الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
A medical record is a file containing records and documents about the patient’s identity, examinations, medications, actions and other services that have been provided to the patient. Medical records play a vital role in the planning, development of health care services Medical records are known as the reflecting mirror of the medical care. Documentation of medical records must be complete, accurate, dated and timed.
Incomplete information in a medical record can lead to duplication of investigations which increase the cost of treatment, loss the communication between healthcare providers, besides missing the diagnosis and wrong treatment.
Statistical process control (SPC) is a technique applying to measure, monitor and control the process. It is a useful tool that helps in improving quality by reducing errors in the process.
A cross-sectional study was conducted in Ras El Tin general hospital in the year 2016 in three departments with the highest admission rate (internal medicine, surgery, and ICU departments) to measure the completeness of medical records, A sample size of 1200 medical records of hospital, 400 medical records per department chosen in a systematic random manner, sixteen records every two weeks from each department. A checklist was prepared to audit all forms in the selected medical records. The records were checked for the presence of the forms, items included in all forms as recommended by the Egyptian Ministry of Health, completeness documentation and legibility of handwriting.
The level of documentation was considered “good” if the average percentage of completeness was 95-100%, “average” if the average completeness was 75-<95% and “poor” if the average completeness was less than 75%.
On measuring the completeness of medical records the following was revealed:
1. The medication sheets were the most frequently absent from the records in the three departments.
2. Missing items were detected in history and physical examination while no missed items were detected in the admission form, nursing progress note, vital sign form, death report, diabetes sheet, fluid balance form, preparing patient before operating form, pre-anesthetic records, intraoperative anesthesia record, and post-anesthesia record and not all pages in the record contain patient number and name.
3. The handwriting was clear in most of the records.
Percentage of complete documentation of items in admission form ranged from 0.0% to 100%, history and physical examination form ranged from 67.2% to 98.0%, doctor’s orders form from 86.0% to 100.0%, medication sheet from 0.0% to 93.7%, discharge summary from 56.6% to 98.9%, nursing progress note form from 55.2% to 100%, nursing admission assessment from 0% to 99.7%, vital sign form from 0.0% to 100.0%, falling risk form from 97.7% to 100.0%, pain assessment form from 96.7% to 100.0%, death report from 85.0% to 100.0%, diabetes sheet form from 80.7% to 100.0%, referral form from 28.6% to 100.0%, fluid balance form from 58.1% to 99.6%, consultant form from 48.8% to 88.4%, blood transfusion consent from 97.0% to 100.0%, and nurse follow-up for blood transfusion form from 58.8% to 100%.
In the special forms of surgical department, the completeness of the items in the informed consent form for high risk operation ranged from 93.3% to 99.0%, operation sheet form from 72.8% to 89.1%, preparing patient before operation form from 1.9% to 96.8%, the instrument in operating room forms from 93.9% to 100%, pre-anesthetic record from 25% to 96.4%, intraoperative anesthetic record from 43.4% to 85.8%, and post-anesthesia care unit record from 83.0% to 94.3%. Completeness of the lab follows sheet in the ICU department ranged from 42.9% to 100.0%.
Data registration was average in the three departments (internal medicine, surgery, and ICU) regarding admission form (85.4%, 87.9%, 85.4%), history and physical examination form (83.1%, 85.0%, 91.7%), medication sheet form (76.3%, 76.4%, 78.1%), discharge summary form (88.7%, 86.2%, 93.3%), vital sign form (90.7%, 90.9%, 91.7%), referral form (82.6%, 80.9%, 87.1%), fluid balance form (88.1%, 88.9%, 90.5%), and nurse follow-up for blood transfusion form (80.4%, 82.4%, 84.8%).
Data registration was good in the three departments (internal medicine, surgery, and ICU) regarding falling risk form (98.9%, 98.9%, 99.0%), pain assessment form (99.5%, 99.5%, 99.0%), death report form (95.4%, 95.4%, 97.2%), diabetes sheet form (97.1%, 96.4%, 98.5%), and blood transfusion consent form (100%, 100%, 97.0%).
Data registration was poor in the three departments (internal medicine, surgery, and ICU) regarding the nursing admission assessment form (71.1%, 69.0%, 71.2%) and consultant form (74.3%, 73.9%, 74.4%).
