Abstract
After studying the professional practices related to the management of medical records in Kuwaiti hospitals, it became utterly evident that there is inadequate understanding about maintaining the health information of patients. This dire situation is further compounded by the absence of official regulations established by the Ministry of Health for hospitals to effectively assess and manage medical records. Through this study, the researchers aimed to assess the medical records system in multiple healthcare settings in Kuwait, comprising government, private, and oil sectors. The study was carried out from May 2019 to July 2020 and used a self-developed, pilot-tested questionnaire measuring various aspects of the medical records management system. A total of 98 participants responded to the survey. The study results revealed that 43% of hospitals were using paper-based medical records, as compared to 53% that used both paper-based and electronic media. Moreover, 40% of hospitals in Kuwait did not adhere to the Ministry of Health policies regarding medical records disposition; instead, they developed their own hospital-based disposition policy. Moreover, the study findings showed that there were clear discrepancies in record retention policies among the participating hospitals, and the duration of record retention varied from 2 years, 5 years, 10 years, and more than 20 years across hospitals in Kuwait. In conclusion, national policies and guidelines need to be established to monitor the medical record systems in Kuwaiti hospitals to further enable better patient care and improve healthcare facilities. Furthermore, it has become indispensable to develop and maintain electronic health records as they constitute an integral part of modern healthcare.
Highlights
In the present medical environment comprising a multidisciplinary team that provides care to a single patient, medical records or health information have become an indispensable part of clinical decision making [1]
Medical records are maintained in all healthcare settings, their quality is poor, despite national standards established by the Ministry of Health (MoH) [9,10], and is further exacerbated by inadequate regulatory bodies overseen by the MoH
The results of this study reveal that the policies and procedures of the health information management system (HIMS) in Kuwait’s healthcare settings are nonuniform and withhold major gaps, lacking sufficiently trained staff for managing health information
Summary
In the present medical environment comprising a multidisciplinary team that provides care to a single patient, medical records or health information (paper or electronic) have become an indispensable part of clinical decision making [1]. Despite health records being a crucial aspect of healthcare, poor clinical documentation practices have been reported in certain countries [5,6]. Medical records are maintained in all healthcare settings, their quality is poor, despite national standards established by the Ministry of Health (MoH) [9,10], and is further exacerbated by inadequate regulatory bodies overseen by the MoH. A case in point is a study conducted in 1985 to assess the medical records in Kuwaiti hospitals, which revealed significant deficiencies in the quality of the medical records system, such as incomplete documentation, lost patient records, misfiled diagnostic reports, and unskilled workforces [10]. A later study conducted by Moghli confirmed that the identified gaps in the medical records system were still persisting in Kuwaiti hospitals [11]
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