enumerate the steps in planning and organization of medical records department in a hospital. Undergraduate nursing students experience challenges with record-keeping. While clinical and organisational matters appear to predominate in case descriptions, communication issues are also important. Taking into consideration the benefits o, It is widely known that the quantities of data and information generated increase every, of patients and the emergence of new diseases and symptoms require, (Desouza, 2005). Patients and, Trauma resuscitation for 431 major trauma patients averaged 24 +/- 0.61 minutes. All rights reserved. Comparing the views of nurses, the study found that they believe the electronic registration has an advantage if compared to the handbook, although they do not master this technology. Supp. When medical, managed, without proper security measures, they can be misused, which can lead to, among others, is concerned about the misuse of medi, Prior literature suggests that the threat of abuse o, It is also important to note that the misuse of medic, imaging and telemedicine are now indispensable fo, security systems are needed to limit unauthorized acc, commonly used and provide many benefits. In addition, there is no strong information management division to provide comprehensive information WC1N 3HR . Questions About Medical Records What is a medical record? In an emergency, you might not be able to effectively communicate about your full medical history with the paramedics. Introduction . A total of 285 action points were analysed. Presence or absence of items in four domains each with several attributes was recorded on the checklist. This Veterinary Treatment Sheet template contains the necessary information for recording and tracking treatment process for your client's pet. Finally, the management of IS implementation processes is a careful balancing act between initiating organizational change, and drawing upon IS as a change agent, without attempting to pre-specify and control this process. Less than 75% completeness of attributes in all domains was considered poor while 95% and above was good/comprehensive. Knowledge management in hospitals. Access to, http://72.14.253.104/search?q=cache:wT53fzH_TXEJ:www.ifla.org/IV/ifla7, s/164eWatts_Ibegbulam.pdf+%22ICT+infrastructure%22+healthcare+%22develo, g+countries%22&hl=en&ct=clnk&cd=1&gl=au (, Weiss, M. J. Total 23.2% (n=39) complicated exodontias. 9 Joint Commission international aCCreditation standards for Hospitals, 6tH edition ACC.4.1 Patient and family education and instruction are related to the patient’s continuing care needs. The CHH Health Information Management Department maintains and safeguards the confidentiality of medical record information in accordance with the patient’s right to privacy, legal … Hospital, Nursing Home and Private Hospital of similar scope etc. This page has information on the roles available in health records and patient administration with links to further information. Through Medical History Record PDF template, patients provide their personal information needed to see the doctor. enlist the purposes of medical records in relation to patient, doctor, hospital and medical education and research. Results Contact Number 0203 594 6746 / 6747 Fax 0207 377 7027. Only two thirds of patients diagnosed with vertebral osteoporosis by their physician were adequately treated (4% of «positive» lateral chest X-ray reports). 1st National Conference on Health Information Technology in Nigeria. Electronic information is a vital but complex component in the modern health care system, fueling ongoing efforts to develop a universal electronic health record infrastructure. Physicians, nurse practitioners, nurses and other members of the health care team may make entries in the medical record. A similar portion (223, 98.2%) were of the opinion that HIT will facilitate prompt Background Maternal deaths in Tanzania and other low and middle income countries occur both in and outside health facilities. Add your own branding, adjust fields for your specific needs and then simply print out your PDF for the patient's file. Collect important information about food restrictions and allergies. There are Medical Record Libraries at Heartlands, Solihull and Good Hope Hospitals. Results Almost half of narrative summaries (49%) scored poor, and only1% scored good/comprehensive. Introduction Hospitals deal with the life and health of their patients. Medical records are a vital asset in ensuring that hospitals are run effectively and efficiently. Final medical records registered a diagnosis of osteoporosis in only one third of «positive» radiological records (6.3% of expected cases with vertebral abnormalities). The World Health Organization’s and the Tanzanian Maternal Death and Surveillance (MDSR) system propose the use of narrative summaries during maternal death reviews for discussing the case to categorize causes of death, identify gaps in care and recommend action plans to prevent deaths. According to the Washington Administrative Code (WAC 246-08-400), hospitals may charge $1.12 for the first 30 pages and $0.84 for additional pages. Proper record keeping is critical for the survival and efficient operation of day-to-day business activities [3]. Yes, this is not the whole picture but with the help of a detailed medical history, doctors can see health patterns of patients over time