Data registration was average in the internal medicine department, good in surgery and ICU departments regarding doctor’s order form (92.8%, 96.1%, 98.2%).
Data registration was average ininternal medicine and surgery departments, good in the ICU department regarding nursing progress note form (92.4%, 93.9%, 96.5%).
In the special forms of surgical department, Data registration was average regarding operation sheet (83.3%), intraoperative anesthesia record (77.0%) and post-anesthesia record (90.6%), good regarding informed consent form for high risk operation (97.1%), count of the instrument in the operating room form (98.6%) and poor regarding preparing patient before operation form (74.0%), pre-anesthetic record (73.2%).
In the special form of ICU department, Data registration was average regarding ICU lab results flow sheet (79.0%).
The process capability technique was adapted to test if the documentation process had met specifications. We came to the conclusion that the documentation process was stable but not acceptable and needed improvement in the history and physical examination form and pain assessment form in the three departments.Falling risk assessment form in surgery and ICU departments, diabetes sheet in ICU department, operating instrument statistics in surgery department.
We recommend improving the quality of medical records through regular auditing, training and good orientation of medical professionals.
Electronic medical records systems are becoming an essential technology for healthcare. It provides complete information about the patient and up-to-date, improving communication and sharing with other departments, helping in the diagnosis of patients, more legible, accurate and with fewer medical errors and costs.
A medical record is a file containing records and documents about the patient’s identity, examinations, medications, actions and other services that have been provided to the patient. Medical records play a vital role in the planning, development of health care services Medical records are known as the reflecting mirror of the medical care. Documentation of medical records must be complete, accurate, dated and timed.
Incomplete information in a medical record can lead to duplication of investigations which increase the cost of treatment, loss the communication between healthcare providers, besides missing the diagnosis and wrong treatment.
Statistical process control (SPC) is a technique applying to measure, monitor and control the process. It is a useful tool that helps in improving quality by reducing errors in the process.
A cross-sectional study was conducted in Ras El Tin general hospital in the year 2016 in three departments with the highest admission rate (internal medicine, surgery, and ICU departments) to measure the completeness of medical records, A sample size of 1200 medical records of hospital, 400 medical records per department chosen in a systematic random manner, sixteen records every two weeks from each department. A checklist was prepared to audit all forms in the selected medical records. The records were checked for the presence of the forms, items included in all forms as recommended by the Egyptian Ministry of Health, completeness documentation and legibility of handwriting.
The level of documentation was considered “good” if the average percentage of completeness was 95-100%, “average” if the average completeness was 75-<95% and “poor” if the average completeness was less than 75%.
On measuring the completeness of medical records the following was revealed:
1. The medication sheets were the most frequently absent from the records in the three departments.
2. Missing items were detected in history and physical examination while no missed items were detected in the admission form, nursing progress note, vital sign form, death report, diabetes sheet, fluid balance form, preparing patient before operating form, pre-anesthetic records, intraoperative anesthesia record, and post-anesthesia record and not all pages in the record contain patient number and name.
3. The handwriting was clear in most of the records.
Percentage of complete documentation of items in admission form ranged from 0.0% to 100%, history and physical examination form ranged from 67.2% to 98.0%, doctor’s orders form from 86.0% to 100.0%, medication sheet from 0.0% to 93.7%, discharge summary from 56.6% to 98.9%, nursing progress note form from 55.2% to 100%, nursing admission assessment from 0% to 99.7%, vital sign form from 0.0% to 100.0%, falling risk form from 97.7% to 100.0%, pain assessment form from 96.7% to 100.0%, death report from 85.0% to 100.0%, diabetes sheet form from 80.7% to 100.0%, referral form from 28.6% to 100.0%, fluid balance form from 58.1% to 99.6%, consultant form from 48.8% to 88.4%, blood transfusion consent from 97.0% to 100.0%, and nurse follow-up for blood transfusion form from 58.8% to 100%.
