Project – Evaluation of the problems and constraints health record keeping by the profession
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
Project – Evaluation of the problems and constraints health record keeping by the profession
