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HSM571 Group 1 Group Project

Health Informatics (Universiti Teknologi MARA)

Studocu is not sponsored or endorsed by any college or university

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FACULTY OF BUSINESS AND MANAGEMENT

BACHELOR OF HEALTH ADMINISTRATION (HONS.)

MANAGEMENT FOR HEALTH RECORD (HSM571)

GROUP PROJECT:
HOSPITAL RECORD MANAGEMENT IN GLENEAGLES HOSPITAL MEDINI JOHOR

BA2354B

NAME STUDENT ID

AHMAD ISHAK BIN CHE MAN 2021112525

MIFZAL FIKRI BIN MAZLAN 2020459432

MUHAMMAD SHUIB BIN BADROL HISHAM 2020960737

MUHAMMAD ZAFIRDAUS BIN ZARAK 2020871782

NUR QURRATU AQILAH BINTI ARIFFIN 2020844078

SITI NUR SOFFEA BINTI MANSOR 2020816836

PREPARED FOR:
MADAM SAADIAH @ JULIANA BINTI SAADUN

DATE OF SUBMISSION:
18TH JUNE 2022

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DECLARATION FORM

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TABLE OF CONTENTS
DECLARATION FORM i
TABLE OF CONTENTS ii
1.0 INTRODUCTION (SOFFEA) 2
1.1 Background of Hospital 2
1.2 Mission and Vision 2
1.3 Core Values 3
2.0 DEPARTMENT OF MEDICAL RECORD (SOFFEA) 4
2.1 Organizational Chart 4
2.2 Operation Hours 4
2.3 Main Function of Department 5
2.4 Service Provided 5
3.0 FUNCTION OF MEDICAL RECORD DEPARTMENT 7
3.1 System Used for Filing (QURRATU) 7
3.1.1 Straight Numeric Filing 7
3.1.2 Advantages 8
3.1.3 Disadvantages 8
3.1.4 Colour Code 9
3.1.5 Filing Control 9
3.2 Folder Used for Filing System (QURRATU) 10
3.2.1 Hanging Folder 10
3.3 Shelves Used for Storing Medical Records (ISHAK) 11
3.4 Security Measures for Medical Record Department 13
(ISHAK)
4.0 SUGGESTIONS FOR MEDICAL RECORD 16
DEPARTMENT 16
4.1 Issues (MIFZAL) 16
4.1.1 Human Errors 17
4.1.1.1 Duplication of Medical Records 17
4.1.1.2 Misplaced 18
4.1.1.3 Labelling 18
4.1.2 Shortage of Staff (SHUIB) 19
4.1.3 Security (SHUIB) 19

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4.1.4 Storing Space (SHUIB) 20

4.2 Suggestions (ALL) 20
4.2.1 Establish Electronic Medical Record (EMR) 21
4.2.2 Training and Requirements 23
4.2.3 Security Control 24
4.2.4 Filing System
5.0 SUMMARY AND CONCLUSION (ZAFIRDAUS) 25
REFERENCES 27

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1. INTRODUCTION
1.1. Background of hospital

Figure 1.0

Gleneagles Hospital Medini Johor (GHMJ) is a private hospital in Malaysia based in

Johor. Gleneagles Hospital Medini Johor (GHMJ) served as a tertiary hospital for the Johor
and Singapore citizen. It is a mere 20-minute drive from Singapore-Tuas checkpoint.
Gleneagles Hospital Medini Johor (GHMJ) is located in the middle of Johor which is right at
the heart of Medini's Lifestyle precinct. This hospital located on an area of 18 aches.
Gleneagles Hospital Medini Johor (GHMJ) is one of the hospitals operated by the Pantai
Holding Sdn Bhd. This hospital starts to operate to public in 2016. This hospital has capacity
300 beds as well as a variety of modern facilities and medical equipment catering to the
needs of every individual patient providing a wide range of medical specialties, diagnostics,
imaging and screening services.

1.2. Mission and vision

Gleneagles Hospital Medini Johor's (GHMJ) mission is to make a difference in people's
lives through excellent patient care. The vision of the hospital is to become the global leader
in value-based integrated healthcare.

