|ZS Fadl Elmula, Ahmed K Bolad
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.
|Janitha Plackal Ayyappan, Faraz Khurshid
Context: This study is conducted to determine the correlation between retinal nerve fiber layer (RNFL) thickness and optic nerve head (ONH) size in normal and glaucomatous subjects by optical coherence tomography (OCT).
Objective: The objective of this study is to compare the thickness of RNFL in relation to ONH size and average retinal nerve fiber thickness in glaucomatous optic neuropathy using OCT.
Subjects and Methods: A prospective study was carried out on one hundred and fifty eyes of 75 patients with 39 normal and 36 glaucoma patients aged between 20 and 60 years.
Results: Stratus OCT, values were correlated with the data obtained by ONHs analysis. The values of RNFL thickness showed a high correlation with the ONH size. The RNFLA values were also positively correlated with the *2.27 value. Mean RNFL in glaucoma patients is 72.20 ± 18.79 (standard deviation [SD]) and in *2.27 is 63.57 ± 17.3 (SD) (calculated Z value is 2.58 and P ≤ 0.004) and is highly significant at 4% level in glaucoma patients. Besides correlation coefficient of RNFLA*2.27 in glaucoma patients found positive correspondence with the correlation coefficient 0.867. In normal subject, mean RNFL is 92.16 ± 9.80 and in *2.27, 85.16 ± 10.21 (calculated Z value is 4.34 and P ≤ 0.007) and significant at 3% level in normal subjects. A negative correlation was seen with the value of correlation coefficient − 0.21.
Conclusions: RNFL thickness *2.27 measurement has high correlation with each other as obtained by Stratus OCT; moreover, it decreased significantly with an increase in optic disc size.
Statistical Analysis Used: To test the difference between two means, Z-test was used. “Z” distribution with population variance not known at that point of time because no normative-based population data were available for Indian population to find out the correlation between two variance correlation coefficient at that point of time.