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公立医疗机构的病历质量:以资源有限的埃塞俄比亚南部为例

Quality of medical records in public health facilities: A case of Southern Ethiopia, resource limited setting.

机构信息

Health Research and Technology Transfer Directorate, 580409SNNPR Health Bureau, Hawassa, Ethiopia.

Head Office, 580409SNNPR Health Bureau, Hawassa, Ethiopia.

出版信息

Health Informatics J. 2022 Jul-Sep;28(3):14604582221112853. doi: 10.1177/14604582221112853.

Abstract

Facility based retrospective study was conducted in three regions in southern Ethiopia to assess quality of medical records. A total of 2,145 medical records were reviewed from 73 public health facilities. Minimum standards of medical records were considered to assess completeness and legibility of records. The completeness of medical records were judged systematically according to national HMIS formats. From total of 2,145 medical cards reviewed, only 394 (18.4%) records had all complete and readable data. Gaps observed include 29.0% missed at least one of identification data, 14.3% lack chief compliant, 20.1% lack diagnosis, 12.5% lack medication and 60.3% records had no date and/or signature. Moreover, 9.5% cards had at least one non-readable component. Records at health centers were 56.8% less likely to be quality record as compared to records in hospitals. Even though completeness of every single record is must, only less than one fifth of records met quality of national medical record standard. Ministry of health should consider rules and regulation to maintain data quality and switching to electronic record, and finally progress in data quality should be monitored routinely.

摘要

在埃塞俄比亚南部的三个地区进行了基于设施的回顾性研究,以评估医疗记录的质量。从 73 个公共卫生机构共审查了 2145 份病历。记录的完整性和清晰度是根据医疗记录的最低标准来评估的。病历的完整性是根据国家 HMIS 格式进行系统评估的。在总共审查的 2145 张病历卡中,只有 394 张(18.4%)记录有所有完整和可读的数据。观察到的差距包括:29.0%的记录至少缺少一个识别数据,14.3%的记录缺少主要主诉,20.1%的记录缺少诊断,12.5%的记录缺少药物,60.3%的记录没有日期和/或签名。此外,9.5%的卡片至少有一个不可读的组件。与医院的记录相比,卫生中心的记录质量更差,只有不到五分之一的记录符合国家病历标准。卫生部应考虑制定规则和条例来维护数据质量,并转向电子记录,最后应定期监测数据质量的进展。

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