Thesis on project to improve medical record completeness in outpatient department, in Dilchora Hospital, Dire Dawa, Eastern Ethiopia.
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Date
2018-06
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Addis Ababa Universty
Abstract
Background: - Any medical information is important in managing patient condition,
follow up, legal issues and useful for any relevant condition related to patient. Despite the
importance of medical records to high quality and efficient care management of patients’
medical records, especially in developing countries like Ethiopia, it has not been a
priority. Studies conducted related to medical record completeness from different aspects
showed that poor medical record management system compromises patient and client
care at different level.
Methods: A hospital bases cross sectional pre and post interventional study was
conducted at Dil-chora hospital, Dire Dawa, eastern Ethiopia from March to June 2018.A
total of 88 patients medical record folder was reviewed, 50 nurses with structured
questionnaire and a focused discussion was conducted with five concerned body. Data
collected using a standard structured questionnaire and reviewed out-patient medical
record folders were transferred into SPSS version 20 for further statistical analysis.
Variables with a p-value of less than 0.05 at multiple logistic regression analysis were
considered statistically significant factors for the utilization of selected variables of outpatient
medical records.
Results: The study revealed that 12% of the health workers had a good level of
awareness on completeness of out-patient medical records, 0%HMIS training and,
supervision, 24% completeness of out-patient medical records during base line
assessment (Pre intervention). And the intervention has showed a significant
improvement for the selected combed variables from 24% to 92%.
Conclusion: As more than half of the health workers working at government health
institutions of East Gojjam were poor health information users compared with the
findings of others studies. HMIS training, data analysis skills, supervision, regular
feedback, and favorable attitude were factors related to routine health information system
utilization. Therefore, a comprehensive training, on HMIS and regular supportive
supervision are highly recommended for improving medical record completeness in all
governmental and privet health facilities.
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Keywords
Out-patient medical records, Dil-chora hospital Dire Dawa, Eastern Ethiopia.