الفهرس 
AcknowledgementOnly 14 pages are availabe for public view
 |  | from | 16 |  |  |
| | | from | 16 | | |
Abstract
The purpose of this study was to evaluate the content of medical record~ in governmental general hospitals in Kuwait. Other factors affecting the medical record system such as medical records storage and retrieval~ medical record staff, physicians’ opinions and medical record policy and procedures were also explored and analyzed in depth. 1. A two stage random sampling design was utilized. In the first stage, the six general h,ospitals representing the six region of the National Health Care System were selected. In the second stage 1320 medical recorda of in-patient admitted to those hospitals dueing 19S6 were chosen by a systematic random sampling procedure. The magnitude of the sample drawn from the various departments is shown below: 484 (36.7) from general surgery, 398 (30.2) from medicine, 259 (19.6) from obstetrics, 90(6.8) from gynaecology, 67 (5.0) from orthopedics and 22 (1.7) from urology. 3. The study also involved 563 medical records personnel which is the total number of staff in the medical records departments of the six studied hospitals. There were 453 (80.4) Kuwaitis and 110 (19-.6) non-Kuwaitis. According to hospitals their distribution was as follow: 138 (24.6) in Farwania, 106 (18.~) in Mubarak 96 (17.0) in Jahra, .84 (14.9) in Arniri, 83 (14.7) in Adan and 56 (9.9 in Sabah hospital. The study also included 279 physicians, 133 out of them from the medical departments, 89 from surgical departments and 57 from obstetrical and gynaecological departments. Their distribution according to the hospitals was as follow: 68 in Farwania, 56 in Jahra, 46 in Adan, 42 in Mubarak, 35 in Sabah and 32 in Amiri hospital. . Regarding identification data, such as patient’s name address.. etc., it was found that it was recorded in more than 92.7. As regards the recording of correct identifying number of the patient it was shown that there was a wide variation between hospitals. The recording ranged from 96.0 in Adan hospital to 16.7in Sabah hospital. There is a significant difference between hospitals in respect to reQording identification data. Comparing Adan and Sabah hospitals as high and low percentage respectively it is found that there was a significant difference between them. ~ Physicians’ progress notes were recorded in more than 80.8 of the studied records. Only 24.0of the records included in¬ structions regarding post-hopsital care. Regarding this point the recording percentage ranged from 27.6 in Adan hospital to 18.3 in Sabah hospital. It was found that there was a significant difference between the hospitals regarding the physicians notes. Comparing Adan and Sabah as high and low percentage respectively regarding the physician’s progress notes it was found that there was a significant difference between them. In general, the items of the discharge summary were recorded in 73.6 of the studied records. The lowest percentages of recording thes~ items were fQund in Sabahand Farwania hospitals respectively 15.7 and 64.2 and there was no significant difference between hospitals regarding discharge summary. comparing Adan and Sabh hospitals as high and low percentages respe~tively as regards the items of discharge summary it was found that there was a significant difference between them. Patient’s consent for surgical procedures was recorded in 85.7 of the sampled records. There was a significant difference between the hospitals on this item. It was also found that the name of the individual who performed the procedure and specification of possibility of risks and complications were not included in the consent form. Only 9.4 of the records specified the name of the surgical procedure. The difference between hospitals regarding the consent forms was statistically significant. Comparing Sabah and Adan D hospitals as high and low percentages respectively with regard to consent form it was found that there was no significant difference between them. Generally, the items of operative report were recorded in 60.3of the sampled records. It was noticed that the highest recording percentage was 63.7 for preoperative diagnosis and the least was 39.3 for specification of the tissue removed. There is a significant difference between hospitals regarding the operative reports items. Comparing Amiri and Farwania hospitals as high and low percentages regarding operative report, it was found that there was a significant difference ,between the two. It appeared from the study that all entries in medical records were signed. It appeared also that 92.9 of the studied records contained dated entries including day, month and year. There was a significant difference between hospitals regarding this point. The study showed that standardized abbreviations and symbols were found in 57.3 of the studied records. The difference between hospitals, regarding abbreviations and symbols was statistically significant. The survey revealed that 26.6 of the studied records contained informations recorded on non-designated forms. The difference between hospitals regarding this point, was statistically significant. The survey also revealed that 55.8 of the studied records contained information recorded on inappropriate forms and it was found that there was a significant difference between hospitals as regards this poin~. The study showed that almost all the studied records contained empty forms and skipped lines between notes. The study pointed that there was a sign~ficant difference between hospitals regarding compliance with general documentation principles in the studied medical records. Comparing Amiri and Sabah hospitals as high and low percentages respectively, , regarding compliance with general documentation principles, it was found that there was no significant difference between them. Studying defects in the filing system, the study showed that only 0.2 of the files contained misfiled records. In general overcrowded records in shelves were found in 83.8 of the selected cabinets from the six hospitals. Overcrowdness was found in 100.0 of cabinets of Adan, Jahra, Mubarak and Sabah hospitals. It was found in 73.0 of that of Farwania and in only 25.7of that of Amir.i hospital. Colour-coding of the files was not used in Farwania, Jahra and Sabah hospitals. In Amiri hospital it was used improperly while in Mubarak hospital it was used properly. Missing files were found in 2.7 and 2.1 of the files of Farwania and Adan hospitals respectively, but in only 0.1 of Sabah hospital. Comparing Jahra and Mubarak hospitals as high and low percentages respectively, regarding defects in the filing system it was found that there was a significant difference between the two. The study showed that 299 (53.1) medical records personnel out of 563 had not attended any training course in the field of medical rcords. Comparing the hospitals, as regard the training course, it was found that there was a significant difference between them. 135 (48.4) of the physicians who participated in the survey agreed that the medical record was well documented. There was a significant difference between hospitals regarding this point. Only 22.2 of the physicians agreed about the availability of the requested medical records. Regarding this point, it was found that there was a significant difference between the hos¬ pitals . Only 38.0 of the physicians agreed that the confidentiality of medical informations contained inthe records were maintained. There was a significant difference between the hospitals on this point. 34.8 of the physicians stated that it was easy to find indi¬ vidual pages in the records. There was a significant difference between hospitals on this point. Also, 56.6 of the physicians stated that the medical records staff were available when they were needed. Regarding staff availability, the study showed that there was no significant difference between the hospitals. I, The study showed that the difference between hospitals, regarding the quality of the medical record services, was statistically significant. of the physicians considered the medical records department as a file room. Comparison of the ~ospitals regarding this point, showed that there was no significant difference between them. Only 29.4 of the physicians perceived the department as a record~ processing center. There was no significant difference between the hospitals, with regard to this point. Only 20.8 of them looked upon the department as a health information center. As regards this point, it was found that there was no significant difference between the hospitals. Considering the overall opinions of the physicians regarding the medical records departments as a whole, 177(63.4) of them stated that the departments were acceptable, 73(26.2) of them stated that they were poor and only 29 (10.4) of them stated that they were good. Comparing the six hospitals according to the overall opinions of physicians regarding the medical record departments as a whole, it was found that there. is a significant difference between them. Although all items studied in this research under the title of policy were included in the handbook for policies of the medical records department, issued by the Ministry of Public Health, the study showed that implementation of procedures ¬ was quite different from one hospital to another. Furthermore, some prosdures were not practiced at all in any of, the six hospitals, medical audit being the most notables example. i15. The main conclusions drawn from the survey were presented ,at the end of the study. Appropriate suggestions and recornmendations were also offered in order to improve the quality of medical records and also the quality of services provided by the medical records departments at all governmental general hospitals, and to ensure optimum utilization of them in future.