![](/images/graphics-bg.png)
Assessment of the documentation completeness level of the medical records in Basrah general hospital
Other Title(s)
دراسة لتقييم مستوى التوثيق في السجلات الطبية للمرضى الراقدين في مستشفى البصرة العام
Joint Authors
Mahmud, Raja A.
al-Hamidi, Nihad Q.
Majid, Utarid A.
Sahyud, Shabib A.
Husayn, Riyad A.
Source
The Medical Journal of Basrah University
Issue
Vol. 36, Issue 2 (31 Dec. 2018), pp.50-59, 10 p.
Publisher
University of Basrah College of Medicine
Publication Date
2018-12-31
Country of Publication
Iraq
No. of Pages
10
Main Subjects
Abstract EN
Background: Medical records documentation is an important legal and professional requirement for all health professionals.
They include information which describes all aspects of patient's care.
But, despite the importance of medical records to support better quality service provided at the health facilities, incomplete documentation is very common all over the world.
Objective of the study: to assess the documentation completeness level of the medical records in the different inpatient wards of Basrah General Hospital.
Methodology: The study was a descriptive cross-sectional one.
Medical records of 268 inpatients from Basrah General Hospital during June 2016 were included from four departments of the hospital (medicine, surgery, pediatrics and obstetrics and gynecology).
A standard Iraqi Ministry of Health inpatient medical record with a two-level scoring system for assessing the level of documentation completeness were used in the study.
Results: the overall documentation level for the medical records included in the study was generally poor in 78% of the records.
Surgical department was found to be the worse in documenting patient's notes related to medical history, while Gynecology and Obstetrics department was found to be the worst in documenting the medical examination assessment and the physician's notes related to the patient's state and details of any improvement / deterioration of his/her condition.
Conclusions and recommendations: The present study confirmed obvious incompleteness of documenting medical data for inpatient records in Basrah General Hospital especially in the general surgery, internal medicine and Gynecology and Obstetrics words.
This is specifically found for the Physician notes (patient’s state and details of any improvement/deterioration of the condition) and the Clinical pharmaceutical sheet.
A hospital based quality improvement project to improve the medical record documentation completion is highly recommended to be implemented by the Quality Assurance Unit of Basrah Directorate of Health
American Psychological Association (APA)
Husayn, Riyad A.& Mahmud, Raja A.& al-Hamidi, Nihad Q.& Majid, Utarid A.& Sahyud, Shabib A.. 2018. Assessment of the documentation completeness level of the medical records in Basrah general hospital. The Medical Journal of Basrah University،Vol. 36, no. 2, pp.50-59.
https://search.emarefa.net/detail/BIM-904151
Modern Language Association (MLA)
Husayn, Riyad A.…[et al.]. Assessment of the documentation completeness level of the medical records in Basrah general hospital. The Medical Journal of Basrah University Vol. 36, no. 2 (2018), pp.50-59.
https://search.emarefa.net/detail/BIM-904151
American Medical Association (AMA)
Husayn, Riyad A.& Mahmud, Raja A.& al-Hamidi, Nihad Q.& Majid, Utarid A.& Sahyud, Shabib A.. Assessment of the documentation completeness level of the medical records in Basrah general hospital. The Medical Journal of Basrah University. 2018. Vol. 36, no. 2, pp.50-59.
https://search.emarefa.net/detail/BIM-904151
Data Type
Journal Articles
Language
English
Notes
Includes bibliographical references : p. 58-59
Record ID
BIM-904151