KNOWLEDGE, AWARENESS, ATTITUDE, AND PRACTICE TOWARDS MEDICAL RECORD COMPLETENESS AMONG MEDICAL PROFESSIONALS IN TEACHING HOSPITAL
Abstract
Introduction: Medical record documentation is vital for patient care, effective communication, and comprehensive data collection. It is essential for healthcare professionals to possess adequate knowledge of medical ethics and record-filling guidelines to ensure the thorough completion of medical records. This understanding is significantly correlated with increased record completeness. A positive attitude towards the importance of detailed medical records further promotes diligent documentation practices. However, South Africa and Uganda studies have revealed deficiencies in attitudes, knowledge, and practices among healthcare personnel.
Methods: A cross-sectional study conducted at Shri B. M. Patil Medical College Hospital evaluated the knowledge, awareness, attitudes, and practices related to the completeness of medical records among nursing staff, physicians, and junior residents. The assessment utilized a self-structured questionnaire comprising 27 items rated on a Likert scale, distributed via Google Forms and hard copies.
Results: A survey reveals that 80% of healthcare professionals believe that incomplete medical records can harm privacy, cause legal penalties, and damage credibility. Computerization improves record accessibility and efficiency, while error correction methods are crucial. Secure authentication enhances patient data security, and patient record trackers are beneficial. Practitioners have varied awareness of critical aspects of medical record management, with 47.5% and 48.5% fully aware of legal implications and consent requirements. Record-keeping is sometimes burdensome, with 41.0% viewing it as a “sometimes” burdensome task. Challenges include meeting deadlines, feeling understaffed, and using approved formats. Despite these, 70.5% fill in identification details, and 43% observe medical record supervision, indicating areas for improvement in practice management.
Conclusion: The study reveals that medical record completeness with Knowledge, ranking as “Average” and Awareness as “Good.” Health institutions should focus on improving documentation through workshops and sharing experiences. Attitude is rated as “Good,” emphasizing positive attitudes among healthcare professionals. In practice, the challenges are insufficient time for documentation, inadequate staffing, and lack of a computerized system. Strategies include teamwork, electronic medical records, regular supervision, training programs, and accessible guideline formats.
