Medical Records Management to support Evidence Based medical Practices Kisii Teaching and Referral Hospital, Kenya

Abstract

In health care, evidence-based practices take place when decisions that affect the care of patients are taken with due weight accorded to all valid and reliable evidence from medical records. Medical records furnish documentary evidence necessary for health care provision hence the need for strategies to ensure medical records are stored in a uniform and standardized manner where they retain their evidential weight. The aim of this study was to assess medical records management in support of evidence-based medical practices at Kisii Teaching and Referral Hospital with a view of proposing strategies to improve medical records management in the hospital. The objectives of the study were: to ascertain the status of medical records in supporting evidence-based practices at Kisii Teaching and Referral Hospital; to establish policies and procedural frameworks governing the management of medical records at Kisii Teaching and Referral Hospital; to find out the knowledge and skills of staff in the management of medical records at Kisii Teaching and Referral Hospital; to explore the use of information and communication technology in managing medical records in supporting evidence-based practices at Kisii Teaching and Referral Hospital; and to propose strategies to improve on medical records management for better healthcare service delivery at Kisii Teaching and Referral Hospital. The study was underpinned by The Records Continuum and The Johns Hopkins Nursing Evidence-Based Practice models. The study adopted a qualitative research methodology using a case study design. Purposive sampling technique was used. The study sample consisted of 52 respondents drawn from four departments that create and generate; use; and manage medical records. Data was collected through the triangulation of interviews, observation, and documentary reviews and analyzed thematically. The findings established that: there was an absence of comprehensive medical records management policies and procedural frameworks; and there was a scarcity of medical records management knowledge and skill at the hospital. Although the hospital has adopted the use of information and communication technology in the provision of healthcare, medical records management processes were partially automated. Overall, the findings revealed several challenges in the management of medical records that impact on the provision of health care based on reliable evidence. In conclusion, the general status of medical records management was inadequately positioned to manage medical records as strategic evidence resource and support evidence-based practices at the hospital. Therefore, the study recommended that Kisii Teaching and Referral Hospital should develop operational policies and procedural frameworks for medical records management, build medical records management capacity and further provide medical records management training to existing staff to acquire skills and knowledge of medical records management among others.