title: An examination of inpatient medical record keeping in the Orthopaedic Department of Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania.
abstract: BACKGROUND
  There is a lack of published evidence examining the quality of patient notes in African healthcare settings. We aim to examine the completeness of the orthopaedic inpatient notes and begin development of a formal audit framework in a large Tanzanian Hospital.
  
  
  METHODS
  A retrospective review of 155 orthopaedic inpatient notes at Kilimanjaro Christian Medical Centre (KCMC) was conducted spanning 3 months. Notes were reviewed using an agreed data collection pro forma considering 3 main outcomes; i) quantity of complete entries, ii) percentage completeness of individual sections, iii) documentation of follow-up.
  8% (n = 13) of the inpatient documents were complete (10/10 sections). 11% (n = 17) of the inpatient documents had 9 of 10 sections completed. 30% (n = 46) of the inpatient documents had 8 of 10 sections completed. Therefore, 51% (n = 79) of inpatient entries had 7 or fewer sections filled in.
  
  
  RESULTS
  Admission information and Demographics were both completed 88% (n = 137) of the time. History and the Examination sections were complete in 96% (n = 149) of cases. Investigations were complete in 77% (n = 119) and Diagnosis in 88% (n = 137). The Treatment section was complete 85% (n = 132) of the time and the Attending doctor 50% (n = 78). Procedures were 27% (n = 42) filled in while Summary of a day and Follow-up were 32% (n = 49) and 0% (n = 0) respectively.
  Follow-up was not completed in any entries.
  
  
  CONCLUSIONS
  There are a number of sections of the inpatient pro forma that remain inadequately completed. Regular auditing is essential for the continued progress in patient care.
authors.affiliation: College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom.
authors.forename: Alexander Conor
authors.initials: AC
authors.lastname: Hollis
authors.affiliation: College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom.
authors.forename: Samuel Robert
authors.initials: SR
authors.lastname: Ebbs
mesh_terms: D004282:Documentation / Q000592:standards*; D005260:Female; D006748:Hospital Departments; D006801:Humans; D007297:Inpatients; D008297:Male; D008485:Medical Audit / Q000379:methods; D008499:Medical Records / Q000592:standards*; D009985:Orthopedics / Q000592:standards*; D010343:Patient Admission; D012189:Retrospective Studies; D013636:Tanzania
keywords: Tanzania; orthopaedics; quality improvement; service evaluation