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Analysis of Filling System and Consequences of Misfiled Patient Case Folders
Analysis of Filling System and Consequences of Misfiled Patient Case Folders
BY
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CHAPTER ONE
INTRODUCTION
Health information system cannot be ignored since health policies and planning in any
country are mostly dependent on the correct and timely information on various health issues.
Health facilities throughout the world keep consistent records of patients/clients. These
medical records are normally kept confidential and in confined places such as records unit or
treatment that includes the patient's medical history and complaints, the physician's physical
findings, the results of diagnostic tests and procedures, medications and therapeutic
procedures. (Anon., 2014). In effect, medical record of a patient is the clinical representation
of the patient that is built over a period by various clinicians with the consent, trust, privacy
and confidence of the patient. It enables continuity of care and again, overtime, it becomes a
comprehensive, clinical database from which various and salient clinical information is
Medical records serve many functions but their primary purpose is to support patient care and
in almost all public health facilities in Nigeria, they are kept in folders. Structuring the record
can bring direct benefits to patients by improving patient outcomes and doctors' performance.
On the side of patients, the records function as medical identification. (Mann R, 2013).
Huffman (2016) affirms that the health records of patients are an important primary tool in
the practice of medicine. The whole idea behind it is to provide better care of the patient
through careful recording of every detail having to do with the patient illness and care
rendered. Therefore, health records of the patient should be made available to the health
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professionals whenever patient visits the hospital for continuity of their previous treatment.
Failure to produce patient health record by the health information manager/officer in the
hospital due to mislaying or misfiling of such health record will bring about untold hardship
on the part of the hospital and the patient. That is, the health professionals such as the
hospital management physician (doctors), nurses, laboratory scientists etc. would not be able
to review the previous treatment and diagnosis given to the patient and wrong treatment and
diagnosis may be given to the patient at the end, which at times may lead to the patient’s
death, financial loss on the part of the hospital and the patient’s relatives may sue the hospital
for negligence and malpractice for damage done to the patient during the cause of the
treatment.
Moreover, Yeo (2019) posits that hospitals deal with the life and health of their patients, good
medical care relies on well-trained doctors and nurses and on high-quality facilities and
equipment. Good medical care also relies on good record keeping, without accurate,
comprehensive up-to-date and accessible patients’ case notes, medical personnel may not
offer the best treatment or in fact may diagnose condition which can have wrong
consequences on the part of the hospitals and the patients. In addition, records also provide
evidence of the hospital accountability for its action and form a key source of data for
According to Nandalal (2013), a patient health record communicates information about their
progress to the physicians and other health professionals who are providing care to the
patient. It is a communication link among the patient care-givers. For those health
professionals that provide care on subsequent occasions, the medical records provide critical
information such as the history of illnesses and the treatment given. Also, health records
provide evidence that may assist in protecting the legal interest of the patient, the physician
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Filling of health records is important for a number of reasons;
c. For continuity of patient care over the course of the patient illness
Huffman (2016) affirms that the health records is an orderly written report of the patient
complaints, the diagnosis findings, treatment and end result that in total form clinical picture
and when completed provides sufficient information to clearly identify the patient to justify
the diagnosis and treatment, and to record result. Because “patient forgets but record
remembers,” the health record is of the value to the patient, the hospital, the physician and for
research and teaching. Sequel to the aforementioned, it could be deduced that health records
keeping is the pivot of medicine. Failure to produce patient health records during his
subsequent visits to the hospital by the health records officer due to mislaying and misfiling
of patient health records in the health records department may inflict a lot of problem on the
patient, the hospital and the physician. The continuity of the patient care would be hampered,
wrong diagnosis may be given to the patient, patient may be delayed unnecessarily before
being attended to by the physician, the hospital management will not be able to review the
quality of care rendered to the patient during his stay in the hospital and the patient relatives
may conclude that negligence and malpractice have been committed during the course of
treatment and therefore sue the hospital management for damages. In order to avoid the
above mentioned, the health records managers/officers should be up and doing in the hospital
