Role of Medical Records Management Practice in Improving Decision Making in University Hospital

Abstract

Hospitals deal with the life and health of their patients. Good medical care relies on well-trained doctors and nurses and on high-quality facilities and equipment. Without accurate, comprehensive up-to-date and accessible medical records, medical personnel may not offer the best treatment or may in fact misdiagnose a condition, which can have serious consequences. The objectives of the study are to identify medical record management in university hospital associated with good practice in managing records, to assess the staff skill in managing medical records appropriately and to see medical record management program contribute for quality decision making. The study applies quantitative method approach with use structured questionnaire. A cluster sampling technique was used to classify the whole hospital into nine departments (clusters). The researcher purposively selected 90 health staff and a records staff to participate in this study. Researcher found that completeness physical note and nursing note of patient and also use and archive lifecycle do not associate with good practice in managing medical records. From the study, it is clear that most of the medical record officers have insight into personal skills and competencies about medical record. Researcher found that for second research question, medical record officers have the right level of staff skill to manage medical records appropriately. From the survey on decision making factor, the finding are, all factor in doing decision making are significant. Good medical record management program associated with quality of decision making. Misfiling and missing files, shortage of records staff and poor staff knowledge are the three main problems that affect the hospital in their quest to managing records effectively and making decisions. So that, researcher recommendation are to make adoption of an integrated Electronic Records Management System, more training for records staff, conducive storage and enlarge storage location, adequate records staff and more alert about security issues. Introduction X-rays, specimens, drug records and patient registers, must be well managed to make patients to be protected. Similarly, good medical records care ensures the hospital's administration runs smoothly: unneeded records to be transferred or destroyed regularly by keeping storage areas clear and accessible; and key records to be found quickly by saving time and resources. Medical record is the only history of …