Increasing patient medical record completion by assigning nurses to specific patients in maternity ward at Munini hospital

Purpose 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. Design/methodology/approach 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. Findings 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. Practical implications The quality improvement project created a cost-effective intervention that successfully improved the documentation completion rate. Ongoing monitoring should be continued to learn sustainability. Originality/value The results are useful for hospitals with similar settings to improve completion of nursing documentation and increase nursing accountability on patient care

Documentation · Guideline · Intervention (counseling · Management system · Medical emergency · Medical record · Operations management · Quality management · Electronic Health Records Systems · Medicine · Nursing · Nursing Diagnosis and Documentation · Patient Safety and Medication Errors · Surgery

• What they fill in today, may not be useful tomorrow

  Open Access•Faramarz Pourasghar, Hossein Malekafzali et al.•BMC Public Health•2008

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