'I Keep My Health Book with Me': A National survey of 20 years' experience of Patient- retained medical records Lesotho

Abstract

Patient-retained medical records (PRMR) are attracting attention because of problems encountered with conventional record-keeping systems. The aim of this study was to formulate recommendations for the use of PRMRs in health care services in a changing Africa and especially in South Africa, A nation-wide survey was conducted in Lesotho where PRMRs have been in use for up to twenty years. The hypothesis tested was that PRMRs can be used with a high degree of satisfaction by patients, nurses and doctors. Satisfaction was measured, in terms of preference, practicality and comparison with facility-retained records. The results were overwhelmingly in favour of the PRMRs. Almost all of the patients (89%) preferred to keep their own records rather than have them kept by the doctor, clinic or hospital. The PRMRs were rated as excellent or satisfactory by 79% of the doctors and 700/o of the nurses in contrast to facility-retained records which were rated as excellent or satisfactory by only 57% of doctors and 49% of nurses. PRMRs were found to be available, durable, and a convenient size both for carrying and for recording. Confidentiality of information was not found to be a major problem. An important advantage of the PRMR perceived by both doctors and nurses was less unnecessary repetitions of tests and treatments and less mistakes due to increased availability of important patient information from other care-givers. Other important advantages included the saving of time and money, opportunities for health education and increased patient responsibility. It is recommended that other health care providers seriously consider implementing PRMRs and in particular, that South Africa do so on a national or provincial basis.