ADDIS ABABA UNIVERSITY

COLLEGE OF HEALTH SCIENCES

SCHOOL OF PUBLIC HEALTH

COMPLETENESS OF INPATIENT MEDICAL RECORD IN ST.PAUL’S

HOSPITAL MILLENNIUM MEDICAL COLLEGE

ADISS ABABA, ETHIOPIA

BY: FitsumGetahun

ADVISERS:

Mr. GashayeAsrat (BSC, MPH)

DemekeAssefa MD, MPH)

A CAPSTONE PROJECT SUBMITTED TO THE SCHOOL OF GRADUATESTUDIES OF

ADDISABABA UNIVERSITY IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR
THE DEGREE MASTERS OF HOSPITAL AND HEALTH CARE ADMINISTRATION.

ADDIS ABABA, ETHIOPIA

OCT, 2018

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Declaration
This project report is my original Work and has not been submitted for any award of a Degree in
any other university, and all those materials used for the cap stone project has been duly
acknowledged

Student name Fitsum Getahun signature ……………….place Addis Ababa University Date of
submission OCT , 2018

This capstone project report has been evaluated under my approval as university examiner

Examines Name ………………………..Signature…………………..

Addis Ababa University date of submission ……………………………..

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 Table of content Page
Abbreviations ………………………………………………………………………………………………………I

Abstract ………………………………………………………………………………......................................... II

1. Organizational description …………………………………………………………………………………..1

2. Background ……………………………………………………………………….......................................... 2.

2.1. Introduction………………………………………………………………………………………… 3

2.2. Problem statement ………………………………………………………………………………… 3

2.3. Anticipated outcome ….....................................................................................................................3

2.4. Public health relevance……………………………………………………………….…..................3

3. Root cause analysis ……………………………………………………………………………………………4

3.1possible root causes …………………………………………………………………………………...4

3.2. Verification ….....................................................................................................................................5

3.3. Identify real root causes ........................................................................................................…...........5

4. Literature review ……………………………………………………………….……………………………..6

5. Objectives……………………………………………………………………………..............9

5.1. Genera objective……………………………………………………………………………................9

5.2. Specific objectives………………………………………………………………………………….....9

6. Methods ………….…………………………………………………………...........................10

6.1. Study area and period………………………………………………………………………………....... 10

6.2. Project design........................................................................................................................................... 10

6.3. Sample population …………………………………………………………………………………….. 10

6.4 study population …………………………………………………………………………………….......10

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 6.5. Sample size determination ……………………………………………………………………………..10

6.6. Sampling technique …............................................................................................................................11

6.7. Data management $ analysis …………………………………………………………………………... 11

6.8. Data quality management…………………………………………… …................................................11

6.9study variable……………………..……………........................................................................................11

6.9.1 Dependant variable ……………………………………………………………...........................11

6.9.2 Independent variable…................................................................................................................11

6.10 Ethical consideration…………………………………………………………………………………….11

6.11plane for dissemination……………………………………………………………………….................11

6.12 operational definition…………………………………………………………………………………...12

7. Develop alternative intervention……………………………………………………………………………13

7.1 Comparative analysis of alternative ……………………………………………………………………..13

7.2 select best intervention …………………………………………………………………………………………..14

7.3 implementation……………………………………………………………………………………………………15

8. Result ………………………………………………………………………………………...16

9. Discussion……………………………………………………………………………………..20

10 project strength ………………………………………………………………………………21

11. Project limitation…………………………………………………………………………………………….22

1.2 Conclusion…………………………………………………………………………………...23

13. Recommendation ……………………………………………………………………………24

14. References …………………………………………………………………………….........25

15. Appendix ………………………………………………………………….....................................26

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List of Table

1. Decision matrix use to select the best intervention among different alternative ……………..13

2. Medical record completeness in each department during pre intervention period …………...16

3. Medical record completeness in each department during post intervention period …………..17

4. Pre-post intervention evaluation ……………………………………………………………...18

List of Diagram
1. Fish bone diagram to display possible root causes of the problem suggested by stake
holders…………………………………………………………………………………………….4

2. Achievement in specific indicators in medical records completeness………………………...19

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 Acknowledgements
I would like to thank Mr. GashayeAsrat and Dr. Demekeassfea from Addis Ababa university
school of public health and for their devoted and sincere contribution in advising and transferring
their skills, knowledge and generously sharing their scarce time for the completion of this
capstone report. I would like to thank to Addis Ababa University to give us this chance to engage
in this program.

I wish to extend my appreciation to St. Paul’s Hospital Millennium Medical College SMT and
staffs for their active participation and putting their efforts during pre -post intervention Data
collection and implementation.

