What they fill in today, may not be useful tomorrow: Lessons learned from studying Medical Records at the Women hospital in Tabriz, Iran

Pourasghar, Faramarz; Malekafzali, Hossein; Kazemi, Alireza; Ellenius, Johan; Fors, Uno

doi:10.1186/1471-2458-8-139

Cited by 20 publications

(22 citation statements)

References 11 publications

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“…Because medical records are kept primarily for patient care purposes with secondary uses for billing, research, and legal documentation, researchers using data derived from medical records must be cognizant of these limitations. [50][51][52][53] However, we expect that the outcomes reported here were likely to be recorded in the medical record with a reasonably high degree of accuracy because of their importance to clinical care. Furthermore, our pre-/postdata review analysis indicated that data were initially entered with a high degree of accuracy.…”

Section: Limitationsmentioning

confidence: 99%

Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009

Cheyney¹,

Bovbjerg²,

Everson³

et al. 2014

J Midwife Womens Health

174

200

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Methods:We calculated descriptive statistics for maternal demographics, antenatal risk profiles, procedures, and outcomes of planned home births in the Midwives Alliance of North American Statistics Project (MANA Stats) 2.0 data registry. Data were analyzed according to intended and actual place of birth.Results: Among 16,924 women who planned home births at the onset of labor, 89.1% gave birth at home. The majority of intrapartum transfers were for failure to progress, and only 4.5% of the total sample required oxytocin augmentation and/or epidural analgesia. The rates of spontaneous vaginal birth, assisted vaginal birth, and cesarean were 93.6%, 1.2%, and 5.2%, respectively. Of the 1054 women who attempted a vaginal birth after cesarean, 87% were successful. Low Apgar scores (Ͻ 7) occurred in 1.5% of newborns. Postpartum maternal (1.5%) and neonatal (0.9%) transfers were infrequent. The majority (86%) of newborns were exclusively breastfeeding at 6 weeks of age. Excluding lethal anomalies, the intrapartum, early neonatal, and late neonatal mortality rates were 1.30, 0.41, and 0.35 per 1000, respectively. Discussion:For this large cohort of women who planned midwife-led home births in the United States, outcomes are congruent with the best available data from population-based, observational studies that evaluated outcomes by intended place of birth and perinatal risk factors. Low-risk women in this cohort experienced high rates of physiologic birth and low rates of intervention without an increase in adverse outcomes.

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Section: Limitationsmentioning

confidence: 99%

Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009

Cheyney¹,

Bovbjerg²,

Everson³

et al. 2014

J Midwife Womens Health

174

200

View full text Add to dashboard Cite

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“…However, there are a number of challenges affecting hospital data generation, preservation, management, accessibility, and utilization [ 5 – 8 ]. The challenges include use of outdated registers/forms that require the need of constant revision; shortage of well-trained and experienced personnel; lack of planning in storage of inactive records; incompleteness of forms (missing of variables); inadequate storage facilities; and lack of determination of records retention period [ 6 , 7 , 9 ]. These weaknesses are compounded in continued use of paper-based hospital information systems in low-income countries that are prone to damage [ 5 ].…”

Section: Introductionmentioning

confidence: 99%

Hospital mortality statistics in Tanzania: availability, accessibility, and quality 2006–2015

