A hospital book contains written account of a patient’s examination and treatment. It includes the patient’s medical history and complaints, the health provider’s finding, the results of diagnostic tests and procedures, prescriptions and therapeutic procedures.
Averagely, every Cameroonians has 2 hospital books which are prove of their visit to a health facility. Despite the nature of the content of these books, their importance is being overlooked. This is probably due to ignorance or intentional neglect as some patient’s deliberately hide their records from the consulting health professional or lack of capacity to manage and maintain medical records.
This negligence of medical records poses a couple of challenges to providing quality and consistent health care services in an attempt to restore health.
Consequences of Negligence of Medical Records
This negligence could result to delays in providing necessary medical treatment as well as incorrect diagnosis in cases of emergencies.
In general absence of medical records result in lower quality of patient care, increased work burden on staff as laboratory tests and other diagnostic procedures would have to be repeated. Information such as the blood sugar level and substance allergy are overlooked thereby putting the patient at greater risk of anaphylactic shock.
Medical records are essential for the proper care of the patient and are paramount for communication between health professionals and their patients as well as their colleagues.
Notes in hospital books made by an internal medicine specialist could enlighten surgeons and radiologists in future procedures related to the patient, but with this negligence of hospital books, there is a barrier in communication which leads to inefficiency in delivery of consistent and appropriate health services.
Why are Medical Records a big deal?
Hospital books are a gateway for doctors and other health care providers to get into the patient’s history and learn about previous medical care, understand current diagnosis and create a treatment plan. If a patient has a severe injury and is unresponsive or has an unclear illness or cannot remember or is unsure of their current medications, an examination of the patient’s hospital book can help the health care provider respond with appropriate treatment and eliminating any potential drug interactions and complications.
These records are not only important to health care providers but also to health policy makers, health organizations like the World Health Organization and research institution. These records are a means of providing necessary data in connection with the health of the people and the prevalence of specific diseases at particular regions.
Medical records contain various facts like personal details, diagnosis, severity of diseases, prescription as well as consulting physician.
Health policy makers could use these facts on planning short as well as long term strategies. A study of these records will contribute towards knowing;
- the health condition of people,
- disease stricken areas,
- causes and effects of diseases,
- the proportion of doctors to patients,
- the number of doctors associated with certain diseases,
- urgency of specialized services,
- availability of physical facilities and resources in order to deliver appropriate services to the people.
Readily available medical records are also instrumental to relevant organizations like the World Health Organization, in understanding the concentration of patients, nature of diseases and all personal details of the patient.
With access to such rich facts and figures, these organizations can alter existing plans and formulate other policies and directives in case of emergencies so as to deliver better quality and more standardized services in the future. The study of medical records helps in the development of preventive measures to accommodate and save lives in time of epidemics and/or pandemics.
With the rising use of medical insurance for treatment in our health facilities, the insurance companies require proper record keeping to prove the patients demand for treatment and prove of treatment to back up medical expenses.
Being aware of the numerous various ways medical records could help in improving health care delivery services, the negligence of these records poses a great challenge in our community. Though some patients deliberately deprive the health professionals of their health records for reasons such as shame or stigmatization and others lose theirs in accidents, negligence of medical records is a shared challenge between health facilities and patients.
Now what can the Health Facility do to make things better?
In our community, there is no clear-cut description of the ownership of medical records, the patient or the hospital? By and large, ownership of medical records should be shared between hospital and patients. Both parties share responsibility of maintaining and safeguarding the medical records.
There are designated sections of the hospital for medical records management but they are more oriented towards patient registration. The method of keeping medical records in our facilities is the manual method which involves papers and books. This method of record keeping creates a further challenge if institutionalized completely. Occupation of large amount of space, difficulty in retrieving records and risk of destruction by insects and rodents are the immediate challenges of manual method of record keeping.
The simplest way of addressing these challenges would be the utilization of the electronic method. The electronic method, despite addressing the challenges of the manual method has its own shortcoming; electronic records could easily be tampered with. The holistic approach to safe guard medical records would be the mixture of both methods to complement and not replace one another.
The hospital being the more responsible of both parties has a greater role to play in arresting the negligence of medical records. Establishing a fully operational medical record department with specially trained persons is a great step towards safe guarding these priceless records.
The hospital administration could educate all relevant hospital staff on the importance of maintaining hospital records including the very small aspects such as the way the information is recorded (very poor hand writing), for medical recording needs the concerted effort of a number of people involved in patient care (doctors, nurses, specialists, laboratory technologists and receptionist).
What can you (yes you) do to make things better?
Patients, being equal shareholders need to be educated on the importance of maintaining and safe guarding medical records.
The government and health organizations could embark on this patient empowerment. This could be done through media like radio and television slots and by display of relevant and educative posters and/or infographics in the waiting rooms of health facilities and any other area where the patients can set their eyes. The health care providers also have as responsibility to remind the patients regularly on the importance of these records.
With the government, health organizations, health facilities and individuals (like you) working in synergy, the quality of health care services being delivered would improve and the communal health shall receive a huge boost. For we are stronger together, and We Love to Meducate You!
This article is a contribution of Nkwain Carlson