Analysis of filing and retrieval of medical records

Abstract

This study focused on analyzing filing and retrieval of medical records in the medical records office of Mulago National Referral Hospital (MNRH), Kampala Uganda. The objectives of the study were to; (1) identify the categories of medical records generated at MNRH, (2) analyze the filing and retrieval methods used at MNRH, (3) determine the relationship between filing and retrieval of medical records, (4) identify the challenges faced in filing and retrieval of medical records and determine solutions to the challenges faced in filing and retrieval of medical records at MNRH. The study reviewed related literature on the objectives of the study from secondary sources which included text books, journals, magazines and websites. Mixed methods research designs were used for the study with interviews, questionnaires, document review and observation as data collection methods. Purposive sampling method was used to identify participants and convenient to interview those who were readily available at the moment. The total target population of the study was 15 from which 12 participants were sampled. Data was collected from the Head of Medical Records Office (MRO), Assistant head of MRO, Medical records officers, Medical records assistants, filing clerks and doctors. The study identified different categories of medical records generated at MNRH and these included; Face Sheets, Admission forms, Radiology reports and imaging reports, Laboratory and test results, Clinical notes, Consultation request forms, Drug administration, Discharge forms, and Certificates. The filing method used was terminal digit filing and medical records are retrieved manually. The challenges faced during filing and retrieving medical records included; dust, light, misfiling, injuries, limited space, few workers, and lost and misplacement of medical files. The study finally recommended; staff expansion, medical records office expansion, more funding for records management activities, dust protection, proper retention and disposition of records, and digitization to ensure that medical records are properly filed and retrieved in the MRO at MNRH. KEY TERMS: Records, Records management, medical records, filing, and Retrieval.