The Quality of Medical Records and Health Information in Primary Health Care Units in Hadiya Zone, Ethiopia

Martha Gebreyohannis Selamu; Liranso Selamu

doi:doi:10.11648/j.ajnhs.20230401.14

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The Quality of Medical Records and Health Information in Primary Health Care Units in Hadiya Zone, Ethiopia

Martha Gebreyohannis Selamu, Liranso Selamu

Published in American Journal of Nursing and Health Sciences (Volume 4, Issue 1)

Received: 24 December 2022 Accepted: 30 January 2023 Published: 15 March 2023

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Abstract

Health information is an essential factor of public health performance depends on the effectiveness of documentation use for routine and evidence based decisions. Medical record is the chronological, organized and comprehensive documentation of services delivered by service providers to the patients or clients. On the other hand, the quality of medical records (MRs) is rarely evaluated and quality dimensions of medical record are not well assessed particularly in the study area as well as in Ethiopia. The study was assessed the quality of medical record in public health care units of Soro district, Hadiya Zone, Southern Ethiopia. Facility based cross- sectional study design supplemented with qualitative inquiry was conducted among randomly selected four public health care units (PHCU) in Soro district, Hadiya zone. Data on the quality of medical records were collected by reviewing document using checklist, while qualitative data for triangulation were obtained by interviewing key informants from the health center and to describe possible reasons for poor medical record quality. The data were entered in to Epi-data version 3.1, exported, and analyzed by SPSS version 22.0. A total of 384 medical records were reviewed from one-year medical records of four public health care units with 98% retrieval rate. Among the dimensions of MRs quality, none of health centers had enough facility for medical record quality and no auditing of medical record document as of the standard. Majority of medical records had incomplete administrative, clinical and legal components as of health centers standard of the country. The studied PHCUs are not fulfilled the national medical record management requirements to run medical record system of health centers since the Ethiopian PHCUs standard set the medical record personnel to be a health information technician and a minimum of three in numbers. Thus, medical record service providers should be trained and necessary supplies should be equipped in all health center.

Published in	American Journal of Nursing and Health Sciences (Volume 4, Issue 1)
DOI	10.11648/j.ajnhs.20230401.14
Page(s)	19-23
Creative Commons	This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.
Copyright	Copyright © The Author(s), 2023. Published by Science Publishing Group

Keywords

Quality, Medical Records, Health Care, Health Information, Ethiopia

References

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[2]	Bennett Sara., editors. World Health Organization, author. Sound Choices: Enhancing Capacity for Evidence-informed Health Policy. ISBN 978 92 4 159590 2 (NLM classification: WA 540. 2002. pp. 1.
[3]	National Healthcare Records Management Advisory Group. Health Service Executive. Standards & Recommended Practices for Healthcare. Records Management. Ireland. May 2011.
[4]	Ministry of Health. Policy Directive, Health Care Records - Documentation and Management. 73 Miller Street North Sydney NSW 2060, Publication. 2002. p. 2 http://www.health.nsw.gov.au/policies/.
[5]	WHO 2003. Improving Data Quality, A Guide for Developing Countries. 2003.
[6]	Health M. Overview of the Sector. 2013; Available from: http://www.moh.gov.et/English/Information/Pages/Overview%20of%20the%20Sector.aspx.
[7]	Federal Democratic Republic of Ethiopia. Ministry of Health, Health Sector Development Program IV In linewith GTP 2010/11 – 2014/15. 2010.
[8]	Waju B. Health care quality management, unpublished teaching material of Jimmauniversity. 2018.
[9]	Bradley E, Hart Wig KA, Laura A, Rowe A, Emily J. et al. Hospital quality improvement in Ethiopia: a partnership–mentoring model. Int J Health Care; 2008; 20 (6): 392–399.
[10]	Kiviri W, Wong R, Davi C, Rahim L, Nyirasebura D, Bizimana T. Improving Patient Medical Record Organization in a Hospital Intensive Care Unit in Rwanda. Global Journals Inc. (USA). 2015; 15: 13.
[11]	MOH 2016. Ethiopian national health care quality strategy: Transforming the Quality of Health Care in Ethiopia.
[12]	Ejigu E, Tadeg H. Development of the National Minimum, Standards for Healthcare Facilities in Ethiopia. A Milestone for Country Ownership and Sustainability of Best Practices. June 2014.
[13]	Tola K, AbebeH, Gebremariam Y, Jikamo B. Improving Completeness of Inpatient Medical Records in Menelik II Referral Hospital, Addis Ababa, Ethiopia. Advances in Public Health Volume 2017, Article ID 8389414, 5 pages. https://doi.org/10.1155/2017/8389414.
[14]	Health Center-Requirements. First Edition. Ethiopian Standard. First edition ES 3611: 2012. Pp 87.
[15]	Central Statistical Agency: Statistical Abstract. Ethiopia: projection report. 2018. Addis Ababa.
[16]	Mohammed N, Kumie A, Curry L. Thesis on: Improving the completeness of medical records at inpatient department of Dalefage Primary Hospital, west Afar, Ethiopia. School of Graduate Studies of Addis Ababa University, 2014. p6.
[17]	Anwar WA, Abo El Ezz, NF, Elhossiney, DM, Abd Allah RA. Measurement of Completeness of Medical Records in Family Health Centre in El Shorouk City. The Egyptian J Comm Med. 2016; 34 (3): 69-77.
[18]	Clinician’s Guide to Record Standards – Part 1: Why standardize the structure and content of medical records? Royal College of Physicians, Published by the Digital and Health Information Policy Directorate October 2008. Gateway number 10508.

