RECORD MANAGEMENT PRACTICES AT HEALTH CENTRES IN GYALLESU AND TUDUN WADA, ZARIA

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RECORD MANAGEMENT PRACTICES AT HEALTH CENTRES IN GYALLESU AND TUDUN WADA, ZARIA

ABSTRACT

The research aimed at investigating the Record Management Practices at Health Centres in Gyallesu and Tudun Wada, Zaria. To achieve these objectives, six research questions were formulated and answered accordingly. The survey design method was adopted for this study. The population under this study consisted of staff of the two Primary Health Care Centres in Zaria. A total of 15 respondents from the population formed the sample for this study. The data was collected by distributing questionnaires, which was the instrument used for data collection. The data collected were analyzed using the frequency distribution tables, simple percentages and histograms. Based on the data collected and analyzed, the result of the findings indicated that a majority of the respondents indicated that immunization records, antenatal record, deliveries record, family planning, diagnostic notes, referral letters/notes and patient’s folders are the basic healthcare records in Gyallesu and Tudun Wada Primary Health Care Centres. The following recommendation was given as The healthcare centres should emphasized more on description slips, admission slips, discharge slips, and other records because of their vitality in healthcare service delivery, there is need to collate all information of the patients whereabouts; The healthcare centre should harness the power of records by using It communicate efficiently and effectively to the patient concerning his health status; There is need for the staffs to go for further studies and training to acquire skills on record management; The Kaduna State Ministry of Health through Zaria Local Government Healthcare authority should provide ample space for records keeping, storage and ease; The primary healthcare should time to time train their staffs on how to communicate effectively and listening to get the appropriate and necessary information documented as medical history of patient.

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

A Primary Health Care Centre is the first level of the healthcare service delivery closer to the people in the community they live or work. The Primary Health Care Centres are mostly run by organizations, institutions or governments of such communities. Where they are not able to attend to the patient, a referral to a bigger (secondary) healthcare centre for better treatment is given. A Primary Health Care Centre is an approach to health beyond the traditional health care system that focuses on health equity-producing social policy (Starfield, 2011). Furthermore, a Primary Health Care Centre lays its emphasis of health care delivery to the people themselves and their needs to reshape their lives health wise. It also includes all areas that play a role in health, such as access to health services, environment and lifestyle. According to White (2015) primary healthcare and public health measures, taken together, may be considered as the cornerstones of universal health systems.

This ideal model of healthcare was adopted in the declaration of the International Conference on Primary Health Care held in Alma Ata, Kazakhstan in 1978 (known as the “Alma Ata Declaration”), and became a core concept of the World Health Organization’s goal of Health for all (WHO, 2011). Between 1986 and 1992, remarkable and innovative progress was made in the development of primary health care, focusing on the Local Government Areas (LGA’s). As a result, Nigeria was placed in the front rank of countries to have improved the health and quality of life of its people through primary health care. Following the recommendation of a high level WHO review team (Decree 29 of 1992), the National Primary Healthcare Centres Development Agency (NPHCDA) was established to capitalize on these achievements and sustain federal assistance to the LGAs. It merged with the National Programme on Immunization (NPI) in 2007 (NPHCDA, 2015)

According to Milena (2015) Health records are the most important database of health treatment of the patient. Consistent recording by doctors, nurses and other staff is proof of proper monitoring of the health, planning and treatment. Initial health records were used to describe individual processes. Today, health records are a much broader concept than in the past because in the past, it was the doctor alone who recorded data. Health records and documents serve as the basis for the realizing of individual rights, both in civil and legal transactions, as well as the exercise of rights relating to privacy and the retrograde determining health status.

These records contain information which is crucial to human endeavour, that information is an indispensable tool in office work, management, and decision making and in work productivity. This is to say that effectively organized and good management of private and public sectors / organizations‟ records, depend heavily on the availability of current, complete, accurate and reliable information which is generated and supplied on time to facilitate planning, decision making and in order to enhance productivity reported by (Akuso, 2014).

