Abstract

Background: Comprehensive medical records are cornerstones in the quality and efficiency of patient care, as they can provide a complete and accurate chronology of treatments, patient results, and future plans for care. The study was aimed to assess the quality of medical records in public health facilities of Jimma Zone.

Methods: A facility-based cross-sectional quantitative study design supplemented by a qualitative method was used from May 30 to July 29, 2020. A total of 384 medical records were reviewed by using the facility inventory form for quantitative data. The data was entered by EPI data 3.1 and analyzed by SPSS 23 and descriptive statistics were used to present the findings. Qualitative data were triangulated with the quantitative data.

Result: The majority of the health facility has a shortage of trained and qualified recording personnel in the medical record department. Among 36 health facilities, only one facility have printer in the record room and 3(8%) of them have tracer card. The overall quality of medical records in terms of content completeness as per the standard of health facilities requirements for districts, hospitals, and health centers were 30.62%, 39.49%, 25.79% respectively. 

Conclusion: The majority of medical records had poor completeness of administrative data, clinical, financial, and legal contents. The overall quality of medical records in Jimma Zone was very low for components of the quality of medical records as per the standard of health facilities requirements.