الفهرس 
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Abstract
Introduction: Medical records form an essential part of a patient’s
present and future health care. As a written collection of information
about a patient’s health and treatment, they are used essentially for the
present and continuing care of the patient. In addition, medical records
are used in the management and planning of health care facilities and
services, for medical research and the production of health care statistics.
In clinical oncology, much of the research is conducted in the milieu of
patient care and the traditional medical record is used for collection of
data.
Aim of the study: Assessment of the needs of the recording and
information system at the center of clinical oncology in Kasr Al Aini
university hospital as a step for improvement of quality of cancer
registration to serve the needs of a comprehensive medical information
system in Kasr Al Aini hospital.
Methodology: We do assessment of the needs of the recording and
information system in the center and design a new medical record for data
collection according to the standards through the following steps: analysis
of the existing system and work flow through direct observation of the
system in action, in depth Interviews of the center of clinical oncology
members, review of the present medical records, then the requirements
and problems of the existing manual recording system are identified and
listed followed by designing a new medical record for data recording
Results: it is clear that almost all medical records in this center were
incomplete in one way or another. This study revealed that lack of
documentation of requested information, poor handwriting, and missing
of medical records and absence of certain important forms in the medical
records are prominent problems with paper based medical record system
(PBMR) in this center.
Conclusion: Due to the low grade of completeness, availability, usability
and compliance to the standards of the medical records in this study, it is
believed that physicians at this center were not aware of the importance of
the medical record as a crucial document for treatment and follow-up of
their patients. Although the PBMR system might be more effective at
bedside and can not be totally eliminated in the near future, it is necessary
to find ways to ensure that the documentation of information will be in a
readable and retrievable format.
Key words: Medical records, Information system, Data quality, Cancer
registration.