Reducing incompleteness of medical records at outpatient service in Biryogo health center

Abstract

Introduction The medical record keeps and provides administrative, clinical, legal and financial data of the patient whether admitted to hospital or treated as outpatient. Good medical record keeping is at the forefront of medical practice and what is not written is considered as not done. Patient record completeness is a considered as a quality indicator of patient medical record by accreditation bodies worldwide, as WHO recommended fully (100%) completeness of MR. Objective The objective of this research is to decrease the rate of incomplete medical records in outpatient service of Biryogo health center, from 21.9 to 5% per cent from January 2017 to June 2019 Method A pre and post interventional design was employed, and the intervention was to establish medical records’ policy regarding completeness of MR. Result The intervention reduced significantly the incompleteness of MR, from 22% among 6489 patients’ files to 1% among 6923 patients’ files in pre and post interventional period respectively, with P-value inferior to 0.001. Conclusion The hypothesis that the use of policy regarding completeness of medical records, would improve completeness of MR, was confirmed. The systematic problem-solving approach generates good results in improvement of quality of healthcare service. The problem-solving approach that involves concerned people in the occurrence of the problem produces good results in the improvement of healthcare services.