Management of Medical Records in a Multispecialty Tertiary Care Hospital at Surendranagar, Gujarat−A Cross-Sectional Study

Health facilities deal with life and health of patients. Quality of medical care relies not only on its staff, high-quality equipment and facilities but also on good record keeping. Proper filing of medical record ensures easy retrieval of health information and prevents delay in healthcare delivery. Objective of the study is to investigate the record management practices in a multi-specialty tertiary care hospital of Surendranagar district, Gujarat.

A survey design was used while a total of 130 hospital staff was sampled using non-probability technique. Questionnaire was used as a tool for data collection. Data collected was analysed using frequency counts and simple percentages.

77.97% of response on type of record created was patient records. Among the staff involved in record management, 31.11% had a working experience between 6-9years. The records were both in paper and electronic format as mentioned by 72.22% respondents. 73% mentioned records were archived in numeric, 14% in alpha-numeric and 13% in both formats. Records were disposed by manual techniques.

Most commonly nursing staff was involved in record creation. Records were created in paper format and filed both in numeric and alpha-numeric sequence. Confidentiality and security of records are the major mechanism employed at the hospital. The most common problem faced in record management in this study was damage of records including tearing and weather effects on paper records.