UNIVERSITI TEKNOLOGI MARA

COURSE INFORMATION

Confidential

Course Code : IMR655

Course Name (English) : MANAGEMENT OF MEDICAL RECORDS APPROVED

Course Name (Malay) : PENGURUSAN REKOD PERUBATAN

Course Level : 6 - Bachelors Degree

SLT : 120 Hours

Equivalent to 3 Credits

Face to Face: 66 Hours

Non Face to Face: 0 Hours

Student Preparation Time: 54 Hours

Pre-Requisite Courses : No course recommendations

Co-requisite Courses : No co-requisite Courses listed

Equivalent Courses : No equivalent Courses listed

Teaching Period Duration : 17 Weeks

Resource Person : NIK AZLIZA BT NIK ARIFFIN

National Education Code : Social Sciences, Business and Law

Delivery Period Duration : 1 Semester

Faculty Name : FACULTY OF INFORMATION MANAGEMENT Start Year : 2020

© Copyright Universiti Teknologi MARA Review Year : 2017
Course Learning Outcomes

At the end of the course, students should be able to:

1. Practice the concept of management of medical records in hospitals. ( A5 )

2. Explain the process involved in the appraisal, storage and retrieval and access of hospital records in the hospital
environment. ( A4 )
3. Describe a clinical coding system for diseases according to the International Classification of Disease. ( C5 )

Course Description

This paper addresses the specific issues involved in managing clinical and non-clinical hospital records, indicating where
particular approaches are needed to meet the specific requirement of records services within a hospital environment. The
principles outlined in this module are also applicable to managing records in other health care facilities.

Syllabus Content

1. The context of hospital records management

1.1 The relationship between medical and health agencies and government
1.2 The organizational structure
1.3 The types of records in hospital environment
1.4 The principles of hospital records management
1.5 The nature of health records
1.6 The role of records manager
1.7 The legal status of hospital records
1.8 The relationship of hospital records to the national/archive institution

2. Managing patient case notes

2.1 Unitary filing system

2.2 Numbering schemes
2.3 Case note, file design and content
2.4 The creation and management of form
2.5 Internal arrangement of files
2.6 Closure of files and creation of continuation files
2.7 Creation and management of the master patient index
2.8 Identification and registration of patients

3. Managing other hospital records

3.1 X-ray, pathological specimen, preparations and related records

3.2 Patient register
3.3 Pharmacy and drug records
3.4 Administrative and policy records
3.5 Financial and personnel records
3.6 Records of nursing activity
3.7 Educational records

4. Appraisal, storage and access issues.

4.1 Appraisal of hospital records

4.2 Determining retention period
4.3 Approving the records schedule
4.4 Storage of hospital records
4.5 Operation of a single site records service
4.6 Moving current records within hospital
4.7 Issuing records
4.8 Return records

Faculty Name : FACULTY OF INFORMATION MANAGEMENT Start Year : 2020

© Copyright Universiti Teknologi MARA Review Year : 2017
5. Access Issues

5.1 Providing electronic access

5.2 Electronic Medical Records
5.3 Casemix

6. Coding System

6.1 International Classification Disease (ICD10)

Teaching Methodologies

Case Study
Discussion
Lectures
Presentation
Seminar/Colloquium

Proposed % Marks Approved by KPP

Question Difficulty Levels Range

C1 - C2 40 - 50

C3 - C4 40 - 50

C5 - C6 10 - 20

Assessment

Continuous 100.00%
Assessment: Assignment - 20% out of 20 on Week 6. Passing Mark(s): 10
Written Report
CLO: 2

Assignment - 25% out of 25 on Week 11. Passing Mark(s): 13

Hospital Proposal
CLO: 2

Assignment - 25% out of 25 on Week 9. Passing Mark(s): 13

A case study on selected hospitals in Malaysia
CLO: 1

Test - 30% out of 30 on Week 13. Passing Mark(s): 15

Final Test
CLO: 3

Transferable Skills

Responsive Confident Expert in the field Ethically socially senstive

Special Regulation

This Module has no special regulation

Reassessment Requirement

This Module has no Reassessment Requirement

Reassessment Description

Faculty Name : FACULTY OF INFORMATION MANAGEMENT Start Year : 2020

© Copyright Universiti Teknologi MARA Review Year : 2017
This Module has no Reassessment Description

Recommended Text

1. International Records Management Trust., Managing Public Sector Records: A Study Program.Managing Hospital
Records, n/a, 1999, ISBN: n/a
2. World Health Organization, Medical Records Manual: A Guide for Developing Countries, n/a, 2002, ISBN: n/a
3. Richard Gartee, Electronic Health Records, Pearson, 2016, ISBN: 9780134257501
4. Bernard Peter Robichau, Healthcare Information Privacy and Security, 9th, Springer Science, 2014, ISBN: 1430266767
5. Kementerian Kesihatan Malaysia, Garispanduan Pengendalian dan Pengurusan Rekod Perubatan Pesakit Bagi
Hospital- Hospital Dan Institusi Perubatan , Kementerian Kesihatan Malaysia, 2010, ISBN: n/a