Medical Record is an important document meant basically for recording the treatment procedure for a patient. This record is important to both the patient, as well as the doctor. It has become the only crucial and effective weapon doctors use to counter the false claims of the patient when they file a case against them. As such medical records are evidential documents which can provide significant evidence in billing reviews, physicians self – assessments, etc. where the physician reflects on and assesses the care that have been provided to the patient (Akuso, 2014).

Furthermore, the patients’ records are used daily to record information about the patients’ personal details, prescriptions and diagnosis for future reference to follow-up patients. The information recorded is eventually used to confirm the patients’ health history during current and future consultations. The paces at which the records are retrieved and served for this purpose determine the patient waiting time for the services. This has an impact on the quality of the service rendered by the health institution (Ngoaka, 2011)

Proper filing of patient’s medical records facilitates effortless retrieval and ensures reduction patient’s waiting time at the hospital and ensures continuity of care. It is therefore, very important, that medical records are always kept in the interest of both the clinician and the patient. The medical folder must always be in the safekeeping of the health facility whiles the patient enjoys the right of information.

1.2 Statement of Problem

An effective management of health records is a critical factor in facilitating health care delivery services.Therefore, the roles of medical record remains very vital as they provide the health history of patients contained in medical files for further assessment, prescription of treatments and possible next line of action.

It is not acceptable from the series of reports from literatures of poor record management in facilities, especially in the Public Health Cares and other secondary health institutions in Nigeria. This study investigates the Record Management Practice at Health Centres in Gyallesu and Tudun Wada Primary Health Care Centres to verify if the problems of poor record management persist.

1.3 Research Questions

1. What is the basic health records documented in Gyallesu and Tudun Wada Primary healthcare Centres?
2. What facilitation roles does the medical health record provide during healthcare delivery?
3. What are the basic qualification of the medical health records officers in Gyallesu and Tudun Wada Primary healthcare Centres?
4. What are the management strategies operated Gyallesu and Tudun Wada Primary HealthCare Centres?
5. Challenges affecting the effective and efficient record keeping in Gyallesu and Tudun Wada Primary healthcare Centres?

1.4 Objectives of the Study

The main objective of the study is to examine records management practice at Zaria Local Government Primary Health Care Centres.

The specific objectives are to:

1. To find out the basic health records in Gyallesu and Tudun Wada Primary healthcare Centres.
2. To find out facilitation roles does the medical health record provide during healthcare delivery.
3. To find out the basic qualification of the medical health records officers in Gyallesu and Tudun Wada Primary healthcare Centres.
4. To find out the management strategies operated Gyallesu and Tudun Wada Primary HealthCare Centres.
5. To find out the challenges affecting the effective and efficient record keeping in Gyallesu and Tudun Wada Primary healthcare Centres.

1.5 Significance of the Study

This research will assist the Zaria Local Government Primary Health Authorities and its facilities to reveal, identify and make recommendation to achieve quality health care service. The project shall add to the body of knowledge on PHC with particular reference to Zaria metropolis.

1.6 Scope and Limitation of the Study

The research was limited to Gyallesu and Tudun Wada Primary Healthcare Centres and the study only focused on records management practices operating within the PHCs.

References

Akuso, A. (2014) Generation, Organisation And Use Of Medical Records In Primary  Health Care Centres Of Ahmadu Bello University, Zaria. [Thesis]. Ahmadu Bello University, Zaria

Milena, M. (2015).The Importance of Health Records. Journal of Health, 7, 617-624.

WHO. (2011). “International Conference on Primary Health Care, Alma-Ata: twenty-fifth anniversary” (PDF). Report by the Secretariat .WHO.Retrieved 28 March 2011.

Starfield, B. (2011). Politics, primary healthcare and health.”Epidemiol Community Health 2011;65:653–655 doi :10.1136/ jech.2009.102780

White, F. (2015). Primary health care and public health: foundations of universal health systems. Med PrincPract 2015 doi: 10.1159/000370197

NPHCDA. (2015). http://www.nphcda.gov.ng/index.php/about-us/our-history