Management of medical records: a study at Princes Marina hospital, Gaborone, Botswana

Abstract

The purpose of this study was to investigate medical records management practices at Princess Marina Hospital (PMH). The Medical Records Unit (MRU) was one of the largest units in PMH and was in possession of records dating as far back as Botswana’s independence in 1996, yet it was not clear if proper systems had been put in place to manage them. The objective of this study was therefore to investigate records management practices from the time of creation (birth) until they were disposed permanently, either through destruction or storage in an archival institution or records centre. Furthermore, the study aimed at making recommendations for the improvement of record management practices at PMH. The study was informed by the record life cycle model and the records continuum model. The theoretical framework for the study subscribed to the principles of good record management based on ISO 15489-1 standards which dictate for the efficient and systematic control of the creation, receipt, maintenance, use and disposition of records. The study used both quantitative and qualitative research methodology to gather information. The research design, therefore used was a mixed method approach which employed both quantitative as well as qualitative methods of data collection. Several documentary sources for this study were reviewed amongst others which included reports relevant to health in Botswana from the Ministry of Health such as policy documents, WHO with specific chapters to Botswana on health issues, the Ministry of Health Portal, SADC Protocol on Health, PMH brochure, local newspapers, internet sources, books, ISO 15489, and dissertations. The study showed that there was poor management of medical records at the Princess Marina Hospital and the record management system in place was insufficient. The study therefore recommended that the policy on records management which was said to be in a draft form be finalized in order to guide the processes and procedures for record management practices at PMH. In addition, the study also recommended that a good records management system at PMH was needed that would ensure that proper data and information was fed into the NHIS. This would enhance proper planning and financing to the health sector by the government of Botswana.