Full Project – Evaluation of constraints facing service delivery of health information practitioners
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CHAPTER ONE
INTRODUCTION
1.1 Background of the Study
Health information management (HIM) is the process of organizing, tracking and maintaining paperwork for patients in clinics, doctors’ offices and hospitals (Wesley, 2013). This industry also involves analyzing the paperwork and communicating with doctors to ensure that patients are treated properly, given appropriate medication and treatment. Health records may be taken by hand or on a computer, and patient data can either be stored in a filing system or on a computer.
Luthuliand (2017) conceived health records as written account of patient’s examination and treatment that include the patient’s medical history, illness narratives and complaints; the physician’s findings; and the results of diagnostic tests, procedures, medications and therapeutic procedures.
In accordance with the guide, the professional expectations in health record keeping are based on the following principles; Good medical record: keeping is part of providing best quality medical. Accurate and complete documentation in the medical record that is in keeping the requirement of the policy is essential in facilitating and enhancing in the communication in collaborative patient carte models. Health record keeping are used in health care settings. Some workplaces use handwritten records, others have moved to computer based systems, and may use a combination of both. Health information managers are responsible for keeping track of this information, whenever it maybe.
Medical records are very important in the management and treatment of patient. Huffman (2004) define medical records “as compilation of pertinent fact of patient life history including past and present illnesses and treatment written by health professionals contributing to patient care” he also states that medical record must be compiled in a timely manner and should contain sufficient to identify the support the diagnosis or reason for health care encounter, justify the treatment and the accurate document the result.
The Health Information Management effort is to improve the health status o the population, information collection analysis and presentation should be organized in such a way that the most needy groups and individuals are identified. A health information system does not exist by itself. It supports management of a health whose ultimate goal is to improve and maintain the health of individuals, families and communities. The role of health information system in the health sector is not just routine collection of health sector data and dutiful conveyance of the same to higher levels of the health care system, but facilitate evidence based decision making at all levels especially at the point of collection.
Modern healthcare is mainly delivered through hospital that are established to meet the need of patient (Williams, 2010) define hospital as a diagnostic and treatment facility providing board and lodging medical care and continuous nursing care for alleviation or care of illness or injury to in-patient and maybe outpatient and emergency patient. He add that the facilities must have at least one physician on the permanent staff make provision for in-patient to remain at least 24hours and maintain clinical records on all patient.
In addition, Mogi (2010) define medical records as “an orderly written document encompassing the patient identification data, health history, physical examination findings, laboratory report, diagnosis treatment, surgical procedure and hospital courses “according to him the purpose of medical records are to provide means of communication among physician nurse and allied healthcare professionals, serve as easy reference for providing continuity in patient care, to furnish documentary evidence of care provided in health care facilities, to serve as informational document to assist the quality of patient care, to protect the physician and healthcare institution and its employees and third party payers.
Health record development began years ago is started in form of drawing cutting tracing on burnt days and inscription is about 2500BC, the earliest records were used primitive nature and much different from the present record keeping service, the clinical data demographic data and physician signature on the patient health record.
In Nigeria missionary organization made great contribution to the growth of medical work not only Nigeria alone but alone but whole west Africa countries such as Saotome 1504 and extended service into the mainland by nineteenth century, the first hospital ever establish in Nigeria is that of roman catholic mission sacred heart in university college hospital Ibadan in 1948, the few missionary hospital and military hospital has scanty records which were kept by non-professionals then the establish university college hospital, Ibadan with facility of medicine in 1984 for training of medical student in year 1956 headed by professional health record officer, Mr. R.P Waye and assisted by Mr. Lahan both from England.
Now that the record is practiced and all medical professionals knows how crucial it’s in a hospital, shortage of trained health record personnel in the service of health record, lack of confidentiality of patient record ignorance on part of patient, missing and misfiling on part of the record department.
In the situation where patient are carrying their case not by themselves in our local hospital, failure to consult health record practitioners when planning health record department in a hospital, as a result of this, where single room is allocated for health record department, this situation has not contributed to the improvement of record keeping.
1.2 Statement of the Problem
Health record keeping and the professionals are inseparable in terms of functions to achieving quality healthcare service delivery. Good medical treatment generally means a good medical and poor medical record keeping which simply means poor delivery in the health care services. These may be due to inadequate health record professionals, inadequate space for storage of medical records, lack of standardized approaches to documentation and so on.
The researcher noted some problems facing health records management in Federal Medical Centre, Owo, some of the constraints includes lack of effective system, training of employees and resistance to change which contribute to poor records management, lack of management support and epileptic power supply will not be able to deploy good Information and Communication Technology (ICT) services for efficient management of health records to its people. The safety and security of medical records is a challenge to personnel in charge of records in various health facilities. This is linked to abuse of patient information. Inadequate security in the management of medical records may expose the patients’ records to several dangers including unauthorized access.
Adeleke (2013) carried out a study on the impact of medical records on service delivery in Federal Medical Centre, Bida. He noted that Health Information Management Department and Health Information Managers plan information system develop health policy and identify current and future information needs. They apply the science of informatics to the collection, storage, use and transmission of information to meet legal professional’s ethical and administrative record keeping requirement of health care delivery. However, he observed that there are inadequate health record practitioners, inadequate space for storage of medical records, ineffective standardized approaches to documentation, poor working conditions in the facility and profession as a whole; He thus noted that there is further need to maintain the practice of maintaining patient records in Federal Medical Centre, Bida.
