lo

AN INTERNSHIP REPORT ON THE ACTIVITIES DONE AT

NEBBI GENERAL HOSPITAL

BETWEEN JAN AND MARCH

BY
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AN INTERNSHIP REPORT ON THE ACTIVITIES DONE AT

NEBBI GENERAL HOSPITAL

BETWEEN JAN AND MARCH

BY
BEDIJO WALTER

REG NO:……………………

AN INTERNSHIP REPORT SUBMITTED TO THE NATIONAL INSTITUTE OF

MEDICAL RECORDS AND INFORMATION MANAGEMENT(NIMRIM) MULAGO
NEBBI BRANCH IN PARTIAL FULFILMENT FOR THE REQUIREMENT OF
THEAWARD OF CERTIFICATE IN MADICAL RECORDS AND INFORMATION
MANAGEMENT

MARCH 2025

BEDIJO WALTER

REG NO:……………………
 AN INTERNSHIP REPORT SUBMITTED TO THE NATIONAL INSTITUTE OF
MEDICAL RECORDS AND INFORMATION MANAGEMENT(NIMRIM) MULAGO
NEBBI BRANCH IN PARTIAL FULFILMENT FOR THE REQUIREMENT OF
THEAWARD OF CERTIFICATE IN MADICAL RECORDS AND INFORMATION
MANAGEMENT

MARCH 2025
 DECLARATION

I Bedijo Walter declare that this field and industrial attachment report is my own work and
has not been submitted before for any academic award for either any academic award for
either any academic award either in this or other learning institutions for academic or any
other purpose. The references used in this report are stated in the reference section.

NAME: BEDIJO WALTER

Signature:_______________ Date:________________

i.
 APPROVAL

This internship report that has been compiled by Bedijo Walter has been under my effective

supervision from 13th to 31 march 2025. And I have endeavored to read through it and

certified the information in it. Therefore, it has been submitted with my approval

FIELD SUPERVISOR

SIGNATURE…………………………………………………….

DATE…………………………………………………………….

MR. OCAN DAVID

ACADEMIC SUPERVISOR

SIGNATURE……………………………………………………

DATE……………………………………………………………

MR. OKWAIMUNGU GEORGE

ii
 DEDICATION

I dedicate this piece of work to my family, who has been the key determinant to all my

academic achievements this far, hence playing a major role in the determination of my career

and future in specific capacities. That is, they have modeled my future; emotionally, morally,

psychologically, economically and spiritually.

God bless you abundantly.

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 ACKNOWLEDGEMENT

I take my special thanks to the Almighty God for giving me life and good health throughout
my attachment.

I also thank the entire NIMRIM Administration who played a great role for releasing us to the
field which has contributed to the success of this report.

It’s my gratitude to thank the in-charge records Nebbi General hospital, Mr. OCAN DAVID
for allowing me to carry my practical attachment at Nebbi General Hospital under their
Supervision. It is also my privilege to thank the staff at large who made my attachment
successful.

It is also our pleasure to give thanks to my dear family for giving me financial and material
support for sustainability. I also thank my colleagues from other institutions who tirelessly
supported me during the attachment.

May God bless you all!

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 LIST OF FIGURES

Figure 1; Intern registering and updating patient in the EMR …………………….1

Figure 2; Intern generating of appointment lists for clients in Art clinic….………4

Figure 3; Intern tracing clients’ files and other medical documents……………….7

Figure 4; lntern compiling monthly reports in MCH……………………………….9

Figure 5: Intern updating child immunization card………………………………..10

Figure 6; lntern uploading data on DHIS2…………………………………………10

Figure 7: Intern admissioning patient at the injection room………………………..11

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 ABBREVIATION

❖ HMIS Health Management Information System

❖ HC III Health Centre three

❖ YCC Young Child Clinic

❖ OPD Outpatient Department

❖ ART Anti-Retroviral Therapy

❖ IPD Inpatient Department

❖ MCH Maternal Child Health

❖ LAB Laboratory

❖ HB Hospital Board

❖ PEP Post-Exposure Prophylaxis

❖ PrEP Pre-Exposure Prophylaxis

❖ EID Exposed Infants Diagnosis

❖ STIs Sexual Transmitted Infections

❖ EMR Electronic Medical Record

❖ DHIS2 District Health Information System

❖ EPI Expanded Program on Immunization

❖ UTI Urinary tract Infection

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 EXACUTIVE SUMMARY

This internship report highlights my experience at Nebbi General Hospital

between January and March 2025 as part of my training in Health Records and
Information Management. The internship aimed to bridge the gap between
theory and practice, providing hands-on exposure to various hospital
departments while enhancing my professional competencies.

