of the Lean management in the MRD is so helpful and
desirable, because it is on the basis of a team work with the presence of the masters of the
processes who are closely involved in the duties and activities of their units and are aware of the
precise details of the current activities.

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FINDING & ANALYSIS


Developed a database for drugs that improved the effectiveness and efficiency to eliminate drugs
wastage through over stocking or expiring of drugs following a stock of inventory of Hyelada
pharmaceutical. They intend to develop not only a database for drug but a computerized medical
record that would encompass other related records of patients within the health care institution.
According to [9] cited by [8], to enhance the work of medical practitioners in hospital/clinics it is
widely recognized that information system is essential for managers, because most organization
need information system for help companies extend their reach too far away location often new
product and services reshape job and work flow and perhaps profoundly change the way they
conduct business. Laboratory information system (LIS) is one of the integrated parts of
information system which involve many different applications. Use of a LIS is a critical piece of
a clinical information technology spectrum of system which contributed significantly to the
overall care given to patients.
Stated that transformation of medical practices is emerging not only as a result of the availability
of these technology but as a deliberate attempt to address the image challenges facing the health
care delivery. According to [11], an Electronic Health Record (EHR) refers to an individual
patient’s medical record in digital format. Electronic health record system co-ordinate the storage
and retrieval of individual record with aid of computer.
By alignment of impact information technology (IT) [12], say that a hospital that moves from a
level to another shows the changes in management information technology (MIT) in hospital
management. Alignments start from the existing business organization and its needs, generating
the supporting IT services. Impacts start from IT opportunities and generate changes to the
overall business plan and the hospital processes. In that way, the software can be used to follow
the developments in hospital overtime; obviously the program can be used to compare several
operation of the hospital at a given moment.

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Patient’s record and procedure vary greatly according to patient data received and the extension
of automation in processing data.
These are some fundamental step which is common to patient record in all clinics and hospitals.
According to [13], some of these steps taken at each treatment of patient and assessment in
clinical procedure include:
Assessment: To get the information and the
 Data entry: recording of data into a patient’s
assessment of patient’s symptom and signs. record (which may be a complex electronic Data
retrieval: extracting data for
data written records results etc) Information interpretation: governance of
interpretation. interpretation of individual patient data utilization of existing knowledge and
guidelines. Therefore, when these fields are put together they produce a medical record.
The procedure involved in the current system is that, when a patient visit the hospital for
medication, the patient will first of all buy the identification card which contains name, and other
relevant information needed, and card identification number. The patient will then waits for the
card to be processed together with a file jacket that holds the card that has column for diagnosis
made by physician, drugs prescribed, and date at the waiting room for the arrival of the card.
When the file arrived, the patient joints the queue to see a doctor. In this current system, file
cabinets are used for keeping individual patient card enclosed in a file. This system is so tedious
in tracing a record files slow in processing of records, space occupied by the file time waiting
while waiting for the patient file to be retrieve by the receptionist.
This new system is design for medical practitioner/physician to keep track of all patient’s
medical record/information such as diagnosis, drug prescribed, admission and discharged, etc the
new system will take care of the long processes and tedium work involved in tracing and

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retrieving a patient’s record in the old system in a nut shell this will improve the efficiency of the
management in a daily work as it can provide required records on time.
Medical Records (MRs) is a set of documents that renders the clinical, para-clinical care, and
financial information about the patient. The Medical Records Department (MRD) is responsible
for collecting, and protecting patient information, and for disseminating it to the right people or
an organization, in order to promote the quality of patient care.[1]
Each MRD in the hospitals includes the following four units, each of which undertakes special
functions:
 Admission: Registration of inpatients and outpatients who are admitted to Hospital wards
and the Accident and Emergency Department
 Archive: Checking to ensure that a complete discharge summary and all other necessary
notes and reports are present in the MRs; assembling and internally organizing the MR
and filing them in an orderly and timely manner; retrieving these records for various
users, for treatment and the provision of other services
 Statistics: Preparing statistics for administration, hospital wards, and external agencies
such as the Ministry of Health; providing health information for physicians, nurses and
students for medical research purposes
 Coding: Analyzing the MRs of all inpatient’ following discharge and assigning a set of
numeric codes to the diagnostic data based on the International Classification of
Diseases-10 and the International Classification of Procedures in Medicine.[2]
As health care expenses continue to erode the budgets of households, governments, and
healthcare providers, more suitable methods to reduce the cost of care are required. One tool that
can increase efficiency and value is a change management technique called Lean thinking.[3]
In recent years, expanses of regulation approaches around these same objectives go emerged
farther down various names. Faultless With, Kaizen, Kanban, and 6 Sigma are approximately
solutions go off act endorse the interchangeable through want of the Lean technique.[4]