References

1. Johnson, Sandra R, Understanding Medical Coding: A Comprehensive Guide., New York: Delmar Publishers., 1999,
ISBN: n/a
2. Maxwell-Stewart, H, J Sherperd and G Yeo, Hospital Patient Case Records: A guide to their retention and Disposal.,
UK: Health Archives Group, 1996, ISBN: n/a
3. Ann Peden, Comparative Records for Health Information Management, Delmar Publishers., 1998, ISBN: n/a

Other References

This module does not have other references

Course Extra Information

This Module has no extra information

Faculty Name : FACULTY OF INFORMATION MANAGEMENT Start Year : 2020

© Copyright Universiti Teknologi MARA Review Year : 2017
 UNIVERSITY TEKNOLOGI MARA

COURSE LEARNING OUTCOMES - MOE LEARNING OUTCOMES - SOFT SKILLS LEARNING OUTCOMES RELATIONSHIP MATRIX

COURSE CODE IMR655 FACULTY / ACADEMY FACULTY OF INFORMATION MANAGEMENT

COURSE NAME (IN ENGLISH) MANAGEMENT OF MEDICAL RECORDS CREDIT UNIT 3

COURSE NAME (IN MALAY) PENGURUSAN REKOD PERUBATAN Resource Person NIK AZLIZA BT NIK ARIFFIN

  Achievement of MOHE Learning Outcomes Achievement of Soft Skills Learning Outcomes

Course Learning Outcomes (CLO) LO1 LO2 LO3 LO4 LO5 LO6 LO7 LO8 LO9 SS1 SS2 SS3 SS4 SS5 SS6 SS7

Practice the concept of

CLO1 management of medical records / /
in hospitals.
( A5 )

Explain the process involved in

the appraisal, storage and
CLO2 retrieval and access of hospital / /
records in the hospital
environment.
( A4 )

Describe a clinical coding

system for diseases according to
CLO3 the International Classification of / /
Disease.
( C5 )

Ministry of Education Learning Outcomes Soft Skills Learning Outcomes

i. Knowledge i. Critical Thinking and Problem-solving Skills

ii. Practical Skills ii. Communication Skills
iii. Thinking and Scientific Skills iii. Team Skills
iv. Communication Skills iv. Ethics & Moral Professionalism
v. Social skills, Teamwork and Responsibilities v. Life-long Learning & Information Management
vi. Values, Ethics, Moral and Professionalism vi. Entrepreneurial Skills
vii. Information Management and Life Long Learning vii. Leadership Skills
viii. Management and Entrepreneurship
ix. Leadership Skills

Faculty Name : FACULTY OF INFORMATION MANAGEMENT Start Year : 2020

© Copyright Universiti Teknologi MARA Review Year : 2017
 UNIVERSITY TEKNOLOGI MARA

COURSE LEARNING OUTCOMES - TAXONOMY LEVELS

COURSE CODE IMR655 FACULTY / ACADEMY FACULTY OF INFORMATION MANAGEMENT

COURSE NAME (IN ENGLISH) MANAGEMENT OF MEDICAL RECORDS CREDIT UNIT 3

COURSE NAME (IN MALAY) PENGURUSAN REKOD PERUBATAN Resource Person NIK AZLIZA BT NIK ARIFFIN

COGNITIVE PSYCHOMOTOR AFFECTIVE

COURSE OUTCOMES
C1 C2 C3 C4 C5 C6 P1 P2 P3 P4 P5 P6 P7 A1 A2 A3 A4 A5

Practice the concept of management of

1 medical records in hospitals. /
( A5 )

Explain the process involved in the

appraisal, storage and retrieval and
2 access of hospital records in the hospital /
environment.
( A4 )

Describe a clinical coding system for

3 diseases according to the International /
Classification of Disease.
( C5 )

Faculty Name : FACULTY OF INFORMATION MANAGEMENT Start Year : 2020

© Copyright Universiti Teknologi MARA Review Year : 2017
 UNIVERSITY TEKNOLOGI MARA

COURSE OUTCOMES

COURSE CODE IMR655 FACULTY / ACADEMY FACULTY OF INFORMATION MANAGEMENT

COURSE NAME (IN ENGLISH) MANAGEMENT OF MEDICAL RECORDS CREDIT UNIT 3

COURSE NAME (IN MALAY) PENGURUSAN REKOD PERUBATAN Resource Person NIK AZLIZA BT NIK ARIFFIN

ACHIEVEMENT OF MOE LEARNING OUTCOMES

COURSE LEARNING OUTCOMES TEACHING METHODOLOGY ASSESSMENT
LO1 LO2 LO3 LO4 LO5 LO6 LO7 LO8 LO9

Practice the concept of management of Lecture Assignment

medical records in hospitals. Tutorial
1 / Project
Blended Learning
Test

Explain the process involved in the appraisal, Lecture Assignment

storage and retrieval and access of hospital Tutorial Assignment
2 records in the hospital environment. / Project
Blended Learning
Assignment

Describe a clinical coding system for diseases Lecture Test

3 according to the International Classification of / Tutorial
Disease. Test
Blended Learning

Faculty Name : FACULTY OF INFORMATION MANAGEMENT Start Year : 2020

© Copyright Universiti Teknologi MARA Review Year : 2017