During my placement, I actively participated in managing patient records, data

collection, and reporting across key departments, including the Outpatient
Department (OPD), Comprehensive Care Centre (CCC), Maternity Unit,
Maternal Child Health (MCH) Unit, Health Information System (HIS) Office,
and Injection Room. My responsibilities included registering patients in the
Electronic Medical Records (EMR) system, organizing medical files, updating
registers, retrieving records, managing appointments, and compiling hospital
reports using the District Health Information System (DHIS2).

Throughout the internship, I encountered challenges such as inadequate filing

space, limited computer access, network failures, and staff shortages.
Nevertheless, I developed essential skills in medical records management, data
handling, hospital statistics, and ensuring confidentiality and security of health
records.

By the end of the internship, I successfully applied theoretical knowledge to

practical situations, enhancing my understanding of hospital operations and
improving my ability to manage health information systems. I recommend
increasing staffing levels, expanding filing spaces, improving network
infrastructure, and acquiring additional computers to strengthen service delivery.
This internship has been a transformative learning experience, equipping me
with the skills necessary for a career in health records management while
deepening my appreciation for the vital role health information plays in patient
care and hospital administration.
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TABLE OF CONTENTS

DECLARATION ………………………………………………………………………..…...i
APPROVAL:………………………………………………………………………...............ii
DEDICATION:………………………………………………………………………….......iii
ACKNOWLEDGEMENT:………………………………………....……………………….iv
LIST OF FIGURES:…………………………………………………………………………v
ABBREVIATION:………………………………………………………………………….vi
EXACUTIVE SUMMARY:………………………………………………………………..vii

CHAPTER ONE: INTRODUCTION…………………………………………………….1

1.1 Historical background…………………………………………………………………...1
1.2 ORGANIZATIONAL STRUCTURE…………………………………………………...2
1.3 MISSION, VISION AND COREVALUES……………………………………………..3
1.3.1 Vision………………………………………………………………………………3
1.3.2 Mission …………………………………………………………………………….3
1.3.3 Values ……………………………………………………………………………..4
1.4 OBJECTIVES OF THE ATTACHMENT ………………………………………………5
CHAPTER TWO: WORK EXPERIENCE ………………………………………………….6
2.1 Introduction ………………………………………………………………………………6
2.2 Outpatient Department …………………………………………………………………..6
2.2.1 Functions of health records and information department at OPD …………………6
2.2.2 Activities of HRIO at OPD ………………………………………………………..6
2.2.3 Tools ………………………………………………………………….6
2.3 Comprehensive Care Centre…………………………………………………….. 6
2.3.1 Functions of health records and information department at CCC …………………6
2.3.2 Activities of HRIO at CCC 7
2.3.3 Tools used 7
2.4 Central Records 8
2.4.1 Function of health records and information department at Central records 8
2.4.2 Activities of HRIO at Central Records 8
2.4.3 Tools used 8
2.5 Maternity Unit 8 Functions of health records and information department in maternity unit
8
2.5.1 Activities of HRIO in maternity unit 8
 2.5.2 Tools used 9
2.5.3
2.7 Maternal child health and family planning unit 9
2.7.1 Functions of Health records and information department in MCH 9
2.7.2 Activities of HRIO in MCH 10
2.7.3 Tools used in MCH 10
2.9 Health information system office 10
2.9.1 Functions of health records and information department at HIS office 10
2.9.2 Activities of HRIO at HIS office 10
2.9.3 Tools used 12
2.10 Injection room 12
2.10.1 Functions of Health records and information department at injection room 12
2.10.2 Activities of HRIO at injection room 12
2.10.3 Tools used in injection room 12
CHAPTER THREE: CHALLLENGES, ACHIEVEMENTS, RECOMMENDATIONS AND
CONCLUSION 13
3.1 Challenges 13
3.2 Achievements 13
3.3 Recommendations 13
Conclusions 13
Reference 13
Appendix 14

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 CHAPTER ONE: INTRODUCTION

1.1 Historical background

Nebbi General Hospital, located in Nebbi District in northern Uganda, was established in
1969, during the tenure of Prime Minister Milton Obote. It was part of broader efforts by the
government to improve healthcare access in rural areas of the country, particularly in the
northern region. The hospital began as a small facility designed to serve the local population,
but over the years, it has grown into an essential healthcare institution.

