University of Basrah
  • Register
  • Login
  • العربیة

The Medical Journal of Basrah University

Notice

As part of Open Journals’ initiatives, we create website for scholarly open access journals. If you are responsible for this journal and would like to know more about how to use the editorial system, please visit our website at https://ejournalplus.com or
send us an email to info@ejournalplus.com

We will contact you soon

  1. Home
  2. Volume 36, Issue 2
  3. Authors

Current Issue

By Issue

By Subject

Keyword Index

Author Index

Indexing Databases XML

About Journal

Aims and Scope

Editorial Board

Advisory Board

Facts and Figures

Publication Ethics

Indexing and Abstracting

Related Links

Peer Review Process

News

Assessment of the documentation completeness level of the medical records in Basrah General Hospital

    Riyadh A. Al Hilfi Rajaa A. Mahmoud Nihad . Q Al-Hamadi Atared Majeed Shabeeb A. Saihoud

The Medical Journal of Basrah University, 2018, Volume 36, Issue 2, Pages 50-59
10.33762/mjbu.2018.159461

  • Show Article
  • Download
  • Cite
  • Statistics
  • Share

Abstract

Background: Medical records documentation is an important legal and professional requirement for all health professionals. They include information which describes all aspects of patient's care. But, despite the importance of medical records to support better quality service provided at the health facilities, incomplete documentation is very common all over the world.
Objective of the study: to assess the documentation completeness level of the medical records in the different inpatient wards of Basrah General Hospital.
Methodology: The study was a descriptive cross-sectional one. Medical records of 268 inpatients from Basrah General Hospital during June 2016 were included from four departments of the hospital (medicine, surgery, pediatrics and obstetrics and gynecology). A standard Iraqi Ministry of Health inpatient medical record with a two-level scoring system for assessing the level of documentation completeness were used in the study.
Results: the overall documentation level for the medical records included in the study was generally poor in 78% of the records. Surgical department was found to be the worse in documenting patient's notes related to medical history, while Gynecology and Obstetrics department was found to be the worst in documenting the medical examination assessment and the physician's notes related to the patient's state and details of any improvement / deterioration of his/her condition.
Conclusions and recommendations: The present study confirmed obvious incompleteness of documenting medical data for inpatient records in Basrah General Hospital especially in the general surgery, internal medicine and Gynecology and Obstetrics words. This is specifically found for the Physician notes (patient’s state and details of any improvement/deterioration of the condition) and the Clinical pharmaceutical sheet. A hospital based quality improvement project to improve the medical record documentation completion is highly recommended to be implemented by the Quality Assurance Unit of Basrah Directorate of Health.
.
Keywords:
    Medical records inpatients documentation Basrah
  • PDF
  • XML
(2018). Assessment of the documentation completeness level of the medical records in Basrah General Hospital. The Medical Journal of Basrah University, 36(2), 50-59. doi: 10.33762/mjbu.2018.159461
Riyadh A. Al Hilfi; Rajaa A. Mahmoud; Nihad . Q Al-Hamadi; Atared Majeed; Shabeeb A. Saihoud. "Assessment of the documentation completeness level of the medical records in Basrah General Hospital". The Medical Journal of Basrah University, 36, 2, 2018, 50-59. doi: 10.33762/mjbu.2018.159461
(2018). 'Assessment of the documentation completeness level of the medical records in Basrah General Hospital', The Medical Journal of Basrah University, 36(2), pp. 50-59. doi: 10.33762/mjbu.2018.159461
Assessment of the documentation completeness level of the medical records in Basrah General Hospital. The Medical Journal of Basrah University, 2018; 36(2): 50-59. doi: 10.33762/mjbu.2018.159461
  • RIS
  • EndNote
  • BibTeX
  • APA
  • MLA
  • Harvard
  • Vancouver
  • Article View: 462
  • PDF Download: 464
  • LinkedIn
  • Twitter
  • Facebook
  • Google
  • Telegram
  • Home
  • Glossary
  • News
  • Aims and Scope
  • Privacy Policy
  • Sitemap

 

 
This journal is licensed under a Creative Commons Attribution 4.0 International (CC-BY 4.0)

Powered by eJournalPlus