ASSESSMENT OF MEDICAL ACCOUNTS PRESERVATION IN KATSINA STATE GENERAL HOSPITALS
ABSTRACT
Medical records are created/ generated in health institutions during the process of treating patients as the Hospital clients. General Hospitals in KatsinaState have over the years generated and accumulated huge amount of medical records. Valuable as these records are, a lot are misplaced and mutilated in the Hospitals. The study came up with four research questions: what types of medical records have been stored, and devices used in storing medical records, the types of filing system adopted in the General Hospitals in Katsina State, and what methods are used in preserving medical records. A descriptive survey research design was employed for the study to find out how the selected General Hospitals effectively stored, preserved and file their medical records. The staff identified to be managing the medical records was 112. The study used Krejcie and Morgan table to determine the sample size which was 43. Forty three. (43} copies of questionnaire were distributed but 42 were filled and returned which gave a response rate of 97.8%. Data analysis of the bio-data variables were presented in frequencies and percentages. Answers to the three research questions were presented. The three research hypotheses were tested at 0.05 alpha level of significance and One-way ANOVA was used to test the hypotheses. The study revealed that good maintenance of medical records in any format largely depends on good storage, preservation and filing, while poor medical records maintenance resulted in misplaced and delayed access to patient’s records. The study concluded that medical records maintenance is not effective because of the manual system they are using in maintaining the records.
TABLE OF CONTENTS
Title Page——————————————————————————————- i
Declaration—————————————————————————————- ii
Certification————————————————————————————— iii
Dedication—————————————————————————————– iv
Acknowledgement——————————————————————————- v
Table of Contents——————————————————————————– vi
List of tables————————————————————————————- x
List of Abbreviations————————————————————————– xi
Abstract——————————————————————————————– xiii
CHAPTER ONE: INTRODUCTION
1.1 Background to the Study—————————————————————- 1
1.2 Statement of the Problem—————————————————————- 8
1.3 Research Questions———————————————————————— 9
1.4 Hypotheses ——————————————————————————– 9
1.5 Objectives of the Study—————————————————————– 10
1.6 Significance of the Study————————————————————— 10
1.7 Scope of the Study———————————————————————– 11
1.8 Operational Definition of the Term—————————————————— 11
References —————————————————————————- 12
CHAPTER TWO: REVIEW OF RELATED LITERATURE
2.1 Introduction – – – – – – – – – 14
2.2 Concept of Medical Records – – – – – – – 14
2.3 Maintenance of Medical Records- – – – – – – 16
2.3.1 Reasons for the Maintenance of Medical Records- – – – – 17
2.3.2 Storage of Medical Records – – – – – – – 18
2.4 Medical Records Filling System – – – – – – 22
2.4.1 Alphabetical Filing- – – – – – – – – 24
2.4.2 Numerical Filing – – – – – – – – 24
2.4.3 Alpha-numerical Filing – – – – – – – 25
2.5 Preservation of Medical Records – – – – – – 25
2.6 Summary of the Review – – – – – – – 30
References – – – – – – – – – 32
CHAPTER THREE: METHODOLOGY OF DATA COLLECTION
3.1 Introduction – – – – – – – – – 36
3.2 Research Methodsadopted for the Study- – – – – – 36
3.3 Population of the Study – – – – – – – 37
3.4 Sampling Techniques and Sample Size – – – – – 39
3.5 Instrument for Data Collection – – – – – – 40
3.6 Validity of the Instrument – – – – – – – 41
3.7 Reliability of the Instrument – – – – – – – 41
3.8 Procedure for Data Collection- – – – – – – 41
3.9 Procedure for Data Analysis- – – – – – – – 42
References – – – – – – – – – 43
CHAPTER FOUR: DATA PRESENTATION, ANALYSIS AND CONCLUTION
4.1 Introduction——————————————————————————– 45
4.2 Response Rates—————————————————————————- 45
4.3 Demographic Analysis of the Respondents——————————————- 46
4.4 Inferential Statistical Analysis———————————————————– 59
Null Hypothesis One ——————————————————————— 59
Null Hypothesis Two——————————————————————– 61
Null Hypothesis Three——————————————————————- 62
CHAPTER FIVE: SUMMARY, CONCLUSION AND RECOMMENDATIONS
5.1 Introduction ——————————————————————————- 63
| 5.2 Summary of the Study —————————————————————— | 63 |
| 5.3 Summary of the Major Findings —————————————————— | 63 |
