Assessment of Quality of Medical Records and Associated Factors in Public Hospital of Wolayta Zone, South Ethiopia , 2023 Mixed Study

Abstract

Abstract Introduction: Medical record is a multifunctional document that is used to communicate and document critical information about patients’ medical care among health care professionals. Medical record completeness is a key performance indicator that is related with delivery of health care services in the hospital. Medical recording system has faced challenges related with resources and lack of infrastructure in worldwide trend. Studies have indicated that medical record systems are lacking medical record management quality in low income countries. Therefore, this study aims to explore the quality of medical record at public hospitals in Wolaiyta zone. Methods and materials: Institutional based cross-sectional study concurrently with qualitative study using stratified sampling method was conducted from March 1–15, 2023. A purposive criterion sampling method key interview method was used qualitative data. A total of 406 Medical records were reviewed at three public hospitals in Wolaiyta zone. Review of medical records was done using a checklist and key informant interviews of health professionals and medical record staff. The quantitative data were collected kobo toolkits and exported and analyzed by SPSS version 26.0.the qualitative data was collected analyzed manually by thematic analysis. Results A total of 406 medical records were reviewed .In the assessment of quality of medical record, clinical components were lowered (76%) compared to Administrative components (87%).Majority of the respondents said that|“… Since lack of regular monitoring and evaluation process, there was problem in quality of medical records in the hospital According to the expected national standard, the study also showed that average quality of medical records of the study area was 68%. Records tertiary hospitals were 44.5% less likely to be quality record as compared to records in primary hospitals. Conclusion The overall quality of medical records in wolaita Zone was very low for components of the quality of medical records as per the standard of hospital requirements.