Implementation of unit in-patient medical record system in an acute hospital

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Implementation of unit in-patient medical record system in an acute hospital


Author: Chan, Chi-keung
Title: Implementation of unit in-patient medical record system in an acute hospital
Year: 2000
Subject: Medical records -- Management -- China -- Hong Kong
Hong Kong Polytechnic University -- Dissertations
Department: Multi-disciplinary Studies
Dept. of Management
Pages: viii, 119 leaves : ill. ; 30 cm
Language: English
Abstract: Medical record is an essential source of patient health information which assists healthcare professional in delivery of healthcare. According to W. D. Scott Report, in 1980s, the medical record in Hong Kong was ineffective in providing a good record of the patient's treatment at the hospital (Coopers & Lybrand, 1985). Following this, Hospital Authority, after its establishment in 1990, launched the medical record management reform. As one of the major acute hospitals under the management of Hospital Authority, Kwong Wah Hospital implemented the medical record management reform in 1994. The present study has been undertaken to look into the implementation of the medical record management reform in Kwong Wah Hospital. Pre-implementation and post-implementation review of the medical record services were conducted to compare the results of medical record management reform. The results showed that there were significant improvements in the form standardization, integrated documentation, record retrieval and record location after the implementation of the reform. Other medical record services introduced such as the transferring records with patient, delivery of records after patient readmission, filing of forms in pre-defined order and filing of loose sheets in the relevant hospital notes are able to facilitate the efficient, effective and complete access to patient information. Besides, an opinion survey was conducted to evaluate the satisfaction and perceived effectiveness of new record system. Two hundred and fifty-eight healthcare professionals were participated in the opinion survey. All of them were selected through stratified proportionate random sampling in Kwong Wah Hospital. The Pearson correlation matrix showed that the availability of medical record, the usefulness in filing sequence and the satisfaction with the filing sequence of medical record were positively correlated to the perceived quality in continuous patient care by healthcare professionals. However, one unexpected finding was noticed in the survey. The hypothesis that timeliness of medical record was correlated to the perceived quality of continuous patient care was not substantiated. The finding suggests that the healthcare professional opined that medical record assist in the perceived quality in continuous patient care. Recommendations for further improvement on medical record based on the present survey including computerization of record content and revision of the filing sequence of medical record are also discussed. Emphasis should be made that the medical record management reform is not an one-off process. Instead, it should go hand in hand with the clinical advancement and development of information management. It should be stressed that good record system serves as the building block for the future development for the clinical information system (Huffman, 1990).

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