Description of medical records across districts
Three hundred eighty-four medical records were reviewed from thirty-six public health facilities in Jimma Zone with a 100% retrieval rate. Of these, 109(28%) medical records were from the Seka Chekorsa district. (Figure 1)
Input attribute of quality
The number of staff in the medical record department in Seka chekorsa district was (19). Educational status of the medical record department 2(40%) certificate holders in the Choraboter district and 5(63%) diploma holders in the Tiro Afeta district, and 7(78%) of medical record staff complete grade ten in the Shebe district. The majority of medical record personnel in the selected districts don’t have both computer skills 56(80%) and in service training 52(74%) on medical records-related topics. (Table 1)
Thirty-six facilities were checked for the availability of the necessary equipment and formats for recording, processing, documenting, filing, and retaining medical records. Photocopy machine was not available in all 36 facilities among 36 facilities only one facility have printer in the record room. (Table 2)
Among the thirty-six observed facilities, 33(92%) of them had medical record units, 22(61%) of them had adequate space to handle medical records, 7(19%) of them had isolated passive medical record units, 21(58%) of them had medical recording unit that serves for 24hrs and only 5(14%) of the facility had lockable shelves for medico-legal cards. (Table 3)
Process attribute of quality
Out of thirty-six facilities 28(78%) of them collect and shelves folder back daily to the medical recording unit, only 2(6%) of the facilities use tracer card system, 11(31%) of the facilities integrate all patient records in an individual folder, 17(47%) of the facilities complete summary sheet correctly and 36(100%) of them provide medical record number to each patient. (Table 4)
Outcome attributes of quality
Ease of retrieving medical records
The mean time to retrieve the medical records from the shelves was 3.4 ±3.52 minutes with a minimum time of 1 minute and a maximum time of 33 minutes.
Completeness of medical records
Three hundred eighty-four medical records were reviewed for completeness of administrative data. Of these, 381(99%) of the title and name of the health center were recorded, 18(5%) date of birth recorded and 12(17%) of the mode of arrival were recorded in their medical record. (Table 5)
Three hundred eighty-four medical records were reviewed for the completeness of clinical data. Of these, 307(80%) of the records were presenting problem/complaint recorded, and in 217(57%) of the records medication and diet were recorded. (Table 6)
Regarding the component of legal and financial data out of three hundred eight-four reviewed medical records document 49(13%) of them were investigation fees recorded, in 19(5%) of the service fee and 8(2%) of them were medication fees recorded. (Table 7)
District Level completeness of medical records
Accordingly, to assess the completeness of medical records to each major section of components, the identified necessary contents of the section was calculated as follows: Total contents completed in each section of the study (Yes’s) divided by total revised medical records multiplied by the number of variables in each section (the number of contents/variables in each of the section). It is reported as % completeness of the medical record. The overall completeness of the medical records was assessed for all reviewed documents in the studied districts:
Administrative data completeness = total contents / total reviewed medical records × by number of factors in each section
Clinical data completeness = total contents / total reviewed medical records × by the number of factors in each section
Legal and financial data completeness = total contents / total reviewed medical records × by the number of factors in each section
Average mean of all components completeness of medical records in percentage =
The overall completeness of the medical records in the studied districts = 30.62%
For the qualitative part, 33 participants were interviewed by using face-to-face in-depth interviews. During an interview, the responses were recorded and the interviewers have taken notes. The responses are summarized in 3 sections.
Input attribute of quality
Most of the interviewees expressed that the presence of many problems regarding medical record-keeping such as lack of trained recording personnel, assigning other or untrained record personnel in the medical record unit, lack of training on the medical records, patient load, and the patient not had enough awareness on proper handling of service identification card. The shortage of different recording formats like MPI cards, ANC charts, tracer cards, and currently available folder has poor quality in terms of thickness as that of the previously used one. Shortage of shelves, Lack of functional computer and the recording system is not an online computer-based system due to the shortage of budgets. A34 year’s old male said that “we face repeatedly similar problems such as lose recorded history, their individual medical folder, and service identification cards”.
All study participants elaborated that lack of standard card room, a need to refurnish shelves, a need to reconstruct the card room, lack of an isolated passive medical record room. None of the card rooms have a lock. Sometimes there is a loss of medical records of the patient’s medico-legal records, because of not handled properly and the room is not locked.
A36 and 29 years old male and female record personnel said that “we ask so many times the head of HC in order to purchase the MPI cards but still the cards not printed”.
Process attribute of quality
All of the study participants describe done patient comes to their facility, it should be identified whether he/she visits the facility previously after that they provide medical record number accordingly. As much as possible all the available formats are used, the necessary information is registered in a single unified central registration book and patient forms are attached to the individual medical folder then transferred to OPD and again in the next day they check the presence of the history sheet and another necessary format before returning back to record room after that they place properly based on its unique MRN in the shelves. A folder is assigned to each individual medical record of the clients.
A 26 years old female with three years of experience said that “most of the time we face the difficulty of getting individual medical records from the shelves, the clients lost their service identification card while coming for another visit due to this they may stay a long time and they complain”.
In this regard, respondents of the qualitative part elaborated that they check-in and checkout medical records that exist from the medical record unit by using an isolated registration book to check whether the medical records returned back or not to MRU. In addition, they use the date of registration on a summary sheet. Some of the respondents expressed that as they are using the tracer card system but not continuously. There is no established medical record auditing system as per facilities standards. But some of the facilities conduct auditing with the insurance scheme team while they work on clinical auditing for payment on a quarterly basis but as such not continuous.
A 27 years old female record personnel with three years’ experience said that “as standard all facilities needed to use tracer cards. But, we are not using tracer cards due to lack of the card instead of that we are using the information on summary sheet”.
A 37 years old male with fifteen years’ experience said that “we have tried to audit those records stay more than five years in the medical record unit, But all records not audited because of many medical records stored in the medical record unit for the long period that are not audited in regular basis”.
Outcome attributes of quality
Ease of retrieving medical records: All participants of the in-depth interview mentioned that most of the time they face difficulty to found the folder in a short time easily due to different reasons like the patient lost (forget) the services cards, wash the service card with their clothes when the patient cannot place service card safely, and the medical records not returned back daily to the medical record unit from service area. A 36 years old male record personnel who has six years of work experience said that “I remember that many days individual medical record of chronic patient lost from shelve then replaced by other medical records”.
Most study participants were elaborated, difficult to get easily the information lost from the folder most of the time the problem arises from the client’s side they always lose their service card due to this they obligated to give them new MRN.
A 32 years old male who has six years of work experience said that “everybody’s is responsible in the proper handling of an individual medical record, for example, those card room workers need to have handled and placed properly, the health worker must record the necessary information completely and accurately, and also the administrative body of the health center must fulfill the different formats and materials timely”.
Participants of the in-depth interview elaborated that on a quarterly basis they conduct surveys by using the checklist that is prepared to review a sample of records to see the proper generation, completion, and filing of patient records. But, as such not continuous or not in an organized manner for example somebody may enter both in the medical record room and OPD to check the generation of the MRS, completion of different formats and filled appropriately or not and in monthly basis while taking monthly report they check the sample of records with the quality team and with partners.
All participants of the qualitative part responded that to improve the quality of medical records trained recording personnel must be assigned in the record room, necessary materials need to be fulfilled as per the standard, need to construct standard medical record unit, the patient record need to be placed in a safe place and necessary information should be completed in every patient’s records.