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Abbreviations

A.A-Addis Ababa

ART-Antiretroviral Therapy

ENT-Ear, Nose, Throat

HIV-Human Immune Deficiency virus

HPMI-Hospital Performance Monitoring Indicators

HMIS-Health Management Information System

ICU-Intensive Care Unit

IPD: -Inpatient Department

I.M.R.C:-Inpatient Medical Record Completeness

KPI-key performance Indicator

KCMC- Kilimanjaro Christian Medical Centre

MHA–Master of Health Care and Hospital Administration

MR-Medical Record

NHPMIM: - National Hospital Performance Monitoring and Improvement Manual

SPHMMC-ST .Paul’s Hospital Millennium Medical College

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Abstract

Medical record is an account compiled by physicians and other health professionals of a patient`s medical
history, present illness, findings on examination, details of treatment and progress notes and it is a legal
record of care. The maintenance of complete and accurate medical record is a fundamental duty of health
care providers. Complete medical record indicates the quality of patient care provided in the facility
.Many ethical and legal issues are implemented in their maintenance including third party access and
appropriate storage and disposal.

Objective: To improve the percentage of inpatient medical record completeness from46.48% to 80

%at the end of Jun 2018.
Methods:A pre- post intervention design was used in this project to examine the completion rate of
inpatient medical records. The pre-intervention assessment was conducted in the inpatient department of
SPHMMC .Base line data were collect in Feb 2018 .based on the baseline, the completeness of
inpatient medical records was low , .only 46.48% of the 202 audited patient folders was completed. After
base line assessment we conducted root cause analysis and identified the real root cause of the problem.
Based on the verification, lack of awareness about inpatient medical record completeness, clinical forms
not suitableto enter data, absence of monitoring and negligence were identified as a real root causes. We
conducted two interventions; one day staff training on importance of inpatient medical record
completeness and develop new clinical forms.
Results:the documentation completion rate significantly increased from 46.48%
pre-intervention to 78.6% post-intervention, the completeness of three out of the five
elements of medical records (physician note, physician order sheet and discharge summery) especially
significantly improved
Conclusion: The results of this project suggests that a simple set of intervention providing training on
the importance of inpatient medical record and availing suitable inpatient medical record forms improves
the inpatient medical record completeness.

Recommendation: Ongoing monitoring and accountability system should be implement , It is better if the
Health Management Information System Department takes special consideration on full implementation and proper
management of inpatient medical records, Intensive and continuous training should be given for the healthcare
provider by Health Management Information System Department. .

Key words: Medical records, Documentation completeness

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1. Organizational description

St Paul’s General Specialized Hospital was built in the year 1968 G.C, by the late Emperor
HaileSilassie with the help of the German Evangelical Church. At the time the hospital was
established mainly to serve those economically under privileged population that providing
services free of charge up to 75% of its patients. Until 2010, it used to be called St. Paul General
Specialized hospital serving as a referral hospital in Addis Ababa under the Ethiopia Federal
Ministry of Health (FMOH). In 2007, it started a medical school and through a decree of the
council of ministers in 2010, it was established as a medical college and is currently named St
Paul Hospital Millennium Medical College. St. Paul’s hospital millennium medical college has
various professionals that included 479 physicians, 750 nurses, 1172 other clinical staff, and 898
administrative staff, making a total of 3362 staff. The hospital, is a 529 bed capacity hospital
and. The 2009 annual average outpatient department attendance was about 314, 687 annual
average admissions about 23,516 with an average length of stay of 5 days bed occupancy rate of
71.4%. SPHMMC provides health care through its different clinical departments which are
General surgery, Internal Medicine, Obstetrics and Gynecology, Pediatrics, Emergency,
Urology, Neurology, Orthopedics, Psychiatry, Ophthalmology, ENT, Dentistry and Maxillofacial
surgery, Radiology, Anesthesiology, , ART, (HIV care), Endoscopy, Physiotherapy, Laboratory
and pharmacy, kidney dialysis and kidney transplantation. Its core services the medical care
teaching & researches are still under the Federal Ministry of Health and governed by the board.
Vision: -To be a medical University with a most sought after medical center and a prestigious
academic and research center in Africa by 2025.G.C

Mission :-To contribute to the provision of quality and affordable, promotive, preventive,
curative, palliative and rehabilitative health care services; to train competent, compassionate
ethical health professionals using integrated and competency based medical education and to
perform need based research

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2. Back ground of the study
2.1 introductions