to make records of patient available whenever it is needed by the health professionals for
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1.2. Statement of the Problem
Proper filing of patient's medical records ensures easy retrieval, contributes to
decreased patient waiting time at the hospital, and ensures continuity of care. It is therefore,
imperative, that medical records are always kept in the interest of both the clinician and the
patient. The medical folder must always be in the custody of the health facility whiles the
patient enjoys the right of information. Studies in other developing countries have observed
their record keeping systems to be inadequate with about half (52.2%) of the records
retrievable within one hour, some of the records were poorly designed and there is use of
Problems of poor record keeping practices in health care facilities such as duplication,
incomplete data, and inaccuracies in data made it difficult for health administrators and
researchers to accurately and reliably identify and define health problems. Therefore, the
strengthening of the medical records in general and a computerized folder retrieval system in
particular, could contribute to its position as a valuable source of information for health care
As attendance in the health facilities increases with time, the volume of medical records
becomes a big challenge to health facility management. This is no different in Nigeria and for
that matter Mother and Child Teaching Hospital, Akure. The hospital is confronted with
filing of medical records especially with the introduction of the national health insurance
scheme, which brought in its wake the introduction of new folders and NHIS identification
cards (ID cards). The hospital is thus saddled with old and new folders for a sizeable number
of the patients having more than two folders due mainly to misfiling or patient forgetting
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This project therefore wants to analyze the causes, consequence and available solution to the
problems of mislaying and misfiling of patient health records in the health records
which will solve most of the challenges if not all that arises from the manual management of
1. To examine the available filing and numbering system in Mother and Child Teaching
2. To evaluate the effect of mislaying and misfiling of patients health records in Mother
3. To assess the types of health records personnel involved in filing and retrieval of
patient health records in Mother and Child Teaching Hospital, Ondo State; and
4. To find solution to the problems of mislaying and misfiling of patient health records
1) What are the available filing and numbering system in Mother and Child Teaching
2) What are the effect of mislaying and misfiling of patients health records in Mother
3) What are the types of health records personnel involved in filing and retrieval of
patient health records in Mother and Child Teaching Hospital, Ondo State?
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4) What are solution to the problems of mislaying and misfiling of patient health records
patient care folders. The study is purely restricted to Health Information Professionals in
Health Information Management Department of Mother and Child Teaching Hospital, Akure,
Ondo State.
Management of MCTH to better buttress filing system and its consequence of misfiled
patient care folders to ensure good delivery in healthcare settings. The findings are expected
to help inform decision making in the area of strategic planning with regard to Health
Records Services. The research will help to improve on efficiency and effectiveness of
administrative work flow in health facilities for better understanding on how records
processing is vital and guide how records are created, distributed, stored, assessed and
The findings will also help in the development and implementation of future policies and
practices that will enhance quality delivery in healthcare. The outcome of this study will also
serve as a base for academicians who want to conduct further studies on the analysis of filling
system and its consequences of misfiled patient care folders in health institutions.
Filing System: In computing, a file system or file system controls how data is stored and
retrieved. Without a file system, information placed in a storage medium would be one large
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body of data with no way to tell where one piece of information stops and the next begins
(Lynn, 2012)
Retrieval of Records: Locating a particular document, file, or record, and delivering it for
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CHAPTER TWO
LITERATURE REVIEW
2.0. Introduction
The review of literature exposes the researcher to available literature and offers new ideas,
perspectives and approaches to the topic. According to Leedy and Omrod (2015) the review
regarding the research problem at hand. It is always based on secondary sources, that is, what
other people have already written on the subject; it is not concerned about discovering new
evaluating and summarizing scholarly materials about the research topic. This chapter is
The main goal of health institutions is the provision of efficient services that enhance health
and prolong life of patients. Achieving this goal therefore requires that there is presence of
reliable and accurate health records. Records are used to hold health institutions accountable
for the service delivery. Mogli (2012) considered health records as documents used by health
institutions and caregivers to record patient history, illness, illness narratives and treatment.
