The document discusses developing an electronic patient medical records system. It outlines the objectives of automating medical records management, which include achieving the highest efficiency given limited resources by providing faster, complete, and error-free access to records on demand. The document also describes how a computer network can integrate and link different types of patient records, allowing generation of complex reports from multiple data sources and high availability of records through the world wide web.

1. Developing the Electronic
Patient Medical Records System
(What Hospital Administrators
Should Know)
- Noel D. Lawas MD -

2. Session Objectives
At the end of the session, the participants
should be able to:
• Appreciate the breadth of possibilities in
customizing what the system can do in
support of managing information
• Appreciate the true value of having a fully
functional electronic patient medical
records system
• Describe tools which can be used to
retrieve patient information and perform
analysis

3. How Patient Health Records Are Linked to
Majors Transactions of a Hospital

4. Simple (Manual) Records
Management System
Record Form Reports
Filing Cabinet
• Data written into a record form
• Completed records are filed
• Summary reports produced and printed

5. Activities Associated with the Handling
of Patients Medical Records
Patient Management Medical Records Mgt
• Recordings of Requirements, • Patient Registration
Observations and Services • Daily Patient Census
Given to a patient • Registries
– Patient Consent
– Birth
– Face Sheet – Death
– Admission Record – Admission
– Clinical History and PE – Discharge
Findings
– Laboratory Exam Results • Index
– X-ray Results – Inpatient
– OR and Anesthesia – Operation
– TPR – Disease
– Doctors’ Orders – Physician
– Nurses’ Notes • Hospital Statistics
• Quality Patient Records Mgt

6. Enhancing Simple Records Management
System Through Automation IT Techniques
Data Capture Database Mgt Report
System Generation

7. Objectives of Automating Medical
Records Management System
• Achieve the highest possible efficiency,
given the limitation of resources, in
managing patient records
– Faster service time
– Complete and error-free records
– Always available on demand
– Increase productivity of hospital staffs
– Increase “profit” margin

8. Limitations of Automating Medical
Records Management System
• Cannot take the place of important legal
requirements attached to medical records
• Not ideal for qualitative recordings
• Details of many services/transactions are
voluminous and very seldom used for
management decision-making
• Doctors and nurses have peculiar ways of
describing different types of medical
information

9. Common Techniques in
Automating Data Capture
• Limiting selection of possible entries in a
data field (use of droplist, look-up table, etc.)
• After selecting an entry, related fields are
automatically filled up
• Computation is performed after entering the
needed set of data
• Use of external devices like bar code reader.

10. Notes in Automating Report Generation
• Used in generating regularly needed
reports by management
• Commonly used forms:
– Printed reports
– Web reports
• Features
– Limited to reports requiring straightforward
calculations and data processing
– Requires pre-determined specification of
output information

11. Supercharging Records Management System
Through a Computer Network System
Data Capture
Data Capture
Database Mgt Report
System Generation
Data Capture
Computer Network Environment

12. Advantages of Records Management Under
a Networked Environment
• Integrated system of records management –
physical barriers disappear
• All records within the system can be linked
together. As such, linked records are treated as
one (Eg. Useful in pts’ billing)
• Complex reports needing inputs to different sets
of records are easily generated.
• All records are readily available to management
anytime and anywhere

13. Example of Integration of Records
Management
Charge Slip Charge Slip
(Nursing Srv)
(Pharmacy) Network Server
Charge Slip
Charge Slip
(Laboratory)
(Other Fees)
Charge Slip
(Radiology)

14. Example of Using Linked Records
to Achieve Greater Performance
Registration Admission Diagnostic Exam
Records Records Records
Name Attending MD Date of Exam
HIN Clin Service Name of Exam
Address Bed No. Type of Exam
PhilHealth Initial Dx Exam Fee
Registration Record ~ Admission Record ~ Diagnostic Exam Performed
Name
HIN
Attending MD
Clin Service
Date of Exam
Name of Exam Type of Exam
Exam Fee

15. Example of Complex Reports
Needing Multiple Inputs
Patient
Billing
Statement
Itemized patient’s charges
Accommodation Professional
Charge Slips
Charges Fees

16. Example of Secured High Availability
of Patients Medical Records
(Using the world wide web)