Management of Medical Records in Primary Health Care Centres in Zamfara State

Management of Medical Records in Primary Health Care Centres in Zamfara State.

ABSTRACT  

The study discusses management of medical records both in traditional system and in modern age in primary health care centres in Zamfara state. Their effective management contributed in providing healthcare services to majority of the populace in the state. Other issues discussed include creation, maintenance, storage, use and preservation of medical records as viewed by scholars, researchers on record management as revealed in review of related literature, survey methods of research was adopted and questionnaire was used as instrument of data collection.

The population sampled stands at 354 and the number of retrieved questionnaires were 340. The data was presented, analyzed and discussed which resulted in coming out with some findings among which include immunization records, antenatal records and referral records were mostly utilized. Alphabetical arrangement and numerical filing arrangement are the systems of record arrangement predominantly in practice.

Also shelves and cupboards were storage facilities used in (PHCs) in the state, the study concludes that the medical records as integral instrument of patient treatment were not properly managed in PHCs due to lack of knowledge and skilled of the records managers. Several recommendations have been proposed. These include training on medical record management which should be organized periodically, modern storage media such as hard drive, flash drive, CD-ROMs and sound recording should be used to store medical records in primary healthcare centres in Zamfara State. 

TABLE OF CONTENTS

Title Page – – – – – – – – – i
Declaration – – – – – – – – – ii
Certification – – – – – – – – – iii
Dedication – – – – – – – – – iv
Acknowledgement – – – – – – – – v
Abstract – – – – – – – – – vi
Table of Contents – – – – – – – – viii
List of Tables – – – – – – – – xi
List of Figures – – – – – – – – xii
List of Abbreviation – – – – – – – – xiii

CHAPTER ONE: INTRODUCTION
1.1 Background to the Study – – – – – – 1
1.2 Statement of the Problem – – – – – – 3
1.3 Research Questions – – – – – – – 5
1.4 Objective of the Study – – – – – – 6
1.5 Significance of the Study – – – – – – 5
1.6 Scope and Limitations – – – – – – 7
1.7 Operational Definition of Terms – – – – – 8
References – – – – – – – – 8

CHAPTER TWO: REVIEW OF RELATED LITERATURE
2.1 Introduction – – – – – – – – 9
2.2 Records Lifestyle – – – – – – – 10
2.3 Records and Records Management – – – – 12
2.4 Creating Medical Records – – – – – – 15
2.5 Types of Medical Records – – – – – – 18
2.6 Purpose of Medical Records – – – – – 19
2.7 Utilization of Medical Records – – – – – 20
2.8 Users of Medical Records – – – – – – 21
2.9 Factors affecting Medical Records Use and Non Use – – 22
2.10 Preservation of Medical Records – – – – – 23
2.11 Staffing – – – – – – – – 25
2.12 Impact of ICTs Application in Medical Records Management – 26
2.13 Summary of the Reviews – – – – – – 29
References – – – – – – – – 31

CHAPTER THREE: RESEARCH METHODOLOGY
3.1 Introduction – – – – – – – – 33
3.2 Research Method adopted for the Study – – – – 33
3.3 Population of the Study – – – – – – 34
3.4 Sample and Sampling Procedure – – – – – 35
3.5 Instruments for Data Collection – – – – – 39
3.6 Reliability and Validity of the Instruments – – – 40
3.7 Procedure for Data Collection – – – – – 40
3.8 Procedure for Data Analysis – – – – – 40
References – – – – – – – – 42

CHAPTER FOUR
DATA PRESENTATION, ANALYSIS AND DISCUSSION
4.1 Introduction – – – – – – – – 43
4.2 Response Rate – – – – – – – 43
4.3 Data Analysis and Discussion – – – – – 45
References – – – – – – – – 63

CHAPTER FIVE
5.1 Introduction – – – – – – – – 64
5.2 Summary of the Study – – – – – – 64
5.3 Summary of Findings – – – – – – 65
5.4 Conclusion – – – – – – – – 66
5.5 Recommendations – – – – – – – 67
5.6 Suggestions for Further Studies – – – – – 68
Bibliography – – – – – – – – 69

INTRODUCTION  

Primary Healthcare Centres were established as essential part of healthcare agencies and its main principles are equity, health promotion and disease prevention, community participation, appropriate health technology and multisectoral approach. This is why WHO (1980) initiated the “Health Promotion” program considered as an essential strategy in achieving the general objective “Health for all” health promotion for the population.

Promotional and preventive measures require support from the community, health politics and multisectoral approach. These primary healthcare centres generate records daily and these records must be properly managed, maintained and stored to ensure their effective utilization by patients, researchers, scholars and other medical records experts. Some of the values of medical records according to Akandji (2006) are to assess the performance of health care rendered to the patients.

Provide data for statistical evaluation of cases to determine the strength and weaknesses of treatment processes. Provide information for training and educating health care providers through seminars or workshops, to protect the legal interest of patient, hospital and health professionals against litigation. Serve as reference sources where physicians can refer to previous cases to treat current and future ailments and finally provide information for research.

No organization can achieve its goals without maintaining its records and these records are the backbone of the entire operation of our primary health care centres. These records can be created either as tangible object or digital information. This view was supported by ISO (2001) as it noted that records stand as information created, received and maintained as evidence or an information by an organization or person in pursuance of legal obligations or in the transaction of business. 

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StudentsandScholarship Team.