One of the major elements improving efficiency in the delivery of health care services is
improving completeness of medical record documentation. A well-managed medical record
system is critical to improve the provision of quality health services to ensure safe medical
practice efficient and effective services and improve the patient experience and satisfaction with
their medical encounter (1). Medical record completeness is a key performance indicator that is
related with delivery of health care services in the hospital. Complete and accurate medical
records are essential to maintain the continuity of patient care and ensure that the health provider
has full information about the patient when providing healthcare. The completeness of this
medical record is a measure of the quality of care provided at the hospital.(2) Government has
strong commitment to improve health care quality. Achievement of quality care service requires
addressing the problems that are associated with medical record incompleteness. the aim of this
project is to find practical solution for the problem related with inpatient medical record
incompleteness .in the inpatient setting some of the important pieces of inpatient documentation
include history &physical, progress Notes, orders, procedure reports and discharge summery.
According to KPI standard only 5 medical documentations (clinical formats) are essential for
medical record completeness. The completeness of this medical record is defined as a proportion
of the five minimums elements of an inpatient medical record which are:-

 Patient care(physician notes) –all present and all entries signed

 Physician/health officer order sheet –all present and all entries signed
 Nursing care plan –present and signed
 Medication administration record –present and all medications given are signed.
 Discharge summary—present and signed.

These five items represent the minimum set of documents that should be present and signed in
the medical record of every discharged inpatient.

The percentage of completeness of 5 items was used in this study.(2)

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2.2. Statement of the problem

.High inpatient medical record incompleteness

Incomplete medical recording is one of a major observed challenges in hospital‘s medical record
management system. Incompleteness of medical records is a sign of significant problems that
affects the quality of health care. quality health care data play a vital role in the planning,
developments, the maintenance of health care service.(3) the most significant effects of
incomplete documentations of inpatient medical records are: - poor quality of care, inaccurate
reimbursement that results inaccurate gross revenue to the provider, impossibility of effective
operational management could be impeded, lack of legal protections, And also if documentation
is incomplete the effectiveness of research activities is significantly impeded. Inpatient medical
records in SPHMMC are frequently incomplete. Therefore, conducting the study on MR
completeness at inpatient department of SPHMMC is an important issue. Baseline assessments
were collected and inpatient medical record completeness showed 46.48% which is low against
the standard in which medical record completeness is expected to be 100%.medical record in
developing countries including Ethiopia are generally inadequately supported and poorly
managed(4)
2.3 Anticipated outcome

This project has a vital role to improve health care quality, patient and staff satisfaction by
increasing the percentage of inpatient medical record completeness from46.48% to80 %at the
end of Jun 2018 by implement beast intervention.

2.4Public health relevance

The public health relevance of this project is improving the provision of quality health care
services to ensure safe medical practice, efficient and effective services and improve the patient’s
experience and satisfaction as well as the public by improving completeness of inpatient medical
record

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3.ROOT CAUSE ANALYSIS
poor medical records completeness in SPHMMC is caused due to different factors that can be
generally classified in four thematic factors: - people, process/policy, equipment and
environment

 Method used to identify the root causes

Discussion with different concerned parties like medical service vice provost, inpatient
directors, doctors and nurses who were working in different wards, matron & selected staffs

.3.1 possible root causes

 Nurses Work load because of shortage of human power

 Lack of awareness about inpatient medical record completeness due to lack of training
 Negligence because of lack of accountability and lack of awareness to the importance ofaccurate
clinical documentation.
 Clinical forms are not suitable specially nursing care plan and medication administration sheet :
 Lack of rooms for paper work because of shortage of space
 Absence of monitoring system because there were no assigned personnel’s

Environment people

Lack of rooms for paper work Nurse’s workload

Negligence

Lack of awareness about inpatient medical record completeness

Inpatient MR Completeness

Forms not suitable to enter the necessary data

Absence of monitoring

Policy Equipment

Figure3.1 fish bone diagram (problem; high inpatient medical record incompleteness) Fish
bone diagram dose not tell the real cause of the problem it is just display the possible root cause
recommended by stake holders so, it needs further analysis

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Therefore, discussions were conducted with key stakeholders atSPHMMC, according to which: Data were
collected through interview, focus group discussion, and showed the standards in order to verify the root
causes that are suggested by concerned parties