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APA Style

Martha Gebreyohannis Selamu, Liranso Selamu. (2023). The Quality of Medical Records and Health Information in Primary Health Care Units in Hadiya Zone, Ethiopia. American Journal of Nursing and Health Sciences, 4(1), 19-23. https://doi.org/10.11648/j.ajnhs.20230401.14

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ACS Style

Martha Gebreyohannis Selamu; Liranso Selamu. The Quality of Medical Records and Health Information in Primary Health Care Units in Hadiya Zone, Ethiopia. Am. J. Nurs. Health Sci. 2023, 4(1), 19-23. doi: 10.11648/j.ajnhs.20230401.14

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AMA Style

Martha Gebreyohannis Selamu, Liranso Selamu. The Quality of Medical Records and Health Information in Primary Health Care Units in Hadiya Zone, Ethiopia. Am J Nurs Health Sci. 2023;4(1):19-23. doi: 10.11648/j.ajnhs.20230401.14

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@article{10.11648/j.ajnhs.20230401.14,
  author = {Martha Gebreyohannis Selamu and Liranso Selamu},
  title = {The Quality of Medical Records and Health Information in Primary Health Care Units in Hadiya Zone, Ethiopia},
  journal = {American Journal of Nursing and Health Sciences},
  volume = {4},
  number = {1},
  pages = {19-23},
  doi = {10.11648/j.ajnhs.20230401.14},
  url = {https://doi.org/10.11648/j.ajnhs.20230401.14},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ajnhs.20230401.14},
  abstract = {Health information is an essential factor of public health performance depends on the effectiveness of documentation use for routine and evidence based decisions. Medical record is the chronological, organized and comprehensive documentation of services delivered by service providers to the patients or clients. On the other hand, the quality of medical records (MRs) is rarely evaluated and quality dimensions of medical record are not well assessed particularly in the study area as well as in Ethiopia. The study was assessed the quality of medical record in public health care units of Soro district, Hadiya Zone, Southern Ethiopia. Facility based cross- sectional study design supplemented with qualitative inquiry was conducted among randomly selected four public health care units (PHCU) in Soro district, Hadiya zone. Data on the quality of medical records were collected by reviewing document using checklist, while qualitative data for triangulation were obtained by interviewing key informants from the health center and to describe possible reasons for poor medical record quality. The data were entered in to Epi-data version 3.1, exported, and analyzed by SPSS version 22.0. A total of 384 medical records were reviewed from one-year medical records of four public health care units with 98% retrieval rate. Among the dimensions of MRs quality, none of health centers had enough facility for medical record quality and no auditing of medical record document as of the standard. Majority of medical records had incomplete administrative, clinical and legal components as of health centers standard of the country. The studied PHCUs are not fulfilled the national medical record management requirements to run medical record system of health centers since the Ethiopian PHCUs standard set the medical record personnel to be a health information technician and a minimum of three in numbers. Thus, medical record service providers should be trained and necessary supplies should be equipped in all health center.},
 year = {2023}
}

