Assessment of Medical Records Documentation in Secondary Health Care Facilities in Kafr El-Sheikh and El-Mahalla El-Kubra Cities

Abstract

AbstractBackground: Accurate, timely and accessible health care data play an important role in the planning, development and maintenance of health care services.Aim of Study: This study was undertaken to assess the quality of medical records documentation in three healthcare facilities, two of them in Kafr El-Sheikh City (Kafr El-Sheikh General Hospital and El Obor Health Insurance Hospital) and the third one in El-Mahalla El-Kubra City (El-Mahalla El-Kubra General Hospital, Gharbia Governerate).Subjects and Methods: The medical record sample calcu-lated was (200) record sample from El-Mahalla El-Kubra General Hospital, (300) record sample from Kafr El-Sheikh General Hospital and (350) record sample from El Obor Health Insurance Hospital. The calculated record sample for each hospital was selected from the discharge logs of 2017 using the systematic random sampling method.Results: General consent form and discharge summary sheet were completely absent from the medical records of El-Obor Health Insurance Hospital. Almost all documentation assessment items of patient identification part were present in more than two third of checked records in El-Obor Health Insurance Hospital. The documentation assessment items of front sheet and discharge summary sheet were not present in more than the half of reviewed records at Kafr El-Sheikh General Hospital. Recording of clinical progress notes daily was not present in more than two third of reviewed records in the three hospitals. Recording of nursing progress notes within each shift was present in the majority of reviewed records (80%) in the three studied hospitals.Conclusion: There was considerable variations between the three studied hospitals according to documentation quality.