The role of medical records in the provision of public healthcare services in the Limpopo province of South Africa

Abstract

Background: The importance of medical records to the provision of healthcare services cannot be overemphasised. Medical practitioners need information about previous diagnoses, treatments and prescriptions in order to note the progress made with previous treatments and how to move forward. If medical records are not managed properly, it becomes difficult to retrieve such records, which results in hospitals not being able to render healthcare services or these services being rendered incorrectly, especially for chronic patients. Despite the importance of medical records, they are not being managed properly, resulting in a lack of effective systems for opening, tracking and indexing files.

Objective: This study seeks to investigate the role of medical records in the provision of public healthcare services in the Limpopo province of South Africa.

Method: Quantitative data were collected through questionnaires distributed to staff members in the records management unit and the information management unit in 40 hospitals in Limpopo. These units were relevant as they made use of patient files daily to discharge their duties.

Results: The study revealed that missing medical records negatively affected timely and effective healthcare service delivery. This resulted in patients having to wait longer to be treated and in some instances patients being treated without medical history.

Conclusion: The study concludes by arguing that missing files contribute to the length of time patients wait to be assisted. As a result, nurses and doctors are unable to assist patients or treat them immediately. The study recommends the introduction of an electronic records management system that can capture and provide access to a full patient record, as well as tracking paper records movement, irrespective of the location.