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1.3. Core values

Gleneagles Hospital Medini Johor (GHMJ) practice five core value in their hospital
which are patient first, integrity, excellence, empathy and teamwork. First core value is
patient first. They always put their patient’s need first. Gleneagles Hospitals anticipates and
plans for any needs that its patients may have. This is accomplished by keeping their best
interests in mind and striving to provide an unrivalled patient experience. The second core
value is integrity. Gleneagles Hospital Medini Johor (GHMJ) staff always practice doing the
right things. They establish an attitude of professionalism that exceeds industry criteria by
being honest and forthright in all of their dealings. They must always be prepared to do what
is best for their patients in difficult situations. The third core value is excellence. Gleneagles
Hospital Medini Johor (GHMJ) is a leading hospital in continuous improvement and
innovation. They strive for excellence by looking for innovative ways to improve and
enhance healthcare while focusing on safety, quality, and efficiency in their procedures and
services. Next, the core value is empathy. Gleneagles Hospital Medini Johor (GHMJ) ensure
their staff listen to their patients with their heart. They reflect on their own expectations as
they learn about their patient's requirements in order to improve their empathy and
compassion. As a result, they are able to form a warm and genuine bond with their patients
and bringing comfort to their life. The last core value is teamwork. They believe that work in
team is better than work alone. They operate as a team at Gleneagles Hospitals, leveraging
individual skills to provide the best possible care, recovery, and outcome for each patient.
They find their greatest strength in their solidarity and provide hope for a better tomorrow.

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2. DEPARTMENT OF MEDICAL RECORD

2.1. Organizational chart

Manager
Ms. Soo Mun Wai

Medical Record Executive

Puan Hamiza

Medical Record Assistant

Fatin Arina Mohamad Muhamad Azim bin Aina Shamin

Syamil Nazreen Kahirul Hanif bin
binti Zulkifli Omar bin Zainudin
bin Isman Daud

Nurhazwana Nurfiqa Aida Danial Fadhli

binti Taha binti Karim

Figure 2.0

Based on figure 2.1, it shows that Department of Medical Record in Gleneagles Hospital
Medini Johor (GHMJ) consist of ten staff. This department lead by the Manager of Medical
Record Department which is Ms. Soo Mun Wai. Then, Puan Hamiza is a Medical Record
Executive for this department. Lastly, this department have eight Medical Record Assistant.
All the Medical Record Assistance have their own duties. For instance, they will manage all
the medical record of the patient in the Gleneagles Hospital Medini Johor (GHMJ).

2.2. Operation hours

The operating hours for Gleneagles Hospital Medini Johor (GHMJ) and the Department
of Medical Record are not the same. There are slightly different from the for the hospital. The
Department of Medical Records is open to the public Monday through Friday from 8:30 a.m.

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to 5 p.m. It also opens one day in the weekend which is on Saturday. On Saturday, the
Department of Medical Record will open half day than usual which is from 8:30 A.M. until
1:00 P.M. However, the department of medical record will be closed on Sunday and public
holiday.

2.3. Main function of department

Every department in the hospital have their own functions. Every department in the
hospital will work together to ensure the hospital properly managed. Basically, there are four
main function of medical record department. Firstly, the main function of the department is to
keep and maintaining confidential of the patient folder that content all the case note. The
detail of the patient is very important to be keep properly. If the details of the patient leak, the
hospital can be sued, or it will be caused harmed to the patient. Secondly, the main function
of medical record department is retrieved of records. All the medical records of the patient
should be kept in the secure place. Therefore, the staff of medical record need to reclaim all
the medical records that are out from the medical report department. All the medical records
that being taken should be send back to the medical record department for confidential
issues. Thirdly, the main function of medical record department is to do online registration of
vital events of birth and death. The vital events should be registered as soon as possible
within 24 hours. Lastly, the main function of the medical record department is to prepare a
report and statistic for folder delivery time, chart review and medical report completion in
timely manner. The report and statistic of those information is important because it will help
to increase the effectiveness of the department in delivery the medical record to another
department. Other than that, it also can help to detect any file missing in the department. The
statistic also helps to give data on any disease that need to be submit to Ministry of Health.

2.4. Service provided

Medical record department of Gleneagles Hospital Medini Johor (GHMJ) is not only
provided service for their staff, but it also provide service for their customer such as patient,
legal firm and insurance agent. The main service provided in medical record department of
Gleneagles Hospital Medini Johor (GHMJ) is receiving all medical record inclusive death
cases. They will receive all the medical record of the patient from all the clinical department

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in the hospital. All the medical record will be kept in the safe area to avoid leak of
information to others unauthorized person. Next, they also prepare a medical report
application that requested from insurance agent, legal firm and patient. All applicant needs to
fill in information in the application form to apply a medical report. Figure 2.1 shows the
example of form for application of medical report.

