Examination of health records documentation and management practices among health records personnel in two tertiary healthcare facilities in Enugu, South-East Nigeria

Abstract

Background: Availability of adequate, timely and accurate information on patients’ health records in line with standard procedures is critical for enhanced accessibility and utilization of relevant information for successful patients’ care. Poor records documentation and management practices adversely affect the quality and effective utilization of health information with negative consequences on healthcare delivery outcomes. The study aimed to examine the health information management practices among health records personnel in two teaching hospitals in Nigeria, for best practices and the extent of alignment to established standards.

Methods: The study adopted descriptive cross-sectional survey to examine the procedure for health records documentation and management in the two facilities. A semi-structured questionnaire was used to collect relevant information from respondents, selected by stratified proportionate random sampling technique, to answer the study questions on health records documentation and management practices and the extent of conformity to Standard Operating Procedures (SOPs), established by the Nigerian regulatory body. Data were collected and analyzed using descriptive and inferential statistics. Any procedure that scored below a criterion mean of 2.5 is considered substandard. Level of significance was set at 5%.

Results: A total of 142 respondents completed the questionnaires. Ages range from 20-56 years with majority (67.6%) as females. Less than half (44%) of the respondents could use information technology applications adequately, while only a few (21.8%) have undergone specialized training in health information management (HIM). More than half of the respondents (53.5%) do not have requisite qualifications in HIM, lacking opportunities for in-service training. The institutions operate mostly paper-based/manual system of health records documentation and management with unitary system of filing. A number of the procedures scored below the criterion mean of 2.5 indicating significant underperformance below acceptable standards especially at ESUTH. These include; Disease and procedure indexing (2.0); identification and reporting of notable diseases (2.13), attaching of deficiency slip to folder without discharge summary (2.38); weeding of inactive records (2.5); and referring for consultative services (2.5).

Conclusion: The study revealed sub-optimal performances in HIM practices among the health records personnel in the study facilities, with gaps in knowledge, infrastructure, policy and practice which is expected to negatively impact healthcare delivery. Findings underscore the need for engagement of qualified professionals, regular in-service training of health records staff as well as expanded use of electronic system in the facilities for enhanced flow of quality HIM, among addressing other identified deficiencies, for efficiency in health service delivery.