26. 26

The aim of Lean management is customer satisfaction through the elimination of waste and the
improvement of processes. To meet customer needs, existing processes should have the
necessary efficiency and effectiveness. A process will be effective when properly done. It should
be done when properly selected and designed.
Lean eliminates waste by taking out unnecessary processes and redirecting human effort toward
value-added business operations.
Patient records are the primary repository of data in the information-intensive health care
industry. Although clinical information is increasingly likely to be computerized, the current,
predominant mode for recording patient care data remains the paper record. Paper records have
the advantages of being familiar to users and portable; when they are not too large, users can
readily browse through them. Paper records, however, have serious, overriding limitations that
frequently frustrate users and perpetuate inefficiencies in the health care system. Further, the
impact of these limitations is growing as the health care system becomes more complex. Modern
patient care requirements have outgrown the paper record.
Quality improvement and cost containment continue to be major concerns for the health care
industry. Quality assurance; utilization management; appropriateness, effectiveness, and
outcomes assessment; clinical practice guidelines; and value purchasing are all prominent
responses to the quality or cost challenges faced by present-day health care. Each of these
initiatives increases the legitimate demand for complete, accurate, readily accessible patient data.
Health care professionals today face an unprecedented information explosion as the quantity and
complexity of patient data and medical knowledge increase practically daily. Current patient
records cannot adequately manage all the information needed for patient care. Paper patient
records have not kept and cannot keep pace with the rapidly changing health care system. As a
result, they increasingly impede effective decision-making throughout the health care sector—
from the bedside to the formulation of national health care policy.
Some health care institutions are already applying computer technologies to this information
management challenge. In general, however, the diffusion of information management
technologies has been slower in health care than in other information-intensive industries.

27. 27

Moreover, the majority of information management applications in the health care sector have
focused on financial and administrative rather than clinical data.
In its study, the committee reviewed the needs of patient record users, as well as existing and
emerging computer technologies. It concluded that better CPR systems—systems that meet user
needs more fully—can be achieved within 10 years. Nevertheless, the committee cautions that
merely automating
The future patient record will be a computer-based, multimedia record capable of including free
text, high-resolution images, sound (e.g., auscultations), full-motion video, and elaborate coding
schemes. CPR systems will offer access (availability, convenience, speed, reliability, and ease of
use), quality, security, flexibility, connectivity, and efficiency. In addition, future patient records
will provide new functions through links to other databases and decision support tools.
No contemporary clinical information systems are sufficiently comprehensive to be considered
full CPR systems. Several existing systems, however, offer prototypes of components of CPR
systems.
The committee considers nine technological capabilities to be essential to CPR systems: (1)
databases and database management systems, (2) work-stations, (3) data acquisition and
retrieval, (4) text processing, (5) image processing and storage, (6) data-exchange and
vocabulary standards, (7) system communications and network infrastructure, (8) system
reliability and security, and (9) linkages to secondary databases.
No new technological breakthroughs are needed to develop robust CPR systems, but some
emerging technologies are crucial. Low-cost yet powerful clinical workstations and improved
human interface technologies are needed. Voice-recognition systems, high-capacity networks
(e.g., fiberoptic), and open-architecture systems will be required to achieve broad adoption of
CPR systems. Emerging clipboard-sized computers that accept input through a hand-held stylus
may also prove to be a critical development. In addition, CPR diffusion requires development of
standards for health care data and greater emphasis on protecting the integrity and confidentiality
of CPR data.

