The Quality of Medical Records Management in Public Health Facilities inthe Jimma Zone, Oromia Regional state, Southwest Ethiopia

Abstract

Background: Comprehensive medical records are the cornerstones for the quality and efficiency of patient care, as they can provide a complete and accurate chronology of treatments, patient results, and plans for care. The study aimed to assess the quality of medical records in public health facilities in the Jimma Zone.
Methods: A facility-based cross-sectional study design supplemented by a qualitative method was employed from May 30 - July 29, 2020. A total of 384 medical records were reviewed from 36 facilities using a facility inventory checklist. EPIData 3.1 software was used to enter the quantitative data, which was then analyzed using SPSS 23, and descriptive statistics were used to present the results. A thematic analysis approach was used for qualitative data which was finally triangulated with the quantitative data.
Result: 384 medical records were reviewed from thirty-six public health facilities in the Jimma Zone with a 100% retrieval rate. Among the 36 health facilities, only one had a printer in the record room and three (8%) had tracer cards. On completeness of the medical records, mode of arrival and date of birth were the least recoded data elements (17% and 5%), respectively.
Conclusion: The majority of health facilities had a shortage of trained and qualified recording personnel in the medical record units. The majority of medical records had poor completeness in terms of administrative, clinical, financial, and legal data. The overall quality of medical records in public health facilities in the Jimma Zone was low as per the standard of health facility requirements. It was recommended to have qualified medical record unit personnel and to standardize the unit in order to improve the quality of medical records.