ISSN: 2222-6990
Open access
Hospitals deal with the life and health of their patients. Good medical care relies on well-trained doctors and nurses and on high-quality facilities and equipment. Without accurate, comprehensive up-to-date and accessible medical records, medical personnel may not offer the best treatment or may in fact misdiagnose a condition, which can have serious consequences. The objectives of the study are to identify 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 cluster sampling technique was used to classify the whole hospital into nine departments (clusters). The researcher purposively selected 90 health staff and a records staff to participate in this study. 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.
Acheampong, E. K. (2012). Electronic Health Record System: A Survey in Ghanaian Hospitals. Journal of Health & Medical Informatics, 03(02). doi:10.4172/scientificreports.164
Adu Freda. (2014). Assessment Of Records Management Practices Among The Administrative Staff Of University Of Education, Winneba – Kumasi (UEW-K) and Mampong (UEW-M) Campuses, (Master's Thesis, Kwame Nkrumah University of Science and Technology). Retrieved from http://ir.knust.edu.gh/bitstream/123456789/7540/1/Adu%20Freda.pdf
Afolabi, M. (2004). Education Training Archivists and Records Managers in Africa, Annual Conference of the Society of Nigeria Archivists, 61-67. Lagos: SNA.
Ajami, S., Ketabi, S., & Torabiyan, F. (2015). Performance improvement indicators of the Medical Records Department and Information Technology (IT) in hospitals. Pakistan Journal of Medical Sciences, 31(3), 717–720. http://doi.org/10.12669/pjms.313.8005
Akor, U. P., & Udensi, J. (2013). An Assessment of Records Management System in establishment division of two Universities in Nigeria. International Letters of Social and Humanistic Sciences, 13, 97-109.
Aiken, L. H., Sermeus, W., Van den Heede, K., Sloane, D. M., Busse, R., McKee, M., … Kutney-Lee, A. (2012). Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ, 344 (Mar 2012), e1717-e1717. doi:10.1136/bmj.e1717
Amo Justice. (2016). The Role Of Records Management Practices In Improving Decision Making In Public Hospitals: The Case Of Ashanti Bekwai Municipal Hospital (Master's Thesis). University of Ghana.
Ben-Assuli, O., Leshno, M., & Shabtai, I. (2012). Using Electronic Medical Record Systems for Admission Decisions in Emergency Departments: Examining the crowdedness effect. Journal of Medical Systems, 36(6), 3795-3803. doi:10.1007/s10916-012-9852-0
Chinyemba, A., & Ngulube, P. (2005). Managing records at higher education institutions: A case study of the University of KwaZulu-Natal, Pietermaritzburg Campus. SA Journal of Information Management, 7(1), 1-19. doi:10.4102/sajim.v7i1.250
Confidentiality Of Medical Records Information : Who's Responsibility? (2016, December 5). Retrieved from http://www.myhealth.gov.my/en/confidentiality-of-medical-records-information-whos-responsibility/
Cowling, C. (2003). Records management manual. London: University of London.
Darwish, H., Saki, N., Sahraei, M., Zakrifar, F., & Talebi, S. M. (2014). Effects of Automated Office Systems (automation) on improve decision making of staff managers (at the airports company of country). Journal of Educational and Management Studies, 4(3), 554-564
Egwunyenga, E. J. (2009). Record keeping in Universities: Associated problems and management options in South West Geo-Political zone of Nigeria. International Journal Education Science, 1(2), 109-113
Ge, M., & Helfert, M. (2006). A Framework to assess decision quality using information quality dimensions. Retrieved from http://www.researchgate.net/publication/220918695_A_Framework_to_Assess_Decision_Quality_Using_Information_Quality_Dimensions
Hare, C., & McLeod, L. (1997). Developing a records management programme. London: Aslib.
Hitler, D. S. (2013). The Contribution of Information Management to Administrative Decision Making in Kinondoni Municipal Council (MPA Thesis). Mzumbe University
Hounsome, C. (2001). The records management challenges of amalgamation. Municipal Monitor, June/July: 1-7.
Hospital Canselor Tuanku Muhriz UKM (HCTM). (n.d.). Retrieved from https://www.ppukm.ukm.my/language/en/
Kemoni, H. N., and Wamukoya, J. (2005). Preparing for the Management of Electronic Records at Moi University, Kenya: A case study. African Journal of Library, Archives and Information Science, 10(10), 125-138.
