Quality of Medical Records Management at Public Hospitals in Tigray Region

Abstract

Background: Comprehensive medical records (MR) are cornerstones in the quality and efficiency of patient care during the hospitalization and in subsequent follow-up visits, as they can provide a complete and accurate chronology of treatments, patient results and future plans for care. However, the quality of MRs in health facilities of Tigray region is not well documented. Objective: To assess the quality of MR management at public hospitals in Tigray region. Methods: A cross-sectional study using stratified sampling method was conducted from March 1-15, 2011. A total of 768 MRs were reviewed at three public hospitals in Tigray Region. Review of MR was done using a checklist and in-depth interviews of health professionals and medical record staff. Data were checked, entered, cleaned and analyzed using SPSS version16. Ethical clearance was obtained from Jimma University public health and medical science ethical review board and Tigray regional health bureau. Verbal informed consent of the participants was obtained before the in-depth interviews. Result: Most of the hospital had adequate medical record staff. Master manual patient index was not used by the hospitals. The mean retrieving (success) of medical record was 13.65(± 1.12) & the time to retrieve MRs was 6.3 (± 2.67). There was a significant difference among the hospitals in the mean retrieving time of medical record (P=0.001). The overall completeness of medical records of the hospitals was 54.1%. Suhul hospital had highest completeness of medical record (67.3%). Conclusion and Recommendation: The number the medical records keepers were adequate to carry out the task of keeping medical records. All the hospitals didn’t have manual master patient index. The overall completeness of medical records of the hospitals was low. Regular and sustainable supervision for medical record staff should be conducted. Basic materials and equipment such as master patient index, registration book, stationeries, folders and computer should be provide to the medical record department