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Full Project – Evaluation of the constraints facing health records practitioners in health records keeping in General Hospital

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CHAPTER ONE

1.0 INTRODUCTION

1.1 BACKGROUND TO THE STUDY

Health records are very important in the management and treatment of patients. Luthuli and Kalusopa (2017) conceived health records as written account of patients’ examination and treatment that include the patients’ medical history, illness narratives and complaints; the physicians findings; and the results of diagnostic tests, procedures, medications and therapeutic procedures.

In addition, Health records as “an orderly written encompassing the patient identification data, health history, physical examination findings, laboratory report, diagnosis treatment, surgical procedure and hospital courses ”According to him the purpose of health records are to provide means of communication among physician, nurses and allied health care professionals, to serve as easy reference for providing continuity in patient care, to furnish documentary evidence of care provided in health care facilities, to serve as informational document to assist the quality of patient care, to protect the physician and health care institution and its employees in the event of litigation, to supply pertinent care information to authorized organization and third party payers (Pyrene, 2015).

Before hospital information can be handled well, run smoothly and accurate, there must be an expert in the field that can handle, monitor and manage the health records of the patient in an authorized and recognized manner. Health records practitioner is a person or an expert in the field of health information management whom has undergone certain training and has the qualification required in health records management profession. For effective running of health record in an organization here must be an influencing factor for job performances of health records practitioner, influencing factor such as good working environment, motivation of the staff, incentive, adequate manpower, adequate tools in health records library such as ladder, stood, shelves etc.

The world health records practitioner is derived from Greek word meaning to supply medical services and health information system so that, the health care institution can provide adequate health care treatment to all individuals. Therefore, in a hospital set-up term a health records practitioner is employed to keep records, it is also the responsibility of health record practitioner to keep classified documents for filling and soon.

The health records practitioner today is a professional. The training demands for intelligence and perseverance. The services of health records practitioner is in dispensable in a hospital set-up, they are the backbone of administration in the hospital. The health records practitioner is at the centre or first point of contact in a given hospital setup. In the past and at present it has been observed that some health records practitioners are performing well while, performing duties for the boss, staff and members of the public. Others are found not performing effectively on their job due to the challenges they are facing (Luthuli, 2017).

Health information management department and health information managers plan information system, develop health policy, and identify current and future information needs. They apply the science of informatics to the collection, storage, use and transmission of information to meet legal professionals ethical and administrative record keeping requirement of health care delivery. In situations where patients carry their case note by themselves in our local hospital, failure to consult health record practitioners when planning health record department in a hospital, a situation where single room is allocated for health record department, and poor lightening of the records library are practices still carried out that has not contributed to the improvement of record keeping (Asunmo & Yaya,2016).

Therefore, successful record keeping requires the services of top managers and middle managers who can organize the chaotic world of information in many organizations and hospitals. Through education and training, the new breed of records manager would be able to improve the present situation of information management in many hospitals and organizations in African countries (Asunmo & Yaya, 2016).

Hospitals deal with the life and health of their patients. Good medical care relies on well-trained doctors and nurses and on high-quality facilities and equipment. Without accurate, comprehensive up-to-date and accessible medical records, medical personnel may not offer the best treatment or may in fact misdiagnose a condition, which can have serious consequences. Associated records, such as X-rays, specimens, drug records and patient registers, must also be well managed if the patient is to be protected. Similarly, good medical records care ensures the hospital’s administration runs smoothly: unneeded records to be transferred or destroyed regularly by keeping storage areas clear and accessible; and key records to be found quickly by saving time and resources.

The medical record is the who, what, why, where, when and how of the patient care during hospitalization. Medical record is the only history of achievement, the only measurement of work being done by the medical and nursing staff, the only record of progress of the patient, and it is the source of information for many purposes. Taking into consideration the benefits of medical records, this paper systematically discusses the concept, significance and challenges of medical records

1.2 STATEMENT OF THE PROBLEM

Health Information Management Department and Health Information Managers plan information system, develop health policy and identify current and future information needs. They apply the science of informatics to the collection, storage, use and transmission of information to meet legal professional’s ethical and administrative record keeping requirement of health care delivery. However, it was observed that there are inadequate health record practitioners, inadequate space for storage of medical records, in effective standardized approaches to documentation, poor working conditions, further need to maintain confidentiality of patient records in General Hospital Ilorin Ilorin, Kwara State. Hence the need to assess the constraint facing health records and health record practitioners in General Hospital Ilorin, Ilorin.

1.3 BROAD OBJECTIVES

The overall objective is to evaluate the constraints that are facing health records keeping and the health records practitioners in health information management department, General Hospital Ilorin.

1.3.1 SPECIFICOBJECTIVES

The objectives of the study are to:

Identify the method of record keeping being practiced and the roles of health records practitioners in General Hospital Ilorin
Find out the challenges facing health records practitioners in record keeping and service delivery.
Ascertain if there are existence of misfiling patient case notes in health records department, General Hospital Ilorin.
Assess if constraints facing health records practitioners in health records keeping are responsible for poor service delivery in health information management department?

1.4 RESEARCH QUESTIONS

What are the method of record keeping being practiced and the roles of health records practitioners in General Hospital Ilorin, Ilorin
What are the challenges that health records practitioners are facing in record keeping and service delivery
Are there cases of misfiling of patients case notes in health records department in General Hospital Ilorin, Ilorin?
Are there constraints facing health records practitioners in health records keeping that leads to poor service delivery in General Hospital Ilorin, Ilorin

1.5 RESEARCH HYPOTHESIS

Ho: The constraints facing health records practitioners in health records keeping are significantly not responsible for poor service delivery in health information management department.

H1: The constraints facing health records practitioners in health records keeping are significantly responsible for poor service delivery in health information management department.

1.6 SCOPE OF STUDY

The study is restricted to the health information management department, General Hospital Ilorin, Ilorin and only health record personnel will be considered in the course of this research for questioning.

1.7 SIGNIFICANCE OF THE STUDY

The study of assessment into the constraints facing health records keeping and the health records practitioners would be significant to patients, health record professionals, allied health care team and the hospital management.

To the patient: It helps to know the continuity and excellence of care in which details of all treatments both previous and current are recorded.

To the Health Record professionals: It helps the health records form a permanent account of a patient’s illness. It helps in data collection and compilation and in scientific research.

To the Hospital Management: It helps to know the accuracy and complete health record, discharge analysis statistics can be drawn and can be used by the hospitals management in estimating and planning for present and future patients services.

Results from this study will be useful to hospitals, Kwara State and the country at large because government operates essential businesses through its public organization. The results will also directly point to the constraints, development and management of health records by health record practitioners and their use in achieving maximum output and good service delivery at General Hospital Ilorin, Ilorin and beyond.

1.8 DEFINITION OF TERMS

Health: According to World Health Organization (WHO) can be defined as the state of complete physical, mental, and social well-being of an individual and not merely the absence of diseases or infirmities.

Health Record: Is defined as a yardstick measure to know the activities of the hospital. It is also defined as a clinical, scientific, administrative and legal document relating to patient care in which are recorded sufficient data written in the sequence of events to justify the diagnosis and warrant the treatment and end result.

Constraints: can be defined as challenges or problems

Professionals: Is the standard of education and training that prepare member of profession with particular knowledge and skill necessary to perform the role of that profession.

Patient-a person registered to receive medical treatment or a person who is under medical care or treatment.

Management: The act of getting things done through the effort of other people.

Practitioners: someone who is qualified to or registered to practice a particular occupation, profession or religion.

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