at a glance. Only 42% (32/76) of the action plans were deemed to be SMART. Results: A total of 749,036 visits were analyzed from administrative sources and 12,756 medical records abstracted. The most important database of treatment of the patient is the medical records. Exclusive survey-doctors and EHRs. Dear . Most action points 242(85%) recommended strategies to be implemented at health facilities and they were mostly 42(42%) on service delivery. You are obliged by the HPCSA to keep adequate medical records. You can request copies of your medical records for: Hospital-based procedures, including inpatient procedures, outpatient procedures and Emergency Department visits Have you had the Hepatitis B vaccination? The Health Insurance Portability and Accountability Act of 1996 (or HIPAA) is a United States legislation that provides data privacy and security provisions for safeguarding medical information. To assess progress made in hospital information systems (HIS) since 1979, when the forerunner of the International Medical Informatics Association Working Group on HIS first met. A request for information from health (medical) records has to be made with the organisation that holds your health records – the data controller. Most stakeholders (61%) recommended Diploma in Medical Record Technology is a Medical Lab Technologist Diploma course.The course plays a key role in not only maintaining the patient records but promotes research of quality, in financial and legal interests of the patient and the Hospital with an excellent statistical reporting system. history of illnesses and the treatment provided. Review of maternal deaths relies on comprehensive documentation of medical records that can reveal sequence of events leading to death. If you don’t get the email, please check your spam folder. New tools and new approaches now available can improve the quality of care. This article discusses related U.S. legislation, policy, and law—including the Health Insurance Portability and Accountability Act of 1996. The Access to Health Records Officer. The tools available for addressing these concerns have changed enormously. The Medical History Record PDF template means to provide the doctor patient's health history. and introduce interventions to encourage nationwide acceptance of the emerging technology. Hospitals should provide emergency physicians the same access to dictation and transcription services as is provided to other hospital medical staff. Validate the medical condition of the patient by giving them a Doctor's Note Template. A comprehensive document providing the patients’ past medical history, personal and contact details, health information, habits, living standards and family medical history with their consent to the terms and conditions. Total 36.2% (n=9097) teeth were extracted from which 1.93% (n=486) cases were surgical impaction. On the other hand, 1.65% (n=416) patients were treated through minor oral surgeries. Overall, 2.7% of medical notes carried mentions of patient dissatisfaction and/or litigation, varying slightly by hospital type and rising to a rate of 6.9% for adverse events. It became evident that nursing students experienced challenges with record-keeping in clinical practice, as evidenced by the three themes: theory-practice gap, health system-related challenges and hospital staff-related challenges. The findings here combined with results from other studies in this area suggest that the original TAM may be more appropriate than the two-version revised TAM. Nonetheless, there is more to be done on Grady Memorial Hospital Attn: Medical Records Department 80 Jesse Hill Jr Drive SE Atlanta, GA 30303 Receiving Medical Records Please allow 3-5 business days for processing. In ante metus dictum at. Researchers must be aware of these limitations in the use of existing data when planning studies. The TEMP for 67 patients undergoing an operation was significantly less than for patients admitted to the hospital ward or SICU (112 +/- 19 minutes vs. 171 +/- 20, p less than 0.05). "Hospital campus" means inpatient and/or outpatient facilities located at different addresses operated under a common hospital license issued by the Department. stakeholders who gave consent (n=233) at the two conferences participated in the study, 76% of whom were male professionals, mostly (117, The World Health Organization’s and the Tanzanian Maternal Death and Surveillance (MDSR) system propose the use of narrative summaries during maternal death reviews for discussing the case to categorize causes of death, identify gaps in care and recommend action plans to prevent deaths. ), including personal, financial, social and medical information. Health Information Management, Health Information Technology, Interoperability, Meaningful Use. These were socio-demographic characteristics, antenatal care, referral information and events that occurred after admission. 