Medical record completeness is a key performance indicator that is related with delivery of healthcare services in the hospital [
Patient medical record review is the most applied technique to investigate adverse events in hospitals. The determination with which information is recorded may influence the visibility of adverse events. Poor quality of the information in patient medical records may be a cause or a consequence of poor quality of care and associated with higher rates of adverse events [
Adverse events occur in an estimate of 2.9 to 3.7 percent of acute care hospitalizations in the United States of America (USA) and it is estimated that between 44,000 and 98,000 patients die in hospitals each year as a result of medical error explained as the failure of planed action to be completed as intended [
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, generally inadequately supported and poorly managed. The study done in a rural hospital in Ethiopia shows that only 45.7% of medical records were complete [
A facility based cross-sectional study was conducted in Ayder Referral Hospital and six-month data have been assessed and showed that 36.7% was inaccurate [
The study done in a Dalefage Primary Hospital, West Afar, Ethiopia, showed that an enhancement of completeness and reporting of inpatient medical record completeness improved significantly from the baseline 0% to 73.6% during postintervention evaluation [
In Menelik II Referral Hospital baseline assessments were collected and inpatient medical record completeness showed 73% which is low against the standard in which medical record completeness is expected to be 100%. In line with this there is a gap of study on medical record completeness particularly inpatient medical records. Knowledge gap and shortage of medical record format were accepted as root cause for existence of incomplete inpatient medical records.
Objective of the study is to improve the completeness of inpatient medical records from 73% to 93% at the end of April 30, 2016, at Menelik II Referral Hospital.
A patient medical record provides two important functions; the first helps to support direct patient care by assisting physician on clinical decision making and provides communication. The second provides a legal record of care given and helps as a source of data to support clinical audit, research, resource allocation, monitoring and evaluation, epidemiology, and service planning [
Improving medical record completeness services is an important step towards improving the quality of healthcare. It can also provide valuable information to help measure progress and effectiveness. The medical record has become an important legal document; good medical records are essential not only for the present and future care of the patient but also as a legal document to protect the patient and the hospitals from litigation [
Medical record is a very important document that is used to communicate and document critical information among health professionals. The incompleteness of medical records compromises the quality of care of patient’s and results in different medical errors and patient dissatisfaction. To alleviate the problem the medical record completeness is part of national key performance indicators to monitor the magnitude of the problem and intervene according to the necessity.
The study was conducted at Menelik II Referral Hospital, governmental hospital found in capital city of Ethiopia in Addis Ababa. Menelik II Referral Hospital has various professionals that included 59 physicians, 203 nurses, 123 other health professionals, and 250 administrative staff, making a total of 635 staff. The study was conducted from September 2015 to April 2016.
Pre- and postintervention study was conducted at inpatient departments of Menelik II Referral Hospital.
All inpatient medical records of patients treated and discharged from Menelik II Referral Hospital were sourced for review medical records after implementing the best intervention. Baseline data were collected in September 2015 and postintervention data was collected in May 2016 and schedule for intervention was carried out in January, February, March, and April 2016.
The sample size calculation for comparing proportions was used to make a valid statistical computation and conclusion; the following sample size calculation for comparing two proportions was made [
Simple random sampling technique was used during the study period which means that for preintervention, September 2015, the total discharged patients were 605 and among these 50 medical records were sampled and for postintervention, May 2016, the total discharged patients were 582 and among these 111 medical records were sampled, respectively, using lottery methods. The above sample size was taken based on Ethiopian Federal Ministry of Health Hospital performance and monitoring improvement reports [
Training for physician and nursing staff consists of the following: Awareness and sensitization creation on the importance of medical records. Medical record as part of hospital reform. Medical record as part of hospital key performance indicator for quality of care.
During intervention implementation the main focus was to provide training for inpatient healthcare worker (physician and nurses) for one day for 122 nurses and 67 physicians totally for 189 healthcare providers on inpatient medical record completeness as well hospital reform by providing onsite training to solve lack of awareness and knowledge gap on the overall hospital reform.
The type of evaluation that was conducted is the cycle of problem solving, PDSA cycle of continuous quality improvement. Process indicators Availability of necessary formats Trained healthcare provider (Physician and Nurse) Outcome indicators Score of completeness of inpatient medical records after intervention.
The training was given to two nurses for one day. These trained data collectors used data extraction checklist and collect information from medical charts. To maintain data quality, training was given to data collectors and supervision was carried out by principal investigator on daily basis to check completeness and consistency so as to ensure quality of data, during the data collection procedures.
