Medical Record Services

Medical records management (MRs) is one of the components of health information system that documents information related to a patient generated during patient-to-health care provider encounters at a health care facility. A well-managed medical records system is critical to improve the provision of quality health care services to ensure safe medical practice, efficient and effective services and improve the patient’s experience and satisfaction with their medical encounter. A strong medical records system is also equally important to make clinical and public health evidence based practices as well as making informed decisions. In addition, medical records may serve as a reliable source of information for medico-legal issues and medical/ public health researchers.

A well-organized medical recording system ensures the availability of reliable healthcare data in the health system; in which it can serve as an input for the implementation of national health sector transformation strategic plan (HSTP) in particular to the information revolution agenda. Poor data quality management system including incomplete medical recording and reporting practices, lack of information technology and its use, shortage of human resource and professional mix, failure to audit medical records and failure to adhere with existing guidelines and SOPs are the major observed challenges in hospital’s medical record management system.

Operational Standards for Medical Records Management

1. Unique medical record number is assigned to a patient during his/her first visit of care.
2. The hospital shall have a single unified medical registration unit for all patients registration.
3. The hospital utilizes paper and computer-based systems to register and retrieve medical records.
4. The hospital avails and utilizes a standard set of formats that comprise a complete medical record for continuum of patient’s care.
5. The hospital shall implement and comply with national guidelines to manage access to patient’s medical records.
6. The hospital performs medical records auditing, data quality checks, archiving/culling procedures and takes corrective actions on a regular basis.
7. The hospital ensures patients medical records return from different service units to medical records unit at the end of each service day in accordance with medical record tracing system.
8. The hospital shall automate health information system through implementation of integrated electronic medical record system.