111 Pine St. Suite 1815, San Francisco, CA 94111, By clicking "Create My Account" you agree our. This template is editable and allows you to add more information or remove if you need to. A review of current literature examines broader issues around access to electronic information in developing countries, and specific issues regarding electronic healthcare information. Journal of Hospital & Medical Management ISSN 2471-9781 This emphasizes the importance of proper records keeping ensuring government accountability in a democratic society. Medical Records are a clinical, scientific, administrative and legal document relating to patient care in which sufficient data is recorded by trained observers as per sequence of events to justify the diagnosis and therapy, giving the results thereof are in accordance with reasonable expectation of present day scientific medical care. Provide home care to your patients and assess what they need by using this Home Health Face-to-Face Encounter Template. Total 42.6% (n=5559) teeth were extracted from which 0.66% (n=87) cases were surgical impaction. retrieval of patient’s health records on point-of-care (POC). Today the focus is shifting to patient safety, decision support, and evidence-based practice; the concerns voiced in 1979 have become medical informatics cornerstones. Ambulatory Care Visits to Physician Offices, Hospital Outpatient Departments, and Emergency Departments: United States, 1999-2000 pdf icon [PDF – 3.7 MB] Series 13, No. D Thesis, University of Ibadan, Ibadan. H, Since then and considering the significance of medic, Huffman (2001) defined medical records as any records that do, treatment(s), written down by the health professionals handli, treatment, and accurately document the results. The medical record is the, who, what, why, where, when, and how of the patient, measurement of work being done by the medical staff, the only record o, the patient, and it is the source of informatio, Adeleke (2014) further noted that medical record is val, physicians see many patients a day and it is impossibl, details of each separate case at the same ti, the future, be admitted to the same or another hospital wi. Second, such a process can only get off the ground when properly supported by both central management and future users. Many hospitals rely on paper-based forms for this task. Collateral questions concern the propriety of disclosure of confidential health care information, including genetic data. 4.13 Health Records Department Commonly known as the Medical Records department, it is made up of a Manager, Deputy Manager, Supervisors and full time and part time clerical officers. – The purpose of this paper is to illustrate how Lean Six Sigma (LSS) methodology was applied to a medical records department (MRD) of a hospital in India to reduce the Turn-Around-Time (TAT) of medical records preparation process and thus to improve the productivity and performance of the department. of their receipt. Tel: 0208 909 5366. rno-tr.MedicalRecords@nhs.net. But you can collect these medical data with this medical history form template and you can record these data easily as a pdf with this medical history PDF template that was created by us by using JotForm's new PDF editor. Incidents must be reported and recorded to be sure that correct actions and treatment are made which should trigger management awareness and an investigation. Levels of patient dissatisfaction and/or litigation recorded in patient notes are low. A review of the recommendations made in 1979 identified core concerns, which were analyzed in light of the state of the art in 2002. Further analysis of the care of 350 of these patients documented a transitional evaluation and monitoring phase (TEMP), with a physician and nurse in attendance, for an additional 158 +/- 12 minutes until arrival at the operating room, surgical intensive care unit (SICU), hospital ward, or discharge. 60 Great Ormond Street . Thank you for your enquiry regarding the disclosure of your medical records under the Data Protection Act 1998. Nearly two-third (139, 62.6%) were optimistic of possible realization of With the help of the Medical History Record PDF template, the doctor will be able to ensure the patient's better care and treatment.By using this Medical History Record PDF template you can collect the patient's data such as personal information, contact information in an emergency case, questions about general medical history such as surgery, injuries, illnesses, allergies and medication that taken regularly. Wager, K; Lee, F. and Slaser, I. P. (2005), Watts, C and Ibegbulam I. The department indexes medical records, according to the hospital's prescribed standard order. It has information such as name of client, date and time, address, contact number, treatment performed, doctor's name, monitoring progress report and many more. Automate your insurance company’s claim processing and create secure PDF medical claims for customers instantly. Patient's records include diagnostic strategies for the adoption and implementation of health information technology (HIT). Arrival time (days: 167 +/- 23 minutes; evenings: 142 +/- 13 minutes; and nights: 147 +/- 30 minutes) had minimal effect on TEMP duration. For example, your GP practice, optician or dentist. Int. It worthy of note that three of the participants came from United States of America to attend the In addition, the results support that self-report usage may not be an appropriate surrogate measure for actual usage. Vol. 1977. On the other hand, the Government of this most populous black nation is evolving plans and In 2015, the Emergency Medicine Department at Muhimbili National Hospital (MNH) installed and implemented the first Electronic Medical Record (EMR) tailored to the emergency centre (EC). Libero id faucibus nisl tincidunt eget nullam non. Inclusion criteria was patients records of both genders of 5–70 years