FACULTY OF INFORMATION MANAGEMENT

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BACHELOR OF INFORMATION SCIENCE (HONS) RECORDS MANAGEMENT (IM246)

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MANAGEMENT OF MEDICAL RECORDS (IMR655)

HOSPITAL PROPOSAL

PREPARED BY:

AMIRA NATASHA BINTI AHMAD ROSHIDI (2020982891)

HASNA DAYANTI BINTI HUZMI (2020976621)
NURUL ADIBAH SABIRA BINTI MUHD BAKARUDDIN (2020971981)
SITI NOOR MASHITAH BINTI HAMMED NOOR (2020980269)
UMMU ARIFAH BINTI MOHD DASUKI (2020957559)

CLASS:
JIM246/6A

PREPARED FOR:
MADAM SITI NOORSIAH BT JAMALUDIN

SUBMISSION DATE:
11 JANUARY 2022
 ACKNOWLEDGEMENT

Assalamualaikum. In the name of Allah the most gracious and the most merciful, first and
foremost. We would like to extend our deepest praise to Allah S.W.T who has given me the
patient, strength, determination and courage to implement this task.

This project is a collaborative effort of many people. To begin with, our most thanks
and gratitude goes to our lecturer Madam Siti Noorsiah Bt Jamaludin for imparting us with her
wealth of knowledge, valuable, guidance and experience.

Our appreciation and thanks are also dedicated to all of our friends for their helpful
insights, cooperation and stimulating comments. We would also like to express our apology
for any mistake and shortcomings in carrying out this task. To end with, we are truly delighted
for this research would bring benefits to others.

Wassalam.
 TABLE OF CONTENTS

1.0 INTRODUCTION ..................................................................................................................... 1

2.0 PROBLEM STATEMENT........................................................................................................ 2
3.0 OBJECTIVES............................................................................................................................ 2
4.0 PROBLEM SOLVING .............................................................................................................. 3
5.0 FRAMEWORK OF THE RECORDS MANAGEMENT PROGRAM.................................... 5
6.0 PROCESS OF OFFSITE STORAGE AND DIGITIZATION OF RECORDS ....................... 6
7.0 TIMELINE FOR RECORDS MANAGEMENT PROGRAM ............................................... 10
8.0 FACILITIES ............................................................................................................................ 11
9.0 TOOLS AND EQUIPMENT ................................................................................................... 13
10.0 STAFF INVOLVED .............................................................................................................. 15
11.0 STAFF TRAINING ............................................................................................................... 17
12.0 BENEFITS USING DIGITAL RECORDS AND OFFSITE STORAGE ............................. 18
12.1 Offsite Storage ..................................................................................................................... 18
12.2 Digitization of Records ........................................................................................................ 19
13.0 FINANCIAL IMPLICATION............................................................................................... 20
13.1 Offsite Storage Budget ......................................................................................................... 20
13.2 Digitization Program Budget ................................................................................................ 21
13.3 Total Cost Budget ................................................................................................................ 21
14.0 CONCLUSION ...................................................................................................................... 22
REFERENCES .............................................................................................................................. 23
1.0 INTRODUCTION
According to Heyd (2022), medical records management refers to a set of policies and
protocols that control patient information throughout the data lifecycle. A patient record must
be properly saved, safeguarded, and maintained from the time it is created. The record must be
appropriately destroyed when it has been retained for the required amount of time. The
effectiveness of management programs is important in every medical organization and it is
related to their use of digital technologies.

In Hospital Tanjung Karang, Selangor, they make the effective medical record
management program through good technologies usage which means that wherever we walk,
we will encounter someone using electronic technology to perform work or socialize. We can
utilize a variety of technologies, including laptops, tablets, and many others to ensure the
patient's record will always be easy to keep. The benefits of technology nowadays make
employment more attainable and accessible.

Plus, it is vital to make sure that the organizations have kept and shredding the proper
documents at the right time and that everything is handled by someone who knows what they
are redoing. Although, an intermediary action such as offsite document storage might improve
workflow, efficiency, building and maintaining a comprehensive records management program
can have a significant influence on the organization. With the proper management in place,
Hospital Tanjung Karang, Selangor will have a road plan that tracks and files all of the records
which will be resulting in more efficiency for the records.

