Developing patient registration and medical records management system in Ethiopia

Abstract

Quality problem. In low-income countries, medical record management is often lacking. We sought to evaluate the impact of an inexpensive business process re-engineering project on the accessibility and completeness of patient information and on physician satisfaction. Design. Pre-post intervention study during 2006-07, using time-motion studies, medical record audits and physician surveys. Setting. A rural hospital in Ethiopia. Participants. Medical record personnel, hospital administrators, clinical staff. Implementation. We implemented a hospital-wide patient registration and medical records re-engineering process, which included a simple, custom-made computer database to manage patient information, standardized medical records forms and processes and enhanced human resource management efforts. Main Outcome Measure(s). We measured medical records accessibility and completeness, and physician satisfaction. Evaluation Medical record accessibility and completeness and physician satisfaction improved significantly (P < 0.05) based on pre- and post-intervention comparisons. The success rate of retrieving the proper medical record number for returning patients improved from 14 to 87% (P < 0.01); time to locate medical records decreased from 31.2 sec per record to 15.7 sec per record (P < 0.01); the percentage of complete medical records increased from 6.5 to 45.7% (P < 0.01). Physician satisfaction with the medical records system was significantly higher after the intervention (P = 0.02). Lessons Learned. Our findings indicate that a well-organized medical record management system can be effective in improving patient information accessibility and completeness in hospitals in low-income countries despite the lack of resources. Longer follow-up is required to assess the sustainability of the hospital improvements accomplished. © The Author 2009. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.