| 5.4 Conclusion——————————————————————————– | 64 |
| 5.5 Recommendations of the Study—————————————————— — | 65 |
| 5.6 Contribution to Knowledge…———————————————————— | 65 |
| 5.7 Suggestions for Further Research—————————————————— | 66 |
| Bibliography—————————————————————————————- | 67 |
Appendices——————————————————————————————–72
LIST OF TABLES
| Table 3.1 Population of the Study————————————————————- | 38 |
| Table 3.2 Sample of the Study——————————————————————- | 40 |
| Table 4.1 Response Rate————————————————————————- | 45 |
| Table 4.2 Educational Qualification of Respondents————————————— | 47 |
| Table 4.3 Working Experience of Respondents———————————————- | 49 |
| Table 4.4 Types of Medical Records Managed———————————————- | 51 |
| Table 4.5 Devices used in Storing Medical Records—————————————- | 53 |
Table 4.6 Filing system of Medical Records———————————————— —— 55
Table 4.7 Preservation of Medical Records———————————————— —— 57
Table 4.8 Difference in the way Medical Record are Maintained———————- —— 59
Table 4.9Difference in the type of Medical Records Filing system Adopted————— 61
Table 4.10 Difference in the Methods used in Preservation of Medical Records———– 62
CHAPTER ONE INTRODUCTION
1.1Background tothe Study
Records are documents in either electronic or print format that serve as evidence of an activity or transaction performed by an organization that require retention for some periods. A records retention schedule is a document stipulating „the length of time a records series must be retained in active and inactive storage before its final disposition to permanent storage, preservation or
destruction(Bryan,2012) Adeniran (2006) defined records as all transactions of an organization within and outside, in performing its functions, kept for future reference that maintain the organization‟s history and ensuring continuity of the organization‟s activities.Records contain information that is valuable resources and important business assets. A systematic approach to the management of records is essential for organization to protect and preserve records as evidence of activities and transaction. University of Pretoria (2010) stated that records constitute information that is recorded in any form, created or received routinely in the course of organization‟s business or correspondences; and retained by the organization as evidence of such activities. The International Standard
Organization (2001) defined recordsas “information created, received andmaintained” as evidence and information by an organization or person, in pursuance of legal obligations or in transaction of business.
A medical record is record generated at the health institution during the process of treating patients as the hospital clients. These records are also known as Personal Health Record (PHR) and are usually characterized by amongst others, the nature and source of information contained. It is defined as “patient managed health records” (Clark and Meiris, 2006). Medical records are important documents meant basically for recording the treatment procedure for a patient. These records areimportant to both the patient and the doctor. It is the only crucial and effective weapon doctors use to counter the false claims of the patients when they file a case against them. As such, both outpatient treatment and impatient management should be documented completely and carefully by the health workers including all preoperative instructions, prescriptions and content recorded carefully (Consumer Protection Act, 1986). Clark and Meiris (2006) also underscored the point that the web–based Personal Medical Records (PMR), created during e-health services, assist clinicians with patients‟ engagement, lifelong health information coordination and information access to both patients and health service providers.
Personal Medical Records (PMR) brought about effective communication between patients and service providers, improves efficiency in medical practice and increased drug security via interaction and contra-indication checks. Properly preserved medical records will enable the evaluation of patient care, medical investigations and medically related administrative decisionmaking and problem-solving. This implies that records management is crucial to the successful management of the health services and it is deemed necessary for any health system, including an ehealth system.
