GENERAL INTRODUCTION
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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 necessaryto 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 Hospitalhave 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 witha 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.
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:-
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:-
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.