Measurement of Completeness of Medical Records in Family Health Centre in El Shorouk City.

Document Type : Original Article

Abstract

Introduction: Medical records play a vital role in the planning, development and maintenance of health care services. A well designed family folder system provides useful summary data on the demographic profile of the family. Objectives: 1-To measure the completeness of the family folder in a family health center in EL-Shorouk city. 2-To identify main causes of record incompleteness including knowledge and attitude of physicians towards medical records. Methodology: The study was conducted in a family health centre in El-Shorouk city using a cross sectional study, a sample of 200 out of 1000 records was estimated to be reviewed. Study tool: 1- Medical record assessment check list. 2-Structured questionnaire. Results: Out of 200 records, 130 (65%) of records had been properly organized. Personal data was the most frequently recorded item (100%). The least recorded was general examination (51.5%). It was found that (88.5%) of records had completeness scores from 80-100% from standards, so they had passed the assessment as the minimal passing score is (80%). Conclusion: To improve the quality of Medical Record, regular auditing, training and good orientation of medical personnel for good record practices.

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