الفهرس 
Value to the health care facilityOnly 14 pages are availabe for public view
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Abstract
Accurate, timely and accessible health care data play an important role in the planning, development and maintenance of health care services. All healthcare practitioners and others who enter information into patient records must understand the importance of creating complete and accurate records, as well as the legal and medical implications of this process failure. The quality of care a patient receives depends directly on the accuracy and legibility of the information documented in the medical record. Medical records have so far been the primary source for researching medical errors. Several studies describe the use of medical record review to measure the occurrence of adverse events in hospitals. The aim of this work is to assess the quality of medical records documentation and to assess medical records management practices in three healthcare facilities, two of them in Kafr El-Sheikh City (Kafr El-Sheikh General Hospital and El Obor Health Insurance Hospital) and the third one in El-Mahalla El-Kubra City (El-Mahalla El-Kubra General Hospital, Gharbia Governorate). A sample size of (300) medical records from Kafr El-Sheikh General Hospital, (350) medical records from El Obor Health Insurance Hospital and (200) medical records from El-Mahalla El-Kubra General Hospital taken from the medical records departments of the three hospitals for evaluating the quality of medical records documentation. The calculated record sample for each hospital was selected from the discharge logs of ”2017” using the systematic random sampling method. For assessment of medical records management practices, the filing facilities (i.e. shelves) used for filing of MRs were identified and counted. Ten shelves were then randomly selected and the contents of their medical records were reviewed. Personnel concerned with the management of the medical records were directly interviewed as necessary. Four data collection tools were used in collection of data. First one is evaluation of the quality of medical records documentation checklist tool. Second one is medical record filing area assessment checklist tool. Third one is questionnaire directed to medical record department personnel for assessment of their qualifications. Fourth one is medical record filing and control function assessment checklist tool. The results of this study showed that some forms were completely absent from the medical records of El Obor Health Insurance Hospital as general consent form and discharge summary sheet. Front sheet, medical history sheet, physical examination sheet, clinical progress notes sheet, treatment order sheet, nursing notes sheet and graphic sheet were completely present in all checked records of the three studied hospitals. As regard to completeness of documentation for items of patient identification part; age, marital status and occupation of admitted patient were not documented in all checked records of El-Mahalla El-Kubra General Hospital. There was a statistically significant difference of documentation of all items of front sheet form between the three hospitals. Documentation of patient’s location and signing of front sheet were present in all records of El- Mahalla El-Kubra General Hospital. Documentation of provisional diagnosis and final diagnosis were present in most (96%) and majority (78%) records of El-Mahalla El-Kubra General Hospital respectively. Documentation of time of admission and time of discharge were the least frequent in Kafr El- Sheikh General Hospital, they were not present in the majority (83.5%) and in all records respectively. Regarding documentation of discharge summary sheet, documentation of patient status at discharge and final diagnosis were present in approximately one third and 22% records respectively in Kafr El-Sheikh General Hospital. Discharge instructions to the patient were absent in all records of Mahalla El-Kubra General Hospital and in most (98.5%) records of Kafr El-Sheikh General Hospital. As regards to surgery/invasive procedure consent form, the name of surgeon was not documented in most (90%) records of Kafr El-Sheikh General Hospital and in the majority (78%) records of El Obor Health Insurance Hospital. There was a statistically significant difference of documentation of all items of surgery consent form between the three hospitals except physician’s signature item. Regarding assessment of documentation of anesthesia or deep sedation consent form, the name of anesthetist was absent in all records of El-Mahalla El-Kubra General Hospital and Kafr El-Sheikh General Hospital and in most (97%) records of El Obor Health Insurance Hospital. Signing rate of blood and blood products consent form was the lowest in Kafr El-Sheikh General Hospital in less than the half of checked records of that hospital. Documentation of patient chief complaint in medical history sheet was highest in Kafr El-Sheikh General Hospital records (92.5%) followed by El Obor Health Insurance Hospital records (90.5%). Regarding treatment order sheet, legible medication name was present in most (90%) of records of the three studied hospitals and physician’s signature was present in most (95%) of checked records in the three studied hospitals. Regarding documentation assessment of consultation requests & reports, documentation of reason for consultation was highest in El-Mahalla El-Kubra General Hospital records (82%). Documentation of clinical findings of the patient and recommendations plan were highest in Kafr El Sheikh General Hospital as it were present in 87.5% and 75% records respectively. As regards to graphic sheet, documentation of four elements of vital signs were highest in El-Mahalla El-Kubra General Hospital as they were present in the majority (70 – 90%) of records. Regarding to completeness of documentation for items of operative/ procedure report, documentation of the name of procedure and complete documentation of operative personnel were highest in Kafr El-Sheikh General Hospital checked records (85.5,13.3%) respectively. The time start and end of surgery were not documented in all records of El-Mahalla El- Kubra General Hospital. Regarding to anesthesia /sedation report; documentation of patient physiological status, medication administration, dose of medication administered and time of administration were statistically highest in El Obor Health Insurance Hospital. The condition of the patient at the end of anesthesia was not present in all records of El-Mahalla El-Kubra General Hospital. All checked medical record forms were in the same size with a descriptive title of the name of the form and with no entries in pencil in the three studied hospitals. All checked record forms in El-Mahalla El-Kubra General Hospital had not a standard format at the top for patient’s name and medical record number. Regarding to general design characteristics of medical record filing area in the MRD of the three studied hospitals, filling bays and shelves were not labeled with the numbers of files stored in them in El-Mahalla El-Kubra General Hospital. All employee in admission and statistic section of El Obor Health Insurance Hospital had previous training courses. Half of employee in archiving section of El-Mahalla El-Kubra General Hospital had previous training courses on medical records management. There was not a coding section in the MRD of the three studied hospitals. All examined records were misfiled (improperly ordered records) in the three studied hospitals. Approximately one third of the checked folders in El Obor Health Insurance Hospital were with projecting pages out. Illegible names & numbers on folders were reported in less than 10% in the three studied hospitals.