DESIGN AND IMPLEMENTATION OF A SEMI AUTOMATED INDEXING AND ABSTRACTION SYSTEM FOR MEDICAL RECORDS

1.1 Introduction

Medical record abstraction (MRA) as a process in which a human manually searches through an electronic or paper medical record to identify data required for secondary use. Abstraction involves direct matching of information found in the record to the data elements required for a study. Medical record indexing is the process of organizing medical records and information into an accessible user friendly system. Medical records indexing is an important function since it involves organizing and storing information such as the patient's demographic and treatment information together in one place for easy retrieval later.

As a prelude to other parts of this study, this chapter will discuss the background up on which this study was initiated, the statement of problems that led to this study, the Aim and Objectives of the study. Others are Significance of the study, Scope of work, Limitations of the Study and Definition of technical terms.

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1.2 Background of Study

Indexing and abstraction for hospital allow health information to be maintained and retrieved by health care facilities for the purpose of education, planning, and research. Indexing the patient record facilitates efficiently and effectively retrieval relevant information from patient documents.

The disease index is organized according to ICD-9-CM disease codes. The procedure index is organized according to ICD-9-CM and/or CPT/HCPCS procedures/services.

According to CDC (2021), the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is based on the World Health Organization's Ninth Revision, International Classification of Diseases (ICD-9).nICD - ICD-9-CM - International Classification of Diseases, Ninth Revision, Clinical Modification (CDC, 2021).

The physician index is organized according to physician number. The physician number is assigned to the physician by the facility. Once a number has been assigned to a physician it is never reassigned to another physician. The database for all three indexes also collects the following information:

1. Patient demographic data (age, ethnicity, gender, inpatient admission and discharge dates or outpatient treatment date, and zip code)
2. Financial data (third-party payer type and total charges)
3. Medical data (attending physician, consulting physician, surgeon, medical service classification, disease and/or procedure/services code(s), date of surgery, and type of anesthesia)

Common registers that are used in the hospital setting are the admission register, discharge register, and death register. Just as the name implies, these registers list the admissions to the hospital, the discharges from the hospital, and the deaths that occurred while hospitalized. Registers and registries provide the facility, as well as the providers and public health officials, with information needed to assess and monitor the health given in a particular population.

Case abstracts have different data elements that must be collected. For example, the organ donor registry case abstract form will have different requirements that the implant registry. The data set used to collect and report data and will depend on the requirements of the facility. Before the case abstract process can begin, a standard method of collecting and reporting individual data elements must be established so data can be easily compared. This is called a data set. In addition, the organization should develop a data set which is a collection of data element definitions.

Patient records contain most crucial documents for managing the treatments and healthcare of patients in the hospital. Care providers waste precious time searching and browsing the patient record to collect all information pertinent to the actual situation.

The Federal Polytechnic Nekede, Medical Centre was established in 1978 owned by the Imo State Government. In Nigeria, primary healthcare is to be provided by Local Governments, secondary health care by State Governments and tertiary health care by the Federal Government. In operationalizing this policy, the Federal Government decided to establish at least one tertiary health institution in each State of the Nigerian Federation.

The challenges encountered that led to the execution of the research work is that, care providers waste precious time searching and browsing the patient record to collect all information pertinent to the actual situation, Difficulty in accessing certain patient file location, the manual system of indexing and abstraction of patient medical files stressful and may result to loss of file indication if not found, and Inaccuracies in patient's medical record keeping due to human errors.

It is against the background that the developments of this software to enable people have access to patient's related files, so the software users should not give false information that is out of the software deeds. This research work is based on providing adequate information about medical records. At the end of this project, the research work, the software will be able to provide precise and concise patient records from the database.

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1.3 Statement of Problems

Some of the problems of the study include:

1. Care providers waste precious time searching and browsing the patient record to collect all information pertinent to the actual situation.
2. Difficulty in accessing certain patient file location
3. The manual system of indexing and abstraction of patient medical files stressful and may result to loss of file indication if not found.
4. Inaccuracies in patient's medical record keeping due to human errors

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1.4 Aim and Objectives of the Study

The aim of the study is to design an application that will eradicate the existing problems of the indexing and abstraction for hospital files. In achieving this aim, the specific objectives below will be adhered to;

1. To develop an application that will enable the care providers search and browse patient record without delay.
2. To store patient file record in a database that will enable care providers to be able to locate patient files in the health facility.
3. To develop an application that will index patient medical files for easy assessment.
4. To develop an application that will provide accurate patient's medical record as provided by the patient.

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1.5 Significance of the Study

This system when completed and implemented it will help provide adequate information about patient's medical record and facilitates quick indexing, abstraction and retrieval of patient records. This project will be beneficial to individuals such as students, pharmacist and doctors, nurses, care providers by providing accurate and complete information about patient's medical record thereby saving patient time during medical checkup. Besides, the study will serve as reference material for subsequent researcher in the field or related topics.

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1.6 Scope of the study

This research work will concentrate on indexing and abstraction of hospital files using Federal Polytechnic Nekede Medical Center Owerri, Imo state as a case study. The proposed system developed will only provide patient's information like patient's name, address, medical report, medical fitness report, medical diagnosis result and advice.

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1.7 Limitations of the Study

During the course of this study, many things militated against its completion, some of which are:

1. Time Constraint: The time frame given to accomplish this project was very short due to school academic calendar and it was carried out under pressure which made the researcher not to implement some necessary features.
2. Establishment Policies: Establishment policies posed a serious limitation as most staffs are not ready to release information needed forth is project work. There were lots of information needed from the staffs of this institute on to enhance the study which took them time to release or they did not release at all for security purposes, hence the scope was reduced.

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1.8 Definition of terms

Indexing: Indexing is broadly referred to as an indicator or measure of something, in the financial markets, indexing can be used as a statistical measure for tracking economic data, a methodology for grouping a specific market segment, or an investment management strategy for passive investments.

Medication: A medication is a substance that is taken in to or placed on the body that does one of the following things: most medications are used to cure disease or condition. (For example, antibiotics are given to cure an infection. Medications are also given to treat a medical condition).

Prescription: A prescription is a health-care program implemented by a physician or other qualified health care practitioner in the form of instructions that govern the plan of care for an individual patient.

Symptom: A symptom is a departure from normal function or feeling which is apparent to a patient, reflecting the presence of an unusual state or of a disease. (For example: tiredness, cough or fever).

Administration: An administration is the act of giving a drug to somebody or a patient. .

Information: Information is used to tell someone that they are wrong about something.

Patient Data: This is the patient medical records such as; name, address, and phone number.