DOI: 10.21276/aimdr.2017.3.4.PE1 Original Article ISSN (O):2395-2822; ISSN (P):2395-2814 Annals of International Medical and Dental Research, Vol (3), Issue (4) Page 1 Section: Paediatrics Clinical Record Keeping Survey of Patients Admitted to Misurata Central Hospital. Mabroka Alfoghi 1 , Mohamed Ben Ramadan 2 1 ABHS, Department of Paediatrics, Misurata Central Hospital, Misurata Libya. 2 FRCPCH, Department of Paediatrics, Misurata Central Hospital, Misurata Libya. Received: April 2017 Accepted: April 2017 Copyright: © the author(s), publisher. Annals of International Medical and Dental Research (AIMDR) is an Official Publication of “Society for Health Care & Research Development”. It is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non- commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Background: The current survey are to evaluate the quality of patient identification documentation and medical notes writing in our public hospital and to ensure compliance with the international clinical record keeping requirements. Methods: This is a retrospective cross-sectional survey of randomly collected case notes from the hospital documentation and information office, where 100 case notes for patients who were admitted during 2015, from five hospital wards and a total of 500 case notes were reviewed and its completeness was assessed in the contents of hospital medical files as frequencies (%). Results: The patient’s registration number, Unit, Name, Age, Nationality, Admission and Discharge dates were recorded in (85-100%) of cases in almost all wards. Mother's name, Birth date, Marital status, Profession, Place of work, Phone number in General Medicine, General Surgery and Orthopaedic wards were recorded in (<20% of cases). Address, Final diagnosis, Outcome also were recorded in (<50%) in General Medicine wards, and in (80-100%) in Surgery and Orthopaedic wards. All the late parameters were recorded in (92-100%) in Obstetric ward. Regarding pediatric wards, the same data were recorded in (60–85%) for all parameters. Regarding Time, round’s leader, doctor’s name and Signature on the clinical entry notes were all recorded in (<40%), doctor’s Designation was not written at all. Conclusion: This survey shows the documentation of important patient information is lacking behind the international standards. Poor documentation in medical records might compromises the quality of care, had a medico-legal implications and undermine analyses based on retrospective medical files reviews. Keywords: Case notes, Documentation, Patient information, Record keeping. INTRODUCTION The medical record by definition is a “collection of data on a patient including an identification, history, statement of current problem, diagnosis and the treatment procedures and progress notes. [1] Case note documentation is a vital process to insure proper recording of patient’s data and keystone to improve communication between different professionals. Proper documentation of patient care is frequently the Achilles heel of Clinical services and has implications for research outcomes, including the development of medical report. [2] The clinical record has many functions, the most important of which are listed in [Table 1]. Higher Standards of recording are a must requirement in providing care for the community members and should be accurate and not vague or open to misinterpretations. It is vital that the medical professionals are concern about legibility and meticulous about clinical details and appropriate medical record keeping. [3] They must keep clear, accurate and legible records which include reporting the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigation and treatment. Structured information which needs to be included in clinical records is listed in [Table 2]. Self-assessment and clinical audits and surveys can help improve the standards of medical record keeping. This would help in identifying the deficiencies, mistakes and shortfalls in medical records documentation and design, implement and review plans to rectify these shortfalls. The objectives of the current survey are to evaluate the quality of patient identification and medical notes writing in our public hospital and to ensure compliance with the international clinical record keeping requirements. Name & Address of Corresponding Author Dr. Mabroka Alfoghi ABHS, Department of Paediatrics, Misurata Central Hospital, Misurata Libya. MATERIALS AND METHODS The retrospective cross-sectional survey of randomly collected case notes from the hospital documentation and information office, 100 case notes from each one of the main five hospital wards (General Medicine, Surgery, Orthopaedic, Obstetric and Paediatric), patients were admitted during the year 2015, The