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2.0 PROBLEM STATEMENT
Hospital Tanjung Karang, Selangor has been operated on in 1966 and there are some
problems regarding their medical record management program.

i. Record overload

The main problem is record overload. There are too many patient files that must be handled
so that the record will not be well organized when the record is overloaded. Plus, the non -
essential records will also be mixed with existing records and it will make the record are easy
to lose. The medical record management program also may lead to giving a bad impact on
patient safety.

ii. Lack of storage area

The problem is the lack of storage area. It can also reduce the capacity to make crucial
organizational decisions fast since they cannot easily obtain the intelligence that they need to
inform them and it can also harm productivity. Then, when the management has improved in
their medical records management program, it can improve accuracy, assure consistency and
protect patients.

iii. Poor in retrieval and track record

The next problem is poor retrieval and tracking record. Therefore, it will be hard to find the
record in the storage and it will affect the time consuming which is taking a long time.in
medical record program. It also will make the record are not easy to retrieve and when the
record is not found, we cannot decide and make the decision making.

3.0 OBJECTIVES
There are some objectives of the medical record management program to our organization:
i. To improve management of record.
ii. To optimize the storage area.
iii. To improve retrieval and tracking of records.

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4.0 PROBLEM SOLVING
Any organization or agency has to manage thousands of confidential records and each time
they need to improvise their technologies in order to protect and secure the important data and
records of their clients and for the organization. Those with good records are when it helps with
decision making, time-saving and help the administration of the hospital effectively. From the
stated problem of managing medical records of the organization, there are solutions with
benefits to help the process of managing the records run smoothly. Below shows the problem
solving of managing the records:

i. Offsite storage

It is necessary for the organization to send their records to the offsite storage as this
process can help with relocating the important records and documents from unprotected
and risky places. Basically, the organization will link with the offsite document provider
hence all the records and data will be managed by the professionals. Plus, the
transportation for the records is handled by the provider and also by the organization as
they are protected and secured transportation to replace the records to an offsite storage
service. The records then will be arranged and saved with a barcode system so it will help
in locating, retrieving or searching the records. It is also saving time when the
organization requesting for the documents so when the records are demanded the
provider will scan the documents and send the medical records through email or can be
delivered to the organization within a few hours.

There are many types of records that can be kept as offsite storage such as any
confidential records or records, paper documents, financial records, data employees and
any selected documents. The electronic records and tapes also can be stored as offsite
records storage. Further, the cost of handling the records will be affordable since the
organization will just pay for the boxes and space storage of the records. With the low
charge for the storage, the records will be managed and handled in a secured place by
trained and professionals, with 24/7 strict security and rules. The records will be secured
well and only an authorized person can access the records. Plus, the records will be kept
in storage with proper protection and avoid damage or loss. The benefits of sending
records to offsite storage are save time, easy for decisions making, improvement in
tracking the of files and records and easy access.

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ii. Digitization of records

Digitization or digitizing can be known as converting paper-based documents by

scanning them into electronic records. It is a common process in ensuring the records and
data are well secured. With the growth of technologies, it is important to digitize the
records in order to protect the data from several factors such as damage or loss, retrieving
process, and time management of handling those paper-based documents. As a good
records management in the organizations, they need to govern a lot of records and
documents. It is the best solution for the organization to manage and handle electronic
records instead of paper-based documents. The records that can be converted into
electronic records are images, X-rays, microfilms or any hard copies. It is crucial to have
better technologies in handling and protecting the records.

The benefits of digitizing the records are to facilitate the authorized personnel in
accessing and retrieving the records. It can improve the work performance of the
organization staff in handling the records since it will help them in accessing the records
efficiently. Plus, digitized records can help with the decision-making and improvements
in tracking the data and electronic documents. Furthermore, all the digitized records will
be kept in the systems which can save up more space in the organization. Cloud storage
and 75 Health Software are the tools for locating digitized records. It is also secured and
can prevent cyberattacks, viruses or hackers. Good privacy and security, better quality
performance, save up storage and reduced costs make managing the records effective and
efficient by the professionals.