Luthuli and Kalusopa (2017) conceived health records as written account of patients’
examination and treatment that include the patients’ medical history, illness narratives and
complaints; the physician’s findings; and the results of diagnostic tests, procedures,
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medications and therapeutic procedures. Connectedly, the World Health Organization
(2016a) classified health records to include doctors’ clinical notes; recording of discussion
with patient/next of kin as regards disease; referral notes to other specialist(s) for
nurses’ reports; consent forms; operation notes; video recordings; and printouts from
monitoring records. Advancing the importance of health records, Adeleke (2014), stresses
that health records are needed for delivery of services in health institutions. Among other
Luthuli (2017), also notes that records management involves accountability, security,
complete cycle. The process includes identifying, classifying, prioritizing, storing, securing,
management also involve appraisal, retention and disposal, which eventually eliminate
ephemeral records that are no longer useful to healthcare institutions. The objectives of
records management as highlighted by Feather & Sturges (2013) include cost reduction,
improved productivity by quick access to needed records, enhanced litigation avoidance and
support, increased audit compliance. Mogli (2012) conceives service delivery as activities
performed by an organization, in line with its mandate aimed at satisfying, responding and
tests, correct medication and follow-up treatment. Connectedly, Kemoni & Ngulube (2013)
opined that effective records management is a key factor in the delivery of service in health
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institutions. Thus, achieving service delivery requires that health organizations develop,
There are agencies and professional associations saddled with the responsibility of ensuring
that records generated by medical practitioners involved in the provision and delivery of
services to patients are efficiently managed in the best interest of patients and healthcare
institutions. With reference to Nigeria, Osundina et.al, (2016) identify Health Records
Officers Registration Board of Nigeria; Nigeria Medical Council, Nurses and Midwifery
Council of Nigeria, among others as agencies and associations that regulate the practice of
medical records management. Against this background, this article provides proper
knowledge and orientation of the subject matter of health records management in the context
development of medical records, issues of medical records management and service delivery
in health organizations and the challenges associated with medical records management in
healthcare institutions.
Hospitals are dependent on its medical records to deliver care efficiently and to account for
its actions. This procedure defines the structure and processes for the management of clinical
records. Records management through the proper control of content, storage, transporting and
access to records reduces the risk of poor medical care, due to missing records, legal
challenge and financial loss (Oromi, 2014). This procedure sets out the way in which
organizations will meet its legal obligations in relation to the Data Protection Act 1998, and
Freedom of Information Act 2000 and standards set by the Care Quality Commission, The
Health and Social Care Information Centre, and the NHSLA in respect of records
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management. This procedure should be read in conjunction with the Corporate and DET
Records Procedure.
included in the terms and conditions of appointment (including position descriptions) for all
performance reviews of clinicians. Failure to maintain adequate health care records will have
An individual health care record with a unique identifier (e.g. unique patient
identifier, medical record number) must be created for each patient / client who receives
health care (Musa, 2018). Every live or still born baby must be allocated a unique identifier
that is different to the mother. Where multiple patient identifiers exist for the same patient /
client must be processes established for their reconciliation and linkage, with the ability to
audit those processes. A reference notation should be placed on the health care record to
identify any relevant other documents that relate to the patient’s health care. Index or patient
administration systems must reference the existence of satellite / decentralized health care
records that address a specific issue and that are kept separate from the principal health care
record. Due to the nature of the information contained in sexual assault records these must be
maintained separately from the principal health care record and be kept secure at all times; as
should child protection / wellbeing and genetics records. Staff screening and vaccination
records are considered as personnel rather than health care records and must be maintained
separately.
