Abstract:
Introduction: The completeness of medical records is an outstanding problem that affects the
quality of health services in many hospitals of Ethiopia. Enhancing the completeness of patients
records is inexpensive that can be implemented with the involvement of health workers.
Objective: To improve the completeness of patient’s card admitted to Dalefage hospital.
Design; Pre - post interventional study from January - August, 2013 GC uses inpatient medical
record review form and focus group discussions.
Setting; Dalefage district hospital, west Afar, Ethiopia.
Participants: Medical director, matron and other clinical staffs.
Implementation: The interventions implemented were avail inpatient medical record
completeness format, facility based inpatient medical record completeness guideline and
procedures were developed and onsite training was provided. The work plan progresses of
implementation were monitored by check list.
Main outcome measures: Availability of inpatient medical record completeness format,
provision of onsite training, development of facility based guideline and procedure and
enhancement of inpatient medical record completeness report.
Evaluation: inpatient medical record format availability and completeness improved
significantly from 0% to 100% and from 0% to 73.6% respectively.
Lesson learned: our findings indicate that a well-organized inpatient medical record
completeness enhancement can improve the quality of available inpatient information, helps to
know our reporting status of inpatient medical record completeness which is crucial to plan
improvement strategy and development of facility based guideline and procedure was required to
accomplish sustainability. Lastly, onsite training was the best strategy for resource limited
countries like Ethiopia to improve health care quality service delivery.
Key words: medical record, availability, completeness, Dalefage hospital, Ethiopia