An examination of inpatient medical record keeping in the Orthopaedic Department of Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania

  • Alexander Conor Hollis
  • Samuel Robert Ebbs

Abstract

Introduction: There is a lack of published evidence examining the quality of patient notes in African healthcare settings. We aim to examine the completeness of the orthopaedic inpatient notes and begin development of a formal audit framework in a large Tanzanian Hospital. Methods: A retrospective review of 155 orthopaedic inpatient notes at Kilimanjaro Christian Medical Centre (KCMC) was conducted spanning 3 months. Notes were reviewed using an agreed data collection pro forma considering 3 main outcomes; i) quantity of complete entries, ii) percentage completeness of individual sections, iii) documentation of follow-up. Results: Primary outcome: 8% (n=13) of the inpatient documents were complete (10/10 sections). 11% (n=17) of the inpatient documents had 9 of 10 sections completed. 30% (n=46) of the inpatient documents had 8 of 10 sections completed. Therefore, 51% (n=79) of inpatient entries had 7 or fewer sections filled in. Secondary outcome: 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 in 77% (n=119) and Diagnosis in 88% (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 were 32% (n=49) and 0% (n=0) respectively. Tertiary outcome: Follow-up was not completed in any entries. Conclusion: There are a number of sections of the inpatient pro forma that remain inadequately completed. Regular auditing is essential for the continued progress in patient care.
Keywords: Tanzania, quality improvement, service evaluation, orthopaedics.

Pan African Medical Journal 2016; 23

Author Biographies

Alexander Conor Hollis
College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
Samuel Robert Ebbs
College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
Published
2016-07-14
Section
Articles

Journal Identifiers


eISSN: 1937-8688