Assessment of medical records management systems

Abstract

Medical Records Management is the art and science of managing all information relating to the operation of a Healthcare Practice. The purpose of this study was to assess the medical records management systems at Mildmay Uganda, the specific objectives were; to identify the procedures used in processing medical records at Mildmay, to establish the types of classification and filing systems used at Mildmay and to establish the retrieval and storage mechanism used at Mildmay. The study applied both quantitative and qualitative methods of data collection. Data was collected from 60 respondents who included records clerks, secretaries, office messengers, records managers and registry users. The found out that Individual health care record, responsibility and accountability, retention and durability, ownership, Storage and security and disposal are the major procedures used in processing of medical records at Mildmay, then Request-oriented classification, Content-based classification and Automatic document classification are the classification methods used at Mildmay and the filling systems were alphabetical, numerical, Alpha-Numeric and chronological filing systems. Finally for storage and retrieval, computer files, paper records, flash disks, magnetic tape are the major storage mechanisms used at Mildmay and for retrieval mechanisms, manual search to retrieve paper records, automatic search for electronic records and use internet based search were identified. The study concluded that ; Individual health care record is mostly used to process medical records at Mildmay, Request-oriented classification is the most used method of medical records classification and is alphabetical filing system is the most method used in filing records. Ccomputer files and paper records are the most storage and retrieval mechanisms used at the ministry. In a nutshell, records management and processing at Mildmay is highly embraced though there some unmet goals. The study recommended training in handling of medical records.