Existing record keeping system in government teaching hospitals of Karachi.

OBJECTIVE To determine the deficiencies in the existing record keeping system (ERKS) in government teaching hospitals of Karachi. STUDY DESIGN Descriptive, qualitative study to determine the deficiencies in the ERKS in government teaching hospitals of Karachi. SETTING The study was conducted in four government teaching hospitals of Karachi from 1.1.1998 to 1.11.1998. METHODS A total of 9725 pre-coded proformas were filled from 136 units of all hospitals including out patient departments (OPD), wards and emergency units. RESULTS Majority of the records (52.2%) were retrievable within one hour. The mean +/- S.D of patients seen per day at all hospitals were 122.49 +/- 92.25 (57 OPDs), 30.04 +/- 16.24 (75 wards) and 186.25 +/- 145.80 (4 emergencies). In majority of units (57.4%), the stationary for record keeping system was either not provided or was not enough. Only 39.0% units have 75% or more required information on records. The important information (except age) i.e. temperature, pulse rate, blood pressure, diagnosis, weight, history of patient, laboratory findings, previous record and discharge report and prescribed doses of medicine were lacking. CONCLUSION The ERKS in the government hospitals of Karachi is inadequate. It is therefore essential that uniform OPD, ward and emergency slips should be developed having all-important queries. So that data could be utilized for research purposes along with better planning and management of the hospital and procurement plan for the government.