Evaluation of the quality of the keeping of the patients' medical records in gynecology and obstetrics at one reference teaching hospital, Burkina Faso

Abstract

The medical record of the patient is inseparable of the medical practice. This study has for objective to estimate the quality of the medical records of the patients in Gynecology and Obstetrics al the Teaching Hospital Yalgado Ouedraogo of Ouagadougou. It was about a transverse study with descriptive aim. A sample of 200 medical records was established by random drawing from the numbers of recording of the patients in the admission. The used assessment grid was inspired by that of the National Agency of Accreditation and of Evaluation in Health which contains several criteria. The drawn lots records were found in 72.5 % of cases. They were in good condition in 76.6 % of cases. The identity of the patient s was noted in all the files. They contained the identity of the providers in 52.4 % of the cases. The main diagnosis was specified in 99.3 % of records. Administered medicine was notified in 8.3 of cases. The partogram was performed in 44.4 % of cases. The date and the hour of exit were noted in 6.2 % of the cases and the abstract of exit was made in no case. The audit of the medical files shows inadequacies in its holding. A raising awareness of the providers and a regular practice of audits tum out to be necessary to improve the quality of the medical record keeping. The computerization of the patient record and the implementation of a system of central archives in the Teaching Hospital are to be promoted.