Completeness of Inpatient Medical Record in St.Paul’s Hospital Millennium Medical College
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Date
2018-10
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Addis Ababa Universty
Abstract
Medical record is an account compiled by physicians and other health professionals of a patient`s medical history, present illness, findings on examination, details of treatment and progress notes and it is a legal record of care.The maintenance of complete and accurate medical record is a fundamental duty of health care providers. Complete medical record indicates the quality of patient care provided in the facility.Many ethical and legal issues are implemented in their maintenance including third party access and appropriate storage and disposal.
Objective: To improve the percentage of inpatient medical record completeness from46.48% to 80 %at the end of Jun 2018.
Methods:A pre- post intervention design was used in this project to examine the completion rate of inpatient medical records. The pre-intervention assessment was conducted in the inpatient department of SPHMMC.
Base line data were collect in Feb 2018 .based on the baseline, the completeness of inpatient medical records was low , .only 46.48% of the 202 audited patient folders was completed. After base line assessment we conducted root cause analysis and identified the real root cause of the problem.
Based on the verification, lack of awareness about inpatient medical record completeness, clinical forms not suitableto enter data, absence of monitoring and negligence were identified as a real root causes.We conducted two interventions; one day staff training on importance of inpatient medical record
completeness and develop new clinical forms.
Results:the documentation completion rate significantly increased from 46.48% pre-intervention to 78.6% post-intervention, the completeness of three out of the five elements of medical records (physician note, physician order sheet and discharge summery) especially significantly improved.
Conclusion: The results of this project suggests that a simple set of intervention providing training on the importance of inpatient medical record and availing suitable inpatient medical record forms improves the inpatient medical record completeness.
Recommendation: Ongoing monitoring and accountability system should be implement , It is better if the Health Management Information System Department takes special consideration on full implementation and proper
management of inpatient medical records, Intensive and continuous training should be given for the healthcare provider by Health Management Information System Department..
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Keywords
Medical records, Documentation completeness