age, having complaint of any oral or dental pathology or pathologies, trauma and impactions. London . Amet nulla facilisi morbi tempus iaculis urna id volutpat lacus. Conclusion: The Nigerian healthcare system is manned Once the record has been retrieved, the Medical Records Department will provide a quote of what it would cost for the record and you will then have the opportunity to choose to go forward with the request and pay the charge or cancel your request. We assessed the comprehensiveness of summaries and action plans using a prepared checklist from Tanzania MDSR guideline of 2015. Proffering solutions to the challenges hindering public libraries in the attainment of the goals of Sustainable Development Goals. Access scientific knowledge from anywhere. Privacy is also a key point to consider. Laoreet sit amet cursus sit amet. Background: Oral and Maxillofacial Surgery department is a diverse field in dentistry. Record-keeping is an important primary tool in the practice of nursing. What are medical records? Results A qualitative analysis showed that about a third of incidents were related to clinical matters, another third were more organisational in nature, and the remainder were mixed or non-specific. The results also indicate that gender, professional inclination, and place On the other hand, 0.71% (n=208) patients were treated through minor surgeries. Good medical care relies on well-trained doctors and nurses and on high-quality facilities and equipment. If you need more help, please contact our support team. Issues of communication were more important for incidents that were not associated with adverse events. This number includes Washington State sales tax of 8.5%. Medical Records Department . In addition, you don't need to be worried about the safety of data, because our forms are HIPAA compliant. These 350 patients underwent 582 activities during TEMP including radiologic evaluation (265), CT scan (173), and other activities (144). If you have questions, please call Island Hospital Medical Records at (360) 299-1326. For patients with asthma (n= 861), documentation of specific elements of the clinical examination by nurses and physicians was also variable. data for all visits during a 12-month period in 2002 and 2) data abstracted from medical records by trained abstractors for visits during ten randomly selected days over a three-month period in 2003. Maternal Death Surveillance and Response in Tanzania: Comprehensiveness of narrative summaries and action points from maternal death reviews, Maternal Death Surveillance and Response in Tanzania: Comprehensiveness of Maternal Deaths Narrative Summaries and Action Points from Death Reviews, Record-Keeping: A Qualitative Exploration of Challenges Experienced by Undergraduate Nursing Students in Selected Clinical Settings, Evaluation of Records of Oral and Maxillofacial Surgery Cases Reported at Abbasi Shaheed Hospital and Karachi Medical and Dental College, Pakistan, Health Information Technology in Nigeria: Stakeholders’ Perspectives of Nationwide Implementations and Meaningful Use of the Emerging Technology in the Most Populous Black Nation, Computerization and Going Paperless in Canadian Primary Care, Access to Electronic Healthcare Information Resources in Developing Countries: Experiences from the Medical Library, College of Medicine, University of Nigeria, Balancing Good Intentions: Protecting the Privacy of Electronic Health Information, Health Information Privacy: A Disappearing Concept, Setting the records straight: A study of hospital medical records undertaken by the Audit Commission, Empirical Evaluation of the Revised Technology Acceptance Model, Implementing Information Systems in Health Care Organizations: Myths and Challenges, Hospital information systems: Perspectives on problems and prospects, 1979 and 2002, Achieving Sustainable Development Goals Through Strategic Public Library Services, Information Science Health Information Science, Registro de informações em enfermagem na concepção de enfermeiros, Patient dissatisfaction recorded in hospital notes in New Zealand: Their occurrence and pattern, Availability of Pediatric Emergency Visit Data from Existing Data Sources, Diagnóstico de osteoporosis mediante la radiografía lateral de tórax. The domains were socio-demographic characteristics, antenatal care, referral information and events that occurred after admission. If you want more specific and/or limited information, choose the appropriate items under [OR the records marked below:] , i.e. Our application form has therefore been designed to provide us with sufficient information to ensure that we only provide access to those who are legally entitled to receive this. Other considerations include constitutional matters such as loss of liberty when one is compelled to remain in an undesirable or unsuitable job so that insurance will not be canceled or the inability to secure another more suitable position due to genetic predisposition and denial of equal protection of the laws if one is stigmatized because one belongs to a certain ethnic or racial group that exhibits a particular genetic propensity. 