ASSESSING THE DIMENSIONS OF HOSPITAL RECORDS (MEDICAL RECORDS) IN DELIVERING QUALITY OF SERVICE TO PATIENTS

ABOUT AUTHORS
Kenneth Amoah-Binfoh1, Collins Marfo Agyeman2, Pradhyuman Singh Lakhawat1
1 Dept. of Business Studies,
SHUATS University, Allahabad, U.P, India.
2
Dept. of Business,
All Nations University, Koforidua, Ghana.

ABSTRACT
Medical records through which hospital statistics are generated serve as eyes and ears to the hospital administrator. Medical records are of importance to the hospital for evaluation of its services for better patients care. Failure of duty towards the patient is failure to maintain proper medical records. Recently, medical records have become very importance in the area of education and training of physicians and others being the basis for clinical research. Medical records make research effective and require scientific observational records. Medical records as perceived to be the instructions documented in a patients file serve as a means of communication between the physicians and other health professionals caring for the patient. The essence of medical record is to ensure continuity of care. Ensuring continuity of care means medical records must be comprehensive, planned, economical, time-honored and classified in a right way. Managing these records are found concerned with several types of problems. The record keeping, making use of the records, destroying the old records of no use; documenting the important records found useful to the researchers and the medical scientists. The objectives of this paper were to find the challenging dimensions of medical records in delivering quality of service to patients and to identify the significant role of medical records in delivering quality service to patients. The researchers employed systematic sampling with a population of about 123 which included nurses, medical records and admission office (clinic-administrative departments) with a desired sample size of 60. It was found that creating as one of the dimensions of medical record was very difficult to do. It was recommended that indexing or cataloguing should be more innovative and simple within time limit, so that the required papers or records are easily made available to the concerned person.

Reference Id: PHARMATUTOR-ART-2598

INTRODUCTION
According to (Amoah-Binfoh et al. 2017) in their research reported that, managerial polices, techniques and industrial development has lagged behind due to ineffective administrative functions of hospitals. The hospital administration continues to make ad hoc arrangements rather than having a carefully planned administrative policy.  You can rectify your mistakes when you are aware of them. Management of hospitals is supposed to manage the present and future for the medical records. They are required to file and document the hospital records. Hospital records especially medical records are useful to the researchers and medical scientists. Globally, the Information Technology revolution has provided benefit to all sectors including healthcare. Management of hospital records is found significant not only the viewpoint of making available to the different persons and agencies information pertaining to the working of hospitals; but also with the motto of evaluating the performance of hospital personnel serving the different department. If you manage hospital records scientifically and in a systematic fashion; your task of making possible qualitative improvements is considerably simplified. In short, good access to healthcare, and access to enhanced healthcare is not enough when the records are not properly kept. Good clinical records are a prerequisite of delivering high-quality, evidence-based healthcare, particularly where several different clinicians are contributing simultaneously to patient care. Unless everyone involved in clinical management has access to the information they require, duplication of work, delays and mistakes are inevitable. Records may be held electronically or manually, or a mixture of both. If essential information is missing, found to be inaccurate or indecipherable, cases may be lost when they could otherwise have been won.

Objectives
1. To find the challenging dimensions of medical records in delivering quality of service to patients
2. To identify the significant role of medical records in delivering quality service to patients

Literature review
Hospital records
McGibony (1952)  stated that, hospital record is a chronicle of the pageantry of medical and scientific progress found in the hospital. The viewpoints of McGibony make it clear that the records of hospital present a true story of events in which the doctors, researchers, managers, medical scientists taking interests in the problem find everything they need. It has been explained by Goel et al. (2002)  that, in hospital or healthcare organization, they are considerable number of records for different purpose. It is quite natural that all records don’t carry equal signification. He classified four major hospital records into the following;
1.Vital Records: in the first category, this record related to critical results, projection of wonderful result by the personal, innovative efforts of doctors in treating the patients, case of fraudulent preferences etc. carry outstanding significance till the existence of hospital. For references or for carrying on research, the records help substantially to the researchers, doctors, medicals scientists and other evincing interests in promoting research.
2. Important Records: In this category, records are useful for future or for undertaking research. A hospital manager bears the responsibility of making available to the researchers the feedback or back up material for reference. Provision for computers, ensures the information is stored in the memory and if not the documentation would be required.
3.Useful Records: In this category, records based on correspondence between the personnel of the hospital and the client which may include patients, attendants, and suppliers of distinct types of material or any useful correspondents for records keeping. 4. Transit Records: the record in this category is found of current of temporary use. This makes it essential that a hospital manager keeping in view the period limit make suitable arrangement for their documentation. It is also important that after the time limit, the record is destroyed.

