The Completeness of out Patient Indivdual folder Medical Recording in Gedo Hospital, West Shoa, Oromia Region, Ethiopia

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Addis Ababa University


BACKGROND: the completeness of outpatient individual folder medical/health documentation are used to document patient’s medical history, illness and treatment procedures. Properly documented medical records are important in patient care. This study is designed to improve the completeness of outpatient medical /health documentation at Gedo hospital. METHODS (project design): , 50 individual patient folder medical recording were randomly selected on pre-intervention and 62 post-intervention after training was provided on medical records. The completeness of each medical records was checked against a EHRIG standard. The pre –intervention was conducted on September, 2011 and post- intervention on March, 2012 RESULTS: The outpatient individual folder medical records completeness was found 34.81% in the pre and has improved later in post intervention to 82.3. It is found statistically significant at (P-value <0.001) CONCLUSION: Capstone project on the completeness of out patient individual folder medical documentation in Gedo hospital was improved after intervention from 34.81% out of 50 medical documentation which were completed in pre- intervention to 82.3% medical documentation completeness level with overall statistically significant result of (P-value <0.001). There were positive relationships also between each of the intervention elements & an increase in improving medical documentation in Gedo hospital.



The Completeness of out Patient Indivdual folder