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

Introduction In the health care environment, a huge volume of data is produced on a daily basis. However, the processes of collecting, storing, sharing, analyzing, and reporting health data usually face with numerous challenges that lead to producing incomplete, inaccurate, and untimely data. As a result, data quality issues have received more attention than before. Objective The purpose of this article is to provide an insight into the data quality definitions, dimensions, and assessment methodologies. Methods In this article, a scoping literature review approach was used to describe and summarize the main concepts related to data quality and data quality assessment methodologies. Search terms were selected to find the relevant articles published between January 1, 2012 and September 31, 2022. The retrieved articles were then reviewed and the results were reported narratively. Results In total, 23 papers were included in the study. According to the results, data quality dimensions were various and different methodologies were used to assess them. Most studies used quantitative methods to measure data quality dimensions either in paper-based or computer-based medical records. Only two studies investigated respondents' opinions about data quality. Conclusion In health care, high-quality data not only are important for patient care, but also are vital for improving quality of health care services and better decision making. Therefore, using technical and nontechnical solutions as well as constant assessment and supervision is suggested to improve data quality.

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“…In addition to missing medical records, the findings showed that primary data quality is weak in health care facilities in northern Tanzania. 35…”

Section: Resultsmentioning

confidence: 99%

“…In addition to missing medical records, the findings showed that primary data quality is weak in health care facilities in northern Tanzania. 35 Table 2 The most common data quality dimensions and their definitions…”

Section: Data Quality In Paper-based Medical Recordsmentioning

confidence: 99%

Data Quality in Health Care: Main Concepts and Assessment Methodologies

et al. 2023

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“…Pre-intervention, maternal sepsis, postoperative sepsis and SSI were poorly documented in patient records [ 29 ]. After intervention, documentation of sepsis and SSI diagnosis and care improved.…”

Section: Discussionmentioning

confidence: 99%

Outcomes of a multicomponent safe surgery intervention in Tanzania’s Lake Zone: a prospective, longitudinal study

Alidina

Menon

Staffa

et al. 2021

International Journal for Quality in Health Care

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Background Evidence-based strategies for improving surgical quality and patient outcomes in low-resource settings are a priority. We evaluated the impact of a multicomponent safe surgery intervention (Safe Surgery 2020) in Tanzania, hypothesizing it would (1) increase adherence to safety practices, teamwork and communication, and documentation in patient files, and (2) reduce the incidence of maternal sepsis, postoperative sepsis, and surgical site infection. Methods We conducted a prospective, longitudinal study in 10 intervention and 10 control facilities in Tanzania’s Lake Zone, across a three-month pre-intervention period in 2018 and three-month post-intervention period in 2019. Safe Surgery 2020 is a multicomponent intervention to support four surgical quality areas: 1) leadership and teamwork, 2) evidence-based surgery, anaesthesia, and equipment sterilization practices, 3) data completeness, and 4) infrastructure. Surgical team members received training and mentorship, and each facility received up to a $10,000 infrastructure grant. Inpatients undergoing major surgery and postpartum women were followed during their stay up to 30 days. We assessed adherence to 14 safety and teamwork and communication measures through direct observation in the operating room. We identified maternal sepsis (vaginal or caesarean delivery), postoperative sepsis, and surgical site infections prospectively through daily surveillance and assessed medical record completeness retrospectively through chart review. We compared changes in surgical quality outcomes between intervention and control facilities using difference-in-differences analyses to determine areas of impact. Results Safety practices improved significantly by an additional 20.5% (95% CI, 7.2%-33.7%; P=.003) and teamwork and communication conversations by 33.3% (95% CI, 5.7%-60.8%; P=.02) in intervention facilities compared to control facilities. Maternal sepsis rates reduced significantly by 1% (95% CI, 0.1%-1.9%; P=.02). Documentation completeness improved by 41.8% (95% CI, 27.4%-56.1%; P<.001) for sepsis and 22.3% (95% CI, 4.7%-39.8%; P=.01) for surgical site infections. Conclusion Our findings demonstrate the benefit of the Safe Surgery 2020 approach. Improvement was observed in adherence to safety practices, teamwork and communication, and data quality, and there was a reduction in maternal sepsis rates. Our results support the emerging evidence that improving surgical quality in a low resource setting requires a focus on the surgical system and culture. Investigation in diverse contexts is necessary to confirm and generalize our results and to understand how to adapt the intervention for different settings. Further work is also necessary to assess the long-term effect and sustainability of such interventions.

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“…Missing patient records is also a problem, as in Tanzania, where a study surveying the completeness of records found 32% missing. 32 HRR studies often carry systematic biases and only provide institutional MMRs. As institutions only serve selected populations, health records represent selected population groups, e.g.…”

Section: Health Record Review Studiesmentioning

confidence: 99%