Completeness and Readability of Health Information in Hospitals Records – North Kordofan State-Sudan 2015
Keywords:
completeness, hospital, information, pediatric, files, internal medicine.
Abstract
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.References
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[14] 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.
[15] 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.
[16] 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.
[17] 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.
[18] 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.
[19] 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.
[20] 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.
Published
2017-06-21
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