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TY  - JOUR
T1  - The Quality of Medical Records and Health Information in Primary Health Care Units in Hadiya Zone, Ethiopia
AU  - Martha Gebreyohannis Selamu
AU  - Liranso Selamu
Y1  - 2023/03/15
PY  - 2023
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DO  - 10.11648/j.ajnhs.20230401.14
T2  - American Journal of Nursing and Health Sciences
JF  - American Journal of Nursing and Health Sciences
JO  - American Journal of Nursing and Health Sciences
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PB  - Science Publishing Group
SN  - 2994-7227
UR  - https://doi.org/10.11648/j.ajnhs.20230401.14
AB  - Health information is an essential factor of public health performance depends on the effectiveness of documentation use for routine and evidence based decisions. Medical record is the chronological, organized and comprehensive documentation of services delivered by service providers to the patients or clients. On the other hand, the quality of medical records (MRs) is rarely evaluated and quality dimensions of medical record are not well assessed particularly in the study area as well as in Ethiopia. The study was assessed the quality of medical record in public health care units of Soro district, Hadiya Zone, Southern Ethiopia. Facility based cross- sectional study design supplemented with qualitative inquiry was conducted among randomly selected four public health care units (PHCU) in Soro district, Hadiya zone. Data on the quality of medical records were collected by reviewing document using checklist, while qualitative data for triangulation were obtained by interviewing key informants from the health center and to describe possible reasons for poor medical record quality. The data were entered in to Epi-data version 3.1, exported, and analyzed by SPSS version 22.0. A total of 384 medical records were reviewed from one-year medical records of four public health care units with 98% retrieval rate. Among the dimensions of MRs quality, none of health centers had enough facility for medical record quality and no auditing of medical record document as of the standard. Majority of medical records had incomplete administrative, clinical and legal components as of health centers standard of the country. The studied PHCUs are not fulfilled the national medical record management requirements to run medical record system of health centers since the Ethiopian PHCUs standard set the medical record personnel to be a health information technician and a minimum of three in numbers. Thus, medical record service providers should be trained and necessary supplies should be equipped in all health center.
VL  - 4
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Author Information

Martha Gebreyohannis Selamu

Hadiya Zone Health Department, Health Plan, Monitoring, and Evaluation Directorate, Hossana, Ethiopia
Liranso Selamu

Department of Psychology, Michigan State University, East Lansing, The United States

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APA Style

Martha Gebreyohannis Selamu, Liranso Selamu. (2023). The Quality of Medical Records and Health Information in Primary Health Care Units in Hadiya Zone, Ethiopia. American Journal of Nursing and Health Sciences, 4(1), 19-23. https://doi.org/10.11648/j.ajnhs.20230401.14

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ACS Style

Martha Gebreyohannis Selamu; Liranso Selamu. The Quality of Medical Records and Health Information in Primary Health Care Units in Hadiya Zone, Ethiopia. Am. J. Nurs. Health Sci. 2023, 4(1), 19-23. doi: 10.11648/j.ajnhs.20230401.14

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AMA Style

Martha Gebreyohannis Selamu, Liranso Selamu. The Quality of Medical Records and Health Information in Primary Health Care Units in Hadiya Zone, Ethiopia. Am J Nurs Health Sci. 2023;4(1):19-23. doi: 10.11648/j.ajnhs.20230401.14

