[Audit of medical records]

Abstract

Objective: TO assess the quality of medical records in a university teaching hospital in Africa.

Material and methods: We conducted a retrospective study at the Souro Sanou University Teaching Hospital of Bobo Dioulasso in Burkina Faso, by randomly selecting 480 medical records from 4 clinical departments (internal medicine, obstetrics & gynaecology, paediatrics and surgery). Items recorded were based mainly on those used by the French agency for the evaluation of health services (now the HAS). Ten physicians were also interviewed about medical file ergonomics file. Descriptive statistics were compiled from the data collected.

Results: Only 368 of the 480 records could be found. Two of the four departments had an adequate record room. Assessment of the overall quality of the files noted that: i) 95 to 100% of the records were in good physical condition; ii) the handwriting in the files was legible in 94 to 100% of the cases; iii) the identity of the staff members making file entries could be determined in 73 to 92% of the cases. A detailed examination of the content of the files revealed that: i) the patient's social and demographic characteristics (name, sex, age, residence, occupation, marital status and religion) were available in 26 to 99% of the cases; ii) the mode of admission was noted in 52 to 88%; iii) the reason for admission was stated in 83 to 100%; iv) the main diagnosis was reported in 68 to 100%; v) surgery notes were found for 93 to 100% of patients who underwent surgery; vi) the disposition on discharge was not found in 31% of the records; vii) the circumstances of death were not recorded for 77% of the patients who died.

Conclusion: The quality of medical records at Souro University Teaching Hospital must be improved, through improving staff awareness and regular audits.