Medical records exist in different forms or formats, irrespective of sex, age, or status. For effective and efficient health care delivery, different types of medical records are created so that the health need of patients with different health challenges is met. The medical records therefore, are powerful tools which allow the physician to track the patient‟s medical history and also identify problems or patterns that may help determine the course of health. They enable physicians to offer quality health to their patients. They are living documents that tell the history of patients and each encounter they have had with any health professionals involved in delivering any of the health services to the individuals/patients. Furthermore, a complete and accurate medical records will meet all legal, regulatory and auditing requirements when the need arise. (Public and Physician Advisory Services, 2012). Kukah (2005), listed medical records as identification records, clinical records, treatment notes, laboratory records, obstetrics records, new born records, ambler records, radiology, physiotherapy records, doctor‟s orders,and family planning records.It also includes any other document (record) created for the patient in the process of any health service delivery. These records are either created as the patient visits the health centre or received either by way of referral or transfer cases all for the purpose of rendering a particular health service delivery. Since these are records created by different health professionals for different purposes, they must then be well captured with content well and clearly stated so that the purpose will be achieved.
AccordingtoNgoepe (2004), sound records management is the heart of good public management since government services are dependent on access to information. This is because every single activity in government service requires accountability and transparency for proper governance. The State Records New South Wales (2004) emphasized that records are used to prove „what happened, why and by whom‟. Records service as a tool for easy accountability and are necessary to meet legal, financial and accountability requirements. In medical records, all the transactions performed during interaction between patients and service providers need proper management for accountability and also to meet legal, financial and administrative requirements. This implies that a successful health records system needs maximum support for proper records keeping and maintenance.
Both paper-based and electronic patients‟ medical records are created simultaneously as each patient consults. The paper format entails all information about the patients, such as personal detail like dates of consultation, financial status for consultation, prescriptions, diagnosis and treatments.
Electronic formats only cover the personal details such as dates of consultation and financial status
(whether the patient paid for consultation or still owe the hospital money)
The medical record is made up of a number of forms, which are all used for a specific purpose. The basic sets of forms in the inpatient medical records include:
- Front sheet or identification and summery sheet, which covers identification, final diagnosis, diseases and operation codes, and attending doctor‟s signature.
- Consent for treatment is often on the back of the front sheet and must be signed by the patient at the time of admission. There are two parts to this form. The first half of the form is a general consent for treatment and the bottom half is consent to release information to authorized persons.
- Correspondence and legal documents received about the patient, e g referral letter, requests for information e t c .
- Discharge summery, if required by the hospital/health authority.
- Admission note, including the patient‟s family medical history, the patient‟s post medical history, presenting symptoms,results of physical examination, provisional diagnosis(reason the patient came or was brought to hospital), proposed tests and care.
- Clinical progress notes recording the patient‟s daily treatment and reaction to that treatment written by the attending doctor and other health professionals;
- Nurses‟ progress notes recording daily nursing care including temperature, pulse and
respiratory charts, blood pressure charts e t c.
- Operation report if an operation occurred or operation performed;
- Other health care professional note, e g physiotherapy, social workers, e t c.
- Pathology reports including hematology, histology, microbiology, e t c.
- Other reports – x-ray, e t c.
- Orders for treatment and medication forms listing daily medications ordered and given with signatures of the doctor prescribing the treatment and the nurse administering it,
- Special nursing forms for observation of head injuries e t c.
