Completion of electronic medical records in general clinics at Yousif engineer health Centre in Bahrain : a clinical audit

الملخص EN

Background: Electronic medical records have largely replaced the conventional, paper-based documents, in many parts of the world, including Bahrain, due to increased portability, and easy accessibility.

In primary-care setting in Bahrain, physicians use the SOAP note to document the patient’s medical history.

The aim of this audit is to estimate the rate of completion of documentation of patient’s medical records by the physicians in Yousif Engineer Health Center using SOAP note in I-SEHA.

Methods: Yousif Engineer Health Center, which is the largest health centre in terms of coverage and number of visits, was the target of this audit.

The date selected, by simple randomization, was November 15th, 2017.

Night shifts, weekends, and records, documented by trainee residents, were excluded from the analysis.

On that day, 11 physicians were on duty, with 426 records.

Every physician was considered as a cluster, and approximately 35 % (n = 147) of the total records (n = 426), were included in the analysis using systematic selection.

Results: A total of 147 records were analyzed.

The SOAP note was complete in 1 (1 %), partially complete in 142 (96 %), and incomplete in 4 (3 %), of the records.

Subsequently, each part of SOAP note was separately assessed.

For the Subjective part, 16 (11 %) were complete, 125 (85 %) partially complete, and 6 (4 %) incomplete.

For the Objective part, 8 (6 %) records were complete, 37 (25 %) partially complete, and 102 (69 %) incomplete.

The Assessment part was complete in 141 (96 %) and incomplete in 6 (4 %) of the records.

The Plan part was complete in 127 (86 %) and incomplete in 20 (14 %) of the records.

Conclusion: In comparison to other studies assessing the competition of electronic medical records, this audit showed a substandard completion rate of 1 %.

Accordingly, recommendations were formulated, which can be adopted to improve the electronic medical documentation.