Figure 2.1

Then, they also need to complete a coding diagnosis, external causes and procedure
based on ICD-10. The coding is very important for the hospital management and for billing.
Furthermore, the service that provided in department of medical records in Gleneagles
Hospital Medini Johor (GHMJ) is to provide a documentation for notification of infectious
disease. The documentation is very important because the notification of infectious disease
should be submitted to the nearest Communicable Disease Control Unit in Health District
Office for further action. Other than that, they also do cull and disposal of medical record.
The patient with medical record that has not been active after seven years will be disposed.
Lastly, the also keep all the new and old medical certificate books in their department.

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3. FUNCTION OF MEDICAL RECORD DEPARTMENT

3.1. The system used for filing in the department
3.1.1. Straight numeric filing system
Providers can use medical record filing systems to securely store and retrieve
data. Patient-identifiable data is also kept safe by filing systems. The type of health
information system a provider employs is frequently determined by the facility's size, the
number of patients it treats, and the volume of records it maintains. Paper records may be
preferred by smaller facilities that provide specialized care to fewer patients, whereas
electronic records may be preferred by larger organizations with multiple departments
and locations.
In Gleneagles Hospital Medini Johor (GHMJ), their Medical Record Department
is using manual instead of automated system. However, the registration of patients as
well as the movement of the medical records are using their computer system that named
CerebralPlus. Currently, Gleneagles Hospital Medini Johor (GHMJ) is using the numeric
filing system which is straight numeric filing (or consecutive filing system) . The term
"straight numeric filing" refers to the filing of medical records in accurate ascending
order by number. As a result, all of the numbered records on the filing shelves would be
in ascending order at the same time (Aurosiksha).

Figure 3.0

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3.1.2. Advantages
The ease with which personnel can be trained to use this type of filing system is
perhaps its most significant advantage. Besides, unauthorized personnel are unable to
retrieve patient records by name. Therefore, this system is making them more secure (a
patient number must be known). It is indeed uncomplicated to retrieve consecutive
records for research or purging, for inactive storage. Last but not least, files can easily be
expanded to add more file space at the end of the file

3.1.3. Disadvantages
However, there are some drawbacks to this method of filing. When filing a record, a
staff member must consider all digits of the record number at the same time, making it
easy to make a mistake. The more digits that must be remembered when filing, the more
likely there is to be an error. Furthermore, because activity in the file area focuses on the
section with the highest consecutive numbers (the most recent patient records will be
filed in that section), workflow issues will arise from time to time. Moreover, when
multiple employees file records, workspace is limited because they must usually file in
the same section.

Figure 3.1

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3.1.4. Colour code

Gleneagles Hospital Medini Johor (GHMJ) also use the colour code in their
Medical Record Department. As mentioned by Puan Hamizah, Medical Record Officer,
colour code can help the staff to find the medical records easily. Examples, number four
is labelled in blue colour, five is in brown colour and six is in light-green colour. In
addition, at the department also has colour code for years (2015 until 2024). Therefore,
the staff-on-duty will patch the sticker with the colour code for year at the bottom side of
the file. Apart from that, they also have colour code for some cases which are PAEDS
(grey), psychiatric (cream) and obstetrics (pink).

Figure 3.2

3.1.5. Filing control

Like the other hospital’s Medical Record Department, Gleneagles Hospital Medini
Johor (GHMJ) also has a form that called as Request For Medical Records. This form
needs to be filled up by the staff who wants to take-out the folders from the shelves. It is
essential to do so because whenever the folders are out from the shelves, it should be
acknowledged by the superior and to keep track of the movement of records in and out of
the file area, and to account for each record that is removed.

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Only health information department and facility staff trained to use the file system
are authorized to file and retrieve records, and facilities establish policies and procedures
to address patient record maintenance and management issues. Policies are established in
facilities to:
1. Establish a procedure for moving a patient's record from one area of care to
another.
2. Determine who has the authority to request a record from the file area.
3. Indicate the length of time the record can be removed.

