Full Project – Automated medical references system

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CHAPTER ONE

INTRODUCTION

1.0 Introduction

Medical record is used to describe the systematic documentation of a single patient’s medical history and are across time within one particular health care provider’s jurisdiction. The medical record includes a variety of types of notes entered over time by health care professional, recording observations and administration of drugs and therapies. Orders for the administration of drugs and therapies, test result, x-ray report etc.

The maintenance of complete, comprehensive and accurate medical records of patients enables reference of those records easier and it is a fundamental requirement of health care providers and it is generally enforced as a licensing.

Information is common everywhere and human advancement in the technology has helped to develop some machines to aid in processing information computer is used to storing medical reports of patients in the hospitals because it is fast in processing, it can store information for a long time. It allows for quick access to the information for reference purposes which is the aim of this research work.

1.1 Theoretical Background

It has been proved that manual record kept by the Teaching Hospital is full of flaws and errors thereby not allowing for easy referencing. This should be remedied using computer system. The use of computer system will facilitate easy strong and retrieval of record, it will allow health care provider to determine patient’s medical history and provide informed care. It will serve as the central repository for planning patient care and documenting communication among patient and health care providers contributing to the patient’s care.

It will serve as a document to relate, educate medical students/resident physicians to provide data for internal hospital auditing and quality assurance and to provide data for research.

1.2 Statement of the Problem

The problems encountered with the manual system are;

Security: The patient’s record has to be secured, records are meant to be private and not to be seen by unauthorized person.

Space: This is another problem faced, as the number of patient’s grow, the space for filling in the cabinet becomes a problem including rowdiness files under processing.

Fire Outbreak: In case of fire outbreak, the records will be completely burn down to ashes thereby not serving as a reference material again to the hospital.

Time Wasting: The time spent manually searching through thousands of records in the serial system can be eased in carry out other productive activities.

Loss of Records: Apparent loss of medical record is another problem that usually occurs during transit of files from consultation room to other sections.

1.3 Aim and Objectives of the Study

The aim of this work is to change the format of making reference to medical record of a patient by the management.

To make storage of records and retrieval easy
To prevent patient’s medical record from unauthorized access

To keep accurate and correct record of patient for research purpose/references.

1.4 Significance of the Study

The above research work is significant in the following;

Firstly, it makes storing of data easy for future reference and retrieval of files easy. The system developed has the capacity to store large amount of information.

Secondly, it eliminates time wasting thereby allowing assessment of patient files to be easily done. Finally, it helps in the justification of result of treatment carried out by doctors.

1.5 Scope of the Study

This project work is focused on the development of a medical reference system in General Hospital, Iquita, Oron Local Government Area.

Therefore, the scope of the research work is mainly limited to medical reference system with emphasis placed on patient’s record keeping.

1.6 Organization of the Research

The general introduction of the work is embodied in chapter one. It also highlights some usefulness of the new system. Chapter two talks about the literature review and other writer’s opinion of the subject. Chapter three talk about the new system design and methodology. Chapter four talks about the implementation of the new system while chapter five summarizes, concludes and recommends the new system, the project work consists of five chapters.

1.7 Definition of Term

Medical Record: This is the record of treatment and history of patients enclosed in a hospital folder for follow-up treatment of patient, research and medical legal case.

Department: This is a group of staffs in the hospital engaged in performing a particular or single function/relation job.

Data: These are raw and unprocessed fact about an item

Reference: This is a remark that calls attention to something

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