Completeness and Readability of Health Information in Hospitals Records – North Kordofan State-Sudan 2015
Documentation of patients` information in the hospital registry is crucial for efficient quality of care. The objective was to assess the completeness and readability of patients` information in the inpatients files of internal medicine and pediatric departments. A descriptive audit study carried out in four hospitals in North Kordofan State. A total of 549 and 555 inpatients` files were reviewed from the internal medicine and pediatric departments respectively. A structured review checklist was used for the audit. Data was managed by SPSS version 20. Comprehensiveness proportions were calculated manually. Chi square test at 95% CL was used for comparison. Complete and readable full names of patients were shown in 6.2% and 34.2% of internal medicine and pediatric files respectively. Patients` full contact address was complete and readable in 11.3% and 4.5% respectively. Only 0.5% of pediatric files had recorded age. Completeness of basic information in inpatients` files was significantly different in favor to the internal medicine department, P- value=0.01. Documentation of clinical assessment items was complete in internal medicine files (65.6%) and pediatric files (62.5%). Pediatric files had complete readable vaccination history (55.7%), complete readable perinatal, natal and postnatal history (40%) and complete readable milestones history(29.9%). The summary discharge pages had comprehensiveness scores, 13% and 18.7% in internal medicine and pediatric files respectively, P-value 0.01. Date of discharge was adequately complete in 74.1% and 77.5% of the internal medicine and pediatric files respectively. Information in hospital inpatients` files was not complete.
Two thirds of inpatients` files were complete and readable for clinical assessment items. The childhood developmental history was under-documented. The summary discharge pages were not completely documented except the date of discharge. A reform plan and computerization of the data base is recommended.
Chin N., Perera P., Roberts A., Nagappan R. Review of medical discharge summaries and medical documentation in a metropolitan hospital: Impact on diagnostic‐related groups and weighted inlier equivalent separation. Internal medicine journal 2013;43(7):767-71.
Niakan Kalhori SR., Tayefi B., Noori A., Mearaji M., Rahimzade S., Zandian E., et al. Inpatient data, inevitable need for policy making at national and sub-national levels: a lesson learned from NASBOD. Arch Iran Med 2014; 17(1):16-21.
Zegers M., de Bruijne MC., Spreeuwenberg P., Wagner C, Groenewegen PP., Van der Wal G. Quality of patient record keeping: an indicator of the quality of care? BMJ quality & safety 2011; 20(4):314-8.
James JT. A new, evidence-based estimate of patient harms associated with hospital care. Journal of patient safety 2013; 9(3):122-8.
Mate KS., Bennett B, Mphatswe W., Barker P., Rollins N. Challenges for routine health system data management in a large public programme to prevent mother-to-child HIV transmission in South Africa. PloS one 2009;4 (5):e5483
MedCalc - User-friendly statistical software. Online calculator available from URL: https://www.medcalc.org/calc/comparison_of_proportions.php
Thomas J. Medical records and issues in negligence. Indian Journal of Urology 2009; 25(3):384-388.
Wang J, Siminerio LM. Educators’ Insights in Using Chronicle Diabetes. A Data Management System for Diabetes Education. The Diabetes Educator 2013; 39(2): 248-254.
Fraser HS., Blaya J. Implementing medical information systems in developing countries, what works and what doesn’t. AMIA Annual Symposium Proceedings 2010: Pages 232-236.
De Marinis MG., Piredda M., Pascarella MC., Vincenzi B., Spiga F., Tartaglini D., et al. ‘If it is not recorded, it has not been done!’? consistency between nursing records and observed nursing care in an Italian hospital. Journal of clinical Nursing 2010; 19(11-12):1544-52.
Black RE., Cousens S., Johnson HL., Lawn JE., Rudan I., Bassani DG., et al. Global, regional, and national causes of child mortality in 2008: a systematic analysis. The lancet 2010; 375(9730):1969- 87.
Bleyer JA., Vidya S., Russell BG., Jones MC., Sujata L., Daeihagh P., et al. Longitudinal analysis of one million vital signs in patients in an academic medical center. Resuscitation. 2011;82:1387–92.
Mitchell I., McKay H., Van Leuvan C., Berry R., McCutcheon C., Avard B., et al. A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients. Resuscitation 2010;81(6):658-66.
Veiby G., Daltveit AK., Schjølberg S., Stoltenberg C., Øyen AS., Vollset SE., et al. Exposure to antiepileptic drugs in utero and child development: A prospective population‐based study. Epilepsia 2013;54(8):1462-72.
Sahni LC., Boom JA., Patel MM., Baker CJ., Rench MA., Parashar UD., et al. Use of an immunization information system to assess the effectiveness of pentavalent rotavirus vaccine in US children. Vaccine. 2010;28(38):6314-7.
Pinquart M. Achievement of developmental milestones in emerging and young adults with and without pediatric chronic illness—a meta-analysis. Journal of pediatric psychology 2014;39(6):577-87.
Murray J., Saxena S., Modi N., Majeed A., Aylin P., Bottle A., et al. Quality of routine hospital birth records and the feasibility of their use for creating birth cohorts. Journal of Public Health 2013; 35(2):298-307.
Ye Y., Wamukoya M., Ezeh A., Emina JB., Sankoh O. Health and demographic surveillance systems: a step towards full civil registration and vital statistics system in sub-Sahara Africa? BMC Public Health 2012; 12: 741. doi: 10.1186/1471-2458-12-741.
DesRoches CM., Campbell EG., Vogeli C., Zheng J., Rao SR., Shields AE., et al. Electronic health records' limited successes suggest more targeted uses. Health affairs 2010 ;29(4):639-46. doi: 10.1377/hlthaff.2009.1086.
Castelnuovo B., Kiragga A., Afayo V., Ncube M., Orama R., Magero S., et al. Implementation of Provider-Based Electronic Medical Records and Improvement of the Quality of Data in a Large HIV Program in Sub-Saharan Africa. PLoS One. 2012; 7(12): e51631.
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