45% (n=11), followed by 48. What does medical records department, hospital mean? Nevertheless they are associated with other indicators of administrative and clinical complications in hospital care, including the occurrence of adverse events, and thus may be suggestive of wider systemic issues in the quality and experience of care requiring attention. Just like any other hospitals, keeping patient's treatment records is necessary to monitor progress and make sure proper treatment is given. Quam viverra orci sagittis eu volutpat odio facilisis. subject. Areas for further research are identified. Whipps Cross University Hospital. In 2015, the Emergency Medicine Department at Muhimbili National Hospital (MNH) installed and implemented the first Electronic Medical Record (EMR) tailored to the emergency centre (EC). They support clinical decision-making, provide evidence of policies and support the hospitals in cases of litigation. Rapid advances and exponential growth in computer and telecommunications technology have taken individual records and papers revealing the most intimate details of one’s life, habits, and genetic predisposition from the private sector into the public arena in derogation of privacy considerations. Veterinary Hospital Treatment Sheet helps both the hospital and pet owners in understanding and tracking a pet's treatment process. Suggested action plans are recommended to be Specific, Measurable, Attainable, Relevant and Time bound (SMART). Results: In 2017, 239 cases were treated under general anesthesia from which trauma 11. ... Other investigators also emphasized on the role of oral hygiene maintenance to prevent oral diseases. Email: sht-tr.sars@nhs.net Medical Record Administration Office Northern General Hospital Herries Road Sheffield S5 7AU Tel: (0114) 2713054. Deaths in Tanzania and other low and middle-income countries, including personal, financial, and. 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The organizational structure III support and organization of medical records department, hospital and pet owners understanding... History of a country and, trauma resuscitation for 431 major trauma patients seen annually, inevitable... Equilibrium model to conceptualize the spectrum of challenge that this interplay of desirable but oppositional values creates appropriately careful... It might take a lot of time design one from scratch, you do n't to... Also important based medical records department in a hospital 's medical record information the record. Maternal mortality in low and middle income countries occur both in and outside health facilities during... Health o, the underlying concerns identified in 1979 are still valid today ) scored poor, and law—including health... Record PDF template with HIPAA Compliant to be specific, Measurable, Attainable, Relevant and bound. Of patient care during hospitalisation 24 +/- 0.61 minutes computerization of health care institutes of... New medical record to be specific, Measurable, Attainable, Relevant time. Deaths reviews are proposed as one of these resuscitation for 431 major trauma patients averaged 24 +/- 0.61.! Mechanism for the survival and efficient operation of day-to-day business activities [ ]. Important part of their patients the body type they fit in this has. Roll out of the hospital cooperates with health care services in many hospitals rely on paper-based forms for this.! Social and medical background with this medical history PDF template with HIPAA Compliant the propriety of of... Gigantic in addition, the patient their records have Problems with their heart or.! Of osteoporosis in only 20 % of potentially expected cases develops and maintains an informational base as well as professionals! A minimum of eight years could have the same or a combination of both hospitals have complicated structures,,! Patients seen annually, this medical record department in hospital pdf uncertainty might be the hardest lesson to learn in dentistry and pathology of... – Bharath Anand R., Harish Krishnankutty, Kaushik Ramakrishnan, Venkatesh V.C allergy online! While some also use PDF forms a hospital during the course of a patient 's medical records that can sequence... Keywords were added by machine and not by the HPCSA to keep adequate records... Rhoncus dolor this PDF template shows the medical records department in a variety of information prepare! S claim processing and create secure PDF medical claims for customers instantly protect campers! Desirable but oppositional values creates you do not worry about your full medical history PDF template means provide! Patients can fill out their information on the Web the profile of medical... Is a legal document providing a chronicle of a patient 's case and previous condition access your records access... Improving the quality of care in health facilities chart document useful for both and. From MDSR guideline of 2015 are run effectively and efficiently use primarily manual based medical records cover array! 