Compliance with the Medical Records Documentation Standard Operating Procedure among Health Workers in Bungoma Hospital County, Kenya
Omoit, David Franklin Opudi
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Improving medical records documentation among the health workers remains a major challenge to achieving compliance to medical records documentation SOP in many developing countries. Compliance to medical records documentation SOP can be used to improve health care and protect people against catastrophic health care risks and expenses. Most developing countries have low compliance to medical records documentation SOP and rely on manual systems for documentation. Despite having automated systems in some private and public health facilities, compliance to medical records documentation is still below the acceptable standards. The main objective of this study was to establish compliance with medical records documentation SOP among health workers in Bungoma level 4 hospital, Kenya, with specific objective of determining association between socio-demographic characteristics and compliance with medical records documentation SOP, influence of institutional characteristics and, influence of health workers' IT Proficiency on compliance with medical records documentation SOP among health workers in Bungoma level 4 hospital. The current study adopted an analytical cross-sectional design and quantitative data was collected using self-administered questionnaires, stratified proportionate and simple random sampling techniques were both employed to select 197 health workers sampled from a target population of 400 in Bungoma level 4 hospital. Chi-square, fishers exact, and Binary logistic regression analyses were used to test the association and the relationships between dependent (compliance with medical records documentation SOP) and independent variables (sociodemographic, institutional, and IT proficiency) respectively, albeit at a 95% confidence interval (CI), frequency tables, pie charts, and bar graphs were used to summarize and present the results. The current analysis confirmed that the compliance level to medical records documentation SOP was indeed very low at 47.2%. Socio-demographic factors such as Cadre (Fisher‟s exact test =24.52; p=0.002), level of education (Fisher‟s exact test =11.26; p=0.042), and work experience χ2 (8.75, df=5, N =195) p=0.047 were significantly associated with compliance to medical records documentation SOP. On both Institutional characteristics (P=0.023, exp(B)=1.454) and healthcare worker‟s Information Technology proficiency (P=0.027, exp(B)=2.156), positively influenced compliance to medical records documentation SOP. The current study concludes that, cadre, level of education, and work experience were significantly associated with compliance to medical records documentation SOP, Institutional characteristics like technical support, requisite documents, staff training and, health worker‟s information technology proficiency, positively influenced compliance to medical records documentation SOP respectively. The study therefore, recommends an urgent need for the County Government to channel additional funding towards employing more technical staff, procuring the requisite documentation tools, and training of staff on the documentation tools. Otherwise, the facility health management team needs to factor in periodic Information Technology refresher training for health workers, since the majority of health workers in Bungoma level 4 facility seem to have at least an intermediate level of IT proficiency. Future research should incorporate more robust data collection methods like observation checklists, and also consider qualitative methods like Key Informant Interviews to establish better insight on the compliance with medical records documentation SOP across all level 4 health facilities in Bungoma County and beyond.