In the special forms of surgical department, the completeness of the items in the informed consent form for high risk operation ranged from 93.3% to 99.0%, operation sheet form from 72.8% to 89.1%, preparing patient before operation form from 1.9% to 96.8%, the instrument in operating room forms from 93.9% to 100%, pre-anesthetic record from 25% to 96.4%, intraoperative anesthetic record from 43.4% to 85.8%, and post-anesthesia care unit record from 83.0% to 94.3%. Completeness of the lab follows sheet in the ICU department ranged from 42.9% to 100.0%.
Data registration was average in the three departments (internal medicine, surgery, and ICU) regarding admission form (85.4%, 87.9%, 85.4%), history and physical examination form (83.1%, 85.0%, 91.7%), medication sheet form (76.3%, 76.4%, 78.1%), discharge summary form (88.7%, 86.2%, 93.3%), vital sign form (90.7%, 90.9%, 91.7%), referral form (82.6%, 80.9%, 87.1%), fluid balance form (88.1%, 88.9%, 90.5%), and nurse follow-up for blood transfusion form (80.4%, 82.4%, 84.8%).
Data registration was good in the three departments (internal medicine, surgery, and ICU) regarding falling risk form (98.9%, 98.9%, 99.0%), pain assessment form (99.5%, 99.5%, 99.0%), death report form (95.4%, 95.4%, 97.2%), diabetes sheet form (97.1%, 96.4%, 98.5%), and blood transfusion consent form (100%, 100%, 97.0%).
Data registration was poor in the three departments (internal medicine, surgery, and ICU) regarding the nursing admission assessment form (71.1%, 69.0%, 71.2%) and consultant form (74.3%, 73.9%, 74.4%).
Data registration was average in the internal medicine department, good in surgery and ICU departments regarding doctor’s order form (92.8%, 96.1%, 98.2%).
Data registration was average ininternal medicine and surgery departments, good in the ICU department regarding nursing progress note form (92.4%, 93.9%, 96.5%).
In the special forms of surgical department, Data registration was average regarding operation sheet (83.3%), intraoperative anesthesia record (77.0%) and post-anesthesia record (90.6%), good regarding informed consent form for high risk operation (97.1%), count of the instrument in the operating room form (98.6%) and poor regarding preparing patient before operation form (74.0%), pre-anesthetic record (73.2%).
In the special form of ICU department, Data registration was average regarding ICU lab results flow sheet (79.0%).
The process capability technique was adapted to test if the documentation process had met specifications. We came to the conclusion that the documentation process was stable but not acceptable and needed improvement in the history and physical examination form and pain assessment form in the three departments.Falling risk assessment form in surgery and ICU departments, diabetes sheet in ICU department, operating instrument statistics in surgery department.
We recommend improving the quality of medical records through regular auditing, training and good orientation of medical professionals.
Electronic medical records systems are becoming an essential technology for healthcare. It provides complete information about the patient and up-to-date, improving communication and sharing with other departments, helping in the diagnosis of patients, more legible, accurate and with fewer medical errors and costs.
A medical record is a file containing records and documents about the patient’s identity, examinations, medications, actions and other services that have been provided to the patient. Medical records play a vital role in the planning, development of health care services Medical records are known as the reflecting mirror of the medical care. Documentation of medical records must be complete, accurate, dated and timed.
Incomplete information in a medical record can lead to duplication of investigations which increase the cost of treatment, loss the communication between healthcare providers, besides missing the diagnosis and wrong treatment.
Statistical process control (SPC) is a technique applying to measure, monitor and control the process. It is a useful tool that helps in improving quality by reducing errors in the process.
A cross-sectional study was conducted in Ras El Tin general hospital in the year 2016 in three departments with the highest admission rate (internal medicine, surgery, and ICU departments) to measure the completeness of medical records, A sample size of 1200 medical records of hospital, 400 medical records per department chosen in a systematic random manner, sixteen records every two weeks from each department. A checklist was prepared to audit all forms in the selected medical records. The records were checked for the presence of the forms, items included in all forms as recommended by the Egyptian Ministry of Health, completeness documentation and legibility of handwriting.
The level of documentation was considered “good” if the average percentage of completeness was 95-100%, “average” if the average completeness was 75-<95% and “poor” if the average completeness was less than 75%.