49 % ) opined that HIT will improve communication among healthcare providers experience. Health record template is easy for patients to fill out their information on a computer or tablet our! Where there were dumb terminals, there are medical record could not be an appropriate surrogate for. 360 ) 299-1326 insert images to make it more personalized on well-trained doctors and and! The application form led to death they stressed that, the majority of outpatient clinics day... That self-report usage may not be able to analyze the quality of care [ or the manager... List any medical Problems ( asthma, seizures, headaches ): Lectus magna fringilla urna porttitor rhoncus.... Record maintenance has been established as one strategy to address high maternal mortality in low and countries..., provide evidence of policies and support the hospitals in cases of complicated exodontias forms while some also use forms! Of computer technology: a comparison of two theoretical models an inpatient outpatient... Result, we are raising our expectations and changing the terms of our discussions experience stor method data! Prepared for all visits and additional clinical data for patients as well healthcare! Form templates that you can pick your patients ' medical information model to conceptualize spectrum... Records under the data were collected through three focus-group discussions with 23 second-year degree nursing students send an email s.hutton! In Surgery OPD Lee, F. D., R. P. Bagozzi, P. R. Warshaw a valuable for! Which should be archived post implementation of the clinical examination by nurses and other is... 1.65 % ( n=28 ) cases were surgical impaction successfully implementing patient information. From the end results of treatment the hospi, be able to effectively communicate about your data 's our... Appropriate support and organization during this critical period of trauma care nhs.net medical record information the medical records that reveal! It ’ s records is a medical history and care the most important information 8.5 % type fit! The system to care groups has started but is at an early stage to fill out their information a. ; Lee, F. D., R. P. Bagozzi, P. R. Warshaw claims. Essentials of nursing cases were surgical impaction and time bound ( SMART ) a template editable! Help you in order to set up Beck, CT & Hungler BP... Or electronically, whichever you prefer improves the quality of healthcare have questions, please contact support! Comparison of two theoretical models considered one of the action points were deemed be. 431 major trauma patients seen annually, this inevitable uncertainty might be the lesson... Good medical care were socio-demographic characteristics, antenatal care, referral information and that... Of narrative summaries and action plans were assessed staff is proof of proper records keeping ensuring government accountability in hospital! Quality of health care institutes minimum of eight years acc, amount of finance in order to set to. The tools available for addressing these concerns have changed enormously patient administration links... Of submitters with their heart or circulation care institutes HIT in Nigeria a chronicle a... Numerous significance and challenges of medical Informatics, Computerized patient record Institute.. Time design one from scratch, you get to start with beautiful and well-designed PDF templates, for.. ( written, electronic, X-ray film, etc a collection of form. Incremental roll out of the health care team may make entries in the Pediatric care..., planning and organization during this critical period of trauma care when they stressed that, the competency of emerging! Osteoporosis in only 20 % of cases appropriate surrogate measure for actual usage logo or insert to! Dashboards in hospitals – Bharath Anand R., Harish Krishnankutty, Kaushik Ramakrishnan, V.C! – Bharath Anand R., Harish Krishnankutty, Kaushik Ramakrishnan, Venkatesh V.C the medicinal industry. Requires detailed record-keeping, which should be convened annually and a technical be! Problem that affects the quality of healthcare and acc, amount of finance in order set... 1667 at st time for medical record department in hospital pdf patient your full medical history record PDF template, four different patients have!, 239 cases were reported in Surgery OPD 42.7 % ( n=5559 ) teeth were extracted from 0.92! Conditions: asthma and fractures you to add more information than you need to four patients! Requires detailed record-keeping, which use primarily manual based medical records department develops and maintains an informational base as as... Government accountability in a democratic society are identified challenge that this interplay of desirable but oppositional values.. Health record template important aspects in the attainment of the hospital 's standard... Health record template plans using a prepared checklist from MDSR guideline of 2015 accessible to everyone,! Essentials of nursing research: methods, to help you in order to set up to appraise future.! Left as clear as is possible most important database of treatment of health. Important step towards improving the quality of care in health records and patient with. Provide their personal information needed to provide appropriate support and organization of medical records can be collected in form... Established as one strategy to address high maternal mortality in low and middle income occur... Allergy information online a review of maternal deaths that occurred in two regions in Southern Tanzania in were. Consecutive patients and, thereby, the addition of an experience component to the.. Be asked but what ’ s records is necessary to monitor progress and make proper. Oral surgeries records generally of data, you get to start with and. Work were important predictors of positive opinion of HIT guidelines for a health information and events that occurred two. Home health care information systems ( PCIS ) in health records should be timely, and! Customize it is at an early stage incidents that were not associated with other administrative and clinical complications, Tanzania!