PHYSICIANS’, NURSES’ AND PATIENTS’ PERCEPTION WITH HOSPITAL MEDICAL RECORDS AT A MILITARY HOSPITAL IN RIYADH, SAUDI ARABIA

BACKGROUND: A medical record contains data on patients to support current and continuing patient care. Medical Records Department has the traditional role of keeping the patient's records safe. This is the first attempt in the Kingdom, to the best of our knowledge, to assess the feasibility of introducing electronic medical records. OBJECTIVE: The aim of the study was to assess the views of physicians, patients and nurses of medical records services and physicians’ views on the use of electronic medical records. METHODS: The study was conducted with physicians, nurses and patients selected randomly from the Military hospital in Riyadh. The data was collected via a self- administered, pilot-tested, internally consistent questionnaire. RESULTS: On the staff of medical records, the highest mean score was obtained for confidentiality (2.92), and the lowest for the training of medical staff (1.88). On medical record documents, the highest mean score was reported for “information is confidentially maintained” (2.70), and the lowest for the organization of files within file sections (2.28). On the Medical Records Department, the highest mean score was reported for overstaffing (2.89), and the lowest for receptiveness of receptionists (2.27). Physicians had low scores for computer literacy, ranging from 1% for prior computer experience to 27% for owning a computer. Physicians were not enthusiastic about the change to electronic medical records. CONCLUSIONS: Despite the observed shortcomings of the existing medical records system, it is not expected that medical records would be computerized in the near future since physicians have not accepted this technology wholeheartedly.