Improving the medical record completeness at Inkurunziza orthopedist specialized hospital

Abstract

Completeness of medical records is a key performance indicator related to hospital delivery of health care services. Although EMRs are associated with quality of patient care, patient safety, and cost reduction, their completion rates are still low. The study aims to increase the rate of electronic medical records from 60% to 85%. A pre-and post-intervention design was used in this thesis. The researcher conducted an assessment to measure the extent of the problem, used as baseline data and root cause analysis, in collaboration with the chief nursing officer. Interventions were selected after a comparative analysis of identified alternatives. The overall mean completeness of medical records at OPD of Inkurunziza Specialized Orthopedic Hospital was 60% pre-intervention and 81% post-intervention. The standard deviation was 21 pre intervention and 20 post-intervention, indicating a significant improv

In addition, the P-value before and after the intervention was 0.003, which indicates a significant improvement in the completeness of the medical records at Inkurunziza Orthopedic Specialized Hospital. The results showed a significant improvement in the completeness of medical records at Inkurunziza Specialized Orthopedic Hospital, and hospital leaders and staff were encouraged to maintain adequate medical record keeping, as well as address outstanding issues and undertake regular program monitoring and evaluation.