assessment of the security of medical records at butabika hospital

Description

The major purpose of this study was to “assessment of the security of medical records, a case study of Butabika hospital”. The objectives of the study were; to find out the types of medical records kept at Butabika hospital, to examine the security threats to medical records, to examine the current security measures in place for medical records, to find out the challenges affecting the security of medical records and to suggest appropriate security measures to medical records at Butabika hospital. The researcher employed qualitative and quantitative research approaches to gather the findings by use of interview and observation guide, purposive sampling were used where individuals were selected according to their role and title held in the medical records. The actual size of study comprised of (10) respondents (1) records manager who was in charge of medical records, (5) records assistants, (1) doctors, (2) nurses, and (1) patient that helped in acquiring relevant data. The research findings revealed the types of records kept and how are generated that is to say Admission notes, Patient case notes, X-ray request forms, Inpatient admission shits, Medical form 5, Patient registers, Lending registers, Discharge forms, Tracer cards, Laboratory progress notes among others. Security threats included viruses, regular crashing system, poor handling of medical records, rodents and pests and then floods. The findings also revealed current security measures as follows; back up of information on computers and flash disks, control of access to medical records through the use of passwords, control of file movement, updating of software regularly. Challenges affecting the medical records security such as inadequate storage facilities, medical records disclosure, medical records alterations and researcher suggested security measures such as; tighten security checks, use of biometric devices, installation of surveillance system, installation of fire alarm systems and others. The researcher recommended the administration to do the following; digitization of records, developing clear disposal guidelines, employing enough records staffs, taking records staffs for further training, providing enough storage facilities and expansion of records department due to increasing number of records. In conclusion,Based on the findings the security of medical records is well done though there are some challenges like inadequate storage facilities, inadequate skills, alteration of medical records among others and it requires improvement and the best way to improve like digitalization of records, taking records staff for further training among others.