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2.2.3. Access
Health care records should be available at the point of care or service delivery. Health
care records must not be removed from the campus unless prior arrangements have been
made with for example required for a home visit, required under subpoena. Health care
records are only accessible to: a) Health care personnel currently providing care / treatment to
the patient / client, b) Staff involved in patient safety, the investigation of complaints, audit
relevant legislation d) Patient / client to whom the record relates, or their authorized agent,
based on a case by case basis in accordance with health service release of information
policies and privacy laws and e) Other personnel / organizations / individuals in accordance
with a court subpoena, statutory authority, valid search warrant, coronial summons, or other
lawful order authorized by legislation, common law (Read et. al, 2013). All requests for
information, that is contained in a patient / client’s health care record, from a third/ external
party should be handled by appropriately qualified and experienced health care personnel,
such as Health Information Managers, due to the sensitive nature of health care records; the
special terminology used within them; and regulatory requirements around access to, and
2.2.4. Ownership
The health care record is the property of the health organization providing care, and
not individual health care personnel or the patient / client. Where shared care models or
arrangements exist for clinicians to treat private patient / clients within health facilities /
settings, responsibility for the management of those health care records must be included in
the terms of the arrangement between the PHO and the clinician (Adeleke, 2014).
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2.2.5. Retention and Durability
Health care records must be maintained in a retrievable and readable state for their minimum
required retention period. Entries should not fade, be erased or deleted over time. The use of
thermal papers, which fade over time, should be restricted to those clinical documents where
hardware changes, capable of being reproduced on paper where appropriate, and have regular
Cuming & Thompson, (2017) establishes statutory requirements for the storage and
security of health care records, health information, including healthcare records, must have
appropriate security safeguards in place to prevent unauthorized use, disclosure, loss or other
misuse. For example, all records containing personal health information should be kept in
lockable storage or secure access areas when not in use. Control over the movement of paper-
based health care records is important (Khumalo, 2017). A tracking system is required to
facilitate prompt retrieval to support patient / client care and treatment and to preserve
privacy. A secure physical and electronic environment should be maintained for all data held
on computer systems by the use of authorized passwords, screen savers and audit trails. If left
unattended, no personal health information should be left on the screen. Screen savers and
passwords should be used where possible to reduce the chance of casual observation.
Consideration may be given to providing staff with different levels of access to electronic
2.2.7. Disposal
Health care records, both paper-based and electronic, must be disposed of in a manner that
will preserve the privacy and confidentiality of any information they contain. Disposal of data
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records should be done in such way as to render them unreadable and leave them in a form
from which they cannot be reconstructed in whole or in part. Paper records containing
large volumes of paper are involved, specialized services for the safe disposal of confidential
material should be employed. The disposal of health care records must be documented in the
health organization’s Patient Administration System and undertaken in accordance with the
Osundina (2014) affirms that for Health Records Department to function efficiently, it is
necessary to have an organized method for storing of the health records. Therefore, filing
system can be described as a set of documents arranged in prescribed order for convenience
of reference and preservation. The purpose of filing records is to facilitate complete and
quick retrieval of patient information from them when the needs arise.
The prime responsibility of the Health Records Department is to undertake the custody,
classification and confidential of the patient case history. The department is also concerned
with the custody of index of diseases and operations. However, an effective filing system
Compactness: To take account of storage space and also need to reduce physical effort
Accessibility: For speed of location and positive means of identification for the items
Simplicity of operation to ensure that the method is understood by those who normally
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Elasticity: The system should expand and contrast according to future requirement.
Cross Reference: This facility must be considered so that a folder can be found under
different heading.
Tracer System: A tracer card must be placed in position of a removed folder to indicate
The personnel operating the system must be well trained i.e. health records
practitioners.
computer science (Unegbo, 2018). The task is to assign a document to one or more classes or
categories. This may be done "manually" (or "intellectually") or algorithmically (Wong &
Bradley, 2019). The intellectual classification of documents has mostly been the province of
science and computer science (Oromi, 2014). The problems are overlapping, however, and
classified may be texts, images, music, etc. Each kind of document possesses its special
classification problems. When not otherwise specified, text classification is implied (Boyle,
attributes (such as document type, author, printing year etc.).There are two main philosophies
subjects in a document determines the class to which the document is assigned. It is, for
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example, a common rule for classification in libraries that at least 20% of the content of a
book should be about the class to which the book is assigned. In automatic classification it
could be the number of times given words appears in a document (Blais, 1995). Request-
oriented classification (or -indexing) is classification in which the anticipated request from
users is influencing how documents are being classified. The classifier asks himself: “Under
which descriptors should this entity be found?” and “think of all the possible queries and
decide for which ones the entity at hand is relevant” (Edwards, 2017).
