Improving Outpatient Medical Record Completeness In Enchini Primary Hospital Oromia Ethiopia

Background: Medical records management is one of the components of health informationrnsystem that documents information related to a patient generated during patient-to-health carernprovider encounters at a health care facility. A well-managed medical records system is criticalrnto improve the provision of quality health care services to ensure safe medical practice, efficientrnand effective services and improve the patient’s experience and satisfaction with their medicalrnencounter.rnObjecti ve:-To i mprove outpati ent medi cal record compl etion from 37% to 90% inrnEnchini Hospit al at t he end of June 2019GC.rnMethods:A pre- post intervention design was used in this project to examine the completion raternof outpatient medical record. The pre-intervention assessment was conducted in the outpatientrndepartment of Enchini hospital. Base line data were collected between January and Marchrn2019. The baseline data showed the completeness of outpatient medical records was low. Onlyrn37% of the 50 audited patient folders were completed. A questionnaire was developed to assessrnknowledge gabs of all workers who were working at outpatient department such as nurses,rngeneral practitioners and medical record workers, whether supportive supervision wasrnconducted by senior management team and availability of printing formats and materials. Thernroot cause analysis was conducted to identify the root cause of the problem. Based on thernverification, lack of awareness about outpatient medical record completeness was identified as arnreal root cause and a two day’s staff training on medical record completeness was conducted.rnResults: the outpatient medical record completion rate increased from 37% pre intervention torn89% post-intervention. Specifically, Summary sheet of all visit dates practice and Internationalrndisease code practice were considerably improved by 90 and 80 percentage points respectively.rnConclusion: The result of this project suggests that a simple set of intervention providingrntraining on the awareness of medical record improves of outpatient medical recordrncompleteness.rnRecommendation: The hospital, the regional health bureau and FMoH need to give emphasisrnfor the completeness of outpatient medical records as it contribute to good quality of healthcare

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