Abstract:
Background: Medical record is initial point of patient data production and primary source for all
health information related to patient care, health service quality, decision making and resource
allocation. However, the quality of medical records (MRs) is rarely evaluated and quality
dimensions of medical record are not well assessed particularly in the study area as well as in
Ethiopia.
Objective: The study was intended to assess the quality of medical record in public health centers of
Soro district, Hadiya Zone, Southern Ethiopia.
Methods: Facility based cross- sectional study design supplemented with qualitative inquiry was
conducted among randomly selected four health centers (HCs) in Soro district, Hadiya zone from
March - April ,2019. Data on the quality of medical records were collected by reviewing document
using checklist, while qualitative data for triangulation were obtained by interviewing key
informants from the health center and to describe possible reasons for poor medical record quality.
The data were entered in to Epi-data version 3.1, exported, and analyzed by SPSS version 22.0.
Descriptive statistics was used for the analysis of data.
Result: A total of 384 medical records were reviewed from one-year medical records of four public
health centers, with 100% retrieval rate. In the assessment of quality of medical record,
Administrative components were lowered (29%) compared to clinical components (88.7%).
According to the expected national standard, the study also showed that average quality of medical
records of the study area was 40%. Among the dimensions of MRs quality, none of health centers
had enough facility for medical record quality and no auditing of medical record document as of
the standard.
Conclusions: Majority of medical records had incomplete administrative, clinical and legal
components as of health centers standard of the country. The studied HCs are not fulfilled the
national medical record management requirements to run medical record system of health centers
since the Ethiopian HCs standard set the medical record personnel to be a health information
technician and a minimum of three in numbers. Thus, medical record service providers should be
trained and necessary supplies should be equipped in all health center.