On measuring the completeness of medical records the following was revealed:
1. The medication sheets were the most frequently absent from the records in the three departments.
2. Missing items were detected in history and physical examination while no missed items were detected in the admission form, nursing progress note, vital sign form, death report, diabetes sheet, fluid balance form, preparing patient before operating form, pre-anesthetic records, intraoperative anesthesia record, and post-anesthesia record and not all pages in the record contain patient number and name.
3. The handwriting was clear in most of the records.
Percentage of complete documentation of items in admission form ranged from 0.0% to 100%, history and physical examination form ranged from 67.2% to 98.0%, doctor’s orders form from 86.0% to 100.0%, medication sheet from 0.0% to 93.7%, discharge summary from 56.6% to 98.9%, nursing progress note form from 55.2% to 100%, nursing admission assessment from 0% to 99.7%, vital sign form from 0.0% to 100.0%, falling risk form from 97.7% to 100.0%, pain assessment form from 96.7% to 100.0%, death report from 85.0% to 100.0%, diabetes sheet form from 80.7% to 100.0%, referral form from 28.6% to 100.0%, fluid balance form from 58.1% to 99.6%, consultant form from 48.8% to 88.4%, blood transfusion consent from 97.0% to 100.0%, and nurse follow-up for blood transfusion form from 58.8% to 100%.
In the special forms of surgical department, the completeness of the items in the informed consent form for high risk operation ranged from 93.3% to 99.0%, operation sheet form from 72.8% to 89.1%, preparing patient before operation form from 1.9% to 96.8%, the instrument in operating room forms from 93.9% to 100%, pre-anesthetic record from 25% to 96.4%, intraoperative anesthetic record from 43.4% to 85.8%, and post-anesthesia care unit record from 83.0% to 94.3%. Completeness of the lab follows sheet in the ICU department ranged from 42.9% to 100.0%.
Data registration was average in the three departments (internal medicine, surgery, and ICU) regarding admission form (85.4%, 87.9%, 85.4%), history and physical examination form (83.1%, 85.0%, 91.7%), medication sheet form (76.3%, 76.4%, 78.1%), discharge summary form (88.7%, 86.2%, 93.3%), vital sign form (90.7%, 90.9%, 91.7%), referral form (82.6%, 80.9%, 87.1%), fluid balance form (88.1%, 88.9%, 90.5%), and nurse follow-up for blood transfusion form (80.4%, 82.4%, 84.8%).
Data registration was good in the three departments (internal medicine, surgery, and ICU) regarding falling risk form (98.9%, 98.9%, 99.0%), pain assessment form (99.5%, 99.5%, 99.0%), death report form (95.4%, 95.4%, 97.2%), diabetes sheet form (97.1%, 96.4%, 98.5%), and blood transfusion consent form (100%, 100%, 97.0%).
Data registration was poor in the three departments (internal medicine, surgery, and ICU) regarding the nursing admission assessment form (71.1%, 69.0%, 71.2%) and consultant form (74.3%, 73.9%, 74.4%).
Data registration was average in the internal medicine department, good in surgery and ICU departments regarding doctor’s order form (92.8%, 96.1%, 98.2%).
Data registration was average ininternal medicine and surgery departments, good in the ICU department regarding nursing progress note form (92.4%, 93.9%, 96.5%).
In the special forms of surgical department, Data registration was average regarding operation sheet (83.3%), intraoperative anesthesia record (77.0%) and post-anesthesia record (90.6%), good regarding informed consent form for high risk operation (97.1%), count of the instrument in the operating room form (98.6%) and poor regarding preparing patient before operation form (74.0%), pre-anesthetic record (73.2%).
In the special form of ICU department, Data registration was average regarding ICU lab results flow sheet (79.0%).
The process capability technique was adapted to test if the documentation process had met specifications. We came to the conclusion that the documentation process was stable but not acceptable and needed improvement in the history and physical examination form and pain assessment form in the three departments.Falling risk assessment form in surgery and ICU departments, diabetes sheet in ICU department, operating instrument statistics in surgery department.
We recommend improving the quality of medical records through regular auditing, training and good orientation of medical professionals.
Electronic medical records systems are becoming an essential technology for healthcare. It provides complete information about the patient and up-to-date, improving communication and sharing with other departments, helping in the diagnosis of patients, more legible, accurate and with fewer medical errors and costs.