3.2 Verification

1. Nurses work Load: This was suggested as a root cause of the problem by nurses who are
working in different wards but, this cause is excluded from real cause of the problem because,St.
Paul’s hospital millennium medical collage nurses bed side ratio is based on national standard
which is for ICU 1:1, for labor ward2:1 for other wards 1:6 which are also recommended by
WHO for developing countries.
2. Lack of awareness: this is proved to be a real root cause of the problem because Training has
never been given to the staffs who were working in any of the wards at all, related to in patient
medical record completeness, medical record as a hospital reform and medical record as key
performance indicator.
3. Absence of monitoring: this is proved to be real cause of the problem because there were no any
assigned personnel who should check whether each of the components of inpatient medical
record is completed and take proper measure at the spot if any problem occurs.
4. Clinical formats are not suitable to enter all the necessary data: this is proved to be real
cause of poor inpatient medical record completeness, especially medication administration sheet
and nursing care plan forms as I observed and compared it with the standard forms developed by
FMOH.
5. Lack of rooms which are suitable to perform paper work: this is excluded from real cause
because, there wereenough rooms and spaces in each ward with necessary tables and chairs to
perform the recording task as I observed.
6. Negligence: this is proved to be a real cause of the problem because each inpatient department
staffs knows that the way they have been recording has never met the standard of inpatient
medical recordaccording to the surveys carried out in the hospital every three months, but there
were nothing done to change and to complete .
3.3 After verification these are identifiedas real root causes
 Absence of monitoring
 Clinical forms not suitable to enter to all the necessary data.
 Lack of awareness about inpatient medical record completeness, medical record completeness as
key performance indicator and hospital reform
 Negligence ( fail to take necessary care to complete the data according to the standard )

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 4 .Literature review

Medical record is an account compiled by physicians and other health professionals of a patient`s
medical history, present illness, findings on examination, details of treatment and progress notes
and it is a legal record of care. Primary records are the original records established to document
the continuation of care given to a beneficiary and three categories for primary records health
record, out patient record and inpatient record (4)

A patient’s medical record provides two important functions. The first is, it helps to support
direct patient care by acting as an aide memoir for individual doctors by supporting clinical
decision-making and providing an important means of communication. The second is, it provides
a legal record of care given and acts as a source of data to support clinical audit, research,
resource allocation, performance monitoring, epidemiology, and service planning (5) It is
important to note at this time that accurate, timely and accessible health care data plays a vital
role in the planning, development and maintenance of health care services. The quality of data in
the medical record and its availability is essential if health care authorities wish to maintain
health care at optimal level.
The main uses of the medical record are:
• to document the course of the patient's illness and treatment;
• to communicate between attending doctors and other health care professionals providing
care to the patient;
• for the continuing care of the patient;
• for research of specific diseases and treatment; and
• the collection of health statistics (6)

For example: -
KCMC Hospital is a tertiary referral center for northern Tanzania. It is a large teaching hospital
which serves a population of around 11 million. According to the hospital annual report
published in 2014 the top disease for the orthopedic department was 'Fracture of femur' with 271
cases. The top killer disease was ‘Cervical injuries’. There were a total of 1415 admissions from
January 2014 to December 2014. A total of 1102 procedures were documented and the most
common procedure documented was ‘Surgical toilet'. All of this information was taken from a

6
combination of hospital patient records and the in-house orthopedic inpatient record books. (7)
Pre- and post-intervention study was conducted at inpatient departments of Menelik II Referral
Hospital. During pre-intervention time, inpatient physician note 96%, physician order sheet, 96%
nursing care plan 70%, medication administration sheet 40%, and discharge summary 64% total
73% after simple set of intervention availing inpatient medical record format and training health
care provider improves the inpatient medical record completeness from the base line 73% to84%
during post intervention. This project indicates that applying strategic problem solving to
medical record completeness can be effective in improving quality of healthcare. (8)

Pre and post intervention study was conducted at inpatient department of Dalefage district
hospital the result of base line assessment of inpatient medical record completeness was 0% there
were different root causes that are contributed the problem that are:- There is no previous
practice, The IPD, staffs had lack of awareness on inpatient medical record completeness,. The
IPD did not have policy and procedure, Total absence of important formats in the department .a
simple interventions implemented such as: - Implement the KPI 18, Create awareness by
providing training Developed facility based guideline and procedure, Avail all important
formats. after these simple intervention the completeness of inpatient medical record
significantly improve from the base line 0% to 73.6% (9)

A retrospective study was carried out to assess the documentation of 780 paper based health
record of inpatients discharged in 2009 at a Nigerian tertiary hospital the conclusion of the study
showed there were inadequacies in clinical documentation especially gross underutilization of
discharge summary forms .the finding of the study shows that the hospital health care providers
possess the necessary skills for quality clinical documentation but lack the will. There is a need
to institute clinical documentation improvement program and promote quality clinical
documentation among staff.(3)