Figure 3.3

3.2. Folder used for filing system

3.2.1. Hanging folder
Medical Record Department in Gleneagles Hospital Medini Johor (GHMJ) chooses
the hanging folder method since the establishment of the company in 2015. The
department which is located in the right-wing of the main building is now in the
evacuation process to move to the new floor in Specialist Centre Complex (SCC) on level

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14. From internal information received, the evacuation has been a going process for two
months and is expected to be fully operationalized in August 2022.
From the insight shared by Gleneagles Hospital Medini Johor (GHMJ)
representative, Puan Hamiza, during this academic visit. The department has benefited
from this particular folder system. She preferred this hanging folder system because it is
an easier way to search patient records. 3 conventional methods usually used in Malaysia
hospital is compactor and open shelf-system. Puan Hamiza shares her opinion that a
compactor system usually will cause disorganization. Meanwhile, open shelf-system will
take much greater space. In real world scenario, hospitals really factor in the amount of
space used to store the medical records. Here we can conclude that Gleneagles Hospital
Medini Johor (GHMJ) chose the hanging folder system due to storage factors and
organization can be benefited from this system.
Like every other thing, it serve the pros and cons respectively. One of the
disadvantages of this hanging folder system is folders that are too big have the tendency
to fall down. However, it is still manageable and only happens in certain occasion.

Figure 3.4

3.3. Shelves used for storing medical records

Gleneagles Hospital Medini Johor (GHMJ) shelves system still utilized the traditional
system to store patient’s medical record. This means that GHMJ have to use maximize space
to safekeep all patient’s medical record in existence currently and sort medical record in its

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designated coded file numbering. The utilization of space or maximum space usage is in
place due to medical record office accordance to project its space usage with patient’s
admission ratio, it provides intel of how many medical records are to be keep or transfer
according to patients ward admission or department or hospital transfer.
Furthermore, the selection of the shelves itself is to optimize the limitation of space and
easier lookup section means shorter time for searching the record itself. Next, the open shelf
system means the stored records can be monitored for easy lookup and count for available
space left. Also, while this open shelf system benefits the medical record officer to detect
defective records or detect records that were infested by pests. While the selection of this
shelf system left with better option of minimum space GHMJ has overcome this obstacle by
choosing a metal material for the shelf to avoid termite or pest’s invasion.

Figure 3.5

Next, on figure 3.5 shows the shelf itself are only present as a frame shelf without any
walls, this means the shelf number and rack number does not being display upfront for
general staff to see besides the management instructions for medical records office to
locate the files is simply by observing the labelling records have on its side to easier
locate. The stickers attached will be the main indicator for file location for staffs to pick

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up required medical records. An addition to that, the method for storing records is by
hanging with clip. This method limits the weight and size of file created for each record
by no more than two-inch file size. Unfortunately, we fail to identify the optimization of
such method in use other than the GHMJ usually refer patients to other hospital
specialist, or most patients has short ward duration or stay.
Shelf organization and localization procedure:
1. Since the medical record used straight numbering system, the first two digits will be
the hospital code, GHMJ for example will be 24. (refer figure 3.6)
2. Follow by the patient’s Medical Record Number (MRN), example; 24-109891 (refer
figure 3.7)
3. The localization of medical records will be according to above structure, first hospital
referral number and colour code.
4. According to above structure, after locating the hospital code staff will proceed with
patient’s MRN and colour code

Figure 3.6 Figure 3.7

3.4. Security measures for medical record department

Security used in Gleneagles Hospital Medini Johor (GHMJ) is standardized as any
other hospitals such as luggage, trolley, and briefcase. The main purpose of security of

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medical records is to ensure security of transferring medical records to other department

or any requested personnel in secure form. Second, is to ensure patient’s privacy is
upkeep to the mandated law that require any healthcare services to ensure complete
patient’s privacy protection against any malicious activity or any potential leakage
information.
First item into account is briefcase, the briefcase is mainly used in transporting few
medical records to requested personnel in secured manner. This type of document
transportation provide versatility but will increase chance suspicion of being prey over
information criminal act due to its overly exposed to every open potential snatching area.
Second, is the luggage. While briefcase main function to transfer requested records to
designated place or personnel the luggage on the other hands while bring the same
purpose but it different in quantity and provide better security to transport documents and
records in large volume. Luggage while huge in size gives better security due to its size
and weight and has better potential to reduce theft and lost documents or records. Lastly,
the trolley used in GHM are considered fortified carrier to transport documents and
medical records to requested department or personnel. It also serves the same purpose as
the other carrier but trolley is used mainly to transport high volume of medical records
and potentially highly valuable patient’s record.
Next, since medical record office is filled with papers and electronic devices this pose
a fire hazard that can be accidentally spark fire and potentially destroy the medical record
itself and further collapse the healthcare system itself that built to support the governing
working system. The figure 3.12 shows that the medical record emergency escape plan,
this is to inform the staff of safe and quick-fire escape from the building. With escape
plan layout in place the safe facility is not complete especially for vital department to
have a fire-resistant door to hold the fire from spread further damaging property and all
documents quickly. The medical record department also equipped with installation of
surveillance cameras to monitor hospital everyday activity this is to ensure no criminal or
malicious act are condone in the hospital especially regarding patient’s medical record
that will raising an alarm when there is a missing record or suspicious activity detected
during absence of people in the area.

