Standard documentation of paper-based medical records at four main hospitals in Khartoum state, Sudan, 2014–2015

Abstract

Background: Medical record management (MRM) has become a crucial part of every hospital or medical facility because MRM has all essential elements of an information system. Although the world of medicine seems to be changing and progressing with each day, one thing that has not changed is the need for good documentation. Aims: The aim of the study was to assess standard documentation of paper-based medical records in four main hospitals in Khartoum State, Sudan. Methods: This is an analytical, descriptive, hospital-based study recruited 400 paper-based medical records gathered equally from four main hospitals in Sudan; hospital A, hospital B, hospital C, and hospital D and they represented Khartoum, Khartoum North, and Omdurman cities. The study evaluated legibility, adequacy, accuracy, authenticity, and the use of abbreviations in paper-based medical records. Data were collected from record sheet using a pre-designed questionnaire, then analyzed using Statistical Package for the Social Sciences (version 21). Ethical clearance was obtained from Graduate College-Neelain University and provided for the study area (four hospitals), whose name was not mentioned for ethical considerations. Verbal consent was obtained from each hospital director and from Ministry of Health after explaining the purpose of the study. Results: Out of four hundred record files taken for the assessment from the four hospitals, mean of legibility was 36.8% for hospital (A, B, C, and D), mean of adequacy was 18.8%, mean of accuracy was 34.2%, mean of authenticity was 40.5% whereas using prohibited abbreviations was reported with a mean of 33.2%. All the four hospitals showed submoderate/poor level of practice regarding criteria of standard documentations ( Discussion: Our findings showed that the overall mean of adequate records in the four hospitals was poor (34.3%). Except hospital C (58%), all the hospitals showed poor level of reporting eligible records (A: 39%, B: 31%, and D: 18%). These findings suggest that the four studied hospitals do not provide satisfying record files since they poorly lack the standard documentation required for proper records (eligibility, adequacy, accuracy, authenticity, and using prohibited abbreviations). This was found compatible with many other reported studies. Conclusion: Our findings have revealed that there is insufficiency in knowledge as well as there is poor practice among nurses in the studies' hospitals toward standard documentation of paper-based medical records, and this necessitates applying in-service training for nurses.