Effect Of An Educational Intervention On Completeness Of Medical Record Documentation In A Teaching Hospital: A Pre And Post Interventional Study

Abstract

Introduction: Medical documentation is essential for patient care, ensuring clear communication among providers, facilitating quality assessment, and supporting research, all while adhering to standards of completeness, clarity, traceability, and truthfulness. Facilities implement various strategies to enhance medical record accuracy. Accurate and accessible medical records are crucial for effective healthcare. Inadequate documentation hampers clinical decisions, while training and best practices improve record quality and hospital administration efficiency.

Methods: In 2023, a pre-and post-interventional study was conducted at Shri B M Patil Medical College and Research Centre, Vijayapura, Karnataka. This analysis examined 500 inpatient medical records—250 before and 250 after a targeted intervention to enhance documentation accuracy and completeness. A systematic random sampling method was used to select records from surgical and allied departments. A four-day workshop trained healthcare staff on documentation principles in line with WHO and NABH guidelines. A validated deficiency checklist was utilized to assess records based on crucial patient assessment elements, ultimately evaluating the effectiveness of the educational initiative.

Results: The study demonstrated notable improvements in documentation completeness across various medical forms. For instance, OPD registration rose to 96.0%, while discharge summaries reached 100%. Other areas, including final diagnoses and consent forms, also significantly increased, enhancing overall efficiency and accuracy in patient record-keeping and care processes.

Conclusion: The inpatient discharge summary reached an impressive 100% completeness, starkly contrasting the 76% completion rate of investigation reports. This project illustrates those simple measures, like standardizing medical record formats and training healthcare providers, can greatly improve the thoroughness of medical records, ultimately enhancing healthcare quality.