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Abstract
Background Appropriately documented medical records enhance coordination, patient outcomes and clinical research.
Objective The aim of this project was to improve Wallaga University Referral Hospital’s (WURH) medical record completeness rate from 53% to 80% from 1 January 2023 to 31 August 2023.
Methods A hospital-based interventional study was conducted at WURH. The Plan-Do-Study-Act cycle was used to test change ideas. A fishbone diagram and a driver diagram were used to identify root causes and address them. Key interventions consisted of supportive supervision, developing and distributing standardised formats, orientation for staff, establishing a chart audit team and assigning data owners.
Result On the completion of the project, the overall implementation of inpatient medical record completeness increased from 53% to 82%. This improvement varies from department-to-department. It increased from 51% to 79%, 53% to 79%, 46% to 81% and 64% to 91% in the departments of internal medicine, paediatrics, obstetrics and gynaecology and surgery, respectively. The project brought improvements in the completeness of physician notes (84% to 100%), physician order sheet (54% to 84%), nursing care plan (26% to 69%), admission sheet (76% to 98%), discharge summary (94% to 98%), progress note (38% to 91%), medication administration (80% to 100%), appropriate attachment of documents (78% to 93%) and documentation of vital signs (50% to 100%).
Conclusion and recommendation The rate of medical record completeness was significantly improved in the study area. This was achieved through the application of multidimensional change ideas related to health professionals, supplies, health management information systems and leadership. However, in some of the parameters, the national targets were not met. Therefore, we recommend providing regular technical updates, conducting frequent chart audits and providing supportive supervision for the enhancement of medical record completeness. It is also advisable for the hospital management to work on its sustainability.
- Quality improvement
- Healthcare quality improvement
- Outcome Assessment, Health Care
- Medical Record Linkage
Data availability statement
Data are available upon reasonable request. The data sets used and analysed during the current study are available from the corresponding author on formal request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Quality improvement
- Healthcare quality improvement
- Outcome Assessment, Health Care
- Medical Record Linkage
WHAT IS ALREADY KNOWN ON THIS TOPIC
Major challenges resulting from incomplete medical records have a negative effect on the standard of healthcare delivery, particularly among contexts with low health literacy.
WHAT THIS STUDY ADDS
Cost-effective and setting-friendly multidimensional change ideas can significantly increase the completeness of inpatient medical records, thereby boosting the standard of care.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This project highlights the positive impacts of cost-effective and setting-friendly change ideas in improving medical record completeness in resource-limited settings.
Introduction
A well-functioning medical records system is essential to improving the provision of high-calibre medical care. It increases patient satisfaction with their medical interactions and provides safety and a good patient experience. Furthermore; it is beneficial for research, healthcare planning, evidence-based decision-making and medico-legal matters.1 2
One of a hospital’s performance matrixes is the completeness of medical records, which can include a variety of documents like admission notes, physician order notes, progress notes, referral notes, diagnostic sheets, medication and vital sign sheets and discharge summaries. Maintaining comprehensive patient data and enabling efficient healthcare delivery depends on the accuracy of these medical records.1–3
According to Ethiopian Comprehensive Specialized Hospital requirements, the hospital shall maintain individual medical records in a manner to ensure accuracy and easy retrieval.4 Additionally, the Ethiopian Hospital Alliance for Quality fourth cycle strongly recommends the completeness of the medical record before returning to the medical record room.5 Hospitals and other health facilities have implemented a variety of measures to enhance the completeness of medical records.6–8 In a similar vein, Wallaga University Referral Hospital (WURH) tried to boost the completeness of medical records. However, due to concerns involving health professionals, supplies and leadership, there is still a worrying degree of completeness in medical records. The Hospital Quality Improvement Team’s baseline survey on medical record completeness also revealed a low rate.
Methods and materials
Study setting and period
This quality improvement project on medical record completeness is conducted at WURH from 1 January 2023 to 31 August 2023. WURH is a teaching referral hospital in western Ethiopia. It is located in Nekemte town. The mission of the hospital is the provision of comprehensive medical care, health science training and problem-solving research and interventions. It has a well-organised multidisciplinary c comprising physicians, nurses, pharmacists, laboratory technologists, anaesthetists and midwifery professionals.
This project was conducted by a multidisciplinary team (MDT) from the quality improvement unit, school of medicine, nursing and midwifery departments. The team consists of three senior physicians (two obstetrician and gynaecologists and one general surgeon), and six other professionals (two nurse specialists, three public health specialists and one midwifery professional). This project was led by the clinical quality coordinator.
Study design
A hospital-based multidimensional interventional study was conducted.
