SESSION 1:

NMT 04210: Basics of Health Information Management

5.2.1.Describe methods of keeping records related to
health
Prerequisite modules :
 Basic Computer Application
 Resources Needed:
 Flip charts, marker pens, and masking tape
 Black/white board and chalk/whiteboard markers
 LCD Projector and computer
 Note Book and Pen
Learning Tasks

 By the end of this session a learner is expected to be

able to:
1. Define health record
2. Differentiate between manual and electronic methods
of record keeping
3. Explain factors influencing choice of method of
record keeping
4. List advantages and disadvantages of manual and
electronic record keeping
What is health record?
 Health records is a collection of clinical information
pertaining to a patient's physical and mental health,
compiled from different sources.
 Health records contain demographic data and next of
kin details
Medical history includes

 Examinations; diagnoses; treatment (including surgical

procedures and drug therapy); Results of investigations
labs (e.g. biochemistry, haematology, pathology),
 Imaging (e.g., plain films, scans)
 Alerts and warnings (e.g., allergies, blood group, drugs,
 Record of preventative measures (immunisations,
screenings breast, and cervical, faecal)
 Nursing records
 Clinical correspondence and referrals for treatment
 Consent forms for surgical procedures; theatre reports
 Discharge letters
 Post-mortem reports
 How many methods of record keeping
There are two types of keeping medical record which are
 Manual methods of record keeping
 Electronic methods of record keeping
 Differentiate Between Manual and Electronic Methods
Of Record Keeping
Manual record keeping

• It tells the story of the patient relationship with the

healthcare facility
• A notebook or binder kept in a central location such as
nurses’ station or main administrative offices
• Some of the forms may be kept in patients record at his or
her bedside for convenience
• The manual health record documents;- assessment data,
care plans treatment outcome and patient’s daily progress.
• Care providers enter information by hand in ink at
frequent intervals.
Electronic record keeping

 The electronic medical record is a complex

computer network that uses a medical
information system for storing, processing
and transmitting patient data.
 This network is a series of terminal attached
to central computer that handle the actual
storing and processing of information
 The terminal consisting of a monitor and
keyboards is located in every nursing care
unit and offices.
 Other systems may use laptop computer and the
patient’s room
 It also record assessment data, plans and nursing
information about the patient’s conditions and response
Question

Outline Factors influencing choice of method of record

keeping
 The simplicity of the method for keeping record
 The safety of the method in record keeping
 Cost effective of the method in record keeping
 Knowledge and skills of the health providers
 Accessibility of the methods
 Amount of information to be stored
Group Question

What are the Advantages and Disadvantages of Manual

Record Keeping?
i. Advantages of Manual Record Keeping

 Correcting entries may be easier

 Data loss is less of a risk, particularly if records are
stored in a fire-proof environment
 Less expensive to set ie piece of paper ,pen etc
 The process is simplified as you don't need to be
familiar with how accounting software calculates and
treats your information
 Data loss is less of a risk, particularly if records are
stored in a fire-proof environment.
 Problems with duplicate copies of the same records are
generally avoided.
 In handwritten hospital charts, doctors and nurses
other health care practitioners may write what they
think and they feel based on their personal observations
in their very own words
ii. Disadvantages of Manual Record Keeping

 Handwritten records are subject to lots of human errors

due to misspelling, illegibility, and differing
terminologies
 Paper records can be easily lost
 We have heard how fires, floods and other natural
catastrophes destroy physical records of many years,
data which are lost forever
 Loss, misplacement of patient details ,check up and
investigation
 In some cases, medical tests that have already been
done were repeated all over again, incurring
unnecessary costs to the patients and the health care
system.
What are Advantages and Disadvantages of Electronic
Record Keeping
i. Advantages of Electronic Record Keeping

 EMRs reduce errors

 The use of EMR supposedly reduces errors in medical
records
 With the use of EMRs, standardization of patient health
records may eventually become achievable.
 EMRs keep records safe
 Digital records can be stored virtually forever and can
be kept long after the physical records are gone
 EMRs help keep records of health information for long
time
 For example Inoculations, previous illnesses and
medications
 EMRs make health care cost-efficient
 EMRs consolidate all data in one place
 EMRs facilitate coordination between health
professionals
 It coordinate between primary care providers and the
hospital care of patients
 Facilitate the continuity of care before, during and
after hospitalization.
 EMRs translate into better treatment for patients
 Correct and timely information can significantly
increase the quality of health care services rendered to
patients
ii. Disadvantages of Manual Record Keeping

 EMRs threaten our privacy

 Not many people are comfortable about having their
entire medical history recorded and digitized for almost
just anybody to see – in other words, incursion into
people’s privacy.
 EMRs can lead to loss of human touch in health care
 In the process of digitalization, the interpersonal aspect
in health care may be lost.
 EMR is simply about ticking off boxes and crossing out
things in electronic forms.
 The doctors are forced to think in categories and can
seldom express a personal opinion on an individual case.
 Because of the lack of flexibility of many electronic
reporting systems, cases of misclassification of patients
and their conditions have been reported.
 EMRs are not safe and secure
 Very few people are confident about the data
protection and security of electronic data such as those
stored in EMRs.
 Many people are not convinced that their data are safe
from those who would want to misuse it.
 EMRs can be difficult to establish and maintain in
developing countries.
 Factors like the population demographics, location, of
the care center and the availability of resources such as
electricity and internet may affect the implementation
of EMR.
Key Points

 Health records a collection of clinical information

pertaining to a patient's physical and mental health,
compiled from different sources
 There are two types of keeping medical record which
are
 Manual methods of record keeping
 Electronic methods of record keeping
Session Evaluation

1. What are the factors influencing choice of method of

record keeping?
2. What are advantages and disadvantages of manual?
3. What are advantages and disadvantages of electronic
record keeping?
Assignment one
 What are the factors influencing choice of method of
record keeping?
 What are advantages and disadvantages of manual
electronic methods of record keeping
References

 Fundamentals of Nursing. (3rd ed). Philadelphia,

USA: Lippincott Williams & Wilkins. Efoghor,J. E. (2010).
 Qualities of a Professional Nurse from
http://ezinearticles.com/?20- Kozier, B., Glenora
E.R.B., Audrey Berman, & Shirlee S. (2004).
 Fundamentals of Nursing. (7th ed). New Jersey, USA:
Pearson Education Inc. MOHSW. (2008).
 Basic Nursing Procedures. (3rd ed). Dar Es-Salaam,
Tanzania:
End of section one