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ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 75-78

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


1 Faculty of Medicine, Department of CPR & Trauma, Faculty of Medicine, Africa International University, State Registered Nurse (England & Wales), M.Sc (Mental Retarded and Learning Disability), Modern Management (Cambridge Tutorial Collage), Birmingham, UK
2 Department of Microbiology, Al Neelain Medical Research Centre, Unit of Immunology, Faculty of Medicine, Al-Neelain University, Khartoum, Sudan

Date of Web Publication14-Sep-2018

Correspondence Address:
Dr. Ahmed K Bolad
Department of Microbiology, Al Neelain Medical Research Centre, Unit of Immunology, Faculty of Medicine, Al-Neelain University, Khartoum
Sudan
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DOI: 10.4103/bijo.bijo_9_17

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  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 (<50%), except legibility in hospital C (58%), accuracy, authenticity, and using abbreviations in hospital A (54%, 84%, and 97%, respectively).
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.

Keywords: Abbreviation, Accuracy Authenticity, Adequacy, Legibility, Medical documentation, Medical Records


How to cite this article:
Fadl Elmula Z S, Bolad AK. Standard documentation of paper-based medical records at four main hospitals in Khartoum state, Sudan, 2014–2015. Albasar Int J Ophthalmol 2017;4:75-8

How to cite this URL:
Fadl Elmula Z S, Bolad AK. Standard documentation of paper-based medical records at four main hospitals in Khartoum state, Sudan, 2014–2015. Albasar Int J Ophthalmol [serial online] 2017 [cited 2018 Nov 13];4:75-8. Available from: http://www.bijojournal.org/text.asp?2017/4/3/75/241123




  Introduction Top


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.[1]

As MRM concerns with managing medical records to be used to plan patient care, to perform medical research, to evaluate patient care who has been previously performed, to provide information for authorized users, and to evaluate hospital progress at time. Personnel in medical records department require to have specialized knowledge of the concepts, principles, and safe practices of medical records because there is a consensus among health-care professional that medical record is an important and necessary adjunct to medical education and medical care.[2]

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.[3] Documenting is a critical component to the delivery of health care. It is a tool to ensure continuity of care as it serves as a communication tool among health-care providers to plan and evaluate the previous care given to the patient, to create a permanent record for patient's future care, and to create a database to evaluate the effectiveness of treatment.

The hospital paper-based medical record has become increasingly exposed to retrospective audits by third-party insurers' quality assessment studies and billing inquiries. As a result, the demand for complete documentation in the record has steadily increased during the past few years. Institutional medical practices are subject to a variety of regulations and standards.

Consistent, current, and complete documentation in the medical record is an essential component of quality patient care.[4]

  1. Each page in the record contains the patient's name or ID number
  2. Personal biographical data include the address, employer, home and work telephone numbers, and marital status
  3. All entries in the paper-based medical record contain the author's identification
  4. Author identification may be a handwritten signature, unique electronic identifier, or initials
  5. All entries are dated
  6. The record is legible to someone other than the writer
  7. Significant illnesses and medical conditions are indicated on the problem list
  8. Use abbreviations that are proved by the facility.


The initiation of paper-based medical records in Sudan has not exactly known or reported, but it almost began at mid-fifties along with the establishment of Khartoum Hospital. A number of Sudanese physicians including only one British expatriate Prof. Lamsdeen, an obstetrician and gynecologist, who worked in the Faculty of Medicine Khartoum University, started to lay the foundation stone of paper-based medical records in Sudan. To record patient's information, Prof. Lamsdeen used a card system for certain period and then it was changed into a patient's file.


  Methods Top


This is an analytical, descriptive, hospital-based study recruited 400 paper-based medical records gathered equally from four main hospitals in Khartoum State, Sudan; hospital A, hospital B, hospital C, and hospital D and they represented Khartoum, Khartoum North, and Omdurman cities.

