Improving in-patient medical record completeness in Bichena Primary Hospital, East Gojjam zone, Amhara Region, North West Ethiopia,2019

Abstract

Introduction: The completeness of medical records is an outstanding problem that affects the quality of health services in many hospitals of Ethiopia. Enhancing the completeness of patients records is inexpensive that can be implemented with the involvement of health workers. Maintaining a good record is important to enable health care workers to provide adequate care for their patients. In patient medical record completeness of Bichena Primary Hospital was lowered (55.6%). Objective: The objective of this study was to improve inpatient medical record completeness in Bichena Primary Hospital East Gojjam zone, Amhara region, Northwest Ethiopia. Methods: A Pre-post interventional study design supported with qualitative approach was conducted to improve inpatient medical record completeness in Bichena Primary Hospital (BPH) from the end of September to December 2019 for pre intervention period and from the end of February to May 2019 for post intervention period. Data were collected using structured audit tool and simple random sampling technique was used to select 384 patients’ cards among the inpatient department of the hospital. The collected data were cleaned for its completeness and then entered into Epi-info Version 7 and exported to SPSS version 20 software for analyses to determine what?.Independent T-test was used for comparing pre and post interventions. For the qualitative approach, six key informants for in-depth interview and 8 for focus group discussion were selected and data were collected through semi structured guide questioner to know the improvement of inpatient medical record completeness. Results and discussion: Inpatient medical record completeness improved from 55.6% to 92.2% when we measured after intervention and other components were also improved for example:patient card completeness from 88.2% to 96.9%progressnote12.4% to 90.4%,, order sheet77.1% to 95.3%, nursing care plan88% to 98.7%, medication administration54.6% to 90.6%, discharge summary28.6% to 93.4% and clinical pharmacist improved from41.9% to 76.3% . Conclusion and recommendations: Following our intervention inpatient medical record completeness was improved at Bichena Primary Hospital. There for, project works like capstone should be practice for better improvement of medical records completeness in all Primary Hospitals of East Gojjam zone in particular and Amhara region in general.