Medical Records Documentation of HIV/AIDS Clinical Services at Primary Health Care (PHC) Facilities and Its Implications on Continuum of Care and Operational Research in South Africa

Background: Patients medical records are used to document care processes for communication amongst healthcare workers for continued patient management. Incomplete or inaccurate documentation can adversely affect the quality of patients’ care, leading to medication and treatment errors, increased morbidity, and mortality. Quality documentation in medical records is therefore an essential component of optimal healthcare and facilitates an individual’s continuity of care. This study aimed to assess the quality of documentation of clinical data through the review of the accuracy and completeness of clinical records among newly diagnosed HIV-positive persons. The study is a sub analysis of a prospective longitudinal study that followed a cohort of 12,413 persons who were newly diagnosed with HIV infection. Severe limitations in retrieving reliable information and data became an obstacle to our research and led the study team to conduct medical records documentation and data audit to verify the accuracy and completeness of the data for newly diagnosed HIV positive persons. Methods: A cross-sectional study was conducted using routine data generated from 75 randomly selected newly diagnosed HIV positive persons aged 12-years-old and above between June 1, 2014 and March 31, 2015 in 36 purposively selected primary health care (PHC) clinics in South Africa. The facilities were selected from three high HIV-burden districts of South Africa (Gert Sibande, uThukela and City of Johannesburg). Results: Significant differences in the accuracy and completeness of clinical records were observed between data generated through the self-assessment by the facility managers and data primarily collected through review of the patients’ clinical stationery and facility registers. 80% of the newly diagnosed HIV positive persons were not documented as screened for tuberculosis (TB) on the clinical chart and 69% of newly diagnosed clients were not clinically staged (WHO staging). Furthermore, 80% of newly diagnosed HIV positive persons’ follow up visit dates were not documented in the patient’s clinical chart. Completeness of the data elements on the case record forms ranged from as low as 26% to a maximum of 66%. It was noteworthy that all the clients’ information documented in HIV counselling and testing registers, continuum of care registers and clinical charts were only partially completed. Conclusion: Each of the health care facilities under study had some significant gaps in medical records documentation of clinical data on newly diagnosed HIV positive persons. Data and information accuracy and completeness were a serious challenge in most facilities during the period under investigation. Of interest was the inconsistency of data recorded in the HCT registers, continuum of care and clinical charts of individual patients. This is a major impediment to HIV/AIDS comprehensive care.

文件整体运动描述:是文件生命周期模式,还是用文件连续体模式?——后保管时代档案学基础理论适应性问题研究之三

本文认为,由于文件生命周期理论是"三位一体"档案学理论框架的核心,而且描述的是文件运动本身,因而,在后保管时代电子文件管理的实践首先对它造成了冲击。从实践发展的需要看,文件连续体理论取代文件生命周期理论是一种必然,文件连续体理论将成为构成后保管时代档案学体系的基石。

CAD电子文件管理流程分析

CAD电子文件管理流程与传统的科技档案管理流程有着显著的差异。这种差异要求我们对CAD电子文件管理流程进行重新的思考和定位。本文从CAD电子文件管理流程的基本指导思想、CAD电子文件管理流程的特点、CAD电子文件管理流程的解析三个角度来阐释其中的差异。

文件横向运动理论与连续体理论关系研究

文件横向运动理论与文件连续体理论均是对文件运动规律认识的系统论述。运用比较研究的方法,通过对比两种运动理论的异同点,进而指出文件横向运动理论作为我国的本土化理论,需要不断吸收文件连续体理论等其他运动理论的思想精华,以进一步完善自身理论体系,更好地指导实践工作开展。

基于文件连续体理论的医院合同文档管理

医院合同文档是维护医院合法权益的凭证和依据,但传统的合同文档分类归档模式已经不能满足日益多样的利用需求。文件连续体理论为信息化背景下的医院合同文档管理提供了一个新的管理模式,即运用全程管理原则和文档一体化思想,通过建立健全医院文档管理组织机构、加强顶层设计和制度建设、构建合同管理系统等具体措施,突破了医院合同文档管理和利用过程中时间和空间的限制,最终达到提升合同文档管理质量、效率和服务水平的目的。

高校附属医院科研文件管理模式的理论基础研究

制定连贯一致的文件管理规划,对规范科研信息的产生、分布、保护、管理和利用具有特别重要的意义。因此,需要通过构建一套适合高校附属医院的科研文件管理模式,使科研文件管理规范化、制度化、常态化,以达到资源共享的目的,最大限度地发挥资源的可利用价值,促进科研信息共享、学科建设、人才培养和成果转化,提高科研水平和管理效率。文章主要阐述了高校附属医院加强医学科研文件管理的必要性及指导意义、文件连续体理论及指导意义、基于综合集成管理模式的科研文件管理应遵循的原则及指导意义这几个方面的内容,力争为医院科研文件管理模式的构建提供科学可靠的理论基础。

城乡规划项目电子文件实施在线管理的要素分析

在自然与社会发展环境不断变化的情况下,城乡规划过程关联的各种因素不断增加,相关文件的形成、运行及管理必然面临运行效率及档案完整性需求的挑战,应对挑战的基本策略就是实现电子文件文档一体化在线管理,为不断的智能化改进奠定基础。本文深入分析了城乡规划相关文件在宏观管理层面特性,探讨了实施电子文件在线管理的技术环境,提出了实施在线管理的基本要素需求与对应的实施策略。