THE MEDICAL JOURNAL OF BASRAH UNIVERSITY 1 MBChB, MSc, PhD CM, General Director, Basrah Health Directorate 2 MBChB, DCM, MPH, PhD CM, Health manager, Basrah Health Directorate, Training and staff Development Center 3 DCM, Health manager, Basrah Health Directorate, Quality Assurance Unit 4 DCM, Basrah Health Directorate, Quality Assurance Unit 5 Board of Family Medicine, Basrah Health Directorate, Quality Assurance Unit Assessment of the documentation completeness level of the medical records in Basrah General Hospital Riyadh A. Hussein 1 , Rajaa A. Mahmoud 2 , Nihad Q. Al-Hamadi 3 , Atared A. Majeed 4 , Shabeeb A. Saihoud 5 ABSTRACT Background: Medical records documentation is an important legal and professional requirement for all health professionals. They include information which describes all aspects of patient's care. But, despite the importance of medical records to support better quality service provided at the health facilities, incomplete documentation is very common all over the world. Objective of the study: to assess the documentation completeness level of the medical records in the different inpatient wards of Basrah General Hospital. Methodology: The study was a descriptive cross-sectional one. Medical records of 268 inpatients from Basrah General Hospital during June 2016 were included from four departments of the hospital (medicine, surgery, pediatrics and obstetrics and gynecology). A standard Iraqi Ministry of Health inpatient medical record with a two-level scoring system for assessing the level of documentation completeness were used in the study. Results: the overall documentation level for the medical records included in the study was generally poor in 78% of the records. Surgical department was found to be the worse in documenting patient's notes related to medical history, while Gynecology and Obstetrics department was found to be the worst in documenting the medical examination assessment and the physician's notes related to the patient's state and details of any improvement / deterioration of his/her condition. Conclusions and recommendations: The present study confirmed obvious incompleteness of documenting medical data for inpatient records in Basrah General Hospital especially in the general surgery, internal medicine and Gynecology and Obstetrics words. This is specifically found for the Physician notes (patient’s state and details of any improvement/deterioration of the condition) and the Clinical pharmaceutical sheet. A hospital based quality improvement project to improve the medical record documentation completion is highly recommended to be implemented by the Quality Assurance Unit of Basrah Directorate of Health. Key words: Medical records, inpatients, documentation, Basrah لعام البصرة ا مستشفن ف الراقدلمرضة لت الطب السجق ف ث ى الت مستم دراسة لتققدمة الم: ةت الطبق السج ثة ت عملاج احتةنب رعا اع ج تصف جم ماتن معلتضمة ت عملن. وىن الصحنع الم لجمم من وم ن قانض. المر لكن وت الطة السجن أىم م الرغم علة، المرافق الصحقدمة فة المة الخدم دة لدعم ج ب فإن الق ال ث تر غ ال مكتمل مشكلة ى شائعة جدالعالم.ء اع أنحا جم فدف: ال كتمال ى ا مستم تقق ف ث التلمرضة لت الطب السجن الراقدلعام. البصرة ا مستشف فةج المن: ة الدراسة وصفة مقطعت الت السج شملة ل طب ـ868 ض مر ا راقد ا فللعام خ البصرة ا مستشفران حز8106 من أربع ة أقسام ف اطفال وب والجراحة وطب االط( لمستشف النسا ا مراة ئد ل والتخدمت الدراسة. واست) " اس الق الطبسجل ال" الصحة العرا زارة لة قع نظام مم ثنائ تق ثائق. ال كتمال ى ا مستم لتق