Data collection and analysis
Based on a high inpatient load, four departments (internal medicine, paediatrics, surgery and obstetrics and gynaecology (OBGYN)) were purposely selected. During each Plan-Do-Study-Act (PDSA) cycle, 55 medical records of admitted patients in that cycle were randomly selected from the central medical record room. Then, the medical records were reviewed for completeness of 10 selected parameters. Data were collected by three trained data collectors using a medical record review checklist prepared based on Ethiopian Hospital Services Transformation Guidelines.1 The collected data were checked for completeness. It was then imported into an Excel database. The summary page received the computed and relevant outcome measures. The results were displayed on a run chart. We evaluate if an enhanced level of performance has been attained and is being maintained after each PDSA cycle. In addition, supportive supervision was conducted by the quality and project team. The total sample size at the completion of the project was 55×7=385.
Operational definition
Medical record
They are papers that document the care and treatment a patient received.
Completeness of medical record
It is the presence of all the necessary information of patients based on the standard formats and all entries are dated and signed.
Inpatient medical record
It is the official record of a patient that contains information on admitted patients to the general ward.
Baseline data
Prior to the implementation of the project, a total of 55 charts were retrieved from the medical record room for the baseline assessment. Accordingly, the baseline data were:
Surgery department=64%.
Paediatric department=53%.
Internal medicine department=51%.
Obstetric and gynaecological departments=46%.
The overall rate of medical record completeness at the project site=53%.
Measurement
Outcome measurement
Proportion of inpatient medical record completeness at WURH.
Process measures
Proportion of internal supportive supervision conduced.
Proportion of empowered departments to assess, analyse their data and implement corrective actions.
Proportion of available stationery (fasteners, staplers and paper puncher) at each departmental level.
Proportion of standardised formats.
Proportional functional chart audit team.
Proportion of service unit heads who took orientation on inpatient medical record.
Proportion of data focal assigned.
Balancing measures
Frequent alerts, meetings and supervision led to increased workload, staff boring and exhausting.
Strategy to implement the project
The MDT analysed the root causes using a fishbone diagram (figure 1), plotted possible intervention packages and designed an implementation plan. A series of PDSA cycles were conducted. Data were collected and analysed. The target unit heads and care providers received feedback after the results were thoroughly interpreted.
Fishbone diagram to increase the rate of medical record completeness from 53% to 80% at Wallaga University Referral Hospital from 1 January 2023 to 31 August 2023. HMIS, Health Management Information System.
Root cause analysis
In this study, using a fishbone diagram, the root causes of the problem were identified. The identified causes were lack of internal supportive supervision, absence of departmental level data assessment and analysis, inadequate stationery materials and formats, no assigned chart audit team and data owners and inadequate orientation about medical record completeness for healthcare professionals (figure 1).
Interventions and change ideas
The following change ideas were targeted to increase the rate of medical record completeness from 53% to 80%. With the use of a prioritisation matrix, we focused on 7 specific change ideas among a pool of 13 potential change ideas. These proposed interventions and change ideas were:
Orientation of unit heads.
Empowering departments.
Ensure the availability of stationery materials.
Ensure the availability of essential formats and registries.
Assign a dedicated chart audit team.
Giving orientation to targeted healthcare providers.
Establishing data owners/focal persons at each service area.
Depending on the root causes identified (figure 1), four primary drivers, eight secondary drivers and seven change ideas were schemed to achieve a complete medical record (figure 2).
Driver diagram to increase the rate of medical record completeness from 53% to 80% at Wallaga University Referral Hospital from 1 January 2023 to 31 August 2023. HMIS, Health Management Information System.
PDSA cycle of the project
Seven PDSA cycles were completed over 28 weeks. In each cycle, an intervention was implemented and studied for 4 weeks. Further interventions were explored in subsequent PDSA cycles, along with reinforcement of the previous one.
PDSA cycle 1
In the first PDSA cycle (sample size=55), the plan was to give orientation about medical record completeness for the unit heads. Accordingly, the project team presented baseline assessment findings for the department heads and created awareness about medical record completeness. This session was concluded with an agreement to improve medical record completeness. After a month, we did an assessment which showed the rate of medical record completeness to be 59%.
PDSA cycle 2
In this cycle (sample=55), we empowered the unit heads to assess and analyse the status of medical record completeness and take corrective actions. After a month, the project team conducted supportive supervision which showed medical record completeness rose to 63%.
PDSA cycle 3
In this cycle (sample size=55), the project team planned to avail different stationery materials at service points. Accordingly, we discussed with the Health Management Information System (HMIS) unit and agreed to avail the stationery materials per the respective unit demands. The unit leaders were also informed to take these materials from the HMIS unit. At the end of this cycle, the medical record completeness was found to be 65%.
