Practice of Nurses on Patient Record Management In Tertiary Level Hospitals

Abstract

Background: Patient record prescribed further state of health of the patient and determines the diagnosis of diseases by exerting the history. The study was conducted to assess the practice of patient record management among nurses in a selected government hospital, Dhaka, Bangladesh. Methods: A descriptive type of cross-sectional study was done among 214 respondents following convenient methods of sampling from Shaheed Suhrawardy Medical College Hospital (ShSMCH), Dhaka, Bangladesh from January to December 2020. Data were collected through face-to-face interview by using a pretested semi-structured questionnaire. Results: The study revealed that about 27% of the respondents were belonging to the 26-30 age groups and the mean ± SD of age was 35.16 ± 6.93. Most of the respondents 48% were diploma in nursing. Out of 214 respondents, the pattern of nursing documentation was always filled up by about 97%, documentation practice was taken manually by 55%, management of missing files was done by 33% of respondents, and confidentiality record kept access for authorized ones was mentioned by 58%. Keeping patient records after death was made by 34.2% of respondents and preservation of medico-legal files was stored on papers narrated by 90% of the respondents. The majority of the respondents 73.4% mentioned inadequate working knowledge as a barrier in medical history training. Conclusion: Practice of Nurses on patient record management may help the authority to identify any error in the patient care, self-evaluation, and assure the quality of care. The study has an immense value if it’s possible to develop the electronic data record-keeping system in every government hospital. JOPSOM 2021; 40(2): 38-43