Medical health records form an essential part of a patient’s present and future health care, so proper recording and documentation is mandatory because improper record keeping can result in poor management as well as declining medical claims.
The aim of this study is to evaluate the degree of writing patient's medical records and the adherence of medical staff to document patients' information's in accurate and proper manner as a guide for management protocols.
This is a retrospective descriptive cross sectional study, carried out in Al-Basrah General Hospital from 1st of January to 15th of February 2015, 250 medical records randomly selected, admitted for both urgent and elective surgeries from the total number of records registered at 2015, The Information from the records are documented on scoring questionnaire arrange by the researchers.
The documentation varies from item to other, for information related to patient identity: name, address, occupation presented completely in 70%, 19.2%, and 60.9% respectively. Regarding medical history, the chief complaint was written in medical term in 39.2% while the duration of illness was documented in 57.2%, whereas present illness, review of system, past, social, family & drugs histories were completely presented in 17.6%, 1.6%, 19.6%, 3.6%, 2%, 20.8% respectively. 38.8 % for general examination, 66% for systemic examination, 32.4% for vital signs, 94.8 % for preoperative & operative anesthetic notes, and 46.8% for operative surgeon notes were not presented at all. The investigations & treatment present in 71.6% & 56.8% respectively while diagnosis was not mentioned in 87.4%. Regarding follow up, nursing notes, consent were not present in approximately 30% of data. The admission sheet was not present in 2.8% while discharging summary report was not present in 97.2%. For diet, height, weight, fluid chart were not recorded in 100%. A comparison between urgent & elective surgeries reveals that the recording was slightly better for elective but this is not statistically significant. The documentation of patient medical records in surgical department of Al-Basrah General Hospital is poor, the majority of sheets in the records lack most of Information that its presence is fundamental for patient management, and the majority of data are not documented in complete and proper manner.