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Figure 3.8 Figure 3.9

Figure 3.10 Figure 3.11

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Figure 3.12

4. SUGGESTIONS FOR MEDICAL RECORD DEPARTMENT

4.1. Issues
It is essential for a department of medical records department to accurately document
patient care and related information. Because keeping accurate medical records will aid
in the scientific evaluation of their patient profiles, analysis of treatment outcomes, and
planning of treatment protocols (Thomas, 2009). If the medical reporting department does
not properly manage medical records, sloppy and careless services will result. Therefore,
it is crucial that the department of medical records to manages it properly. As a result of
our analysis of Gleneagles Hospital Medini Johor (GHMJ), we have identified a number
of issues with the hospital, including the following:

4.1.1. HUMAN ERROR

When a medical record assistant or manager deviates from regular operating
procedure or makes a recording error, the consequences might be avoided if the error is
immediately discovered and corrected. However, if an error goes unreported, the
resulting costs can be significant. Even a minor error might result in the rejection of an
entire batch, which wastes material, manufacturing resources, and staff time. This process
started early especially during the registration process of the patient at the emergency

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department. The officer usually acts fast, as they need to handle the patient. At the same
time, need to treat and record the necessary information such as the cause of the patient
admission. No matter how many checks and inspections are implemented, humans are
prone to concentration gaps and committing errors. Errors that occur either do or do not
harm patients and reflect numerous problems in the system.

4.1.1.1. Duplication of medical record

As a result of patient identification mistakes, duplicate medical records and
overlays are created. A duplicate medical record is created when a single patient has
multiple medical records. Frequently, duplicate medical records are simply partial
duplicates that contain a subset of a patient's medical history. When one patient's
record is overwritten with data from another patient's record, generating a combined,
erroneous record, this is known as an overlay. For instance, every five years,
foreigners must renew their passports. Therefore, when a person becomes a patient at
this hospital, their passport number will also change. Additionally, they may forget
that they have previously visited this hospital. This may result in duplicate patient
information when they reappear. This is serious as a health record should have a
history of illness and treatment that the patient has received. Furthermore, another
major cause of medical record duplication problems is inconsistent naming practices.
For instance, a single patient may be listed as Muhammad, Mohd, or Muhd. Although
the pronunciation is similar, the spelling is distinct. When multiple patients share the
same name and other identifying information, patient identification becomes even
more challenging. In such situations, the possibility of overlays can be especially
high.

4.1.1.2. Misplaced
Misplaced of health record information is still a problem that haunts health
information management. This error occurs frequently since new employees and
interns often perform tasks without direct supervision from a supervisor. This makes
it simple to lose track of the document. This wastes a great deal of time and effort.

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Moreover, if a person is prone to forgetfulness due to factors such as age, personal

health, or self-neglect, this error is likely to occur frequently.

4.1.1.3. Labelling
Simple mistakes, like misspelling a patient's name, mistyping their Social
Security Number, or using inconsistent acronyms or abbreviations can easily create
duplicate medical records for a single patient, or merge multiple records together,
resulting in impartial and inconsistent medical histories and information. For instance,
sometimes Gleneagles Hospital Medini Johor (GHMJ), receives a large number of
hospital admissions, requiring staff to work faster during the registration process to
ensure that all records can be kept and recorded. However, there are times when staff
members incorrectly record patient admission records and the date of hospital
admission. Then, when there is a shift change, there may be information that requires
clarification from previous employees, which may result in the record not being
written as accurately as the patient's illness and treatment. Thus, a well-written
medical record can help to protect a surgeon and the institution from allegations of
negligence in the event of operative complications. It is important that the following
data set is written accurately to avoid this kind of human error.