Mremi

Rumisha

Chiduo

et al. 2018

Popul Health Metrics

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BackgroundAccurate and reliable hospital information on the pattern and causes of death is important to monitor and evaluate the effectiveness of health policies and programs. The objective of this study was to assess the availability, accessibility, and quality of hospital mortality data in Tanzania.MethodsThis cross-sectional study involved selected hospitals of Tanzania and was carried out from July to October 2016. Review of hospital death registers and forms was carried out to cover a period of 10 years (2006–2015). Interviews with hospital staff were conducted to seek information as regards to tools used to record mortality data, staff involved in recording and availability of data storage and archiving facilities.ResultsA total of 247,976 death records were reviewed. The death register was the most (92.3%) common source of mortality data. Other sources included the International Classification of Diseases (ICD) report forms, Inpatient registers, and hospital administrative reports. Death registers were available throughout the 10-year period while ICD-10 forms were available for the period of 2013–2015. In the years between 2006 and 2010 and 2011–2015, the use of death register increased from 82 to 94.9%. Three years after the introduction of ICD-10 procedure, the forms were available and used in 28% (11/39) hospitals. The level of acceptable data increased from 69% in 2006 to 97% in 2015. Inconsistency in the language used, use of non-standard nomenclature for causes of death, use of abbreviations, poorly and unreadable handwriting, and missing variables were common data quality challenges. About 6.3% (n = 15,719) of the records had no patient age, 3.5% (n = 8790) had no cause of death and ~ 1% had no sex indicated. The frequency of missing sex variable was most common among under-5 children. Data storage and archiving in most hospitals was generally poor. Registers and forms were stored in several different locations, making accessibility difficult.ConclusionOverall, this study demonstrates gaps in hospital mortality data availability, accessibility, and quality, and highlights the need for capacity strengthening in data management and periodic record reviews. Policy guidelines on the data management including archiving are necessary to improve data.

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“…In primary health care (PHC), e-records have uses beyond simply retrieval of patient information; for example, warnings of allergies and drug interactions, developing management protocols for chronic illness, generating pre-appointment reminders and establishing communication links between different levels of care [2,3]. E-records are assumed to improve the quality of documentation over paper-based medical records via automatic reminders to health-care professionals of important data that are missing [4,5]. Some authors, however, have warned that inadequate computer skills or lack of training of health professionals together with limitations in erecords software could result in the data in e-records being truncated compared with paper-based records [6].…”

Section: Introductionmentioning

confidence: 99%

Quality of documentation of electronic medical information systems at primary health care units in Alexandria, Egypt

Noureldin

Mosallam

Salah³

2014

East Mediterr Health J

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Limited data are available about the implementation of electronic records systems in primary care in developing countries. The present study aimed to assess the quality of documentation in the electronic medical records at primary health care units in Alexandria, Egypt and to elicit physician's feedback on barriers and facilitators to the system. Data were collected at 7 units selected randomly from each administrative region and in each unit 50 paper-based records and their corresponding e-records were randomly selected for patients who visited the unit in the first 3 months of 2011. Administrative data were almost complete in both paper and e-records, but the completeness of clinical data varied between 60.0% and 100.0% across different units and types of record. The accuracy rate of the main diagnosis in e-records compared with paper-based records ranged between 44.0% and 82.0%. High workload and system complexity were the most frequently mentioned barriers to implementation of the e-records system. RÉSUMÉ Les données disponibles sur la mise en oeuvre de systèmes de dossiers électroniques en soins de santé primaires dans les pays en développement sont limitées. La présente étude visait à évaluer la qualité de la documentation des dossiers médicaux électroniques dans des unités de soins de santé primaires à Alexandrie (Égypte) et à recueillir les commentaires des médecins sur les obstacles et les leviers ayant un impact sur le système. Des données ont été recueillies au sein de sept unités sélectionnées aléatoirement dans chaque région administrative ; puis dans chaque unité, 50 dossiers au format papier et leurs dossiers électroniques correspondants ont été sélectionnés aléatoirement pour les patients qui avaient consulté dans l'unité de soins au cours de trois premiers mois de l'année 2011. Les données administratives étaient presque complètes dans les dossiers au format papier et au format électronique, mais l'exhaustivité des données cliniques variait entre 60 % et 100 % en fonction des unités de soins et du type de dossiers. Le taux d'exactitude du diagnostic principal dans les dossiers électroniques par rapport aux dossiers papiers était compris entre 44,0 % et 82,0 %. Une lourde charge de travail et la complexité du système étaient les obstacles les plus fréquemment cités à la mise en oeuvre du système de dossiers électroniques.

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What they fill in today, may not be useful tomorrow: Lessons learned from studying Medical Records at the Women hospital in Tabriz, Iran

Cited by 20 publications

References 11 publications

Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009

Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009

Hospital mortality statistics in Tanzania: availability, accessibility, and quality 2006–2015

Quality of documentation of electronic medical information systems at primary health care units in Alexandria, Egypt

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