28. 28

Technology is not the only potentially limiting factor in advancing CPR systems; informational,
organizational, and behavioral barriers must also be addressed. Barriers to CPR development
include development costs and lack of consensus on CPR content. CPR diffusion is adversely
affected by the disaggregated health care environment, the complex characteristics of CPR
technology, unpredictable user behavior, the high costs of acquiring CPR systems, a lack of
adequate networks for transmitting data, a lack of leadership for resolving CPR issues, a lack of
training for CPR developers and users, and a variety of legal and social issues.

29. 29

Recommendations
RECOMMENDATION 1. The c ommittee recommends that health care professionals and
organizations adopt the computer-based patient record (CPR) as the standard for medical
and all other records related to patient care.
The committee believes that future patient records must be more than a way to store patient
data—they must also support the clinical decision process and help improve the quality of patient
care. Achieving widespread use of CPRs is a major component of building a national health care
information system that can support the provision of integrated health care services across
settings and providers of care. Further, widespread use of CPRs would contribute to the
collection of patient care data as a national health care resource. Achieving these objectives
requires that CPRs be more than automated paper records.
The committee defined the CPR as an electronic patient record (i.e., a repository of health care
information about a single patient) that resides in a system specifically designed to support users
through availability of complete and accurate data, alerts, reminders, clinical decision support
systems, links to medical knowledge, and other aids. Further, the committee identified 12
attributes that comprehensive CPRs and CPR systems possess.
1. The CPR contains a problem list that clearly delineates the patient's clinical problems and
the current status of each (e.g., the primary illness is worsening, stable, or improving).
2. The CPR encourages and supports the systematic measurement and recording of the
patient's health status and functional level to promote more precise and routine
assessment of the outcomes of patient care.
3. The CPR states the logical basis for all diagnoses or conclusions as a means of
documenting the clinical rationale for decisions about the management of the patient's
care. (This documentation should enhance use of a scientific approach in clinical practice
and assist the evolution of a firmer foundation for clinical knowledge.)
4. The CPR can be linked with other clinical records of a patient—from various settings and
time periods—to provide a longitudinal (i.e., lifelong) record of events that may have
influenced a person's health.

30. 30

5. The CPR system addresses patient data confidentiality comprehensively—in particular,
ensuring that the CPR is accessible only to authorized individuals. (Although absolute
confidentiality cannot be guaranteed in any system, every possible practical and cost-
effective measure should be taken to secure CPRs and CPR systems from unauthorized
access or abuse.)
6. The CPR is accessible for use in a timely way at any and all times by authorized
individuals involved in direct patient care. Simultaneous and remote access to the CPR is
possible.
7. The CPR system allows selective retrieval and formatting of information by users. It can
present custom-tailored "views" of the same information.
8. The CPR system can be linked to both local and remote knowledge, literature,
bibliographic, or administrative databases and systems (including those containing
clinical practice guidelines or clinical decision support capabilities) so that such
information is readily available to assist practitioners in decision making.
9. The CPR can assist and, in some instances, guide the process of clinical problem solving
by providing clinicians with decision analysis tools, clinical reminders, prognostic risk
assessment, and other clinical aids.
10. The CPR supports structured data collection and stores information using a defined
vocabulary. It adequately supports direct data entry by practitioners.
11. The CPR can help individual practitioners and health care provider institutions manage
and evaluate the quality and costs of care.
12. The CPR is sufficiently flexible and expandable to support not only today's basic
information needs but also the evolving needs of each clinical specialty and subspecialty.