4.1.2. Shortage of staff

Record Management practices are not prioritized in organizations, and
records are typically managed by personnel with very limited experience or expertise
in managing records. Mere branding of health policies without improving what
constitutes the health system such as manpower capacity and quality as well as staff-
patients ratio will be wasteful efforts. In peninsular Malaysia, recruitment must be
conducted in accordance with the Employment Act of 1955, which regulates the
relationship between employers and employees in the private sector. It contains
provisions regarding employee rights and minimum employment standards. The Act
protects non-manual workers whose monthly wages do not exceed RM2,000 and
manual workers with no salary cap (Employment Act).

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It is quite difficult for management to hire employees because it must adhere

to recruitment conditions that restrict the hiring of less qualified candidates.
Furthermore, the number of employees in hospitals is decreasing, resulting in less
assistance to manage health records for an ever-growing patient population. These
factors contribute to several problems that hinder the department's productivity.
Among them is the fact that the employee shortage causes existing employees to
become fatigued due to an increasing workload, and this issue cannot be resolved
within the allotted time frame. Then, there are employees who are required to work
overtime, particularly health records officers who must oversee the work of their
subordinates. For effective and efficient management of hospital records, hospitals
need records personnel with the necessary skills to manage the records created in the
course of their business.

4.1.3. Security
Data security is any preventive measure that aids in safeguarding and protecting
data. The goal of data security for healthcare operations is to develop an effective and
efficient plan to ensure the maximum security of their data and patient data. In order to
protect patient privacy and comply with HIPAA-mandated regulations, the healthcare
industry must ensure data security. However, the lack of security in this section of the
hospital's medical records creates a very high risk of medical record loss; only locked
doors serve as access to this department. This will increase the likelihood that medical
records will be stolen or lost. Then, in the event of a theft, it is difficult to obtain evidence
because the storage room lacks sufficient CCTV to monitor the entire department. In
addition, even though the department is equipped with a Pyro shield fire extinguishing
system, the medical record document area will be exposed to water in the event of
flooding because the filling rack is in the open position, resulting in the destruction of
medical records.

4.1.4. Storing space

Most of the records service's responsibilities will involve patient case notes and
related series, such as admission and discharge records. Case note files are created when

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new patients are registered, as explained in by the officer. Therefore, it is appropriate for
the records service to have responsibility for patient registration, or at least a close
working relationship with reception and registration personnel. Patient case notes are
likely to occupy most of the available space in the record storage areas. However, it looks
like the space provided by the hospital is not sufficient and not according to the suitable
requirement by HIPAA and WHO in medical records manuals

4.2. Suggestions
A hospital's medical records department is essential to the present and future care of its
patients. They are used for the management and planning of health care facilities and
services, for medical research, and for the production of health care statistics (Thomas,
2009). Thus, after conducting an analysis on issues that being stated above, we have
discussed and provided suggestion for Gleneagles Hospital Medini Johor (GHMJ) Medical
record department are as following:

4.2.1. Establish electronic medical record (EMR)

As we all know, human error is a natural occurrence that cannot be avoided. And
hence, the use of paper-based records will result in a number of disadvantages for the
health records department, including a lack of storage space, security concerns,
susceptibility to damage, transporting documents, editing issues, environmental damage,
and high costs. Consequently, in order to improve the medical record recording system,
the medical records department must create Electronic Medical Records (EMR) as a new
method for recording their medical reports. In the modern era, everything has become
electronic and digital, and the medical records department in this hospital should use
Electronic Medical Records (EMR) because it will result in numerous benefits for their
department, including:
• Providing accurate, current, and comprehensive patient information at the
point of care.
• Enabling rapid access to patient records to improve care coordination and
efficiency.

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• Reducing costs by decreasing paperwork, improving safety, reducing testing

duplication, and enhancing health.
• Enhancing patient data privacy and security.
• Conserving storage space.

4.2.2. Training and requirements

Hospitals deal with their patients' lives and health. Good medical care requires
well-trained physicians and nurses, same goes to the medical record officer. Without
accurate, comprehensive, up-to-date, and accessible medical records, medical
personnel may not be able to provide the most effective treatment or may
misdiagnose a condition, which can have severe consequences. Due to the
increasing documentation burden in the health records department, the department
must hire additional personnel. The demand for skilled individuals who can locate
medical records is rising. Officer of health records must be extremely attentive to
detail, proficient with computer systems and technology, and well-versed in general
medical concepts and terminology.
All employees are responsible for the effective management of records,
including the documentation of all decisions and actions; the effective maintenance
of records throughout their lifecycle, including access, tracking, and storage; and the
timely review and disposal of records, which may include transfer to an archive for
permanent preservation, confidential destruction, or recycling. It is recommended
that the following professional skills and competencies be possessed by the records
manager:
• An ability to apply and adapt records management standards and best practice
effectively in the organization’s context.
• An understanding and ability to establish various records management tools
and techniques.
• A good understanding of records management software applications and their
use.