The hospital’s history is closely linked to the broader political and health landscape of
Uganda. During the colonial period, healthcare facilities were limited, and much of the
medical infrastructure was concentrated in urban centers. Nebbi, being in a rural region, had
limited access to healthcare services. However, with the establishment of the hospital in 1969,
the government aimed to address these gaps.

Following Uganda’s independence in 1962, the hospital became an important part of the
country's healthcare system, providing general medical care to residents of Nebbi and
surrounding areas. The facility grew over time, with expansions in infrastructure and services,
adapting to the needs of the increasing population.

During periods of regional conflict, such as the Lord’s Resistance Army (LRA) insurgency
in the 1990s, Nebbi General Hospital played a critical role in providing medical care for war-
related injuries, trauma, and psychological support. The hospital became a vital center for
treating the casualties of war and for offering essential medical support to both civilians and
military personnel.

In recent years, the hospital has benefited from various government and donor-led
initiatives to improve its services, infrastructure, and medical equipment. These efforts have
helped the hospital better serve the local population with improved healthcare delivery.
Today, Nebbi General Hospital remains a key healthcare institution in northern Uganda,
offering services such as maternity care, outpatient treatment, emergency services, inpatient
care, and specialized medical services.

Overall, Nebbi General Hospital has evolved over decades, from its establishment in 1969
to becoming a critical healthcare provider, contributing significantly to the well-being of the
local population and the broader region.

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1.2 ORGANIZATIONAL STRUCTURE OF NEBBI GENERAL HOSPITAL

HOSPITAL BOARD

MEDICAL
SUPERETENDANT

PRINCIPAL SENIOR MEDICAL SENIOR HOSPITAL

NURSING OFFICER OFFICER ADMINISTRATOR

SENIOR NURSING ALLIED HEALTH HOSPITAL

MEDICAL OFFICER
OFFICER PROFESSIONALS ADMINISTRATOR

ALL OTHER
NURSING CADRES MIDWIFERY CLINICAL OFFICER SUPPORT STAFF ADMINISTRATIVE
CADRES

SUPPORT STAFF SUPPORT STAFF SUPPORT STAFF

1.2 1.3 MISSION, VISION AND COREVALUES

1.3.1 Vision

To be a district center of excellence in holistic health care development, medical research and

education.

1.3.2 Mission

The mission of Nebbi general Hospital is to provide quality, affordable, specialized and

sustainable promotive, preventive, curative and rehabilitative health care services.

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1.3.3 Core values;

1Client focus:
* We prioritize our client`s needs and provide quality Health care services that meet client`s
expectation.

* We value and attend to client`s request, Ideas and suggestion, complaints and constructive criticisms.

1. Quality Care:

* We provide care that meets the Who and MoH standards; the Medical and professional ethics and
customer care standards within Uganda.

2. Equity:

* We provide equal opportunity and access to services to patients’ same condition.

3. Professionalism and Ethics:

* We observe and hold the higher level of professionalism, honesty and trust at enshrined in the
professional code of conduct of the different professional councils and guidelines from

the Ministry of Health.

4. Professional development:

* We seek to continuously Learn from medical research findings; practices and

policy changes in Health care management systems in order to remain relevant.

* We endeavor to build high capacity of staff through continuous professional Development,

provide coaching and mentorship through continuous medical education.

5. Transparency and Accountability:

* We maintain high level of transparency and accountability to the community,

Administration and Political system for the performance of the Hospital.

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1.4 OBJECTIVES OF THE ATTACHMENT

The attachment is aimed at bridging the gap between theory and practice this includes;

• To produce practically oriented graduates that meet the required job related
competencies of my future employer.
• To enable me as a student, get hands-on/real life experiences that am expected to
work in when I graduate.
• To provide an opportunity for students to apply the principles and techniques theoretically
learnt into real-life problem-solving situations.
• To provide an opportunity for students and academic staff to interact with the stakeholders
• and potential employers and appreciate field situations that will also generate information
for curricula review and opportunities.
• To enhance and strengthen linkages between Nebbi general hospital and various

stakeholders

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CHAPTER TWO: WORK EXPERIENCE
2.1 Introduction
The Hospital has 11 sections that work together in achieving the hospital objectives. They are listed as
follows:
2.2 Outpatient Department
This is the department where clients or patients are provided day health care services.
2.2.1 Functions of health records and information department at OPD
■ Registration
■ Reception
■ Maintaining Security of health records equipment and information
■ Confidentiality of patient health information.
■ Data management
2.2.2 Activities of HRIO at OPD
S Registering of patients into the EMR system
S Receiving of patients and clients
S Issuing of appointment cards to various departments
S Updating clients who revisit for services into the EMR
S Directing patients or clients to various areas of service
Figure 1: Intern registering and updating patients’ file in the EMR.