Predesigned questionnaire was used to fulfill data of standards of documentation in paper-based medical records. It included legibility, adequacy, accuracy, authenticity, and the use of abbreviations. A number of records with standard documentation in each criterion was considered for the benefit of the hospital as positive practice and calculated as percentage. Data were collected from record sheet using a predesigned questionnaire, then analyzed using Statistical Package for the Social Sciences (version 21) (Manufactured by IBM SPSS Inc. PASW Statistics for Windows, Version 19; 2009. Chicago: SPSS Inc; IL, USA). 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 Top


Documentation in paper-based medical records

The following tables showed standard documentation practices in paper-based medical records in hospital A, B, C, and D [Table 1].
Table 1: The following tables showed standard documentation practices in paper-based medical records in hospital (A), (B), (C) and (D)

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Legibility, adequacy, accuracy, and authenticity were assessed in four hospitals, out of each 100 files were taken for the assessment. Legible paper-based medical records were reported in 39% in hospital A, 31% in hospital B, 58% in hospital C, and 19% in hospital D. The overall mean of legibility in the four hospitals was 36.8%. Adequate paper-based medical records were reported in 24% in hospital A, 22% in hospital B, 19% in hospital C, and 10% in hospital D. the overall mean of adequate records in the four hospitals was extremely poor (18.8%). Accurate paper-based medical records were reported in 54% in hospital A, 28% in hospital B, 30% in hospital C, and 25% in hospital D. The overall mean of adequate records in the four hospitals was poor (34.3%). Authenticity of medical records was observed in 84% in hospital A, 34% in hospital B, 15% in hospital C, and 29% in hospital D. The overall mean of adequate records in the four hospitals was poor (40.5%). Abbreviations and symbols were found used properly by 97% in hospital A, 12% in hospital B, 15% in hospital C, and 9% in hospital D. the overall mean of using abbreviations and symbols in the four hospitals was 33.3%.


  Discussion Top


Standard documentation of paper-based medical records was evaluated in the four hospitals by observing five criteria; legibility, adequacy, accuracy, authenticity, and the use of abbreviations in paper-based medical records.

The 400 paper-based medical records which represented the four studied hospitals revealed poor practice of eligibility in paper-based medical records; the mean of eligible records was submoderate (36.8%). 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 health-care providers remarkably gave no attention to the importance of legibility as an integral part of documentation due to that healthcare providers lacked knowledge of documentation and they were unaware how to document properly on paper-based medical records.

Nancy et al. in 1990 discussed the benefit of eligible records showing that well-organized and eligible paper-based medical records facilitate identifying patient's complaint, symptoms, procedures, or actions to alleviate or eliminate the patient's illness or injury, status of the patient condition following treatment, and final outcome.[5]

Adequacy of paper-based medical records was also found poor with a mean of 18.8% in the four hospitals; in each hospital, adequacy in paper-based records ranged between 24% in hospital A and 10% in hospital D. These findings also indicate that health-care providers practiced poor documentation as a result of their unawareness of the importance of documentation as an essential element of paper-based medical records documentation. Mean of accurate paper-based medical records in our findings showed also a poor/submoderate score (34.2%), whereas only hospital A showed slightly higher percent of records reported accurately.

Reporting authenticated medical records was found poor as mean in the four hospitals (40.5%). However, hospital A showed very good performance in this matters since 84% of paper-based medical records found authenticated. This percent indicated that health-care providers did not practice authenticity in a proper way in their daily use of paper-based medical records. The mean of using prohibited abbreviation in the four hospitals was found poor in general (33.2%). Although it was found very good in hospital A since it was applied in 97% of paper-based medical records. This means that using of abbreviations in paper-based medical records as a crucial document was not properly done by health-care providers. Poor knowledge about the above-mentioned aspects might be reflected as poor performance.

This to some extent compatible with some studies in Isfahan,[6],[7] Kashan,[8] Iran,[6],[9] and Shiraz[10] medical universities and in other countries[11],[12] which showed that there were many deficiencies in the patient records. The study of Kerman in 2000 showed proportionally higher level of adequacy in histories, progress notes, and order sheets (50%–70%).[13]

Reported studies concerned with practice more than level of knowledge as reported by Stausberg et al., Barrie and Marsh (1992); Barrie and Marsh in 2012 reported a completeness of 62% and an accuracy of 96% in an orthopedic.[14],[15] The Canadian Medical Association discussed the issue of medical records management in 2012 indicating that there is no excuse for having illegible records as well as they believe that illegible records delay the process of management specially when receiving an emergency case.[16]


  Conclusion Top


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.

