The role of medical records in the provision of public healthcare services in the Limpopo province of South Africa

Abstract

Background: The importance of medical records to the provision of healthcare services cannot be overemphasised. Medical practitioners need information about previous diagnoses, treatments and prescriptions in order to note the progress made with previous treatments and how to move forward. If medical records are not managed properly, it becomes difficult to retrieve such records, which results in hospitals not being able to render healthcare services or these services being rendered incorrectly, especially for chronic patients. Despite the importance of medical records, they are not being managed properly, resulting in a lack of effective systems for opening, tracking and indexing files.Objective: This study seeks to investigate the role of medical records in the provision of public healthcare services in the Limpopo province of South Africa.Method: Quantitative data were collected through questionnaires distributed to staff members in the records management unit and the information management unit in 40 hospitals in Limpopo. These units were relevant as they made use of patient files daily to discharge their duties.Results: The study revealed that missing medical records negatively affected timely and effective healthcare service delivery. This resulted in patients having to wait longer to be treated and in some instances patients being treated without medical history.Conclusion: The study concludes by arguing that missing files contribute to the length of time patients wait to be assisted. As a result, nurses and doctors are unable to assist patients or treat them immediately. The study recommends the introduction of an electronic records management system that can capture and provide access to a full patient record, as well as tracking paper records movement, irrespective of the location.

Digital Literacy

“…Maintaining patient records, tracking of disease prevalence, monitoring drug supplies, maintaining ordering system for supplies and billing procedures. For example in Africa-the South African Department of Health has developed a National Health Care Management Information System (NHC/MIS) to cover medical records, patient registration, billing and scheduling modules in selected hospitals in all the 9 provinces (Marutha & Ngoepe, 2017). In Bangladesh, a similar project with different scale was developed to register, schedule and track immunization of children (Bangladesh Development Research Center-BDRC, 2015).…”

Managing health records in the Bulawayo and Matabeleland South provinces hospitals, Zimbabwe

“…Properly managed records provide information that is accurate, valid, reliable, timely, relevant, legible and complete in support of a safe and reliable healthcare. Thus, it is imperative that medical records be managed properly in order to enable citizens to receive proper healthcare (Marutha and Ngoepe 2017).…”

An evaluation of the quality of discharge summaries from the general paediatric wards at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa

“…Furthermore, the rate of completed discharge summaries compares unfavourably with settings in Australia and the USA, [11,12] where >99% of discharge summaries are completed. To our knowledge, the completion rate of discharge summaries in SA state hospitals is not known, but the poor rate of retrieval of hospital records (~39% in district hospitals [8] ) and acknowledgement of poor hospital record management systems [9,10] make it likely that missing discharge summaries are an important problem in SA.…”

“…Notwithstanding the fact that the Department of Paediatrics at Chris Hani Baragwanath Academic Hospital (CHBAH) is one of the largest paediatric facilities in Africa, paediatric admission files are extremely difficult to retrieve from the CHBAH record archive, as is also the situation in many other clinical departments in SA state hospitals. [8][9][10]…”