Improving Completeness Of Inpatient Medical Records In Amdework Primary Hospital, Amhara,North Ethiopia.
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Date
2019-06
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Addis Abeba University
Abstract
Back ground: Globally, Medical recording service is a component of all health care system, as it is the entry point of the health service and one of the key areas to have quality service in the health facilities. Clinical record documentation is one of the most basic professional responsibilities even if it is often poorly practiced. Record keeping and information management are the requirement for the provision of quality patient service.
They are essential for the patient’s present and future healthcare decision making. The information contained in the record is essential, but the process of documenting it is often considered a lesser priority by many health institutions.
Objective: The overall objective of the project is to improve completeness of inpatient medical records from 65 % to 90% in Amdework primary hospital by the end of June,30, 2019.
Method: A pre-post intervention study design was applied to improve inpatient medical record completeness in Amdework Primary Hospital (APH) from January1-5,2019 for pre intervention period and from June1-5,2019 for post intervention period.Data was collected using structured audit tool and by simple random sampling technique a sample of 85 inpatient medical record was taken out of all inpatient medical records in Amdework Primary Hospital. The collected data was cleaned for its completeness and then entered into SPSS version 20 software for analyses and Independent T-test was used for comparing pre and post interventions.
Result :The intervention was associated with improving completeness of inpatient medical record. At the beginning of the project completeness of inpatient medical record in Amdework primary Hospital was 65%, after intervention completeness of inpatient medical record became 93.6%.
During post intervention from 85 inpatient cards the result shows that 97.6% has complete progress note, 97.6% has complete order sheet, 98.8% has complete medication administration record, 35.3% records has complete clinical pharmacist record and 100% has complete discharge summary.
Conclusion :The overall completeness of inpatient medical record in mdework primary Hospital after intervention was 93.6% which have 28.6% improvement from the baseline assessment and the higher rate of completeness was seen in discharge summary 100 % completed and the
least completed was clinical pharmacist record 35.3 % completed.
Although there is significant improvement in completeness of medical record completeness and clinical pharmacist record still the objective is not achieved because the clinical pharmacist hiring is late and still forgetting to dated and signed to the main card. So in order to meet the objective of the indicator continuous supervision of inpatient clinical staffs should be done.
Description
This is to certify that the project entitled “Improving Completeness of Inpatient Medical Records in Amdework Primary Hospital” is submitted in partial fulfilment of the requirements for the degree of MHA (Master of hospital and Health Care Administration) to the Graduate Program of the College of Health Sciences of Addis Ababa University and has been carried out by Abay Nakachew under my supervision. Therefore, I recommend that the student has fulfilled the requirements and hence hereby can submit the thesis to the Department.
Keywords
Medical record, Incompleteness, Amdework Primary Hospital, Ethiopia.