Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Multicenter Study
. 2020 Dec 31;13(1):1765526.
doi: 10.1080/16549716.2020.1765526.

Assessing completeness of patient medical records of surgical and obstetric patients in Northern Tanzania

William Lodge  1 , Gopal Menon  1 , Salome Kuchukhidze  1 , Desmond T Jumbam  1 , Sarah Maongezi  2 , Shehnaz Alidina  1 , Boniface Nguhuni  3 , Ntuli A Kapologwe  3 , John Varallo  4
Affiliations
Multicenter Study

Assessing completeness of patient medical records of surgical and obstetric patients in Northern Tanzania

William Lodge et al. Glob Health Action. .

Abstract

Background: Strengthening surgical services in resource-constrained settings is contingent on using high-quality data to inform decision making at clinical, facility, and policy levels. However, the evidence is sparse on gaps in paper-based medical record quality for surgical and obstetric patients in low-resource settings.

Objective: We aim to examine surgical and obstetric patient medical record data quality in health facilities as part of a surgical system strengthening initiative in northern Tanzania.

Methods: To measure the incidence of Surgical Site Infections (SSIs), sepsis and maternal sepsis surgical and obstetric inpatients were followed prospectively, over three months in ten primary, district, and regional health facilities in northern Tanzania. Between April 22nd to May 1st, 2018, we retrospectively reviewed paper-based medical records of surgical and obstetric patients diagnosed with SSIs, post-operative sepsis, and maternal sepsis in the three-month follow-up period. A data quality assessment tool with18 data elements related to documentation of SSIs and sepsis diagnosis, their respective symptoms and vital signs, inpatient daily monitoring indicators, and demographic information was developed and used to assess the completeness of patient medical records.

Results: Among the 157 patients diagnosed with SSI and sepsis, we found and reviewed 68% of all medical records. Among records reviewed, approximately one third (34%) and one quarter (23%) included documentation of SSI and sepsis diagnoses, respectively. 6% of reviewed records included documentation of all SSI and sepsis diagnoses, symptoms and vital signs, inpatient daily monitoring indicators, and demographic data.

Conclusions: Strengthening data quality and record-keeping is essential for surgical team communication, continuity of care, and patient safety, especially in low resource settings where paper-based records are the primary means of data collection. High-quality primary health information provides facilities with actionable data for improving surgical and obstetric care quality at the facility level.

Keywords: Data quality; Tanzania; sepsis; surgical care; surgical site infections.

PubMed Disclaimer

Conflict of interest statement

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: William Lodge II, Salome Kuchukhidze, Gopal Menon, Shehnaz Alidina, Desmond T. Jumbam, and John Varallo had financial support from GE Foundation for the submitted work; John Varallo declares financial support from ELMA Philanthropies. The authors have had no financial relationships with any organizations that might have an interest in the submitted work in the previous three years and no other relationships or activities that could appear to have influenced the submitted work.

References

    1. Meara JG, Leather AJM, Hagander L, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–9. - PubMed
    1. Mock C, Donkor P, Gawande A, et al. Essential surgery: key messages of this volume. Dis. control priorities [Internet]. 3rd ed; 2015; [cited 2020 March10]. Available from: http://dcp-3.org/sites/default/files/chapters/DCP3_Essential%20Surgery_C... - PubMed
    1. Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage [Internet]. 68th World Health Assembly; 2015. [cited 2020 March10]. Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_R15-en.pdf
    1. Citron I, Saluja S, Amundson J, et al. Surgical quality indicators in low-resource settings: A new evidence-based tool. Surgery. 2018;164(5):946–952. . - PubMed
    1. MoHCGEC . National surgical, obstetric and anaesthesia plan (NSOAP) 2018-2025 the United Republic of Tanzania [Internet]. 2018; [cited 2020 March11]. Available from: https://docs.wixstatic.com/ugd/d9a674_4daa353b73064f70ab6a53a96bb84ace.pdf

Publication types

LinkOut - more resources