Kemoni, H. N., Ngulube, P., & Stilwell, C. (2007). Public Records and Archives as Tools for Good Governance: Reflections Within the Recordkeeping Scholarly and Practitioner Communities. ESARBICA Journal: Journal of the Eastern and Southern Africa Regional Branch of the International Council on Archives, 26(1). doi:10.4314/esarjo.v26i1.31012
Kemoni, H., & Ngulube, P. (2008). Relationship between Records Management, Public Service Delivery and the Attainment of the United Nations Millennium Development Goals in Kenya. Information Development, 24(4), 296-306. doi:10.1177/0266666908098074
Liakopoulou, M. (2013). Investigating Motivational Factors Influencing Pre-Service Teachers’ Choice of Profession and Their Personal Theories of Teaching and Learning. Multilingual Academic Journal of Education and Social Sciences, 1(1), 101–118.
Making Better Medical Decisions. (2016). Retrieved from https://www.psychologytoday.com/us/blog/modern-medicine/201609/making-better-medical-decisions
Malaysian Medical Council. (2006). Medical Records and Medical Reports, Guideline of The Malaysian Medical Council, MMC Guideline 002/2006
Malykh, V. L., and Rudetskiy, S. V. (2018). Approaches to Medical Decision-Making Based on Big Clinical Data, Journal of Healthcare Engineering, Vol. 2018, Article ID 3917659, 10 pages, 2018. https://doi.org/10.1155/2018/3917659.
Mampe, G., and Kalusopa, P. (2012). Records Management and Service Delivery: The Case of Department of Corporate Services in the Ministry of Health. Journal of the South African Society of Archivists, 45, 2-23.
Marutha, S. N. (2011). Records Management in support of Service Delivery in the Public Health Sector of the Limpopo Province in South Africa (Master of Information Science). University of South Africa. Retrieved from http://uir.unisa.ac.za/bitstream/handle/10500/5737/thesis_marutha_n.pdf?sequence=1
Marutha, N. S. (2017). A framework to embed medical records management into the healthcare service delivery in Limpopo Province of South Africa, PhD Thesis, University of South Africa
Mathioudakis, A., Rousalova, I., Gagnat, A. A., Saad, N., & Hardavella, G. (2016). How to keep good clinical records. Breathe (Sheffield, England), 12(4), 369-373.
Mensah, M. (2011). Organizational commitment of medical records personnel at the Korle-Bu teaching hospital, Unpublished MA dissertation, University of Ghana, Legon.
National Archive Act 2003. (2003). Undang-undang Malaysia Akta 629. Retrieved July, 2018, from: http://www2.arkib.gov.my/borang/Akta_Arkib_Negara_2003.pdf
National Records of Scotland. (2016). Records Management Competency Framework July 2016, (July).
Ngoepe, M. S. (2004). Accountability, Transparency and Good Governance: the National Archives and Records Services of South Africa’s role in helping Government to better Service Delivery to the South Africans. Retrieved from http://www.liasa.org.za/conferences/conferences2004/papers/LIASA_Conference_2004_Ngoepe.pdf
Nooraie, M. (2012). Factors Influencing Strategic Decision-Making Processes. International Journal of Academic Research in Business and Social Sci, 2(7), 405-429.
Northwest Territories. (2002). What is Records Management? Records Management Bulletin, (3), 1-2.
Ohsfeldt, R. L. (2005). Implementation of Hospital Computerized Physician Order Entry Systems in a Rural State: Feasibility and Financial Impact. Journal of the American Medical Informatics Association, 12(1), 20-27. doi:10.1197/jamia.m1553
Ojo, T. (2009). Communication Networking: ICT and Health Information in Africa. Information Development, 22(2), 94-101
Palmer, M. (2000). Records management and accountability versus corruption, fraud and maladministration. Records Management Journal. 10. 61-72. 10.1108/EUM0000000007256
Pfeffer, J., and Sutton, R. I. (2006). Hard Facts, Dangerous Half-truths, and Total Nonsense Profiting from Evidence-Based Management. Boston, MA: Harvard Business School Press.
Pourasghar, F., Malekafzali, H., Kazemi, A. (2008). What they ?ll in today, may not be useful tomorrow: lessons learned from studying medical records at the Womens Hospital in Tabriz, Iran. BMC Public Health 2008;8:139.