Recommendations

The study recommends applying methods of medical documentation in curriculum of nursing colleges and providing routinely set in-service sessions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Available from: http://www.slideshare.net/NcDas/nursing -audit -12084093/. [Last accessed on 2016 Jul 09].  Back to cited text no. 1
    
2.
Hickey WJ. The management audit: A tool for organization effectiveness. Med Rec News 1970;41:32.  Back to cited text no. 2
    
3.
Clarkson EH. An Approach to Effective Management: Medical Record News. Collage of American Pathologists; 1974.  Back to cited text no. 3
    
4.
Greiver M, Barnsley J, Glazier RH, Harvey BJ, Moineddin R. Measuring data reliability for preventive services in electronic medical records. BMC Health Serv Res 2012;12:116.  Back to cited text no. 4
    
5.
Nancy R, Logan WW, Tierney AJ. The Elements of Nursing: The Medical Record. 3rd ed., Ch. 38. Singapore: Longman Publisher; 1990. Available from: https://www.quizlet.com/101972182/chapter-38-the-medical-record-flash-cards/.  Back to cited text no. 5
    
6.
Raihani A A. Model for evaluation of medical records in order to effective evaluation of medical education, Proceedings of the Iranian 3th national medical records conference 1998.  Back to cited text no. 6
    
7.
Raihani AA. Model for Evaluation of Medical Records in Order to Effective Evaluation of Medical Education. Proceedings of the Iranian 3th National Medical Records Conference; 1998.  Back to cited text no. 7
    
8.
Rangraz Jeddi F, Frazandipour M. Qualitative Evaluation of Medical Records at the Hospitals Affiliated with Kashan University of Medical Sciences. Proceedings of the Iranian 3th National Medical Records Conference; 1998.  Back to cited text no. 8
    
9.
Asadi F. Qualitative Evaluation of Patient Records at the Teaching Hospitals Affiliated with Iran University of Medical Sciences. Dissertation of MSc. Degree, School of Management and Medical Information Sciences; 2017.  Back to cited text no. 9
    
10.
Ahmadzadeh FA. Study on Adequacy of Patient Records at the Teaching Hospitals with Shiraz University of Medical Sciences. Dissertation of MSc. Degree, School of Management and Medical Information Sciences; 1998.  Back to cited text no. 10
    
11.
Lauderdale DS, Goldberg J. The expanded racial and ethnic codes in the medicare data files: Their completeness of coverage and accuracy. Am J Public Health 1996;86:712-6.  Back to cited text no. 11
    
12.
Solberg EE, Aabakken L, Sandstad O, Bach-Gansmo E, Nordby G, Enger E, et al. The medical record – Content, interpretation and quality. Study of 100 medical records from a department of internal medicine. Tidsskr Nor Laegeforen 1995;115:488-9.  Back to cited text no. 12
    
13.
Aryaie M. A survey about medical records contents in general teaching hospitals affiliated with Kerman university of medical sciences during the first three months of 1998. Q J Manag Med Inf Sci 2000;4:65-70.  Back to cited text no. 13
    
14.
Barrie JL, Marsh DR. Quality of data in the Manchester orthopaedic database. BMJ 1992;304:159-62.  Back to cited text no. 14
    
15.
Stausberg J, Koch D, Ingenerf J, Betzler M. Comparing paper-based with electronic patient records: Lessons learned during a study on diagnosis and procedure codes. J Am Med Inform Assoc 2003;10:470-7.  Back to cited text no. 15
    
16.
Canadian Medical Association. Module 6: Medical Records Management; September, 2012. Available from: https://www.cma.ca. [Last accessed on 2017 Jun 12].  Back to cited text no. 16
    



 
 
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