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

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.