Medical records management in HUKM Medical Records Department : a case study / Fakhurrazi Ibnu Omar

Medical records growth can be considered as one of the trade off in community
development. Number of new patient register, tell that there are increasing
number of community member, whereas particular cases tendency will show the
pattern and lifestyles of the community. Medical record as individual physical,
mental health valid evidence in presenting his well being, treatment, defect and
the assessment received from medical practitioner. The issue of privacy in
medical records has long been a trademark, even not a patient should know their
own. Medical records not only serve as patient medical history, but will be used
later in many legal related activities such as insurance claim, evidence in court,
as valid evidence in employee leave, benefit claim and exemption. Records
management practice in any field is necessary in pursuance of a good, quality
records keeping. Intention is to provide the records when needed as possible. All
elements in records management give prior attention into all aspect of records
safekeeping- how to measure the growth, the location, to separate into different
group and so on. This study conducted in attempt to documenting the practiced
Medical Records Management in HUKM Medical Records Department. There are
few local content on the subject done by people with medical background
himself. This writing from records management side into medical records
treatment will just add variety into a wide understanding of medical records
management to understand the program in work setting. The scopes are all
patient medical records, specifically the medical records files, element of records
management such as inventory, appraisal and retention, vital records, disaster
planning and recovery, form management, directives management, report
management, active record system, records storage and records disposition
studied and investigated over their practiced. Standard research methodologies
used in gathering the information, such as structured interview, structured
distribution of questionnaires, existing document review. During the study,
observation being made on the working area, storage equipment and the
handling process. Medical has always paid high concern, on keeping safe the
medical records, as it among legal and professional requirement in their field.
Case study HUKM Medical Records Department, presented understanding the
program implementation. Moreover, any additional knowledge hoped to be
harvested, and recorded in this study. From the study it can be concluded HUKM
as parent organization recognized the function of Medical Records Department
as core service supportive element. Medical Records Department itself, seriously
undergone service overhaul timely to increase the service capability, procedure
manner to in line with organization objective. Long waiting time for patient
appointment with doctor that become a critics recently trigger the alarm for
reviewing the element contribute to the matter.