Improving outpatient medical record completeness in Enchini Primary Hospital, Oromia, Ethiopia

Abstract

Background: Medical records management is one of the components of health information system that documents information related to a patient generated during patient-to-health care provider encounters at a health care facility. A well-managed medical records system is critical to improve the provision of quality health care services to ensure safe medical practice, efficient and effective services and improve the patient’s experience and satisfaction with their medical encounter. Objecti ve:-To i mprove outpati ent medi cal record compl etion from 37% to 90% in Enchini Hospit al at t he end of June 2019GC. Methods:A pre- post intervention design was used in this project to examine the completion rate of outpatient medical record. The pre-intervention assessment was conducted in the outpatient department of Enchini hospital. Base line data were collected between January and March 2019. The baseline data showed the completeness of outpatient medical records was low. Only 37% of the 50 audited patient folders were completed. A questionnaire was developed to assess knowledge gabs of all workers who were working at outpatient department such as nurses, general practitioners and medical record workers, whether supportive supervision was conducted by senior management team and availability of printing formats and materials. The root cause analysis was conducted to identify the root cause of the problem. Based on the verification, lack of awareness about outpatient medical record completeness was identified as a real root cause and a two day’s staff training on medical record completeness was conducted. Results: the outpatient medical record completion rate increased from 37% pre intervention to 89% post-intervention. Specifically, Summary sheet of all visit dates practice and International disease code practice were considerably improved by 90 and 80 percentage points respectively. Conclusion: The result of this project suggests that a simple set of intervention providing training on the awareness of medical record improves of outpatient medical record completeness. Recommendation: The hospital, the regional health bureau and FMoH need to give emphasis for the completeness of outpatient medical records as it contribute to good quality of healthcare.