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• Experience with or knowledge of other organizations’ records management

systems.

A skilled workforce is essential to the success of any organization. Without

daily high-performing employees, the organization will disintegrate and fail.
Implementing an effective recruiting and training process is the key to having
competent employees. Successful recruiting techniques concentrate on identifying
qualified candidates, whereas successful training techniques consist of providing
as much guidance as possible to new employees before allowing them to dive into
their positions.
An organization's qualified records management personnel ensures that
records management tasks are performed efficiently. Employees must be equipped
with the knowledge and abilities necessary to create and maintain the records
management program. The required knowledge should encompass all aspects of
records management. If health care and decisions are to be enhanced, the
knowledge and expertise of healthcare providers and their contributions to the
creation, use, maintenance, and preservation of records cannot be understated.
The following knowledge and abilities are required of personnel responsible for
dealing with recordkeeping:
• A solid grasp of records management issues and best practices, as well as their
relevance to the organization.
• The ability to adapt to and support others in the development and
implementation of new recordkeeping practices and procedures.
• A capacity to assess current recordkeeping systems and provide feedback to
the records manager on their strengths and areas for improvement.
• A capacity to communicate effectively at all levels of the organization.
• A capacity to identify potential issues related to records management and
communicate them to the appropriate staff.
• Enthusiasm and a proactive approach to improving recordkeeping practices.
• A good understanding of the regulatory environment in which they operate.
• The ability to contribute to the development and implementation of new
records management systems and solutions.

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• An understanding of how good records management can lead to improved

business efficiency and working practices, in addition to other organizational
benefits.
• Able to apply records management principles and practices to own work role
and the work of others.
• Able to monitor and provide feedback on compliance with policies and
procedures.
• Knowledge of different types of risk in relation to recordkeeping.
• The ability to work under pressure and to deadlines.
• Accuracy and attention to detail.
• Problem-solving skills.
• Knowledge of information, advice, and guidance sources.

4.2.3. Security control

Security controls are all essential components of medical records
management systems when it comes to preventing, detecting, denying, or otherwise
minimizing malicious attacks and other threats. Information must be protected by a
comprehensive set of security controls that addresses computer security, physical
security, and personnel security. The medical records department of this hospital
collects, utilizes, and stores clinical and individual patient data. Thus, this
department are more prone to data leaks and privacy and security breaches than
another department. They must therefore pay more attention to safety issues in
accordance with applicable medical rules, regulations, and laws. The medical
records department at Gleneagles Hospital Medini Johor (GHMJ) can strengthen
their security measures by implementing physical security controls.
• Physical security controls

After identifying the problems in the medical department of this hospital, it

is necessary to increase the physical security by increasing the number of
surveillance cameras (CCTV) and the storage of medical records. This is due to the
fact that, in the event of a data breach or theft, it will be simple to obtain evidence
and determine which documents are missing. If CCTV is installed in every

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significant area of the department, monitoring can be performed more frequently.

Furthermore, after identifying problems in this hospital's medical record department,
it is necessary to increase physical security by increasing the number of surveillance
cameras and medical record keeping. This is because, in the event of a data breach
or theft, it is simple to obtain evidence and determine which documents are missing
and monitoring can be done more frequently if CCTV is installed in every critical
area of the department. Furthermore, the entrance used is only a locked door, so the
risk of theft and misuse of documents is very high; therefore, to prevent this from
happening, they must tighten the physical security aspect to enter the room. This can
be accomplished by enhancing existing physical security measures such as security
guards, photo ID scanners, locked and deadbolted steel doors, and biometrics such
as fingerprint, voice, face, iris and handwriting. With the improvement by using
physical security, it will help them to overcome any problems of theft and abuse will
occur and the risk can be reduced.

