Effectiveness of medical records in the provision of Healthcare Services at Kenyatta National hospital

Abstract

Health is a fundamental human right in the development of a country and the delivery of quality healthcare services is largely supported by medical records. The aim of the study was to investigate the effectiveness of medical records in the provision of healthcare services at KNH with a view to proposing a model for managing medical records. The specific objectives of the study were; establishing the business activities that generate medical records at KNH, determining the types and formats of medical records generated as part of KNH healthcare system, determining the contribution of medical records in the provision of healthcare services at KNH, analyzing the status and effectiveness of the present medical records management practices in supporting healthcare services at KNH and analyzing the medical records management challenges faced in the provision of healthcare services at KNH. Qualitative research method was used in the study. The data was gathered through in-depth interviews administered to 58 employees of KNH using purposive sampling complimented by observation and analysis of documentary sources. Data was analyzed based on the grounded theory approach. The results of the study were that medical records played a critical role in patient care, healthcare planning, medical research and health policy development. It was established that the quality of medical records was inadequate which impacted negatively on healthcare delivery. Research findings also revealed that the medical records management practices were not fully effective hampering access to medical records critical in the provision of healthcare services. In addition, there were numerous challenges facing the management of medical records which had undermined provision of quality healthcare services at KNH. The study recommends measures towards improvement of the medical records management situation at KNH. The key recommendations were; establishment of clinical documentation standards to enhance integrity of medical records. Development of policies focused on medical records management, disaster management and medical records retention and disposal. Further, the recommendations address the need to strengthen top management support for medical records management. In addition, the recommendations focus on the need to integrate ICT into medical records processes. The study finally proposes a framework for managing medical records based on the recommendations to adequately support provision of healthcare services at KNH.