Improving the quality of nurse clinical documentation for chronic patients at primary care clinics: A multifaceted intervention.

Ozayr H Mahomed,Myra Taylor,Shaidah Asmall,Salsohni Naidoo

doi:10.4102/curationis.v38i1.1497

Ozayr H Mahomed, Myra Taylor + Show 2 more

Open Access

https://doi.org/10.4102/curationis.v38i1.1497

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Abstract

BackgroundDeficiencies in record keeping practices have been reported at primary care level in the public health sector in South Africa. These deficiencies have the potential to negatively impact patient health outcomes as the break in information may hinder continuity of care. This disruption in information management has particular relevance for patients with chronic diseases.ObjectivesThe aim of this study was to establish if the implementation of a structured clinical record (SCR) as an adjunct tool to the algorithmic guidelines for chronic disease management improved the quality of clinical records at primary care level.MethodA quasi-experimental study (before and after study with a comparison group) was conducted across 30 primary health care clinics (PHCs) located in three districts in South Africa. Twenty PHCs that received the intervention were selected as intervention clinics and 10 facilities were selected as comparison facilities. The lot quality assurance sampling (LQAS) method was used to determine the number of records required to be reviewed per diagnostic condition per facility.ResultsThere was a a statistically significant increase in the percentage of clinical records achieving compliance to the minimum criteria from the baseline to six months post-intervention for both HIV patients on antiretroviral treatment and patients with non-communicable diseases (hypertension and diabetes).ConclusionsA multifaceted intervention using a SCR to supplement the educational outreach component (PC 101 training) has demonstrated the potential for improving the quality of clinical records for patients with chronic diseases at primary care clinics in South Africa.

Highlights

South Africa is experiencing a ‘profound health transition’ (Mayosi et al 2009:1) characterised by four simultaneous epidemics (Bradshaw et al 2003). This quadruple burden of disease consists of the Human Immune Deficiency Virus (HIV) that manifests as Acquired Immune Deficiency Syndrome (AIDS), accidental and non-accidental injuries, other communicable diseases such as tuberculosis, diarrhoea and pneumonia, which interact in vicious negative feedback loops with malnutrition and the growing incidence of non-communicable diseases (NCDs) (Norman et al 2006)
The World Health Organisation (WHO) estimated that NCDs were responsible for 28% of the total burden of disease measured by disability adjusted life-years (DALYs) in South Africa in 2004
The proposed strategies to target chronic diseases include reorganising and improving the functioning of clinical services with the extension of care of both communicable and nonhttp://www.curationis.org.za communicable into communities. This is being implemented through an integrated chronic disease management (ICDM) framework which is being implemented through the reengineered PHC framework (NDOH 2010b)

Summary

Introduction

South Africa is experiencing a ‘profound health transition’ (Mayosi et al 2009:1) characterised by four simultaneous epidemics (Bradshaw et al 2003). These deficiencies have the potential to negatively impact patient health outcomes as the break in information may hinder continuity of care. The proposed strategies to target chronic diseases include reorganising and improving the functioning of clinical services with the extension of care of both communicable and nonhttp://www.curationis.org.za communicable into communities. This is being implemented through an integrated chronic disease management (ICDM) framework which is being implemented through the reengineered PHC framework (NDOH 2010b)

Objectives

Results

Conclusion