الفهرس 
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Abstract
Accurate, timely and accessible health care data play an important role in the planning, development and maintenance of health care services. All healthcare practitioners and others who enter information into patient records must understand the importance of creating complete and accurate records, as well as the legal and medical implications of this process failure.
The quality of care a patient receives depends directly on the accuracy and legibility of the information documented in the medical record. Medical records have so far been the primary source for researching medical errors. Several studies describe the use of medical record review to measure the occurrence of adverse events in hospitals.
Field work observations in Alexandria Teaching Hospitals showed that the quality of the medical records is far from being adequate. Also, no previous assessment of Medical Records quality in the Medical Research Institute hospital was done to our best knowledge.
Aim of the work
The aim of this work is to evaluate the quality of medical records in the Medical Research Institute’s hospital in Alexandria. Necessary interventions will be devised to improve the quality of medical records for a better provision of health care to the patients.
It also aims at comparing the standards regulating documentation in the medical records in JCI standards with those in the currently applied ISQua accredited Egyptian standards for hospitals, and carrying out the assessment with each of the two sets of standards independently. It also aims at developing an integrated tool covering the quality parameters in both International Society of Quality accredited and Joint Commission International standards and carrying out the assessment with the newly developed tool. Moreover, the study will identify the different determinants of quality of medical records.
Materials and methods
This study was a retrospective study. A sample size of 349 medical records of MRI Hospital taken from the medical records department.Sample size was determined by Lot quality-assurance sampling (LQAS) sampling method.
Evaluation of the medical records’ compliance to the Egyptian and JCI standards was carried out separately using their scoring systems. Also, comparison of the medical records related standards in both accreditation systemswas done to extract the measurable elements that developedour newly integrated tool. Both Egyptian and JCI scoring systems were used to evaluate the medical records’ compliance to the measurable elements of the new tool.
Data about determinants of the medical records quality (such as department of admission, qualifications of physician/surgeon(s) who essentially made entries in the medical records, availability of printed medical record’s forms and previous training of the staff making entries in the medical records) were collected. Statistical analysis of data was done using IBM SPSS v22and suitable statistical methods were used. All statistical analysis were performed using 5% level of significance.
The most important findings of our study were:
• Poor medical records quality in all departments of the MRI hospital which failed to meet the accreditation criteria of neither Egyptian nor JCI standards.
• Of the Egyptian standards there were 56 (41.7%) standards related to the medical records similar to 43 (75.4%) JCI standards related the Medical Records quality. Also, 78 (58.2%) Egyptian standards had unique requirement in comparison to 14 (24.6%) JCI standards. The measurable elements of the Egyptian standards constituted (90.5%) of the newly develop integrated tools’ elements.
• There were no written policies and procedures regarding the needed information to be documented in the records or related to continuous monitoring and quality improvement of the medical records.
• The newly developed integrated tool is easy to use and considered to be a manual for measuring performance of medical records quality according to both Egyptian and JCI standards.
• All forms of the medical records in our study showed poor compliance to the measurable elements. The highest level of compliance was found in the patient identification forms with mean compliance of 71.2% in the records.
• According to the determinants of Medical Records quality, the study concluded that:
There was a statistically significant difference between documentation patterns in different hospital’s departments(p <.001).
The records that were signed by both consultants and residents showed higher median compliance percent than other records (P < .001).
There was a positive linear correlation between the availability of printed forms of the medical records and the mean compliance of the record to different measurable elements(P < .001).
To our knowledge there was no official training program delivered to any of the medical staff about the importance of proper documentation in the medical records.