ROUTINE DATA ANALYSIS TO IMPROVE PATIENT FILE DOCUMENTATION

ABSTRACT

TOPIC:ROUTINE DATA ANALYSIS TO IMPROVE PATIENT FILE DOCUMENTATION

PREPARED BY: VALENTINE MARIWA

SI MATER HOSPITAL

BACKGROUND

• Documentation is a process of providing evidence. Nine Quarters that is 24 months back to be precise the clinic had a big

problem with documentation. Patients’ files were not being well updated and it was a challenge in tracing patients. the main

areas focused on include:

• TB intensive case finding form the percentage was at 2% out of the total active patients on care.

• The Medical data form for active patients was at 40%.This made the medical Officer to come up with a way forward of

dividing all active files to staffs to update the medical data. This was a tiring exercise especially for old files, there were a lot

of forms to be updated.

• It took staffs three months to update the forms.

• This was discussed during one of the CQI meeting, and a strategy was invented. It was called “NAME AND SHAME

PROJECT’

OBJECTIVES

• To get the TB Intensive case finding from 2% to 95%

• Patients medical data form updated after every patients visit from 40% to 95%

• During routine data entry , the SI Person does file evaluation in each file.

• Files which are not fully documented or updated mostly the three areas, are put aside.

• The SI person analyses the files and makes a list of staffs responsible.

• During daily meetings, the SI person announces the staffs responsible in documenting a specific file.

For example. Kioko had 3 files TB ICF not documented. After the meeting ,the responsible staffs collects files from the Data

Office to document or note the file during patients’ next visit. This happened on daily basis for six months. The first

month an average of about 25 files were seen, this reduced to two, one or zero files in a day by third month of the exercise .

METHODOLOGY

Figure:1

TB-ICF documentation became almost perfect. Patients were being screened for TB during every visit. This is as shown below:

RESULTS

• Data summary form is currently updated for all active patients on care. This is from 60% to 95% by March 2014 it was 94%:

Figure: 2

0

500

1000

1500

2000

2500

3000

3500 Files documented out of Total Active files

No.of files documented

Total active patients

CONCLUSION

• The aim for these findings was to ensure that all HIV positive patients on care are screened for TB during every visit they make to the clinic.

• To ensure that patients file documentation is up to date so as to help monitor the progress of the patients. This will easen in follow ups for priority patients.

RECOMMENDATION

• Make sure all staffs understand the reason for various documentation and necessity for documentation.

• The SI person ‘s responsibility to feedback the staffs on documentation progress on DAILY basis because doing it daily is manageable.