Patient held medical records in public hospitals in Bulawayo

Abstract

The purpose of the study was to examine the use and handling of PHMRs by patients and the clinical staff at public hospitals in the Bulawayo Province. The study employed a qualitative research methodology in which open ended questionnaires were used to collect data. Data were collected from doctors, nurses, records clerks and patients at 2 of the 4 targeted major public hospitals in Bulawayo, giving a total of 150 participants. This study revealed that PHMRs contained vital patient health information such as diagnosis, patient name, and prescribed medications. PHMRs did not have an official uniform structure, and patients used whatever booklets that were affordable to them. In some cases, patients used pieces of paper, although this was not encouraged. PHMRs were considered as legal records that are admissible in courts of law on the basis of them being authenticated by dating, officially stamped and signed by the attending medical practitioner. However, there were cases of unlawful manipulation of PHMRs through editing by patients, and in some cases, documentation incompleteness of the PHMR. The study further found out that the biggest challenge faced in the use of PHMRs was their loss by patients, which negatively impacted health care service delivery. The study recommends that patients be continuously educated about the importance of, and effectively managing their PHMRs for the purposes of continued health care delivery and accessibility. The study further recommended the use of structured hospital-designed booklets that patients can purchase at the hospital. This would avoid the use of any type of book/booklets and pieces of paper. The Ministry of Health and Child Health Care in Zimbabwe needs to consider introducing personalised electronic health records as alternatives to physical PHMRs.