2.2.3 Tools
• Outpatient card MOH 201
• Computer
2.3 Comprehensive Care Centre/ ART CLINIC

It is a department that deals with health care services for HIV infected clients.

2.3.1 Functions of health records and information department at CCC

■ Clinic preparation
■ Appointment management
■ Records management
■ Maintaining confidentiality of patient’s health information
■ Registration
■ Data management
■ Maintaining security of health records equipment and information

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2.3.2 Activities of HRIO at CCC

V Booking and giving appointment to clients for next visit

V Retrieval of client’s files
V Filling back of the retrieved file using alphabetical for T.I, adolescent and pediatrics
V Compiling monthly report
V Updating the DAR register
V Updating of Pre ART and ART register
V Preparation of appointment list
V Recording of viral loads and CD4 results
V Sorting of clients files
V Editing of clients file
V Checking of misfiling
V Directing clients to various service points
V Receiving clients
V Tracing of clients files and other medical documents
V Weeding of inactive/dormant files
Figure 2: Intern generating appointment list for clients in Art Clinic.

2.3.3 Tools used

• Computer
• Green Card MOH 257
• Appointment card MOH 258
• Treatment Preparation Register-MOH 361A
• ART Cohort Register -MOH 361B
• PEP register
• Daily activity register for CCC MOH 366
• Calendars
• Diary

Figure 3: Intern tracing clients file and other medical documents.

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2.4 Central Records

It is the main library or filing section for medical records in the hospital.

2.4.1 Function of health records and information department at Central records

■ Records management
■ Data management
■ Maintenance of confidentiality of patient’s information
■ Maintaining security of patients records and equipment
2.4.2 Activities of HRIO at Central Records

f Checking and correcting for misfiling

f Sorting of patient files
f Tracing of medical records
f Filing medical files using terminal digit filing system
f Filing disease index cards using alphanumeric filing system
f Weeding of inactive/dormant files
f Editing of case notes before filing
f Retrieving medical records
2.4.3 Tools used
• Computer
2.5 Maternity Unit

This unit provides inpatient services to the sick pregnant mothers and newborns. It also

provides delivery care and post-natal health services. It has the following wards namely;

■ Antenatal ward (ANW)

■ Labor ward (LW)
■ Postnatal ward (PNW)

2.5.1 Functions of health records and information department in maternity unit

■ Coding and indexing

■ Records management
■ Data management
■ Maintenance of confidentiality of patient’s information
■ Maintaining security of patients records and equipment
■ Assisting in civil registration of Births and deaths
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2.5.2 Activities of HRIO in maternity unit

f Checking and correcting for misfiling

f Sorting of patient files
f Indexing of diseases and injuries using diagnostic index card MOH 268
f Tracing of medical records
f Filing medical files using straight numerical filing system
f Uploading coded files in DHIS2
f Weeding of inactive/dormant files
f Editing of case notes before filing
f Retrieving medical records Figure 4: Intern compiling of monthly reports

2.5.3 Tools used

• MOH 301-in-patient register

• MOH 333-Maternity register
• MOH 268- Diagnostic index card
• Computers
• Medical files
• Tracer register
2.7 Maternal child health and family planning unit
It is unit that provides preventive health services.

It consists of the following services;

• Immunization
• Antenatal
• Post-natal
• Child welfare clinic
• Family planning and cervical cancer screening
• HIV care services
• Nutrition
2.7.1 Functions of Health records and information department in MCH
■ Records management
■ Data management
■ Maintenance of confidentiality of patient’s information
■ Maintaining security of patients records and equipment
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2.7.2 Activities of HRIO in MCH

■ Ensuring daily summary of all MCH registers
■ Compiling monthly reports
■ Ensuring MCH care model files are filed
2.7.3 Tools used in MCH
■ MOH 262- Cervical cancer screening and treatment Register
■ MOH 361A- Treatment Preparation Register
■ MOH 366- DAR for CCC
■ MOH 405- ANC Register
■ MOH 510- Immunization Register
■ MOH 511- Child Welfare Clinic (CWC) Register
■ MOH 512- Daily Activity register for contraceptives
■ MOH 216- Mother Child Booklet
■ HIV Exposed Infant (HEI) Card
■ Green Card - MOH 257
■ MOH 702- Immunization and Vitamin A tally sheet
■ MOH 704- Child Health Nutrition Information System tally sheet
Figure 5: Intern updating child immunization card

