Assessment of physicians' recordings in admitted patient's charts: Al-Gaumhoria Teaching Hospital, Aden

ABSTRACT

This study was designed to assess the admitted patient's charts at Al-Gaumhoria Teaching Hospital, Aden. The total patients' charts were 172 [60 from the medical wards and 112 from the surgical wards] who were admitted to the medical and surgical wards during September to November 2005 and discharged alive. Fourteen variables from the chart were chosen. They were demographic data, date of admission, chief complain, history of present illness, past history, family history, physical examination, differential diagnosis, initial therapy, signature and stamp of physician who admitted and discharged the patient, final diagnosis, daily follow up, and date of discharge. The parameter for the findings was the percentage of registered and unregistered variable. For the total charts, we found deficiency in recording the variables of signature and stamp of physicians by discharging patient 65.1%, final diagnosis 55.8%, demographic data 43%, date of discharge 40.1%, family history 34.3% and past history 27.9%. The rest unregistered variables ranged between 12.2% and 3.5%. We concluded that negligence of physicians and deficiency in recording the full items in patient's chart is attributed to the following factors deficiency of supervision of head of departments, deficiency in knowledge of medical ethics and importance of patient's chart, deficiency of guidelines and lack of the coordination between faculty of medicine, teaching-hospitals administrations and the Yemeni Council for medical Postgraduate studies