Quality of medical records in public hospitals of Wolaita Zone, south Ethiopia, 2023: mixed study

Abstract

Introduction: A Medical record is a multifunctional document that is used to communicate and document critical information about patients’ medical care among health care professionals. Medical record completeness is a key performance indicator that is related to the delivery of health care services in the hospital. Medical recording systems have faced challenges related to resources and a lack of infrastructure in the worldwide trend. Studies have indicated that medical record systems are lacking in medical record management quality in low-income countries. This study aims to explore the quality of medical records at public hospitals in Wolaiyta zone.

Methods and materials: An institution-based cross-sectional study, concurrently with a qualitative study using a stratified sampling method, was conducted from March 1-15, 2023. A purposive criterion sampling method key interview method, was used for qualitative data. A total of 406 Medical records were reviewed at three public hospitals in Wolaiyta zone. The quantitative data were collected using Kobo toolkits and exported and analyzed by SPSS version 26.0. The qualitative data were collected and analyzed manually by thematic analysis.

Results: A total of 406 medical records were reviewed. In the assessment of the quality of medical records, clinical components were lowered (76%) compared to Administrative components (87%). The majority of the respondents said that “… Since the lack of regular monitoring and evaluation process, there was a problem in the quality of medical records in the hospital According to the expected national standard, the study also showed that the average quality of medical records of the study area was 68%. Records in tertiary hospitals were 44.5% less likely to be quality records as compared to records in primary hospitals.

Conclusion: The overall quality of medical records in Wolaita Zone was very low for components of the quality of medical records as per the standard of hospital requirements.

Key words: Quality, medical records, hospitals, medical records, electronic medical records.