2.9 Health information system office

This is a section where hospital reports are compiled and disseminated to the next level by
uploading onto DHIS. Hard copies are submitted to the DHO office.
2.9.1 Functions of health records and information department at HIS office
a. Data management
b. Maintaining security of health records equipment’s and information
c. Maintaining confidentiality of health information
Activities of HRIO at HIS office
2.9.2
■ Collection of patients’ data in all departments
■ Collection of DBR from wards
■ Uploading data on DHIS2
■ Downloading monthly reports

Figure 6: Intern uploading data on DHIS2

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2.9.3 Tools used

■ MOH 717 -Monthly work load
■ Computer
■ MOH 711-National integrated form for reproductive health, TB, HIV/AIDS and child nutrition
■ MOH 705A-Outpatient summary under 5years
■ MOH 705B-Oupatient summary over 5 years
■ MOH 731-Comprehensive HIV/AIDS facility reporting form
■ Service delivery form-MOH 105
■ Malaria commodities form
■ Sexual gender-based violence form-MOH 365
■ Monthly nutrition summary sheet -MOH 713
■ Immunization and vitamin A summary sheet-MOH 710
■ Laboratory summary sheet-MOH 706
2.10 Injection room
This is a very important unit in the hospital where emergency cases are handled first.
Most of the patients brought in at casualty are always service immediately.
2.10.1 Functions of Health records and information department at injection room
■ Admission
■ Registration
■ Reception
■ Maintaining Security of patient’s health information and health records equipment
■ Maintaining confidentiality of patient’s information
■ Data management
2.10.2 Activities of HRIO at injection room
S Recording clients’ details in MOH 301 and medical file
S Admission and re-admission of patients in the EMR system
J Admission of BID and internal bodies in the system
J Creation of patient file
J Entering of patient’s bio data and updating in the EMR system
J Issuing of both outpatient and inpatient cards to patient
J Receiving of the patient/clients
J Directing of patients/clients to various service points
 Figure 7: Intern admissioning patient at the injection room

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2.10.3 Tools used in injection room

• Computers
• Medical Files
• MOH 301 inpatient register
2.11.0 Triage section
This a place where the patients’ temperature, blood pressure and weights are recorded
Tools used
1. Thermogan
2. Weighing scale
3. Blood pressure monitor
2.11.1 Administration;
This was the management body which comprised of governing staff of the hospital. This had the
medical superintendent and an administrator.
2.11.2 Function of HRIO at Administration department
● Data entry
● Participation
● Auditing
2.11.3 Activities of HRIO at administration department
* Supporting data entry and record-keeping tasks.
* Participating in departmental meetings to understand workflow and reporting structures.
* Assisting in audits of medical records for accuracy and completeness.
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CHAPTER THREE: CHALLLENGES, ACHIEVEMENTS, RECOMMENDATIONS
AND CONCLUSION
3.1 Challenges
• Inadequate filing space
• Inadequate staffs
• Inadequate computer
• Network failure
• High dust
3.2 Achievements
• Able to calculate hospital administrative statistics
• Able to manage patient medical records
• Able to manage appointments and prepare clinics
• Able to manage health data
• Able to consider ethical and legal issues pertaining to health records and information
• Able to coordinate and manage health records and information services.
• Able to maintained the cleanliness of medical records.
3.3 Recommendations
• The administration should improve on network connection
• The hospital administration should procure more computers
• The Nebbi district should employ more staffs
• The hospital administration should build secondary filing areas
• The government should tarmac road near the facility to limit dusts
3.4 Conclusions
I concluded that despite the challenges encountered during attachment, I was able to achieve
the objective of gaining skills and knowledge in relation to the health records and information
training. I also gained experience in management and coordination of health records services.
Therefore, I encourage the college to continue sending students for attachment to this
institution since there is good learning atmosphere.
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REFERENCE.
[Link] of Health Uganda. (2010). Health Management Information system (HMIS)
Manual. Kampala
2. Uganda Public service commission. (2017). Internship policy Guidelines for public
institutions. Kampala: Government of Uganda
[Link] of Health Uganda. (2016). Records and information Management policy for the
Health Sector. Kampala
[Link] Bureau of Statistics (UBOS). (2020). Stastical Abstract. Kampala; UBOS.
[Link] Health Organization (WHO). (2006). Electronic Health Records: Manual for
Developing Countries; Geneva. WHO Press.
[Link] institute of Medical Records and information Management (NIMRIM). (2023)
Student Field Attachment Handbook. Mulago: NIMRIM Publications
[Link] of Health Uganda (2023). District Health Information Software 2 (DHIS2)
Reporting Guidelines; Kampala.
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