The purpose of this paper is to describe the quality improvement project to increase the medical record documentation completion rate in a district hospital in Rwanda. Despite the importance of medical records to support high quality and efficient care, incomplete documentation is common in many hospitals.
The pre- and post-intervention record completion rate in the maternity unit was assessed. Intervention included assigned nurse to specific patients, developed guideline, provided trainings and supervisions.
The documentation completion rate significantly increased from 25 per cent pre-intervention to 67 per cent post-intervention, p < 0.001. The completeness of seven out of the ten elements of medical records also significantly increased.
The quality improvement project created a cost-effective intervention that successfully improved the documentation completion rate. Ongoing monitoring should be continued to learn sustainability.
The results are useful for hospitals with similar settings to improve completion of nursing documentation and increase nursing accountability on patient care.
The authors would like to thank all the staff at Munini hospital for participating and supporting this project. The authors also want to thank the Minister of Health for the opportunity to study the MHA program.
Ufitinema, Y., Wong, R., Adomako, E., Kanyamarere, L., Kayonga Ntagungira, E. and Kagwiza, J. (2016), "Increasing patient medical record completion by assigning nurses to specific patients in maternity ward at Munini hospital", On the Horizon, Vol. 24 No. 4, pp. 327-334. https://doi.org/10.1108/OTH-07-2016-0040
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