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@article{10.11648/j.ajnhs.20230401.14,
  author = {Martha Gebreyohannis Selamu and Liranso Selamu},
  title = {The Quality of Medical Records and Health Information in Primary Health Care Units in Hadiya Zone, Ethiopia},
  journal = {American Journal of Nursing and Health Sciences},
  volume = {4},
  number = {1},
  pages = {19-23},
  doi = {10.11648/j.ajnhs.20230401.14},
  url = {https://doi.org/10.11648/j.ajnhs.20230401.14},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ajnhs.20230401.14},
  abstract = {Health information is an essential factor of public health performance depends on the effectiveness of documentation use for routine and evidence based decisions. Medical record is the chronological, organized and comprehensive documentation of services delivered by service providers to the patients or clients. On the other hand, the quality of medical records (MRs) is rarely evaluated and quality dimensions of medical record are not well assessed particularly in the study area as well as in Ethiopia. The study was assessed the quality of medical record in public health care units of Soro district, Hadiya Zone, Southern Ethiopia. Facility based cross- sectional study design supplemented with qualitative inquiry was conducted among randomly selected four public health care units (PHCU) in Soro district, Hadiya zone. Data on the quality of medical records were collected by reviewing document using checklist, while qualitative data for triangulation were obtained by interviewing key informants from the health center and to describe possible reasons for poor medical record quality. The data were entered in to Epi-data version 3.1, exported, and analyzed by SPSS version 22.0. A total of 384 medical records were reviewed from one-year medical records of four public health care units with 98% retrieval rate. Among the dimensions of MRs quality, none of health centers had enough facility for medical record quality and no auditing of medical record document as of the standard. Majority of medical records had incomplete administrative, clinical and legal components as of health centers standard of the country. The studied PHCUs are not fulfilled the national medical record management requirements to run medical record system of health centers since the Ethiopian PHCUs standard set the medical record personnel to be a health information technician and a minimum of three in numbers. Thus, medical record service providers should be trained and necessary supplies should be equipped in all health center.},
 year = {2023}
}

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TY  - JOUR
T1  - The Quality of Medical Records and Health Information in Primary Health Care Units in Hadiya Zone, Ethiopia
AU  - Martha Gebreyohannis Selamu
AU  - Liranso Selamu
Y1  - 2023/03/15
PY  - 2023
N1  - https://doi.org/10.11648/j.ajnhs.20230401.14
DO  - 10.11648/j.ajnhs.20230401.14
T2  - American Journal of Nursing and Health Sciences
JF  - American Journal of Nursing and Health Sciences
JO  - American Journal of Nursing and Health Sciences
SP  - 19
EP  - 23
PB  - Science Publishing Group
SN  - 2994-7227
UR  - https://doi.org/10.11648/j.ajnhs.20230401.14
AB  - Health information is an essential factor of public health performance depends on the effectiveness of documentation use for routine and evidence based decisions. Medical record is the chronological, organized and comprehensive documentation of services delivered by service providers to the patients or clients. On the other hand, the quality of medical records (MRs) is rarely evaluated and quality dimensions of medical record are not well assessed particularly in the study area as well as in Ethiopia. The study was assessed the quality of medical record in public health care units of Soro district, Hadiya Zone, Southern Ethiopia. Facility based cross- sectional study design supplemented with qualitative inquiry was conducted among randomly selected four public health care units (PHCU) in Soro district, Hadiya zone. Data on the quality of medical records were collected by reviewing document using checklist, while qualitative data for triangulation were obtained by interviewing key informants from the health center and to describe possible reasons for poor medical record quality. The data were entered in to Epi-data version 3.1, exported, and analyzed by SPSS version 22.0. A total of 384 medical records were reviewed from one-year medical records of four public health care units with 98% retrieval rate. Among the dimensions of MRs quality, none of health centers had enough facility for medical record quality and no auditing of medical record document as of the standard. Majority of medical records had incomplete administrative, clinical and legal components as of health centers standard of the country. The studied PHCUs are not fulfilled the national medical record management requirements to run medical record system of health centers since the Ethiopian PHCUs standard set the medical record personnel to be a health information technician and a minimum of three in numbers. Thus, medical record service providers should be trained and necessary supplies should be equipped in all health center.
VL  - 4
IS  - 1
ER  -

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