Saturday, August 22, 2015

Pengurusan Rekod Perubatan Efektif Menjamin Ketepatan Rawatan

Saya kongsikan berita dari Bernama berkenaan kepentingan pengurusan rekod perubatan yang cekap dan teratur. Menurut Bernama, pengurusan rekod perubatan boleh membantu pusat perubatan memberikan khidmat terbaik serta membantu memberi rawatan yang tepat kepada pesakit. Bernama telah mendapatkan ulasan dari pakar-pakar akademik dalam bidang pengurusan rekod di UiTM, antaranya Dr.Irwan, Dr.Azman dan Puan Nik Azliza.


Date: 21-07-2015
Author: Mohd Hisham Abdul Rafar 

    KUALA LUMPUR, July 21 (Bernama) -- The rapid growth of Malaysia's private
healthcare industry and medical tourism calls for more efficient management of
patients' records and documents, said a Universiti Teknologi MARA (UiTM)
    The head of UiTM Puncak Perdana campus' School of Records Management Studies
at the Faculty of Information Management, Dr Irwan Kamaruddin Abd Kadir, said
with the growth in patient numbers, more medical records have to be created and
    Medical records do not only help doctors to prescribe appropriate treatments
but, when updated regularly, they also indicate the patients' current health
status. The information provides for the proper monitoring of the patients'
progress and medicines and treatments prescribed, even if they are examined by
different doctors each time they undergo a medical check-up.

        Irwan Kamaruddin said the rapid growth of the healthcare industry has
necessitated the creation of a new post at hospitals and medical centres - that
of Medical Records Officer.
    "In Malaysia, it is gaining wider acceptance and many hospitals are
creating the post," he told Bernama.     
        He explained that the rise in patient numbers and diversity in diseases
warranted effective and efficient management and classification of records as
they allowed medical personnel to gain access to accurate information and was
time-saving as well. 

    Irwan Kamaruddin said immaculately maintained medical records could also
serve as sources of reference for medical researchers who need full and
comprehensive information.
    "UiTM introduced the Records Management Programme (under the Faculty of
Information Management) to fulfil the requirements of the medical industry in
    "The signing of the memorandum of understanding (MoU) between UiTM and the
National Heart Institute (IJN) in 2014 showed that both the university and the
industry viewed the management of medical records as significant," he said.
    IJN and UiTM had signed the MoU on June 16 last year to encourage the
transfer of technology pertaining to the management of health-related
    Meanwhile, three senior lecturers from UiTM's School of Records Management
Studies concurred with Irwan Kamaruddin's views on the importance of managing
medical records effectively, saying that these records contained all the facts
and information on the patients' medical history. 
    Nik Azliza Nik Ariffin said although patients' records were categorised as
confidential, information contained in these records could be retrieved for the
purpose of carrying out research and administrative work, as well as for the
compilation of health statistics. 

    "Medical practitioners should record the details of all their treatments and
prescriptions in full," said Nik Azliza Nik Ariffin, adding that the patient's
medical record was also recognised by courts as evidence should a doctor or
hospital face a lawsuit.
    Her colleague, Dr Azman Mat Isa said despite the advances made by medical
science, medical practioners and hospitals faced the risk of being dragged to
court for alleged malpractice. 
    "In this context, the patient's medical record comes in handy as it contains
information on the treatments prescribed. Hence, it's a trustworthy source of
information," he said.
       He also said that the effective management of patients' records also
hospitals to run smoothly as the medical personnel have access to accurate and
up-to-date data.
       "The availability of accurate clinical records will allow doctors to make
informed decisions in future," he added,

        Azman also suggested that risk management be incorporated into records
management, saying that such an approach was an effective and holistic way for
hospitals to identify risks and deal with any eventuality.
    Mohd Nizam Yunus, also a senior lecturer, said although most hospitals
already had proper records management practices in place, there was a need to
establish a medium through which all healthcare providers - government and
private hospitals and clinics - could gain access to the information.
        "It comes in useful when, for instance, a patient from a rural area has
to seek medical treatment in the city. Having access to his patient's medical
history will allow the new doctor or specialist to prescribe proper treatment
immediately, instead of doing it on a trial-and-error basis," he explained.
        When systematically organised and maintained, medical records can ensure
optimum care for patients and even help to avert unwanted lawsuits.
    -- BERNAMA

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