Development of the Emergency Room Patient Record in Theodor Bilharz Research Institute Hospital
The primary aim of this study was to improve the quality of medical care in Theodor Bilharz Research Institute Hospital (TBRIH) through development of the most appropriate emergency room patient record. A hospital based interventional study was conducted in the period from October 2009 to May 2011 in TBRIH. The study sample is purposive for both the provisional and final record as well as the whole health team. The study involved situation analysis of the emergency room record cycle, assessment of the provisional record structure and quality, needs assessment of the health team and finally implementation and assessment of the final record form. As for the provisional record, data quality showed insufficient conciseness, where unclear signature forms, spelling mistakes and bad hand writing were common. Needs assessment of health team highlighted the need for: more spaces, classification of items, use of checklists with preference to make physicians responsible for diagnosis coding and training to improve documentation was recommended. Finally, a trial form was modified according to health team needs and national standards in order to develop the final form, where the newly added items, sub classifications as well as checklists showed obvious success. To conclude, the use of structured template design which was modified according to national standards and data quality was the key to ensure the applicability and convenience of the final record form.
Emergency room; medical records; data quality; clinical coding.