Pre-post interventional study was conducted to Improving Patient Medical Record Organization
in a Hospital Intensive Care Unit in Rwanda by conducted root cause analysis and by
implementing best intervention The overall time for physicians to locate clinical information
significantly decreased from 348 to 173 seconds (50%decrease, P=0.029). The overall time for
nurses to locate clinical information decreased by from 79 to 62seconds (22% decrease),

7
although the change was not statistically significant (P-value =0.195). The COHSAS
Accreditation scores for the medical records related standards increasedfrom47to

81(72%increase=0.026(10).
A retrospective review of 155 orthopedic inpatient notes at Kilimanjaro Christian Medical
Centre (KCMC) was conducted spanning 3 months. The study shows, Admission information
and Demographics were both completed 88% (n=137) of the time. History and the Examination
sections were complete in 96 %( n=149) of cases. Investigations were complete i 77 %( n=119)
and Diagnosis in88 %( n=137).The Treatment section was complete 85 %( n=132) of the time
and the Attending doctor 50% (n=78). Procedures were 27% (n=42) filled in while Summary of
a day and Follow-up were32% (n=49) and 0% (n=0) respectively. (7)

A prospective study conducted in Netherlands, patients admitted to the general internal medicine
ward of two acute care hospitals, shows that the medication history in the hospital medical record
is often incomplete, as 26% of the prescription drugs in use is not recorded and 67% of all
patients has one of more drugs that are either not registered in the hospital medical record or
registered but not in use (12)

) A cross-sectional study that involved interviewing patients and reviewing their clinical records
at medical admission ward, at UNIVERSITY TEACHING HOSPITAL , was conducted over a
period of 3monthsThis study shows that medication histories in clinical records of patients in
medical admission ward are poorly documented this means In this study, out of 287 medication
histories, 112 (39.1%) were accurate as no discrepancies were noted in medication name, dose,
route and frequency of administration but,61 % were un accurate as discrepancies were noted in
medication name ,dose, route and frequency of administration(13)

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5. Project Objectives

5.1 General Objective of the study

 To improve the percentage of inpatient medical record completeness from 46.48% to80
%at the end of Jun 2018.This figure determine based on similar studies reviewed and
based on the required time and resources.

5.2 Specific objectives of the study

 To improve staff awareness about inpatient medical record completeness at the end of
Jun2018.
 To vail100% new clinical forms at the end of Jun2018.

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6. Methods and Materials
6.1. Project area and period
The study was conduct at St. Paul’s Hospital Millennium Medical College found in capital city
of Ethiopia in Addis Ababa GuleleSub city Woreda9 kebele10/11/12.Thestudywas conduct from
Feb 2018 to Jun2018

6.2 Project design

A pre- post intervention design was used in this project to examine the completion rate of
inpatient medical records. The pre-intervention assessment was conducted in the inpatient
department of SPHMMC .,base line data were collect in Feb 2018 .based on the baseline, the
completeness of inpatient medical records was low .therefore ,an intervention was conducted to
improve the completeness.

6.3 source population

All inpatient medical records of patients treated and discharged from SPHMMC

6.4 study population

An individual folder of inpatients treated and discharged from NOV 2018to JAN 2018for pre
intervention and the month of May 2018 for post intervention.

6.5 sample size determination

The sample size of the survey medical records were taken from the HPMI manual which is 50
as minimum or 5% of the discharged patients medical records to be reviewed based on the
protocol to assess the completeness of inpatient medical records For the hospitals like SPHMMC
with high patient flow better to use 5% of the discharged patient’s medical record as a minimum
sample size. Based on the protocol reviewed 202 discharged patients medical record they were
discharged from medical, surgical, maxillofacial, gynecology and pediatric departments.
Duringpre-intervention time and 75 discharged patient record during post intervention. Using
standardizedprepared check list to assess the completeness among from those admitted and
discharged patients’ medical record
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6.6 Sampling technique

Simple random sampling technique was applied. After identifying the sample size randomly
select patients from the discharged list of all patients who were discharged from an inpatient
ward this information was obtained from Admission/Discharge. The Medical Records of these
patients were obtained from the Medical Records Department.

6.7Data management and analysis

Data collection instrument (check list) adapted from national hospital performance monitoring
and improvement manual survey protocol used by the hospital. After the appropriate number of
medical records has been reviewed collected all completed Medial Record Review and put
together for Processing and analyzedby SPSS (IBM statistic) and the result of inpatient medical
record completeness displays in percent by Table and Graph.

6.8 Data quality management

The data collection team was oriented on the checklist that use for data collection and the way to
collect data and the data quality was check during data collection process by assigned supervisor.

6.9 Study Variables

6.9.1 Dependent variable: the completeness of the five indicators.

6.9.2 Independent variables: availability of human resource, availability of necessary clinical
forms, staff willingness and commitment, staff awareness.