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SCOPE OF THE STUDY
System design is the process of art of defining the architecture, component, modules, interface,
and for system to satisfy specified requirement. Architecture desire creates a blue-print for the
design with necessary specification for the hardware, software; people and data resources. In
many cases multiple architectures are evaluated before one selected. The research question such
as what is currently being done, how is it being done. How well is the task being perform.
The analysts gather details about the business (medical record) process and try to improve on
them.
In order to enter information into an electronic medical record, special software is required. In
designing the program with Microsoft visual basic the design will include the following.
i. Use case diagram
ii. Database design and
iii. Normalization.
Database: is a collection of structure and related record (information) stored somewhere or some
location for easy retrieval and exploration. Database is designed in order to assist in eliminating
unnecessary data and to minimize duplication of data.
Database Normalization
Normalization is the organization of data to conform to a standard called Normal form and for
efficient manipulation, storage and update of data.
Database Implementation
The database of this application was implemented in Microsoft office Access. MS-Access is
database application with which one can create database files using the relational model. With
this model you can create tables, store and manipulate data within the tables as required.
Relationship can also be established to create communication among them.

32. 32

Computer-based patient records and the systems in which they function are becoming an
essential technology for health care in part because the information management challenges
faced by health care professionals are increasing daily. Technological progress makes it possible
for CPRs and CPR systems to provide total, cost-effective access to more complete, accurate
patient care data and to offer improved performance and enhanced functions that can be used to
meet those information management challenges. CPRs can play an important role in improving
the quality of patient care and strengthening the scientific basis of clinical practice; they can also
contribute to the management and moderation of health care costs.
The Institute of Medicine (IOM) study committee believes that the time is right for a major
initiative to make CPRs a standard technology in health care within a decade. Achieving this
goal within 10 years will require a nationwide effort and a great deal of work. More research and
development are needed in several critical areas to ensure that systems meet the needs of
patients, practitioners, administrators, third-party payers, researchers, and policymakers. For
example, the need to protect patient privacy must be balanced by the need for timely access to
data at multiple sites. Systems must offer both considerable flexibility for users and standards
required for data transfer and exchange.
The committee recommends the following:
1. Health care professionals and organizations should adopt the computer-based patient
record (CPR) as the standard for medical and all other records related to patient care.
2. To accomplish Recommendation 1, the public and private sectors should join in
establishing a Computer-based Patient Record Institute (CPRI) to promote and facilitate
development, implementation, and dissemination of the CPR.
3. Both the public and private sectors should expand support for the CPR and CPR system
implementation through research, development, and demonstration projects. Specifically,
the committee recommends that Congress authorize and appropriate funds to implement
the research and development agenda outlined herein. The committee further
recommends that private foundations and vendors fund programs that support and
facilitate this research and development agenda.

33. 33

4. The CPRI should promulgate uniform national standards for data and security to facilitate
implementation of the CPR and its secondary databases.
5. The CPRI should review federal and state laws and regulations for the purpose of
proposing and promulgating model legislation and regulations to facilitate the
implementation and dissemination of the CPR and its secondary databases and to
streamline the CPR and CPR systems.
6. The costs of CPR systems should be shared by those who benefit from the value of the
CPR. Specifically, the full costs of implementing and operating CPRs and CPR systems
should be factored into reimbursement levels or payment schedules of both public and
private sector third-party payers. In addition, users of secondary databases should support
the costs of creating such databases.
7. Health care professional schools and organizations should enhance educational programs
for students and practitioners in the use of computers, CPRs, and CPR systems for patient
care, education, and research.

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CONCLUSION
This study embarked on the patient medical information which substitutes the current (manual
system) of sorting, handling, searching, amending and keeping of patient medical records. This
portrays the importance and indispensable nature of the computer and its application in the
hospital. The database aimed at reducing paper work in the reception area to reduce the time
wasted by patients in the course of waiting for their files to be retrieved. This also reduced the
spaced occupied by the files and provide adequate security for patient s medical record. Based on
the finding of this study, the design of hospital patient database record will be a solution to the
problem being experienced by the current manual method of keeping patient medical records.
The study has critically indentified the importance associate with using electronic in keeping
patient medical record to eliminate missing files and enhance speedy retrieval of patient’s record.
The management of Paras Hospital, Gurgaon has agreed that the manual method of keeping
patient records should be change to computerized patient medical records which will help them
to eliminate inefficiency, and unreliability associated with the manual method. Through the
exhausted study and analysis made in this research, it was recommend that General hospital
Makurdi and other medical centre that had been providing health care service should have an
automated system for effective operations.

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