ArticleGlobal health action2020
Assessing completeness of patient medical records of surgical and obstetric patients in Northern Tanzania.
Article in Global health action, 2020. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 8 papers.
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Who cites it
8 citing papers in PubMed, 20 citations in OpenAlex.
- Completeness of Paper-Based Clinical Records as a Dimension of Clinical Record Quality in Selected Public Hospitals in Mpumalanga and Eastern Cape Provinces, South Africa.Medical sciences (Basel, Switzerland) · 2026Article
- Design and content of health facility routine data recording and reporting forms for maternal, newborn, and child health: a scoping review of literature.JAMIA open · 2026Review
- Introducing a standardised register for strengthening the inpatient management of newborns and sick children: Implementation research in selected health facilities of Bangladesh.Journal of global health · 2024Article
- Data completeness and consistency in individual medical records of institutional births: retrospective crossectional study from Northwest Ethiopia, 2022.BMC health services research · 2023Article
- Receiving antenatal care via mobile clinic: Lived experiences of Jordanian mothers.International journal of nursing sciences · 2023Article
- Assessment of perioperative anesthesia record sheet completeness: A multi-center observational study.Annals of medicine and surgery (2012) · 2022Article
- Surgical service monitoring and quality control systems at district hospitals in Malawi, Tanzania and Zambia: a mixed-methods study.BMJ quality & safety · 2021Article
- Outcomes of a multicomponent safe surgery intervention in Tanzania's Lake Zone: a prospective, longitudinal study.International journal for quality in health care : journal of the International Society for Quality in Health Care · 2021Article
Corrections and comments
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Authors and funding
9 authors at 3 institutions in 2 countries.
Funding
Abstract
backgroundStrengthening surgical services in resource-constrained settings is contingent on using high-quality data to inform decision making at clinical, facility, and policy levels. However, the evidence is sparse on gaps in paper-based medical record quality for surgical and obstetric patients in low-resource settings.
objectiveWe aim to examine surgical and obstetric patient medical record data quality in health facilities as part of a surgical system strengthening initiative in northern Tanzania.
methodsTo measure the incidence of Surgical Site Infections (SSIs), sepsis and maternal sepsis surgical and obstetric inpatients were followed prospectively, over three months in ten primary, district, and regional health facilities in northern Tanzania. Between April 22nd to May 1st, 2018, we retrospectively reviewed paper-based medical records of surgical and obstetric patients diagnosed with SSIs, post-operative sepsis, and maternal sepsis in the three-month follow-up period. A data quality assessment tool with18 data elements related to documentation of SSIs and sepsis diagnosis, their respective symptoms and vital signs, inpatient daily monitoring indicators, and demographic information was developed and used to assess the completeness of patient medical records.
resultsAmong the 157 patients diagnosed with SSI and sepsis, we found and reviewed 68% of all medical records. Among records reviewed, approximately one third (34%) and one quarter (23%) included documentation of SSI and sepsis diagnoses, respectively. 6% of reviewed records included documentation of all SSI and sepsis diagnoses, symptoms and vital signs, inpatient daily monitoring indicators, and demographic data.
conclusionsStrengthening data quality and record-keeping is essential for surgical team communication, continuity of care, and patient safety, especially in low resource settings where paper-based records are the primary means of data collection. High-quality primary health information provides facilities with actionable data for improving surgical and obstetric care quality at the facility level.
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