الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
The medical record (MR) is a multifunctional document used to record critical information about patients’ medical condition and care among health care professionals. High-quality emergency department (ED) medical records promote improved patient care and capture patient evaluation, management, medical decision making, and disposition accurately.
Emergency Department in Alexandria Main University Hospital suffered from ineffective, primitive, and insufficient documentation especially with those patients attending triage and casualty area in ED.
The aim of this study is implementing and evaluating the documentation of care in Emergency Department in Alexandria Main University Hospital. The study was carried in five stages;
• Stage 1: Situational analysis of the preexisting documentation system & needs assessment: : via self- administered preliminary questionnaires ](one for physicians (56 physicians), and one for nursing staff (28 nurse)[
These questionnaires revealed that the main causes of shift preference was presence of sufficient number of man power (50%), better mental & physical status (50%), followed by less work load (37.5%), availability of specialties representing (33.9%), and finally socially appropriate (30.4%). The preexisting Emergency Department MR was scored depending on physicians’ opinion as 53.2% ± SD= 19.4%, while the nurses’ was 52.14% ± SD= 18.8%.
They staff defined causes of poor documentation in the preexisting documentation system as; work load was the main cause (96.4% of nurses, and 92.9% of physicians), followed by urgent and emergent cases, poor document formatting, shortage of medical and nursing staff, and lack of communication between ED and other departments.
Both physicians and nurse were dissatisfied with the preexisting system (with no significant difference between both opinions P= 0.051). Both groups also agreed with the need of the department for change with differing degrees, while as regarding their support to the change the nurses were more ready to support the change.
The physicians chose the blank form (51.8%) as the preferred format of forms followed by structured checklists (37.5%) and they chose the senior resident by 62.5% as the person more suitable to review MRs before archiving.
The physicians mainly suggested using EMR (57.1%), while nurses suggested increase fixed number of nursing staff, improve work environment, then adherence to one nursing reporting authority, assign a nurse every shift responsible for MR only and implement staff appraisal system.
• Stage 2: Design & Format: Design and format of medical record forms was done meet ED needs and the ED MR was formed of 13 forms added as needed according to the patient conditions.
• Stage 3: Training: training of the staffs who deal with MR in ED including all emergency physicians and staff members, all nursing staff assigned to triage and casualty area, and medical recording technicians in ED using presentations done in frequent training sessions.
• Stage 4: Implementation: This stage was conducted in two steps;
- First was updating of some of the reviewed medical records policy and procedures of Alexandria University Hospitals and development of new ones specified for Emergency Department,
- Second was implementation of the new documentation system in ED
• Stage 5: Evaluation of the new documentation system as regarding;
- Implementability: through three self- administered questionnaires ]one for physicians (35 physicians), one for nursing staff (26 nurses), and one for medical record technicians (11 technicians)[,
- Completeness of medical records through reviewing a sample of 501 Medical records issued in ED during the period of implementation.
The results of this questionnaires revealed that; as regarding the physicians’ documentation performance depending on the staff opinion; most of the nurses (88.4%) and technicians (63.7%) evaluated physicians’ as very poor and poor. While the physicians (77.2%) evaluated themselves with a higher scale poor to fair. While as regarding documentation performance of nurses and MR technicians there is no differences between the opinions of the three evaluating categories as both ranged from good to poor.
The physicians and nurses admitted that the process of documentation reduce the time given to direct patient care, most of their responses were between agreeing and strongly agreeing with (no statistically significant difference between both groups P= 0.839)
As regarding staff satisfaction with the preexisting and new documentation systems in ED; there was an agreement between the two nurses groups that they were not satisfied with both systems with no significant differences between both opinions.(P value= 0.258).The physicians were more satisfied by the new documentation system and the difference between both groups are statistically significant (P value= < 0.001), while the medical record technicians (100%) were dissatisfied with the new system.
The ED staff defined the main difficulties facing the implementation of the new system as; increased work load (physicians 91.4%, nurses 84.6%, and technicians 81.8%), shortage of staff (physicians 85.7%, nurses 92.9%, and technicians 72.7%), followed by inadequate working conditions, and time consuming. Nurses considered doubling the documentation in other nursing records the main cause (96% of nurses)
The ED staff suggested improving the new system by; increase staff number, some changes of medical records forms format, maintain continuous training on documentation, implementing documentation appraisal system, use of EMR, documentation of nursing notes in MR without duplication in other records, and improve the working condition.
As regarding reviewing of a sample of 501 ED MR issued during the period of implementation, the data filled by MR technicians; patient identification was partially done in 95% of the reviewed MR while the administrative data was partially done in 73.9% of reviewed MR and signed informed consent for acceptance of the treatment system in the hospital which was not done in 100% of indicated MR.
The data filled by physicians differed in their completeness; from data mostly complete as anesthesia and operative data (84.6%), discharge summary and instructions (67.3%), consultations reports and follow up (66.4%), to data complete in around the half of medical records as; radiological data (56.8%), history (present & past) (46.7%), and clinical progress notes (46.7%), to data mostly were not done in all reviewed MR as; triage assessment (96.2%), signed informed consent for discharge against medical advice and/or acceptance or refusal of interventions were not done in (62.9%), interventions done (61.3%), and treatment plans & medications (49.4%).
While nursing staff are responsible for filling in; patient identification on every form which were completely done in (87.7%), nursing notes & supplies used which completely not done in 85.4%. Laboratory data was partially recorded by 13.3% while not recorded by 34%. The correspondences were attached in 91.7%, while blood transfusion observations and consent were partially done in 42.9%.
Medical records review revealed that admission& discharge sheet/ authorization sheet (MR ED 1/2) was 100% appropriately used followed by patient assessment form (MR ED3) 69.1%, while consultation form (MR 12) was the most commonly misused form in ED MR (23.4%). The handwriting was legible in all forms in 72.6% of the reviewed MR, and in some forms in 27% of them.
The reviewed MR were categorized according to their completeness score as; 1% of all reviewed medical records had a score of <20%, 30.1% of MR had a score of 20- 40%, 34.7% of MR had a score of 40-60%, 17.8% of MR had a score of 60-80%, and 16.4% of MR had a score of > 80%.The mean completeness score was 54.4% ranging from 16.67% to 93.33%.
Physicians had got a mean completeness score of 36.6% ± 13.2% SD, while nursing staff had got a mean score of 45.1%± 11.5%SD, and finally medical record technicians got a mean score of 56.02 %± 17.6%SD
Different variables were tested to assess their relationship with completeness of medical records. There is statistically significant difference in the median completeness scores and the disposition of patient from ED, primary diagnoses, the presenting ED shifts, area of care in ED, length of stay in ED.