Assessing the Usability of Paper-Based Clinical Records for Patient Care in Selected South African Hospitals

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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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