peer review
A cross-sectional review examined the usability of paper-based clinical records across four referral hospitals in the Eastern Cape and Mpumalanga provinces of South Africa. Using a standardised tool adapted from the Canadian Institute for Health Information Quality Framework, 255 records were evaluated across four usability dimensions. The overall usability score was moderate at 53.1 percent, with 65.1 percent of all evaluated records categorised as having poor usability. Temporal documentation usability scored highest at 96.6 percent, followed by accessibility and filing at 74.9 percent. In contrast, legibility and readability scored poorly at 32.6 percent, and communication usability was the lowest at 8.4 percent. Usability scores varied significantly across the participating hospitals, highlighting substantial documentation weaknesses that affect continuity of care and overall health service delivery.
Paper records remain the primary method of managing patient information in many South African public hospitals. When clinical notes suffer from severe illegibility and poor communication performance, healthcare staff face difficulties coordinating treatment. Identifying these specific recordkeeping deficits provides health authorities with clear targets for operational interventions to improve patient safety, clinical communication, and continuity of care.
The findings highlight an urgent operational need for improved health information management systems and electronic record solutions within public hospital settings. Developers and suppliers of digital healthcare tools, clinical documentation software, or automated record management systems could target public sector healthcare providers, although the research itself is an applied observational study rather than a commercial technology development.
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Background Paper-based clinical records remain widely used in South African public hospitals despite ongoing challenges related to healthcare information management. There is limited evidence regarding the usability of paper-based clinical records in South African hospitals. Aim This study assessed the usability of paper-based clinical records for patient care in four selected South African referral hospitals. Methods A quantitative cross-sectional record review was conducted in four referral hospitals located in the Eastern Cape and Mpumalanga provinces of South Africa. A standardised questionnaire developed from the Canadian Institute for Health Information (CIHI) Quality Framework was used to assess clinical record usability. The usability dimension comprised four constructs: record accessibility and filing, temporal documentation usability, legibility and readability, and communication usability. A total of 255 clinical records were reviewed. Data were analysed using descriptive statistics, the Kruskal–Wallis test, and Fisher’s Exact test, with statistical significance set at p < 0.05. Results Overall usability demonstrated moderate performance, with a mean score of 53.1% (SD: 13.3). Temporal documentation usability achieved the highest performance (mean: 96.6%; SD: 11.2), followed by record accessibility and filing (mean: 74.9%; SD: 21.2). Legibility and readability performed poorly (mean: 32.6%; SD: 45.1), while communication usability demonstrated the lowest performance (mean: 8.4%; SD: 20.2). Significant differences in usability construct scores were observed across hospitals (p < 0.05). Overall, 65.1% of reviewed records were classified as having poor usability. Conclusion Paper-based clinical records in the reviewed hospitals demonstrated substantial usability limitations, particularly regarding legibility and communication. Strengthening clinical documentation practices and improving health information management systems are necessary to enhance patient care quality, continuity of care, and healthcare service delivery in South African hospitals.
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DOI: 10.5256/f1000research.202881.r505614
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