After data is collected, it was coded and entered into Epi data of version 3.1 and was exported to SPSS for windows version 22 for cleaning, editing, and analysis, and
The completeness of medical records was assessed in terms of physician note, physician order sheet, nursing care plan, medication administration sheet, and discharge summary. Accordingly, the result showed that physician note format was attached for 111 (100%) and completed for 103 (92.8%), physician order sheet was attached for 111 (100%) and completed for 107 (96.4%), nursing care plan was attached for 109 (98.2%) and completed for 85 (76.6%), medication administration format was attached for 103 (92.8%) and completed for 78 (70.3%), and at last discharge summary was attached for 107 (96.4%) and completed for 93 (83.8%) (Figure
Status of completeness of medical record completeness in Menelik II Referral Hospital, Addis Ababa, Ethiopia, May 2016.
There are prepared standardized formats and three of them were completed by physician (inpatient physician notes, physician order sheet, and discharge summary) and two of them completed by nurses (nursing care plan and medication administration sheet). An enhancement of completeness and reporting of inpatient medical record completeness improved significantly from the baseline 73% before intervention to 84% after intervention (
Pre- and postintervention changes in medical record completeness in Menelik II Referral Hospital, Addis Ababa, Ethiopia, May 2016.
Indicators | Preintervention, September 2015 | Postintervention, May 2016 |
---|---|---|
Inpatient physician note | 96% | 92.8% |
Physician order sheet | 96% | 96.4% |
Nursing care plan | 70% | 76.6% |
Medication administration sheet | 40% | 70.3% |
Discharge summary | 64% | 83.8% |
Total | 73% | 84% |
Since calculated
The result of the study showed that the intervention done has increased the overall inpatient medical record completeness by 11% from 73% to 84% (
When compared with aspects of medication administration sheet the study done in England shows that the medication history in the hospital medical record is often incomplete, as 26% of used medication is not recorded. Similarly in this study medication administration sheet is incomplete for 29.7% of the medical records [
Aspects of discharge summary in this study: 16.2% of inpatient medical record is incomplete in comparison with study done in Canada which shows discharge summaries were assessed for completeness and accuracy. Most items were completely reported with given items missing in 5% of summaries. However there is improvement of completeness of discharge summary as compared to preintervention but low as compared to study done in Canada. The reason for this observation might be that the country gives due attention for medical records for better health information and decision making [
The study done in a rural hospital in Ethiopia shows that the proportion of medical records that were complete increased significantly (6.5% preintervention and 45.7% postintervention,
The study done in a Dalefage Primary Hospital, West Afar, Ethiopia, shows that an enhancement of completeness and reporting of inpatient medical record completeness improved significantly from the baseline 0% to 73.6% during postintervention evaluation. Similar to our study after introduction of simple intervention inpatient medical record completeness improves from the baseline 73% to 84% during postintervention evaluation. This implies that, by implementing a set of intervention, it can bring improvement in completeness of medical records [
The overall inpatient medical record completeness in Menelik II Referral Hospital was 84% and the higher rate of completeness was seen in inpatient physician order sheet 96.4% completed whereas the least completed was inpatient medication administration sheet 70.3% completed. The finding of this project suggests that a simple set of intervention availing inpatient medical record format and training healthcare provider improves the inpatient medical record completeness. This project indicates that applying strategic problem solving to medical record completeness can be effective in improving quality of healthcare.
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 responsible body. The Quality Officer and Chief Executive Officer at the administrative positions of the study hospital are recommended to design and launch intervention programs to improve medical record completeness. Effective long-term follow-up is needed to assess the sustainability of intervention by inpatients department head. Quality improvement project of this approach should be encouraged to be applied in other departments of hospital to enhance quality of healthcare services by quality team.
All authors declare that they have no competing financial or any other interest in relation to the work.
Kasu Tola conceived the study, undertook statistical analysis, and drafted the paper. Dr. Haftom Temesgen, Yemane Gebremariam, and Birhanu Jikamo made major contributions to the study design and statistical analysis. All authors contributed to the writing of the paper and approved its submitted version.
The authors appreciate the management of Menelik II Referral Hospital and Healthcare provider working in inpatient departments. Kasu Tola also extends his thanks to Dr. Haftom Temesgen, Mr. Yemane Gebremariam, Mr. Dawit Tatek, and Mr. Birhanu Jikamo for their inspiration and technical support in many ways.