4.2.4. Filling system

In many developing countries, where medical records typically span from birth to
death, a great deal of storage space will be required. The hospital administration must
provide adequate storage space for medical records and a suitable workspace for medical
record personnel. The staff of the Medical Record Department must protect medical
records from alteration, loss, and unauthorized use. They are responsible for ensuring that
the patient's right to privacy and the confidentiality of medical record information are
always protected. There must be ample space for filing medical records, and the filing
area should be clean, organized, and well-lit. The file area should include desks for
medical record clerks to sort medical records and create tracers, as well as space for
documents awaiting filing or completion. It is easy to calculate the amount of space
required for medical record flies:
• Measure one full shelf.
• Count the number of flies on the shelf.
• Calculate the number of files per linear metre.
• Count the number of new flies created last year.

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• Calculate the number of linear metres required per year.

• You can then calculate the number of linear metres required for one, five or 10
years.

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5. SUMMARY
In summary, the Department of Medical Record ensures that the medical report is
complete and up to date. The assurance that all patient records are preserved in an orderly
manner. This also results in a consistent growth in medical records; they guarantee that
the facility or storage is always updated to ensure that papers are not overlooked or
stolen. All records taken from the storage facility must be informed and recorded by the
person in charge. Patient records must be handled to ensure that patients are adequately
treated and that diagnostic errors are avoided. Furthermore, medical records must follow
a strict set of criteria in order to be compliant with the most recent regulations and
records.
The patient's records are private and protected. As a result of the information
breach, the others who are not eligible to investigate it will be one of the offenders. The
Department of Medical Controls manages patient data throughout their life cycle, from
manufacturing through reception, maintenance, and disposal. Without rapid and simple
access to health information that has the potential to save or alter lives, mismanaged
health data poses a significant danger. A lack of structure in terms of recordkeeping may
potentially pose a legal risk. Furthermore, patients might see the lack of organization and
policy as an indicator that Gleneagles Hospital Medini Johor (GHMJ) has fallen behind
the times, since workers are always straining to find products.
Medical record keeping has evolved into a science of itself. This will be the only
way for the doctor to prove that the treatment was carried out properly. Moreover, it will
also be of immense help in the scientific evaluation and review of patient management
issues. Medical records form an important part of the management of a patient (Thomas,
2009).
If a medical record assistant or manager deviates from standard operating
procedure or makes a recording error due to human error, the repercussions may be
avoided if the problem is quickly detected and addressed. However, if an error is not
disclosed, the consequences might be severe. Even tiny mistakes might lead to the
rejection of an entire batch, wasting material, manufacturing resources, and staff time.
In the information-intensive health care business, patient records are the key data
store. Although clinical information is increasingly likely to be automated, the paper

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record remains the current, dominating mechanism for documenting patient care data.
However, Gleneagles Hospital Medini Johor (GHMJ) continues to use paper-based
medical records. Paper records offer the benefits of being known to users and portable
when not too large, they can be easily browsed through. However, paper records have
significant limitations that frequently irritate consumers and promote inefficiencies in the
health care system. Furthermore, as the health-care system gets more sophisticated, the
impact of these restrictions grows. The paper record no longer meets the needs of modern
patient care.
Quality improvement and cost containment continue to be major concerns for the
health care industry. Quality assurance utilization management; appropriateness,
effectiveness, and outcomes assessment; clinical practice guidelines and value purchasing
are all prominent responses to the quality or cost challenges faced by present-day health
care. Each of these initiatives increases the legitimate demand for complete, accurate,
readily accessible patient data (Dick, Steen and Detmer, 1997).
Besides, management of medical records is essential for the practitioner and
patients. It makes a difference especially between life and death situations. Unfortunately,
medical record maintenance s not seen as a crucial or important jo in some medical
facilities. As such, they do not build an efficient and compliant policy through training or
structure, which then affects the productivity and credibility of these medical facilities
and its practitioners.
Lastly, the research found that from the other Hospital about the breach of the
medical records can put the patients in danger. Due to software vulnerabilities, security
failures, and human error, these databases are sometimes accessed by unauthorized users.
This leads to the exposure of sensitive data in the form of data breaches. Sometimes,
insider attackers cause damage to protected health information, which results in the loss,
theft, or disclosure of sensitive healthcare data. The price of a complete record file of a
single patient can be hundreds of dollars on the dark web. In comparison to other data
industries, the healthcare industry is among the worst affected (Seh et al., 2020).

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Dick, R., Steen, E. and Detmer, D., 1997. The computer-based patient record. Washington, D.C.:
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