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5.0 FRAMEWORK OF THE RECORDS MANAGEMENT PROGRAM

Figure 1 Framework of the records management program

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 6.0 PROCESS OF OFFSITE STORAGE AND DIGITIZATION OF RECORDS
Objective
1. Improve management of records
2. To optimize the storage area
Solution Process
Offsite storage 1. Choosing the records
 Identify and choose records that
want to be transferred.
 Records that are infrequently used
or records that are no longer active
should be transferred.
 They must be retained for legal
reasons.
 For example, records of history
and physical examination,
immunization records, consent for
the treatment forms.
2. Preparing the records
 Ensure that the records are free
from staples, post-it notes,
stickers, paper clips and other
items.
 Remove the unnecessary item on
the records to make sure the
records can be placed properly in
the storage box.
3. Organizing the records
 Organizes the records according to
the records retention and disposal
schedule.
 Using the records retention and
disposal records in organizing the
records will be practical since it
identifies which records that
should be transferred offsite and
which records that should be kept.
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3. To improve retrieval and tracking of
records
4. Boxing the records
 Make sure that the boxes used to
store the records are in the correct
size to minimize the possibility of
records damage.
 If the organization arranged the
records in the filing cabinets
according to alphabetical or
numerical, it is necessary to
maintain the records in the same
order when moving the records
from the filing cabinets to the
storage box.
5. Completing the inventory
spreadsheet
 The organization needs to
complete all the details in the
inventory spreadsheet.
 The inventory spreadsheet
contains details about the barcode,
department ID, box ID, contents of
the box as well as destruction date.
 The organization needs to provide
a clear description of the records
contained in the box.
Digitization of records 1. Preparation of records
 Make sure that the records are free
from staples, paper clips, pins,
fasteners or any other object.
 We should remove all the items or
objects that interfere with the
records because all the record’s
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 content will be scanned along with
the item’s shape.
2. Repairing the records
 If the organization has used
staplers on the records, when we
remove the staplers from the
records, it will leave a hole in the
records. So, we need to cover the
hole with cellophane tape.
 Cover all rips and tears in the
records with cellophane tape.
 If the records have been folded, we
need to iron them flat by using our
hand or a ruler.
 Avoid folding the records because
this can create creases and cause
the scanning process to be
disrupted.
3. Scanning the records
 Use the Automatic Document
Feeder (ADF) in scanning the
records.
 Ensure that the documents in the
ADF's tray are appropriately
placed.
 While scanning it's a must to use
clear protective sleeves. The
purpose of using the sleeve is to
keep the papers from being
damaged while being scanned.

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 4. Determine the format
 Store the records in images format
such as png, jpeg, jpg as well in
PDF format.
 Format of the records also can
affect the resolution of the scan
records.
 For example, if we want to upload
the records to the internet or want
to send them via email, the
suitable resolution is between 75
and 150 DPI.
5. Determine the storage
 Use 75 Health Software and cloud
storage in storing the records that
have been digitized.
 We can track the records by
sorting them by the records name,
the date when the records are
produced as well as the format of
the records.
Table 2 Process of offsite storage and digitization of records

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7.0 TIMELINE FOR RECORDS MANAGEMENT PROGRAM

Figure 2 Timeline for records management program

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 8.0 FACILITIES
Objectives Solutions Facilities Descriptions
1. To improve management of Offsite Storage 1. Location  Name offsite: Cube Self
records management Storage
 Address: Unit G1, Bangunan
2. To optimize the storage area THK, 2A, Jalan 51a/243,
Seksyen 51a, 46100 Petaling
Jaya, Selangor.
 15km from the hospital.

2. Transportation  We use Daihatsu Security Van

and lorry to transfer the
medical records to offsite
storage
3. Storage Box  Before transferring the
medical records, we will use
the storage box to organize the
records into its category.
 We use three different sizes of
storage box which are small,
medium and big.
 We use acid-free containers
which is it will help to
maintain the originality of
medical records.

3. To improve retrieval and Digitization of 1. In-Training  The in-training room can

tracking of records
records Room provide several benefits as the
suitable training location.
 We will teach the employees
on how to digitize the medical
records such as to do scanning

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 the records and accessing
them.
2. Digitization  This will be the place to
Area conduct a digitization process.
 Digitization is a process where
the paper-based records will
be converted into paperless
which is electronic medical
records.

Table 2 Facilities

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 9.0 TOOLS AND EQUIPMENT
Objective
1. To improve management of
records
2. To optimize the storage
area
3. To improve retrieval and
tracking of the records
Solution Tools and Equipment Description
Offsite Storage Hardware  A barcode reader is an optical
1. Barcode Reader scanner that can read printed
barcodes, decode the data
within the barcode, and
communicate the information
to a computer
 For every record that needs to
transfer to offsite storage, we
will create a barcode for a
better management
 We will use a bar code reader
for the offsite program.
 It is used to scan the medical
records that need to be
transferred.
Digitization of Software  We use cloud storage to keep
the records 1. Cloud Storage medical records online.
 Cloud storage also allows us
to back up the data and
recover it off-site.
 It is accessible at any time
from any location and readily
shared with those who have
been authorized access.
2. 75 Health Software  Helps us to manage
electronic records creation,
organization and retrieval.
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  Does not allow us to share
all electronic logs with
others
 It is convenient and quick to
use because by using this
software, all the data are
provided in an electronically
accessible format for
different health care
providers.
 Data privacy is very secure
because it enables better
access and allows an only
authorized person to access
the personal health
information

