Abstract:
Quality medical record-keeping facilitates the management of patient information
fin better quality care. The preprinted structured format of record-keeping could improve
(the documentation quality which has been proved by overseas studies. The aim of this
study was"to evaluate the impacts of structured pediatric records on the documentation
ijtuilily as well as the performance satisfaction of the staff in a Sri Lankan district general
hospital,
A prospective comparative study was carried out in two pediatric units of Ampara
| District General Hospital. One hundred preprinted structured records (one record has a
set of six forms: admission record, daily status sheet, drug chart, observation form,
investigation form and discharge summary) introduced to patients admitted to one unit
(intervention group) were compared with the traditional free text records of 100 patients
of the other unit (control group) over a period of two months. The major outcome
measures were the completeness and legibility of documentation which were scored on a
_ ranking scale. Mann-Whitney U test. was used to compare both groups. A staff.
performance. satisfaction survey using a self-administered questionnaire was carried out at
the end of the study among the nurses and doctors who involved in documenting the newly introduced structured records.
The implementation of the structured records had positively influenced the
documentation quality as well as the staff performance in many aspects. In terms of
completeness of the daily status sheet, investigation chart, and discharge summary improved
significantly (p< 0.0000) and with regard to legibility observation chart, drug chart,
investigation chart and the discharge summary showed significant improvement (p<
0.0000) in the intervention group. The satisfaction was high among staff on the newly
introduced format of documentation during their routine ward work. Replacing the
traditional pediatric records with preprinted structured records would improve the
documentation quality and staff performance satisfaction in the future.
