Measurement of Completeness of Medical Records in Family Health Centre in El Shorouk City

Abstract

Family practitioners and other staff working in primary care require comprehensive and accurate data on patients at the point-of-care if they are to provide high quality health services to their patients. Medical records are an effective method of achieving this objective. The family folder is the grouping of a set of patient care documents. Usually for an entire family or household, that is stored in a cardboard file box container. This file box, commonly referred to as the “family file folder,” contains several documents, these documents represent a picture of the family household from several perspectives. For instance, they reflect the socioeconomic and demographic data of the family unit, children’s ages and levels of educational achievements are noted in the file. The file folder contents also summarize the health history of the family unit, identifying family member’s specific diseases and illnesses as well as a list of the names of all members of the household. All entries in the medical record must be complete. A medical record is considered complete if it contains sufficient information to identify the patient; support the diagnosis/ condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers. All entries in the medical record must be dated, timed, and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service provided. So, this study aimed to measure the completeness of the family medical records in a family health center in EL-Shorouk city and to identify main causes of record incompleteness including knowledge and attitude of physicians towards medical records.