الفهرس 
Primary Health CareOnly 14 pages are availabe for public view
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Abstract
Background: Improving medical record completeness services is an important step towards improving the quality of healthcare. The medical record has become an important legal document. Many studies have been carried out to assess the completeness of family health records; but this data must be checked regarding its accuracy. The current study will determine to what extent the recorded data represent the true situation by interviewing the patients at the selected family health center. The current study will focus on family forms specific for the most prevalent chronic diseases among adults in Egypt Hypertensive and Diabetic patients as evidenced by the latest Demographic and Health Survey, 2017.
Aim of the Study: To measure the completeness and accuracy of the family health record forms specific for diabetic and hypertensive patient and to identify main causes of record incompleteness, Barriers and difficulties facing health care providers during recording.
Design: Descriptive Cross-sectional study
Patients & Methods: Convenient sample of Hypertensive & Diabetic Patients whose files were functioning and active, were included in the study sample, and Health care providers included in diabetic or hypertensive patient flowchart* (e.g. 6 Family doctor - Nurse– auditing person). The study was conducted at an accredited center (Meet Okba family health center, Giza Governorate Feb, 2019). Three Study Tools were used; first one for checking the Completeness of Family Records through medical record assessment checklist, second one for checking the accuracy of Family Records through Interview questionnaire to Hypertensive and Diabetic Patients whose fully functioning files (200 files) were selected to be included in the study sample the third was Focus group discussion with health care providers included in diabetic or hypertensive patient flowchart with Deductive approach used.
Results: This study found that Regarding completeness; 76%, 57%, 34% and 2.3% of the personal data form, investigation form, clinical exam form and referral form sheets respectively showed completeness more than 90% (according to standard scoring level). Regarding accuracy; inaccurate results were found as (90%, 73, 5%, 67, 5% and 63.4%) of the personal data form, investigation form , clinical exam form, referral form sheets respectively.
Conclusion: To improve the quality of Medical Record we need regular auditing, training and good orientation of medical personnel for accurate record practices.