Student Dissertation

Agency : Medical Records; DMAIC Methodology; Quality; Inpatient Medical Records

Background : The improvement in quality of inpatient medical record documentation is essential as it plays a vital role in sustaining the acquired accreditation from JCI, as the JCI surveyors pays a special attention to analyzing the documentation pattern being followed by the staffs, it’s also important when it comes to the matter of complete, legible documentation, also in avoiding legal involvement of hospital and staffs, etc. This study elucidates the application of a five-phase Six Sigma define, measure, analyze, improve, and control (DMAIC) approach to improve the quality of documentation of inpatient medical records errors. The objective of this study to improve the quality of inpatient medical record documentation in THFUJ. The hospital has an activated EMR system for OPD but for inpatient the activation still has time which is the basic reason that the quality of documentation is on priority.

Methodology : A stratified random sample of 183 inpatient medical records taken to analyze the quality of documentation by clinical and non-clinical staffs, followed by a set of forms in medical records and parameters in each form as a checklist owing to analyze documentation error. In the context of the five phases, the tools which have been applied to make decisions are: • Root cause analysis by fishbone analysis • Cause-and-Effect Matrices

Findings : On the basis of collected data based on the parameter in each form of medical records compliance percentage of staffs is calculated to rule out the loopholes in documentation in achieving 100% compliance, for physician 93%, nurses 96%, PAD 75%, MRD 14%, pharmacist 86%, dietician 87%, ICN 0%, ICD 32%.

Recommendations : For improvement recommendations suggested which can be used in the implementation phase to collect baseline data after the recommendations are adopted to improve the discharge process