Management ofmedical records is the art and science of managing all information relating to the operation of a health practice. This includes filing and storing patient charts, scanning, medical records, ensuring adherence to regulations and retention schedules, and managing the destruction of medical records after their retention period. Medical records management also involves effective administration of a practice of non-clinical information including accounting records, contracts, and other business-related documentation (Shoreline, 2007). Hospitals and other organization that manage their records properly are rewarded with several benefits. The benefits include, but not limited to, easy retrieval and access to records, ability to prevent and tract fraud and corruption, ease to follow informed problem-solving and decision-making and the protection of organizations against legal charges/claims (litigation). The organization is also able to comply with pieces of legislation as well as professional administration and accountability. Gerntholtz van Heerden and Vine (2007) endorsed that electronic medical records (EMRs) make records management even better since it enable a quicker and cheaper clinical documents compilation, patient summaries formation, information retrieval and diverse clinical information audits. Bhana (2008) states that records keeping are enabler since, without it, things like auditing and financial management will not be possible. Records can be used to support businessactivities, decision-making and accountability. Proper records management assists the organizations in preserving well-organized records in their business. This is due to the fact that a well-organized medical record has the following advantages;
- It enables the hospital to find right information easily and comprehensively;
- It enables the organization to perform its functions successfully and efficiently and in an accountable manner;
- It supports the business, legal, and accountability requirement of the organization ;
- It ensures the conduct of business in an orderly, efficient and accountable manner;
- It ensures the consistent delivery of services;
- It allows continuity in service delivery when staff leaves
- It supports and document policy formation and administrative decision-making
- It provides continuity in the event of a disaster;
- It protects the interests of the organization and the right of employees, clients and present and future stakeholders;
- It supports and document the organization‟s activities, development and achievements;
- It provides evidence of business in the context of cultural activity and contribute to the cultural identity and collective memory of the nation (National Archives and Records Service of South Africa,( 2007)
Records maintenance is an important phase in the records lifecycle. Records maintenance ensures orderly organization and storage of records so as to properly position them for easy retrieval for decision-making. Maintenance is the process of preserving a condition or situation or state of being preserved. Michael (2010), listed three types of maintenance operations: preventive, operational and corrective maintenance. In preventive maintenance, care and servicing by personal for the purpose of maintaining equipment and facilities in satisfactory operating condition, by providing for systematic inspection, detection, and correction of incipient failure either before they occur or before they develop into major defects. Maintenance includes tests, measurement, adjustment, and parts of replacement, performed especially to prevent faults from occurring. The primary goals of maintenance are to avoid or mitigate the consequences of failure of equipment or facilities/document. This may be by preventing the failure before it actually occurs with planned maintenance and condition based maintenance to achieve. It is designed to preserve and restore equipment and facilities reliability by replacing worn components before they actually fail.
Operational maintenance is the care and minor maintenance of equipment/ facilities using procedures that do not require detailed technical knowledge of the equipment‟s or systems function and design. This category of operational maintenance normally consists of inspection, cleaning, servicing, preserving, lubrication and adjusting as required.
Corrective maintenance is a maintenance task performed to identify, isolate, and rectify a fault so that the failed equipment, machine, or system can be restored to an operational condition within the tolerance or limits established for in-service operation (Morow, 2011).
Records maintenance therefore, is a very important aspect of records management program.This is because records need to be properly maintained in order to be organized and arranged for effective utilization. Records maintenance has occupied an important position in information management cycle. Records maintenance ensures orderly organization and storage of records so as to properly position them for easy retrieval for decision making In view of this, Steward (2005) observed that one sure way to cause chaos in an office is for administrators to leave materials, which should be put in their proper orders in files lying around because no one know how to maintain and get them into the system.
In many other organizational tasks or work activities, records maintenance is introduced for certain purposes, ensure availability of relevant and timely information. Relevant and timely information will always be available if records are properly maintained. Records maintenance is also there to improve compliance with legal and regulatory requirements and community expectations. The improvement of knowledge sharing, retention and access to organizational memory would also be guaranteed. Furthermore, it ensures better management of risks with the availability of evidence; providesevidence on organizational actions and decisions taken. Proper records keeping would also decrease storage, material and labor costs (Man, 2005, Swan; Cunningham: Robertson 2002; Carvalho, 2001).
Furthermore, Willis (2005) showed that with a sound and proper information and records maintenance system, the organization will have the ability to comply with the six key organizational requirements which are transparency, accountability, due process, administrative compliance, statutory and commonlawas well as the information security. Effective and proper records maintenance ensures that:
- .Complete records are protected
- .Records can be located when needed.
- .Records andnon-record materials and personnel papers are maintained separately.
- .Identification and retention of permanent records are facilitated.
- .Contribution is made to economy of operations by facilitating records disposition.
1.2 Statement of the Problem
Medical Records are vital assets in ensuring that health institutions are governed effectively and efficiently. The information recorded is eventually used to confirm the patients‟ health history during current and future consultations. The paces which are retrieved and served for this purpose determine the patient waiting time for the services which consequently impact on the quality of the service rendered by the health institution. For instance, United State Department of Health and Human
Services (2006) reported that in health service institutions, the ratio for missing medical records is 1:7. This means that for every seven patients consulting at the health institutions, one medical file would be missing. It can be deduced that this is the result of ineffective records maintenance.
