HEALTH RECORDS & INFORMATION OFFICER

LUKE KIPTOON

HEALTH RECORDS & INFORMATION OFFICER (ICT)

PETER WAINAINA

HEALTH RECORDS & INFORMATION OFFICER

BERNARD BOWEN

Historical Background
In 1752  Benjamin Franklin set up an incorporated Hospital in Philadelphia in United State of America. This hospital is presently known as Pennsylvania Hospital. He introduced medical record by preparing file of special cases on which patients’ name, admission date, discharge date etc. were written. In the same way, another hospital was opened in Boston in 1821 where a typical method of keeping relevant data was initiated. Separate files were opened for different individual patients in order to keep records. This process proved to be more helpful in finding the necessary data regarding the patients. Besides this, it helped in acquiring important facts that could make easier to take care for patients and to conduct the proper research work. With the passage of time Medical record has been a backbone for developing a new dimension in the health sector in each of the countries in the world. It has been indispensable for countries for continuing the research works, to deliver the appropriate health services to the patients, create the skilled manpower and to enhance the goodwill of the nation as well.

Introduction of Medical Records in Kenya
In 1978, it was perceived that medical records served as an important tool for the patients, public, and the hospital. Due to its usefulness both to the administration and the patients in terms of planning and treatment of patients respectively, a certificate course in health records and information was started at KMTC Nairobi. Later this course was introduced in Murang’aMTC, MsabweniMTC and SiayaMTC.

This process produced officers who were well knowledgeable in the management of medical records. Initially these officers were at the certificate level and later on a diploma level was introduced in KMTC Nairobi. A few years ago a degree course took off in a number of our local universities.

In this county we have one KMTC which is a Semi Autonomous Governmental Agency(SAGA).

Functions/Role of the Health Records & Information Department in Health facilities:
The Health Records and Information professionals organize, and manage health data and information, ensure quality, and security of the health information in both paper and electronic. They use various classification systems to code and categorize patient information for among others inpatient reports, insurance reimbursement purposes, for databases and to maintain patients’ medical and treatment histories. Assist in the implementation of the health electronic document management system, through District Health Information System (DHIS), Electronic Medical Records (EMR), Master Facility List (MFL), and Master Community Unit List (MCUL). At the health facility they assist in the processes of records storage and the implementation of the Archives Management Plan. They process requests from researchers who may require to conduct researches related to health (this is after passing through the laid down procedures or protocol), and also undertake the daily functions of health fraternity in terms  of documentation of  information management system to provide an efficient and effective service to the ministry. Their services provide information for planning and informed decision making.

Through the national Ministry of Health, there is a web based reporting system (DHIS) where the DHRIOs’ are able to post their reports for anyone with internet access these reports.

Quite a number of our facilities in our county have attempted to go paperless in terms of managing their patients. That means the patient do not have to have hard copies of their records. The two main hospitals, PGHNakuru and Naivasha District Hospitals are good examples of these. Many other hospitals across the country have been visiting these 2 hospitals as benchmarks so that they can implement in their hospitals.

Human Resource:
The county is served by about 38 officers who are deployed across the county. Due to a very acute shortage of this cadre, they are only deployed in the main hospitals and each sub-county is manned by one District Health Records & Information Officer (DHRIO) who is charged with the responsibility of compiling reports for the sub-county. This is a challenge as it is the departments’ wish to have all the Health Centres in our county manned by a qualified officer.

Health Records and Information Management is one of the key service that contribute to the provision of efficient and effective health services. The service is provided by the Health Records and Information Officers at the hospitals, Sub Counties and County level. The Sub County Health Records and Information Officers man the 9 Sub Counties, and the majority of the officers are based in the hospitals. Up in the ladder is the County Health Records Information Officer who  coordinates all activities in the County assisted by two other officers. Nakuru County  health is comprised  of: Health Records Officer manning 9 sub-counties evenly distributed within the county. A bulk of these officers are based in the hospitals where most of the services are needed. Others are based in the sub county headquarters to take charge of all health information issues in the respective areas. These officers have a title of sub-county health records information officers. Up in the ladder is the County Health Records Information Officer who  coordinates all activities in the county assisted by two other officers.

Duties of Health Records and Information Officers/ Technicians
The Health Records and Information professionals organize, and manage health data and information, ensure quality, and security of the health information in both paper and electronic.
They use various classification systems to code and categorize patient information for among others inpatient reports, insurance reimbursement purposes, for databases and to maintain patients’ medical and treatment histories. Assist in the implementation of the health electronic document management system, through District Health Information System (DHIS), Electronic Medical Records (EMR), Master Facility List (MFL), and Master Community Unit List (MCUL). At the health facility they assist in the processes of records storage and the implementation of the Archives Management Plan. They process requests from researchers who may require to conduct researches related to health (this is after passing through the laid down procedures or protocol), and also undertake the daily functions of health fraternity in terms  of documentation of  information management system to provide an efficient and effective service to the ministry.
Their services provide information for planning and informed decision making.

Medical records and health information organize and manage health information data. They ensure quality, accuracy, accessibility, and security of health information in both paper and electronic system is adhered to. They use various classification systems to code and categorize patient information for among others inpatient reports, insurance reimbursement purposes, for databases and to maintain patients’ medical and treatment histories

They also assist in the implementation of the health electronic document management system, through District Health Information System (DHIS)

They also assist in the processes of the facilities records storage facility and the implementation of the Archives Management Plan. They also process requests from researchers who may require to conduct researches related to health (this is after passing through the laid down procedures or protocol).

They also undertake the daily functions of health fraternity in terms  of documentation of  information management system to provide an efficient and effective service to the ministry. These services include information purely for planning and informed decision making.

Types of Health Records:
Health records take many forms and can be on paper or electronic. These are just some of the few types of health records in the health sector:

  • Consultation notes, which your clinician takes during an appointment,
  • Hospital admission records, including the reason you were admitted to hospital the treatment you will receive and any other relevant clinical and personal information,
  • Hospital discharge records, which will include the results of treatment and whether any follow-up appointments or care are required
  • Laboratory test results
  • X-rays Reports including magnetic resonance imaging (MRI) or computerized tomography (CT) scanners.
  • Workload Reports
  • HIV/AIDS Reports
  • MCH/FP Reports
  • Surveillance Reports