Table 3 Tools and equipment

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10.0 STAFF INVOLVED
It is important for the personnel in every department in the organization to ensure the
management of the business is running efficiently. The personnel is also responsible for
handling the data and records to be accurate, precise and clear for easy decision making and
other business purposes while using the records. Hence, the staff is the front liner of the
organization by sharing the accountability and ensuring the records are well managed and
accessible. Having good records management skills will improve business management as a
whole. The records are the evidence of every business transaction or activity that occurs in the
organization especially in a medical context. Below shows the staff involves in records
management and operation:

i. Hospital Administrator
Hospitals require such a big number of records to manage. The Hospital Administrator
will handle and manage the records related to the organization and the government body
(if any) and the files related to the department and daily activity files will be managed
by the Hospital Administrator. Besides, any records such as duty logs, or annual reports
of the organization are accountable to the Hospital Administrator. In addition, the
administration in the clinical department will also handle by the professionals since the
Hospital Administrative needs to trace and look for summaries in every activity in that
department. However, the Hospital Administrative yet still needs to be guided by the
Records Manager in handling those data and records. The policy and guidelines of the
records management were also created by Hospital Administrative.

ii. Records Officer

Generally, the Records Officer will ensure the data and records are managed well
according to the guideline and policy in the organization. The Records Officer will also
track the employees in managing the records and secure the data and records well. the
records and confidential records should be secure and protected very well and can be
accessed by the authorized person only and the Records Officer is one of the personnel
who can access the records.

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iii. Principal Nursing Officer
Like the other department, the nursing department will generate some records which
relate to the staff. Any staff records, memos, minutes of the meeting, reports and
correspondence. Basically, the wards in the organization can have a lot of data and
documents recorded and the nursing will manage the records related to the patients;
discharge, deaths, or patients admitted.

iv. IT Specialist
Anything related to the systems and digitization, the IT Specialist is responsible for
handling the system and electronic records. The IT Manager will also be able to secure
the electronic records from cyber-attacks and manage all the e- records of the
organization. Plus, the IT Manager will also facilitate the other Manager and Supervisor
in ensuring the data is accessible and keep in better storage. The systems should be
managed by trained and professionals since people will low knowledge in handling the
systems can affect the management of the electronic records which might cause the
records to be missing and misplaced.

v. Medical Records Supervisor

The medical records supervisor will ensure any records related to the medical records
such as patient records, medical records, medicine, pharmacy and drugs records to be
managed well. The medical records also will be guided by the Records Officer in
managing those records so there will be no mistakes in managing the records.

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11.0 STAFF TRAINING
Solution Training
Offsite Records Storage  The training will improve staff productivity
and efficiency in records management.
 Staff will be trained on how to prepare the
records and choose the right records for
delivering the records to the provider of the
offsite storage.
 This program and training class will conduct by
medical records supervisor.
Digitization  The staff will be trained according to the stages
which are principal, moderate and professional
training in records management. the IT
Specialist
 IT Specialist will be the instructor for the
trained staff and ensure the staff gained good
knowledge from the Program or digitizing class
 They will be exposed to managing the systems
such as cloud storage and 75 Health Software.

Table 4 Staff training

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12.0 BENEFITS USING DIGITAL RECORDS AND OFFSITE STORAGE
In this era of technology, many organizations believe in the paperless concept of how
digitization might be utilized when creating or giving anything in the form of a website or
software version. Digitization is the initiatives and processes required to digitally manage
information even more, whether it is digital or offsite records. There are some benefits of digital
records and offsite storage.

12.1 Offsite Storage

i. Efficient for retrieving crucial documents

It is very efficient for retrieving crucial documents. When we pending hours or days
seeking for a certain document is time that may be better spent for productive
purposes. When we move our records to an offsite storage facility, each box is
indexed, classified, and labeled with a scan-able barcode. When we require
information, it is simple to locate and obtain it in a timely and efficient manner.

ii. Cost-Effectiveness

The benefit is cost-effectiveness. It gives benefits rather than hiring personnel to

index or retrieves our papers, an offsite storage provider handles records
management for 50–95 cents per month, allowing them to focus on our
organization. It also provides better record management and will have more office
space, increased security, more valuable jobs for staff, and increased savings.

iii. Protection of Secure Information from Theft or Accidental Destruction

The benefit is the protection of secure information from theft or accidental

destruction. Offsite storage employs security measures such as 24-hour video
surveillance and secured buildings to protect your documents from anyone who is
not allowed to view them so that the records are always protected.