PDSA cycle 4
In this cycle (sample size=55), we reinforced all previous interventions. The project team has developed essential formats. We showed these formats to unit heads and encouraged them to use them. This improves the rate of medical record completeness to 72%.
PDSA cycle 5
Given the previous PDSA cycle results (sample size=55), the project team communicated with the chief clinical director of the hospital to establish a chart audit team. Accordingly, this team was established. The team conducted audits with feedback from unit heads. This cycle resulted in medical record completeness of 75%.
PDSA cycle 6
In the last PDSA cycle (sample size=55), we reinforced all previous interventions and planned to give update orientation on how to use formats for front-line staff and unit heads. This raised the rate of medical record completeness to 79%.
PDSA cycle 7
In the last PDSA cycle (sample size=55), the project team communicated to the unit heads to assign a focal person who follows medical record completeness. Accordingly, the focal persons were assigned. At the end of this cycle, the rate of medical record completeness rose to 82%.
Results
Up on completion of the project, medical record completeness at the inpatient department of WURH was improved from 53% to 82% (figure 3). There were improvements in the completeness of different records like physician notes (84% to 100%), order sheet (54% to 84%), nursing care plan (26% to 69%), medication administration record (80% to 100%), admission sheet (76% to 98%), discharge summary (94% to 98%), progress note (38% to 91%), proper document attachment (78% to 93%) and vital sign record (50% to 100%) (figure 4).
Run chart showing the rate of medical record completeness at Wallaga University Referral Hospital from 1 January 2023 to 31 August 2023. MRC, medical record completeness.
Rate of medical record completeness for each criterion at Wallaga University Referral Hospital from 1 January 2023 to 31 August 2023. MRC, medical record completeness.
Department of internal medicine, surgery, paediatrics and OBGYN also showed improvement in medical record completeness from 51% to 79%, 53% to 79%, 64% to 91 and 46% to 81%, respectively (figure 5).
Departmental level medical record completeness at Wallaga University Referral Hospital from 1 January 2023 to 31 August 2023. IPD, inpatient department; OBGYN, obstetrics and gynaecology; QIP, quality improvement project.
Discussions
Ethiopian medical documentation culture is not ideal. The health workers’ attitude towards medical documentation, time constraints, inadequate knowledge and lack of training could all be contributing factors.9 10 These elements have been the main focus of the ongoing quality enhancement initiative.
The effort resulted in a notable improvement in the completeness of inpatient medical records. Other interventional studies carried out at Dalefage Primary Hospital,11 Menelik II Referral Hospital8 and Saint Paul’s Hospital Millennium Medical College7 are comparable to it. However, in our situation, the difference is more noticeable. This is primarily because, in contrast to other research, this particular study had periodic supportive monitoring. The overall success rate for inpatient medical record completeness in this project is encouraging. However, a lack of formats, a knowledge gap, provider commitment and leadership commitment need attention. The accuracy of inpatient medical records should therefore be a priority for the unit leaders.
The national target in inpatient medical record completeness was met in physician notes, medication administration and all five vital signs. It was nearly met for the discharge summary and admission sheet. This is better when compared with other studies conducted in Ethiopia.7 8 11
The nursing care plan’s completeness was lower than the national target and other indicators, despite the fact that it showed a considerable change. However, this is still better than the results from Iraq (46.3%)6 and Menelik II Referral Hospital (56.8%).8 The hospital’s nursing council must so concentrate on making sure that nursing care plans are complete.
The study’s four departments showed a notable improvement in the completeness of inpatient medical records as a result of the project. However, further work is still required to reach the national goal.
Limitations
In this project, clinical pharmacy notes were not included during the implementation phase of the project. This is because the hospital has yet to assign clinical pharmacy professionals. However, all other prerequisites were met in order to begin clinical pharmaceutical services.
Conclusion and recommendation
The rate of medical record completeness was significantly improved in the study area. This was achieved through the application of multidimensional change ideas related to health professionals, supplies, health management information systems and leadership. However, in some of the parameters, the national targets were not met. Therefore, we recommend providing regular technical updates, conducting frequent chart audits and supportive supervision for the enhancement of medical record completeness. It is also advisable for the hospital management to work on its sustainability.
Data availability statement
Data are available upon reasonable request. The data sets used and analysed during the current study are available from the corresponding author on formal request.
Ethics statements
Patient consent for publication
Acknowledgments
We are very grateful to Wollega University Referral Hospital for the facilitation of the necessary quality improvement project processes including the support letter.
Footnotes
Contributors GB, LG, KB, ND, MA, HD, MT, AT and TT were involved in Conceptualisation, Data curation, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Formal analysis, Software, Writing—original draft and Writing—review and editing. All authors prepared figures 1–3. All authors reviewed the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.