Assessing levels of documentation performance of the medical records during the first and third COVID-19 pandemic waves in Egypt.

SH Refaee, Abdelrahman; M. Kamal, Nourhan; Moubarak, Shymaa; M. Gaballah, Marwa; Ibrahem, Hoda Younes; Elassi, Abeer Elsayad; A.Abo Elmagd, Mohamed; Ammaar, Taghreed; Shabaan, Mohamed; Salah, Marwa; Abdalgeleel, Shaimaa Abdalaleem; Allam, Rasha Mahmoud; M. Samir, Mahmoud; Aly, Doaa Hamdy; Mohamed Eisa, Nehal

doi:10.21608/erurj.2025.323472.1185

Assessing levels of documentation performance of the medical records during the first and third COVID-19 pandemic waves in Egypt.

Document Type : Original Article

Authors

¹ Clinical research department at Giza health affairs Directorate, MOHP, Giza, Egypt.

² Cancer Epidemiology & Biostatistics depatment, National Cancer Institute, Cairo University, Egypt

³ ICH-CRC, MOHP, Giza, Egypt

10.21608/erurj.2025.323472.1185

Abstract

This study aims to investigate the differences in medical record quality between the early stages of the COVID-19 pandemic and one year later in Egyptian general hospitals. The impact of these differences on documentation performance and length of stay was also evaluated. A retrospective comparative study was conducted in seven governmental hospitals in Giza. Data was collected from medical records during the first wave of the pandemic before the implementation of unified formal medical records and compared with records one year later after the implementation. A random sampling strategy was used to select a representative sample of at least 3% of the total hospitalizations in the previous year.The study assessed the performance and quality of medical records from the internal medicine departments and the intensive care units for adult patients. Evaluation criteria included documentation of identification information, administrative information, medical information, and care-provider information. The results showed no statistically significant difference in the total scores of doctors' medical records between the two periods (p<0.001). However, significant differences were found when comparing scores within each hospital. The length of stay did not show a significant difference between the two periods (p= 0.005), except in two hospitals (p=0.029 & <0.001). The diagnosis and patient outcomes showed significant differences between the two periods.Overall, this comparative study demonstrated that during the COVID-19 pandemic, medical records' data quality was substandard. Greater care and scrutiny should be given to the documentation of data in medical records to guarantee patient safety and appropriate data use for research.

Keywords

Main Subjects