To keep up to standard of Health Records in the facility, it is necessary to identify the scope of the problem; this instigated the researcher to carry out a research on evaluation of the constraints facing service delivery of health information practitioners in Federal Medical Centre Owo Ondo State
1.3 Objectives of the Study
The main objective of the study is to evaluate the constraints facing service delivery of Health Information Practitioners in Federal Medical Centre Owo Ondo State.
The specific objectives of the study are:
- To evaluate training opportunity that is available to health information practitioner in federal medical centerowo Ondo state.
- To assess records management technique that is in use by health information practitioner in federal medical center owo Ondo state.
- To examine the level of management support to health information department in federal medical center owo Ondo state.
1.4 Research Questions
- What is the level of management support to health information department in federal medical center owo Ondo state?
- Are there training opportunity for health information department in federal medical center owo Ondo state?
- What technique of health records management is in use by health information practitioner in federal medical center owo Ondo state?
1.5 Significance of the Study
This research work will be aiming to evaluate constraints facing service delivery of Health Information Practitioners in Federal Medical Centre Owo Ondo State so as to enhance health workers productivity, reduce waiting time of the patient, improve the staff-patients relationship, reduce missing filling to the barest minimum and improve the quality of healthcare service rendered to the patient in all ramifications.
Findings from the study will be of immeasurable importance to the Nigerian government and all citizens of Nigeria. It will serve as a manual that will guide hospitals on how to go about on Health Records Management. It will as well help to bridge the gap that might have existed in the Health Records Activities.
The study will add to the body of existing knowledge in Literature, It will serve as a base line for future study and will help students equip themselves in the current studies of health records management.
Results from this study will be useful to hospitals most especially Federal Medical Center Owo, Ondo State and the country at large. The results will also directly point to the constraints, development and management of health records by health record practitioners and their use in achieving maximum output and good service delivery at Federal Medical Centre Owo Ondo State and beyond.
1.6 Scope and Limitation of the Study
This study will evaluate the constraints facing service delivery of Health Information Practitioners. The study is restricted to the Health Information Management Department, Federal Medical Centre Owo Ondo State and only Health Records personnel will be considered in the course of this research for questioning.
Evaluating Health Records as a tool in the growth and development of Nigerian seems too broad for the time frame of this research work therefore; the scope of this work was confined towards Federal Medical Centre Owo Ondo State.
This research was not an exception to the usual problems associated with research in Nigeria. The researcher:
- Could be with the problem of finance as the researcher may not have enough funds to visit necessary ventures to get necessary materials, collate date and receive responses from stakeholders
- The availability of required data have continued to be a problem of Nigerian researchers as those data are not readily available and where available, are also well assembled for immediate use.
- The assistant for the completion of the research also is an issue for a project as this.
- Besides, to obtain information from the respondents was somehow difficult due to the busy nature of their work schedule
- Nature of the professional jobs that makes some of the staff to be on shift or call duty during the time of visit to the hospital. Also, most of the time the available staff complains about busy nature of their job to attend to the research
However, these limitations have been put in perspective to ensure that outcome of this research shall not in any way be defeated.
1.7 Definition of Terms
Constraints: can be defined as challenges or problems (Webster Dictionary). A state of being restricted confined prescribed bound, constraints can also being regarded as challenges or problem.
Evaluation: Is the structured interpretation and giving of meaning to predict or actual impacts of proposals or results.
Health: According to World Health Organization (WHO) can be defined as the state of complete physical, mental, and social well-being of an individual and not merely the absence of diseases or infirmities.
Health Record: Is defined as a yard stick measure to know the activities of the hospital. It is also defined as a clinical, scientific, administrative and legal document relating to patient care in which are recorded sufficient data written in the sequence of events to justify the diagnosis and warrant the treatment and end result. Adepoju, (2016) refers to a clinical, scientific, administrative and legal document of a patient care and treatment so as to assist in the treatment of present and future aliment. It is usually recorded in chronological order so as to justify the diagnosis and warrant treatment and end result. Health Record is a clear, concise and accurate history of a patient life and written from the medical point of view. A health record is a collection of recorded facts concerning a particular patient (Lusi 2014)
Management: The act of getting things done through the effort of other people. The act or skill of controlling and making decision about department or business organization.
Patient-a person registered to receive medical treatment or a person who is under medical care or treatment.
Patient Health Record: This is defined as the collection of data complied on a patient to assist in a clinical care of present and future illness.
Practitioners: someone who is qualified to or registered to practice a particular occupation, profession or religion.
Problems: A state of difficulty that needs to be resolved.
Professionals: Is the standard of education and training that prepare member of profession with particular knowledge and skill necessary to perform the role of that profession. Is a number of a profession, the term also is the standard of education and training that prepare member of profession with particular knowledge and skill necessary to perform the role of that profession.
Record: Is a unit of data representing a particular transaction or basic.
Service Delivery: This is the part of a health system where patients receive the treatment and supplies they are entitled to (Webster Dictionary).
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Full Project – Evaluation of constraints facing service delivery of health information practitioners