Records in hospitals are also used to collect and validate statistical information daily. The statistics collected are used to regularly review the hospitals monthly performance in all activities. It is through proper records management that the data collected can be complete and accurate. To improve these,
Barry (2001) argued that organizations need to come up with an electronic system to comply with and implement electronic records management as a necessity. It is legitimate options are eventually cheaper in terms of money, time and energy to ensure speedy service delivery
Despite the fact that patient‟s records in hospitals are very vital, the researcher observed that patient‟s records inGeneral Hospitals in Katsina State were missing, misplaced, mutilated, or incomplete files. Wamukoya and Mutual (2005) stated that, poor records management is guaranteed to result in information gaps that lead to inadequate records and the loss of document heritage. As a result, cases of lost or misplaced patient‟s medical records/documents as well as mutilated or incomplete files become common occurrences. This and other reasons prompted the researcher to assess the records maintenance in Katsina State General Hospitals.
1.3Research Questions
The study addressed the following research questions: –
- What types of medical records are being stored inGeneral Hospitals ofKatsinaState?
- What types of devices are used in storing medical records in General Hospitals of Katsina State
- What types of medical records filing system are adopted in the GeneralHospitals ofKatsinaState?
- What methods are used in preserving medical records in General Hospitals of KatsinaState?
1.4 Hypotheses
The following null hypotheses were advanced to guide the research:
HO1: There is no significant difference in thetypes of medical records stored in General Hospitals ofKatsina State.
HO2There is no significant difference in the devices used in storing medical records in General Hospitals of Katsina State.
HO3: There is no significant difference in the filing system of medical recordsadopted in General
Hospitals ofKatsina State.
HO4: There is no significant difference in the method used in preserving medical records in General Hospital ofKatsina State.
1.5 Objectives of the Study
The followingwere the objectives of the study
- To identify the types of medical records stored in General Hospitals of Katsina State.
- To find out the devices used in storing medical records in General Hospitals of Katsina State
- To identify the types of filing systemfor medical records adopted inGeneral Hospital ofKatsina
State.
- To find out the method used inpreserving medical records in General Hospitals of
Katsina State
1.6Significance of the Study
The study was deemed to be significant to the General Hospitalsin Katsina State because it would provide analysis of records management and demonstrate the shortcomings of current records keeping practices of the General Hospitals in KatsinaState, Ngolube (2003) stated that “research into records management trends and practices can lead to a better understanding of records management problems and challenges, as well as providing solutions to what is done, and how resources should be used.” This research however, was expected toprovide solutions to the challenges that exist in the maintenance of medical records in the selected General Hospitals in Katsina State. Finally, the research would contribute to the body of knowledge especially in areas of storage, filing, preservation and general maintenance of medical records.
1.7 Scope of the Study
. This study covered some selected General Hospitals of Katsina State which includethe following local Government where the General Hospitals are situated:Katsina, Daura, Dutsinma, Kankara, Mani, and FuntuaGeneral Hospitals..
1.8Operational Definition of Terms
The following terms were defined operationally to ease their understanding and usage in this study.
Assessment: is the act of judging how medical records are maintained in Katsina State General Hospitals.
Medical Records:these are the types of records generated or received at the health institutionin Katsina State during the process of treating patients as the hospital clients.
Records: These are documented information ineither electronic or print format that serve as evidence of the activities or transaction inKatsina State General Hospitals
Record Maintenance: -Is the process of preserving medical records in Katsina State General Hospitals.
RecordsManagement:The systematic control of all records in Katsina State General Hospitals from their creation or receipt through processing, distribution, organization, and retrieval to their ultimate preservation and disposition.
Record Maintenance: -Is the process of preserving medical records in Katsina State General Hospitals.
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ASSESSMENT OF MEDICAL ACCOUNTS PRESERVATION IN KATSINA STATE GENERAL HOSPITALS