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Background: Medical record completeness is an outstanding problem that affects the
quality of health services in many hospitals of Ethiopia. The medical record must contain
sufficient data to identify the patient, support the diagnosis or reason for attendance at the health
care facility, justify the treatment and accurately document the results of that treatment. On the
other hand, Incomplete medical recording, Poor data quality management and reporting system,
lack of information technology and its use, shortage of human resource and professional mix,
failure to audit medical records and failure to adhere with existing guidelines and standard
operational procedures are the major problems in hospital’s medical record management
system. However, so far there is a dearth of literatures pertaining to this problem in Ethiopia in
general and in Shinshicho primary hospital in particular.
Objective: The aim of the current study was to assess the completeness of inpatient medical
records in Shinshicho primary Hospital.
Methodology: This study was a facility based cross-sectional one. The population was inpatients
medical record in Shinshicho primary hospital from July 1/2007- December 30, 2010 E.C and
the number of samples was 258 medical records which were chosen by systematic sampling. The
data was collected by inpatient medical records structured standard checklist. The collected data
was entered in to EPI INFO version 7.0 and then exported to SPSS windows version 20
statistical software for both descriptive and inferential statistics and presented in statistical tables.
Result: The overall inpatient medical record completeness was 63.7% and this was
significant(P<0.030): Physician note was completed for 74.4%(95% CI: 0.904-0.965), physician
order completed for 79.5%(95% CI: 0.772-0.858), nursing care plan completed for 13.2 % (95%
CI: 0.104-0.191), medication administration completed for 87.2%(95% CI: 0.853-0.930) and
discharge summery sheet was completed for 64.0%(95% CI: 0.605-0.721) at (P < 0.05).
According to the findings, nursing care plan sheet was the most incomplete item than others.
Conclusion and Recommendation: The finding of this study suggests that availing inpatient
medical record standard formats and capacity building training for healthcare providers
especially for nurses. Therefore, Shinshicho hospital was recommended to design for availing
medical record standard formats and plan capacity building training programs to improve
medical record completeness |
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