Pohlig, C. (2014). Practice economics medical decision-making: Avoid these common coding & documentation mistakes.
Ryan, D. (2010). What is the essence of records management? Records Management Journal, 20(1), 117-123. doi:10.1108/09565691011039889
Sanderson, M., & Ward, S. (2003). Records management mission critical. Library and Information update, October, 1-7. Retrieved December 2, 2018 from www.cilip.org.uk
Shekelle, P. G., Morton, S. C., & Keeler, E. B. (2006). Costs and Benefits of Health Information Technology. doi:10.23970/ahrqepcerta132
Shepherd, E. and Yeo, G. (2003). Managing Records: A Handbook of Principles and Practice. Facet Publishing, London.
Silow-Carrol, S., Edwards, N. J., and Lashbrook, A. (2011). Reducing hospital readmissions: Lessons from top-performing hospitals, Care Management (17)5, 14-31.
Simon Fraser University. (2007). What’s Records Management? Bumaby B.C. Canada.
State of Montana Historical Society. (2002). Performance audit report: State government records management. Legislative audit division: Helena. Retrieved March 8, 2014 from leg.state.mt.us.
Stephenson, C. B. ( 2012). What causes top management teams to make poor strategic decisions?(Doctoral Thesis). Southern Cross University, Lismore, NSW. Retrieved from http://epubs.scu.edu.au/theses/280/
Tale, S., and Alefaio, O. (2011). “Records management in developing countries: challenges and threats – towards a realistic plan”, Association of Commonwealth Archivist and Records Managers. (ACARM) Newsletters, No. 37, available at:
www.acarm.org/documents/issue37/37.6%20Records%20Management%20in%20Developing%20countries%20-% 20challenges%20and%20threats.pdf.
Tagbotor, D. P., Adzido, R. Y., & Agbanu, P. G. (2015). Analysis of Records Management and Organizational Performance. International Journal of Academic Research in Accounting, Finance and Management Sciences, 5(2). doi:10.6007/ijarafms/v5-i2/1557
Tavakoli, N., & Jahanbakhsh, M. (2013). Investigation of retention and destruction process of medical records in the hospitals and codifying appropriate guidelines. Journal of Education and Health Promotion, 2(1), 17. doi:10.4103/2277-9531.112687
Thompson, T. G., and Brailer, D. J. (2004). The Decade of Health Information Technology: Delivering Consumer Centric and Information-rich Health Care. Washington, D.C.: U.S. Department of Health & Human Services
Tola, K., Abebe, H., Gebremariam, Y., & Jikamo, B. (2017). Improving Completeness of Inpatient Medical Records in Menelik II Referral Hospital, Addis Ababa, Ethiopia. Advances in Public Health, 2017, 1-5. doi:10.1155/2017/8389414
Wamukoya, J., and Mutula, S. M. (2005). E-Records Management and Governance in East and Southern Africa. Malaysian Journal of Library and Information Science, 10(2), 67-83.
West, A. F. (2002). Clinical decision-making: coping with uncertainty. Postgraduate Medical Journal, 78(920), 319-321. doi:10.1136/pmj.78.920.319.
Wong, R., Bradley, E. H., & Hopkins, J. (2009). Medicine International, Johns Hopkins University, Baltimore, MD, USA, and Public Health, Yale School of Medicine, New Haven, CT, USA, Developing patient registration and medical records management system in Ethiopia, International Journal for Quality in Health Care; Volume 21, Number 4: pp. 253–258
Zegers, M., De Bruijne, M. C., Spreeuwenberg, P., Wagner, C., Groenewegen, P. P., & Van der Wal, G. (2011). Quality of patient record keeping: an indicator of the quality of care? BMJ Quality & Safety, 20(4), 314-318. doi:10.1136/bmjqs.2009.038976
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). Role of Medical Records Management Practice in Improving Decision Making in University Hospital. International Journal of Academic Research in Business and Social Sciences. 10(11), 1160-1175.
Copyright: © 2020 The Author(s)
Published by HRMARS (www.hrmars.com)
This article is published under the Creative Commons Attribution (CC BY 4.0) license. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this license may be seen at: http://creativecommons.org/licences/by/4.0/legalcode