particular audience or user group. For example, a library or a database for feminist studies
classification: The classification is done according to some ideals and reflects the purpose of
the library or database doing the classification. In this way it is not necessarily a kind of
classification or indexing based on user studies. Only if empirical data about use or users are
(Kwatsha, 2010)Automatic document classification tasks can be divided into three sorts:
document classification (also known as document clustering), where the classification must
classification where parts of the documents are labeled by the external mechanism (Mampe,
2008). Here are some of the filing systems employed in the management of records;
2.3.2. Alphabetical
There are two types of alphabetical filing according to Tagbotor et al., (2015); Topical filing
arranges files in straight alphabetical Order, such as subject correspondence arranged from A
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to Z, based on the name of the subject. Classified filing arranges related documents under a
major subheading, such as customer complaint correspondence filed under the general
heading of customer relations, its advantages include; avoids the use of an index, effective
filing if adhered to and ease of browsing through files however this type of filing system is
also associated with various demerits which include; increased risk of misfiling versus
numeric systems, retrieval problems arising over name changes, may be inefficient and
cumbersome in large systems and ease with which unauthorized persons can find records.
If a numerical record identification system is used, then a numerical filing system is used
(Ngulube & Tafor, 2006). There are two main systems of filing records numerically: straight
numeric and terminal digit. This filing method reflects exactly the chronological order of the
creation of records. Straight numeric filing is typically used when serial health record
numbers are assigned, however, a unit health record number may also be filed in straight
numerical order. The advantages of straight numeric filing include: people are used to this
"logical" order and training is easy, easy to retrieve consecutive numbers for research or
inactive storage; the disadvantages, however the disadvantages include; easy to misfile, one
must consider all the digits of the number in order to file the record; easy to transcribe
numbers where one digit is wrongly written or read, for example: 1 for 7 and easy to
transpose numbers (reverse digits), for example, record number 194383 is filed as 193483
Tagbotor et al., (2015) emphasizes that alpha-numeric filing is one of the most indexing
systems because of how accurately it identifies folders contents and the system involves the
use of numeric numbers and alphabetical letters to index a record. According to Gledhill,
(2015), alphanumeric filing involves using both letters and numbers .In line with this also,
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(Prof & Roux, 2012) argues that alphanumeric filing system is alphabetical filing (arranged
from A-Z) and numeric filing system(ordered from the smallest to the largest.
Chronological filing is the filing by date. Usually you will find this used for bills of lading,
copies of freight bills, cancelled cheques, also in some banks or as a reserve file. It is
normally used only where there is little or no reference made to the record once the
number. Reasons for this type of filing can be several. Countries have different laws and
importance; subject filing system and according to (Callaghan & Groves, 2015) this is the
arranging of documents by the given subjects. This is the filing by descriptive features
instead of by a name or number. Such filing involves choosing a word to indicate the subject
matter of filing based on the subject matter. It is sometimes known as the matter of filing
based on the subject matter and terminal digit filing system; Marquette (2013) says that this
type is also called “End digit filing”; he emphasizes that terminal digit filing is most
commonly used in large filing systems especially in hospitals, government personnel offices
and financial institutions. Terminal digit filing system is achieved by grouping all the files
Aremu (2019) affirms that the following will aid the Qualified Health Records Personnel in
solving the problems of mislaying of patients’ health records in the Health Records Library,
they are:
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Introduction of efficient tracer system to Health Records Library
Provision of auxiliary equipment, for example, sorting shelf, ladder, stool guide cards
etc.