Dimensions of Hospital Records Management
The dimensions of hospital records have five different phases. It’s against this phases that a hospital manager is required to be careful at the different stage of managing the hospital records. However, with the development of information technology, a hospital manager finds it convenient to manage the hospital records better. The following are the dimensions of hospital records;   
1. Creating the Hospital Records: this is the first constituent or dimension of records management which draw an attention on the development of filling system, indexing, and cataloguing, record keeping in view of the requirements of different department for which the records are created. The creation focuses attention on the system adopted and quality promoted for the said purpose.
2. Administering the records: this is the second dimension of the management of hospital records which gravitates our attention the implementation of the system of developing records that you have created. Irrespective of the fact that it is technology driven or manual driven, you need to make it sure that the system is functioning on our direction and instruction.
3. Retaining the hospital records: since hospitals face the problem of space constraint, it is right that a microscopic analysis of the facts that how and in what way, the record are to be retained for future reference. While making classification of hospital records, some of the records are vital, important whereas some of the records are of temporary use.
4. Submitting the records: this is the first stage before you take a decision to destroy the records. This dimension of the management of hospital records make it essential that being a hospital manager, you come to know about the rationale behind documenting the same or storing the same in the memory of your computers.
5. Destroying the hospital records: This dimension of records management is found occupying an outstanding place because once you take a decision, you are not able to make use of the same. This makes it essential that before taking a decision regarding the destroying of the records, you consult different heads of department and in consultation with them take a final decision.

Concept of medical records
According to Stedman's (Medical Dictionary 2002), defined medical record as a  chronological written account of a patient's examination and treatment that includes the patient's medical history and complaints, the physician's physical findings, the results of diagnostic tests and procedures, and medications and therapeutic procedures. Patient care includes a chronological record of care and treatment, namely medical records. Accurate and adequate medical records are very important for clinical, legal, fiscal and research purposes and is based on the principle ‘people forget, but records remember’ Medical Records Department is a very important department in every hospital. (Natarajan 2010), in her book, explained that, medical record is a storehouse of knowledge concerning the patients; it’s a standard measure of quality of work done by the physicians and hospital personnel. In simple terms, a medical record, health record or medical chart is a systematic documentation of a patient’s medical history and care. Medical record is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient’s health history. The life and health of every patient depends on the Hospitals and management of records. An effective medical care depends on the skills and competency of doctors and nurses and on high-sophisticated quality facilities and equipment. Without precise, complete up-to-date and available medical records, medical personnel may not offer the best treatment or may in fact misdiagnose a condition, which can have severe consequences.  (Haux 2006)  explained that, any records for patients kept confidential by healthcare professional or organization. The medical record contains the patients personal details (address, name, gender, date of birth) a summary of the patient's medical history, and documentation of each event, including physical examinations, symptoms, provisional  diagnosis, treatment, progress report and outcome. Other pertinent documents and correspondence (like referrals, consultancy reports) are also included.

Content of medical records
According to (Natarajan, 2010), said, though medical records content may vary depending upon specialty and location. In the matter of time different scholars like (Berg, (2001)WHO(2003,2006) &Huffman 2001)  because of advance form of research,  identified the following intellectual and physical items as in whole or in part, which make up the contents of a patient’s Medical Record:

Non-Medical 

Medical history and encounters

 


Demographics: Name, Address


Doctor’s clinical notes


Medications and medical allergies


 contact numbers, race, religion Nationality ,family history


Recording of discussion with patient


Imaging records and reports Clinical Photographs


Social history: workplace,  


next of kin regards disease


Consent Forms, At-Own-Risk Discharge Forms


Occupation, career, school 


Referral Notes to other specialist


Operation Notes/Anaesthetic Notes


 


Nurses’ Reports, Video Recordings


Printouts from monitoring equipment (e.g. Electro-cardiogram, Electro-encephalogram)


 


Surgical history


Physical examinations, progress notes

Types of medical records
In 2005 Desouza   in his research asserted that, the increase in population, escalating number of patients and the new diseases and symptoms necessitate healthcare industry to deal and control enormous amounts of data and information. Medical Records form an essential part of any medical practice since it facilitate quality care for patients as well as a critical point of contact for  any future dispute or investigation or legal issues.  However, according to (Durking, 2006)  posited that, there are different types of medical records normally found in hospitals; this statement was elaborated by (Durking,2006) when he itemized medical record which includes:

Types

 

Types of form


Patient History and Examination report 


 Clinical notes


Core forms: discharge summary, operative notes, doctors and nurses records 

Diagnostic forms : X-ray, ECG

Department specific forms : outpatients and inpatients


Consultation report, Operative report


Autopsy report


Radiology report, Pathology report


 Biopsy report


SOAP note report (Subjective, Objective, Assessment & Plan notes


Psychiatric observations


Emergency report, Laboratory report


X-ray report, Daily report


Progress note report, Therapy report


Scan report,  Referral letters

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