ABSTRACT
Objective: To evaluate the effect of implementation of the Electronic File System [EFS] on the completeness of clinical evaluation in the Chronic Non-Communicable Diseases [NCD] Clinic
Design: A Cross-Sectional, Comparative Study
Setting: Health Center, Bahrain
Method: All patients attending NCD clinic before implementation of Electronic File System [EFS] from 15 February to 31 March 2015 were reviewed and considered the first group [156]. All patients attending NCD clinic after the implementation of EFS from 15 May to 30 June 2015 were reviewed and considered the second group [168]. The clinical item evaluations to be completed by the physician were 9 items and by the nurse 30 items for each patient. The total number of clinical evaluation items before EFS multiplied by the number of cases [39 x 156] was 6,084. The total number of clinical evaluation items after EFS multiplied by the number of cases [39 x 168] was 6,552
Results: Three hundred twenty-four patients were included in the study. The patients were divided into two groups, 156 [48.1%] before EFS and 168 [51.9%] after EFS. The completeness of clinical items evaluation improved after the implementation of the EFS from 3,684 [60.5%] to 4,224 [64.5%]. The completeness by the nurse improved significantly after the implementation, from 2,988 [49.1%] to 3,653 [55.8%] and deteriorated by the physician from 696 [11.4%] to 571 [8.7%]
Conclusion: The average completeness of clinical evaluation remains low after the implementation of the EFS. There are several possible causes and further studies are needed to identify the main underlying causes for such low figures in order to plan and implement improvement