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DESIGN AND IMPLEMENTATION OF AN AUTOMATED PATIENT RECORD SYSTEM

CHAPTER ONE

INTRODUCTION

1.1 Introduction

Granting patients the statutory right to have access to their medical records is relatively recent, having its foundation in the access to health records act 1990 which came into force on 1st November, 1991 As a result of this act, subject to certain safeguards, patients were allowed to see their own manual health records made after this date and earlier records if they were necessary to understand the later ones.

A patient record, health record is a systematic documentation of a patient individual medical history and care. The term ‘medical record’ is used both for the physical folder each individual patient and for the body of information each comprises, the total of each patient health history. Patient records are intensely personal document and there many ethical and legal issues surrounding them such as the degree of third-party access and appropriate storage and disposal.

General Automation plays an important role in the global economy and in daily experience. The Patient Information Management System (PIMS) is an automated system that is used that is used to manage patient information and its administration. It is meant to provide the Administration and staff, with information in real-time to make their work more interesting and less stressing.

1.1     BACKGROUND OF STUDY

The scope of the service in Delhatu Specialist Hospital, Lafia is basically curative and preventive and is offered in clinic unit X-ray/ultra sound, laboratory and dental unit in the hospital. Other services include admission (ward) inpatient where drugs are issued, physiotherapy and family planning.

The hospital others 24 hours services to its staff and the entire population. The records of patients in Dalhatu Specialist Hospital have over time been run down due to large number of patients. This led to poor record keeping since it’s a paper based system.

Reason why the current system used is manual has led to a variety of problems and these include; unnecessary duplication of the data especially for inpatients and outpatients, inconsistence, may occur since data is held more, that ones and it’s hard to analyse the data hence difficult to trace the flow of patient past medication data. There are several department in the new extension of Dalhatu Specialist Hospital which include medicine, surgery, psychiatry, public health, ear, nose, eyes and throat, casualty, obstetrics and gynecology among others.

Patient record and disease pattern documentation is concerned with documentation of information obtained from patients and their particular health system in order to function properly. If this information is not documented perfectly, causing some data to get misplaced, the health system will not be efficient. The inpatient record using a computerized database  system with a secure procedure for accessing if one of the unit of the std/aids control progam (STD/HCP) a server doctor at consultant level who is assisted by 3 doctors, a secretary, 5 medical assistance, 7 nurses, trained consolers and part-time statisticians and 2 laboratory technologist head of unit. The various disease managed at the unit include the following:- syphilis, molluscus, scabies, public lice, gonorrhea, trichomoiasis, gentle mart etc.

Patient information past and present is extremely vital in the provision of patient’s care which guides the physicians in the making of right decision about the diagnosis.

1.2     OBJECTIVE OF STUDY

Several possible advantages to automated patient medical records over paper record have been proposed. But there is a debate about the degree to which these are achieved in practice. Because of the relevance of project to Dalhatu Specialist Hospital later the following are the objective of this project.

a.      Improve quality of care:- The implementation of patient medical record can help lessen the patient sufferance due to medical error and the inability to analysis to access quality. The automated medical records are claim to help reduce medical by providing the health care workers with decision support.

b.     Record keeping and mobility:- Automated patient record has the advantage of being able to connect too many electronics medical records system.

c.      Promote evidence based medicine:- Automated patient medical records provide access to unprecedented amount of hospital and clinical date for research that can accelerate the level of knowledge of effective medical practices. These benefit may be realistic sense only of the automated medical  records are interoperable and wide spread so that various system can easily share information.

d.     To provide useful and flexible program that will add value existing system in Dalhatu Specialist Hospital Lafia.

e.      To automate the processes and report base on information entered that can reduce the work load you can expect to run the medical processes in a non-computerized environment.

1.3     SCOPE OF STUDY

This project work, design and implementation of an automated patient medical record is limited to Dalhatu Specialist Hospital Lafia. This became necessary because it will be easy to me to present a comprehensive software only if it is confirm to limited area.

1.5     LIMITATION OF THE STUDY

The basic challenges and limitation I encountered during this project work, design and implementation of automated patient medical record, A case study of Dalhatu Specialist Hospital Lafia are:-  

ü Time constraint:- Due to the nature of work in the hospital, was unable to me with the medical doctor, because he is very busy, and he don’t keep up to appointment. It is also stressful for my project supervisor, because she is always busy during examination period.

ü Lack of text book:- The lack of text book and a standard library also contribution to challenges I face during this project work, due to high cost of transportation, browser (going for research) online which is also money.

ü Virus:- Virus can affect computer system, which can lead to the lost of the project materials.

1.4     SIGNIFICANCE OF STUDY

The automated medical record is of a great impotence, considering the information compliment existing surveillance programs by accessing the large majority of episode illness for which no etiologist agents are identify. Additional significant includes:-

a.      Sensitivity, Uniformity and efficiency, since detection of event do not depend on clinicians to actively report diagnosis.

b.     Timeliness, the data are available within a day of clinical event.

c.      Ease of information into automated surveillance system. These features facilitate early detection of condition of public health importance including regularly occurrence, such as bioterrorist attack that first manifest as respiratory symptoms.

1.6     DEFINITION AND TERMS      

Computerization: This is to control and process data by the use of computer. It help to spore problems and solution easier.

Hospital:- Is define as the entity that provides the medical services to the patient in questioned of a given period of time which is basically curative and preventive and is offered in clinic unit X-ray/ultra sound, laboratory and dental unit in the hospital.

Patient Record Management System:- It is a system that can manage multiple administrators and can have the track of the right assigned to them. It makes sure that all the administrators functions with the system as per the right assigned to them and they can get their work done in efficient manner.

Medical Form:- Is refers to the medical document describing the patient initials, diagnoses and treatment of particular patient in question that can be used for future reference in case of no improvement on the health condition of the patient hence the changes can be carried out accordingly.

Consultation Fee:- is the money paid by the patient in question at the receptionist desk before any medical attention.

Order and prescriptions:- Written orders by a medical provider are included in a medical record. These details the instructions given to other numbers of the health care team.

Test result:- The result at testing such a blood test (complete blood count). Radiology (X-ray), pathology (biopsy result), or specialized testing (pulmonary function testing) are included.

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