HEALTH RECORDS: The lifeblood of patient and hospital management

PHOTO | KEN NDUNG’U: Stella Karimi, Senior Health Information Officer

By Verah Mugambi

Good quality medical records – whether electronic or handwritten- are an essential component of safe and effective healthcare for the continuity of care for the patient.

For the management and systematic maintenance of Medical Records in the Hospital, a Medical Record Department is necessary.

The ultimate role of the department is to initiate Medical Records, facilitate proper storage, and retrieve when and as required for the treatment of the patient.

The Newsline team visited the department located at No.19 and had a sit down with Dr. Mark Mudenyo, KNH’s Health Information HOD, and members of his department.

“Health Information is a department under the clinical services division. Our work is mainly to support the clinical department in the provision of patient documents for treatment. Our officers are situated everywhere; from the entry that is at A&E, to the wards, Labs, theaters and generally all over the hospital”, Dr. Mudenyo stated.

“A medical record is a document that is presented or created by the clinician for the patient for treatment. A health records officer initiates or creates the medical record documents so that the patient can be seen immediately or in the future using the same document,” he says.

“Statistics is one of our major functions as a department. My team generates all the statistics for the hospital; from the entry point (casualty) to exit: how many patients are seen in A&E, how many patients are in the wards, how many beds are available in the hospital, the average stay of patients … These statistics helps the hospital in planning and the country at large when it comes to health policies; KNH being the biggest referral hospital in the country,” adds Dr. Mudenyo.

He goes on: “Once a patient has been received or gone to the wards or the clinics, another date is set for them to come for the continuation of treatment. That is where one of our major functions comes in; we schedule appointments as given in the clinics. He adds that the document or file created is stored by the hospital for a maximum of 10 years from the last date the patient was seen at our hospital.”

“The same documents are used for training and research purposes for paramedical and medical officers. Clinicians come and register their research interests and we produce the documents to aid in their research. This is done at our research office or library since they are private documents and no one is allowed to take them out of the hospital.”

Dr. Mudenyo then proceeds to explain the file creation process, “After creating the file, we do the coding and indexing of the diseases; one disease is given the same code number worldwide using the directory provided by Wealth Health Organisation and indexing is putting them all together.”

“In case there is a medical-legal issue, good medical records are vital for defending a complaint or clinical negligence claim; they provide a window on the clinical judgment being exercised at the time. The presence of a complete, up-to-date, and accurate medical record can make all the difference to the outcome.”

“Our main challenge, however, is filing. KNH is the apex of treatment in Kenya and everyone wants to come to Kenyatta, so we have more than 40 million file documents. Therefore, we are trying to come up with a paperless method in future to make the day to day services smooth and quicken the turnaround time”, Dr. Mudenyo concluded.

Health record technicians organize and manage health information data by ensuring its quality, accuracy, accessibility, and security in both paper and electronic systems.

By use of technology they classify, code, and categorize patient information for databases and registries and maintain patients’ medical and treatment histories.

“After receiving files from the wards, we code them also termed as classification using the International Classification of Disease from WHO. Then we put all the patients’ information in our database. The database helps us when it comes to questions like; how many patients are treated with a specific disease, mortality list, etc. All research done in the hospitals must come through here. We facilitate research by giving the doctors files and preparing them to be taken to the library room”, explained Mercy

Dr. Mark Mudenyo- HOD Health Information

PHOTO | KEN NDUNG’U