Prompt collection of patients Health Records after patient is discharged from the ward
Department
Huffman (2014) opines that regardless of the number of record control system used in the
health records department file area, occasionally, a patient’s record will be placed in the
wrong location (misfiling) or will not be signed out correctly (mislaying). Various
techniques are available to assist a person in locating a medical record that has been
1. Look for transpositions of the last two digits of number, or of the hundreds or thousands
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2. Look for misfiles of “3” under “5” or “8” and vice versa; and “7” or “8” under “9”. The
3. Look for misplacement or mislaying of health records on the floor, tables, racks, cabinets
and shelves
4. Check for a certain number in the hundred group just preceding or following the number
6. Check the folder just before and just after the one needed. It sometimes happens that a
folder is put into another folder rather than between two folders.
Medical Record Storage is a vital concern for Practices, Clinics, and Hospitals of every size.
As the requirements for Medical Records Management continue to change, practices need to
stay updated on the latest Regulations and ensure that they're in compliance with the latest
Records Retention Requirements. With these additional responsibilities, it's more important
than ever that Healthcare Organizations have a trusted Partner for Medical Records
Management. The available literature is scant. The problem was identified as critical in 1965
solutions. A year later Chelew, (1996) working at the Mount Zion Hospital and Medical
Center in San Francisco, reported the results of a study of the utilization of active and
inactive records; the age of the record and the purpose of the retrieval was noted. Records
more than 12 years old made up less than 2 percent of all record retrieval at Mount Zion, and
on this basis Chelew concluded that there was "little economic justification for retaining
medical records beyond the minimum legal requirements." Chelew did not attempt to define,
except by this implication, when records become "less active"; the legal limit, of course,
varies significantly from state to state. Recently Lennox 2010 has suggested that records
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should be culled and only summary documents (in most cases the discharge letter with a few
other items) be kept available. In this system the bulk of the culled record would be kept in
quite inaccessible storage. The method currently most used to identify and separate active
from inactive records is based on a single variable-the elapsed time since the patient's last
visit to the clinic or hospital. At arbitrary intervals all records are examined for the length of
time since the patient's last visit or the last use of the record. Records not used during some
previous number of months are sent to the inactive file or, in some hospitals, microfilmed;
records that have been used within this time period are left in active status.
According to Chinyemba, (2005) record storage and retrieval faces myriad challenges that
include included limited qualified staff such as a records manager and archivist; Lack of
records management policies and procedures; Records management costs that are not
immediately apparent. Cost may only become significant over a period of time and thus not
requirements (legislation).
According to Chavez-borja, (2012) limited guidelines was cited as the major problem to
record storage and retrieval; employees need guidelines to manage all the information
resources on their desktops, in their files, and in the computer systems with which they
interact. Further, they need to determine which of those information resources are records
storage has been unevenly implemented with few agencies devoting a full-time position to
the task. Even then, the job of records management has been driven by the need to destroy
vast amounts of paper rather than to systematically control, manage, and use information
and knowledge of the agency. As budgets have tightened and governments have turned to
technology to “do more with less,” e-mail, Web portals, databases, and other electronic
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applications have been typically implemented without regard for managing the information
The electronic office poses unique challenges to recordkeeping (Webster, Hare, & Mcleod,
2019). As noted in a previous section of this paper (Joseph, Debowski, & Goldschmidt,
2012), the most essential qualities of a record are that it is authentic and that its content is
fixed over time. In other words, people must have confidence that a record is what it says it
is. Electronic records, unfortunately, do not intrinsically inspire this confidence in the same
way that paper records do. The ease with which electronic documents can be created,
altered, accessed, duplicated, and shared jeopardizes their value as records. Ironically, the
most appealing aspects of creating electronic documents are what weaken our confidence in
electronic records.
In a study that examined the challenges of Record storage and retrieval in two Health
Institutions in Lagos State Abdulazeez et al., (2015), Nigeria where the specific objectives
include: to investigate the challenges being faced in handling health records by the surveyed
health institutions in Lagos State; and to suggest some solutions on the preservation and
conservation of health records in the surveyed health institutions in the State, the findings
showed that the major challenges faced in handling health records in the surveyed hospitals
include: poor funding, inadequate computer and other ICT devices, poor skill in computing,
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