6.10. Ethical consideration

Written consent was obtained from the hospital administrative office to conduct study on
inpatient medical record completeness. Measures were taken to ensure strict confidentiality.
Clinical records were handling within the hospital premises and in line with hospital regulations.

6.11 Plan for dissemination

The findings of this study will be disseminated to local and external partners including
SPHMMC, A.A University and any other concerned bodies

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6.12Operational definition

6.12.1 Completeness of medical record: define as proportion of the five minimum elements
of an inpatient medical record

6.12.2:complete in patient medical records: are essential clinical formats used for inpatient
care which includes: patient card sheet, physician note, nursing care plan sheet, medication
administration sheet and discharge summary sheet

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 7. Develop Alternative intervention
1. Assign personnel’s to control completeness for each ward
2. Conducting onsite training
3. Develop clinical format(change the existing formats)

7.1 Comparative analysis of alternative

Alternative strategies are compared using the decision matrix tool as follows.

Decision Matrix Quantities

Evaluation criteria 5=very high; 4=high ;3=moderately high;1=low

Strategic alternative Impact Feasibility Cost Time Total

onsite training 5 5 4 5 19
develop new clinical forms 5 5 4 4 18
Assign personnel’s for each ward 5 3 4 3 15

 ONSITE TRANINIG

Impact; majority staff doesn’t know about what is medical record completeness, what are the
necessary clinical forms should present in all inpatient folder. So, training is needed to improve
their knowledge and skill, increase their performance and efficiency and also according to
EHIRG all employees need onsite training in every year he/she will do all activities required to
meet the standard.

FEASIBLITY ; this is feasible because the training was provided for the staff at their own
premises which did not require much time and money in addition ,the trainingwasgiven by local
staff which minimize time and financial costs rather than bringing trainer from outside.

COST;the cost of this intervention was low and could be afforded by the hospital as mentioned
above the training was given within the organization.
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TIME; this intervention needed aone daytraining for each group and was implemented withinthe
implementation period.

 Develop new clinical forms (modify the existing medication administration

and nursing care formats )

IMPACT; studies have shown the importance of convenient working materials make employee
work smooth and improve their work interest. And also the hospital has to use standard clinical
forms developed by FMOH

FEASIBLITY;this intervention is feasible because all member of the management team

supported the intervention and also there was pre prepared format which is standardize moreover
the hospital has its own printing enterprise thus it was cost effective and took less time.

COST; the cost of this intervention was low because of the reasons mentioned above.

Time; this intervention needed few weeks and could be implemented with the implementation
period.

 Assign personnel’s to monitor the work

Impact; assign personnel’s who are responsible to follow the completeness of each recordings of
nurses and physicians is important because if there is monitoring, employee’s negligence will
decrease and they will take it as there routine activity so as to increase their performance and
motivate to do their work .

Feasibility; it was require additional human resource who did not have another responsibility. in
order to have the required professional the organization needed budget. Assignment of the
required budget is the mandate of another government authority.

Cost; recruitment process required much time and cost.

Time; not possible to implement it within the implementation period.

7.2 Selected intervention (Best Intervention)

Based on the result of comparative analysis the best strategies were

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  Onsite training
 Modify medication administration sheet and nursing care plane formats.

7.3 Implementation

The following interventions implemented in the hospital:

 Onsite training:-Onsite training was given at April last, 2018 for Inpatient Healthcare
Worker (Physician andNurse)training given by local staff (health management
information system department staff) and training for physician and nursing staff consists
of the following topic
(i) Awareness and sensitization creation on the importance of medical records.
(ii) Medical record as part of hospital reform.
(iii) Medical record as part of hospital key performance
indicator for quality of care

During intervention implementation the main focus was to provide training for the selected
inpatient healthcare worker (physician and nurses) for 50 nurses and 20 physicians a totalof 70
health care providers for one day for each group on the above topic.

Avail New Medical Record Format: - all clinical contact should be documented in the
Medical Record using a hospital standardize medical record format. Samples of all Medical
Record Forms, including Investigation Order and Report Forms, Medication Administration
Record etc, are presented in Appendix B of Chapter 6MedicalRecords Management under
EHSTG volume1. So, the second implementation is changed existing clinical formats into the
national standard format. The overall implementation was lasted from April up to Jun 1 for two
months duration.

Indicators
Process indicator

 Number of physician and nurses trained.

