Medical documentation practice and associated factors among health workers at private hospitals in the Amhara region, Ethiopia 2021

Abstract

Introduction Medical documentation is an important part of the medical process as it is an essential way of communication within the health care system. However, medical documentation practice in the private sector is not well studied in Ethiopian context. The aim of this study was to assess the practice of medical documentation and its associated factors among health workers at private hospitals in the Amhara region, Ethiopia. Method An institution-based cross-sectional quantitative study supplemented with a qualitative design was conducted among 419 health workers at the private hospitals in the Amhara Region, Ethiopia from March 29 to April 29 /2021. Data were collected using both a self-administered questionnaire and interview guide for quantitative and qualitative respectively. Data were entered using Epi data version 3.1 and analyzed using SPSS version 20. Descriptive statistics, Bi-variable, and multivariable logistic regression analysis were performed. In-depth interviews were conducted using semi-structured questionnaires with eight respondents to explore the challenges related to the practice of medical documentation. Respondent’s response were analyzed using OpenCode version 4.03 thematically. Results Four hundred seven study participants returned the questionnaire. Nearly 50 % (47.2%) health workers had of good medical documentation practice. Health workers who received in-service training on medical documentation AOR = 2.77(95% CI: [1.49,5.14]), good knowledge AOR = 2.28 (95% CI: [1.34,3.89]), favorable attitude AOR = 1.78 (95%CI: [1.06,2.97]), strong motivation AOR = 3.49 (95% CI: [2.10,5.80]), available guide line formats AOR = 3.12 (95% CI: [1.41,6.84]), eHealth literacy AOR = 1.73(95% CI: [1.02,2.96]), younger age AOR = 2.64 (95% CI:[1.27,5.46]) were statistically associated with medical documentation. Conclusion More than half of the medical services provided were not registered. Therefore, it is important to put extra efforts to improve documentation practice by providing planed trainings on standards of documentation to all health workers, creating positive attitudes and enhancing their knowledge by motivating them to develop a culture of information.

Health professionals’ routine practice documentation and its associated factors in a resource-limited setting: a cross-sectional study

“…Health professionals for whom standard documentation tools were available were 2.5 times more likely to document routine practices than those for whom standard documentation tools were not available. This finding is consistence with a study done in Australia,26 Tigray18 and Amhara regions 23. This might be due to familiarisation with standard documentation sheets, and the accessibility of integrated routine health information forms for recording and reporting 27…”

“…The study revealed that health professionals’ routine practice documentation was good (51.1%). This finding is higher than previous similar studies, which found 44.2% in Nigeria,17 33.3% in Indonesia12 and 37.4%–48.8% in different parts of Ethiopia 3 18 23. However, the finding is lower than the study done in Jamaica, which reports that health professionals’ documentation practice is 98% 24.…”

“…Health professionals who lack motivation were 59% less likely to have documentation practices when compared with those who had gained motivation. This finding is inconsistence with studies done in Ethiopia 23 25. This might be poor professional encouragement, poor financial support, less opportunities for further educational development, poor infrastructures and low hospital management support 25…”

“…Additionally, record-keeping in the light of recent public inquiries, national interests in shifting from paper to digital storage of data, the capability of electronic health records to generate a complete record of an episode of care and the longitudinal nature of the electronic system might be possible reasons 1. Moreover, a need for real-time access to health information when and where it is needed might be reason why an electronic system could be more likely to be good for documentation 23…”

Improving medical record completeness at Wallaga University Referral Hospital: a multidimensional quality improvement project

“…Ethiopian medical documentation culture is not ideal. The health workers’ attitude towards medical documentation, time constraints, inadequate knowledge and lack of training could all be contributing factors 9 10. These elements have been the main focus of the ongoing quality enhancement initiative.…”