A framework to embed medical records management into the healthcare service delivery in Limpopo Province of South Africa

Abstract

The importance of records management to the provision of healthcare services cannot be overemphasised. If medical records are not managed properly, this might result in the provision of poor healthcare services. This is because usually if medical records are not properly managed, the healthcare institutions attain inaccurate, untimely, incomplete and unauthentic records or the records fade completely. Records that are not managed properly are easily lost, modified, altered, misfiled and/or damaged, which results in a struggle to locate them and, eventually, much time is lost. Records of this kind may not support healthcare service providers properly in decision-making, problem-solving, monitoring and evaluation of service for continuous service improvement. This study utilised the five elements of trusted records management (records management governance practice, staff capacity and competencies, recordkeeping system and technology, and records archival processes) to investigate the development of a framework to embed medical records management into the healthcare service delivery practice for effective records management practice. The study predominantly utilised a quantitative approach with some support from a limited scope of qualitative data to augment numeric data. The data was collected using the four different techniques, namely questionnaire, interview, observation and system/documents analysis. The study revealed that the mode of medical record management was not effectively enabling the institution to manage medical records properly due to lack of integrated medical records management framework into the healthcare business process. The medical records management technology also lacked file tracking system, records backup, and audit trail which compromise records safety and security. The study recommended supply of the necessary resources, with a framework that the healthcare institutions may adopt to embed medical records management into the healthcare service delivery. ECM may also be implemented to incorporate electronic records management systems, information management, web content and other add-ons to support the records management framework in ensuring effective discharge of all records management functional requirements on the healthcare business process. A further study was recommended about the development of an online outpatient consultation system and medical records access to avoid patient long turnaround time for service.