8 USES OF HOSPITAL RECORDS

Sometime in 2011, I went back home (Benin-City) to visit my parents. While there, I decided to "browse" my personal record file that my Dad had kept from the day of my birth. The file contained my birth certificate, the first comic book I wrote, my primary school results, my secondary schools results and a lot of other records. Some of which I won’t share with you! Looking through that file, I was able to trace my educational journey from kindergarten (Well, not really. More like "akara school") to university. I could even recall things and people that I had long forgotten. I was amazed that my parents had kept such good records for all their children. I really can’t say the same for myself (and I have just two)!

That visit got me thinking about the importance of good records to an individual and an organization. To me, the most important organization where good records are crucial to its very existence is the hospital. Unfortunately, hospitals in general and private hospitals in particular are notorious at keeping poor records. Admission data, diagnosis data, monthly income records, pharmacy records and laboratory data are all poorly kept. I was told of a private hospital that burns (yes, burns) patient's folders after 4 years claiming that they have expired. How absurd! Without proper health records, we cannot make progress as a nation. Keeping records means having a good history. History helps us to take decisions today that will eventually shape our future. This implies that you cannot effectively plan for the future without having a good record of the past. A wise man once said "the faintest ink is sharper than the sharpest memory".

 I came across a study some years ago called the Framingham Heart Study. It was part of the learning tools in my Online Bio-statistics course at the Harvard School of Public Health. This study was started in 1948 and it involved an initial population of about 5000 people. Today, the children and grandchildren of some of the initial enrollees have been enrolled in the study. The Framingham Heart Study has helped improve our understanding of CHD and HTN in the last 70years or so. This is the result of good record keeping.

What drives me first and foremost is a burning desire to see the quality and standard of healthcare improve in Nigeria (and across the African continent). This will be achieved if the healthcare professionals themselves embrace change and commit to self-improvement; not only in clinical skills but also in managerial skills. So, to the multitudes that share this desire, I say “let’s go on”.

Now, why is it important to keep good hospital records? What are the uses of hospital records? I will write on 8 uses of hospital records. There are a lot more.

1.     Research and planning

2.     Assessment and evaluation

3.     Detection, Prevention & Control

4.     Process improvement

5.     Profit

6.     Provides confidence

7.     Effective Resource Management

8.     National Security

1.     Research And Planning

Good hospital records form the bedrock of any clinical research project. Can you imagine how difficult it will be to get the National HIV prevalence rate if health facilities do not send in HIV data?(let’s assume that the records are actually accurate) Without good records, a researcher will lack data on which to build his/her research. Without research findings, there can be no action plan on HIV/AIDS. You can step this scenario down to your local facility. Research leads to improved understanding of present knowledge and discovery of new facts. This invariably leads to better planning.

2.     Assessment And Evaluation

When you study your hospital records, you will be able to assess and evaluate your hospital’s performance. Let’s take Delivery records for instance: A glance at the annual delivery record will show the number of life births, still births and ENND. You can maybe calculate the cumulative incidence of ENND, compare with the state average (if the records are available!), assess the deviation of your facility from that average and then evaluate the effectiveness of your hospital delivery methods. You may discover that most of the ENND occurs when a particular staff is on duty. All the conspiracy theorist can get to work now! (Have you seen the movie ‘coma’? Watch it and you will get the drift).

I will end this post here. The article on hospital records will continue in my next post.