 Availability of new clinical formats

Outcome indicator
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  % of inpatient medical record completed
 % of available new clinical formats

8. Results
The intervention showed a significant improvement in the completion of inpatient medical
records inSPHMMC. Providing onsite training and availing new clinical formats was the key
contributor to the success of this project. Before our intervention, nurses and physicians were not
aware about inpatient medical record completeness and the existing medication administration
and nursing care plan forms were not suitable to record all clinical history of the patients. During
the baseline assessment, we found that documentation elements under the responsibly of nurses
and physicians had the lowest completion rates. Therefore, designed the intervention with a
strong focus on nurses and physicians. As a result, nurses and physicians were showed strong
commitment for completing all clinical processes and documentations related to patients
assigned to their care; this directly led to the improvement in the completion rate of
documentation the success of the intervention was because of many factors. The intervention
was simple, effective and utilized resources that were available without generating additional
costs tothe hospital. By following the strategic problem-solving approach, we were able to focus
our efforts and resources on a problem that could be solved within our power. By identifying the
root causes using data and evidence systematicallywere able to create an intervention that was
relevant and effectivealigned with the hospital’s priorities. That embraced teamwork and team
spirit, which was not only good for the project but also good for the hospital. In generalan
enhancement of completeness and reporting of inpatient medical record completeness improved
significantly in each department.

Inpatient medical record completeness in each department during pre intervention

Clinical format medical Surgical Pediatric maxillofacial Gynecology TOTAL

Physician note 29.6% 50% 50% 53.85% 48% 43.8%
Physician order 64.3% 59% 37.5% 38.46% 48.7% 54.7%
Nursing care plan 24% 35.6% 37.5% 34.62% 32.5% 32.5%
Medication 31% 32.3% 0% 42.3% 19% 24.6%
administration
Discharge summery 74% 81.2% 75% 76% 69.3% 76%

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TOTAL 38.7 49.78 40 51.24 41.7 46.48%

Inpatient medical record completeness in each department during post intervention

Clinical format medical Surgical Pediatric maxillofacial Gynecolog TOTAL

y
Physician note 100% 100% 85.7% 100% 95% 96%
Physician order 85% 87% 92.9% 100% 80% 89%
Nursing care plan 14.3% 39.1% 64.3% 100% 65% 57.3%
Medication 42.9% 21.7% 35.7% 90.9% 75% 54.7
administration
Discharge summery 100% 100% 100% 100% 90% 96%

TOTAL 68.44 69.56 75.72% 98.18% 81% 78.6%

% %
The result of each department showed significant change especially maxillofacial, gynecology
and pediatric department, improve inpatient medical record completeness from 51.24% to
98.18% from41.7% to 81% and from 40% to75.72% respectively which are showed the
willingness and commitment of health care providers (nurses and physicians) were working in
the above departments. In the other hand medical and surgical departments showed low
improvement in related with the above departments specially nursing care plan sheet and
medication administration sheet this showed nurses were working in the above departments had
less commitment and they need close supervision .

Thebaseline 46.48% to 78.6% during post intervention evaluation the completeness of medical
records was assessed in terms of physician note, physician order sheet, nursing care plan,
medication administration sheet, and discharge summary. Accordingly, the total result showed
that physician note format was attached during pre-intervention for190 (94%)and completed for
89(43.8%) post intervention 73(97.3%) and completed for 72(96%),physician order sheet was
attached during pre-intervention for198(98%) and completed111(54.9%) post intervention 69
(92%) and completed for 67 (89.3%), nursing care plan was attached during pre-intervention for
160(79.2%) and completed 66(32.5%) post intervention 48 (64%)and completed for 43 (57.3%),
medication administration format was attached during pre-intervention for 193(95.5%) and
completed 50(24.6%) postintervention 48 (64%)and completed for 43 (57.3%), discharge
17
 summary was attached during pre-intervention for156(76.8%) and completed 156(76.8% )post
intervention 73(97.3%) and completed for 72 (96%) .There is prepared new clinical formats and
three of them were completed by physician (inpatient physician notes, physician order sheet, and
discharge summary) and two of them completed by nurses (nursing care plan and medication
administration sheet.

Pre and post intervention changes in medical records completeness

inSPHMMC.
Activities pre intervention Post intervention Variation

Inpatient Physician note 43.8% 96% 52.2%

Physician order 54.7% 89% 34.3%

Nursing care plan 32.5% 57.3% 24.8%
Medication administration 24.6% 54.7% 30.1%
record
Discharge summery 76.8% 96% 19.2%
Total 46.48% 78.6% 32.12%

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Figure 2; Show the achievement in specific indicators in medical records
completeness in SPHMMC.
pre intervantion post intervantion

