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

Abstract

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.