Comparative Analysis of Patient's Records in Manual and Electronic Basis During Consultation

Topics: Electronic medical record, Medical record, Medical history Pages: 19 (5133 words) Published: February 5, 2011

A Research Proposal submitted to
Ms. Bettina Joyce Ilagan
Department of Languages and Mass Communication
College of Arts and Sciences



October 14, 2010
Hospital medical records traditionally have been maintained in bound ring file folders. However, many settings are now utilizing electronic medical records. They can found at nursing stations throughout the hospital. The patient’s name, date of birth, room number, hospital identification number. The top cover of the folder will list any alerts associated with the patient. These alerts might include: name alert (two persons on the same ward with same/similar names), specific drug allergies, infectious disease alert (TB, Hepatitis A, HIV positive), or infection control alert (requires gown, gloves, mask, booties to enter room). The medical record is divided into numerous sections typically including: demographic data, discharge summary, admitting history and physical health and problem, physician progress notes, consultations, pharmacy notes, dietary notes, laboratory, pathology, and x-ray/radiology reports, operative reports, physician orders, and nursing notes. Individual services (e.g., cardiology, pulmonary, Gastro Intestinal) may also have their own sections. All appropriate sections should be reviewed prior to evaluation of the patient so that the patient’s current status may be determined. In most cases, the optometrist will chart within the consultation section of the medical record. Many hospitals will have specific preprinted consultation forms that are to be filled out and placed within the consultation section of the medical record. In other cases, a consultation note may be written in the physicians’ progress note section. Notes from the examination or procedure performed must be kept in the patient’s medical record. A copy (photocopy or carbon) of the examination form should be retained in the physician’s office files. If medications are to be ordered, the optometrist should chart this in the physicians’ orders section. On the other hand, for hospitals to provide high-quality service, they must administer the right treatment in the quickest manner to ensure its ability to save lives. A hospital's information system is what allows them to deliver the highest level of service. Older workflow methods based on hard-wired information systems seemed inefficient by newer standards. Medical staff had to write a patient's life signs and treatment information on paper before entering it into a computer terminal. Not only was this time-consuming, it added steps to the workflow that led to an increase in errors. It was nearly impossible to have on hand the entire history of doctor's orders since some of that information did not exist in electronic format. However, incomplete treatment history was only the tip of the iceberg. Errors in billing and mistaken identities of patients could occur when patients with the same name were admitted or when severely ill patients were moved from one area to another area of the hospital.

As a result, when the factors associated to patient’s records during consultation are identified and acted upon with the use of the two choices which is manual and computer based, there will be a better consultation and medication in hospitals and clinics. Because of this, researchers will be able to motivate themselves and other people in giving importance in this study by identifying the factors associated to patient’s consultation and medication, will it be more convenient with manual or electronic basis through comparative analysis.

Statement of the Problem
This study will aim to compare the Patient’s Records in Manual and Electronic way of storing data...
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