Seniors Improved the Documentation of Junior Physicians’ Medical Records in a Teaching Hospital in Ethiopia

Abstract

Background: Complete medical documentation is an integral part of health system quality and safe patient care. However, this is compromised during duty hours while the physician is tired, high patient-to-physician ratio, and a lack of senior physician guidance from junior doctors. This quality improvement project aimed to improve medical documentation duty hours for admitted patients through the senior physician’s audit feedback strategies. Methods: This quality improvement project was undertaken to improve the medical documentation of junior physicians for patients admitted during duty hours. We did it through the senior physician-led audit feedback system and by integrating the project tasks into senior physicians’ workflow. A collective group of project members teams, duty-assigned senior physicians, internal medicine residents, medical interns, nursing team, internal medicine, quality personnel, internal medicine department heads, and clinical vice provost. Quality improvement methods were used to test the role of the senior physician in improving the medical records documentation and maintaining the improvements obtained. Results: The medical record documentation improved from 73% to 96.4% before and after implementing the improvement interventions, respectively. It was effectively maintained for six months (97.2%). The senior physician-led audited feedback strategies increased the clinical audit score by 24%. Conclusion: The senior physician found to improve the junior physician’s medical record documentation of hospitalized patients during duty hours. The project also showed successful integration of the intervention into the routine clinical workflow. Keywords: medical record, senior physicians, Ethiopia