IOSR Journal of Nursing and Health Science (IOSR-JNHS) e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 8, Issue 4 Ser. IX. (July-Aug .2019), PP 36-41 www.iosrjournals.org DOI: 10.9790/1959-0804093641 www.iosrjournals.org 36 | Page Status of Inpatient Medical Records Clerking At Nakuru Provincial General Hospital, Nakuru County, Kenya. Obwoge Ronald Omenge 1, Oigara Nyakoinani Lydiah 2 1 (Department of Community Health, Faculty of Health Sciences, Egerton University, Kenya) 2 (Department of Health Records and Information Technology, Faculty of Research and Information Science, Kenya Medical Training College) Abstract: Medical records completeness is an important task in effective and efficient health care service provision. The completeness provide timely patient information at delivery points. The completeness play a vital role during planning and provision. This study aimed to evaluate the status of inpatient medical records clerking at Nakuru Provincial General Hospital. In order to: 1) determine the completeness of bio data, 2) completeness of family history, 3) completeness of patients’ medical history, 4) completeness of patients’ treatment history and 5) to establish the rightful usage of specific forms at inpatient services. A retrospective record review (3R) study design reviewing 200 inpatient medical records of discharges through a checklist, between the periods 12th February to 25th February, 2019. Data was analyzed using SPSS version 22 and expressed in percentages, in tables and graphs. The study concluded that there was incompleteness in clerking of the patients’ medical records where high rates were noted on patient’s occupation incomplete at 34%, patients’ presence/absence of known medical conditions at 25%, indication of allergies at 22%, frequency of medication at 25% and finally wrong usage noted with the registration at 21%. The study recommends that the Hospital management should initiate a regular Intensive continuous medical education (CME) to the healthcare providers on the importance of completeness in clerking medical records at all service provision points and also the Health Records and Information Officers to ensure availability of various medical record forms at service points. The research permitted by National Commission for Science, Technology and Innovation, Kenya. Keywords: completeness, incompleteness, Medical Records, Clerking, right usage --------------------------------------------------------------------------------------------------------------------------------------- Date of Submission: 09-08-2019 Date of Acceptance: 23-08-2019 --------------------------------------------------------------------------------------------------------------------------------------- I. Background information Medical health records form an essential part of patient’s present and future healthcare. Their completeness is important in the sense that it enable right patients’ services provision, also in p lanning, medical research, production of healthcare statistics, and development of healthcare sector. Completeness in medical records provide timely patient information for the healthcare professionals’ efficient and effective service care. For efficiency, it is necessary for all medical data to be written down and in the right forms. Tufo & Speidel (1971) indicated that there are consensus among health care professionals that medical records are important and necessary for medical education and medical care. Also that the traditional medical record is often seriously deficient. Completeness of patient’s medical history is a necessity in all facilities. It allows health professional to begin with a review of the initial data, during the interview will further investigate this information, probing deeper and wider to arrive at a judgment as to what type examination procedures would be best suited for the particular patient and complaints involved. So, incomplete medical records can contains gaps that may result to poor clinical care, insufficient research evidence, not adhering to institutional policies, claims of alleged negligence and fraud. Complete medical records are important since they are essential for the continuity of care of patients. Also, good and complete medical records are vital for defending a complaint or clinical negligence claim against health professionals or the health system. Ignoring completing the necessary patient’s medical form may lead to a lot of disadvantages to the Health professionals, facility’s administration system and to loss of patients’ life, since the wrong diagnosis maybe arrived at or even can result in legal action. Also can lead to inappropriate billing and loss of revenue due to fraudulent charging. Thus the presence of a complete, up to date and accurate medical record can make all the difference to the outcome by sorting out the unlikely events. Hence the study aims to evaluate the status of inpatient medical records clerking in Nakuru Provincial General Hospital. The study findings is a basis for further action to improve or maintain quality of clerking for better service delivery avoiding legal issues, high cost due to duplication of services, inappropriate billing leading to charges of fraud, inaccurate and poor care information and poor patient care.