Perceptions of patients, doctors and clerks of their roles in causing problems in medical records

ABSTRACT

To study the perceptions of clerks, doctors and patients regarding their roles in the causation of current problems in medical records in Primary Health Capital area. The problems were summarized as follows the nonretrieval, improper storage and loss by clerks, the non recording by doctors, and the no-arranging and nonrequesting for file retrieval by patients. The aim was to study the possible strategies for each group of personnel dealing with the medical records in Kuwait. Method: 16 clinics in the capital health area were studied out of 20. Four clinics were excluded as the percentages of Kuwaiti citizens were less than 50% of the population. The study consisted of three parts. Self-filled questionnaires were administered at the three possible levels of interaction the clerks, the doctors and the patients. The sample of doctors consisted of all those working in primary care clinics of the capital area [101 participated], the sample of clerks consisted of all clerks working in general practice section in the morning shift from the 16 clinics [47 participated], and then a convenience sample of patients in the waiting rooms of each clinic taken in the morning shift [521 patients participated]. Main outcome: The perceptions of clerks, doctors and patients of their roles in the current problems in medical records. [a] The majorities of patients [82.7%], clerks [93.5%] and doctors [92%] had good perception of the importance of having a medical record for every patient. [b] The overall rate of file retrieval by clerks was 69% [range 48-100%]. [c] The overall rate of doctor's recording in the file was 60.5% [range 42-100%]. 56% of clerks blamed the lack of files on the clinic itself and 53% blamed overcrowding as a cause of not retrieving the medical record. A significant correlation [two-sided] at 0.001 level was observed between the non-retrieval of files and the absence of files from the clinic, absence of a law for punishment, lazy clerks and the ways of keeping and storing medical records. 66% of doctors insisted on retrieving patient's file on each visit, 74% of doctors could work without a file. 87% of patients already had their medical records but only 46% of patients always asked for their files when they came to the clinic. 79% of patients said that they always brought their civil identity cards for clinic visits and 71% agreed to make a file when they didn't have one. Conclusions: Although clerks, doctors and patients had good perceptions of the importance of having a medical record, yet there was a real problem of the medical records retrieval and storing system. All the three parties played a role in the filing system defect and should cooperate to correct it