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12.2 Digitization of Records
i. Easily accessible and always available
The main benefits of digital records are easily accessible and always available. The
documents or details of the converted patient are accessible easily through the use
of the cloud or the system through any device with the Internet, such as the nurse
enter in the computer data that the doctor can view on the tablet or computer. Tablet
use is becoming easier since we can simply carry it instead of a computer, thus most
hospitals utilize keys in the data information. The information can be disseminated
and made available in various ways so that access is no longer limited to people. It
can also access existing resources, for instance, huge stored materials on the system,
previously limited by their format.

ii. Increase security

The benefits of digital records are can increase security when the use of
digitalization documents. Every organization of operation and financial viability of
each, documents, records and reports are crucial. That is why it is so necessary to
protect them against robbery, fire, damage to sprinklers, mold spores and any other
kind of hazard that could arise anywhere. The protection of the hospital records
guarantees that data is accessible whenever necessary and also speeds the recovery
from unforeseen disturbances.

iii. Save space

It can help to save space in the organization. It also does not need to create records
rooms or buy a paper or a document which is the use of digitalization can save space
in the organization. Then, when we use digitization, the data on the given cloud or
space may be saved. Digitization also gives an advantage when the organization can
upgrade its size of the cloud after the cloud is comprehensive and complete. The
digitization also has improved the productivity of the records such as the patients
just need to give their identity card number to the staff of the hospital and all the
records are already stated in the system.

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13.0 FINANCIAL IMPLICATION
13.1 Offsite Storage Budget
i. Facilities Budget

No. Item Pricing Total (RM)

1. Transportation 20,000.00 20,000.00
2. Storage box 399.00 399.00
3. Cube Self Storage 599.00 (Annual) 599.00
Total 20,998.00

Table 5 Facilities budget

i. Tools and Equipment

No. Item Pricing Quantity Total (RM)

1. Hardware
 Bar Code Reader 200.00 2 400.00
Total 400.00

Table 6 Tools and equipment budget

ii. Others Budget

No. Item Pricing Quantity Total (RM)

1. Staff Training 100.00 3 300.00
Total 300.00

Table 7 Others budget

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 13.2 Digitization Program Budget
i. Facilities

No. Item Pricing Total (RM)

1. In-Training Program - -
2. Digitization Area - -
Total -

Table 8 Facilities budget

ii. Tools and Equipment

No. Item Pricing Total (RM)

1. Software
 Cloud Storage 103.00 (Per month) 103.00
 75 Health System 150.00 (Per month) 150.00
Total 253.00

Table 9 Tools and equipment budget

iii. Others Budget

No. Item Pricing Quantity Total (RM)

1. Staff Training for digitization 150.00 3 450.00
program
Total 450.00

Table 10 Others budget

13.3 Total Cost Budget

No. Content Pricing (RM)

1. Offsite Storage Budget 21,698
2. Digitization Program Budget 703.00
Total (RM) 22,401.00

Table 11 Total cost budget

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 14.0 CONCLUSION
Objectives Solutions Hardware Software Benefits
1. To improve management of Offsite Storage Barcode -  Efficient for retrieving
the records Scanner crucial records
2. To optimize the storage  Cost-effectiveness
area  Secure information from
theft or accidental
destruction

3. To improve retrieval and Digitization of - 1. Cloud  Easily accessible and

tracking of the records the records Storage always available
 Increase security

2. 75 Health  Save space

Software

Table 12 Summary

As a conclusion, for the factors of effectiveness of records management, based on the

problems found in the Hospital Tanjung Karang, we have created three different objectives
which are to improve management of the records, to optimize the storage area and to improve
retrieval and tracking of the records. On top of that, we have found two different solutions that
can be made by Hospital Tanjung Karang are offsite storage and digitization of the medical
records. For the offsite storage, only a barcode reader is needed to conduct this solution for the
medical records. Meanwhile, for the digitization of the records, we only need Cloud Storage
and 75 Health Software to accomplish this solution. Moreover, the benefits for offsite storage
are efficient for retrieving crucial records, cost-effectiveness and securing information from
theft or accidental destruction. Besides, the benefits for digitization of the records are easily
accessible and always available, increase security and save space. By considering all the factors
in the hospital, we are sure that the solutions can be performed perfectly. All the processes,
steps and costs that have been stated and reviewed in the proposal are reasonable and
affordable.

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