Ensuring correct and complete patient file documentation : a data driven quality enhancement approach at Chtoura hospital

Abstract

Correct and completer patient file documentation has a paramount significance in achieving patient safety and quality care.The intern’s practicum took 281 hours to be completed within the quality department of the Chtoura hospital in order to examine the gaps in the documentation practices. A checklist was created after reviewing all the policies and protocols related to patient files. This checklist was composed of nineteen major documentation items which was applicable for all the seven units of the hospital. Then, audit was done by the unit managers in the hospital to check the compliance of each item in the patient file with the documentation policies and protocols. Later, the collected data was entered into Excel and the compliance rates for each item in every unit and in the whole hospital were calculated. Chtoura hospital showed a good compliance with the patient file documentation policies. A completion rate of hundred percent was given for most of the documentation items, except for the patient contact information, family history, progress notes, discharge summaries, and education. After identifying the main issues of the documentation with the quality personnel, some recommendations were given to the hospital management such as the use of regular audits, training all the staff members on the documentation requirements and creating new documentation protocol.