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

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.