Text in English with summaries in English, Afrikaans and Zulu / Bibliography: leaves 102-115 / The study investigated the management of medical records in the Primary Health Care services (PHCs) of Diepsloot. The study investigated the regulatory framework, records infrastructure, records security, records management staff skills and the filing system. A qualitative design guided by the interpretive paradigm was used to guide the case study. Interviews, focus groups, and observations generated data from 50 participants. The study revealed that the regulatory instruments used to manage records lack implementation and compliance. There was a lack of security measures, a shortage of records management infrastructure and inconsistency in the filing system. There is a low level of skill in the records management staff. The study recommended the implementation of a regulatory policy that will guide and ensure effective governance of records in PHCs. Records should be secure from misuse by unscrupulous individuals. PHC records need to be managed by experienced professionals. The filing system should be easily accessible. / Die studie het ondersoek ingestel na die bestuur van mediese rekords in die Primêre Gesondheidsorgdienste (PHC's) van Diepsloot. Die studie het ondersoek ingestel na die regulatoriese raamwerk, rekord van infrastruktuur, rekord sekuriteit, vaardighede vir rekordbestuur en die liasseerstelsel. 'n Kwalitatiewe ontwerp gelei deur die interpretatiewe paradigma is gebruik om die gevallestudie te lei. Onderhoude, fokusgroepe en waarnemings het gegewens van 50 deelnemers gegenereer. Die regulatoriese instrumente wat gebruik word om rekords te bestuur, het geen implementering en nakoming nie. Die studie het aan die lig gebring dat daar 'n gebrek aan veiligheidsmaatreëls was, 'n tekort aan infrastruktuur vir rekordbestuur en teenstrydigheid in die liasseringstelsel. Die personeel in rekordbestuur het 'n lae vlak van vaardigheid. Die studie het die implementering van 'n regulatoriese beleid aanbeveel wat die doeltreffende bestuur van rekords in PHC's sal lei en verseker. Rekords moet beskerm word teen misbruik deur gewetenlose individue. PHC-rekords moet deur ervare professionele persone uitgevoer word. Die liasseerstelsel moet maklik toeganklik wees. / Lolu cwaningo luphenywe ngokuphathwa kwamarekhodi ezokwelashwa emnyangweni Wezokunakekelwa kwempilo okuyisisekelo (i-PHCs) eDiepsloot. Ucwaningo luphenywe ngohlaka lokulawula, ingqalasizinda yamarekhodi, ukuphepha kwamarekhodi, amakhono okuphathwa kwamarekhodi nohlelo lokufayila. Umklamo olungaqanjwa uqondiswa yi-paradigm yokutolika wasetshenziselwa ukuqondisa ucwaningo lwesigameko. Izingxoxo, amaqembu okugxila kanye nokubukwa kukhiqize idatha evela kubahlanganyeli abangu 50. Izinsizakusebenza zokulawula ezisetshenziselwa ukuphatha amarekhodi zingenakho ukusebenza nokuhambisana. Ucwaningo luveze ukuthi bekukhona ukuntuleka kwezindlela zokuphepha, ukushoda kwengqalasizinda yokuphathwa kwamarekhodi kanye nokungahambelani ohlelweni lokugcwalisa. Kunezinga eliphansi lekhono kubasebenzi bokuphathwa kwamarekhodi. Ucwaningo lincome ukusetshenziswa kwenqubomgomo yokulawula ezohola futhi iqinisekise ukuphathwa kwamarekhodi kuma-PHCs ngendlela efanele. Amarekhodi kufanele avikeleke ekusetshenzisweni kabi ngabantu abangathembekile. Amarekhodi we-PHC adinga ukuqhutshwa ngochwepheshe abanolwazi. Uhlelo lokufayila kufanele lutholakale kalula. / Information Science / M. Inf.

Indiana University-Purdue University Indianapolis (IUPUI) / Reducing medical error remains in the forefront of healthcare reform. The use of health information technology, specifically the electronic health record (EHR) is one attempt to improve patient safety. The implementation of the EHR in the Emergency Department changes physician workflow, which can have negative, unintended consequences for patient safety. Inaccuracies in clinical documentation can contribute, for example, to medical error during transitions of care. In this quasi-experimental comparison study, we sought to determine whether there is a difference in document quality, error rate, error type, cognitive load and time when Emergency Medicine (EM) residents use paper charts versus the EHR to complete physician documentation of clinical encounters. Simulated patient encounters provided a unique and innovative environment to evaluate EM physician documentation. Analysis focused on examining documentation quality and real-time observation of the simulated encounter. Results demonstrate no change in document quality, no change in cognitive load, and no change in error rate between electronic and paper charts. There was a 46% increase in the time required to complete the charting task when using the EHR. Physician workflow changes from partial documentation during the patient encounter with paper charts to complete documentation after the encounter with electronic charts. Documentation quality overall was poor with an average of 36% of required elements missing which did not improve during residency training. The extra time required for the charting task using the EHR potentially increases patient waiting times as well as clinician dissatisfaction and burnout, yet it has little impact on the quality of physician documentation. Better strategies and support for documentation are needed as providers adopt and use EHR systems to change the practice of medicine.