Evidence map›Paper›PMID 38458759›Full record

ArticleBMJ open quality2024

Improving medical record completeness at Wallaga University Referral Hospital: a multidimensional quality improvement project.

Gedefa Bayisa, Lammii Gonfaa, Ketema Badasa, Nemomsa Dugasa, Mulugeta Abebe, Habtamu Deressa, Misganu Teshoma Regassa, Amsalu Takele, Temesgen Tilahun

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Article in BMJ open quality, 2024. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 7 papers.

0numbers the graph read from it
0cells of the map it votes in
7citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

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Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

7 citing papers in PubMed.

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4 · The record

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PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

9 authors.

Gedefa BayisaQuality Assurance, Nursing and Midwifery, Wallaga University Referral Hospital, Nekemte, Ethiopia.
Lammii GonfaaDepartment of Obstetrics and Gynecology, Wollega University Institute of Health Sciences, Nekemte, Ethiopia.ORCID 0000-0003-2345-4219
Ketema BadasaQuality Assurance, Nursing and Midwifery, Wallaga University Referral Hospital, Nekemte, Ethiopia.
Nemomsa DugasaQuality Assurance, Nursing and Midwifery, Wallaga University Referral Hospital, Nekemte, Ethiopia.
Mulugeta AbebeQuality Assurance, Nursing and Midwifery, Wallaga University Referral Hospital, Nekemte, Ethiopia.
Habtamu DeressaInpatient Nursing Service, Wallaga University Referral Hospital, Nekemte, Ethiopia.
Misganu Teshoma RegassaDepartment of Midwifery, Wollega University Institute of Health Sciences, Nekemte, Ethiopia.
Amsalu TakeleDepartment of Surgery, Wollega University Institute of Health Sciences, Nekemte, Ethiopia.
Temesgen TilahunDepartment of Obstetrics and Gynecology, Wollega University Institute of Health Sciences, Nekemte, Ethiopia ttamuko@yahoo.com.ORCID 0000-0003-4138-4066

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

backgroundAppropriately documented medical records enhance coordination, patient outcomes and clinical research.

objectiveThe 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.

methodsA 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.

resultOn 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.

Indexed as

Medical RecordsQuality ImprovementChildFemaleHospitals, UniversityHumansPregnancyReferral and ConsultationUniversitiesHealthcare quality improvementMedical Record LinkageOutcome Assessment, Health CareQuality improvement

Identifiers

PMID38458759
PMCPMC10928758

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.