96%

96%
89%

76.80%
57.30%
54.80%

54.70%
43.80%

32.50%

24.60%

PHYSICIAN NOTE PHYSICIAN ORDER NURSING CARE PLAN MEDICATION DISCHARGE SUMMERY
SHEET ADMINSTRATION

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9. Discussion

This study showed that the inpatient physician note had high rate of completeness as 96% in
SPHMMC whereas, the study conducted in Menelik II Referral Hospital the post intervention
change of inpatient physician note was 92%(8) so, the study in SPHMMC shows higher rate of
inpatient physician note completed. The same study in SPHMMC showed the discharge
summary completed as 96 % whereas the study in Dalefage Hospital, on the other hand showed
the discharge summary completed as 74 %.(9) And another study conducted in Menelik II
Hospital (8) showed discharge summary were completed as 87 %.Aspects of physician order in
this study 85 % of inpatient medical record is completed whereas, the study done in Dalefage
Hospital the post intervention change showed the physician order completed 84% Still the study
in our hospital showed higher rate of completeness than the study in the two hospitals. Whereas
the higher rate of non- completeness seen in inpatient medication administration record and
nursing care plan record 55% and 65 % only completed respectively compared with the study
conducted Menelik II Hospital showed medication administration record and nursing care plan
were completed 76.6 % and 70.3% respectively .And also study conducted muniniHospital a
district hospital in the Southern Province ofRwanda medication administration record and
nursing care plan record were completed(4) 87% and 81% respectively. Even though, the result
showed higher completeness than the study conducted Dalefage hospital medication
administration was completed 20%,in line with this, in our study there is also significant
improvement in inpatient medical record completeness which implies giving due attention
tomedical records and applying simple set of intervention can bring changes .(9)The study done
in Dalefage Primary Hospital, West Afar,Ethiopia, shows that an enhancement of completeness
and reporting of inpatient medical record completeness improved significantly from the baseline
0% to 73.6% during post intervention evaluation. Similar to Menelik II Hospital after
introduction of simple intervention inpatient medical record completeness improves from the
baseline 73% to 84% during post intervention evaluation this implies that, by implementing a set
of intervention, it can bring improvement in completeness of medical records

20
10. Project strengths

Without the support from hospital leadership, the project would not have been successful.
Gained the support from the hospital senior management team at the early stages when presented
baseline assessment results. Staff participation was also very interesting. They were involved in
the root cause analysis all the way through implementation and evaluation. The project also
created opportunity for the staff to gain knowledge and develop new skills. The staff learned
about the strategic problem-solving approach, by building their capacity. This project also
enabled them to initiate new quality improvement projects in the future. The utilization of pre-
determined standardized sample size and data collection tools avoids the problem related to
sample and content of the study. The study was simple and cost effective not requires
sophisticated technology and specialized personnel.

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11. Limitations of the project
Although the results showed positive changes, encountered several challenges during the
implementation process Members of the management team was busy; finding time in their busy
schedule was a constant challenge. Despite the improvement in medical records completeness,
the project has some limitations. The sustainability of the project will depend on a long-term
follow-up. The post-evaluation period was relatively short. A longer evaluation period is
necessary to ensure the change detected was not an isolated incident. Additionally, our
intervention only focused on some real root causes of the problem because of lack of resource
and time.

22
12. Conclusion
The overall inpatient medical record completeness in SPHMMC was 78.6% and the higher rate
of completeness was seen in discharge summery sheet and physician note both were
96%completed whereas the least completed was inpatient medication administration sheet 54.7
% completed. The finding of this project suggests that a simple set of intervention availing
appropriate inpatient medical record format and training healthcare provider improves the
inpatient medical record completeness. The project conducted inpatient medical record has the
potential to directly influence and improve clinical practice in this Hospital. Recommendations
have been made to improve future record keeping. However it will only be once a
cultureincreased priority of record keeping develops that changes will be fully appreciated. It is
also vital that monitor and provide regular training to the professionals in order to sustain the
change. This project indicates that applying strategic problem solving to medical record
completeness can be effective in improving quality of healthcare.

23
13. Recommendation
This project was conducted to improve the inpatient medical record completeness in the
SPHMMC. By applying the strategic problem-solving approach, implemented a cost effective
intervention that successfully improved the documentation completion rate without additional
financial cost to the hospital. Ongoing monitoring and accountability system should be
implement, The hospital should adopt the use of strategic problem solving approach in other
quality improvement projects, It is better if the Health Management Information System
Department takes special consideration on full implementation and proper management of
inpatient medical records, Intensive and continuous training should be given for the healthcare
provider by responsible body. (Health Management Information system Department)

24
Appendix
1. Complete Medical Record Review Form
2. Written consent

3. Medication administration sheet and nursing care plan sheet which are newly developed

25
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