Completeness of inpatient medical records of two general Hospitals, oromia regional state, central ethiopia: The case of batu and abomsa

Abstract

Background A medical record is considered complete if it contains sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers. However, there is paucity of latest published information in this regard in the study area. Objectives: To assess and to comparing the completeness of inpatient medical records between Batu General Hospital and Abomsa General Hospitals in 2021. Methods: An institution based cross sectional study was conducted at two general Hospitals found in central Oromia region from March to May 2022. Two population proportion formula was used to determine the sample size. The sample size required in each comparison group will be n= {𝑝1(1 − 𝑝1) + 𝑝2(1 − 𝑝2)}(𝑍/𝐸) 2. , n is the sample size required in each group, z, 95% confidence level. Two general Hospitals were compared for medical record completeness, permission was obtained from the Hospitals officials after ethical clearance was issued from Jimma University institutional review board prior to getting to data collection. Quantitative data was collected from the inpatient medical records using medical record review checklist prepared based on EHSTG and qualitative data was collected using focus group discussion and simple random sampling was employed to collect data. Clinical records were handled within the hospital premises to secure confidentiality. Before data entry, checklists were checked for errors, cleaned, coded and entered into SPSS version 23 software package for analysis. Independent-sample t test was used to compare two Hospitals' scores. Result, the result showed significant differences for all variables as follows: - Total inpatient MR completeness score of Abomsa General Hospital (60.5%) whereas that of Batu general Hospital was (69.2%). Conclusions: overall inpatient medical record completeness proportion in Batu general Hospital and Abomsa general Hospital was comparable with other hospitals in the country with highest rate of completeness physician order and physician note both were 0.92% in Batu