ISSN: 2222-6990
Open access
Hospital is an institution which is sick to death or wounded person are given clinical treatment. Well prepared doctor and nurses also as a first-class facilities and equipment for valuable aset of hospital to become a good medical care industry. Medical record also form an vital part of patient’s present-day and forthcoming health care. Misdiagnose a patient conditon can give serious consequences to patient which happen when medical record are inaccurate, incomplete, up-to date and reachable medical record. Aims of the paper are to classify medical record management in university hospital associated with good practice in managing records, to assess the staff skill in managing medical records appropriately and to see medical record management program contribute for quality decision making. The study applies quantitative method approach with use structured questionnaire. A technique of cluster sampling was to organise the entire hospital into nine departments (clusters). The researcher goal-directed selected 90 health staff and a records staff to contribute in this research. Researcher found that completeness physical note and nursing note of patient and also use and archive lifecycle do not associate with good practice in managing medical records. From the study, it is clear that most of the medical record officers have insight into personal skills and competencies about medical record. Researcher found that for second research question, medical record officers have the right level of staff skill to manage medical records appropriately. From the survey on decision making factor, the finding are, all factor in doing decision making are significant. Good medical record management program associated with quality of decision making. Misfiling and missing files, shortage of records staff and poor staff knowledge are the three main problems that affect the hospital in their quest to managing records effectively and making decisions. So that, researcher recommendation are to make adoption of an integrated Electronic Records Management System, more training for records staff, conducive storage and enlarge storage location, adequate records staff and more alert about security issues.
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In-Text Citation: (Amin, et. al., 2020)
To Cite this Article: Amin, N. A. M., Yatin, S. F. M., Jali, J. M., Sahid, N. Z., Shuhidan, S. M., Noordin, S. A., & Abdullah, W. A. M. W. (2020). Making an Informed Decisions in a Teaching Hospital: How Medical Record System Helps. International Journal of Academic Research in Business and Social Sciences. 10(11), 549-564.
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