Quality of Medical Records and Patient Care in Kabale Regional Referral and Rugarama Hospitals.

Abstract

TIBEMANYA DAVID (2012-M191-10026) Quality of Medical Records and Patient Care in Kabale Regional Referral and Rugarama Hospitals There have been considerable attempts to standardise medical records management in Uganda because of the understanding that medical records are vital in ensuring quality health care. Despite the efforts, available evidence in Uganda shows that existing record keeping systems are still inaccurate and the quality of care in the health facilities also remains a key concern. This study was, therefore, conducted to: describe the process of medical records generation and management, establish the quality of medical records, establish the quality of patient care in the two hospitals and identify challenges faced in medical records generation and management. A descriptive research design using both qualitative and quantitative methods was used. The study was carried out from Kabale regional referral and Rugarama hospitals and it involved the review of 499 and 207 records from the IPD and OPD respectively, and interviewing 203 outpatients and 35 staff. This study found out that the process of generating and managing medical records in the two hospitals was collective, involving different categories of staff performing different roles. The process of medical records generation and management was found to start from obtaining bio-data from patients, examining patients, recording examination findings and classifying, filing, storing and retrieving the records. The quality of records especially those in the IPD in the two hospitals were found to be inadequate as indicated by about 68% of them being incomplete. Regarding the quality of care, this study has further indicated that the quality of care in both the OPD and IPD in both hospitals was generally good with Rugarama hospital being better than Kabale regional referral hospital for both IPD and OPD. This study has also demonstrated that there was no relationship between the quality of records and quality of care in the two hospitals. Based on the findings, this study recommends that the two hospitals need to: review and improve their medical records management systems and procedures, regularly build the capacity of staff for proper medical records management and better quality of care. The study also encourages the two hospitals to examine their quality of care with a view of having improvements in both the IPD and OPD. Key Words: Quality, Medical Records, Patient Care, Regional Referral Hospitals, Kabale, Rugarama, Districts